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