Mark Harrison. Medicine and Victory: British Military Medicine in the Second World War. Oxford: Oxford University Press, 2008. xiii + 320 pp. $50.00 (paper), ISBN 978-0-19-954121-8.
Reviewed by Antoine Capet (Université de Rouen)
Published on H-Albion (August, 2009)
Commissioned by Mark Hampton
Caring for Tommy’s Mental and Physical Welfare
“Assuming no previous knowledge of either medical or military history, Medicine and Victory provides an accessible introduction to a vitally important, yet often neglected aspect of the Second World War,” the “blurb” on the back cover tells us. This is a slightly optimistic inducement to buy and read the book, since there are a lot of medical terms (if only to name all the numerous forms of illness and injury that faced the combatants). In addition, even though the book provides a kind of military history of the Second World War in itself (at least for the theaters in which the British Army was massively engaged), one glaring absence is that of maps to enable the reader to follow the text and locate the mountains, forests, deserts, rivers, towns, ports, airports, hospitals, etc., mentioned in the analysis of the operations, especially for chapter 5, on “Burma and North-East India,” whose topography and place-names will be unfamiliar to most readers.
That the subject is an “often neglected aspect of the Second World War” is not, however, in doubt: most of the books and articles listed under secondary sources of the classified bibliography are on general military and/or medical topics rather than British military medicine in the Second World War properly speaking--and we can trust Mark Harrison to have provided an exhaustive coverage of what is currently available. The latest of the heavy tomes in the massive Official Histories, edited by Sir Arthur S. MacNalty, dates back from 1966, and a fresh look at the state of the question including the primary sources that have emerged since then is naturally most welcome.
The book is arranged chronologically. The advantage is that the reader is thus made to follow the progress in the treatment of disease and wounds and in the organization of the medical operations, which forms the central thread of the monograph. The disadvantage is that the narrative becomes extremely repetitive after a time, as we follow the advance of Bernard Montgomery’s troops from El Alamein (1942): the incidence of venereal disease (VD) in Egypt, the incidence of VD in Tunisia, the incidence of VD in Italy, the incidence of VD in the Netherlands or typhus treatment in Naples, typhus treatment in conquered Germany, etc. It is easy to pinpoint this weakness, but it is far more difficult to say how the author could have avoided it. The elements of the problem facing military medical authorities are clearly recalled: the First World War “was the first major conflict in which the number of deaths from wounds exceeded those from disease” (p. 276). How then could one best plan for a further reduction on both accounts when the next world war broke out?
The reduction of disease rested primarily on personal hygiene and sanitation, but also very much on the attitudes of the military commanding officers, both at the head of armies and on the field, as unit commanders. For the former, Harrison draws two revealing contrasts, in two totally different theaters of operations as far as terrain, climate, and fighting methods were concerned. The first is between Montgomery and Erwin Rommel (chapter 3, “The Western Desert, 1940-1943”). “Rommel [who himself suffered from repeated attacks of hepatitis] was fully aware of the incidence of sickness in his army, and his failure to address the problem constitutes one of the great mysteries of the campaign,” Harrison tells us, adding that he “had little understanding of the causes of dysentery and other bowel infections, ascribing these diseases solely to the poor quality of rations consumed by the Afrika Korps” (p. 90). Apparently, he was not aware of the problems of fly-borne disease or contaminated water. In contrast, Montgomery’s legendary attention to detail led him to give a free hand to his medical officers who insisted on the importance of sanitary precautions. One more factor came into play according to Harrison: Britain’s colonial past, with the British Army having a long tradition of fighting in hot climates. “As a result of bitter experience, the Army had evolved strict rules and regulations governing such matters as cleanliness of barracks, the preparation of wood [sic: food?], and the purification of water supplies,” he observes (p. 91). But it seems curious that the arguably even more methodical Prussian (later German) Army had not developed such obvious routines before the loss of the colonies in 1919. When Harrison writes: “Whereas Rommel concentrated overwhelmingly on tactics--on personal leadership in battle and on the element of surprise--Montgomery was preoccupied with organizational matters and the preservation of material and human resources,” one remains highly skeptical (p. 91). It seems extremely doubtful that Rommel would have risen to such a prominent position unless he, too, had been “preoccupied with organizational matters and the preservation of material and human resources.”
