Injuries in World War I

Wounds and Physical Injuries

A modern surgeon, magically transported 100 years ago, would find much that was familiar. The first principleWound Debridement in Improvised OR
of wound treatment is, and has been, debridement. This means cleaning the wound of all dirt and foreign matter, cutting out tissue which is too damaged to heal, and washing out the wound to remove dirt and debris too small to be seen. Today, the surgeon has an array of antibiotics, which are used to irrigate the wound, and given systemically, to prevent and treat infection. During the Great War, antibiotics were still 20 to 30 years in the future. The great advance of general anesthesia, however, was very well-established, permitting the surgeon to take enough time to properly clean and debride wounds. Further, aseptic surgery was well-accepted, and practiced even on the battlefield. This avoids putting new bacteria in the wound, to further complicate healing. Even irrigation fluids were (and are) sterile.

Lacking antibiotics, surgeons used the older doctrines of antisepsis. A number of local antiseptics were available, including various preparations of iodine, phenol, alcohols, and, ironically enough, chlorine. The problem was to use something which would kill bacteria, yet not damage tissue. The English-American chemist, Henry Drysdale Dakin, devised a solution of sodium hypochlorite, made initially by bubbling chlorine gas through a solution of sodium hydroxide or sodium carbonate. It was not harmful to tissues, and even would help to “float” dead cells free of the surrounding tissue. Working with the French-American surgeon Alexis Carrell, mentioned above, they developed the so-called Carrell-Dakin technique of wound irrigation. To this day, the solution is still available as Dakin’s solution. After the surgeon has debrided the wound, it is then irrigated with one or more liters of Dakin’s solution, some of which is left in the wound. Open wounds were then irrigated with Dakin’s solution every three or four hours, or left packed with Dakin’s-soaked gauze. Military surgeons have long learned that trying to close battlefield wounds frequently resulted in closed wound infections. Most battlefield wounds were left open for subsequent closure. Before the war, both Carrell and Dakin were in New York, and they may have developed the technique there. It was first used in early in the war, when Maj Carrell was serving in the French Medical Corps.Treating Shock with Oral Fluids

What sort of wounds were commonly seen? While popular literature emphasizes machine guns, rifles and bayonets, the grim reality was that two-thirds of all casualties on the Western Front were produced by artillery shells. Machine guns and rifles used the same ammunition, and between them produced most of the rest. Bayonet wounds were so uncommon that they were tabulated under “miscellaneous wounds” in the hospital log books. Shrapnel from bursting artillery shells produces particularly ugly wounds, with a great deal of tissue damage and foreign material carried into the wound, including dirt from the trench environment.  Frequently, the unfortunate soldier was also buried in the collapsed trench.

An important component of wound treatment was tetanus antiserum. As noted elsewhere (see “Diseases”), tetanus antiserum was routinely given to patients with wounds heavily contaminated with dirt. While the improved surgical techniques were at least as responsible, the use of antiserum was credited at the time with the virtual elimination of tetanus.

Injuries in World War I

Triage

Triage is one of the most important concepts of battlefield care.   It was probably formulated by Jean Larrey, the chief surgeon of Napoleon’s Grand Armée. Formally, it consists of dividing patients into three categories:
1. Those who will recover with minimal care, or even with no care.
2. Those in whom immediate intervention may be life-saving, and who may die without that.
3. Those who are unlikely to live, regardless of treatment

Triage is a cold concept. It requires abandoning some patients to die, in order to spare resources for those who can be saved with reasonable effort. Civilian medicine is not usually practiced this way, outside of disasters. But on the battlefield, time and resources are finite. Herculean efforts to try to salvage a patient who is likely to die may use time and resources that might better be used to save the lives of several patients less severely wounded. 

Injuries in World War I

Burn Injuries

Spraying a Burn Wound of the FaceBurn injuries are among the most devastating injuries known.  Burns have been known for 5,000 years, or longer.  The use of flame and/or hot liquids in war goes back to the dawn of history.  With the onset of mechanized warfare and the use of high explosives in World War I, burns became more and more common.  However, therapy was inadequate. Major burns - 50% or more of the body area - were generally fatal. By later in the century, surgeons had realized that early and aggressive intravenous fluid therapy is the key to survival for large burn injuries.  Intravenous fluids were available in World War I, and were used to a limited extent, but not to the extent required for treating major burns.    

