PART X
Epilogue
One of the reviewers of the manuscript of this monograph thought that it would be advisable to end it with a short summarization that would recapitulate the principles of preventive medicine and their advance through the centuries. Although I agreed that it would be nice to close the monograph with a pat epitome, I found it difficult to construct a static abstract of an on-going process. Furthermore, I would regret supplying abbreviated copy to fit the needs of the casual reader, or appear to be conducive to the comfort of those who might prefer to skip the main text. Nevertheless, after many attempts to recapitulate an essay which is already a recapitulation, I offer the following summary and commentary, indicatively, bearing in mind that the period under consideration is only 332 years from 1607, from the founding of the English settlement at Jamestown, Virginia, to 1939, when the United States was preparing for its possible combatant role beside Great Britain in World War II.
In the evolved doctrines and practices of preventive medicine, some of the earliest elements of the remote past are still present. Some of these are vestigial residues, of little use today; but others are as determinative as they were centuries ago, and, indeed, even more influential than ever before because they are now implemented by better technics. Many of the principles and procedures of military preventive medicine were developed by forces and events within the Army. Many others, however, evolved under environmental influences outside the military situation. Military preventive medicine is, in fact, the product of military thought and activities and of the intellectual,
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scientific, economic, and political movements and forces in the civilian world. Therefore, the evolution of preventive medicine in the United States Army cannot be considered as an isolated affair. Rather, it is to be regarded and understood as the result of the interaction between civilian and military knowledge and opinion as to what should be done, and how to do it, to preserve the health of soldiers.
The evolution of preventive medicine in the United States Army may be summarized chronologically, episodically, or ideologically. No set of boundaries can prevent penetrations, and the mingling of one set with others is unavoidable because all form a matrix.
The table of contents in this monograph is essentially a chronological summary, because this essay was constructed on a framework of dates and events. Of course, military preventive medicine practiced in the United States Army did not begin with Captain John Smith`s squad at Jamestown in 1607. It began before recorded history, probably as soon as a leader took a marauding or defensive band of armed men into campaign. There are plenty of examples of preventive medicine practices in the records of the military forces of ancient China, Egypt, Arabia, Greece, and Rome. Some of those practices are principles of today. Cleanliness in posts and camps, disposal of wastes, isolation and quarantine against communicable diseases, avoidance of overcrowding, precautions for drinking water, nutrition, proper clothing, and psychological factors of morale were incorporated in the Mosaic sanitary code in almost modern terms.
No matter what system of divisions and subdivisions is used, it must be borne in mind constantly that there have been actually four major periods in the evolution of preventive medicine in the time span under consideration.
These have been:
1st. The empirical period, 1607-1876.
2d. The period of the Sanitary Reform Movement in Europe and America, centered chiefly in the decades from 1850 to1890.
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3d. The etiological period, "The Bacteriological Era," from1876 into the present, including the era of viruses.
4th. The epidemiological (statistical) period, from the mid-19th century continuing into the 20th century, concerned with (a) communicable infectious diseases and (b) noncommunicable, noninfectious diseases.
In the following discussion, unequal weights will be given to these various periods, as it is desired in this limited summarization to emphasize a few selected phases.
It is astonishing how many important principles were established in the empirical period. From 1607 until about 1876, the predominant activities in preventive medicine in the Army were the everyday practices, well established by usage, although all sorts of strange notions were given for their justification. From British sources, chiefly the British Surgeons General Pringle and Brocklesby, sanitary knowledge came into the American Colonies and the American military contingents that served in the lines with British forces in severe episodes of European wars that were fought on American soil. In the American Revolutionary War, a German source of preventive medicine doctrine was introduced by Baron von Steuben who, after having served in the armies of Frederick the Great of Prussia, became Inspector General, drillmaster, and disciplinarian of the Continental Army of the United States.
A notable advance over mere empiricism was made in 1721 when Zabdiel Boylston, encouraged by Cotton Mather, inoculated against smallpox (variolation)in Boston. This was the first deliberate experimental immunization, under controlled conditions, in the Colonies-the first positive biological achievement in preventive medicine based upon principles that remain valid to this day. In 1812, a vastly important technical refinement and advance was made when the Army, under a general order of the War Department, was vaccinated against smallpox with Jennerian cowpox matter.
In addition, in the colonial period, the foundation of controlled preventive nutrition was laid by Lind`s promo-
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tion of the use of citrus fruits and vegetables to prevent and cure scurvy.
For the British training of American physicians and doctors-by-apprenticeship, the 25 years just preceding the outbreak of the American Revolutionary War, the years 1750 to 1775, were of prime importance. A number of men who served in high positions in the Medical Department of the Revolutionary Army were trained in England under Sir John Pringle and under others at universities in Edinburgh and London. Thus, the basic principle that preventive medicine in the army requires a supply of trained personnel went into operation to some extent at an early date.
