Between Flesh and Steel

by Richard A. Gabriel

  The quality of medical talent, including that of physicians and surgeons, was poor.93 Few of the medical students who had served their one year of military service before the war had attended their required training sessions. Reserve doctors often failed to attend as well. Once pressed into service on the battlefield, most found their skills inadequate to their responsibilities. It did not help that in hard-pressed sectors, line officers stripped the hospitals of their medical personnel, including physicians, and pressed them into service as combat soldiers. Of all the major combatants in World War I, with the possible exception of Russia, the French Army presented the poorest example of a military medical service.

  Great Britain

  In August 1914, the British Army had 100,000 men on the continent resisting the German advance toward Mons, Belgium. By 1918, more than 4 million British soldiers had seen action in the war. More than 700,000 of them were killed, were missing, or had died of their wounds; 2 million more were wounded—or a hundred times more men than in the Boer War—and 6 million men had been hospitalized at one time or another for disease or illness. At the Battle of the Somme in 1916, 316,000 men were admitted to the field ambulances, with 24,675 carted away in the first twenty-four hours of the battle. In France alone, the British Army Medical Corps attended 129,675 wounded and sick officers and 2,525,350 men of other ranks.94

  At the outbreak of war, the regular army and reserve components of the British medical service had only 20,000 men. By 1918, 13,000 officers and 154,000 enlisted men had seen service in the medical corps. Medical assets deployed in the war included 235 field ambulances, 127 sanitary detachments, 78 casualty clearing stations, 48 motor ambulance convoys, 63 ambulance trains, 4 ambulance flotillas, 38 mobile hygiene and bacteriological laboratories, 15 mobile X-ray units, 6 mobile dental labs, 18 advanced depots of medical supplies, 17 base depots, 41 stationary hospitals, 80 general hospitals, and 77 hospital ships. In 1914, the British had only 18,000 hospital beds spread throughout the empire. By 1918, the number of hospital beds had expanded to 637,000, with more than half of them located in England.95

  The static nature of trench warfare made moving the wounded easier. Although motor transport for casualties was introduced in 1911, the army staff vetoed using these vehicles for medical transport because it maintained the roads were already overburdened with more important supplies. Once again, the British attempted to use empty trucks and wagons of the supply train for double duty as casualty transport. The time required to load and unload the casualties disrupted combat supply timetables, so the army decided to equip the medical corps with its own wagons and motor transport operating on its own schedules. The sequence of evacuation ran from the stretcher bearers at the regiment and its medical officer, who, in turn, passed his casualties to the advanced dressing station and then to the main dressing station.

  In its major innovation in the structure of medical care, the British placed their casualty clearing hospitals behind the main dressing station. This clearing unit was developed from the prototype that had been first attempted on a small scale during the Boer War. Originally it had been intended to serve as a drop point that would allow the field ambulances to “clear” themselves before returning to the front line, but the large number of World War I battle casualties changed their nature and function completely. Casualty clearing hospitals were located barely beyond the range of the most intense artillery, or about seven miles from the front. Six medical officers and eighty orderlies sorted and stabilized the casualties before passing them down the line.96 These stations could handle two hundred patients on stretchers, but they were not supplied with beds.97 The clearing station had only marginal surgical equipment available since the unit was not designed to undertake major operations. Each station was attached to a division and had its own horse and lorry transport that the division quartermaster supplied.

  As the burden of casualties grew, the casualty clearing stations expanded so that they could receive, stabilize, ship, or post a thousand casualties a day.98 Their staffs increased to include medical surgical specialists, anesthesiologists, and special medical teams for serious surgery. They added two hundred beds per station, which became the main providers of field surgery in the forward area. In 1917 at the Third Battle of Ypres, for instance, surgeons performed 61,500 operations with anesthesia at the clearing stations.99

