Military Medicine in World War I
Roman Wound Care
Care of the injured soldier is as old as war. And war is as old as history. Perhaps older. People were fighting and hurting one another back into the old stone age, long before organized societies and armies. Military medicine goes back a very long way. In fact, to the very first civilizations. From around 4000 BCE to around 1500 BCE, organized civilization arose separately in Mesopotamia and Egypt; the Indus River valley, present-day Pakistan and India; the Yangtze River valley in China; and the Americas, meso-America and the Andes. All were agriculturally based, and featured organized governments and armies supported by hereditary ruling and military castes. Without exception, all were warlike.
Even in the ancient world, all armies had to care for their wounded. But the civilizations themselves varied widely in their underlying medical institutions. Some cultures had such rudimentary medical care that wounded soldiers were given hardly more than token care, others had fairly sophisticated treatment of wounds. Roman military medicine most closely approached what we have today. The Roman army had organized field sanitation, well-designed camps, and separate companies of what we would now call field engineers. They had a much better grasp of sanitation and supply than anyone else before, or for a long while after. They had medical corpsmen, called immunes. They practiced front-line treatment, with evacuation through well-organized supply and logistics chains. Because of their improved sanitation, their armies suffered somewhat less from the epidemics which swept military camps. But that was only by comparison with their opponents. Two-thirds of their casualties were still due to disease. Their world-view included no such thing as bacteria or protozoa. Immunizations were two millennia in their future. And, perhaps most important, their practices did not outlive their empire.
After the Romans, medical care on the battlefield became disorganized, almost an afterthought. In the Middle Ages and the Early Modern period, medical care was done by whoever was nearby. This meant local surgeons, camp followers, servants, and whoever else would volunteer or be conscripted. Armies were small. The famous battle of Crecy, for example, in 1346, was fought between an English army of 10,000 men, and a French army of 20,000. Camp sanitation was totally unheard of, and disease ravaged armies of the day. Until the 20th century, at least twice as many soldiers died from disease in camp than from wounds on the battlefield.
What is military medicine? Today’s military medicine is an amalgam of trauma care, infectious disease treatment, preventive medicine, and public health. All of these are important. Trauma care includes not only the treatment of wounds, but also the rescue of injured soldiers, their evacuation, and the provision of a graded system of care from the front line to hospitals far in the read.
Equally important is infectious disease care and preventive medicine. Anyone who has been in military service can testify to the large number of immunizations they received. These have controlled the diseases that caused most of the casualties in previous centuries. Those that cannot be controlled by immunizations can be treated. Today’s antibiotics and other treatments are vital in military medicine. Unhappily, antibiotics were not available in World War I, and diseases such as pneumonia, dysentery, and tuberculosis continued to claim victims.
Public health, including environmental medicine, is recognized as a crucial part of military medicine. Disease agents such as mosquitoes can be controlled. Water supplies are routinely treated. Human waste is controlled and not allowed to spread disease. Environmental medicine is a large part of this. Wars are not usually fought in nice places. Even when they are, as in Flanders and northeastern France, those places quickly become adverse environments.
French Soldier in a Trench
The First World War was fought largely in the trenches of the Western Front. That’s not the full story, but it was a dominant part of the war, and remains the public image. Trench conditions were miserable from a military standpoint, but a disaster for public health. Sanitation was so bad that after a week or two in the trenches, troops had to be rotated back of the lines to be deloused, thoroughly cleaned, and provided with fresh clothing and equipment. Even so, disease was common, and wound contamination universal.
Wounds were usually contaminated with the mud of the trenches. Tetanus immunization was available, and wounded soldiers were routinely given tetanus toxoid. Wound care was much better than during previous wars. It emphasized debridement of devitalized tissue and thorough cleaning with antiseptic solution (Dakin’s solution). Aseptic technique was (usually) used in operating rooms. General anesthesia was available. Bowel injuries could be routinely repaired. Intravenous fluids were available, as were blood transfusions (sometimes). Radiography had only been invented some 16 years before, but was deployed on the battlefields by 1914. As an index of how much things had changed, mortality following amputation had been 25% in the American Civil War, and was 5% in World War I. Deaths from wounds dropped, but deaths from disease dropped even further. Far fewer soldiers died of disease as a percentage of total deaths than ever before. And this was despite the influenza epidemic of 1918-19, which claimed many victims at the end of the war.
Aid Station in a Trench Dugout
Even acknowledging all of the difficulties imposed by trench conditions, the casualty care system was still much better than in any previous war. Specialized military units, called ambulances were charged with picking soldiers from the battlefield and transporting them to aid stations, and then to field hospitals. For further evacuation, hospital trains were staffed with nurses and orderlies, and equipped to care for even difficult wounds. There were base hospitals and convalescent facilities both on the French coast and in England. As the American Army deployed to Europe in 1917-18, hospitals, doctors, nurses, and ambulances went with them.
