Private jack wounded at the Western Front

Mattijn Buwalda

Anesthesiologist-intensivist Medical & Educational Services

www.mattijnb.nl

The Great war - statistics

under arms wounded killed

Great Britain 8.689.467 2.272.998 956.703

Canada 619.500 172.950 66.655

France 8.410.000 4.266.000 1.357.800

Belgium 267.000 44.686 13.716

US 4.335.000 264.000 126.000

Russia 12.000.000 4.950.000 1.700.000

Germany 11.000.000 4.216.058 1.773.700

Allied powers 42.188.810 12.831.000 5.152.115

Central powers 22.850.000 12.831.000 3.386.200

http://www.flandersfieldsmusic.com/WWI-statistics.html

The Western front

The Western front

Comparison of Casualties from Major Western Front Battles

Battle Year Allies German

1st Marne 1914 263,000 220,000

First Battle of Ypres

1914 126,921 –

161,921 134,315

Verdun 1916 400,000 –

542,000 355,000 –

434,000

Somme 1916 623,907 465,000 –

595,294

2nd Aisne 1917 118,000 40,000

3rd Ypres 1917 200,000 –

448,000 260,000 –

400,000

Spring Offensive

1918 851,374 688,341

Hundred Days Offensive

1918 1,069,636 1,172,075

Total Casualties 1914 – 1918 3,619,838 –

4,077,838 3,370,731 –

3,684,025

WW1: a defensive war!

• machine gun

• field artillery

• stalemate - entrenchment

• superiority to the defence

• mass casualties during direct assault

Regimental Aid Post

Advanced Dressing Station

Main Dressing Station

Casualty Clearing Station

Rear Area Hospital

Emergency surgery

surgery

Full medical care

Stretcher bearers

More docters; loosen tourniquets, stop bleeding, clean wounds

Doctor: stop bleeding, splinting, tourniquet, tetanus

Wounded Soldier

Evacuation system

• poor care for wounded in Crimean war • the Boer war (1899-1902) • WW1: static conditions, mass casualties • WW2: mobile war • present: still in use but more flexible

WW1

Role 1 The collecting zone

Role 2 The evacuation zone

Role 3 The distributing zone

Private jack

• private Jack

• born 1899

• coal miners family

• started mining at 14 yrs of age

• enlisted in 1916 at the age of 17

• he wanted “to do his bit”

West Yorkshire Regiment

“The Prince of Wale’s own”

Ypres - Passchendaele

• third battle of Ypres

• July-November 1917

• heavy rain and mud

• many Australians

• West Yorkshire Regiment (Prince of Wales's Own)

Over the top

Wounded in action

• Advancing troops were not allowed to stop and care for wounded soldiers • Jack was carried back to the British line by stretcher bearers

“A bright flash, then there was the stench of cordite and rotten flesh, cries of pain, the rattle of machine gun fire, shell burst I feel weak, nauseated, can’t get up. My palls are passing by and seem to ignore me”

Stretcher bearers

• equipment: arm band and several dressings • unarmed • 4 SB per company (227 men)

Regimental Aid Post (RAP)

• first echelon • near the frontline • sheltered • 16 stretcher bearers • one Medical Officer

(RMO) • basic equipment

– check, clean and dress wounds

– amputation – splinting – anti tetanus serum – morphine

Regimental Medical Officer

• tasks: – preventive medicine – emergency medicine – operative treatment was

discouraged – get wounded ready for

transport

• was issued with a revolver • was not allowed to join

the men in battle! • max 1 year

Manual of injuries and diseases in war, London, HMSO, 1918, p2

Modern first echelon care

• US: Battalion Aid Station

• German: Truppenverbandplatz

• NL: Bataljons hulppost, de AMA opleiding

Jack arrives at the RAP

• pale, weak

• complicated open fracture right leg

• bleeding!

• shrapnel wounds in the abdomen

• laceration of his scalp

• tourniquet

• Thomas splint

• cleaning and dressing of abdominal wounds and scalp

• shock prevention:

– blanket

– encourage to drink!

