MILITARY MEDICINE DURING THE TWENTIETH CENTURY

MD0405
Chapter 3


LESSON ASSIGNMENT
LESSON 3 Military Medicine During the Twentieth Century.
LESSON ASSIGNMENT Paragraphs 3-1 through 3-48; appendixes A, B, and C.
LESSON OBJECTIVES After completing this lesson, you should be able to:
3-1. Identify major medical and military events associated with the twentieth century, including the time frame and people associated with the events.
3-2. Identify major medical and military events pertaining to the development of aeromedical evacuation during the twentieth century.
3-3. Identify medical and military events associated with operations other than war.
3-4. Identify the terms civil affairs and civil action and tactical, operational, and strategic medical missions.
3-5. Identify the major characteristics of a staff ride.

SUGGESTION After studying the assignment, complete the exercises at the end of this lesson. These exercises will help you to achieve the lesson objectives..


Section I. WORLD WAR I



3-1. MILITARY MEDICINE AT THE START OF THE TWENTIETH CENTURY

   At the start of the twentieth century, there was a revolution in technology that affected all aspects of military medicine. Advances such as the telephone and telegraph, national and international medical journals, and travel to foreign hospitals gave the American medical community a new outlook on health care and research. For the first time, the United States competed with Britain, France, and Germany on an equal basis in science and medicine.

   a. The advent of antiseptics, X-rays, vaccines against diseases, and major breakthroughs in surgery pioneered by scientists such as Lister and Pasteur occurred toward the end of the 1800's.

   b. In the first decade of the 1900's, military medicine was also growing. Research in sanitation, nutrition, pathology, surgery, and chemistry promoted new treatments.

      (1) In 1900, Karl Landsteiner of Vienna discovered the ABO antigens of blood and developed the method of typing and matching donor and recipient for safe transfusions.

      (2) Continued research led to successes such as the discovery by Dr. Walter Reed and his associates that the mosquito was the carrier of yellow fever. William Gorgas, chief sanitary officer in Havana, immediately began to eliminate mosquito breeding places. In a matter of months, the pattern of yellow fever transmission in the city was broken.

      (3) The 1902 Biologics Control Act authorized the New York Hygienic Laboratory to produce vaccines and serums for typhoid fever, diphtheria, yellow fever, and tetanus. It also performed other medical research on behalf of the government. In 1904, it moved to Washington, D.C., where it later became the United States Public Health Service.

      (4) In 1904 William Gorgas was assigned to assist with the construction of the Panama Canal. He began applying mosquito-control efforts to control malaria and yellow fever. When he encountered objections to his efforts, he received the personal support of President Theodore Roosevelt. Although Gorgas never totally freed the Canal Zone from malaria and yellow fever, the morbidity rate of malaria in 1913 was only 10 percent of the 1906 rate.

      (5) The U.S. War Department organized the Army Shoe Board in 1908 under Major Edward Munson. His team studied over 2000 soldiers' feet to determine the problems related to poor shoe fit and natural bone deformities, and developed the "Munson last" shoe frame to create better military boot designs. Dr. Munson also published many texts on field sanitation and preventive medicine.

      (6) Around 1910, Dr. Leonard Rowntree of Johns Hopkins and his colleagues developed plasmapheresis--a discovery which led to separation of blood components (plasma, red cells, platelets, etc.) for specific transfusion uses.

      (7) Purification of drinking water by the use of liquid chlorine was developed in 1910 by Major Carl Rogers Darnell, Professor of Chemistry at the Army Medical School. He later designed a purification filter for field use in World War I. Around the same period, Major William Lyster used a solution of calcium hypochlorite in a linen bag (Lyster bag) to treat water.

      (8) George Crile conducted research on blood transfusions, treatment of traumatic shock, and thyroid operations.

      (9) Harvey Cushing made neuro-surgery and brain operations a specialized field.

      (10) Alexis Carrel was the first to operate extensively on the aorta and the heart and performed early work on organ and tissue transplants.

   c. One of the most important military medical issues concerned the command of hospital ships. Medical and line officers both wanted command authority. The issue was settled by President Theodore Roosevelt when he named Navy surgeon Charles Stokes to be the commanding officer of the new hospital ship Relief, which joined the Great White Fleet as it sailed around the world 1907-1908.

   d. The reconstituted American Medical Association (AMA), originally founded in 1847 in Philadelphia, worked vigorously to improve the social position of American physicians and to ensure that those practicing medicine in the United States would represent the highest achievable standard of professional expertise. The chief hallmark of this movement was the reform of medical education under the direction of the Council of Medical Education of the AMA and given popular credibility by Abraham Flexner's 1910 muckraking report on the state of medical education in the United States. The Flexner report spurred increasing concern with the quality of clinical instruction and awareness of the emerging importance of postgraduate medical education and subsequent specialized medical practice. The area where specialization was having its most dramatic impact was in the rapid emergence in urban centers of skilled general surgeons.

   e. Many new professional societies and boards were established, such as the American College of Surgeons in 1913. Various other specialty organizations also made strict standards for both education and medical practice and monitored the licensing of practitioners.

      (1) In 1915, the American Medical Association (AMA) created the National Board of Medical Examiners to test new medical graduates. Internship programs were also started to give new doctors more practical experience in the hospital setting before allowing them to set up their own practices.

      (2) The Army improved its screening of new medical officers by requiring graduation from a reputable medical school, at least one year of practice, and the successful passage of an examination.    f. Frederick Russell of the Army Medical School developed a safe and effective typhoid fever vaccine which was demonstrated in a large-scale test in San Antonio, Texas (only two out of 12,000 men inoculated contracted the disease). In 1911, the Army and Navy made Russell's new vaccine mandatory. With the discovery of the paratyphoid bacilli, the vaccine was expanded to include paratyphoid A and B (TAB). By late 1917, all U.S. soldiers were receiving the TAB vaccine.

3-2. START OF WORLD WAR I

   a. On 28 June 1914, Archduke Ferdinand of Austria was assassinated by a Serbian nationalist in the city of Sarajevo. Austria soon declared war on Serbia. Russia mobilized to support Serbia. Germany, fearing a Russian invasion of its ally Austria, declared war on Russia. When France mobilized, Germany declared war on France and stated that Germany forces would march through Belgium to attack France. Great Britain, an ally of Belgium, declared war on Germany on 4 August 1914 to protect Belgium. Italy and other countries soon entered the conflict.

   b. The United States attempted to remain neutral. However, public outrage at incidents such as the sinking of the Lusitania by a German submarine finally resulted in the United States entering the war on the side of the Allies late in 1917. The War Department began proceedings to draft civilians into military service early in 1918. Local examination boards had the power to either unconditionally accept or reject draftees and volunteers. Questionable cases were referred to Medical Advisory Boards.

