Photo of the Day

Sidney Stanfield in 1918.

Sidney Stanfield in 1918. Photo: courtesy Susan Paris

Wounded,Conflict, Casualties and Care

How battlefield surgeons treated shellshock, shrapnel and gas

And poor Jim was laying there cuddled up in a heap as men die. Don’t forget we was all young, we didn’t die easy. You don’t die at once, you’re not shot and killed stone dead. You don’t die at once. We were all fit and highly trained and of course we didn’t die easy, you see. You were slow to die and you’d find them huddled up in a heap like kids gone to sleep, you know, cuddled up dead.

Sidney George Stanfield (Stan) was born in Tinui, near Masterton, in 1900. He worked as a farmhand before sailing for war in 1916 with the Wellington Infantry Battalion. He saw action in France and Belgium and at the end of the war was still nearly two years under the age limit for service overseas.

On being a stretcher-bearer at Passchendaele 12–14 October 1917

It rained and rained and bloody rained, and rained and rained, see. Just like here in the autumn time, when it comes to rain and it was cold. And we were picking them up from a gathering point as a regimental aid post. Well there were hundreds of men laying out, around. You couldn’t get them inside, it was an old German concrete emplacement and you couldn’t get them all inside, but the doctors were working inside. And they were just laying around where they’d been dumped by the stretcher-bearers from off the field and at one period I believe there were 600 stretcher cases laying round the place in the wet and cold, just dying there where they were dumped off. They weren’t even laying on stretchers, just laying on the ground with an oil sheet tied over them if anyone thought to do that, or if one of their mates could do it. Just laying there, because the stretchers were used for picking up other men, you see, there couldn’t be a stretcher for every stretcher case. We just carried till you couldn’t carry more. You just went until you couldn’t walk really, you just went until you couldn’t walk.

On how infantrymen saw themselves at Passchendaele

An ordinary infantryman at Passchendaele was a pretty dumb beast. That’s how he’s treated, you see. He was only gun fodder and when all is said, and that’s what I feel. We were pretty dumb beasts you see, or we wouldn’t have been slapped, thrown into that sort of warfare, because it was hopeless before you started. We all knew that.

There was one place at Passchendaele … where we heard a man crying at night out in front and went out and we couldn’t find him and we heard him crying part of the next day. Calling, you know, calling, sort of crying, not screaming or anything, crying out. We just knew there was a wounded man lying down under something you see. We never found that man. That’s the only thing that’s stuck in my memory. The others, I’ve seen them lay gasping and panting and scratching up the dirt with their fingernails on their face and all crawling around semi-delirious and all sorts of things.

His feelings about the misery of the war

I felt that the war was never going to end. It was going to go on forever. I felt that I would never see the end of the war, that it was not possible. I felt it was not possible that I would survive the war … I can remember feeling at times that I’d be quite happy to engage in any sort of slavery at all if I could be taken away from this, what, misery. Misery.

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Mr and Mrs Stanfield. Photo courtesy Alan Doak.

Wounded men would be moved (by stretcher-bearers if necessary) to regimental aid posts for hurried medical treatment. Another team of stretcher-bearers would carry them to dressing stations. There, treatment was limited: bleeding was stopped; splints were applied; wounds were quickly stitched; shock was treated as well as possible; and badly shattered limbs were removed. Morphia and other anaesthetics would be given only in small doses, if at all. The use of penicillin for fighting infection had not yet been developed.

The wounded were then taken to the relative safety of casualty clearing stations, which were often a few miles from the dressing station. Ambulances (motorised or horse-drawn) and stretcher-bearers carried those who could not walk. Surgical teams made up of a surgeon, anaesthetist, sister and orderly – worked at clearing stations, along with other medical staff, orderlies, chaplains and stretcher-bearers. Once treated or diagnosed, men would be sent on. Some went to the New Zealand Stationary Hospitals in Hazebrouck or Wisques for more serious operations or treatments. Others went to hospitals in the United Kingdom where some remained for the rest of the war. Still others returned to the front.

In May 1917 medical staff, including 35 nurses from the New Zealand Army Nursing Service, moved from Amiens to set up the New Zealand Stationary Hospital at Hazebrouck, closer to the front. It was a makeshift hospital: a girls’ boarding school and a couple of big tents converted into wards and operating theatres.

There the doctors and nurses waited for the wounded who would inevitably come once the planned offensive against the Germans started. The first New Zealanders arrived on 9 June, two days after the Battle of Messines had started. Many had head injuries, which this hospital specialised in.