  The litter bearers at regiment who served as the first line in the casualty evacuation system faced many obstacles. While the British planned to use two men to carry a stretcher, the explosive artillery disrupted the farmlands’ irrigation and stream patterns where battles were fought, and the extensive network of trenches soon produced a year-round sea of mud. Often moving a single litter required as many as seven men. Even in relatively safe rear areas, the medical service used a mix of no fewer than eighty-three types of special transport—including stretchers, motorized lorries, mules, and sledges—compounding the problem of medical evacuation.100 Medical units often designated combat soldiers to move their wounded comrades to the rear, but the British commander of the western front Gen. Douglas Haig (1861–1928) attempted to stop the practice because it drained combat power at the front. The average time elapsed from wounding to evacuation to a field hospital was five hours and then ten hours to the evacuation hospital. A number of factors slowed medical evacuation. Because of the sweeping machine gun and artillery fire, men wounded in the trenches could only be safely evacuated at night, often causing a delay of twelve hours. Men were told that if they were wounded in no-man’s-land to crawl to the open shell craters and wait there until darkness, when “scavenger teams” would search for them. Finally, the mud, generally poor road conditions, and harassment fire falling in the rear exposed ambulance convoys to destruction.101 Sometimes hand-carried litters transported the wounded the entire distance from the front to the field hospital.102

  The United States

  The American Expeditionary Force sent 2,039,329 men to combat duty in France, and of these men, about twenty-eight divisions, or 784,000 soldiers, engaged in battle. The total mortality of American soldiers in the western theater of operations was 75,658, of whom 34,249 were killed in action, 13,691 died of wounds, 23,937 died of disease, and 3,681 died of suicide, drowning, homicide, and other accidents.103 Among American medical officers in France, 46 were killed in action; 212 were wounded, of whom 22 died; 101 died of disease; 9 died from accidents; and 7 were missing.104

  During World War I, the American Army expanded twelve-fold from its peacetime strength. In June 1917, the medical department of the army had 443 medical officers, 146 medical reserve officers, and 4,670 enlisted men assigned to it,105 but it had no real organization and mostly old equipment. By war’s end, the medical corps had grown to 30,591 officers—of whom 989 were regular officers and 29,062 temporary active duty officers—and 264,181 enlisted men, for a total strength of 294,772 men. In addition, 8,587 nurses served on active military duty.106 In France, the U.S. medical service provided 261,403 beds to service 193,448 patients—99,405 sick and 94,043 wounded. Stateside, 69,926 patients occupied another 121,883 available beds. The total beds, 383,286, were twice that available to the Union forces during the Civil War.107 By November 1918, the American medical service had evacuated 129,997 men via twenty-one hospital trains and had transported another 197,708 on hospital trains that the French made available.108 U.S. forces had sent some 6,875 motorized ambulances to France along with fifty medical barges operated on French inland waterways. Three hundred and thirty-three hospitals had been constructed by the U.S. government and military, with ninety-one of them located in the United States.109

  The medical corps also provided other services, including administering psychiatric examinations to recruits. The high rates of psychiatric casualties had prompted field commanders to ask the medical corps to find some way of screening troops. The idea that some individuals were more prone to psychiatric collapse than others was adopted from the era’s emerging racial and eugenics theories, wh
ich held that particular behavioral proclivities were characteristic of certain “races.” This notion had already been established in criminology and psychiatric practice and had struck deep roots in Britain, Germany, and the United States. The medical corps administered 1,151,552 psychiatric examinations in an effort to screen the “unfit” from military service, but the screening had no effect at all on American rates of psychiatric casualties.110

  The army medical corps also had the task of designing and producing gas masks. Until the task was turned over to the Chemical Warfare Service in June 1918, the medical corps produced 1,718,000 gas masks for soldiers, 154,000 masks for horses and mules, 502,000 breathing canisters, and 11,000 trench fans.111 The introduction of gas warfare in the middle of the war was at first thought to present the medical corps with new challenges in treating gas casualties. It was soon discovered, however, that the effects of wind, temperature, terrain, and better training in the use of protective masks made delivering effective gas attacks very difficult. The number of physical casualties from gas proved remarkably small, while the number of psychiatric casualties (hysterical reactions and self-inflicted smearing of mustard gas residue on one’s body) increased. In 1922 a British Army investigation concluded that most British “gas casualties” had in fact not been gassed at all or had inflicted the wounds upon themselves.

