189: The Medical War Pt. 1


In this special episode we discuss medical care during the war.



Hello everyone, and welcome. The First World War would begin in August 1914 and it would very quickly become the largest conflict in human history as Britain, France, Russia, Germany, Austria-Hungary, Italy, and the Ottoman Empire, joined by many smaller countries sent millions of men to the war. It would last for 52 months, a bit over four years, and during that time 10 million military personnel would be killed, 6 million civilians would die, and 22 million more would be wounded. That number, is so large that it is almost impossible to really wrap our heads around, so lets first add all of those numbers up, 38 million killed and wounded and then lets start dividing that number up by time. With 52 months that is 730,000 a month, that is still a pretty big number, 24,250 a day, 1,010 per hour, over 16 per minute, over 16 people per minute either killed or injured, for over 4 years. Many of those individuals would depend on the medical services from around the world to help them, to hopefully save them, and it is those medical services we are going to talk about today. This talk will basically be broken down into three sections. The first section will cover the state of medicine in 1914, before the war started, both from a technological and theory standpoint. Basically what did the doctors know, what did they have to work with, and what did they expect would happen when a war started? Then we will talk about the actual realities of that war. When the fighting started what were the problems that the doctors at the front had to deal with, how did they approach those problems, and what were some of the solutions that they came up with. Then our third topic will be to take the path of a wounded soldier, who after being wounded on the battlefield would be transported, first by stretcher, then by ambulance, then by train through the medical facilities arranged behind the front. Most of my discussion today will focus on the British and American experience for one simple reason, I only speak English so sources can be hard to come by but in many cases the experiences of doctors in other countries would have been roughly similar. I also want to make it clear that I am not a medical expert, the closest I come to any medical expertise is my deep knowledge on the topic of how frustrating it is to break your foot and not be able to walk for 6 months. With all of that in mind, lets jump into our first topic, a very brief introduction to the first world war.

I know that many of you may not have a ton of knowledge about the war, so I am going to give you a brief summary of the conflict. Do not worry, I will not spend the rest of my talk discussing this, although I certainly could, we need to discuss it enough to put the medical side of the war into some sort of context. First, this was a truly global war, there were of course many major European powers like Britain, France, Germany, italy, Russia, Austria-Hungary, the Ottoman Empire, but then also many smaller countries like Serbia, Belgium, Bulgaria, Greece, and Portugal. Then many countries joined in from around the world, Japan, China, several South American countries, and of course the United States. Fighting was also not just contained to Western Europe and the stereotypical trenches, fighting would occur in Northern Italy in the Alps, in the Balkans, Eastern Europe, and of course Russia. There was also fighting in the Middle East in modern day Iraq, Syria, and Israel. In the Caucasus mountains in modern day Armenia and Azerbaijan, in sub-Saharan Africa, and on Pacific Islands. In many of these theaters the fighting continued for the duration of the war. As you can tell from the variety of geographical areas where the fighting was taking place, the conditions under which the fighting occurred was equally varied. There was fighting in the sweltering heat of the East Africa jungle, and in the high peaks of the Carpathian mountains where men, quite literally, froze to death. On the Western Front, which most of our discussion today focuses on the conditions were also variable. As with most temperant areas the weather in Western Europe varied based on the seasons. During the opening German attakcs in late summer 1914 the heat was sweltering and the dust suffocating. During the winters the cold was almost unbearable. But none of these weather conditions were as impactful on the conduct of the soldiers than a more terrestrial matter, the mud. Most of the fighting around the world took place in trenches, which while far more than just simple ditches, they were still of course dug into the ground and many men would spend good portions of the war below ground level. The best known example of this was in Flanders where the mud would gain a mythical quality that would echo down through the ages. You see, the problem was that the armies could not just abandon the front line when it rained, and instead they were stuck in place getting wetter and colder and sinking deeper into the mud. These conditions are important to sort of set in your mind because it is the environment where all of these doctors and nurses were trying to perform medical procedures. There are countless accounts from doctors discussing how their patients are coated in mud and other filth. One thing I want to mention is that an individual soldier would not spend four straight years in the trenches, there was a rotation system where units would move in and out of the trenches at intervals. This interval would vary a bit based on the year and the army, but it was often something like 1 week in the line, 2 weeks out. It was found that any more than this would just cause the soldiers to mentally and physically break down. Due to their importance, and how all consuming they were in the lives of the soldiers during the war, lets talk about the trenches for just a bit. After the opening offensives of 1914 the fighting would remain in basically the same areas, give or take a few miles, until 1918. For protection the troops first dug some simple trenches to hide in and these eventually expanded to be a continuous line of fortifications from Switzerland in the south all the way to the North Sea. These were not just simple ditches in the ground to hide in, they included deep dugouts, reinforced with wood or even concrete. The trenches themselves would be shored up with wood or other materials and there would be multiple lines of them, all connected by communication trenches allowing troops to move forward and back. While these trenches provided protection they also meant that the fighting was forced to be very static, and this resulted in the soldiers of both sides fighting and dying over the same ground for over 4 years. That meant that at times remnants of past fighting might surface, or might be found. Sometimes these remnants of past battles, and to be clear here I am talking about dead bodies, would be unearthed by the thousands and millions of artillery rounds that would be used along the front. Other times they would surface due to rain. There are countless first hand accounts of large shell holes that would fill with water, and dead bodies, then an artillery shell would drop right in the pool spreading that nastiness in all directions. One thing I have not mentioned yet is the United States, and that is because they came into the war quite late, not declaring war until April 1917. American troops would not be in the fighting in any quantity until the spring of 1918 just a few months before the war was over. The primary contribution of the United States was in money, by giving large loans to the allies, and then in raw material and food. That does not mean that the United States did not participate in the fighting, they certainly did in the waning months of the war. In fact the most costly battle in American history, that is all of American history, would take place in September, October, and November, it was called the Meuse-Argonne offensive.