The First World War claimed 9 million soldiers, and 7-10 million civilian lives. Civilian casualty estimates vary widely, and the true figure is probably unknowable. In 1918-20, over the course of the influenza epidemic (misnamed the Spanish flu), some 20 to 40 million people died. Half of all American soldier deaths from disease were due to influenza, many in training camps in the United States. Did the war cause the flu epidemic? Perhaps so. Certainly, it created the conditions in which the epidemic began and spread. The question has been debated ever since. Whatever its cause, the flu epidemic killed more people than the war itself.
Practice of Medicine
Precedents for American military medicine
British Regimental Aid StationModern military medicine is a product of the 19th and 20th centuries. At the beginning of the 19th century, the organized practice of military medicine began. However, it didn’t reach its modern form until the beginning of the 20th century. American military medicine during World War I represents the coming of age of modern military medicine. But it built on the achievements of the previous century.
The epic Napoleonic wars, which began the 19th Century, were on a previously unheard-of scale. Armies of 100,000 or more raged throughout Europe. This forced the recognition of a need to care for the wounded, and to provide some organization to the medical system. This was done best in the French army.Dominique Jean Larrey, Napoleon's Surgeon
Dominique Jean Larrey, surgeon-in-chief of French armies from 1797 to 1815, contributed in many ways to modern military medicine. He established the criteria for “triage”, which is why we still use a French word to describe sorting casualties into urgent, emergent, and delayed treatment. He invented the “ambulance volante”, or flying ambulance. These were horse-drawn carriages, which could move quickly around the battlefield to provide evacuation. He staffed ambulance units with corpsmen and litter-bearers, placed aid stations just behind the battle, and formalized the use of field hospitals a few miles back from the battle. He is considered to be the first modern battlefield surgeon.
Civilian medicine made impressive advances over the course of the 19th Century, during the 100 years between the Napoleonic wars and the Great War. Perhaps first and foremost, medicine became an organized and respected profession. And not only doctors, but nurses, dentists, and veterinarians. The increasing status of medicine in civilian life carried over to the military. Medical professionals were not only better-established in the military services, they were heard at the highest levels.
The theories of disease and infection, and immunization, had its roots in the 18th century, but became firmly established through the 19th. These had great implications for military medicine. By the end of the century, immunizations for tetanus and typhoid fever were available, and there was effective prophylaxis for malaria. Typhus was known to be transmitted by body lice. These could be controlled by periodic delousing and other measures. Yellow fever was controlled by eliminating the mosquito vector. And the correct identification of bacteria as a cause for wound infection enabled effective treatment for wounds, and prevention of many, although not all, wound infections.
Surgery made great strides. The development of general anesthesia meant that longer and more sophisticated operations became practical. Operations were done with sterile technique, and then aseptic technique. Abdominal surgery became possible, and its development over the last half of the 19th century was rapid and dramatic. Equally, general anesthesia made possible more extensive treatment of wounds. Such measures as débridement of wounds (another French word) prevented infection and promoted healing. One of the great advocates of débridement was Alexis Carrell, a French-American surgeon who won the Nobel prize in surgery for that and other contributions. Local wound antisepsis with measures such as Dakin’s treatment was developed. These advances are discussed in more detail elsewhere (Wounds and Injuries), but taken in sum, they made military surgery far more effective.
X-ray of Forearm
Other aspects of medical therapy, were advancing rapidly. Intravenous fluids were available by the time of the great war. Early blood transfusion was available, but its use was uncommon. Blood banking was not developed until after the war. The existence of x-rays (“roentgen rays”) was established only in 1898, but their use in diagnostic medicine was firmly established by 1914-18. the Curie Institute in Paris, named for the chemist and physicist Marie Curie, was actively training doctors and technologists in the new field of radiology. Equipment was sufficiently portable to be carried to the battlefield. Medical laboratory studies became available, and incorporated into battlefield medicine.
The development of what we now know as modern military medicine occurred over the course of the late 19th century, and into the 20th. It evolved through major wars, sometimes in adverse environments. This evolution took place across Europe as well as in North America. In the case of Europe, those were the Crimean War and then the Boer War, in South Africa. In the American experience, this was the Civil War and the Spanish-American War.