  The casualty servicing structure of each regiment had a medical detachment of fifty-five officers and men. As this number proved inadequate, in times of heavy casualties the service commonly drew eight to twelve men from each combat company to assist the medical unit, usually as litter bearers. From the regimental aid post, the litter bearers from the ambulance company evacuated patients to the ambulance collecting stations, which were usually located at the most advanced points where motorized or horse-drawn ambulances could reach the casualties. The ambulance company headquarters was located about a mile from the fighting, and when a full ambulance passed through the headquarters’ control point, an empty one headed to the front to replace it on the line.

  As with the British units, American field hospitals were located immediately outside the range of artillery fire. Each division had four field hospitals, two of which deployed for immediate use with the other two held in reserve in the event that the division began to move. Only emergency surgery, stabilization, and resuscitation— wounds redressed, splints applied, pain relieved, nourishment given, and shock treated—were done in these field hospitals, and the patient prepared for movement to the rear. Shell-shocked soldiers suffering light to moderate symptoms were held at the field hospital for a few days. If they recovered, they were sent back to their units. Those men with persistent symptoms were eventually evacuated to psychiatric hospitals in the rear.

  The evacuation hospitals were located on railway lines twenty to twenty-five miles to the rear. These hospitals were well equipped with physicians, surgeons, and female nurses. After surgery, hospital trains and motorized ambulances transported casualties to general hospitals. When the war of movement recommenced, the force never had enough ambulances to move casualties to the evacuation hospitals. At times the distance between the field hospitals and the evacuation hospital was fifty miles or more over poor roads. During the Meuse-Argonne offensive (1918), U.S. ambulance drivers made twenty-four thousand trips to the evacuation hospitals, averaging twenty-eight miles each way.112 Each ambulance section had twelve ambulances, and two ambulance companies were assigned to each division. Even at the war’s end, the number of ambulances was never adequate.

  The American force lost 58,075 men from disease over the course of the entire war.113 This figure is somewhat misleading, for the medical corps did a good job of controlling those diseases that had traditionally decimated armies of the past. There were, for example, only 1,055 cases of typhoid and paratyphoid with only 165 deaths. Diphtheria produced 4,860 cases but only 76 deaths. The 1,975 cases of dysentery resulted in 35 deaths; 950 cases of malaria, 2 deaths; 9,618 admissions for measles, 358 deaths; and 24 deaths from smallpox.114 The greatest killers were influenza, which produced 167,141 admissions with 6,072 deaths, and pneumonia, which resulted in 20,445 cases and 6,481 deaths.115 At the height of the influenza epidemic in November 1918, influenza patients occupied 193,016 hospital beds of the total 276,347 beds available.116 Meanwhile, the introduction of the Lyster bag— a double-lined, spigoted canvas water bag that purified water with the addition of calcium hypochlorite—did much to reduce water-borne disease.117

  The high rates of manpower loss to psychiatric casualties forced the American Army to confront the problem. Dr. Thomas Salmon (1876–1927) visited France to learn how the French and British handled their psychiatric casualties. These two armies evacuated psychiatric casualties in the normal medical chain, a practice that resulted in large numbers of troops being lost to the war effort. Seeking to avoid this situation, Salmon designed a system based on the proximity of treatment, the screening of casualties for psychiatric symptoms, and an expectation of the patient’s return to combat. The American military began training doctors and support staff in military psychiatry and, by war’s end, had 693 military psychiatrists in its ranks with 263 stationed in France.118 Following the established Russian and German practice of forward treatment of psychiatric casualties, the Americans provided each division with a psychiatric section under the command of the division psychiatrist, and small psychiatric hospitals capable of handling thirty patients at a time were established near the front lines. Larger psychiatric hospitals were set up in the rear but still relatively close to the front. Approximately thirty-five men per thousand per year were admitted to these psychiatric facilities, with 40 percent returned to service.