3-3. CHANGES IN WARFARE

The advent of new ballistic weapons, airplane and submarine warfare, and gas warfare resulted in the worst battlefield wounds suffered up to that time.

   a. Advances in weaponry included new rifle cartridges which traveled at higher velocities with even more force to shatter bone and destroy tissue. Older weapons such as machine guns were improved. Wounds produced by shrapnel, shell, and grenade fragments were destructive to large areas of the body and almost always infected by pieces of dirty clothing driven inside the tissues. Searches for shrapnel, shell, and grenade fragments were performed at rear area hospitals using X-ray and magnet applications.

   b. Chlorine gas released from canisters set along the front was introduced by the Germans. The deadly gases sank down into the trenches causing initial symptoms of watery eyes and an irritated bronchial tract. Panic soon resulted. Protective masks and respirators containing filter pads soaked with hyposulfite and sodium bicarbonate were developed to protect troops against these gasses. Soon additional chemical agents, such as mustard gas, were used. Mustard gas was usually not noticed at first, but soon caused inflamed eyes, vomiting, and blisters on exposed skin similar to burns which became infected.

Approximately 97 percent of all gassed soldiers survived, but evacuation, decontamination, and treatment placed a severe strain on medical treatment facilities and evacuation resources.

3-4. PATIENT EVACUATION PROCESS

   Fortunately, the Allies had a treatment and evacuation system in place that was far superior to any previous evacuation system.

   a. Buddy-aid treatment of injuries was performed at the injury site using individual first aid supplies.    b. Field medics provided emergency care to stabilize the patient for evacuation.

   c. First aid stations were usually located about 500 to 1000 yards behind the regimental reserves in a sheltered spot outside, in a house cellar, or in the ruins of bombed buildings. They had a water supply, dressings, and surgical equipment for rapid initial treatment. Arriving patients were given a shot of anti-tetanus serum.

   d. Casualties were moved from aid stations to field hospitals by ambulance squads. Each ambulance squad had ten cars and a repair vehicle that carried two mechanics, extra tires, gasoline, and spare parts. Each ambulance could hold 4 to 6 litters or 10 to 12 ambulatory patients.

   e. Field hospitals, located in the rear of the divisional reserves, consisted of a combination of tents and local buildings such as churches, schools, and hotels. Field hospitals performed urgent surgery for hemorrhage, perforating head and abdominal wounds, immediate-need amputations, and bone splinting.

   f. Patients evacuated to treatment facilities in the rear traveled in hospital trains converted from civilian passenger railway cars. Each car held about 18 casualties and a hospital corpsman. There was one surgeon for the whole train. Small infirmaries were set up along the rail route for those casualties unable to continue the train trip. Upon arrival at the final depot, casualties were cared for by volunteer Red Cross nurses and assigned to hospitals based on reported bed space.

3-5. HOSPITAL CARE

   a. The prevention of shock was found to be directly related to the prevention of blood loss. Tourniquets and compression bandages were used as soon as possible after injury and loss blood volume was restored.

   b. Although Landsteiner had demonstrated the safety of blood transfusions if properly matched by antigen type, general public donation programs had not been established by the beginning of the war. Due to the shortage of available blood and problems with storage and preservation, transfusions were generally limited to direct (vein to vein) transfusion between donor and patient. Transfusions following surgery proved to be of great benefit in preventing and controlling shock.

   c. The general surgical treatment was conservative. Amputation was rarely used unless the body part was so mutilated that it was unsalvageable. Every effort was made to give the patient at least partial use of the limb.

   d. Fractured femurs were secured by the Blake splint, which elevated and extended the leg in a traction apparatus. After the original infection of the wound had subsided and the bone fragments had begun to regenerate and unite, plating and wiring and/or grooving a "V" and "point" out of facing bone ends aided complete and secure union.

   e. Most of the men wounded in the brain or spinal cord died on the battlefield or at first-aid stations. Those who survived to reach the rear base hospitals had 90 percent mortality from meningitis.

   f. Dental surgery was a major activity due to the several facial disfigurement wounds suffered through grenades, shrapnel, and bullets. Facial/dental surgery was performed at the rear base hospital. Ragged tissue was carefully trimmed, leaving as much of the lip area as possible, and sutured. A metal bridge with artificial teeth was connected to the remaining good teeth and a portion of a rib or tibial was used to rebuild the jaw. Skin flaps were carefully sewn to avoid excessive scarring.

3-6. PREVENTIVE MEDICINE

   Diseases such as typhoid, typhus, malaria, and tetanus spread through the troops due to the wet, cold environment of the trenches, insect vectors, and poor sanitation. However, efforts were made to help prevent a repeat of the medical disasters of previous wars.

   a. Safe drinking water treated with sodium hypochlorite was supplied to the troops in mobile hundred gallon metal tanks. Also, local deep wells and springs were tested and labeled either fit to drink or of need of boiling before use.

   b. The systematic collection and incineration of refuse, wastes, and other garbage, along with chemical treatment, did much to decrease the spread of disease.

   c. In 1916, the Army Medical Department was formally organized by corps. A Veterinary Corps was added to the Medical Corps and the Dental Corps. In addition to caring for animals (essential when much of the army still moved by horse), the Veterinary Corps was given the task of ensuring that food supplies were safe for troop use, a mission that increased as time went on.

3-7. AVIATION MEDICINE

   Theodore Lyster, chief surgeon of the Air Division Medical Section, developed and implemented new physical standards for pilots. He also established a medical research board to do research. Experiments established the need to supply oxygen to pilots at high altitudes. Lyster went to Europe to investigate why accident rates in the U.S. aviation services were so high (three times as many pilots were dying from accident than from enemy action). He found that pilots were flying to the point of exhaustion and the untrained medical officers did not recognize the nature of this stress. Lyster's response was the creation of a new type of medical officer, the flight surgeon. In addition to specialized education, the flight surgeons were required to learn to fly.

3-8. END OF THE WAR

   The fighting in World War I ended on 11 November 1918. This was the first major American war where deaths from battle injuries outnumbered deaths from disease. Deaths from disease were decreased due to advances in the development of vaccines against disease, higher sanitation standards, and developments in shock therapy and surgical techniques. The increase in battle deaths was related to the use of new weapons and delivery systems.

Section II. WORLD WAR II AND KOREA

3-9. MEDICAL ADVANCES BETWEEN THE WARS

   a. The Army, with the aid of the American Medical Association, created an internship program in 1920 offering continuing education to medical officers through Walter Reed Medical Center, the Mayo Clinic, the New York Neurologic Institute, and the Eye and Ear Infirmary in New York City. This program, while improving the skills of the students, also acted as both a recruitment and retention tool for the Army as it faced a major force reduction following the postwar draftee release.

   b. The first use of refrigeration to preserve blood was in the 1920's. The first blood bank in the United States was established at Cook County Hospital, Chicago, in 1937.

   c. The major breakthrough was the discovery of antibiotics.

      (1) In 1928, Alexander Fleming accidentally discovered that a petri dish contaminated by penicillium mold caused the death of bacterial colonies around the mold. Additional research soon developed procedures to mass produce purified penicillin extract for Allied troops. Penicillin soon proved effective against a wide variety of bacterial infections and was also used prophylactically in orthopedic and thoracic surgeries.