While military medicine by the beginning of the 19th century looked much better than at any time in the previous millennia and a half, both trauma care and military public health were primitive by today’s standards. The development of what we now know as modern military medicine occurred over the course of the late 19th century, and into the 20th. This evolution took place across Europe as well as in North America. Medical and trauma care made slow progress during the limited wars of the 19th century. It evolved, through major wars, sometimes in adverse environments. In the case of Europe, those were the Crimean War and then the Boer War, in South Africa. In our experience, this was the Civil War and the Spanish-American War.
American Civil War Hospital
The American Civil War (1861-65) was fought with mass armies, modern industrial technology, railroad transportation, and telegraphic communications. Unfortunately, its health care was barely up to the 18th century. Both armies had physicians, and organized medical corps. There were systems of aid stations, field hospitals, and medical evacuation on both sides. But they usually failed to meet the huge demands placed upon them by the large numbers of casualties. Both armies depended heavily upon civilian physicians and makeshift facilities to care for their injured soldiers. Even “army doctors” were often contracted civilians. Further, public health was not well developed. Twice as many soldiers died of disease as of injuries, often in training camps far from the battlefield. Sanitation was poor. Epidemics of dysentery, pneumonia (“camp lung”), and typhus swept both armies. These systematic failures were widely recognized among the medical profession, and there was a growing movement to improve military medicine.
The brief Spanish-American War (1898), was fought in the tropics, notably Cuba and the Philippines. Typhoid, yellow fever, and malaria were new to American troops. Disease killed five times as many soldiers as did enemy action. There was inadequate organization, too few medical supplies, and poor use of resources. The war was highly publicized in the newspapers of the day. After the war, there was a great public outcry about the number of soldiers dying from disease. The so-called “typhoid board,” often called the Reed commission, was set up during the war, and made a number of recommendations about sanitation, malaria control, and mosquito control. The Reed commission paved the way for the construction of the Panama Canal, overcoming the high rate of yellow fever among the workers in previous attempts to dig an Atlantic to Pacific canal.
Dr. Walter Reed Walter Reed chaired the typhoid board. He was an outstanding Army physician, one of the true heroes of the Army medical corps. He had immense influence during and after the war. He died in 1902, of appendicitis, but his work was carried on. The subsequent Dodge commission conducted a much more comprehensive review of the shortcomings of the Army medical services. These included poor preparation, poor sanitation in the camps, and failure to organize nursing services. As a result, there was a major re-organization of the Army’s medical support. During the first decade of the 20th century, the Army recognized the need for doctors, nurses, hospitals, corpsmen, and, in short, today’s medical services. Immediately prior to World War I, the Army was headed by a chief of staff who was a physician, Leonard Wood. He oversaw much of the transition of the Army medical service into a modern military medical system.
Re-organization of the Army medical service began in 1901. Among other changes, the Army Nurse Corps was established. The Medical Corps was recognized as a formal organization in 1908, although the term had been unofficially used for over a century. Today’s Army Reserve began as the Army Reserve Medical Corps, in 1908. It was established as a way to identify and mobilize civilian doctors in the case of war. These efforts were a major change in the medical care of soldiers. And fortunately, they happened in time to provide the framework of medical care in World War I. For example, the Army Nurse Corps, only 200 in 1901, expanded to 20,000 by the end of 1918.
The public health aspects of military medicine lagged behind medicine in general. The importance of public health in military medicine was poorly recognized through most of the 19th century. A famous comment made by a Civil War general to a medical officer was, “Don’t worry. All Army camps smell that way." The story is probably apocryphal, but it expresses a general attitude. There was a sort of pessimistic complacency. Senior officers knew that if they could keep down losses from disease, they would have more men to fight. But they didn’t think anything could be done. Even if it could, they didn’t want to do it themselves, and they often failed to listen to the doctors. This changed. Public health finally came into its own as a crucial component of military medicine in the early 20th century.
American military medicine during World War I was able to incorporate many advances of the previous 60 years, and apply them on the battlefield. The great accomplishment of the war was to take the best of civilian medicine in 1917, move it overseas, and apply it on the battlefield. To accomplish this, some of the finest American physicians of the day, such as George Crile, Harvey Cushing, and the brothers William and Charles Mayo, served during the war. (See "Mobilizing of American Medicine")
Practice of Medicine
Mobilization of American Medicine in World War I
Base Hospital 20, Châtelguyon
The Army was not well-prepared for the Great War. Less than 20 years earlier, the Spanish-American war was a medical wake-up call. Poor organization and lack of preparation resulted in adequate casualty care and very high rates of disease. Five times as many soldiers died from disease as were killed by enemy action. The resulting public outcry had prompted reform of the military medical services, chiefly the Army. As a result, the Army Medical Department had done a great deal to prepare for war. The Medical Corps had been formalized, the Army Nurse Corps formed, and training had been greatly improved. A Medical Reserve Corps had been established to provide doctors to the active services in the event of war. Later in 1917, this became the Officers Reserve Corps, and would eventually grow into today’s Army Reserve. An Army Medical School was established in Washington, DC. But even with all these preparations, the Army was still not ready for a war of million-man armies, and huge battles.
