War, Medicine & Death

You can’t say that we don’t progress. In every war, they kill you in a new way.

—Will Rogers, ca 1929

War is as old as human culture. But modern war is very different from warfare even two centuries ago. Technological advances have made weapons far more lethal. Yet medical progress in the care of casualties has partly offset the increased lethality of wounds in war.

Consider , which simply adds up the numbers of battle casualties (non–fatal casualties plus deaths) and compares that with the number of deaths for U.S. wars.1,2,3 U.S. history goes back only to the late 18th Century. Trauma care at that time was far better than in medieval or ancient times. Yet over the 250 years of U.S. wars, the ratio of deaths to wounds decreased from 42% to 10%.

Table 1

WarNon-fatal wounds plus deathsDeathsPercent lethalityU.S. PopulationRevolutionary10,6334,435422,500,000War of 18126,6652,260337,000,000Mexican War5,8851,7332920,000,000Civil War (Union)422,295140,4143331,000,000Spanish American War2,0473851976,000,000World War I257,40453,4022198,000,000World War II963,403291,55730132,000,000Korea137,02333,74125151,000,000Vietnam200,73747,43424218,000,000Persian Gulf (1990–91)61514824248,000,000Iraq/Afghanistan10,3691,00410300,000,000Open in a separate window

There are a number of reasons for this. Medical care of wounded soldiers has evolved from having a few poorly–trained doctors tagging along behind the army to a military health care system fully integrated with the military force. Entire systems of triage, evacuation, and surgical care are now in place, on the battlefield. Trauma care and surgical care in general has vastly improved. Antibiotics, blood transfusions, immunizations, and other non–surgical advances have contributed greatly. Public health in the military setting has greatly improved. Military medicine has developed into a true specialty over the last century and a half.

But there has been a much broader effect of military medicine on war itself. Consider medieval and early modern warfare. Armies were small. Weapons were either face–to–face or short–range projectiles. Everyone fought. Supply and services were non–existent. Battles were violent, but limited to a small area, and lasted only a day or two. Disease was endemic in armies, and in fact killed more fighters than did the enemy. Disease imposed a serious limitation on the size of armies, and on the length of time they could be kept in the field. Casualty care was primitive. Organized casualty care only began in the 19th Century, becoming effective only in the 20th.

Yet by the 20th Century, battles took place over large areas, involved millions of men, and lasted for months. Here, we encounter a paradox. Better casualty care has been a great benefit, despite the ever–increasing deadliness of our weapons. But by putting more soldiers back in the field, it has also reduced the impact of wounds on the overall force. Greatly improved public health in armies has lowered the toll of disease to a fraction of what it was in earlier centuries. Modern military medicine has thus allowed larger and larger armies. In short, military medicine, while greatly improving the care of the individual soldier, has enabled us to have bigger armies and wars.

The common image of war is the brave soldier charging towards the enemy with his comrades, dying heroically with the name of his loved ones on his lips. Like most other images of war, this image is nonsense. Soldiers die in many ways, most of which are not at all heroic. Let us consider just how soldiers die during war. Broadly speaking, these are death from disease, from accidents, from battle, and from wounds.

Consider the pathways towards and away from that battlefield. Before he or she can charge across no man’s land, the soldier goes to a camp in the U.S., then travels to the theater of operations and to the battlefield. This has its unique hazards. Up until a century ago, the greatest hazard was disease. Many more soldiers died from disease than from enemy action. As a classic example, Napoleon took his Grande Armee, 600,000 strong, across Russia to the outskirts of Moscow. Six months later, 100,000 returned, an 80% casualty rate. The Russian defenders shot more than a few. But most of the deaths were from cold, frostbite, typhus, typhoid fever, pneumonia, and epidemic diarrhea.

In the American Civil War, twice as many soldiers died of disease as from hostile action. In the Spanish–American War, nine times as many, largely from tropical diseases such as yellow fever. Among American troops in World War 1, disease deaths were higher than combat deaths, 63,000 to 51,000. To be complete, other armies had much lower rates of deaths from disease, about half of all combat deaths. The Americans joined the war in 1918, and were caught by the Great Flu Epidemic. By World War II, disease deaths in most armies were 10% of battle deaths. Even though it was fought in the tropics, the Vietnam War saw less than half as many deaths from disease as from combat. Control of disease has been largely from greatly improved public health measures, but also from disease–specific treatments and from vaccination for such diseases as yellow fever. The net effect has been to cut casualties by 60–70%, compared with historical wars.