      (2) Other antibiotics, such as streptomycin, were discovered in the 1930's. Antibiotics proved useful against typhus, typhoid fever, spotted fever, atypical pneumonia, brucellosis, and gram-negative bacterial diseases.

   d. Increases in aviation science resulted in increased medicine research. As aircraft were developed that could fly higher than twenty thousand feet, it became necessary to develop heating flying suits. A centrifuge was used to study the effects of acceleration on the human body. Captain Harry G. Armstrong studied the problems of air embolism in pilots, a condition similar to the "bends" suffered by naval divers. Armstrong determined that formation of nitrogen bubbles in the body at high altitudes could be controlled if the pressure could be controlled using a pressurized cabin or by the pilot wearing a pressure suit when flying above 63,000 feet of altitude.

3-10. START OF WORLD WAR II

   A world-wide economic depression occurred in the late 1920's resulting in unemployment everywhere. Countries such as Germany, Italy, and Japan turned to military expansion to provide employment and to seize needed resources from neighboring countries. In the late 1930's, Hitler began to rearm Germany. In the Pacific, Japan invaded areas of China. In September 1939, German forces attacked Poland using their blitzkrieg (lightning war) tactics. German forces attacked and quickly defeated France. Great Britain was soon in danger of destruction from the air and invasion from across the Channel. When Germany attacked the Soviet Union, Russian troops retreated, trading territory for time until stands could be made at Stalingrad and other cities. Although the United States tried to stay out of the war, attacks by Japan on Pearl Harbor and other American Pacific bases in December 1941 brought it into the war.

3-11. MEDICAL PERSONNEL

   At the beginning of the war, Army medical personnel strength was below authorized levels. When the draft was activated, the government began recruitment and draft programs for medical civilians. Selection of doctors, dentists, and nurses for military service was done by the Bureau of Procurement and Assignment. Civilian medical education programs were accelerated. By 1943, two-thirds of all physically fit American physicians under age 45 were in the Armed Forces and 80 percent of all enrolled medical students were bound for the military. This created a major shortages of physicians in the United States.

3-12. EVACUATION AND TREATMENT FACILITIES

   Because combat operations were fought on a global scale, the various theaters of operation varied considerably. So did the medical support. In Europe, the medical evacuation through echelons was fairly simple due to the open land maneuver spaces, roads, and built-up settlement areas. However, the Pacific's jungles, swamps, and lack of roads forced location of medical aid to be near beaches.

   a. Combat Medics. First aid care was given at the site of injury by company aidmen, usually within the first half-hour after wounding. Each soldier carried a packet of field dressings and sulfa tablets and powder for immediate antibiotic and sanitary care.

   b. Aid Stations. First echelon medical support was conducted by medical detachments such as aid stations with attached aidmen and litter bearers. Battalion aid stations, usually located 300 to 500 yards behind the front lines, had two leaders--a medical officer and a medical administration corps officer in charge of evacuation organization.

      (1) The "backbone" of the evacuation system was the litter bearer. Litter bearers often worked 72-hour shifts, with trips over wooded and rugged country from 1000 yards to four miles. In Sicily, evacuation over mountainous terrain was accomplished by relay teams of litter bearers which ran continuously for 12 to 15 hours just to cover a few miles. Many litter bearers were injured or killed by enemy mines and fire or suffered emotional breakdowns from stress and exhaustion. When needed, units employed cooks, musicians, and company clerks as replacements.

      (2) Aid stations were often unable to obtain adequate medical supplies through normal channels. This resulted in medics being used to hand-carry drugs and other medical supplies forward to the aid stations. Evacuation from the aid stations was usually done using ground ambulances.

   c. Clearing Stations. Second echelon medical support was provided by the medical battalion commanded by a lieutenant colonel who was also the division surgeon. A medical battalion usually consisted of three collecting companies and one clearing station.

      (1) The collecting station personnel examined the field dressings, gave I.V. morphine and plasma transfusions to shock patients, and (near the end of the war) administered penicillin.

      (2) At the clearing station, patient triage sent the less serious case to evacuation hospitals and the problem patients to field hospitals. The clearing station was also the forward supply point for whole blood shipments.

   d. Mobile Hospitals. Third echelon medical support involved hospitals at greater than Corps level, such as field and evacuation hospitals.

      (1) A field hospital's surgical team was made up of two surgeons, an anesthetist, a surgical nurse, and two enlisted technicians. It was highly mobile and did immediate/urgent surgical care on massive chest and abdominal wounds, severe compound fractures, and traumatic amputations. Because of such violent pre-operation trauma, the death rates were from 12 to 25 percent. Auxiliary surgical groups composed of specialized surgical teams (thoracic, orthopedic, neurological, maxillofacial/dental, and shock treatment) were attached to field hospitals to aid patients whom the general surgeons at the field hospitals could not adequately treat.

      (2) Evacuation hospitals were located on rail and water transport lines approximately 15 to 30 miles behind the front and 3 to 15 miles behind the field hospital. Patient evacuation was done by ambulance, boat, or air to rear/CONUS facilities as soon as possible to conserve needed medical resources.

      (3) In September 1942, the portable surgical hospital (PSH) was introduced in the Pacific Theater to provide prompt surgical care to battle casualties. A team consisted of three surgeons, one internist, and 25 enlisted men. Surgery was performed in the forward battle areas near the battalion aid station.

         (a) The surgical teams were highly qualified and picked not only for their technical expertise but also for their stamina and physical condition. This was important because their equipment, about 40 pounds per person, was manually carried to the front. They worked quickly, used blood and plasma transfusions to prevent shock, and prepared casualties for evacuation.

         (b) The litters on which the patients were brought served as operating tables. Water was provided by a Lyster bag over the scrub sink. Lighting was natural (sunlight) in the daytime and by hooded flashlight and kerosene lanterns at night.

         (c) The only method of evacuation to the rear was by litter. This sometimes resulted in occupying most or all of the enlisted personnel in patient evacuation duties and created personnel shortages at the PSH.

   e. General Hospitals. The next echelon of medical support involved fixed general hospitals providing complete medical care. They were usually located in Allied rear areas in the European and Pacific Theaters of Operation and were under the control of the communications zone (COMMZ) headquarters. Patients were held for a maximum of 90 days, then returned to their unit or sent to CONUS/Zone of Interior for care in Army or VA hospitals.

      (1) Paris became the hub of the European continental evacuation system. Its main hospital train depot handled hospital trains and two airports handled the air evacuation cases.

      (2) Hospital ships were also very active during the war. They were marked with Geneva Convention protective symbols and theoretically immune from enemy fire. In 1943, landing ship tanks (LSTs) used to haul assault troops were modified to evacuate and treat wounded personnel in the Pacific and beaches in Africa. Approximately 150 folding army cots were placed in each LST to establish a ward. Casualties were evacuated to the LST using smaller vessels called DUKWs. Casualties were later evacuated from the LST to a hospital ship. Despite early doubts, the system worked quite well. LSTs were controlled by the U.S. Navy. LSTs were not considered "immune" targets under the Geneva Convention and could be fired upon by the enemy.