Okay, I think that is a decent enough picture of the war and the fighting, if you have any more questions on any of that let me know at the end. The First World War takes place at an interesting point in history, there were some key pieces of modern day medical theory that they already knew about. At the top of this list, from a battlefield medicine perspective, was their knowledge of bacteria, infections, and how to prevent them. This means that during the war doctors knew to sterilize utensils and equipment, they used antiseptics at various points to try and reduce the chances of infection. They also had a pretty good idea about what infections did, and they understood most of the basic mechanics of how infections happened. This is a big change from for example the American Civil War where the causes for infections, gangrene, and similar issues were not well known and so few steps were taken to prevent them. While they knew about all of these things they were still missing one very important key piece of the puzzle, antibiotics. Penicilin would not be discovered until 1928, a decade after the war ended. This meant that while they knew some of the problems and some ways to hopefully prevent them, if an infection took hold, trying to then stop it would be a problem. Both before and during the war Doctors would spend a lot of time trying to figure out how to keep battlefield wounds from becoming infected, and they would be at least partially successful.

There were also other treatments that were available for problems not directly related to battlefield wounds. One great example of this is anti-tetanus serum. Tetanus had been a serious problem for militaries all over the world before a treatment was found in the form of a serum. This serum could be given to soldiers as soon as they were wounded and it would drastically reduce the probability that tetanus would occur. Early in the war, before this serum became available in the quantities required by the British army, of the cases that arrived at Casualty Clearing Stations behind the front, which were the second step in the evacuation process, as many as 58 percent of them were suffering from tetanus. This number would be drastically reduced later in the conflict. Another kind of preventative medicine that was available was vaccines, which they had for some diseases, the most important being smallpox. Many soldiers would get this vaccine, but many countries were hesitant to mandate innoculation so it is not given to everyone.

Another very important technology that was present during the war was blood transfusions, a very critical piece of the treatment puzzle in trauma medicine. The basic concepts of shock and its relation to blood and fluid loss was reasonably well understood in 1914, after having been discovered and researched during the 1890s. A lot of this work was done by a doctor named George Crile, and he determiend that the blood loss caused some kind of physical reaction that caused the shock. While this outlined the problem, a solution would not be found for almost a decade, it would be at that point, in 1901 that the different blood types and how they interacted was finally determined, obviously an important step to making blood transfusions a possibility. While this discovery unlocked the technology of blood transfusions, it could still only be done on a small scale. Before the war these transfusions would be done from person to person because nobody knew a way to properly store blood for any length of time. Obviously this limitation is problematic in a wartime scenario when an army might have thousands of wounded soldiers, a workable solution would eventually be found which involved keeping the blood cold and mixing in some anti-coagulant which allowed it to be stored for a reasonable amount of time. This would also blood banks to be created during the war, and blood transfusions were a critical piece of treatments by 1917.

The final bit of technology that I will mention today is one that I always like to throw out there when having these discussions because it surprises some people, and that is the presence and pervasive use of X-Rays during the war. X-Rays had been discovered in 1895 and since that point they had rapidly spread throughout the medical world. By the time of the first world war the general discussion was not about how to use an x-ray but instead how to get the machines as close to the front as possible to help save lives. Obviously these machines would be used in all of the ways you would imagine, they were also heavily used by the American Neurosurgeon Harvey Cushing, whose methods I will discuss in much greater detail in my next talk. These are just some examples of the technology that was available before the war, and during the war almost all of them saw evolution and improvement if only due to the sheer number of patients that they were applied to.

