War Wounded

Paul Theerman, Associate Director

On April 6, 1917, the United States entered the Great War on the side of the Allied powers. By the following fall, those powers were victorious, in part due to the American presence, adding industrial might and men to the stalled conflict and making up for the Russian withdrawal after the October Revolution.

Combat is the most vivid part of war. Victory often depends, however, on maintaining the military effort, and this meant mobilization, training, logistics, supply, and above all, the “medical front.” Armies had to take the wounded soldier, help him heal, and return him to battle. For World War I, that front was where men’s wounds met the medical machine.

Dupuy-Stretcher Bearer-Fig 134_watermark

From a training book for stretcher bearers. Image source.

How were men wounded in the war? The strain and the boredom of trench warfare are part of our collective memory; the drama of that war comes from two sources: mustard gas and machine guns. The use of chemical weapons and the mechanization of shooting brought horror to men’s lives at the front. Yet they were not the greatest source of casualties. By far, artillery was the biggest killer in World War I, and provided the greatest source of war wounded.

In his book Trench: A History of Trench Warfare on the Western Front (2010), Stephen Bull concluded that in the western front, artillery was the biggest killer, responsible for “two-thirds of all deaths and injuries on the Western Front.”[1] Of this total, perhaps a third resulted in death, two-thirds in injuries. Artillery wounded the whole body. If not entirely obliterated, the body was often dismembered, losing arms, legs, ears, noses, and even faces. Even when there was not superficial damage, concussive injuries and “shell shock” put many men out of action. Of course, shooting—in combat as well as from snipers—was another great source of wounding. Gas attacks were a third. Phosgene, chlorine, mustard gas, and tear gas debilitated more than killed, though many ended up suffering long-term disability. Overall the war claimed about 10 million military dead, and about 20–21 million military wounded, with perhaps 5% of those wounds life-debilitating, that is, about a million persons.[2]

Church-Doctors Part_p168_watermark

Moving the wounded. Image source.

Outcomes depended on getting treatment quickly. Evacuation and triage became watchwords of the war-wounded. For the British Army, for example, the Royal Army Medical Corps developed an extensive system to move the wounded from the front to the rear, with triage at each step. Stretcher bearers evacuated the wounded to Regimental Aid Posts (RAP)—or at least those that they had the means to move, for when stretcher-bearers were few, the worst cases were left on the field of battle.

Church-Doctors Part_p54_watermark

The path from the front to the hospital. Image source.

In one report of a man severely wounded in the abdomen, “Since ‘death awaited him with certainty . . . I gave him a hypodermic of morphia and we propped him up as comfortably as we could’ and left him there.”[3] Behind the RAPs were Advanced Dressing Stations, then further back Main Dressing Stations, and finally, Casualty Clearing Stations. Each move to the rear—always challenging in itself—was based on an assessment of the injury and the chances of survival. The lightly wounded—those likely to recover quickly—and the “moribund”—those likely to die—were kept, and the others sent on. Each station provided stabilization and immediate care, with some basic surgeries, such as amputation, at Casualty Clearing Stations. More advanced treatment occurred at hospitals, either back in Britain or in France. As the war wore on, more of the wounded were kept in France, at hospitals far back from the lines. This was to use less transport and to maintain military morale, with the goal of returning the men to the front as quickly as possible. And indeed, American medical entry into the war came first in the form of hospitals. “The first six [mobile hospitals] to arrive in France took over British General Hospitals and provided hospital level care for the British. Other American hospitals arriving later in the summer of 1917, remained assigned to the American forces.”[4] The Allied pattern of medical triage and evacuation became the model for American efforts.

Church-Doctors Part_p84_watermark2

The fracture ward; the term “machine shop” likely refers to the frames and power belts that characterized such shops at the turn of the last century. Image source.

How well did the system work? “War is a matter of expedients.”[5] The medical operation was persistently understaffed and under-resourced. In the latter part of the war, as the static front changed to a dynamic one, some medical units had difficulty achieving the mobility needed. And inevitably, given the need continually to evaluate the severity of wounds, and the difficulty of transport, some men ended up in the wrong place, some facilities were too crowded, and others were underused. Finally, in 1918 the medical system began to be overrun with influenza cases. Overall, though, the magnitude of the challenge needs to be kept in mind. In just the American experience, for an army that numbered almost 2 million men in France at the end of the war, 1.2 million men passed through the medical system, with about quarter million military wounded.[6] That is an astounding number for which to provide medical services under severe stress.

Souttar_Surgeon in Belgium-p22_watermark

Surgery in a Belgian field hospital. Image source.