Soldiers die from accidents away from the battlefield. These range from training deaths to motor vehicle crashes going to or from the battlefield. These are smaller than either disease or combat deaths, but are still significant.

Finally, soldiers die from wounds. To give one example, 50% of amputations during the Civil War resulted in death. Only 5% of amputations in World War 1 ended in death. The chances of dying from a battle wound dropped markedly from 1865 to 1918. The difference? There was an organized military medical system, including front–line surgical care, early evacuation, and sophisticated rear area hospital. There were many technical improvements including management of shock, intravenous fluids, sterile surgical technique, general anesthesia, improved wound debridement, and the Carrell–Dakin technique of wound irrigation (yes, using Dakin’s solution). By World War II, the first antibiotics were available, transfusion of plasma and blood was routine, and shock was treated more effectively. Mortality from wounds dropped to a few percent. That’s where it has remained across Korean, Vietnam, and the wars of the Middle East.

In talking about military deaths, we must distinguish between casualty and mortality. Casualties include all injuries, from whatever cause, and all illness. Depending on the data source, casualties may also include missing soldiers, although not those who become prisoners of war. But various sources often manipulate the data. In particular, the term, “battle casualties” has long been used to cover up disease and non–battle (accidental) casualties and deaths. If one adds up all battle casualties during the Civil War, for example, the resulting number omits casualties from disease in military camps. As noted, disease casualties were twice battle casualties.3

An important measure of casualty care is the survival percentage of soldiers reaching the health care system, usually defined as the forward aid station. The military care system begins with the corpsman on the battlefield, who can stop bleeding and apply dressings, and who transports the patient to the forward aid station. Only emergency care and stabilization is available there, but patients can be moved fairly quickly to either a Combat Support Hospital or a Forward Surgical Team (FST), where surgical care can be given. From one of these, further evacuation is available to a rear area hospital. Currently, survival of patients reaching the system is around 97%. As helpful as this figure of merit can be today, we don’t know what it was before 1900. In the U.S., military medical systems were re–organized after the Spanish American War, that is, between 1896 and 1917. That period saw the development of the Army Medical Corps, the Army Reserve Medical Corps, and the Army Nurse Corps, with early versions of the Dental Corps, Veterinary Corps, and Medical Service Corps. While we can estimate this survival percentage for earlier wars, such estimates are only educated guesses for anything before World War I. And clearly, some wounds are immediately lethal, or so quickly lethal as to preclude treatment. The best casualty care system available cannot save patients who cannot reach it.

To take a somewhat broader perspective, what can we say about the ongoing human costs of war? Or putting it another way, how do casualties in the wars of the 20th and 21st Centuries compare with casualties in previous wars? A glance at shows that in U.S. history, only the American Civil War was comparable to the wars of the last 100 years. It appears to have been much less costly than World War II. But the U.S. population in 1860 was far smaller than in 1940. If we do the math, the Civil War was almost twice as costly as World War II. In fact, during the Civil War, about 1.8% of the entire population of the North and South, were casualties. In World War II, not quite 1%.

This perspective allows us to make two points. First, earlier wars may have been just as devastating to the countries involved as modern war. Casualty numbers have to be considered in terms of the overall population. And second, when even a relatively small percentage of the overall population is lost to war, there may be a disproportionate impact on the country at large. To take an example, the Korean war (1950–53) had about the same impact as the Vietnam War (1965–73). In each, casualties were about 0.11% of the total population. But the Korean War, coming after World War II, had very little impact. It’s often called the Forgotten War. Vietnam, coming after years of peace and great prosperity, had an impact which is felt to this day.

What can we conclude from all this? While casualty care has improved to an extent unheard of even a century ago, modern weapons are increasingly lethal. Modern public health and transportation technology has enabled the formation of far larger armies than ever before. The last 50 years have been relatively peaceful, even counting wars in the Middle East. Many have concluded that perhaps peace can become the norm. But we have now re–learned what our fathers and grandfathers learned during World War II. War cannot always be avoided. The Russo–Ukrainian War has clearly shown that it doesn’t even take two sides to make a war. It only takes one aggressor. War continues to be a scourge upon us.