By the end of the American Revolutionary War and the first years of the republic, nearly all of the modern principles of military preventive medicine, except those which could not be developed before the bacteriological era, were formulated, announced, and sometimes made mandatory by the Commander-in-Chief and even by the Congress. These are listed in condensed form as follows:
1. Responsibility of command for the preservation of the health of troops.
2. Use of medical officers as advisers to line officers.
3. Discipline, general and specific.
4. Personal hygiene; cleanliness.
5. Diet and nutrition.
6. Clothing and shoes.
7. Avoidance insofar as possible of exposure to extreme degrees of heat, cold, and fatigue, and to prolonged wetness.
8. Morale-building; recreational activities.
9. Health education.
10. Immunization (active): inoculation for smallpox.
11. Environmental hygiene:
a. Selection of campsites and shelters with regard to factors affecting health; ground water level, drainage, avoidance of marshes, attention to winds, and ventilation.
b. Avoidance of crowding; floor space.
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c. Sanitation of camps; cleanliness.
d. Disposal of excreta and other wastes.
e. Selection and protection of water supplies; purification of water.
12. Reduction of possible disease-transmitting human contacts; isolation of patients and quarantine.
13. Medical intelligence; rudimentary information about disease prevalence in areas occupied or to be occupied by troops.
During the first three-quarters of the 19th century, the chief contributions to military and civilian preventive medicine came from vaccination (Jennerian)against smallpox and from the sanitary reforms and public health movement originating in Europe and England in the early 1800`s and extending thereafter to America. Sanitary surveys, the use of disease reporting and of vital statistics, and the development of a more rational and precise epidemiology characterized the period. In the United States Army, Surgeon General Lovell instituted meteorological registers, established climatology, and required carefully detailed surveys of posts and camps. In 1850, Lemuel Shattuck`s "Report of the Sanitary Commission of Massachusetts" was the foundation of modern public health in the United States, and the Army derived benefits from the consequences. Lessons were learned from the Mexican War and the Crimean War (especially with regard to Florence Nightingale`s establishment of public health nursing). The American Civil War, which started in a morass of disease and poor sanitation, finished by producing some models of sanitary engineering and effective preventive medicine.
Progress, however, did not advance evenly between wars, or even during wars. Between wars, the Army, as usual, was largely demobilized and medical services were so neglected that at the beginning of a new war preventive medicine activities were inadequate and losses by disease were large. This was characteristic of the mobilization before World War II.
Although Pasteur, Koch, Sternberg, and a host of keen
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investigators were imaginatively and effectively at work in the field of bacteriology even in the 1860`s, and although there were published brilliant speculative essays on the subject of the possible microbial causes of disease, the revolutionizing bacteriological era has been dated arbitrarily only from 1876, when Robert Koch, in Berlin, demonstrated the pathogenic power of the anthrax bacillus. Thereafter, discoveries followed discoveries in quick succession. Bacteria and viruses causing many types of infection were found and studied, and on the basis of new knowledge thus acquired, new measures of preventive medicine, of hitherto unanticipated potency, were devised and applied. The era of scientific military preventive medicine sprang forward, and has been multifariously developed since then.
At the beginning of the 20th century, or shortly before 1900, insect vectors of infectious agents were discovered, and preventive medicine gained new powers. For example, when it was found that mosquitoes transmitted malaria and yellow fever a whole new discipline of preventive entomology was uncovered, and great advances in control measures were made.
After the beginning of the 20th century, the weaponry of preventive medicine was strengthened by the acquisition of new drugs capable of preventing, suppressing and curing certain infectious diseases. Chemotherapy, chemoprophylaxis, and the use of antibiotics began to relegate some of the infectious communicable diseases to minor causes of casualties. Increasingly, support of extensive research and conduct of research on problems of numerous infectious diseases became an essential part of the program of the Preventive Medicine Service of the Office of The Surgeon General of the Army.
Toward the end of the period under consideration, from about 1914 to1939, interest in the preventive aspects of noninfectious diseases, noncommunicable in the ordinary sense, arose and grew. In this group of diseases, so-called, are psychiatric disorders, mental aberrations, industrial injuries and industrial health hazards, accidents, nutri-
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tional deficiencies, and many problems of general hygiene and sanitation. To deal with the problems presented by these and other basically related conditions, a newer type of epidemiology has been developed. In this kind of study, ecological factors of an individual and his total environment are more then ever taken into account, observationally and experimentally.
This exercise in abstracting could be continued at length. I feel, however, that, as this small monograph is in reality a summarization of the evolution of preventive medicine in the United States Army, additional condensation would be superfluous. Sufficient has been written herein to lead expectantly to the sequel in which will be described the application of the old and newer preventive medicine, and the establishment of some new principles, in the global setting of World War II, which should furnish an extended recapitulation under new conditions.