3-13. PREVENTIVE MEDICINE

   Twice as much time was lost to disease as was lost to nonbattle injuries and combat wounds combined. Most illnesses were preventable, but many unit commanders did not enforce the proper discipline.

   a. The United States Typhus Commission was established in 1942 with the roles of research, preventive medicine, and care of the sick. Typhus, a louse-borne rickettsial disease, was epidemic throughout North Africa and Europe during the war due to poor sanitation and the decay of refuse and the dead. The Typhus Commission distributed three million individual doses of vaccine. Delousing (dusting with DDT) of civilian and military personnel and of the areas around military camps was also performed.

   b. Quinacrine hydrochloride (Atabrine), used to fight malaria, was distributed with rations four times a week and intense indoctrination on sanitation was given, especially about food preparation, water purification, and waste disposal.

   c. At the beginning of the war, it was believed that preinduction testing could eliminate the unfit and remove the possibility of psychological problems. Although the tests could identify obviously unfit personnel who exhibited frank behavior disorders, they could not predict the reaction of individuals to combat stress. American forces suffered large numbers of combat stress reaction (also called shell shock or battle fatigue) casualties in North Africa and the South Pacific. As the war progressed, the importance of friendships and rapid return to duty after rest treatment was recognized.

   d. The winter of 1944-45 was the coldest and wettest that Europe had seen for many years. In the Third Army, there were six cases of cold injuries for every 10 battle casualties. In November and December of 1944, the equivalent of five and a half divisions were lost to cold injury. This quickly drew attention to the importance of measures to prevent cold injuries. Foot inspections were done by unit commanders and preventive medicine workers to ensure that proper foot self-care was being performed.

3-14. ADVANCES IN TREATING SHOCK

   a. Colonel Edward Churchill studied the development of shock and resuscitative process following trauma. He discovered that shock was not only related to blood fluid loss but also to electrolyte loss. This led to improvements in intravenous solution preparation.

   b. The Blood Donor Service of the American Red Cross was organized in 1941. Unlike World War I, new procedures made indirect transfusions practical. Human blood plasma could be dried to a powder, stored for an extended time, and later be reconstituted with distilled water. It was primarily used to stabilize shock cases at the front lines until evacuation could be made to rear hospitals.

3-15. END OF THE WAR

   In May 1945, Germany surrendered. This was followed in August by the surrender of Japan and the dawning of the nuclear age. The Medical Department had proven itself to be an effective force multiplier.

3-16. POST WORLD WAR II DEVELOPMENTS

   a. In 1947, the Medical Service Corps was created to care for various administrative, sanitary, and pharmacy units; the Women's Medical Specialist Corps was created for dieticians, physical therapists, and occupational therapists; and the Nurse Corps was created as a regular army establishment. At first, only females were allowed to serve in the Women's Medical Specialist Corps and the Nurse Corps. In 1955 they were opened to reserve male practitioners and, in 1966, both corps were open to regular commissioned male practitioners.

   b. Efforts supported by General Dwight Eisenhower to unite all military medical services into one large medical service failed.

3-17. KOREA

   The Korean War provided an opportunity to test new ideas and procedures.

   a. Vascular reconstruction had been postulated since World War I as the appropriate therapy for vascular injuries. Traumatic aneurysms and arteriovenous fistulas were repaired by a vascular surgical team at Walter Reed Army Institute of Research in 1950. In 1951, Lieutenant Colonel Carl Hughes took a vascular repair team to Korea and taught the newer methods of repair for vascular injury. These procedures vastly reduced the amputation rates. The progress was dependent upon the availability of trained specialists and dedicated medical resources as well as rapid evacuation times and, in general, a lower volume of casualties.

   b. Colonel Kenneth Orr led a research team studying cold injuries which resulted in a better understanding of the effects of cold (especially frostbite) on the human physiology. This led to the development of better protective clothing for cold climates and improved preventive medicine advice for cold-weather operations.

   c. A renal insufficiency center was established by Captain Paul E. Teschan of the U.S. Army Medical Corps. The center used the new artificial kidney to perform dialysis on patients with Korean hemorrhagic fever and with renal insufficiency from septic shock.

   d. Efforts led by Major James C. Beyer resulted in the development of lightweight body armor which reduced mortality and morbidity from wounds. The research eventually resulted in bullet-proof vests used by civilian police officers.

   e. During the Korean War, the Mobile Army Surgical Hospital (MASH) which evolved out of the Portable Army Surgical Hospital and the forward surgical teams of World War II was used in combat for the first time. Helicopter air ambulances greatly decreased the amount of time it took to move casualties from the battlefield to a hospital.

3-18. POST KOREA

   a. In the 1950s, Colonel John Paul Stapp used a high-speed rocket-powered sled to study the medical effects of abrupt acceleration/deceleration such as those effecting pilot ejecting from a jet aircraft. Colonel Stapp's experiments resulted in the development of new restraining gear which led to the use of seat belts in automobiles.

   b. The study of virology at the Walter Reed Institute of Research and other institutions led to the isolation of the rubella (German measles) virus in 1962.

   c. The success of helicopter evacuation in Vietnam resulted in civilian institutions to evacuate casualties to medical facilities by helicopter. In 1970, the Military Assistance to Safety and Traffic (MAST) program which provided military assistance in developing civilian evacuation systems was initiated.

   d. In Operation Desert Shield/Desert Storm, the military alliance lead by the United States forced the invading Iraqi army from Kuwait.

      (1) There was a good supply of drinking water and the modern water discipline of forced drinking was in place. Adequate personal hygiene and field sanitation services were provided, yet some units became ineffective due to dysentery during the early stages of deployment. The dysentery was caused by consumption of local foods grown under unsanitary conditions. Proper food inspection procedures were instituted and the problem was controlled.

      (2) A new burden was the threat of chemical weapons and the need for mission-oriented protective posture (MOPP) gear. MOPP gear prevents sweat evaporation and hence makes heat injury far more likely. In closed MOPP gear, the predicted time to 50 percent unit heat casualties, the point at which units are considered combat ineffective, can be less than 60 minutes. Fortunately, the American forces quickly defeated the Iraqi forces and were not forced to fight in MOPP for extended periods of time.

Section III. AEROMEDICAL EVACUATION

3-19. BIRTH OF THE AEROMEDICAL EVACUATION CONCEPT


   As warfare evolved, technology produced new weapons to inflict more death and destruction on the enemy. However, new technology also helped to save the lives of injured soldiers. One of the best examples is the development of aeromedical evacuation.

   a. In 1903, Orville and Wilbur Wright demonstrated that a heavier-than-air machine could fly and carry human passengers. The military soon recognized that the airplane could be used to scout enemy positions and, later, as a platform from which bombs could be dropped on enemy positions.

   b. A group of military officers, including Captain George Gosman (an Army physician), saw the possibility of using aircraft to save lives. They conceived and designed a method to employ aircraft to carry patients. In January 1910, they tested a plane capable of carrying a single patient. Although the aircraft crashed, they were encouraged by the test and went to Washington, D.C., to ask the War Department to finance the rebuilding of their aircraft.


In his attempts to persuade the War Department, Gosman stated:

"I clearly see that thousands of hours and ultimately thousands of patients would be saved through the use of airplanes in Air Evacuation".



   c. Although the concept was supported by Army Surgeon General George Torney and others, the project was turned down. The decision was due both to the danger in transporting patients by air and to financial problems.