It is terrible to see these men wounded in the head — numbers of them become paralysed and quite a number were minus arms and legs or eyes. For the first few days they were quite silly — lost their reasons and some speechless. Oh, it was ghastly and desperately busy — we just went on and on doing dressings no hope of finishing … Crowds died of course.

Elsie Grey, New Zealand Army Nursing Service, in Anna Rogers, While you’re away: New Zealand nurses at war 1899–1948, 2003.

When British Forces went over the top of the trenches on July 1, 1916, no one could have predicted the outcome. As the Sun set on that first day of the Battle of the Somme, some 57,000 British men lay dead, wounded or dying on the battlefield in northern France. The scale and severity of wounding in the First World War was totally unprecedented. The medical collections give a slightly untold story, so rather than the people who lost their lives, it looks at those who were wounded and had to continue to live with their wounds and what happened to them in the years after they returned home.”

When British Forces went over the top of the trenches on July 1, 1916, no one could have predicted the outcome. As the Sun set on that first day of the Battle of the Somme, some 57,000 British men lay dead, wounded or dying on the battlefield in northern France. To mark the centenary of the beginning of the Battle of the Somme, the Science Museum in London, has opened a new exhibition that brings together objects that highlight not only how deadly the First World War was, but also the innovation and advancement in technology, science, and medicine. “The scale and severity of wounding in the First World War was totally unprecedented,” explains Vikki Hawkins, curator of the exhibition Wounded: Conflict, Casualties and Care, to IFLScience. “The medical collections give a slightly untold story, so rather than the people who lost their lives, it looks at those who were wounded and had to continue to live with their wounds and what happened to them in the years after they returned home.”

Blood transfusion kit from the First World War. Science Museum/SSPL

As troops were faced with weapons they had never experienced before, doctors and medics where conversely having to treat wounds of an unprecedented nature and scale. Due to the mechanization of warfare, they were often in uncharted territory. Even if the men survived the trauma of slashed muscle and splintered bone, they then had to contend with blood loss and infection. Some of the most basic techniques, such as applying pressure and a tourniquet to stem the bleeding, were often the first line of treatment, but some doctors were trying to develop more advanced, long-term treatments.

While blood transfusions had been around beforehand, it was really during the First World War that the technique was refined and pioneered. Blood transfusion was not at the level that it would be able to provide a real difference until about 1917. The first 1917 blood transfusion was achieved by mixing the blood with sodium citrate, the medics were able to prevent the blood from clotting. This proved to be an invaluable advancement, as it meant that blood could be banked and stored in preparation for the casualties from major battles, and as a result save countless lives.

The importance of blood transfusions during warfare is something that has remained unaltered in the 100 years since the Battle of the Somme. It is fascinating how important blood transfusion is. How in the First World War they were trying so hard to get blood transfusions closer and closer to the front line to give it to people as soon as possible.” Now, doctors have “intraosseous drills” – which inject blood and fluid directly into the bone – and coupled with a huge amount of blood stored on the helicopters, this allows medics to provide transfusions literally as soon as they are off the battlefield. “The principles are exactly the same, it’s just the technology that has changed.”

Oxygen therapy apparatus invented by John Scott Haldane, c.1916-18, c. Science Museum, SSPL.

Oxygen therapy apparatus invented by John Scott Haldane, c.1916-18, c. Science Museum, SSPL.

But doctors were not only having to treat injuries of unparalleled scale, they were also forced to deal with those never before seen in battle. In April 1915, chlorine gas was first used on the Western Front. Taken by complete surprise, the medical staff were unsure what to do as patients arrived vomiting, coughing, and initially dying in high numbers. Within days of the attack, which terrified the soldiers who had never experienced anything like it, the British Army sent scientist John Scott Haldane to the front line to help identify the gas and how best to treat its effects.

He actually discovered what the gas was from looking at somebody’s button that had just been on an officer’s uniform. It had just been polished the day before and was now completely tarnished. As a scientist he was aware that that could be because chlorine was present.” Haldane returned to London where he started experimenting with a team, often using themselves as test subjects, gassing the corridors, and digging trenches in the university’s grounds to allow them to see how the gas dispersed.

After conducting these experiments, Haldane realized that the most effective way to treat men who had been gassed was to increase their blood oxygen concentration. This all resulted in him producing “Haldane’s oxygen apparatus”, a life-saving piece of equipment that was eventually stationed near the front lines to treat soldiers as soon as possible. The one on display shows one of these apparatuses adapted for use by four separate people, and would have been attached to a cylinder of oxygen.