When the United States declared war, the entire US Army was 120,000 men. The Medical Corps was proportionally small. There were 491 active duty Army doctors, including reservists. By war’s end, 30,500 physicians were supporting the troops. The Army Nurse Corps was 403 officers, with a sizeable reserve of 8,000 Red Cross nurses. Before the war ended, over 20,000 nurses would be serving on active duty. Dentists were in the Dental Section of the Personnel Division. It went from 86 officers, mostly contract dentists at examining stations, to 5,000. A separate Dental Corps was established after the war. All of these were professionals, commissioned officers. They were supported by far larger numbers of enlisted men: orderlies, technicians, stretcher bearers, ambulance drivers, and many others. These numbered 6600 at war’s outbreak, but rose to over 250,000 by war’s end.
Veterinary Corps PosterAnd then, there was the Veterinary Corps, which was newly created, and contained 62 officers at the start of the war. They were responsible for food inspection and for animal care. Like all other armies of the day, the US went to war with horses and mules in large numbers. Motor vehicles, even heavy tractors, were simply not up to the demands of the battlefield, particularly pulling artillery and other heavy equipment. Horses and mules were used for all those things. Officers rode horses, to be able to get around the battlefield. The large number of animals required a significant amount of veterinary care. Besides veterinarians, who were officers, there were enlisted veterinary specialists, as well as blacksmiths, farriers, and an array of others.
A new Ambulance Service and a Sanitary Corps were created. Besides providing organizational structure for both of these essential functions, they also provided a way to supplement the limited supply of physicians with other professionals who could carry out non-medical duties. Engineers, public health administrators, bacteriologists, chemists, and other experts could be brought into the Sanitary Corps.
Facilities and supply were limited. In 1917, the Medical Department could staff seven field hospitals and nine ambulance companies. There were 38 field hospitals and 26 ambulance companies in the National Guard. At this time, the Guard was under the control of the governors of the individual states. Supply was equally limited. There was some expansion capability, but planning had envisioned an Army of 300,000 men, not more than 3 million.
The recruiting and training of civilian physicians and surgeons was the most obvious and pressing need. The American Medical Association, which included about two-thirds of practicing physicians, was indispensable in this effort. Screening its list of members, some 69,000 letters were sent out to physicians under fifty, asking for volunteers. Some 10,000 joined in the first three months alone. Four training camps were set up just for medical officers, at Fort Riley, Kansas, Fort Oglethorpe, Georgia, Fort Benjamin Harrison, Indiana, and Fort Ethan Allen, Vermont. Other camps trained enlisted specialists, including stretcher bearers, the predecessors of today's medical corpsmen, nursing assistants, operating room technicians, ambulance drivers, and many others.
William Mayo 1917The famous Mayo brothers, Charles and William, were in the Reserve. They were instrumental in mobilizing the American Medical Association to support the war effort. Both were promoted to Brigadier Generals after the war, and continued to support the Army Reserve efforts.Charles Mayo, 1917
Establishing base hospitals was an early priority. These were mobilized, staffed, and equipped with the support of the Red Cross. Six hospital units, consisting of personnel from major teaching hospitals, went overseas in May, 1917. They were assigned to support the British army, as no American units were yet in combat. The first of these was Base Hospital Number 4, from Cleveland, leaving for England on May 8. It was headed by Dr. George Crile, one of the leaders of the surgical profession, a professor of surgery at Western Reserve University. Dr. Crile had previously served in Europe as part of a hospital from Western Reserve supporting the allies, and it was he who originated the concept of base hospitals drawn from individual communities. Harvard University’s Base Hospital Number 5, shipped out a few days later. It was led by Dr. Harvey Cushing, a world-famous brain surgeon, who had also served in Europe previously. Eventually, many hospital units were sent from communities and teaching hospitals, including the University of Kansas, Duke University, Bellevue Hospital, Washington University, Johns Hopkins, and many others.
Drs. Crile and Cushing were Majors (later Colonels) in the Reserve Medical Corps. The two of them were instrumental in mobilizing the American College of Surgeons to support the war effort. Once in England, Crile was detached from his hospital, and moved to Paris as the US representative to the Interallied Surgical Congress. He actually arrived in Paris before the AEF headquarters arrived in France. He had to issue his own orders. As he put it, for a brief time, “I was the US Army!”
