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| Near the Front Treatment at a British Wound Dressing Station |
The military experience in World War I profoundly shaped the medicine practiced on the battlefield. Trenches were inherently unhealthy environments. “We lived a mean and impoverished sort of existence in lousy scratchy holes,” recalled British soldier George Coppard in his memoir.
Overcrowding with poor sanitation led to diarrheal diseases like dysentery. Rats ran freely. Closely packed men lacking the ability to shower or change clothes created conditions amenable to the spread of vector-borne diseases like the aptly named trench fever, transmitted by lice. Prolonged standing in cold water resulted in a malady dubbed trench foot. These conditions came on top of the exhaustion, malnutrition, and malaise that afflicted frontline combatants .
Doctors also struggled mightily to contain the epidemic of trauma that engulfed Europe over these four years. In their efforts to do so, they established intricate evacuation chains to move the wounded to hospitals where ongoing research on shock and infection led to novel therapies like blood transfusions and innovative wound irrigation methods. By 1917, surgery became increasingly aggressive across multiple specialties as laparotomies and craniotomies emerged as standard of care.
Problematically, the medical and surgical needs of the war outstripped the abilities of belligerents’ medical professions. The resulting personnel deficit left illprepared physicians treating the wounded while also providing women doctors with unprecedented opportunities . . .
Those individuals who survived their initial injury were at high risk of death from infection. The unsanitary conditions of the trenches where, according to one military medical manual, “the earth teemed with micro-organisms,” exacerbated the problem. By October 1914, almost 70 percent of German wounds were infected. Physicians responded to this threat with multiple interventions. Anti-tetanus sera proved particularly effective in World War I and by 1915 became a mandatory therapy. With its addition, the rate of tetanus dropped from around 20 percent of wounds in 1914 to 0.1 percent by 1918.
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| In the Rear Treating a Wounded Man at an American Base Hospital |
In the Russo-Japanese and Boer Wars, doctors treated most injuries conservatively, reasoning that operative intervention would cause increase morbidity and mortality compared to allowing the body to heal on its own. This strategy seemed to work well on the steppes of Manchuria and veldts of South Africa, but it failed miserably in the manure-churned fields of Flanders. Pioneers like H.M.W. Gray in the British Army, and especially Antoine DePage in the Belgian military, recognized the importance of keeping fresh wounds open with delayed primary closure, removing all foreign bodies, and extirpating any necrotic or devascularized tissue. These steps markedly reduced the rate of infection and helped obviate amputation following extremity injury.
By 1917, almost every doctor on the Western Front recognized the value of debridement; one even wrote a poem to memorialize it.
Of the edge of the skin
Take a piece very thin
The tighter the fascia
The more should slash’er
Of muscle much more
Till you see fresh gore
And bundles contract
At the least impact
Hardly any of bone
Only bits quite alone
JRL Learmonth
Surgeons soon recognized that they could not cut out every bacterium with their scalpels. With the recently adopted principle of aseptic surgery impossible in the filthy trenches, they reverted to antiseptic principles, deploying various chemicals to kill the bacteria debridement missed and that compromised immune systems struggled to eliminate. Surgeons proposed a variety of modalities, but by far the most popular came from Nobel laureate Alexis Carrel.
Carrel worked with Rockefeller chemist Henry Dakin, who invented an antiseptic treatment consisting of a solution of sodium hypochlorite buffered to physiologic pH–Dakin’s Solution. Carrel designed a series of fenestrated catheters to distribute the solution evenly through the wound bed. Anecdotally at least, the Carrel-Dakin system significantly reduced the rates of infection and remained the standard of care for treating septic wounds until the arrival of penicillin in the 1940s. Dakin’s Solution remains in use for contaminated wounds in both military and civilian patients.
Note: For a list of other articles on treating wounds during the First World War that we have published on Roads, click HERE.
Source: Extracted from "From Trench to Bedside: Military Surgery During World War I Upon Its Centennial," Military Medicine 184, 2019.
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