Field ambulance unit

• originally designed for a mobile front to perform emergency surgery

• main task WW1: to relieve the RAP of sick and wounded – motor ambulance cars – horse drawn wagons

• ADS: advanced dressing station – inspection of dressings and splints

• MDS: main dressing station – surgery – classification for further transport – rest, feeding, anti tetanus serum – usually bypassed for CCS

Dressing station

Jack at the ADS

• dressings changed

• dislocated tourniquet

• lost more blood

• urgent evacuation to CCS

• by motor ambulance

Casualty Clearing Station

CCS: • primary surgery (life/limb

saving) including intracranial and abdominal!

• close to the frontline (< 10 km)

• in proximity of railroad • CCS: 500 – 1200 patients • 1 ccs/division • 1917: 59 CCS’s in Western

front • usually 2-3 CCS’s sited

adjacently • Tents & Nissen huts

Staffing: • 6 medical officers • 2 surgical specialists • 7 nursing sisters • 120 orderlies • Staff could de borrowed

from other CCS’s or base hospitals

CCS

– admission/ triage

– walking wounded

– dressing tent for stretcher cases

– pre-op

– resus

– further treatment

– evacuation tent

– OR (Nissen hut)

– X-ray hut

– staff and logistics

Jack goes for triage

• pale, drowsy

• tachycardia

• open fracture right femur, swollen!

• tourniquet removed and reapplied

• abdominal wounds superficial

• transfer to shock ward (resuscitation ward)

Therapy of wound shock

• prevent exposure (hypothermia) because shivering agravates wound shock

• raise the foot of the bed in case of collapse

• shock ward to prepare for surgery

• 1914: – saline solution 8 ounces subcutaneously or per rectum 3 hourly

– glucose 5% en soda bicarb continuous per rectum or by mouth if possible

• 1916: – IV administration NaCl solution (1831)

– hypertonic saline

– 6% gum acasia solution (1880)

• 1917: – blood transfusion standarized

Foëx BA. How the cholera epidemic of 1831 resulted in a new technique for fluid resuscitation. Emerg Med J 2003;20:316-318

The concept of shock

• “wound shock” – symptoms: ashen skin, copious sweating, rapid

pulse, dilated pupils, lethargic, withdrawn behaviour

– primary shock: signs within 20 min after wounding

– secondary shock: symptoms after a few hours

• Blood pressure measurement was rare < 1917

• Captain Ernst Cowell, surgeon at CCS 23 started to use the sphygomanometer

The first IV colloid.......

• William Maddock Bayliss (US)

– Medical Research Committee 1917

– included: Starling, Cannon

– significance of colloid osmotic pressure (animal experiments, 1916)

• 6% gum Acasia solution IV

Kloot W. William Maddock Bayliss’s therapy for wound shock. Notes Rec R Soc published online June 2, 2010, DOI:10.1098 Bayliss WM. Viscosity and intra-venous injection of saline solutions. J. Physiol 1916;50, xxiii-xxiv

Crystalloids vs colloids.......

Shock ward: candles to provide heat

http://www.ourstory.info/library/2-ww1/hospitals/mh6.html

Mobil Hospital No 6 American Expeditionary force

Blood transfusion

• < 1917: direct transfusion – arterial- venous anastomosis

– syringe-cannula technique

• > 1917: preserved and stored red cells – 500 ml donor blood + citrate and

glucose in icebox

– after 4 days red cells were settled on the bottom

– storage up to 14 days (ice box)

– donors: lightly wounded (3 wks leave)

– only type IV blood (O)

Robertson OH. Transfusion with preserved red blood cells. BMJ 1918;june 22: 691-695

Bottles and needles

X-ray tent

Shattered right femur

Pre op

CCS No. 36 standard preoperative instructions:

• removal of clothes

• previous night: castor oil

• enema and bladder emptied

• omnopon and scopolamine 1 amp

• cotton wool plugs in both ears

Courington FW, Calverly RK. Anesthesiology 1986;65:642-53

Omnopon = alkaloid mixture • morphine • papaverine • codeine

Jack in the shock ward

• resuscitation under responsibility of the surgeon!

