Between Flesh and Steel (39 page)

Japanese surgical practice followed the then current thinking on conservative treatment of wounds that had become popular through the British experience in the Boer War.
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Most of the wounded in the Russo-Japanese War also suffered injuries from the new high-velocity, lightweight jacketed bullets that had made their appearance a decade earlier. Shells and hand grenades injured only one-seventh of the wounded.
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Thus, the Japanese instructed their soldiers and medical personnel not to touch a wound unless it was absolutely necessary to do so. Soldiers received instructions in advanced first aid and how to apply sterile first aid pouches and bandages. Each company was assigned a number of “instructed men”—enlisted soldiers who were especially skilled in advanced first aid, bandaging, and stopping hemorrhage—to serve as combat medics. Their goal was to stop bleeding and keep the wound as sterile as possible. Within the medical chain itself, surgery was permitted on the battlefield only to the degree that it was absolutely necessary to stop hemorrhage.
Otherwise, emphasis was on stabilizing and rapidly evacuating patients to rear hospital facilities, where surgery could be performed under antiseptic conditions. During the sixteen days of fighting around Mukden, the division hospital performed only five amputations.
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While each division hospital was equipped with an X-ray machine, personnel only rarely used it since they did not anticipate that the surgeons at the division level would need the information. Japanese medical doctrine reasoned that a soldier was at greater risk from infection than from the injury itself.

The Japanese medical corps was structured and utilized as an integral part of the military command apparatus. Its chief held the rank of lieutenant general and was a member of the general staff. Each field army also had a surgeon general who held the rank of major general. Unlike most armies of the West, Japanese medical officers held full command rank and status in their armies and were regarded as essential personnel to the fighting effort.
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In the field, the medical corps had its own parallel chain of command and had effective control of medical matters at all levels. Combat priorities might lead a line officer to override his medical officer's recommendations, but he did so at great risk since the medical officer reported the incident up through his own independent chain of command, ensuring that the line officer's decision would soon be brought to the attention of his commander.

The Japanese Army became the first army in history to require that the combat operations field order routinely include a plan for medical support.
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The fact that all officers, regardless of assignment, were required to take staff courses in hygiene and medical care and that field hygiene was a subject for examination in the naval and army academies also testifies to the importance that the army placed upon medical support. Further, the Japanese medical officers earned the line officers' respect by bearing the burden of battle. At Mukden, for example, fourteen medical officers were killed or wounded.
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The emphasis placed on military hygiene and preventive medicine led the Japanese to staff their medical system with sufficient numbers of medical personnel at all levels. The Japanese never experienced a shortage of doctors or medical supplies at any level of command during the war. The ratio of doctors to patients was approximately 1 to 100, and the ratio of nurses to patients was 1 to 5. The Japanese had twelve major hospitals in Japan itself, each with five attached branches in the military districts. By war's end, the rear area hospital system had 58,263 available beds.
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As the war progressed, Japan drew upon its supply of 45,000 physicians and surgeons for wartime duty, and almost 10 percent of the army's manpower resources
were assigned to the military medical system. The success of the Japanese system led most Western nations to adopt this 1 to 10 ratio as the basis for assigning medical personnel in their own armies, if only for planning purposes.
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The Japanese Army was the first to establish a successful medical supply service, originally designed around the German system. The Japanese soon introduced major innovations to their system, and chief among them was establishing the medical supply system as an independent section of the medical corps. Each level of the medical support structure had its own supply section, which was responsible for providing and moving medical supplies. Once in the theater of operations, these supplies moved through the medical supply system's own dedicated transport. Rear area supplies moved in regular army ships and trains but in a planned, allocated space specifically for medical supplies. The Japanese utilized prepositioning of supply amounts based on tables of consumption calculated at various levels of combat activity, an innovation that Dr. Jonathan Letterman introduced during the Civil War. The provisioning of medical supplies was very efficient, and the Japanese Army did not report a single case of a medical unit finding itself short of necessary medical supplies.

The Japanese success in reducing death and illness due to disease was also attributable to their excellent field hygiene system. Their disastrous experience in the China incident of 1894 taught them that one of the most important roles of the medical officer was disease prevention, and the Japanese created an excellent military hygiene program for their armies.

The army had an official hygienic code that was promulgated among all ranks. Each line officer was responsible for continuously educating the men and enforcing hygiene practices in the field. Through their own chain of command, the medical officers immediately reported any line officers who failed to accomplish their duty. Every division hospital had a bacteriological unit whose job was to diagnose illness and to ensure that steps were taken to prevent the further outbreak of diseases. All units down to the battalion level were issued equipment for testing water supplies, and water testing was a command responsibility. The standard practice was to boil drinking water, and troops never ventured into the field without adequate supplies of boiled water. Division medical officers were assigned to lower units on patrols to test and mark wells, and a medical briefing was standard procedure prior to undertaking combat operations in unfamiliar areas. Foraging and scouting parties routinely brought along a medical officer to make assessments. Medical officers were also responsible for cleansing newly captured positions so their troops would not
be exposed to diseases left by the enemy. The Japanese utilized the most advanced system for enforcing field hygiene measures that the world had ever seen to that time.

