Medical War Pt. 3

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Hello everyone and welcome to History of the Great War Premium Episode number 28. So far in this series we have discussed a lot about the logistical side of getting doctors into the army and keeping them at the front, but we have been very light on discussing what these doctors were actually doing, that ends right now. This episode will be completely focused on how and why medical care during the war ws provided. The reasons why many treatments were performed as they were often going far outside a simple history of the war, or even war adjacent activity, and starts digging into the history of medical science as a whole. We will touch on those subjects when we need to. The First World War would be the first major conflict that utilized many technologies that would seem very familiar to modern life, techniques like blood transfusions and technologies like antiseptics would be available for the first time and would be used to heal battlefield wounds and save the lines of countless soldiers. What these new technologies provided, and how they were used on the battlefields of world war 1 will be a big part of this episode. As a programming note, the next episode will be focused on the journey on a wounded soldier from the battlefiedl to the base hospital and even back to their home countries.

As with everything in the war the medical world was completely unprepared for what they would be forced to do once the war started. One of the reasons for this is that doctors, both military and civilian had gotten used to a very clean environment when they were treating injuries. For civilian doctors an aseptic environment was the normal, with most wounds free of any great contamination of bacteria or any other foreign objects. This meant that during their civilian lives they may have used a few minor antiseptics, but that was often more than enough to handle almost all civilian wounds. On the military side, at least for the British, they also believed that most wounds would be aseptic. This was caused by their experiences during the Boer War. During that conflict most of the fighting had occurred on the South African Veldt, or uncultivated and very natural land. In this environment there was a very low risk of infection, and the British army developed treatment processes around this type of environment. Here is Major A.J. Hull to explain “the surgical experiences of the present war 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 dression, which was not removed until the patient reached a base hospital, proved successful […] the experience in the presetn war is otherwise, and the treatment of wounds by an undisturbed dressing is to be deprecated.” The reason that the wounds were different on the Western Front was due to the highly cultivated land that was often being fought over in northern France and Flanders. Another problem was the types of wounds that were being experienced. Gunshot woulds, at least at this point in history, were often quite clean wound, the bullet would go in, penetrate through the body, and then exit. However, artillery wounds were the exact opposite, oddly shaped bits of metal spinning and flying around absolutely wrecks the human body, creading oddly shaped wounds contaminated with flying debris and other nastiness. For these reasons the doctors would have to figure out a new way to treat battlefield wounds, or infections would simply run rampant.

When the war started many doctors, even experienced ones, were suddenly in unfamiliar territory. Here is H.S. Souttar who would be one of the British Medical Officers present at some of year battles in 1914 “With surgery on rather bold lines it was extraordinary how much could be done, especially in the way of saving limbs … We were dealing with healthy and vigorous men, and once they had got over the shock of injury they had wonderful powers of recovery. We very soon found that we were dealing with cases to which the ordinary rules of surgery did not apply. The fundamental principles of the art must always be the same, but here the conditions of their application were essentially different from those of civil practice. Two of these conditions were of general interest: the great destruction of the tissues in most wounds, and the infection of the wounds which was almost universal.” Beyond the wounds caused by combat there were other difficults for which the medical profession was unprepared for. One of these was the delay that was often experienced between when a casualty occurred in the front lines and when they were able to be brought in for medical treatment. There was also the prevelance of mud and dirt on everything. Then there were other, complicating, factors that began to crop up in late 1914. Over the winter of 1914 to 1915 rain and cold led to large outbreaks of trenchfoot and frostbite, to try and combat these maladies there was a new Army Routine Order, number 554 which was issued in January 1915. In this order men were told to wipe their boots with whale oil before going into the trenches, and that they should regularly wash and dry their feet, and most importantly change their socks.

Trench foot was just one example of how unprepared Medical Officers were for what they were now facing. Even doctors with military backgrounds were suddenly in very unfamiliar circumstances. In this regard the British were joined by the large continental armies as well. In the German and French armies for ecample, even though many doctors had served some time in the military due to mandatory conscription, they often did not spend this time as Medical officers. When they had served their time in the armed forces it was often in traditional units of cavalry, artillery, and infantry and while this did give them some experience in military life it did not help them when they were called upon to be medical officers. Many British doctors did not even have any military experience to fall back on. An Australian Medical Officer would say in 1915 that having some Medical Officers from the prewar army was invaluable to newly recruited doctors “The presence of two regular officers was of the greatest value, for while they frankly confessed to great ignorance of the science and art of the profession, yet they understood the necessity and the machinery of military organisation and the importance of carefully kept records.” While this gave prewar doctors some leg up on the administrative side, it did not mean that they were totally prepared.