Lets shift over to talk just a bit about what the medical world thought they would need to do when the war started. For the purposes of this talk we are going to focus on the British experience and what the leaders of their army medical services thought they were going to be asked to do. AS with many armies, the medical corps of the British army was shaped in many ways by the previous conflict that they had participated in, for the British that meant the Boer War. The Boer war had been a conflict in South Africa in the early years of the 20th century. During that conflict the British had faced off against the Boers, which was a group of Europeans in Africa. During this conflict most of the wounds faced by the army were in the form of nice clean bullet wounds, quick in and quick out. Most of the fighting also took place on the clean areas of the South African veldt, which was kind of like unclaimed wilderness. The most important impact that this had on the British doctors is that it caused them to believe and prepare for most wounds to be nice a tidy and with a very small risk of infection. With this belief they then setup their processes to treat those kinds of wounds. Here is Major A.J. Hull, a doctor during the First World War describing the general British theory on how to treat wounds before 1914. “the surgical experiences of the present war [that being World War 1] suggest that the influence of the surgical work in South Africa exercises an untoward effect upon some surgical procedures. Although in previous campaigns the treatment of clean bullet wounds by one dry antiseptic dressing, which was not removed until the patient reached a base hospital, proved successful […] the experience in the present war is otherwise, and the treatment of wounds by an undisturbed dressing is to be deprecated.” Along with the institutional problems based on previous war experiences there was also the problem of trying to take civilian doctors and make them into military medical officers. All of the armies of Europe would have this problem, they would all have to rely on doctors that were trained for civilian practices, and trained for the types of experiences that came with being a civilian doctor. Their experience in these roles would have been similar to what general physcians deal with today, not a ton of serious injuries, probably some pretty boring stuff, and in the rare case of something serious happening they could depend on being able to treat it in a familiar, clean, and tidy environment. In the military there was obviously nothing like this, and instead of nice, clean, well-lit rooms they would find themselves in dirty, cold, barely-lit regimental aid posts and casualty clearing stations.

So with all of these expectations in mind, lets move on to talking about what they actually found once the fighting started. The first big shock for many military doctors is that most of the injuries that they were seeing were not caused by rifle bullets. The first World War would be the conflict where the artillery would truly come into their own and would truly rule the battlefield, with more casualties caused by the artillery than by any other weapon. This meant that the wounds found on many soldiers were quite different than the clean in and out gunshot wound. When you think about a bullet and what it does when it hits a human body, especially the rifle bullets used in the military, it generally goes in and out, might hit a few bones on its way, but it has enough velocity to generally cause a nice and clean entry and exit wound. Now consider an artillery shell that has exploded. The shell will explode into oddly shaped, sometimes quite large, pieces of shrapnel and they will fly through the air while tumbling and spinning. When a piece comes in contact with ahuman body it is anything but neat and tidy. Whole chunks of a soldier’s body might be removed, and tissue and bones would be pulverized. Artillery shells also increased the problem of contamination. Bullets just fly through the air and into the body, usually, but artillery shrapnel may not even be created until the shell explodes underground, or it might penetrate through the ground, or bounce of it. In all cases it has a much higher chance of bringing contaminating matter like dirt, mud, water, or anything else. Artillery shrapnel also had a tendency to lodge bits of uniform and equipment inside the soldier’s body. All of these problems brought with it the second biggest shock, the fact that the wounds were basically never sterile, they were often deeply contaminated. Even if the projectile itself was not contaminated, when it hit the body it would often bring in dirty from uniforms. This contamination meant that the body could not be counted on to fully heal the wounds and so there had to be treatments that found a way to help the body along. Finding these solutions would have to be done while also trying to grapple with the other problems caused by the war, some of which were far from the battlefield itself.

One of these problems is going to cause me to jump into a topic that you may not have expected to hear much about today, and that is the logistical problem of finding enough doctors for the armies. All of the countries that entered into the war would have to massively expand their armies, and no army would expand more than the British and American armies. In both cases they would struggle to try and find enough doctors to send to the front. The problem was one of training. If you want to create an infantryman, what do you need? An able bodied person and a few weeks, maybe a few months if you are not in a big hurry. But finding trained and capabale doctors was a very different story. It can take years to educate and train a doctor capable of handling the variety of trauma situations that you find in a military medical unit. This meant that the army could not just pull in random people and make them doctors after a few weeks in basic training, instead they had to rely on doctors that were either already in practice or were close to being done with medical school. But you cannot just pull a bunch of doctors out of the civilian world without ramifications. Imagine in the modern day if suddenly the US military had to expand to 100 times its current size and needed to find doctors to staff up. They would have to turn to civilian hospitals and private practices. It isn’t like those doctors are just sitting around twiddling their thumbs, or at least I hope they are not. Instead they have patient lists, rotations, surgeries, whatever it is they do. It is is not as if the armies during the war just needed a few doctors here or there, in Britain, France, and Germany they called up almost 75% of all of the civilian doctors in the country. Young and fit doctors would be sent up near the front, older more experienced ones would be in hospitals and casualty clearing stations in the rear. Can you imagine the chaos if suddenly even half the doctors in the country were suddenly just sent overseas? Sounds like a recipe for chaos. There were also some mistakes made early in the war that made this problem even worse. One of the problems that they had is that early in the war they made some mistakes that reduced the number of doctors available later on. The best example of this is the fact that early in the war countries would let medical students volunteer to join the army as infantry, or any other type of soldier, instead of finishing school. This was allowed because everybody thought that the war would be short, over in a few months, home by Christmas. But then as the war entered its second and third year people began to kind of panic as all of these doctors that should have been graduating were actually in the trenches fighting. Not the best situation.