3-20. WORLD WAR I

   a. In World War I, trench warfare taxed the medical support and evacuation systems of the United States and its allies. Some countries experimented with air evacuation, but the American military decided that all American airplanes were needed for combat duty.

   b. Although air evacuation was not used in combat by the United States, it did prove its usefulness in the training environment within the United States. Training military pilots resulted in many crashes. In 1918, a biplane at an Army training site in Louisiana was converted into an air ambulance capable of carrying a physician to the crash site and evacuating the injured pilot to a hospital. The success of this operation prompted a directive to convert selected aircraft for crash rescue purposes.

3-21. BETWEEN THE WORLD WARS


In May 1921, the War Department stated:

"...the use of airplanes for the transportation of sick and wounded soldiers, when other safer means of transportation is available, could not be justified."



   a. During the 1920s, air ambulances were developed that carried one to two litters but no medical attendants. During 1927 and 1928, the U.S. Marines fighting against guerrillas in Nicaragua successfully used aircraft to evacuate casualties from remote locations.

   b. Another attempt at designing an evacuation vehicle was the autogiro, a machine that contained a rotor similar to that of a helicopter and the wings of an airplane. It was hoped that this design would allow the craft to land and take off in shorter distances at a lower speed. Field testing was conducted during Marine operations in Nicaragua in 1932, but the craft was hampered by an underpowered engine.

   c. Proponents of air evacuation developed the principles needed for air evacuation. The Army Air Corps concluded that air evacuation required two types of aircraft--a heavy transport-type for long-range flights and a lighter craft for unimproved forward locations. Efforts concentrated on developing heavy transport aircraft for long evacuation flights. Due to a lack of funding, obsolete military aircraft were converted for use as air ambulances for long evacuation flights. Light aircraft that could use short, unimproved landing strips were not developed at this time.

   d. Other countries, especially Germany, continued to develop aeromedical evacuation. Strategic evacuation on a large scale proved successful during the Spanish Civil War of 1936--38.

3-22. WORLD WAR II

   a. As the war began in Europe, money for procurement became available. By late 1940, General Arnold, Chief of the Army Air Corps, directed the Air Corps Medical Division to plan for conversion of transport planes for evacuation missions. Recommendations included installation of litter brackets on cargo planes for long evacuation flights, the use of single-engine liaison airplanes for short forward evacuation, and the organization of an air ambulance battalion.

   b. Because of resource constraints, the cargo and light aircraft could not be used exclusively for evacuation. However, the conversion of these aircraft to perform both cargo and evacuation missions did occur. Cargo aircraft fitted with litter supports allowed them to "backhaul" casualties to rear bases after delivery of supplies forward.

   c. Evacuation during the war was divided into light (tactical) and heavy (strategic) evacuation. By the beginning of the war, strategic evacuation by transport plane had become an accepted and safe mode of evacuation. Evacuation by the "heavy lift" aircraft that cruised at greater heights for longer durations had several medical restrictions placed upon them. Consequently the training of flight surgeons, flight nurses, and enlisted technicians was considered necessary. Included in this training was responsibilities for classification of patients, loading and unloading procedures, and en route care. This en route care varied from feeding patients to changing dressings to administering medication, fluids, and oxygen.

      (1) Strategic evacuation generally consisted of movement from the various theaters to and within the United States. Evacuation within the combat zone was difficult, but was accomplished by the larger transports. Aeromedical evacuation was credited with saving thousands of lives during the war.

      (2) Although strategic aeromedical evacuation was officially accepted, the use of light aircraft for forward air evacuation was performed on an "informal" basis. As the use of light aircraft for artillery observation, courier service, and personnel transportation spread, the improvised use as air ambulances also increased. Casualties were moved by whatever means were available to a location where light aircraft could land. Casualties were staged, triaged, treated, and evacuated by air.

   d. The first use of helicopters in forward air evacuation occurred in 1944 when four soldiers were rescued from deep in the Burma jungles. Although the early Sikorsky R-4 helicopters were limited in their capacity (only one patient could travel inside the craft), development of better helicopters soon followed. In 1945, the Sikorsky R-6 had two covered external litter "capsules" attached to it.

   e. By the end of the war, thousands of casualties had been moved rapidly and effective by air.

3-23. POST-WORLD WAR II

   Even though a significant number of casualties had been successfully transported by aircraft during World War II, the early postwar years did not see large changes in aeromedical evacuation. There was no new doctrine for dedicated tactical air evacuation aircraft. Also complicating the situation was the creation of the U.S. Air Force. In September 1949, the Department of Defense directed that air evacuation was the responsibility of the Air Force. The Air Force focused its resources on building strategic bombing forces and paid only small attention to air rescue. The Army, even though it was limited in the size of aircraft it could maintain and utilize, still had the requirement to collect casualties from forward locations.

3-30. KOREA

   In June 1950, hostilities broke out in Korea. The invasion of South Korea by North Korean troops caught the United States off guard and the issue of battlefield evacuation took on immediate importance.    a. It soon became apparent that North Korea would not abide by the Geneva Conventions pertaining to medical vehicles. In addition, the rugged terrain and long evacuation routes made ground evacuation difficult. The solution was air evacuation.

   b. Early in the conflict, forward evacuation was provided by an Air Force fixed-wing aircraft based in Japan. However, the aircraft was hampered by the terrain and lack of adequate airstrips. By the end of July, Air Force H-5 helicopters equipped with external litter pods were deployed to Korea where they successfully served as air ambulances.

   c. The Army also used helicopters for medical evacuation. In January 1951, a newly formed helicopter detachment was activated and attached to a 60-bed Mobile Army Surgical Hospital (MASH), another new innovation of the conflict. Later, two more detachments were attached to other MASH units.

   d. Some problems resulted from the perception that the helicopter could fly and land anywhere, anytime. A lack of armor and inability to fly at increased heights left the craft highly vulnerable to ground fire. Helicopter evacuations were restricted to daylight hours, although a few nighttime missions were conducted using flashlights. Some casualties were evacuated directly to awaiting hospital ships. Since medical care could not be provided during air evacuation, as much medical treatment as could be given without delaying evacuation was administered to the patient prior to movement.

   e. As the war continued in Korea, problems over air evacuation continued between the Army and Air Force. In October 1951, the Air Force turned over responsibility for forward (tactical) air evacuation to the Army. The Air Force retained responsibility for strategic evacuation.

   f. A new detachment, the Helicopter Ambulance Unit, was soon developed. It consisted of five helicopters and was attached directly to forward medical or line units for support just as the early attachment to the MASH units had been done. The major difference was that this new evacuation unit was under administrative and operational control of the Army Medical Service for the first time ever. In February 1953, a Helicopter Ambulance Company was formed to provide command and control for these units.

   g. During the Korean War, more than seventeen thousand casualties were evacuated by helicopter.

3-25. POST-KOREA

   Post-Korea after action reports praised the air ambulance helicopter as a success. Medical planners stressed the idea of a more powerful helicopter that could carry patients inside the fuselage for protection and allow en route care. In 1957, the UH-1 Iroquois (more popularly known as "Huey") was developed. It could evacuate up to six litter patients at a time and was soon recognized as one of the most useful aerial platforms ever produced.

