Now all roads lead to France and heavy is the tread
Of the living; but the dead returning lightly dance.
Edward Thomas, Roads

Friday, February 9, 2024

Battlefield Sanitation Improvements Due to the Great War

British Motorized Bacteriological Laboratory

The First World War caused upheavals in many spheres of life but especially in medicine, where it acted as a giant field trial. A new feature amongst the many problems caused by so great and widespread a conflict was the medical  administration and sanitation of vast armies. This prompted American Fielding Garrison author of the History of Medicine to state that:

Viewed after the lapse of a decade, the medical innovations and inventions of the war period seem clever, respectable, but not particularly brilliant. The administrative achievement was, however, truly remarkable. 

There was a general lack of preparedness (except Germany) for war and following the outbreak of hostilities the medical services of the Allied nations were expanded on an unprecedented scale. The United Kingdom drew 11,000 civilian practitioners, France mobilized the whole of the medical profession, and the United States expanded the medical services 20-fold, enrolling 29,602 doctors as reserve officers. Napoleon is quoted as saying "Three fourths of mankind never do the necessary thing until occasion arises, and then it is just too late." Fortunately, it was not too late, and the medical services responded well and learnt many lessons. 

Interior of one of the bathing compartments of one of
Germany's special bathing trains that traveled behind the firing lines to provide bathing accommodation for the soldiers.

The full version of this article makes the salient point that there was a vast improvement in the percentage of deaths of wounded men from previous wars. "The point we need to realize is that the mortality amongst the wounded of 10%  [in WWI] was very low as compared with previous wars, i.e. 39% in the Crimean, 32% in the Russo-Turkish, and 25% in the Franco-German wars."

[In Britain] sanitation was an area in which the Director General Army Medical Services Lt General Sir John Goodwin could not be accused of falling prey to Napoleon's dictum. In 1904, he read a paper at the Royal United Services Institute" and stated:

The future success of an army in the field must, and will, to an enormous extent, depend on the efficiency with which measures for the prevention of disease can be carried out. 

Field Sterilizer at an American Hospital


Goodwin ascribed the vast improvements in rates of disease to the advances made regarding water purification, disposal of waste and field sanitation generally and to the improved education in hygiene of the Army as a whole, and last but not least to the increase in preventive inoculation. The vaccine department of the Royal Army Medical College made and issued during the war years over 23 million mililitres of typhoid and paratyphoid vaccine. Tetanus was prevented by prophylactic injections so successfully that its incidence immediately fell 90%. An even more successful reduction was achieved with typhoid. 

As late as the last decade of the 19th century, this disease was still causing 5,000 deaths annually, and in the Crimean War, it had caused greater mortality than the war itself. Colonel Sir Almroth Wright began trials using vaccines made from killed typhoid bacilli on himself and the military surgeons at the Royal Victoria Hospital at Netley, which subsequently became a psychiatric center (no connection). The current thinking, developed by Pasteur, was that immunity could be acquired only by infection with living pathogens. Wholesale inoculation of British troops was attempted in the South African War, but due to bitter opposition from influential persons, less than 4% of the soldiers received the vaccine. As a result of this blunder, the Army had some 58,000 cases of typhoid and about 9,000 deaths. During the whole of the Great War there were 7,423 British cases, with 266 deaths, in an average strength of 1,200,000.

French Soldiers Receiving Anti-Typhoid Vaccination

The French figures decreased dramatically with the introduction in their army of compulsory inoculation. In January 1916 records showed a British death rate from typhoid 31 times higher among the unprotected. In June 1916, the ratio had increased to 50 to one, a fact brought home to the public by a popular medical journalist of the time. Goodwin made the point in 1919 that inoculation was still voluntary in the British Army and that in 1914 the efforts made to persuade the men to have it were met by "the production of the page of a certain daily journal which strongly advised against inoculation." He goes on to state "I think it says something for the persuasive powers of our eloquence and for the intelligence of the British soldier that we were able to overcome this most pernicious advice, and that 98% of our Army were inoculated against the disease." Armies were not slow to adapt current technology and modes of transport for the massive sanitation problems found.

Source: Excerpted from "Medical advances consequent to the Great War 1914-1918," Journal of the Royal Society of Medicine, Volume 83


  1. Indeed, medical advances gained from experiences of WW1 made great leaps of medical science for the 21st century. Anesthesia, sterilization, immunization, pain relief, surgical procedures, rehabilitation, - etc. And many more positive outcomes came from those dire conditions. It seems a shame that War should be a means to advance medical science, but it was all born out of necessity.

  2. A hard learned lesson was that gas gangrene wounds should not be closed after surgery. This lesson was forgotten by WWII and had to relearned, again with difficulty.