Introduction

When Britain went to war in 1914 the army medical services were organised, equipped and staffed to care for the medical needs of the small standing army -160,000 men - and a Territorial Army - most of whom were not expected to serve overseas. No one, military or civilian, thought in their wildest dreams that in four years British military manpower would rise to over 5 million men, and several thousand women, and that the daily British (excluding Empire) deaths were 500 a day to total 704,000. Only the American Civil War and the Boer War gave some inkling of the long drawn out slog of a war it would be. There were, of course, no antibiotics or sophisticated anaesthetics - simple formulations of Novocain were the drugs of choice for even the most serious operations. Resuscitation and battle trauma kits as we know them today did not exist. The soldiers' own first line of trauma treatment was modest indeed: Field Dressings that consisted of large and small gauze pads, impregnated with Acroflavin, attached to long bandages. Even the medical instruments for surgery were rudimentary when one considers those available in a modern Field Ambulance unit

Casualties and care

In the early part of the war, most of the wounds were from small arms and machine-gun fire. But, as the war progressed and the artillery gained an ever increasingly important role, wounds due to shrapnel and high explosives became predominant. If mortars and hand-grenades are included along with rifled-shells as projectiles, this category of weapon subsequently accounted for 61% of all British battle wounds; the much dreaded bayonet wounds only accounted for 0.3%.

Whilst one would not expect disease to account for a large proportion of casualties on active service in continental Europe, in fact, 60% of all hospital admissions on the Western Front were due to disease, with a death rate of 1%; wounds gave an 8% death rate. However, in the tropical war zones diseases rates were much higher. The hospital admission rate in German East Africa was 240%! And in areas like Mesopotamia and Greece, it was not much less. Effectively, British troops of Caucasian race could not fight a sustained war in these highly diseased environs, and where ever possible Empire troops with more innate resistance to these tropical diseases had to be drafted in, e.g. East Africa.

A lot of the initial but vital treatment of wounds, particularly where blood loss and/or shock was concerned, had to take place in the forward areas - frequently with long delays before evacuation was possible. A steep learning curve produced rapid improvements during the progress of the war; particularly in fluid replacement, blood loss, blood transfusion and wound infection. Sterile replacement fluids had originally to be made up in situ, with all the dangers that entailed, but later on, standardised solutions were prepared under more ideal conditions at the Base Hospital level and forwarded into the Line. Blood transfusion, which could be highly hazardous in view of the then current ignorance about blood groups, was revolutionised by the introduction of a simple matching test and the direct transfusion from donor to patient was replaced by stored blood. This enabled blood donations to be transported down the Line as far as the Advanced Dressing Station level. Wound infections have always been a serious hazard of war. Due to the heavy use of manure in the highly agriculturalised terrain of the Western Front, tetanus and gas-gangrene stalked the wards of all West Front hospitals, particularly those dealing with abdominal and chest wounds and deep wounds of the limbs. A more vigorous debridement (excising of damaged tissue) of wounds also led better outcomes.

Behind the Lines the first tentative steps in the creation of a plastic surgery capability took place and by the end of the war, considerable progress had also been made in this sphere.

Mental exhaustion due to the stresses which occur on active service was known and recognised long before the Great War. But in the Great War it became, for the first time, a cause of the loss from active duty of a relatively large number of fighting soldiers. Known as 'shell shock' a cure was never found. However, considerable success was attained in the rehabilitation of even some of the more serious cases. Many of less serious cases were also returned to duty after appropriate rest and recuperation.

Conclusion

The Army Medical Services could and did do better on another occasion 21 years later, but under the quite unforeseen circumstances under which this war was fought, it would be hard to deny that it had achieved, in general, a creditable success.

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