[1]“Krilling for Company.” Mud Feud [Review of Trench: A History of Trench Warfare on the Western Front, by Stephen Bull (Osprey Publishing 2010)]. Papyrocentric Performativity. Published July 14, 2014. Accessed March 21, 2017.
[2] The total number of killed from the Allied Powers exceeded that of the Central Powers by over a million; the total wounded exceeded by perhaps 4 million. Accurate statistics are hard come by; these are based on Antoine Prost. War losses. 1914-1918-online: International encyclopedia of the First World War. Published August 10, 2014. Accessed March 21, 2017.
[3] Carden-Coyne A. The Politics of wounds: Military patients and medical power in the First World War. Oxford: Oxford University Press; 2014. P. 65.
[4] Jaffin J. Medical support for the American Expeditionary Forces in France during the First World War. Published 1990. Accessed March 31, 2017. Pp. 95–96.
[5] Helmuth Karl Bernhard Graf von Moltke. Wikiquote. Published October 7, 2006. Updated September 1, 2016. Accessed March 31, 2017.
[6] Jaffin J. P. 166.

Uncle Sam, M.D.

By Paul Theerman, Associate Director

Health Almanac, 1920 front cover.

Health Almanac, 1920 front cover.

How to get the word out? For the last two hundred years, health has been as much about education and prevention as intervention and response. And so an intrepid young doctor in the U.S. Public Health Service (USPHS) latched onto using the almanac as a public health vehicle. Health Almanac 1920 (Public Health Bulletin No. 98; Washington, GPO, 1920) was a 12-page almanac entwined in a 56-page public health pamphlet. Amid checking for the phases of the moon or the times of sunrise and sunset, one could find short pieces giving warning signs for cancer, means to prevent the spread of malaria, the necessity of registering births, and how to build a good latrine. These and many other topics were all presented by “Uncle Sam, M.D.”; the almanac was free for the asking.

Uncle Sam Image 4--July right page

Health Hints and Notable Events for July 1920. Click to enlarge.

In the distant past, almanacs became linked to health through “astro-medicine” or “iatromathematics,” that is, medical astrology. Each of the signs of the zodiac was held to influence a system of the body, from Ares controlling the head to Pisces the feet, and so for everything in between. Almanacs were calendrical and astronomical, and in addition to marking sunrise and sunset, the phases of the moon, and religious holidays, they charted the day-by-day progress of the moon through the zodiac, with its supposed medical consequences. To this technical data, the most famous American almanac, Benjamin Franklin’s Poor Richard’s Almanac, added moralistic lessons and practical advice, wittily presented. Health Almanac 1920 provided these same features within the context of progressive secular government. The publication started with inspirational statements from President Woodrow Wilson, the Secretary of the Treasury, and the Surgeon General —who together formed the chain of command for the Public Health Service! Instead of a calendar of religious seasons and saints’ days, the almanac noted national days and significant events in the history of medicine and in “The Great War,” just concluded. Everywhere were health aphorisms: “Good health costs little, poor health costs fortunes” (from the back cover), and “Large fillings from little cavities grow” (April 20). Some “health hints” were quite flatly presented: “Every home should have a sewer connection or a sanitary privy” (July 20), and “Food, fingers, and flies spread typhoid fever” (July 31). Some were just to the point: “Be thrifty” (November 15) and “Wear sensible shoes” (December 18). Throughout, the almanac highlighted the role of the USPHS in promoting health.

Uncle Sam Image 2--back cover

Health Almanac, 1920 back cover.

The Health Almanac was published in 1919 and 1920—we have the 1920 edition—as was a parallel publication called the Miners’ Safety and Health Almanac, put out by the Bureau of Mines. Both were the brainchild of Dr. Ralph Chester Williams (1888–1984), then at the outset of his successful career with the Public Health Service. Born in Alabama and a 1910 graduate of the University of Alabama Medical School, Williams entered the USPHS in 1916 and was posted to the Bureau of Mines during World War I. Pulled into the Office of the Surgeon General, he edited Public Health Reports, served as Chief Medical Officer to the Farm Security Administration, as Medical Director of the USPHS’s New York City office, and starting in 1943, as Assistant Surgeon General and head of its Bureau of Medical Services. In that capacity he oversaw a third of the operations of the USPHS, including immigration inspection and USPHS hospitals. In 1951 the Commissioned Officers Association of the USPHS published his standard history, The United States Public Health Service, 1798–1950. At almost 900 pages, it dwarfs the Health Almanac 1920, but both show their author’s dedication to getting the word out about health and, not incidentally, about the agency that helped make that happen.