3-26. VIETNAM

   a. As the Vietnam conflict escalated, the number of American troops and aeromedical evacuation assets increased. Using the Medical Detachment (Helicopter Ambulance) as the base unit, the first elements were sent to Vietnam in 1962. These detachments were authorized five UH-1 A or B model helicopters. Transition to the more powerful UH-1D model as well as development of a new six-ship detachment followed. A new 25-ship Medical Company (Air Ambulance) soon came on line as the buildup of combat troops increased. At the peak of combat operations in 1968, there were 116 air ambulances operating throughout the country.

   b. The peculiarities of combat in Vietnam required adaptation of doctrine to fit the combat situation.

      (1) Air superiority early in the conflict allowed helicopter transport without significant interference from enemy air activity. This combined with more powerful engines gave the helicopter the ability to fly higher where it was out of range of most small arms fire.

      (2) Operating in remote, rugged conditions called for the development of additional methods of extraction. In addition to the already available Stokes litter, the jungle penetrator litter (a cable with an attached seat designed to be lowered through the thick jungle) was developed. The seat was lowered and raised using a winch in the helicopter. Winch extraction missions were decidedly dangerous and resulted in losses of both personnel and aircraft.

      (3) The nature of combat operations without an established "front" also changed the employment of medical evacuation units as well. Most evacuation missions could overfly organic medical units such as the battalion aid and division clearing stations. Flying directly to hospitals required the establishment of effective command and control as well as a responsive medical regulating system. Beginning in 1966, medical regulating of all in-country patients was performed by the 44th Medical Brigade.

      (4) In-country evacuation was provided by U.S. Air Force assets such as the C-141. Patients requiring further treatment or hospitalization were entered into the Military Airlift Command (MAC) aeromedical evacuation system. This system moved patients throughout the Pacific and on to CONUS.

   c. The use of short range radios early in the conflict caused many problems. With the installation of long-range radios, response time was drastically reduced allowing more direct communication between requesting units, en route aircraft, and the receiving hospital. Effective radio communication allowed the air crew to notify the receiving hospital with pertinent patient information or special needs while en route.

   d. It took an average of 9 minutes to launch an aircraft after receipt of the request. Many times an aircraft was diverted from one mission to another because of higher priority and the patient's condition. Most aircraft spent no more than a minute on the ground as the casualties were loaded and on-board emergency treatment was begun. Medical regulating of patients while airborne was based upon the extent of injuries and the assessment done by the flight medic. This information combined with the surgical backlog and capabilities of the closest facilities determined which facility would be the receiving hospital.

   e. As the number of hospitals increased, the average time of 1 to 2 hours from wounding to treatment decreased to about 35 to 40 minutes. This is significant when compared to Korea where the average evacuation time was 4 to 6 hours. During 1969 (the peak year for air evacuation), over 200,000 casualties were transported by air.

   f. Quick response and a willingness to attempt evacuation under almost any condition became the hallmarks of forward air evacuation in Vietnam. Early medical evacuation support soon provided a doctrine and legacy that has come to epitomize tactical evacuation. "Dust Off," a radio call sign chosen at random, soon became the popular term for air evacuation --not only in Vietnam but throughout the world.

3-27. POST-VIETNAM

   Doctrine formed during the Vietnam conflict and tested in combat remained essentially unchanged following the end of hostilities in 1973. In 1976, the UH-60 Blackhawk became the newest member of the Army helicopter family. It was designed as an all-purpose utility helicopter with medical evacuation in mind.

3-28. GRENADA    In Grenada (Operation Urgent Fury) in 1983, difficulties arose from the lack of coordination and training of Army helicopter crews in shipboard landing. This resulted in several cases where casualties had to be returned to Army divisional medical elements rather than treated aboard ship.

3-29. PANAMA

    In Panama (Operation Just Cause) in 1989, casualties were airlifted out of Panama directly to San Antonio, Texas, by U.S. Air Force aircraft. This situation resulted in the over-evacuation of injured soldiers who could have been treated in-country.

3-30. PERSIAN GULF

   a. The war in the Persian Gulf (Operation Desert Shield/Desert Storm) saw the most rapid and largest deployment of medical assets since World War II, all within a 6-month period. This rapid and successful mobilization is highlighted by the longest self-deployment of a helicopter unit in U.S. Army history from Germany to Saudi Arabia.

   b. In Desert Storm, the need for forward evacuation was combined with the challenges associated with the terrain. Lessons learned from the Grenada conflict were incorporated into new doctrine. Fortunately, the need for medical evacuation was not as great as had been anticipated.

Section IV. OPERATIONS OTHER THAN WAR

3-31. DEFINITIONS


    Operations other than war might be new to formal operations doctrine, but it is not new for the Army or for the Army Medical Department (AMEDD). The AMEDD has a long history of helping civilians, first within the Continental United States and then later outside our shores. FM 100-5, Operations, gives 13 activities that are U.S. Army other than war missions. Three that pertain to the AMEDD are nation assistance, humanitarian assistance and disaster relief, and support to insurgencies and counterinsurgencies.

    a. AMEDD actions fall into two general arenas--civil affairs and civic action. These two terms are often used interchangeably, but they are different. The following definitions will be used for the purposes of this lesson.

       (1) Civil affairs. Civil affairs refers to a situation in which the U.S. Army is in control of civil operations either under martial law or as an army of occupation.

        (2) Civil action. Civil action refers to a situation in which the U.S. Army assists an existing government in conducting civil operations.

    b. The remaining paragraphs in this section gives examples of civil affairs and civil actions during the twentieth century.

3-32. PUERTO RICO

    After the end of the Spanish-American War, President William McKinley placed Puerto Rico under military rule. During the time that Spain controlled Puerto Rico, it did not immunize the population against smallpox. Lieutenant Colonel John van Renssalear Hoff, the Force Surgeon of the American army of occupation, was faced with a smallpox epidemic. At that time, smallpox vaccine was produced directly from calves. Hoff established a vaccine farm and used military law and authority to set up immunization sites throughout the island. He also imposed quarantine and isolation on patients and ultimately eradicated smallpox from Puerto Rico. This was an example of civil affairs--medical management of a civilian population under military control.

3-33. POLAND

    At the end of World War I, typhus was raging in Poland. President Wilson's humanitarian beliefs led the United States into civic action activities following the Versailles peace conferences. The President asked Herbert Hoover, Director General of Relief and Rehabilitation for the Supreme Economic Council of the Allies, for advice in managing the epidemic. Hoover concluded that he lacked the necessary resources, but that the American army under General John J. Pershing had the needed resources. President Wilson then ordered Pershing to solve the problem using a civil action approach.

    a. Typhus (epidemic louse-borne typhus fever) is a rickettsial disease which has a mortality rate of 10 to 40 percent in the absence of specific therapy with the fatality rate increasing with age. In 1909, Charles Nicolle discovered that the disease was transmitted by body lice. The significance of the discovery was that the disease could be controlled by killing the vector (lice).

    b. Colonel Harry L. Gilchrist was chosen as the commander of the American Polish Typhus Relief Expedition. During World War I, he had developed a unit for decontaminating soldiers exposed to mustard gas.

    c. Gilchrist acted quickly since the American troops would soon leave for home. He organized his new unit into field teams and set up mobile bath units to reach the Poles living in small towns and villages. He realized that many people believed that lice were not harmful so he established an education program and got local officials involved. The local officials were useful in persuading fellow citizens to bathe and be deloused. His problem, however, was further complicated by the 1920 Russo-Polish War which resulted in additional refugees and prisoners of war with typhus. Controlling the spread of typhus was made more difficult by a lack of fuel during winter. People huddling together for warmth made the spread of lice easier.

    d. Gilchrist never fully accomplished his mission since the American forces left before the task was completed. The Polish government continued the battle against typhus utilizing Gilchrist's techniques. The disease was finally brought under control in 1923.

    e. Gilchrist saw both the humanitarian and the political effects of his efforts. He felt that the association of American soldiers with the medical efforts made to help the inhabitants was of inestimable value in leading the Poles to adopt American ways.