Even the doctors that did join the army as doctors could not just instantly inserted as a medical officer. There was sort of the training problems of taking a civilian and turning them into a medical officer, and they were truly officers in the army, treated as officers and expected to lead like officers. This meant changing their mindset to line up with what the military authorities wanted. New doctors were notoriously soft when it came to bringing men off the firing line for even very minor problems, like minor sickness or other ailments. This gave rise to serious concerns about malingerers, using the softness of their unit medical officer to get out of duty, which was of course unacceptable. The new doctors were taught to be quite hard on the men, to make sure that shirking did not become a problem.There was also the problem of making sure that they knew what they were doing medically. As I mentioned many of these doctors might only see a truly serious injury once a month or ever less frequently, but when they were in the military they might see 100 a day. Finally there was the mental component of being a doctor in a combat situation, and that meant proper triage of the cases that were put in front of them. Not everybody could be saved, and it was important that the doctors could recognize when time was better spent on a different patient that had a better chance of survival. This would often mean making a judgement call, a literal life and death judgement call. It might mean putting a patient over in the corner and letting them die while moving on to others. Shifting to this mindset was not an easy transition for many doctors, or nurses, who were expected make these decisions. There are many first hand accounts of the doctors dealing with the doubts and mental anguish that these decisions caused.

With so many surprises and so much adaptation being required from doctors during the war, they also had to evolve their treatments to match the situations that they were seeing, and they were not always successful. Mistakes were sometimes made, entire treatment paths might be followed through for months or even years only to later realize that they were not effective or were maybe less effective than other possible treatments. There are a whole bunch of examples that we can talk about along this line, with many being due to new types of injuries and illnesses being present during the war like gas poisoning or shell shock, which we refer to as post traumatic stress disorder today. For right now I am just going to go down the path of talking about how relatively straight forward penetration wounds, or blunt force trauma wounds in the case of artillery shrapnel, were treated. I will be talking more about shell shock later today. So a soldier with this wound may have been shot or maybe he had been hit by some artillery shrapnel and a chunk of tissue had been removed from his body. One of the early paths that the British doctors went down for these types of injuries involved not using any antiseptics at all, even though they were available. This treatment was championed by Sir Almroth Write who led a school of thought that revolved around the usage of hypertonic salt solutions. This treatment involved just constant cleaning and hydration of the wound using this salt solution instead of antiseptics, and this salt solution would be the standard practice of the British Army in 1915. This was also at a time when the British were sticking with their prewar practice of leaving as much tissue in place as possible, while relying on the body to do most of the heavy lifting. It would only be in 1915, the second year of the war, that things began to change as the British began to realize that it was actually better to just start hacking away on a wound instead of mostly leaving it alone. It was better to sacrifice any borderline tissue than to even give the possibility of any foreign matter being left in the wound, even if large amounts of tissue had to be removed. This type of treatment was championed by Sir Anthony Bowlby here is a lengthy quote from him about the treatment and about why it should be done, and that it should be done as soon as possible after the wound was incurred “[It is] absolutely essential for success that this excision should be done as soon as possible after the infliction of an extensive wound because in such cases gas gangrene may become widely spread within 24 hours. It is therefore necessary to operate on such cases before the patient is sent by train to the base, as he will seldom be surgically treated there until more than 24 hours has elapsed since the time at which he was wounded. This method of treatment has entirely supplanted the application of strong antiseptics to a recent wound, or the use of continual saline infusions. It is a method whose value is agreed upon by the surgeons of all the Allies, and has recently been unanimously approved by the Meeting of the Surgeons of the Allied Armies in Paris.” Along with the growing evidence that this kind of mass excision was ncessary, the British also began to use different solutions to clean out the wounds. The most widespread of these was a system designed by Alexis Carrel and Henry Dakin which used a sodium hypochlorite solution, or basically bleach but quite diluted, that would be constantly circulated over and in a wound using a system of tubes. This would prove to be quite successful and would eventually be the primary solution used by British doctors. One thing that is reaily apparent when digging into the various treatments done by doctors in all of the armies during the war is the relative autonomy given to the physicians by the military leaders. In general there was a huge amount of trust placed in the doctors, their education, and their experience, so instead of being quite forceful on what treatments should be administered it was often left up to the individual doctors. This did mean that some doctors were not providing the best treatment all of the time. But this was believed to be an acceptable sacrifice because it allowed for better treatments to be found and iterated on quickly. One thing that was not lacking was test patients, especially when it came to something so common as a gunshot or simple shrapnel case. There were many attempts to make sure that the doctors were not operating in total isolation though. To this end there were military medical societies formed to allow for information to be shared between doctors. These were supported and promoted by political organs like the Royal Army Medical Commission. The RAMC also put in place two practices that were invaluable when it came to determining and spreading best practices around the medical groups in the British army. The first was the creation of mobile surgical teams that would move around the front both in response to various attacks but also just to work with doctors all along the front, learning from them and also teaching them what they had learned elsewhere. This took care of both education and dealing with the massive influx of wounded during large actions. The second practice was an effort to make sure that front line doctors were informed about how their cases progress once they were sent further back from the front. This was the only way for front line doctors to know if what they were doing was actually working or not, but was also information that only somebody much higher up the chain of command could have access to. With all of these changes and adaptations happening, lets just look at what the sort of final form of the British wound care process looked like. I will be clear, most of my knowledge of modern medicine comes from House and ER, so I don’t actually know anything about actual medical treatment, other than it is never lupus, but what is being described here seems pretty reasonable to me. First the hands of the nurses and doctors would be thoroughly washed in soap and water, then soaked in a 1 in 20 carbolic solution. All instruments that would be used would also be sterilized either by boiling or steaming, and all bandages and dressing would be heat sterilized. The wound would then be cleaned with soap and water, and then withe alcohol or ether. Then it would be washed with an antiseptic solution, generally iodine, then rinsed with saline. Once this initial rinsing was complete any obvious foreign objects would be removed. Then it would be dressed while waiting for surgery to remove any other foreign objets and any tissue that needed to be removed. Once that surgery was done the process of cleaning and changing bandages, often with that sodium hypochlorite solution, would begin. All pretty simply really.

