The First World War was the first conflict in which deaths from wounds greatly exceeded those due to illness; this resulted in the creation of a health care system without precedents, based on a quick and efficient evacuation of the wounded thanks to the railways.
The challenges that the health services of all armies faced were mainly those that are now recognized as the main features of the Great War: poor hygiene, diseases brought on by exhaustion and immobility and the great mobilization of personnel and equipment. All these distinctive features required the organization of a health care system unprecedented in European military history. The Great War was the first conflict in which deaths from wounds greatly exceeded those from disease. Until that time, soldiers died from fatigue, food shortages, lack of hygiene, epidemics and venereal diseases; a clear demonstration of this trend is the American Civil War, during which the Union lost 96,000 men in battle and 183,000 due to illness.
This shift was due not to an improvement in the living conditions of the soldiers: immobility in the trenches exhausted both the body and the mind; during the winter lung diseases and rheumatism claimed victims while, in summer, death spread due to intestinal infections and venereal diseases. What changed was the efficiency of the organization of the health service and provision of medicine, along with the general improvement of living conditions during the nineteenth century. The progress of medical science corresponded to an advancement of war technology which became more lethal and less “personal”: the bayonet, the saber and the rifle were not the main weapons. Hence the main causes of death were no longer due to disease but to wounds.
Despite this change, disease was still a serious problem that, if ignored, threatened to put whole contingents out of action. Epidemic diseases represented a major threat to army fitness and the most common were cholera, typhoid, malaria, smallpox, meningitis, and, of course, venereal diseases. Within the first weeks of the war the army had engaged in massive prevention work through the application of strict hygiene rules and by increasing awareness among the population and soldiers.
The first serious epidemic was cholera, which affected the soldiers of the 40th Infantry Division of the X Corps from July 1915. In about a month, the disease spread among the troops of the frontline, behind the lines and among the civilian population. The crisis finished only at the beginning of 1916; by then over 16,500 people in the area had contracted the disease and 4,500 had died.
Venereal diseases were fought through close supervision of prostitutes: those infected or considered to be infected were immediately removed. As of mid-1916 soldiers were required to undergo health inspections and brothels controlled by medical officers were set up.
During the war there were several epidemics of typhus, smallpox and tuberculosis, and in spring 1918 the “Spanish flu” arrived, with a very high number of people infected (25,000) but few deaths. A second phase of the epidemic began in late July and continued throughout the autumn and winter with one Italian in seven contracting the disease and one in twelve, of those affected, dying.
The Italian war health service consisted in a huge system, also from a bureaucratic point of view, and an intricate hierarchy of military and civilian offices and sections. The Supreme Command was at the top of the hierarchy, followed by the General Superintendency, in charge of all facilities and supplies for the army in the war zone. At the beginning of the war the General Superintendency consisted of a general staff and five sections but over the months it enlarged, adding a general superintendent with a secretariat responsible for the chief and the deputy chief of staff; below the general superintendent were numerous offices and inspectorates - just the main ones included transport organization, the inspectorate for areas behind the front line and that of civil engineering, the medical inspector’s office, the Red Cross delegation, and many others.
The organization of the evacuation and hospitalization of the wounded was less complex from a bureaucratic point of view but definitely more complicated from a practical viewpoint and was organized into four zones:
• Zone 1, army corps. This zone was part of the area of operations and was used for the care of those with minor wounds and illnesses requiring a hospital stay of no more than ten days, and for those in need of particularly urgent care.
• Zone 2, superintendencies. The zone was located immediately outside the area of operations, therefore still in the war zone, and was for hospital stays of no more than twenty days.
• Zone 3, first evacuation or quarantine. This zone was still located within the war zone but as far as possible from the area of operations. The wounded and the sick in need of a hospital stay of no more than thirty days were taken to this zone.
• Zone 4, second evacuation. The zone identified any part of the national territory not included in the war and was used for soldiers in need of care for more than thirty days who, however, were initially held in the first evacuation zone for prevention reasons.
The backbone of this military health organization was the rail network. The sick and wounded were sent away from the front aboard freight trains, passenger trains, third-class or hospital trains of the Italian Red Cross and the Sovereign Military Order of Malta. Transport of the wounded among the four health zones was organized by train, as was the transport of an increasing number of troops to the frontlines.