The Japanese solider had good personal hygiene habits. Daily bathing, a regular routine in peacetime, was practiced whenever possible, as was daily shaving and ensuring that the soldier kept his hair short. The men themselves regularly laundered their own uniforms, although fumigating ovens were provided at division level for cleansing the uniforms of disease patients. On average, the Japanese soldier was also younger than the Russian soldier and carried a lighter load in the field.
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The extensive use of coolies, forced or hired from local populations, and the greater availability of rail transport also kept the soldier's load light. Used to a light diet of rice and vegetables, the Japanese soldier adjusted better to the hot weather than the Russian did; indeed, even Russian commanders were impressed by how little the Japanese succumbed to sunstroke and heat exhaustion.
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The Japanese Army also practiced excellent field discipline to reduce venereal disease and alcohol problems. No camp followers were permitted, and only a small coterie of licensed vendors was allowed near the army. The only place to obtain alcohol—a scourge of the Russian ranks, especially in hot weather—was in canteens located fifty miles behind the Japanese lines. The soldier was provided with cigarettes, handkerchiefs for personal cleanliness, toothbrushes, soap, rice paper fans with which to cool himself, and writing paper. He was also allowed to fish to supplement his diet with protein.

One of the most important factors reducing disease was the Japanese cultural practice of cremating their dead. At the start of the war, the Japanese prepared individual funeral pyres, but the shortage of wood on the Liao-tung Peninsula quickly led to the dead being cremated in groups of five or six. Individual cremation was reserved for high-ranking officers. Immediate cremation of the dead removed a potentially dangerous source of disease contagion.
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The emphasis on disease and infection control was also present in the hospitals that treated the wounded. Japanese surgeons preferred to operate without rubber gloves, but strong antiseptic control of all elements of the surgical process kept the wound infection and hospital death rates to a minimum.
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All hospitals had hand-washing basins scattered throughout the wards and corridors, and the doctors and nurses washed their hands in disinfectant before they entered a ward. The staff kept the wards spotlessly clean, and all human and medical waste was burned every day. Latrines were covered and disinfected every day, and mosquito netting was provided
for each bed. These measures' effectiveness in reducing infection and disease is evident from the record of Toyama Hospital, which treated 15,759 patients after the Battle of Mukden from April through June 1905: it lost only 41 patients in this period to infection and disease.
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At Daley Hospital, within the war zone itself, 222,000 casualties were treated during the war, and only 3,150 died, or a hospital death rate of 1.4 percent.
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One of the more interesting aspects of the Japanese military medical system during this period was the field evacuation system. For most of history, the seriously wounded found being transported to rear area hospitals on springless vehicles was the bane of their existence. The Japanese, however, did not use any vehicles to transport the wounded. Instead, thousands of litter bearers organized into bearer companies carried all the wounded in stretchers through each stage of the casualty servicing structure from the front line to rear area hospitals behind division level, or a distance of approximately five miles.
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No estimate is available indicating how many seriously wounded men reached medical treatment alive because of the gentle nature of this type of transport, but it must have been substantial.

The Japanese medical structure that made its debut in the Russo-Japanese War was the most sophisticated medical service that any army had used until that time in history. The Japanese willingness to examine the medical services of the West and to improve upon them proved a major resource for conserving the manpower of their small nation for war. For the first time in history, the emphasis on disease and infection prevention allowed the Japanese to bring the latest advances in bacteriology to bear on military operations and to achieve incredible results. For at least two hundred years prior to the Russo-Japanese War, armies lost 25 percent of their field forces to disease and infection. The Japanese, however, lost less than 2 percent of their force to these causes. Moreover, their various hygiene procedures were so effective that more than a third of the field army went through the entire war without ever reporting sick.

The Russian medical system in this war was unchanged in its essentials from what the Imperial Russian Army used in the Crimean War. As in Russian society, the status of physicians and surgeons in the military was far lower than in any army of the West. Contract physicians and feldshers, the latter of questionable medical training, provided most of the medical care. Russian doctors in military hospitals were not
usually billeted with line officers and had to sleep on the floor between the patient's beds. General Ezerski, the chief inspector of hospitals at Sha-Ho, was not a medical officer but a former police chief. The status of Russian medical officers was so low that doctors who did not wear their swords in the wards while attending patients were disciplined. Even the diagnosis of disease was biased by status pressure. Because the line officers considered an outbreak of dysentery as reflecting poorly on their commands, they often forced doctors to classify dysentery cases as influenza.
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The old practice of having line officers command medical units, abandoned in most Western armies after the Crimean and American Civil War, was still in effect in the Russian Army, as was the habit of relying on the quartermaster to supply transport for moving casualties. The Russian Army had no official ambulance corps and still depended on troops from the firing line to carry casualties back to the dressing stations, as it had in the Crimea. As Wellington had noted in the Peninsular War, when several soldiers carried a wounded comrade to the rear, their absence negatively affected combat power on the firing line. Using the same methods during this war left Russian combat power seriously depleted at critical points in numerous battles.
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Without ambulance vehicles assigned to the medical service to evacuate casualties, the army expected that soldiers would use empty supply wagons. They carried the wounded over the rough Manchurian roads and trails in small springless carts (
dvukolks
) that had been shipped to the army to move supplies. As in the American Civil War and the Boer War, the rough treatment the wounded suffered while being transported in these “avalanches,” as the troops sometimes called them, caused a considerable number to die.

In Port Arthur, some Russian hospitals were large, spacious buildings. Most, however, were makeshift affairs with little medical equipment. The medical staff in Port Arthur comprised 136 surgeons and apothecaries, 15 medical students, 17 army officers used as inspectors, 11 priests, 46 clerks, and 112 female “nurses,” who were actually girlfriends and family members of the officers.
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