Obviously that example is all about one specific type of wound, and yes I chose an easy one to describe, and there were of course an almost infinite number of treatments for the almost infinite number of wound types and severities. Here is a quote from an Australian nurse about how they treated burn wounds late in the war “The blisters were cut and all loose skin removed. Surface of wound was irrigated with Peroxide and surrounding parts cleaned with alcohol and would dried with electricity. Apply zinc oxide omade to healed edges. Spray Aniline on the raw suface and cover with a thin layer of sterile cotton wool, then spay with another application of aniline and bandage with a thick pad of cotton wool. Change dressing daily.” Some injuring like burning were treatable, up to a point, others like gas inhalation or blinding were often just a matter of cleaning the area of the wound and hoping that things worked out.

Up to this point I have discussed doctors almost exclusively, but I need to pause on that discussion for just a second to give a shout out to the nurses who were also critical components of providing medical care to soldiers during the war. The treatment and role of nurses, and especially female nurses varied based on the country from which the nurse orginated, but regardless of what their exact responsibilities were at the beginning, they often greatly expanded during the war. The value of nursing was well known by all of the countries, they could make sure that patients were well taken care of over the long term. But the number of patients that flooded into all levels of the medical evacuation chain meant that nurses were often asked to do far more than they were trained to do. They were of course trained in the latest techniques for dressing and treating wounds but they would also find themslves doing anaethesia, trying to desperately stop life threatening bleeding, and make complex decisions about what should be done for a patient. Often it would be a nurse that was making the life and death decisions that we talked about earlier. This was due to how busy many doctors would be, especially during large actions when they would be completely swamped, during those times nurses would be the ones to meet the patients on arrival and be called upon to instantly make treatment decisions that would decide whether the patient would live or die. Julia Stemson, was a nurse that worked in a French hospital in 1917 and she would write about the mental strain that nurses found themselves under ‘These frightful sights would work havoc with one’s brain…what will we think when we get through with it all. How are we going to stand the mental strain.’ Nursing was also a risky job, even if they were often no closer to the front than the Casualty Clearing stations. As with every other job at the front these nurses pulled long, sometimes seemingly neverending hours, and contracting infections could lead to drastic consequences on their exhausted bodies. Nurses were also not just restricted to Western Europe, they would be present all over the world, here is an account from Eva Lea who was on the Mediterranean island of Lemnos in September 1915 “1. Flies, flies everywhere. 2. You can’t bathe because the sea is full of scum and dead horses. 3. Only 1 pint of water is allowed to each one for all purposes as it is so scarce and has to be taken there. 4. Food is awful. 5. Work to much. 6. No butter, only goat’s milk, no shops, no news, in fact the only good thing about it as far as we can hear, is the beautiful sunsets and sunrises and that the climate is cooler. It is still very hot here and we have all been a bit bowled over by it.” In locations outside of France each conflict area brought with it its own set of challenges for medical providers. in the Middle East it was often the heat and the sand, they would also be much shorter on supplies and personnel compared to the Western front.