While there were some issues adjusting to military life, the biggest problem for civilian doctors was simply dealing with a completely different set of injuries, in a very different environment, and while acting under a different set of priorities. Civilian doctors rarely interacted with gunshot wounds, let alone artillery casualties, they were doctors with far more experience with sickeness and maybe a severe injury here and there. They were also being asked to work in environments about as far away from their civilian practices as possible. Instead of clean and well-lit offices they might find themselves in a cramped, cold, dirty tent or in a very basic building. They woul dhave less equipment, many more patients, and less help in treating them. On top of these problem they then had to get used to military priorities. During the war there were a large variety of hard choices that had to be made, and this was definitely the case when it came to medical care. This could come in the form of whether or not a man was fit to stay in his unit due to sickness or injury. In this scenario many formerly civilian doctors were found to be far too lenient, with Medical Inspectors having to be very clear that avoiding leniency was critical to maintaining the army. Then it also came in the form of knowing which patients were worth trying to save, and which were beyond help. During large actions there would be a torrent of wounded brought into every medical facility. Doctors had to learn who to treat, and who to set aside, as hard as those decisions may have been they had to be made and no amount of training or experience made it much easier. This led one orderly to describe the kinds of decisions that had to be made all the time. “Stretchers were brought down on which were the mangled remains of manhood. The doctor sees him at once, he says, put him round the corner, he’s beyond all assistance and in three minutes he will be no more. Time could not be wasted on such as those for no earthly power could restore them.”

With so many doctors finding themselves in situations they were unprepared for, training was critical. The facilities for training doctors had to expand just as fast as the armies did, and for the British they would have to expand from almost nothing. Before the war there was only one training depot for medical personnel and it could handl training 800 personnel at a time, already by September 1914 it had to triple in size. this was just teh beginning though, and soon the training facilities around Britain would see a ten fold increase. Early in the war, for the first two years anyway, Medical Officers in Britain were constantly complaining about the training they received in these camps. The primary complaint was that there was far too much drill and not enough training on the medical side. Early in the war many of the challenges at the front began to filter back home and medical officers still in training were frustrated that they were not being properly prepared. While this was true, there was an issue with these complaints, they did not properly appreciate how important being able to lead the military life would play in their lives as Medical officers going forward. These men were, after all, officers, and they would be at least partially responsible for maintaining discipline, so they needed to know what that was. These processes began to change by the end of 1916, but it was never truly possible to prepare the doctors before they shipped off to the front, and it was therefore essential that training continue as long as they were serving in the military.

Training, and the spreading of new information, was accomplished in several different forms at the front. The first was publications created throughout the war. These could range from very specific documents detailing how to handle specific types of wounds to far more general publications. An example of one of the latter variety was the Memorandum on the Treatment of Injuring in the War which was published in the middle of 1915. This document sought to summarize the experiences of all o fthe British hospitals in France since the war started. These types of publications would be produced for the enitre war. The second method of training was through lectures, these would often involve training on new processes and procedures for events like gas poisoning, head injuries, or any other topic that might need to be discused. These lectures were one of the primary ways that new developments were introduced to medical officers. Another way that best practices were moved around the front was through the usage of surgical teams. These teams would move from one area of the fron to enother, often in preparation for large actions. They were full of experienced and capable Medical Officers who specialized in surgery and they were used to supplement the Medical officers behind the front of an attack. This allowed inexperienced Medical officers to see the pros in actions, and then also allowed the surgical teams to back them up in high stress situations. While information was being shared there was initially some hestitation around too strongly recommending and forcing treatments onto doctors. There was concern that this type of behavior would shut down initiative and reduce innovation, although in the short term it would save lives.

One of the big innovations that would be widely used during the war was blood transfusions. The concept of transfusions had been present in medical treatments before the war, but it was still a relatively new method. It had only been in 1901 that doctors began to determine that there were different blood types, which were generally incompatible with each other, which was a critical step to making blood transfusions work. By 1917 blood transfusions were a critical part of treatment at the front. It was recognized that keeping blood pressure above a certain point was critical to getting a patient through even the most drastic injuries and blood transfusions were the best way to make this possible. One of the innovations that did happen during the war, and due to the war, was the ability to store blood for a lengthy time period. Before the war transfusions were done from one person to another, directly, without giving the blood time to coagulate. This was not really a workable solution for the scale of combat during the war but a solutions was found that by keeping the collected blood cold, and then mixing in an anti-coagulant it could be stored for a reasonably long period of time. This allowed for blood banks to be created and then utilized during large actions. It is difficult to overstate how important it was to have this kind of transfusion infrastructure in place when it came to saving lives. When it was combined with efforts by nurses to keep the patients war using blankest, hot water bottles, and heated beds the chances of surviving after even the large losses of blood dramatically increased.

Another big change from previous conflicts was the presence of an anti-tetanus serum. This serum was introduced early in the war, before the end of 1914, and it would soon become a pivotal part of treatment. Even soldiers with the slightest of wounds would be given three doses of serum every week to prevent possible infection. Before this process was created tetanus was what has become the forgotten killer. It is estimated that during 1915 alone tetanus was present in 58 percent of cases that came through the Casualty Clearing Stations, this is a huge number, and was only kept under control and the men were only healed through the use of the serum.