Yet it wasn’t just the visible wounds that soldiers were suffering from. In what was originally called “shell shock”, countless men during the First World War were impacted by what we now know to be Post Traumatic Stress Disorder (PTSD). When this first manifested itself on the battlefield, often as symptoms including paralysis, muteness, vomiting, and tremors, there was little done to help the men and little sympathy given. In fact, many men who are now thought to have been suffering from shell shock were appallingly executed during the war, accused of cowardice and treason.

And when those who survived returned to England with these “invisible wounds”, some of the men weren’t necessarily treated any better. “Because there was no standard treatment for men who had been exposed to war and who suffered shell shock, some of them sadly were sent to asylums.  But out of the dramatic rise in patients suffering PTSD – some 32,000 war pensions were given to those suffering shell shock – came the groundwork for modern mental health practices that informs much of how people are treated today.

Colt’s stretcher for narrow trenches, 1916. c. Science Museum, SSPL

Colt’s stretcher for narrow trenches, 1916. c. Science Museum, SSPL

The first day of the Somme caused an immense amount of casualties. What was the immediate impact of that for the men and women administering to them in those vital first hours?

This was the highest number of casualties that British Forces have ever suffered in a single day. The devastating potential of industrialised weaponry was reaching progressively new levels during the First World War, and the physical impacts could be catastrophic. Although medical personnel had experienced nearly two years of fighting, their capabilities were constantly hampered by the scale of casualties they had to deal with and the conditions they were working in.

As on the battlefield today, blood loss was the most immediate danger to life, so dealing with it – be it violent haemorrhage or slow oozing – was a huge challenge. Rapid intervention was vital in the most serious cases and this was never easy at the best of times in trench warfare, let alone on the first day of the Somme. Many men died because nobody could treat them in time. Where they could help, medical personnel employed some well established techniques; manual pressure to stem the flow, attaching tourniquets to bleeding limbs or ligatures to tie off damaged blood vessels.

But less dramatic blood loss could also be fatal. ‘Wound shock’ was a condition characterised by falling blood pressure and the shutting down of vital functions. Initially something of a mystery, as it could strike those with only minor wounds, it was a major killer on the Western Front. While blood transfusion begins to prove its value towards the end of the war, it’s not being used on any real scale in July 1916. It was also realised that other factors apart from blood loss had an influence on the development of wound shock as experience on the front line showed that warmth, liquids and comfort could improve the chances of survival – but these were not easy to provide in the circumstances.

In the slightly longer term, infections posed a serious threat to every soldier wounded on the Somme as they were essentially fighting on heavily manured farmland. Bacterially contaminated soil, ballistics and other debris could be blasted deep inside the body. Wounds became gangrenous within hours, and many men survived blood loss and shock only to succumb to infection.

Field surgical pannier set, complete, British, 1905 pattern in use 1914-1916. c. Science Museum, SSPL.

Field surgical pannier set, complete, British, 1905 pattern in use 1914-1916. c. Science Museum, SSPL.

What were Casualty Clearing Stations like and what level of care were they capable of providing?

Early on in the war Casualty Clearing Stations (CCSs) lived up to their name. They were intended essentially as transit points, not heavily staffed, where casualties would be assessed and sorted then then sent on to hospitals nearer the coast or even straight onto a hospital ship. Once the static nature of trench warfare was established and the value of earlier medical treatment, nearer to the frontline, CCSs expanded and became semi-permanent facilities – positioned near enough to the front line to be easily accessible, but out of range of most of the German artillery.

Wherever possible they were established in buildings; convents, schools, factories and existing hospitals, often expanding into huts and tents to provide more accommodation. As the war progressed they became centres of specialist medical care, furnished with the latest technology including x-ray equipment for locating metal shell fragments, blood transfusion equipment, and a suite of operating theatres.

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British stretcher-bearers near Boesinghe, Belgium, 1917. c. Science Museum, SSPL

The surgeons at a CCS had several core objectives. One was to patch up the lightly wounded for return to the front. Another was to stabilise then forward those with moderate injuries to hospitals further down the line. They also performed life-saving surgery on the most seriously wounded. At a CCS, the wounded were likely to encounter female carers for the first time, as trained nurses were assigned to the units from October 1914. Some nursing tasks could be mundane and repetitive; others required technical skill and carried great responsibility. Nurses administered pain relief, re-dressed wounds and assisted in the operating theatre. At busy times, some also carried out surgical procedures.