While combat casualties would often get all the headlines, and have been the majority of our conversation up to this point there was another, and far more dangerous, enemy that stalked all of the armies in the war, disease. Disease came in many forms, at times it was deadly like with the Spanish Flu that would sweep the globe near the end of the war, sometimes it was just annoying like the constant dysentery that would degrade the combat effectiveness of the troops. The most common of these latter illnesses were generally just stomach bugs, infections, or colds, basically just the whole range of things that childen would describe as making you feel icky. This was then joined by various skin conditions that were almost universally present due to the hygiene situation at the front. These skin conditions would then be aggrevated by the very healthy populations of mice and lice. The mice and rats just thrived in the trenches, carrying disease with them of course. Lice were much the same, with lice being almost universally present for all soldiers. Their uniforms would often be crawling with lice, and they spread more concerning diseases like fever and typhus. There was a good amount of effort put into trying to reduce the rat and lice population, but completely removing them was impossible and so the armies had to figure out ways to deal with them and reduce the danger caused by the pests. One of the key weapons in this never ending war was the work done by sanitary companies. Remember, the fighting on the western fron did not move around very much, and so areas where the troops were when both behind the front and at the front soon became, well very unfortunate when discussing sanitation. To try and handle some of these problems sanitary companies were created which just sort of went around behind the front cleaning up after other units had defiled the landscape. The hope was that this would keep the hygiene situation somewhat under control, or at least reduce the build up of filth. There were also concerted efforts to educate both officers and NCOs on how to help out with hygiene and to emphasize its importance to all of the soldiers. Oddly enough it took until 1918 for the British to create proper delousing pits that were actually effective. It is shocking that it took this long because every uniform had been crawling with lice since 1915 and a proper method of removing them had been implemented by many other armies. In British accounts of the war there are many stories of soldiers killing lice with lighters, candles, or just squeezing them with their fingers, and doing that killing by the hundreds. The delousing pits that were eventually implemented are interesting I think. They would create a dugout behind the front that would contains rows and rows of clothing racks. There would also be brick stoves, after the clothes were arranged inside the stove would be lit and the temperature brought up to 90 degrees Celsius, more than enough to kill the lice. But this was always just a temporary fix, and hours after arriving back at the front most of the uinforms were crawling with lice again.

Now we are going to move into our final section of the talk where we are going to follow the path of a wounded soldier from the battlefield to a base hospital. This lets us talk about how medical care was physically and geographically located, and also what kinds of treatment a soldier could expect to receive at each step along the way. I am going to be using British terminology here, so Regimental Aid Posts, Casualty Clearing Stations, and Field hospitals but all armies had a similar setup that may have vaired slightly in specifics but the overall concept was the same. One theme that would travel throughout the entire medical chain was simply the amount of wounded soldiers that it would have to be capable of dealing with. This was really a problem during large scale operations, and it was a problem that was never really solved. By the time you get to 1916 things are handled a bit better, but even at that point it was difficult for the armies to properly prepare for the incredible influx of wounded soldiers that they would see during offensives. The perfect example of this is the Battle of the Somme, the largest British attack of 1916. For this attack they setup a whole complex system of Casualty Clearning Stations, they had trains ready and waiting to be loaded to transport wounded to hospitals, they thought that they were perfectly prepared for up to 10,000 casualties a day. 10,000 seems like a lot, but not for the Battle of the Somme where the first day saw 60,000 wounded Britsh soldiers. This completely swamped the entire system, and even though the doctors and nurses did not stop working for days at a time it was impossible to catch up. All that they could do was keep trying, and that is a pretty good theme for all medical personnel at all levels. It often felt like an impossible job, because it often was.