Burns of the face and extremities, while not often fatal, could still produce major disability.  Therapy consisted of supportive care, trying to reduce infection, and skin grafts for full thickness areas.  Small areas could be adequately treated. But a major facial injury such as that shown here would usually produce major scarring, even after skin grafting.  The best that could be hoped for was a mask-like face.  

The need to provide better treatment of burn wounds stimulated a great deal of research after the war by plastic surgeons and trauma surgeons.  By World War II there was an extensive body of knowledge and practice available.  But this came too late for the unfortunate victims in World War I. 

Injuries in World War I

Gas Injuries

Gas! GAS! Quick, boys! — An ecstasy of fumbling,
Fitting the clumsy helmets just in time;
But someone still was yelling out and stumbling,
And flound'ring like a man in fire or lime ...
Dim, through the misty panes and thick green light,
As under a green sea, I saw him drowning.
In all my dreams, before my helpless sight,
He plunges at me, guttering, choking, drowning.

— Wilfred Owen, "Dulce et Decorum est", 1917

 Chlorine Attack Using Gas CylindersFirst introduced on April 22, 1915, the use of poison gas quickly became commonplace by all of the combatants. In the popular imagination, poison gas became one of the defining symbols of the Great War. All of the European powers had signed the Hague Declaration in 1899, never to use poison gas in artillery shells or other projectiles. Again, the Hague Convention of 1907 forbade the use of poison weapons. But once Germany used gas on the battlefield, all other armies began to use it. By 1917, one third of all artillery shells contained gas. Not surprisingly, then, about one-third of all casualties in the AEF were from gas.

 Poison gas evolved rapidly during the war. That first use at the second battle of Ypres employed tanks of gas half-buried in the earth. When the wind was blowing away from their own lines, Germans opened the valves and allowed the gas to billow towards the French lines. There were 1,000 deaths and 4,000 casualties. It was used twice more during the same battle, against British and Canadian troops. By the fall of 1915, all sides were using poison gas, including in artillery shells. Chlorine gas, when it contacts tissue, dissolves in water to form hydrochloric acid. Its primary target is the lung, and death usually results from inhalation injury. Chlorine can also cause severe damage to eyes and exposed mucous membranes.

 Soldiers Under Gas AttackPhosgene was introduced in late 1915. It was used extensively, frequently combined with chlorine. The British called the combination “White Star”, after the symbol painted on artillery shells filled with it. The accompanying picture was actually staged in 1918 by the U.S. Army Corps of Engineers to illustrate the effects of phosgene. While the picture is dramatic, the truth is that phosgene may not show major symptoms for up to 48 hours. It causes pulmonary failure and heart failure. Death is usually from lung failure.

 Lung Lesions from Mustard Gas, with Plugging of Terminal BronchiolesNitrogen mustard was Introduced in July 1917 by the Germans. Mustard gas became known as the “King of Battle Gases”. It eventually caused more chemical casualties than all the rest put together. Mustard gas is a vesicant, causing severe blistering of the skin, and attacking the respiratory tract and the mucous membranes of the eyes, nose, and mouth. It is especially dangerous to the eyes. While most patients recovered their vision, a significant number remained permanently blind.

A number of other gases were developed. The most important of these was lewisite, which was developed only late in the war. It is also a vesicant, but with more immediate action than mustard. It can enter the body through the skin, and do further internal damage.

Gas Casualties, British 55th Division
Official response was rapid. The Army Medical Department formed the Gas Defense Division on August 31, 1917, to carry out gas mask research and supervise manufacture and supply. The Chemical Warfare Service (later Chemical Corps) was formed on June 28, 1918.

Treatment was limited to supportive care.  About all the medical services could do for chlorine and phosgene gas victims was to put patients on bed rest, and hope that severe symptoms didn’t emerge. Mustard gas was another story. The casualty had to be stripped, and completely washed. The eyes had to be washed out completely to avoid late damage. Although it acted more slowly, mustard also attacked the lungs, especially the lower respiratory tract, causing a refractory kind of pulmonary edema.