SS BalticPershing and his headquarters arrived in early June. On the same ship, the SS Baltic, came Base Hospital Number 19, the Johns Hopkins unit, which was to set up the first base hospital for American troops in France. With Pershing was his nominee for chief surgeon, Col. Merritte Ireland. In the event, however, Col. Alfred Bradley, who had served as an observer with the British, was named chief surgeon of the AEF. Ireland eventually replaced him.
The Red Cross hospitals in Europe, established in support of the allied armies, were an invaluable resource. Hospital units at all levels above field and evacuation hospitals were consolidated under the Services of Supply. This system worked well enough, but there was considerable organizational confusion. Camp hospitals, for example, were local, and under the control of the local or divisional commanding general. Hospital centers and base hospitals, on the other hand, were controlled through the chief surgeon of the AEF. The total number of hospital beds grew from 30,000 in May, 1918, to 260,000 by the end of October, with the Meuse-Argonne offensive in full swing. Too, by the end of the war, the influenza epidemic was claiming an ever-increasing number of victims, and requiring increasing numbers of hospital beds.
Harvey Cushing 1917Surgeons were in short supply even among the allied armies, and the influx of American civilian surgeons was extremely helpful to the allied armies. Orthopedic surgeons were in particularly short supply. A group of 20 orthopedic surgeons tasked with supplementing British hospitals was sent with Base Hospital Number 21, from Washington University in St. Louis, Missouri, in May, 1917.
Medical supply came under the General Munitions Board, a branch of the Council of National Defense, established on April 8, 1917. Congress authorized $1 million for supplies and equipment but this was completely inadequate. By June, $30 million was authorized. The medical supply system was hampered by this initial lack of funds, and also by a very rigid procurement system. Supplies were short throughout the American involvement in the war. After the war, there was significant back-biting over the alleged deficiencies of the medical supply system.Ford Ambulance
Ambulances were a priority. The Red Cross had a number of ambulance units in France, and many of these were simply transferred to the control of the US Army. To provide the numbers needed, General Motors was contracted to supply 2300 ambulance bodies, to replace the lighter and more fragile Ford ambulances. Both types continued in service until the end of the war.William Crawford Gorgas
The Surgeon General at this time was William C. Gorgas. He was famous for his work on typhoid fever and tropical diseases in general, and his influence with Congress was critical in moving up the priorities for medical recruitment and supply. Without him, the medical effort would have received a much lower priority, and might well have proved a national scandal. But he was old, and ready to retire. When he resigned in October, 1918, he was replaced by Merritte Ireland, now a major general. Ireland subsequently proved to be perhaps the best surgeon general in the history of the Medical Department.
Merritte Ireland These two strong leaders, Ireland in Europe and Gorgas at home, greatly facilitated the medical support of US forces in Europe. The effort was hurried, over-stretched, and hampered by obstacles both large and small. But medical support of the American Expeditionary Force was a real success, and became a model for medical care during the next, far larger, World War II.
Practice of Medicine
State of American medicine in World War I
American Red Cross Hospital
We think of medicine 100 years ago as relatively primitive when compared with today's. But medical science had in fact progressed rapidly over the previous half-century. This section will review the state of medical practice in 1917, with particular attention to those areas relevant to military medicine.
Medical education, the foundation of all medical practice, was undergoing a revolution. The Flexner Report was published in 1910, condemning most proprietary schools and holding up as examples university-based schools such as Johns Hopkins and Case Western Reserve. Today, all schools adhere to Flexner’s standards. In 1917, the newer and better schools, such as Johns Hopkins, were active in supporting the military medical effort. Base hospitals were sent to Europe staffed by Johns Hopkins, Harvard, Western Reserve, Washington University, Duke University, and the Universities of Kansas and Michigan. Leading organizations, in particular the American Medical Association and the American College of Surgeons, strongly supported the effort. Still, the Army had to provide additional training for most physicians, to enable them to practice in the military environment, and to educate them about such threats as gas warfare (see Mobilization of American Medicine).
Surgical techniques were relatively sophisticated. Antisepsis, and the newer practice of aseptic surgery, was universal. The bacteriologic origin of wound infections has been proved for decades. Surgical instruments were routinely cleaned and sterilized before use. Instruments were similar to today, although there were none of the motorized drills and saws used in today’s orthopedic surgery. Anesthesia depended on ether or ethylene oxide, usually combined with nitrous oxide, and was given by mask or an open drop technique. Surgeons could effectively operate upon most parts of the body. Surgery of the extremities, while much less sophisticated than today, was quite adequate to deal with broken bones, joint injuries, and soft tissue trauma. Abdominal surgery was well-developed. Most abdominal injuries could be treated surgically, assuming the patient could be evacuated quickly. Thoracic surgery was, however, in its infancy. Operations on the chest were difficult and hazardous, in large part because endotracheal anesthesia, while known, was not generally used. Chest tubes for drainage of injuries and air were also known, but not widely used. Empyema, or infection of the chest following injury, was a difficult problem, with a 30% mortality in base hospitals. An Empyema Commission was established in 1918 to make recommendations, but it came too late to make much difference.