Admittedly, there is another example, even though somewhat lower down the scale of command: that of Brigadier Orde Wingate (the leader of the famous “Chindit” force), whose attitude to these questions Harrison contrasts with those of General (later Field Marshal Viscount) Slim in chapter 5. For Harrison, “Wingate was, to all intents and purposes, a Victorian: a muscular Christian [his parents were Plymouth Brethren] who equated disease with dishonor” (p. 212). Wingate, who had “contracted a near-fatal bout of typhoid by drinking water from a flower vase” (which delayed the second Chindit operation by several weeks) was accused of being “contemptuous of hygiene and sanitation”--so much so that “the high incidence of disease among Wingate’s force led some medical officers to doubt his suitability for command” (p. 202).
In the same theater, Slim was trying to reconquer Burma, lost in 1942 to the Japanese, from his Indian base--with a radically different approach. Morale was low--so low that men from his 14th Army deliberately tried to contract VD before leaving for the front in order to be evacuated back to Indian safety after a few days of incubation. This was an easy undertaking: “during the Second World War India recorded the highest VD rate, rising to nearly eighty per thousand troops by 1945--higher even than in Italy” (p. 198). A surgeon provided a chilling description of the practice: “the venereologist would understand ‘Full House’ not as a poker term but as referring to a patient who had acquired both syphilis and gonorrhea, lymphogranuloma and soft-chancre all at one session” (p. 198). Slim decided on strong action. For him, “medicine and morale were mutually dependent” because “poor morale encouraged men to ‘malinger’ and catch disease, while good medical arrangements could do much to maintain morale and unit cohesion” (p. 199).
Now, we come to a central element in the whole undertaking. Compassion for the ill and injured played a secondary role in comparison with less lofty, but more rational, considerations. As Harrison puts it, “with manpower at a premium, commanders came to see that military success depended on keeping their soldiers fit for service” (p. 278). Thus, according to him, Slim “was the very model of the new professional soldier” notably because he had “a keen awareness of the importance of manpower economy” (p. 212). And just as he lists the importance given to medical questions as one of the contributing factors to Montgomery’s victories in the Western Desert in 1942-43, he points to Slim’s superiority over the Japanese high command in the constant fight against malaria, “the largest cause of sickness in the 14th Army” (p. 229).
In fighting the spread of disease, medical officers were greatly aided by the progress of scientific research and new discoveries, like the radical effect of DDT against lice and the typhus infection which they propagated, and, of course, the introduction of penicillin. However, one should not exaggerate the impact of these medical breakthroughs: “penicillin was by no means a panacea ... nearly 50 per cent of infecting bacteria were insensitive to penicillin” (p. 229). Still, the ubiquitous syphilis greatly benefited from its general use after 1943, with treatment times “reduced from an average of forty or fifty days to less than ten” (p. 275).
Far more difficult to reduce was the level of casualties due to wounds, especially in the abdomen, in spite of the new treatments. The reason was that speed of action was of the essence, and here it was a case of coordinating very complex elements of intervention sometimes in extreme circumstances, as in the event of an emergency evacuation under enemy aerial fire (Dunkirk, 1940; Greece and Crete, 1941), before a beachhead was secure (Sicily and Italy, 1943; Normandy, 1944), or in a thick jungle (Burma, 1942-45). A good example is that of blood transfusion, which the British Army pioneered with the creation of the Army Blood Transfusion Service in 1938. Unrefrigerated blood became useless after an hour--and refrigeration was “a facility that airborne forces lacked” (p. 242). How to make sure that there was a constant supply of blood was a daunting problem, which was by and large successfully overcome in the Normandy landings (“blood reached the Normandy beaches by naval despatch boat at the rate of 400 bottles per day”)--but never really solved in Burma (p. 239). This blood--and other requisites, like medicines and medical equipment, sometimes bulky--had to be there exactly when and where needed, like the medical staff that was to use it.