  WORLD WAR II

  The Spanish Civil War, which ended six months before World War II began, was a testing ground for new weapons and tactics that the Germans and Soviets supplied to the respective sides. It also became a testing ground for military medical advances. Gaston Ramon (1886–1963) introduced a new tetanus vaccine at the Pasteur Institute in 1931 that received its first large-scale field test in the Spanish Civil War. For the first time that the new sulfonamides—sulfa drugs, or a new group of antibacterial drugs working by bacteriostatic action—were used in war. Both sides generally adopted the German methods of antiseptic and aseptic surgery, leading to the widespread use of antibiotics and new antiseptics. The war saw the medical services widely utilize mobile surgical teams, which the Allies later perfected in World War II, and combat blood transfusion using stored blood for the first time.119 Overall these innovations in military medical care resulted in a drastic decline in the wound infection and amputation rates. Despite often primitive surgical conditions, only 342 of 42,000 wounded soldiers underwent amputations in the Spanish Civil War.120

  During World War II, the British medical service treated 5 million patients, of whom 104,076 died of their wounds. Another 239,457 were wounded but survived.121 More than a thousand British medical units were mobilized for the war, including 148 field and general hospitals in the overseas theaters and 88 at home, 36 casualty clearing stations, 141 field ambulances, 49 ambulance trains, 34 hospital ships, 42 medical supply depots, 50 surgical field units, 36 blood transfusion teams, 64 field dressing stations, 27 convalescent centers, 122 field hygiene units and sanitary sections, 71 antimalarial control units, and an unknown number of mobile laboratories and other specialized units.122

  The British went to war with a medical structure essentially unchanged since World War I, but the new mobile tactics and distances that it had to cover during casualty evacuation required more mobile medical facilities. To solve the problem, they adopted the American idea of equipping the entire medical structure with motorized transport. They reduced the size of the casualty clearing stations and made the field ambulance units lighter but gave them more vehicles, created field dressing stations and mobile surgical teams and equipped them with enough surgical supplies to conduct a hundred operations without replenishment. They also introduced mobile
neurosurgical, maxillofacial, and field transfusion teams. The Blood Transfusion Service quickly became an integral part of forward surgical units.

  The British experience at the start of the war demonstrated that a casualty had to be transported 133 miles from the forward aid station to the casualty clearing station and another 236 miles to the general hospital.123 This situation led to the creation of the advanced surgical center (ASC), which was located forward in the combat zone and designed to provide and rapid surgical care. Attached to a casualty clearing station or field dressing station, the unit was totally self-sufficient with complete facilities, personnel, and transport, including a field transfusion unit. The center could be quickly attached or detached from its parent unit and rushed to the point of greatest casualties. The advanced surgical centers dealt with all shock, penetrating abdominal wounds, chest wounds, amputations, femoral fractures, and major arterial injuries. They serviced approximately 15 percent of the total casualty load.124

  New tactical units, such as airborne and commando outfits, required their own independent medical support, so the British developed special commando and airborne medical units. They trained twenty-five thousand special medical personnel for these sections, and the first air-droppable division medical component was used at Arnhem (1944).125 The long distances that the casualty transports traveled placed a premium upon limb immobilization. At the Battle of Tobruk (1942), the British used the Tobruk splint with great success. Essentially an adaptation of the Thomas splint of World War I, the Tobruk splint incorporated a plaster shell with a traction pulley anchored to the splint’s heel to allow constant traction on the fracture. Meanwhile, the first large-scale use of tanks and other armored fighting vehicles resulted in a high proportion of burn casualties. The early use of tannic acid for burn treatment proved ineffective and even damaging. Armored vehicle crews were later issued wound dressings made of sheets of gauze, which were impregnated with surgical jelly to which sulfanilamide had been added, and loose gloves made of waterproof silk that sealed at the wrist for hand burns. These efforts drastically reduced pain and infection from burns.126