Operating Room, Base Hospital 28, Limoges
Medical techniques were also relatively modern. During the previous decades, immunization had become available for tetanus and typhoid fever, and both were universally given to soldiers. Smallpox vaccination was universal. Prophylaxis for malaria was known and available. On the therapeutic side, intravenous fluid therapy was available. It was used both for medical diseases such as diarrhea, and surgical diseases such as hemorrhagic shock. Blood transfusions were available and were used by 1917, thanks to pioneering British and American physicians. They were not very common, and blood banking was yet in the future. Treatment of sepsis and shock were not very advanced, but the importance of supportive care was recognized. Nutrition as a factor in preventing and treating illness was recognized. Army rations had advanced far beyond the “hardtack and bacon” of earlier wars.
Mandatory Typhoid ImmunizationsCommunicable diseases were well known. Such techniques as quarantine, control of the water supplies, and basic hygiene limited the spread of epidemics which had formerly ravaged Army camps. Nonetheless, some 57,000 American soldiers died of disease, at least half from the epidemic of H1N1 influenza of 1918-20. Aside from the flu, discussed below, the most common cause of illness and death was pneumonia (“camp fever”), but gastroenteritis, measles, mumps, and meningitis were also common. A major limitation was the lack of effective treatment for infectious disease. Antibiotics were still 20 years in the future. Diseases like pneumonia, empyema (see above), and tuberculosis, still were lethal. Much could be done by screening soldiers on admission for communicable disease, by isolating camps from one another, and by moving ill soldiers to quarantined quarters. But the crowded training camps and troopships remained ideal incubators for epidemics, and the techniques of the day were simply not adequate. Disease actually killed more Americans than did injuries, although by a small margin. Still, considering that disease killed twice as many soldiers as injuries in the Civil War, and five times as many in the Spanish-American War, considerable improvement was evident.
U.S. Casualties 1917-1919
Control of venereal diseases was primarily prevention. There were treatments for syphilis, but these involved mercury compounds, toxic in themselves. Gonorrhea could be treated with local antiseptics, a process best left un-described. Antibiotic treatments. which have today relegated these scourges to mere annoyances, didn’t exist. Treatment was primarily a matter of waiting for them to heal. These were also a serious discipline problem, which meant that the medical system became involved with the Army judicial system.
Psychiatry had been well established for a half-century or longer in the US. But Army psychiatric care was not up to dealing with the cases of shell shock which began to appear. While this was not nearly as great a problem for the AEF as it was for the British and French, care of these casualties was difficult. There was no consensus on the appropriate treatment. Unlike the British and French, American practice was to give soldiers a rest for a day or two, feed them and clean them up, and then get them back to their units if at all possible. Only severe cases were evacuated. Probably, this resulted in a lower rate of disability and later post-traumatic stress disorder. But no one will ever really know.
Alcoholism was a major problem. The tradition of heavy drinking among soldiers was long-established. Then too, young men away from home for the first time have a tendency to binge drinking. The appropriate role of alcohol in society was undergoing a great revolution at this time. Prohibition was enacted in November, 1918, after a long campaign by the “drys” to outlaw drinking. Alcohol was banned from Navy ships around this time, because Josephus Daniels, Secretary of the Navy, was a strict prohibitionist. Newton Baker, Secretary of War, was a “dry”, as well. The Selective Service Act of May, 1918, banned alcohol on or around all military bases. These regulations simply drove drinking underground, and the medical service was often left to pick up the pieces.
X-ray TruckRadiology was in its beginnings. Roentgen rays had only been discovered 20 years earlier, yet their use in medical diagnosis had become well-established. However, only the largest Army hospitals had this equipment. Its use in bony injuries and in trauma in general was obvious. Even the early equipment of the day provided a great advantage in being able to see fractures and foreign bodies such as bullets. But the equipment was complex and bulky. “Portable” x-ray machines required a small truck. A Division of Radiology was established in 1918, to facilitate training and equipping units with x-ray machines. Equipment remained in short supply until the end of the war.