Harrison reminds us that the uncertainties of war compounded the problem, for example, for the “Market Garden” operation around Arnhem, when the best logistical preparations were ruined by actual events. The wonder is that any progress was made in this domain. One aspect was the reorganization of the field ambulance and field hospital services following the experience acquired during the First World War. Flexibility and mobility became the order of the day for medical units, with the idea that treatment as near to the front as possible was the key to better rates of success. Somewhat paradoxically, this resulted initially in higher psychiatric casualties among medical staff--not many of the stretcher-bearers sent to Normandy (“more than a third of the medical staff attached to the airborne division consisted of conscientious objectors”) had seen “a wounded man with his intestines protruding from a gaping wound in his stomach” before (pp. 237, 239).
If penicillin could be quickly administered to the severely wounded, infection was so much delayed that they could wait until they received definitive treatment in distant hospitals, and the introduction of evacuation by air produced spectacular results. It took some time before the procedure was fully adopted, but obstacles were at last lifted at the time of advance into the Low Countries, before the final offensive across the Rhine. The objective of evacuating five hundred to seven hundred casualties per day by air was fully met--solving the problem of setting up cumbersome hospitals as the troops made their hopelessly fast progress from the point of view of medical logistics. Medicine and Victory clearly shows that there is a lot in common in hurried retreat and almost unopposed conquest from the point of view of the organization of heavy medical services--and air evacuation solves the problem in both cases.
Progress seems to have been far slower in the field of psychiatric disorders. One problem was that though it was recognized that low motivation was the most potent factor, the medical profession could do nothing to improve the military situation, which largely dictated the combatant’s evaluation of his own role in the conflict. Hence the importance of commanders like Montgomery or Slim, who greatly enhanced the troops’ self-respect by assiduously cultivating esprit de corps and above all the sense of duty toward their friends and comrades in the common cause--eventual victory over Nazidom and its allies, demonstrably attainable after El Alamein and the first defeats inflicted on the Japanese in Burma, which showed that the enemy was not invincible in spite of his easy initial progress. Harrison convincingly suggests that the so-called People’s War played a considerable role in sustaining and boosting morale--and correspondingly reducing mental failure. Elements like the Beveridge Report (1942), with its promise of social protection for all after the war, or the creation of the Army Bureau of Current Affairs (ABCA), which propagated values of citizenship and community, were better than any form of remedial psychiatric treatment. He has excellent passages on how basically (and indirectly) the same type of persuasion techniques based on his sense of loyalty was at work to maintain the soldier’s fighting spirit and to persuade him to avoid contracting VD: in both cases, it was suggested that he owed it, not to himself, but to his comrades on the frontline and to the women of his heart on the home front (his wife, fiancée, or sweetheart) to keep fit in body and mind. He had to ensure he did not fail their trust in him by disseminating contagious diseases of letting them down under enemy fire. The introduction of group therapy was linked to the idea of “group identity” and “equality of sacrifice” (p. 181). Still, Harrison tells us, “40 per cent of medical discharges during the war were for psychiatric reasons” (p. 279).
This is as much a reflection on the concurrent progress in the treatment of wounds and diseases between 1939 and 1945 as a reminder that the psychosomatic factor in human resistance to the stress of combat remained (remains?) largely intractable, in spite of the best efforts of the high command, if not always out of compassion, at least on purely utilitarian calculations. Curiously, Harrison repeatedly wonders, the supposedly peerless efficiency of the Nazi war machine did not remotely match that of the British Army in this respect. The readers of this most informative monograph will draw their own conclusions from this little-known fact.
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Antoine Capet. Review of Harrison, Mark, Medicine and Victory: British Military Medicine in the Second World War.
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