Antiseptics were also a critical piece of the treatment puzzle during the war. This would be one of the last conflicts before the widespread use of penicilin, and so infections were still a very big deal and how to treat them was still very much up for debate. Unlike the anti-tetanus serum and blood transfusions antiseptics were not as readily accepted by the British Medical officers. Even in 1915 they were still not using them in all cases, instead favoring a hypertonic salt solution which was proposed by Sir Almroth Write. He did not believe that would should, or even could, be sterilized with antiseptics and was able to make it standard military procedure to use his salt solution. It would take many years before another solution would be widely adopted with it eventually being the world of Alexis Carrel and Henry Dakin which led to a sodium hypochlorite solution which proved effective at disinfecting wounds, even after this solution was proven it took a lot of work and perseverence to get it adopted throughout the army.

Outside of new technologies and medicines one of the most critical improvements to wound care that would occur on the British side during the war was a change in how wounds were handled, and the change to complete excision was a critical stepping stone away from pre-war mindsets. Before the war the general course of treatment called for as much tissue as possible to be left around the wound, it should just be cleaned and bandaged. In the infection heavy atmosphere of the war this proved to be ineffective and as early as 1915 another way began to be discussed, although it would not see widespread acceptance until 1917. It had also been the practice of British medical officers to only do serious surgical work at the base hosptials, which was a habit that would slowly change as it became apparent that they earlier a wound was excised, the better. Here is Sir Anthony Bowlby who would be one of the leading voices in getting the British to change their processes “[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.” While precise process would differ from unit to unit, here is a pretty good idea of what would happen. Before operating the hands of doctors and nurses would be washed and soaked in a 1 in 20 carbolic solution and utensils and dressings would be sterilized, often using heat. Then the skin around the wound would be cleaned as much as possible and then any tissue removal would happen. This involved removing damaged tissue, paying special attention to get out any foreign objects, mud, debris, etc. Then the wound was cleaned with an antiseptic solution, usually iodine, then it would be washed with saline. Once this was complete it would be dressed and bandaged, which would then be changed on a daily basis. At a high level that was the basic process for wounds caused by bullets or shrapnel, although there were other processes for other types of wounds. Here is Australian nurse Sister Nelli Morrice discussing how burns were treated “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 to the healed edges. Spray Aniline on the raw surface and cover with a thin layer of sterile cotton would, then spay with another application of aniline and bandage with a tick pad of cotton wool. change dressing daily.”

While battlefield wounds are the most obvious and well covered types of injuries sustained during the war, the much more pressing, and ever present type of medical care revolved around diseases and sanitation. Maintaining unit sanitation and helping the sick was actually the primary job of the Medical Officers, and it was something that was well discussed before and during the war. While this had been the job of Regimental Medical Officers before the war, it would of course also have to grow and change as the army grew and changed. There were all kinds of processes that made sense in the small pre-war army that would move around a lot that simply did not work on the static western front. One example of this would be the general process of disposing of human waste, which before the war had been to dig shallow trenches and then cover them back up when they were full. On the western front this did not work, since the lines never moved, and so the recommendation became to incinerate it whenever possible. there were constant inspections of the front line to make sure that everything was up to standard, and these standards were critical in trying to control the spread of disease. While these inspections were first done to keep the standards, it was discovered that they also had another, less concrete benefit. What the British found was that morale increased whenever it was clear that there was a skilled medically trained officer close by. This rise in morale makes sense, by having a Medical Officer visibly present the men felt that they were more likely to be taken care of if they needed it. During these inspections of the front Officers, NCOs, and enlisted men would all be lectured on ways to prevent diseases like trenchfoot, how to maintain a high level of hygeine, and how to prevent gas poisoning after a gas attack. There were also special units setup early in 1914 whose sole job was to move around the front and clean up areas previously occupied by the men behind the front and then to setup sanitary arrangements before more units arrived. By the end of the war there would be 66 of these units working behind the British front, working basically nonstop to try and keep up.

One of the major threats to the health of the troops was rates and lice. Mice were everywhere, carrying with them disease while also contaminating food supplies, but the far larger problem was lice. Lice spread all kinds of diseases from trench fever to typhus. The men at the front would become covered in lice, and no matter how many they killed they always seemed to come back stronger and more numerous than ever. There were efforts to reduce these large lice infestations, men were provided with bathing facilities and clean clothing, but nothing seemed to stop their spread. By 1918 it was standard practice for all clothing to be sent through a delousing pit when soldiers came off the line. These delousing pits would be described as “a dugout in which clothes would be hung or placed on racks, and brick stoves kept lighted in the interior. A simple pit constructed in this way showed that the temperature inside could be raised to 80° or 90° Centigrade, and that this temperature — and indeed a very much lower temperature – killed lice effectually.” Lice feature prominently in many first hand accounts of life in the trenches, and the ways in which soldiers tried to kill them, be it fire, knives, or just squishing them with their fingers make for some interesting reading. That is all for this episode, one small note, I did not discuss the outbreak of influenza during this episode, and indeed I will not discuss it next episode either. I am going to hold off on discussions of it until later this year when we will doe at least 2 episodes on the spread of the 1918 influenza pandemic during the main episodes. Thank you for listening, and thank you for your support.