American medicine in the second decade of the 20th century was surprisingly capable. Few injuries were beyond the reach of the surgeon’s care, excepting brain injuries and chest wounds, Even these could often be treated effectively. Communicable disease remained a constant problem, but sanitation, water treatment, and hygiene were far advanced from the previous century. Psychiatry was still developing, and the effective treatment of “shell shock” and combat fatigue in general remained controversial and uncertain. But the picture overall was still encouraging. Wounded soldiers who were able to reach care survived at a rate over 95%. Deaths from disease were half the rate of earlier wars. Immunizations could prevent some of the most troublesome diseases. For all of the haste and inevitable confusion of moving large numbers of medical personnel and equipment across the Atlantic and setting up in the field, American medicine was able to meet the challenge of the Great War.
Practice of Medicine
Public Health and Sanitation
Sanitary Corps Insignia
Public health has always been important to armies. Wars have been decided by disease. For example, Napoleon’s invasion of Russia in 1812 failed as much because of typhus, a louse-borne disease, as because of the Russian army, or for that matter, the Russian “General Winter”. In the American Civil War, disease killed twice or more soldiers than enemy action. In the Spanish-American War, between 5 and 9 times as many soldiers died of disease as of wounds in battle. Public health includes things like clean food and water, sewage disposal, insect control, and the design and maintenance of encampments. Up until the Great War, all of this was the responsibility of the military commander, advised by military physicians. But as knowledge of diseases and their prevention grew, this simple approach became more and more inadequate. As the Army expanded in the Great War, Surgeon General Gorgas established the Sanitary Corps. Its purpose was to recruit officers who had "special skills in sanitation, sanitary engineering, in bacteriology, or other sciences related to sanitation and preventive medicine…” By the end of the war, it had expanded to 2900 officers, freeing medical officers to care for patients, and making specialized expertise available to commanders. The Sanitary Corps was the predecessor of today’s Medical Service Corps.
Consider the problems of maintaining an Army division in the field. As organized in World War 1, an American division included 27,000 men, plus another 10-12,000 support troops. Even at 12 men to a tent, that’s a lot of tents, spread out over a large area. Simply providing latrines is a major engineering effort, not to mention waste disposal. Add to that bringing in clean water every day, enough food for tens of thousands of soldiers, providing as many as 200 mess halls, and carrying out the resulting trash and garbage. Then consider the horses. Even in an Army which had little horse cavalry, the division still had a regiment of cavalry, plus enough other horses for officers. Horses require still more food and water, and the waste disposal was a chronic problem. Not to mention flies. Then, disease prevention, which includes keeping down mosquitoes, making sure troops are lice-free, setting up quarantine wards for soldiers with communicable diseases, and vaccinating for smallpox and typhoid, and yellow fever in tropical environments.
Before the American Army could be sent to France, it had to be gathered up, and trained. The goal was to send two million men to France. The first major job of the Army Medical Department, for which the Sanitary Corps was crucial, was to oversee inducting those men into the Army, help to set up a large number of training camps in the United States, and ensure that those camps were as disease-free as possible. Bringing young men in large groups into communal living, often in tents, was then and is now an invitation to epidemic disease. Some 40 camps were set up, with about half being in the states of the old Confederacy. Many were in former National Guard camps, others were new. In all cases, large numbers of barracks, classrooms, mess halls, laundries, dispensaries, hospitals, and other facilities had to be built.
As units began to move over to France, more facilities were built to house and train the new American army. Before advancing to the front lines, soldiers typically underwent several weeks of training by French or British instructors on the new form of trench warfare. Again, the Medical Department was responsible for maintaining health, including inspecting the facilities, ensuring food and water supplies, and of course treating illnesses as they occurred. Just in the American Expeditionary Force, there were cases (and deaths!) from measles, mumps, meningitis, tuberculosis, typhoid fever, malaria, diphtheria, and smallpox. The largest problem was influenza and pneumonia. Influenza, when severe, would lead to pneumonia, and pneumonia carried a 40-50% death rate in this pre-antibiotic era.
Supervision of food preparation fell under the Sanitary Corps. While the Medical Department didn’t set up or operate kitchens and mess halls, save for its own troops, medical officers were responsible for inspecting eating facilities to ensure proper practices. Under field conditions, this could be difficult; but badly prepared food could put an entire battalion out of action.
Medical Supply Depot, Is-sur-TillMedical facilities such as dispensaries, aid stations, and hospitals require an immense amount of supply. Separate supply depots were established in the United States and in France to collect the needed supplies in the United States, prepare them to be shipped overseas, and then collect and distribute them in France to some 30 to 40 hospitals and many smaller medical facilities.