Canadian Soldier with Mustard Gas BurnsThe AEF had about 1500 deaths from poison gas, out of 52,000 battlefield deaths. But the total number of gas injuries was estimated at 90,000 to 100,000, or 30% of all casualties. Overall, there were 1.3 million gas casualties during the war, and about 90,000 deaths. About half of the deaths were among the Russian army, which was notably slow in providing protective gear to its soldiers.

American Signal Corps Operators working in Gas Masks
After the war, an international agreement – the 1925 Geneva Protocol – was signed, with all nations swearing never to use poison gas. And in fact, it was not used during World War II. It has been used in lesser conflicts since, notably the Iran-Iraq war. The US, which didn’t formally sign the Protocol until 1975, has maintained stocks of poison gas, but has never used them on the battlefield since World War I. It is probably worth noting that newer poison gases, such as the organophosphate nerve agents sarin, soman, tabun, and VX, are much more potent. They cause death from pulmonary edema and respiratory failure, and are more lethal and more rapidly-acting than the gases used in World War I..

Injuries in World War I

Psychological Injuries

Dr. Thomas W. Salmon, Pioneer in Treating Combat Stress Disorders

Soldiers have been returning from battle with psychologic damage for millennia. Ancient Egyptian texts described it 4000 years ago. The Greek historian Herodotus wrote about it 2500 years ago. More recently, we now know that soldiers in the American Civil War often exhibited what we now call post traumatic stress disorder. For example, Dr. William Chester Minor, who served with the Union army for three years, became paranoid and delusional after the war. In 1872, he shot and killed a man in London, England, in the belief that he was an enemy soldier. He died in England, in an insane asylum.

Yet the psychological toll of the Great War was without precedent.  Soldiers who had endured the awful conditions of trench warfare, especially those who experienced the terrible artillery barrages seen in the war, sometimes developed a neuropsychiatric syndrome known by various names, but most commonly as “shell shock”.  First described by a British physician, Charles Myers, it consisted of an array of symptoms.  These included uncontrollable trembling, headache, tinnitus, dizziness, inability to concentrate, memory loss, confusion, and sleep disorders.  Some patients were barely able to walk, or had partial paralysis, or stammered uncontrollably, or were unable to talk.  

The disorder we now know as Post Traumatic Stress Disorder (PTSD) bears a strong relationship to shell shock. However, there is a great deal of evidence that the disease as seen in World War 1 had a strong neurologic component. Many of these patients may have had traumatic brain injury, to at least some degree, as well as PTSD. The more recent research into chronic traumatic encephalopathy is highly suggestive that frequent “minor” head trauma can indeed produce long-term changes in the brain. This line of thinking is, of course, speculative.A Soldier Comforting Another, in a Later War

Thomas W. Salmon, AEF consultant in psychiatry, formulated the treatment used throughout the AEF. It was based on treatment as far forward as posssible.  There were five principles.  Immediacy meant beginning treatment early.  Proximity meant treating close to the soldier’s unit.  Expectancy was the universal expectation by caregivers and soldiers that the episode would be short-lived, and the soldier would return to duty.  Simplicity meant using simple treatments, such as food, rest, sleep, and behavioral psychology.  In later jargon, that would be “three hots and a cot”.  Centrality meant consistency in the treatment of psychologic casualties. 

Dr. Salmon set up a psychiatric unit in 1918, at a base hospital. His methods, including early intervention as near to the front lines as possible, appear to have been successful, and were adopted widely in the American Army. These five principles were then promptly forgotten after the war. They were re-discovered independently during World War II, and remain today the philosophy of treatment for combat stress disorders.

Source:  Psychological Injuries

Crocq MA, Crocq L.  From Shell Shock and War Neurosis to Posttraumatic Stress Disorder:  A History of Psychotraumatology.  Dialogues in Clinical Neuroscience 2:47-55, 2000. 

Volume X, Neuropsychiatry.  The Medical Department of the United States Army in the World War (Washington, 1925)