'THE GREAT WAR'

MEDICAL SERVICES ON THE WESTERN FRONT,

1914-18: LESSONS FOR THE FUTURE

Mark Harrison

INTRODUCTION

Over the last two centuries, medicine has played a vital role in the organisation and conduct of war, mitigating its financial, human and political costs. However, expectations of medical care (for service-personnel and civilians) have varied greatly according to advances in medicine, social policy and the nature of conflict. They have also varied from state to state and even among non-state combatants. In some cases, as in the UK and US in recent years, state-of-the-art medical care is deemed essential for morale and in securing public acceptance for military intervention. The public and the armed forces have become accustomed to high-level medical and surgical intervention within hours of wounding as well as rapid transportation to hospital, exemplified by Medevac in Afghanistan. But war against a ‘peer enemy’ or contingency operations in remote areas with poor infrastructure would render these expectations unrealistic. Modes of evacuation and surgical doctrine may have to alter radically and in ways that would inevitably prove controversial. With this in mind, it may be instructive to consider historical scenarios in which new forms of warfare challenged military and medical expectations, not to mention public perceptions. In this lecture, I shall examine some key developments in the First World War with a view to deriving insights applicable to future conflict scenarios. What had changed since the beginning of the war?

1914 - CHAOS

The British Army deployed to continental Europe with a medical plan that was not fit for purpose. Despite warnings from one of the pre-war Director General Army Medical Services (Launcellot Gubbins), the Director of Military Operations, Henry Wilson, insisted on evacuating the majority of casualties to Britain. Even in 1911, this seemed unrealistic to Gubbins who thought that forward facilities would be necessary. He was proved right. In the first few months of the war, medical services were in disarray and many casualties were let lying at the front due to lack of medical transport. There were also few medical units between the front and the base hospitals, which were mostly located in larger towns and ports. Consequently, many injured men lost limbs or their lives due to wound infection and shock. This could not be kept secret for long and created a public scandal. Across the Empire, the public made generous donations. Senior commanders and politicians also saw a need to address public concerns in order to retain public confidence.

CONSTRUCTING A CHAIN OF EVACUATION

By the end of 1914, it became evident that the conflict would be protracted and that mobility had given way to stasis. This provided an opportunity to improve medical provisions closer to the front in order to address public concerns and stem further losses of manpower. A definite chain of evacuation developed, running from Regimental Aid Posts to the Base Hospitals and ultimately to the UK. The aim of this system was to treat as many casualties as possible in France and Belgium in order to improve clinical outcomes and return men to duty more quickly. Only the most serious cases returned to the UK. Transportation was the key to ensuring that the system worked. Motor Ambulance Convoys were created to take casualties from RAPs and Advanced Dressing Stations near the front to Casualty Clearing Stations.

Trains and occasionally barges were the main form of transport from the latter to hospitals further down the line. Hospital ships conveyed the most seriously wounded from the Channel ports to the UK or from Marseille in the case of Indian troops and members of the Labour Corps recruited from across the empire. Coordinating this vast transportation network was extremely difficult because it entailed liaison with the French and Belgian authorities, the Red Cross and different branches of the British Army. Most problems were ironed out by the end of 1915.

This vast ‘medical machine’, as some observers, referred to it, resembled a factory, with trains and other transport acting as conveyor belts carrying casualties to and sometimes back to the front. However, it is important to remember that so much depended on the heroism and dedication of individuals and also the fact that many of those who received treatment were dealt with close to the front at Regimental Aid Posts. The dangers faced by medical staff are shown by the fact that 7,000 RAMC men lost their lives, with over 6,500 earning Gallantry awards, including seven VCs (in one case, that of Capt. Noel Chavasse, with bar) and 499 DSOs. In total, 1:20 of the men serving with the RAMC were honoured for their bravery.

Capt. Noel Godfrey Chavasse

THE HUB OF THE ‘MEDICAL MACHINE’: THE CASUALTY CLEARING STATIONS

I now want to focus on the Casualty Clearing Station 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 railhead 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 orthopaedic 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.

The shape formed by these splints can be seen under the Blanket

in the triage tent of the Casualty Clearing Station above

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. A dental kit can be seen in the display.

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.

NEW CHALLENGES IN 1918

In 1918, the system of casualty evacuation on the Western Front faced three major challenges. The first of these was the German Spring Offensive, which saw many forward medical units, including CCSs, overrun by the Germans. Evacuation by rail was also badly disrupted. However, the situation was ameliorated by the extensive use of motor ambulances and other forms of motorised transport to clear casualties from some CCS in the line of the German advance and to mop up others from the field.