The link between CWG sites and the locations of Casualty Clearing Stations is particularly sobering. What happened to the men who died in the CCSs – or who arrived dead – and how was their death processed?

As CCSs became established and grew into much larger sites, with operating theatres, various diagnostic facilities and hundreds of beds they inevitably became places where many thousands would succumb to their wounds. When wounded soldiers arrived at CCSs, many were beyond help. Initially, hopeless cases were often transferred to die in so-called ‘moribund wards’, where their passing was eased as much as possible – when time allowed. Towards the end of the war, doctors recognised that salvation for some could lie with blood transfusion, and although the method was fraught with difficulties, as the war continued viable methods began to emerge. By 1918, those entering a growing number of so-called ‘resuscitation wards’ had at least a chance of surviving. From September 1914, a British Red Cross unit began to collect information about British fatalities and the haphazard location of graves. Graves Registration Units soon became incorporated into the army and were responsible for recording the burial of the dead and the cemetery sites, partially in response to public concern about the recovery, identification and proper burial of their loved ones. However, with such huge numbers of casualties, many deaths were still recorded as missing or fell through the administration process.

Set of 50 artificial glass eyes, all shapes and sizes, by E. Muller, Liverpool, English. c. Science Museum, SSPL.

Set of 50 artificial glass eyes, all shapes and sizes, by E. Muller, Liverpool, English. c. Science Museum, SSPL.

What were the major innovations in trauma care at the time of the Somme, and how did the experiences of the Somme inform or inspire changes in trauma care?

It’s difficult to link specific changes – or indeed clear fundamental shifts in care – to the experience of the Somme, but the events of 1916 do feed into the improving and expanding medical services. While continuing to be overwhelmed at times throughout the remainder of the war they are implementing best practice and proven strategies based on what has been experienced as they deal with the daily flows of casualties.

Innovations in medical treatment during the war were not always the result of new techniques or technologies – often it was the rediscovery and wide scale application of ideas and equipment that helped to save lives.

Early in the war, around 80 per cent of soldiers with fractured femurs (thighbones) were dying. During the slow evacuations over bumpy terrain, their unstable broken bones caused further, often fatal, bleeding. In such conditions, standard-issue splints or improvised supports such as rifles were of limited value. The re-discovery and wide scale application of a Victorian medical device – the Thomas splint – dramatically reduced both death rates and the degree of long-term disability.

Another example is the way in which infected wounds were treated. Belgian surgeon Antoine Depage led the successful call for the return of débridement – an 18th-century practice of thoroughly cutting away all of the damaged and infected tissue. It remains a crucial tool of infection control in trauma medicine.

Protective mask, leather and chain mail, worn by tank crews, probably British, 1917-1918. c. Science Museum, SSPL.

Protective mask, leather and chain mail, worn by tank crews, probably British, 1917-1918. c. Science Museum, SSPL.

The prevalence of shrapnel – and the existence of the ‘splatter mask’ is testament to the unique horror set aside for facial scarring. How was this treated?

Over four years, thousands of men received serious facial wounds, and these devastating injuries prompted major advances in specialist fields of reconstructive surgery. In Britain, progress was driven by New Zealand surgeon Harold Gillies. Having treated over 2,000 cases from the Somme, he lobbied for the establishment of a specialist hospital for facial injuries, and in 1917 the Queen’s Hospital in Sidcup, Kent was opened. Rebuilding a damaged face could take many years, and patients at Sidcup might undergo multiple procedures and operations, with each stage of treatment painstakingly recorded in case notes. Some did not survive the ordeal.

Gillies quickly appreciated that 3D imaging could transform the work of the plastic surgeon. A team of sculptors was brought to Sidcup to make plaster casts of the men’s faces. With a solid record of the damage, ears, noses and chins might then be added – often in Plasticine – to show how a soldier’s face could look after surgery. Among Gillies’ key advances was a skin-grafting method called the ‘tubed pedicle’ technique. Here a flap of skin was separated, but not detached, from a healthy part of the soldier’s body and then attached to the injured area. There it was rolled into a tube and sewn into place to allow new tissue to form.

We will be displaying a number of Henry Tonks’ pastels in the exhibition which are on loan from the Royal College of Surgeons. Tonks drew portraits of the patients before and after surgery, in addition to producing diagrams of the operations in order to record the various stages of reconstruction. The combination of Tonks’ medical and artistic training enabled him to depict the physicality of the flesh, and to help Gillies achieve an aesthetically pleasing result.