3-34. NORTH AFRICA

    After the United States entered World War II, Colonel James Stevens of the Office of the Surgeon General requested the establishment of a special organization to address the problem of typhus in the theaters of operation. Simmons knew the problems that typhus epidemics caused troops in World War I and knew that American troops would face similar problems in future combat actions. President Roosevelt was persuaded that the historically proven power of typhus to delay, disrupt, and disorganize military campaigns and its current prevalence in potential areas of operations required the formation of a special organization. As a result, the United States of America Typhus Commission was established.

    a. In November 1942, U.S. Army troops faced their first major action in North Africa. In February 1943, General Leon Fox, Director of the USA Typhus Commission, began aggressive studies of vaccines and lousicides in Cairo, Egypt. Efforts were made to control typhus in Egyptian port workers since a typhus epidemic among these workers could close the port and cripple the military campaign. These efforts were aided by a new powder (DDT) which proved to be very effective in killing lice.

    b. Due to the modesty of Arab women, the normal procedure of disrobing and dusting the inside of the clothing would not work. This problem was overcome by blowing the powder up the sleeves, down the front and back, and on the head while the clothing was still on the person. This method produced outstanding success and was quickly adopted as standard practice. With the ease of this new procedure, medical teams began to dust workers and the general population.

3-35. NAPLES

    a. U.S. Army troops entered a Naples that had been destroyed by bombs, shells, and the retreating German army. Citizens were crowded in caves or bomb shelters without heat and light and having little water, food, clothing, or soap. U.S. Army medical personnel were suddenly confronted with an outbreak of typhus in the civilian population. Naples became an excellent example of civil affairs in its earliest stage in conquered enemy territory.

    b. Typhus control teams followed sound practices of contact dusting, targeting all individuals known to have been associated with typhus victims, and setting up mass delousing stations throughout the city. Teams dusted as many as 50,000 civilians per day and contained the epidemic by dusting all individuals entering or leaving the city.

3-36. GERMANY

    Near the end of World War II, typhus was present throughout Germany. The greatest challenges were displaced persons, released prisoners of war, conscript workers, and the holocaust victims liberated from Nazi concentration camps. In response to the threat, medical personnel re-immunized American troops and conducted dusting with DDT among the afflicted civilian populations. Efforts were aided by the introduction of a new power duster. Typhus was successfully contained and the experience gained in these civil affairs activities helped to prepare for the role as military governor of Germany.

3-37. KOREA

    a. Before the start of the Korean conflict, South Korea contained around 2.8 million refugees. The United States agreed to provide assistance to South Korea in dealing with this problem. This was the first time active duty military personnel in peacetime were assigned to civilian governments in advisory positions. Once again, U.S. military medical forces provided medical services, inoculated civilians against smallpox, and dusted civilians with DDT to eradicate typhus.

    b. When the North Korean army invaded South Korea, American medical personnel became part of the United Nations police action. Medical personnel faced waves of refugees and displaced persons numbering over four million. Now the operations fell under civil affairs. The programs remain the same, but a new organization was formed when Eighth Army Civil Assistance Division combined with a multinational team send by the United Nations. The new organization become the United Nations Civilian Assistance Command, Korea.

    c. The new command placed greater emphasis on education and training. Teams were sent out to the provinces to set up and train local (Korean) sanitation teams. Other teams trained Korean health professionals and helped establish a system of mobile clinics to reach outlying areas.

3-38. VIETNAM

    a. The United States began by providing assistance to the South Vietnamese government to help it put down rebel forces supported by North Vietnam. When North Vietnam declared war on South Vietnam, President Kennedy issued instructions to strengthen South Vietnam using Special Forces teams as military trainers and advisors.

    b. The Military Assistance Advisory Group becomes Military Assistance Command with instructions to win the "hearts and minds" of the people, thus strengthening the resolve of South Vietnamese to resist Communism. Medical personnel were crucial to this program by providing projects with immediate, short-term, and long-term benefits. This was the first Medical Civic Action Program (MEDCAP).

    c. Medical personnel dedicated to MEDCAP began to arrive in Vietnam in January 1963. They formed teams that were dispersed to South Vietnamese army units, displaced persons encampments, and strategic hamlets. They performed direct patient care done in tail-gate medicine fashion over periodic visits. The program resulted in over 914,000 treatments that year and in over 3 million treatments the following year.

    d. In 1965, President Johnson authorized air strikes against North Vietnamese military targets and then committed ground troops. The MEDCAP program became MEDCAP II. MEDCAP II had the same objectives, but it was run directly out of the maneuver units.

    e. Efforts were joined by the United States Agency for International Development (USAID) in the Provincial Health Assistance Program (PHAP). The United States military portion was known as MILPHAP. By September 1965, the military teams (Army, Air Force, and Navy) began arriving. The primary goal was to improve the medical skills of the Vietnamese while carefully coordinating all activities with local hospital chiefs in support of their programs. This program closely resembled what had been done in Korea.

    f. In 1967, the U.S. Army established the Civilian War Casualty Program (CWCP). Three separate field hospitals provided hospital care for civilians. In previous wars, the AMEDD has taken care of civilian casualties; but this was the first time the policy was formalized and directed by Congress.

    g. At the same time, MEDCAP II medical personnel were seeing over 188,000 Vietnamese per month and establishing dental and veterinary programs. Dental Civic Action Programs (DENTCAP) resulted in 15,000 dental treatments per month and Veterinary Civic Action Programs (VETCAP) treated over 2,000 animals each month.

    h. Following the North Vietnamese Tet Offensive in 1968, the system of separate hospitals for the South Vietnamese civilians began to collapse. U.S. medical personnel started to treat civilians at all U.S. health care facilities. The South Vietnamese civilian and military hospital system followed suit and integrated their patient populations, which greatly increased the quality of care available to civilians in South Vietnam.

    i. In 1969, President Nixon announced troop withdrawals and the scaling back of assistance programs. Census levels show that U.S. field hospitals were caring for about 600 South Vietnamese each day and that MEDCAP II was treating over 1.3 million civilians per year.

    j. In May 1972, U.S. hospitals withdrew ending the Civilian War Casualty Program. In June, the MEDCAP II and MILPHAP programs were terminated. These programs undoubtedly assisted many individuals whose medical conditions might have worsened without intervention and resulted in the training of many South Vietnamese health care workers.