The second major challenge was the resumption of mobile warfare in August – the period of the Allied advance known as the 100 Days. CCSs still played a crucial role but they had to become mobile hospitals once more. Finding the necessary amount of trucks and labourers to assist in transportation was one of the greatest difficulties in this phase of the campaign and this was worked out by trial and error until an effective procedure was established. The other difficulty lay in the evacuation of forward hospitals. The CCSs were fortunate in that they were able to use train lines as they moved forward but these were often congested with other traffic. Over time, evacuation by rail became more systematic as commanders of CCSs liaised continually with staff officers to minimise delays in the collection of wounded. Motor ambulances were also made available to collect casualties from Advanced Dressing Stations.

The final challenge of 1918 came in the form of influenza. The second wave of influenza hit in October and placed an enormous strain on medical facilities for a few weeks. There were 158 admissions to medical units from influenza per 1,000 strength of the B.E.F. MOs were powerless and the only measure that was conceivably effective was to retain as main cases (the less serious) in forward units to prevent further infection and congestion of the larger hospitals. Despite the pressure, the system never collapsed.

KEY LESSONS

The key to success in casualty evacuation on the Western Front was integration into operational planning. Commanders saw arrangements for evacuation and treatment as crucial to their success. Manpower economy and moral – both of troops and the general public – depended upon it. This situation contrasted markedly with many other theatres – such as Mesopotamia and the Dardanelles – in which MOs were excluded from planning and staff meetings. As a result, the incidence of disease and treatment of casualties became a public disgrace.

The key lessons from the Western Front may be summarised as follows:

a) Importance of integrating medicine into operational planning

b) Importance of logistics

c) Importance of information exchange (evolving best practice)

d) value of bringing in civilian experts

e) value of forward treatment (manpower, clinical outcomes)

f) importance of flexibility

Then and now – relevance of the Western Front for modern peer/peer-plus warfare Conditions on the Western Front were very different from operations in which the British Army has recently been involved but offer insights into what could be expected in coalition warfare against a peer-plus enemy, i.e.:

a) dealing with heavy (and complex) casualties in forward facilities

c) importance of non-aerial forms of evacuation to alleviate congestion at the front

d) probable reversion to 1914-15 surgical doctrine (i.e. prioritisation of less serious cases)

e) importance of capacity in tentage, water-supplies, etc.

f) need to coordinate across coalition partners and branches of the Army

g) difficulty of adapting culturally to the above

h) difficulty of managing (unrealistic) public expectations

The evidence from 1914-18 shows that public expectations of medicine were very high at the start of the war and this led to severe criticism of medical arrangements in 1914. However, both medical provisions and public attitudes adapted over-time. The public came to understand and largely accept the need for treatment in forward areas, as opposed to the evacuation of casualties to the UK. Casualties were tolerated because the war was largely perceived as just or as an existential necessity.

However, the military authorities had to ensure that facilities for evacuation and treatment of casualties at the front became more efficient. They also had to make some concessions in surgical doctrine to avoid the perception that the Army was callous (i.e. leaving the wounded to die).

CONCLUSION

The adaptability of public expectations offers some hope that public and military expectations could adjust to casualty levels markedly higher than those of HERRICK and TELIC and to lower standards of treatment. However, that would depend crucially on how far the conflict was perceived as just and necessary. That cannot be guaranteed and might even be considered unlikely. The situation facing medical services in a conflict against a peer/peer plus enemy is likely to be far more difficult than even the most intense periods of war on the Western Front: not in terms of the total numbers of casualties but because major road and rail links are likely to be severed by artillery fire. The main advantage enjoyed by the B.E.F. in 1915-18 would therefore be lost. At the same time, electronic communications are likely to be disrupted making coordinated casualty collection and evacuation difficult.

It is therefore likely that large numbers of casualties will be scattered across the front and many of these could be complex, e.g. blast, burn and pressure injuries from thermobaric weapons, perhaps even chemical weapons. This suggests the need to strengthen forward medical capabilities and improve capacity for ground evacuation (as in 1914-18). To the extent that rail evacuation may be possible, skills in coordinating and marshalling rail traffic will need to be re-learned, as will the handling of casualties in contaminated environments.

Attention needs to be paid to basic equipment and provision of water supplies to forward areas. Knowledge of the effects of thermobaric/chemical weapons and how to deal with the injuries arising for them needs to be widely disseminated.