• almost no pulse palpable

• clothes removed

• warm water bottles & blankets

• two bottles preserved red blood cells

Jack goes for surgery

Marshall apparatus 1917 – ether, O2 N2O

– bubble flow meters

– mask and balloon

Marshall G. Anaesthetics at a casualty clearing station. BMJ June 2, 1917

21 hours post wounding, mid thigh amputation

CCS – operating theatre

Bricknell MCM. The evolution of casualty evacuation in the British army 20th century (part1) – Boer war to 1918. JRAMC 2002;148:200-207

3 teams 8 h work – 4 h rest 2 active teams ‘round the clock’

CCS

the ‘anaesthetist’

• At the onset of WW1: – usually MO with no special training or skill

– transferred after 6 months

– no continuity of expertise

• > 1917: One expert anaesthetist (permanent posting) – to supervise & train young MO’s

– to maintain the apparatus and supplies

– to provide (difficult) anesthesia

Anaesthetic techniques in WW1

1916: Shipway’s apparatus • warm anaesthetic vapours • ether/chloroform mixture to shorten

induction (5min) • maintenance with ether • blow over

1914: same techniques as in civilian world • ether, chloroform • open technique

1917: Marshall apparatus (ether, O2 , N20)

Shipway FE. Advantages of warm anaesthetic vapours, and an apparatus for their administration. The Lancet Jan 8, 1916

Anaesthesia of patients in shock I

Sir Geoffrey Marshall 1887 - 1982

Spinal anaesthesia • stovocaine 0.05-0.1 gram • safe in lightly wounded patients • but not in shocked patients! • rarely used in a CCS

Pre war: demonstrator physiology

Served 3 yrs at No 17 CCS Ypres Salient

Anaesthesia of patients in shock II

• Iv ether

• postoperative hypotension

• Ether open technique

• Postoperative hypotension

‘Boyle’s machine’

• ether, O2, N2O stable anaesthesia in severely wounded patents

• mortality 90 > 25%

• apparatus made by Coxeter UK

Evans B. A doctor in the Great War- an interview with Sir Geoffrey Marshall. BMJ 1982;285:1780-1783

No 1 field surgical pannier

Anaesthetic equipment:

• 1400 ml chloroform

• ether

• 2 drop bottles

• hypodermic case

• drip set

• mouth gag

• tongue forceps

• skinner mask

• tracheotomy set

The surgeon

• civilian surgeons + assistant surgeons

• biggest challenge was preventing wound infection

Preventing wound infection

• Experiences from the last war: the Boer war – wound infection not a big problem – expectant surgery – mind set: a bullet wound is sterile – South Africa: dry rocky soil

• Western front: – gas gangrene and tetanus huge

problem – Belgium/ France: dirty muddy, wet

soil – need for immediate surgery,

cleaning of wounds etc – Initially expectant surgical

policy…….. – then: drainage + carbolic & H2O2

irrigation, hypertonic salt solution

• What did help was: – complete excision of wounds

ASAP – prevention of shock (to maintain

tissue perfusion) – continuous irrigation with the

Carrel-Dakin solution (bleach)

Base hospital

• rear area

• train station

• good roads

• existing buildings

Base hospital

• non urgent surgery • recuperation • active service • convalescent hospital

England

General hospital

Private Jack goes home

Army pension.....

Bookmarks

• An orthopedic surgeon’s storty of the great war: http://libcudl.colorado.edu/wwi/pdf/i73730658.pdf

• Diary of an assistant surgeon: http://www.firstworldwar.com/diaries/casualtyclearingstation.htm

• WWI The medical front: http://www.vlib.us/medical/

ISBN 978-1783461745

This lecture can be downloaded at www.mattijnb.nl