3-39. KURDS

    Shortly after Operation Desert Storm ended in February 1991, the United States found itself engaged in civil affairs activities under Operation Provide Comfort. The Kurds living in northern Iraq rebelled against Saddam Hussein's authority, but the Iraqi army suppressed the uprising. Approximately 500,000 Kurds fled toward Turkey. The majority were stranded in several remote mountain passes between the two countries where they experienced hostile environmental conditions without adequate food, water, or shelter.

    a. A United Nations Security Council Resolution authorized U.N. military forces to conduct operations on humanitarian grounds in the territory of another state which it was not formally occupying and without an invitation from that government. U.S. forces made up part of a joint task force augmented by civil affairs and other support teams which established and executed a resettlement plan. The military was particularly well suited to this operation which required well defined command and control, massive logistics requirements to be delivered to remote areas, and adequate security to ensure the proper distribution of the supplies and the safety of the population from Iraqi and Turkish military forces. The AMEDD played a relatively minor role in the hands-on civilian/refugee medical care; this care was primarily provided by military units of other nations and by numerous private volunteer organizations (PVOs).

    b. U.S. Army preventive medicine personnel, however, played a key advisory role in fighting diarrhea, dehydration, and malnutrition which were the main causes of death among the refugees. The primary difficulty was the lack of a safe water supply. The few small streams available were used for drinking, washing, and sewage simultaneously. Alternate water supply systems were established and sanitation projects were implemented. These programs along with aggressive rehydration and other preventive and primary care programs provided by the PVOs and other military units resulted in the successful drop in mortality and morbidity rates among the refugees. By the end of June 1991, the Kurds were successfully resettled.

Section V. SUMMARY

3-40. MILITARY MEDICAL STANDARDS


    Military medicine differs from civilian medicine in that it must uphold two separate standards. It must meet the standards of civilian health professions and, at the same time, meet the standards of military readiness. Military medicine must function as a large health-care organization during peacetime (including licensing and hospital accreditation) and, at the same time, plan and train for war.

3-41. THREE LEVELS OF WAR

    The medical wartime mission can be defined in the same way that other military activities are defined--tactical, operational, and strategic.

    a. The tactical level is the hands-on application of medicine including direct patient care and evacuation of patients from the battlefield. The command and control of medical elements by medical personnel is included in this level.

    b. The operational level includes the functions in which medical department personnel offer specialized advice to the line command who is responsible for implementing the advice. Examples include planning preventive medicine activities, planning medical logistics, and planning the placement of hospitals based on battle plans and casualty estimates.

    c. The strategic level is concerned with predictions about disease threats, medical research, and projections of medical needs for possible mobilization.

3-42. APPENDIXES   

Three appendixes are found following this lesson. Appendix A contains an article by Jay Luvaas (reprinted with permission from Parameters) which discusses the importance of the study of military history. Appendix B discusses how to plan and conduct a staff ride, an excellent method for instructing other officers in military history. Appendix C contains a reading list developed for the AMEDD officer.


1. William Gorgas was supported by President Theodore Roosevelt when he reduced disease by controlling mosquito population in:

   a. Florida.
   b. Mexico.
   c. Panama.
   d. Spain

2. In 1916, the medical department was formally organized by corps and a veterinary corps was added. The Veterinary Corps was concerned with:

   a. Inspecting food supplies.
   b. Providing an insect-free environment.
   c. The health of military horses.
   d. Responses a and c.
   e. Responses a, b, and c.

3. Which of the following was NOT a major NEW weapon introduced during World War I?

   a. Aircraft.
   b. Gas warfare.
   c. Machine guns.
   d. Submarines.

4. During World War I, a gas that was not very noticeable at first but which soon resulted in inflamed eyes, vomiting, and blisters was:

   a. Chlorine gas.
   b. Mustard gas.
   c. Nerve gas.
   d. White phosphorus.

5. In the 1930's, Captain Harry Armstrong showed that pilots who flew at high altitudes developed problems very similar to the decompression sickness suffered by naval divers. This resulted in the use of by airplane pilots.

   a. Compression vaccine.
   b. Liquid nitrogen.
   c. Liquid oxygen.
   d. Pressurized suits.

6. Research on the effects of cold on human physiology by Colonel Kenneth Orr is associated with:

   a. First World War.
   b. Korean War.
   c. Second World War.
   d. Vietnam War.

7. Which one of the following is least concerned with civilian standards and expectations?

   a. Medical care given to a soldier during combat.
   b. Medical care given an active duty member during peacetime.
   c. Medical care given to the dependent of an active duty military member.
   d. Medical care given to a retiree.

8. What two officers made possible the purification of drinking water during the latter part of the 1910s?

9. According to William Robertson, Karl von Clausewitz defines critical analysis as having three stages. What are they?

10. According to Robertson, which of the following is more valuable for studying military history?

   a. Good maps.
   b. First-hand knowledge of the terrain.

11. A hypothetical military scenario played out on actual terrain, usually employing current doctrinal concepts is a description of a:

   a. Historical battlefield tour.
   b. Staff ride.
   c. Tactical exercise without troops.

12. A visit to the actual site of a military campaign with very little systematic preliminary study is a description of a:

   a. Historical battlefield tour.
   b. Staff ride.
   c. Tactical exercise without troops.

13. The optimum preliminary study phase for a staff ride should contain:

   a. Group discussion guided by knowledgeable instructors.
   b. Individual research.
   c. Lectures by knowledgeable instructors.
   d. All of the above.

14. Which of the following statements is true?

   a. Military medical personnel must plan and train for war.
   b. Military medical personnel are exempt from the need to plan and train for war.

15. Which of the following is/are good suggestion(s) when planning a staff ride?

   a. Plan for medical support.
   b. The logistical coordinator should also be the primary instructor on the staff ride.
   c. Plan the most scenic route, making stops at random to allow students to reflect.
   d. All of the above are proper.

16. Which of the following describes the term civil affairs?

   a. AMEDD actions taken while the U.S. Army is assisting the existing government in conducting civil operations.
   b. AMEDD actions taken while the U.S. Army is in control of civil operations as an army of occupation.
   c. AMEDD actions taken while the U.S. Army is in control of civil operations while the country is under martial law.
   d. Responses "b" and "c" above
   e. Responses "a," "b," and "c" above.

SOLUTIONS TO EXERCISE 3

   1. c (para 3-1b(4))

   2. d (para 3-6c)

   3. c (para 3-3a)

   4. b (para 3-3b)

   5. d (para 3-9d)

   6. b (para 3-17e)

   7. a (para 3-40)

   8. Major Carl Rogers Darnell
   Major William Lyster (para 3-1b(7))


   9. Determine the facts.
   Establish cause and effects.
   Analyze the results. (Appendix B, p. B-1)

   10. b (Appendix B, p. B-2)

   11. c (Appendix B, p. B-2)

   12. a (Appendix B, p. B-2)

   13. d (Appendix B, p. B-6)

   14. a (para 3-40)

   15. a (Appendix B, pp. B-8, B-13)

   16. d (para 3-31a(1))