'BONES CAN BREAK'

Having dealt with the respiratory and cardiac systems in the last two chapters, it is important to remember that in order for these and all the other organs to operate properly they have to be protected.

This is what the skeleton is for. It is made up of --- bones which have a dual role, that of protection and support, protection in the form of the skull, rib cage and pelvis and support in the form of its general shape and the legs which have the arduous job of supporting the main skeletal structure and all the organs contained within.

The only problem with it is, as with any relatively fragile structure, ‘bones can break.’ in most cases these ‘breaks’ or fractures are not life threatening and are relatively easy to put right, that is so long as we have the correct facilities and instrumentation available to us. This, as with all other modern procedures, has not always been the case.

In many cases of fractures, the earlier forms of treatment at grass routes level was ‘improvisation’ in many cases using another limb or part of the body as an impromptu splint.

If, however, we take this one step further and look at the clinical approach, there has been any number of failed attempts to treat fractures over the years. Some have been due to lack of sufficient research into how the procedure would work or how long it would last once within the skeletal structure. However, there have been far more successes than failures.

If we start with basic developments in times of War. One of the MOST successful developments was actually the Re-introduction of a device that had been designed in the previous Century.

THE HUB OF THE ‘MEDICAL MACHINE’:

THE Casualty Clearing Station

I now want to focus on the Casualty Clearing Station (CCS) which was in many respects the key unit in the medical system that evolved behind the firing line. CCSs were usually located about 5-8 miles from the front at rail-head with good road links.

They were originally named ‘Clearing Hospitals’ but this term was scrapped because it gave the public a false idea of its facilities, which, in 1914, were rudimentary. By the end of 1915, these units had grown into large, well-equipped hospitals, with around 7 MOs and 5-7 nurses in addition to RAMC orderlies. Before large engagements, additional staff were usually brought in, including surgeons and anaesthetists.

The condition of wounded men entering the CCS was variable but better treatment in Advanced Dressing Stations – particularly the management of shock – improved their prospects, as did extensive use of anti-tetanus serum. Another important innovation was the Thomas Splint, which revolutionised the care of orthopedic injuries. In 1916 the mortality rate from complex fractures of the femur was as high as 80%, most dying in transit or at CCSs.

The widespread use of the splint from that year – pioneered by the orthopaedic surgeon Robert Jones (nephew of the splint’s inventor) – brought that figure down to 16% by the end of 1917.

Thomas splints reduced pain and bleeding from the wound. These splints can be seen in the triage tent of the CCS. It was here that casualties were sorted into groups with wounds or medical conditions of different severity or type. Their dressings were replaced and urgent cases were sent as quickly as possible to the operating
theatre. At the beginning of the war, these theatres were likened by some to butcher’s shops, with severed limbs piled outside. The need for amputation decreased massively as a result of the innovations already mentioned and surgical procedures became both quicker and more ambitious.

From late 1916, time and motion studies were conducted in CCSs, which allowed far more operations to be performed. The key innovation was the ‘twin table system’, in which the surgeon stood between two tables, attending to one patient while the other was prepared for surgery. Having finished with one, he simply turned around to deal with the other. This typified the tendency to import methods from business and the growing influence of civilian experts within the armed forces.

As the war progressed, more complex operations began to be performed in CCSs and occasionally even further forward, in Advanced Operating Centres. Surgeons built up expertise in dealing with types of injury they had seldom encountered in civilian life and shared best-practice by visiting each other and participating in symposia. Better anaesthetics also greatly assisted surgical procedures. Chloroform was also gradually replaced by
machines which enabled a mixture of nitrous oxide and oxygen to be administered. This reduced the incidence of wound shock and assisted recovery. In the last two years of the war, surgeons recorded high rates of success in cases that would simply have been left to die in 1914-15, e.g. abdominal wounds. This was very important for the morale of troops and their families.

From 1916, specialization in certain forms of treatment became common in CCSs, e.g. orthopaedic wounds, gas, shell-shock and even venereal disease. This allowed for more efficient treatment of casualties and reduced case fatality. After the battle of Loos in September 1915, in which casualties were very unevenly distributed across CCSs, CCSs were grouped in pairs. As one became full, the other opened. This system worked well on the whole and allowed enormous numbers of casualties to receive timely treatment during the Somme and Ypres offensives of 1916 and 1917.

However, the effective operation of this system depended on rapid evacuation of surgical cases from the CCS. Mismanagement of rail evacuation on the first day of the Somme meant that CCSs were choked with casualties.
One dealt with over 5,000 casualties in the first 24 hours. However, from then on, evacuation from CCSs went smoothly.

Lastly, some mention should be made of dental surgery, which made a huge – but often forgotten – contribution to manpower efficiency. At the beginning of the war, many men who were otherwise fit to fight were invalided because of dental caries and many were temporarily unfit to fight because of infections. Twelve dentists were attached to CCSs on the Western Front, where they also repaired damaged teeth, and from 1916 mobile dental
surgeries began to serve soldiers along the front. The importance of dentistry to the war effort was finally recognized in the creation of the Army Dental Corps in 1923.

The net result of these scientific and organisational developments was a significant increase in rates of return to duty. In 1916, 45% of those wounded on the Western Front were returned to duty within the theatre. By 1918, this figure had increased to 57%. This was precisely what the system of forward treatment was designed to achieve.

(Taken from: - 'LESSONS OF WORLD WAR 1'

By Professor Mark Harrison

Professor of History of Medicine

Oxford University

Presented at 'Operation Reflect' - R.M.A.S. October 2018

In conjunction with T.M.M.R.

By Kind Permission of the Author)

'BONES CAN BREAK'

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