The first problem for a soldier after being wounded was getting to the aid post, and that meant being retrieved from the battlefield. When the war started this job was often, and had traditionally been done by the regimental bands, but these men were quickly found to be insufficient in number to the task at hand. Soon dedicated units of stretcher bearers were created for each unit at the front. They were the EMTs of their day, their goal was to go to where the wounded soldiers were and transport them back to the first stop on their journey, the Regimental Aid Post. If only it were that simple. This seems like a pretty straight forward task, and under perfect conditions it was, but it pretty much never happened in perfect conditions. In theory it would only take two men to carry a stretcher, and if they were on a basketball court that would work, but they were on a broken, often muddy, battlefield that was often full of shell holes to go around and trenches to cross. Sergeant W.J. Collins was a stretcher beared in the Royal Army Medical Corps during the war, this is how he would describe the challenges of transporting the wounded men “A stretcher squad consists of four men and you lift the stretcher up on to your shoulder, and each corner had a man. Now that’s the only way you can carry a man properly. But, my God it was hard work, really hard. When conditions got really appalling it required 12 men to a stretcher, but they couldn’t get on the stretcher all at the same time.” That last bit, with 12 men on a stretcher is referring to when the ground was really muddy. When that would happen the bearers would line up and pass the stretcher forward, they could not walk because by the time they passed the stretcher overhead they might be up to their waste in mud. Being a stretcher bearer was also a very dangerous job, they were often exposed and they could rarely go through trenches due to all of the corners present in them. I guess I should mention that trenches were rarely straight lines, and they would instead resemble very large zippers if you looked at them from the air, an arrangement done to prevent shell fragments from spreading up and down the line. Even though the stretcher bearer’s job was challenging and difficult, it was still often done, so where were the stretcher bearers taking the wounded soldier?

His first stop would be the Regimental Aid Post. Early in the war this would often be a tent or even just a sheltered spot behind the front, however with the prevalance of trench warfare it soon changed. By 1917 the aid post was almost always a dugout close behind the front where the lighting was poor, the ventilation was also poor, and it would be very cold in the winter. A Dutch Doctor J.A. Verdoorn would tour one of these aid posts later in the war and have this to say about his experience “In this environment of death and suffering, of blood and sweat, the front-line medical officer in charge, physically and mentally exhausted after working day and night, had to ensure the reliable functioning of this part of the chain of medical aid and at the same time more or less decide the fate of each of the countless wounded who passed through the aid post.” The Aid Post would be manned by the Regimental Medical Officer, with a small group of orderlies for direct assistance and then the stretcher bearers to provide transportation of the wounded. While in this example the job of the Medical Officer was to take care of soldiers wounded in battle, the most important job of the regimental medical officer was actually far more, I guess you would call it mundane. These duties revolved around keeping the regiment fit to fight, and that meant preventative medicine and maintaining health and hygiene of the troops. Being a RMO was by far the most dangerous job that doctors could be assigned to during the war, and as such it was often the territory for young men, and they paid for it. The casualty rates for RMOs in the British army was around 40 per 1,000 per month, that is per month. With these young men came another feature of wartime service, something that was not really present at other levels of medical care. These men were around soldiers all the time, and they felt a pull to sort of show how manly and brave they were, or at least how dedicated to the cause they were. They could not fight because they were doctors and so sometimes they ended up overcompensating by putting themselves in dangerous positions so that they could prove how brave they were. This practice and tendency got so bad that the British Medical authorities had to crackdown on the situation. They would send a message to all RMOs that said they were not to take any uncessary risks, and that the most important service they could provide to their units required them to actually be alive. While these moments of danger would occur the overwhelming majority of time spent at the front was by all accounts very boring, which was also a contributing factor in the RMOs search for adventure and danger. Assuming that the RMO was alive when the patient arrived they could expect to be examined by the RMO. Once this examination was complete the RMO would clean the wound, do anything that was absolutely necessary to keep the patient alive and then prepare them for transport. This might mean something simple like spliting a broken bone or bandaging a wound. But it could also mean so much more, the possibilities were almost endless including amputations and other more drastic surgeries. Basically the entire goal of the aid post during combat was to take any patient that could be saved and do whatever was necessary to prepare them for transport to the Casualty Clearing Station. This would also be the first point where patients may be set aside if they were deemed to be too seriously wounded to survive transport.

The next step in the chain would be the Field Ambulance. Before the war these were highly structured units based around the idea that the wounded would have to be transported from the highly mobile front line to a Casualty Clearing Station that would be any number of miles behind the front. This put a huge burden on the field ambulances in terms of the care that they were expected to provide since the exact duration of transport could be quite variable. The British planned for the Field Ambulances to actually carry out most of the work in terms of surgry due to the belief that the transport time would be too long to wait for the patients to reach the Clearing Station. As with so much else, this concept would see drastic change almost right from the start of the war. The Front line was not really moving, the Casualty clearning stations were not moving, everything was static. Therefore the Field Ambulance’s job quickly became one of exacting transport standards, often very short due to the Clearing Stations moving closer to the front. This did not solve the problem of Volume. The British began the war using horse-drawn amublance wagons, but even in the early battles where casualties were comparitively light these proved wholly inadequate. When news reached the homefront about how bad the Field Ambulance situation was a collection was taken up for the purpose of buying motorized ambulances for the field Ambulances. These helped, but would never solve the problem.