In summary, the public health aspects of military medicine remained a continuing challenge. If the goal of forming the Sanitary Corps was to prevent disease, it was only partially successful. Taking the Army as a whole, more soldiers died of disease (57,460) than of battle injuries (50,280). Half of those disease deaths were from the world-wide influenza epidemic, which peaked in the fall and winter of 1918-19. But none of the armies of the Great War did very much better. Conditions of training camps across the world were much better than in the previous century, but they were still worse than would be seen today. The trench warfare of the Western Front, in particular, forced troops into a disease-ridden, anti-hygienic, hostile environment. Public health as a component of military medicine had been neglected for so long, and the concepts were so new, that all armies struggled with preventing disease. No army was more than partly successful in maintaining the health of their soldiers.
Practice of Medicine
Soldiers have forever been crippled by war. One of the great accomplishments of World War 1 medicine was to institute rehabilitation programs on a scale which had not previously been seen. Reconstruction and rehabilitation of injured soldiers assumed a much greater importance than after previous wars. Battlefield survival after injury was much higher. Once an injured soldier reached medical care, there was a 95% chance of surviving. The types of injuries were more likely to produce mutilating injuries. Two-thirds of casualties were from artillery, rather from rifle or machine gun bullets. Mortality following amputations was only 5%, compared with 50% or higher in earlier wars. Finally,society in general had come to see a much greater obligation to wounded soldiers. American policy was that no patient should be discharged until their wounds were completely healed, and they were provided adequate physical therapy and reconstruction.American Amputees in Convalescent Hospital
Facial ProsthesisSurgical reconstruction and physical therapy had advanced greatly over the last half of the 19th century. Orthopedic surgery had advanced the care of fractures and other extremity injuries far beyond that seen in earlier wars. Plastic and reconstructive surgery had emerged as a medical specialty. Its development was greatly accelerated by the large number of soldiers who could benefit from reconstruction. Facial wounds in particular were the subject for extensive reconstruction, to permit men with disfiguring injuries to have an acceptable appearance. Psychiatry and psychology were still struggling to deal with mental casualties such as “shell shock”, but their abilities to deal with these mental diseases were far better than earlier generations of physicians. In all of this, American military physicians were greatly assisted by their British and French counterparts, who had been caring for war casualties for the previous three years. Many American physicians had already traveled to Britain or France to help care for wounded soldiers and civilians.
Physical therapy, which is supervised exercise closely targeted on recovery from musculoskeletal injuries, was just emerging as a specialized medical field. It includes both physicians and non-physician therapists trained to help people recover to the extent of their abilities. But there was no such service in the Army before the Great War. Seeing a need, Surgeon General Gorgas established, on 22 August 1917, the Division of Special Hospitals and Physical Reconstruction. Finding few trained therapists, the Army set up 6 training schools across the country, from Boston to Oregon. While most stayed in the U.S., 80 were assigned to the AEF in France. Physical therapy was retained as a part of Army medicine after the war, and is now an important part of the Army Medical Specialist Corps today.Physical Therapy Ward, Walter Reed Army Hospital, Washington, DC
Prosthetics for amputated limbs and other body parts was considerably advanced over previous centuries, when a “peg leg” was about as much as the victim could expect. In 1913, Charles Desoutter, an aeronautical engineer, made an artificial leg for his brother Marcel. He used duralumin, an aluminum alloy. Their prosthesis was half the weight of wooden prostheses. The British government contracted Desoutter Brothers (est. 1913), to make large numbers of these prostheses for war veterans. A U.S. Company, American Welder
J.E. Hanger, also made them for the British, and later for the United States. Upper extremity prostheses were also greatly improved. While some prostheses simply provided a lifelike hand, so theyprostheses were also greatly improved. While some prostheses simply provided a lifelike hand, so they could be used to conceal the loss of an arm, others increasingly were fashioned to accept functional attachments.
Surgeon General Gorgas also recognized the need for education, to prepare injured veterans to return to productive lives. The current term is vocational rehabilitation. An education branch was established, providing not only specialized vocational training but also general education in subjects such as English and mathematics. Training was begun while patients were still recovering from wounds, and then continued for the duration of their rehabilitation. Between 110,000 and 120,000 soldiers participated in the education program.Workshop for Disabled, Walter Reed Army Hospital, Washington, DC
The Great War, with its large number of casualties, and its severe and disfiguring wounds, placed a great obligation on Army medicine not only to preserve life, but to repair injuries and to prepare injured veterans for their return to society and to productive lives. Doing this required that the Medical Department take on a number of new roles, and to become far more comprehensively involved with rehabilitation medicine than ever before. These new roles and responsibilities have become a part of military medicine today, to the great benefit of the American soldier.