During the war the Casualty Clearing Station would become the workhorse of the medical evacuation train, but that was not the initial plan. They were initially designed to be mobile units that would just fill in the link between the field ambulance and the base hospital. They would take in the wounded, treat them in however they needed to once again make them fit for transit, and then expedite their travel. They were designed to be easily expandable and easily transportable due to the expectation that during normal circumstances they would have only very small numbers of men moving through them, then during battles they would have to get much larger. They would also fill the role of the stopping point for sick or wounded soldiers that would soon return to fighting. In essence, they were just sorting centers, passing on those that could travel and be saved, keeping those who couldn’t or would soon be sent back to the fighting. The reality of what they were called upon to do during the war was quite different. With the front so static the Casualty Clearing Stations, or CCSs no longer have to move, and therefore they started to grow both in size and duties. Very quickly the CCSs became, essentially, full on hospitals with surgical work being done in large numbers. Eventually they would be all setup in a simple arrangement that was modular and easily expandable, often involving tents. The first tent was a general admission tent, where arrivals were sorted. Another tent would be setup for patients that were walking wounded, which obviously meant a certain low level of criticality. The next tent would be for patients on stretches that did not require immediate surgery. The next tent would be for those patient who were being prepared for surgery, then of course there was the surgery tent itself, and then a recovery tent. There would be a tent for those under long term care, and another for those ready for evacuation. Of course, since these tents were, well, tents, it was almost infinitely expandable and customizable based on the situation. this type of flexibility was priceless when it came to dealing with the variety of situation and wounds that the CCSs were called upon to deal with. Here is quote from a nurse from one of the CCSs, quite early in the war actually “Our division had the heaviest casualties of any of the divisions who took part in the attack (neuve chapelle) and it was an appalling affair. For three days we never stopped dressing the wounded men as they were brought in, and at the end of those three days we still have something like 60 or 70 stretcher cases outside. We just didn’t know what to do with them. The Major I was with dropped on the floor exhausted and I had to give an anaesthetic for the removal of an arm and I have never given an anaesthetic in my life”

As the CCSs became a more permanent fixture behind the front they also changed in other ways, one of these being the presence of female nurses, previously forbidden from the CCSs because they were considered to be too close to combat. This change in the role of female nurses represented an important change in how women were treated and employed by the armies but it did not mean that CCSs were totally outside the scope of danger. They still fell victim to attakcs from the air, a threat that continued to grow as the war progressed. They would also be under more direct threat during the campaigns of 1918 when the Western Front finally became more mobile after four years of stalemate. There were some organization changes during the war to try and cope with the number of patients that would flood into the CCSs, one of these was the idea that the CCSs should work in pairs so that they one could fill up, then work through its patients while the other filled up. This worked to some extent but did not solve the problem that would inevitably occur when both of the pair were at capacity. During the war the British CCSs went from operating on just 5 percent of the cases that came through them in 1915. By 1917 that number had risen to 30%, so if you were a patient who needed surgery there was a 1 in 3 chance that it occurred in the CCS instead of at the field hospital far behind the front.

In many cases the final stop on the path of a wounded soldier was the Field Hospital. The path to these hospitals was often manned by trains that would take the wounded from the CCSs to the hospitals which were often permanent buildings, often pre-war hospitals behind the front that were commandeered by the military. These were often subdivided into general and specialist hospitals with all cases coming through the general hospital before some cases were moved to the specialist facilities, which seems pretty similar to the hospital setups we have today. At these hospitals could be found all the latest medical technology with x-ray machines, specialist operating rooms, including neurosurgery. This would either be the end of the line for the soldiers that were thought to be at some point capable of returning to duty. For those patients who were not going to be able to return to the front this would be the second to last stop, with the final stop being hospitals back in their home country.

Just to sum up here, I would say that the medical services during the war did the best that they could. They were put in a situation where they were ill prepared for, the volume of patients they would be called upon to treat while also facing injuries that they were not trained to deal with. Did they always get it right? No. But I do believe that they did their absolute best to help as many patients as possible, and sometimes that is all you can do. I will leave you today with a slightly less inspiring quote from a French Doctor, Doctor Duhamel who would attempt to describe his visit to a Casualty Clearing Station in the aftermath of a major attack late in the war. I include this here at the end because it is often easy to come away from these discussions with a sterilized view of what the situation on the ground was actually like for patients and doctors during the war. Hopefully this account can leave you in a place that closer to reality. “The brutality of circumstances, the relief of units, the enourmous sum of work, all combined to create one of those situation which dislocate and overwhelm the most willing service. We opened a door, and the men who were lying within began to scream at the top of their voices. Some, lying on their stretchers on the floor, seized us by the legs as we passed, imploring us to attend to them. A few bewildered orderlies hurried hither and thither, powerless to meet the needs of the mass of suffering. Every moment I felt my coat seized and heard a voice saying “I have been here 4 days. Dress my wounds, for God’s sake” and when I answered that I would come back again immediately, the poor fellow began to cry “They all say they will come back, but they never do””