Leg amputees practise with crutches, c.1916, c. Science Museum, SSPL.

Leg amputees practise with crutches, c.1916, c. Science Museum, SSPL.

Similarly, loss of limb is now part of traumatic public memory of World War I. What sort of prosthetics were available to the wounded of the Somme, and how did these improve over the rest of the war?

British military amputees had been entitled to a free artificial limb since Napoleonic times, but within months of the beginning of WW1 existing systems of provision were overwhelmed. Only in 1915 did things really begin to be dealt with through the establishment of Queen Mary’s hospital in Roehampton, which rapidly expanded throughout the war and became the focus of limb manufacture and fitting as well as a centre of rehab and training for amputees.

Throughout the war, the majority of amputees were leg amputees. With the British limb-making industry failing to keep up with escalating demands, American manufacturers were shipped over in 1915 to set up workshops at Roehampton. As a range of manufacturers battled to meet requirements, amputees could find themselves with limbs made to varying standards. Most ‘first issue’ legs were wooden and many based on the design once popularised by the Marquess of Anglesey, who had lost his leg a century before at the Battle of Waterloo.

The Somme added significantly to the growing backlog of amputees that had to be fitted and processed. During the war waiting lists ran into four figures. While there was certainly innovation both in limb design and re-training for work the men who wore them during the war, the experience for amputees could be varied and it was only in the post war period that the situation was properly dealt with.

In their efforts to compete for lucrative government contracts in the post-war period, limb-making companies experimented with new designs and new materials. One of the fundamental shifts for amputees came with the move from wood to metal limbs. Having been issued with wooden limbs during the wartime rush, amputees clamoured for the lighter metal designs that were issued throughout the 1920s. For a range of reasons, many amputees did not wear prostheses – sometimes through choice. Limbless men on crutches or in wheelchairs remained familiar sights around the country for years.

Artificial arms by Carne Artificial Limb Co., c.1915, c. Science Museum, SSPL.

Artificial arms by Carne Artificial Limb Co., c.1915, c. Science Museum, SSPL.

Of all the physical injuries associated with World War I, few are as grimly iconic as poison gas. As there was no precedent in the history of the British Army, how was this treated?

Many veterans remembered being more afraid of gas than of any other weapon, although it killed ‘relatively’ few men. It did wound in huge numbers, taking men away from the front and flooding the hospitals. Even for those only lightly exposed to gas, up to 60 days’ recovery might be needed before they were fit again. The treatment available to those wounded by gas was limited, at times experimental and often applied in combinations. Gases such as chlorine and phosgene essentially drowned victims as it irritated the lungs and they filled with fluid. Some doctors believed that bleeding (venesection) could help drain these toxins from the body, as could salt-water emetics, which induced vomiting. The most effective treatment for such casualties was to artificially increase the oxygen concentration of the blood.

With the arrival of mustard gas in July 1917, the medical services faced a horrifying new challenge. This gas caused severe burning of the skin, eyes and internal organs. Heavier than air, it eventually settled to further contaminate clothing, food and water. In an attempt to dissolve or neutralise the mustard liquid, various chemicals were tried, including bleach ointment, petrol and kerosene. Soap would then be used to wash off the residues. Paraffin ointment was carried in field medical kits to treat more conventional burns, but it could also be applied to the skin of mustard gas burn victims. Afterwards, salt baths were prescribed as the blisters began to heal.

Oxygen therapy apparatus invented by John Scott Haldane, c.1916-18, c. Science Museum, SSPL.

Oxygen therapy apparatus invented by John Scott Haldane, c.1916-18, c. Science Museum, SSPL.

The psychological effects of battlefield trauma are all now recognised – though perhaps not as widely as we’d like – and are remembered as part of the memory of World War I. At the time of the Battle of the Somme, what understanding of the psychological effects of combat existed? 

Early in the war doctors had begun to see a new phenomenon. Large numbers of men, apparently unharmed, displayed bewildering symptoms that might include paralysis, anxiety, dizziness, muteness, deafness, terrifying dreams, vomiting, extreme fatigue, chest pains and tremors. It was initially believed that these were physical reactions from being in close proximity to an exploding shell, hence the catch-all term ‘shell shock’ – though this term was not coined until 1917.

Shell shock numbers began to rocket as the Battle of the Somme progressed. The numbers involved greatly concerned military authorities who worried that it was in effect an almost ‘contagious’ form of hysteria which could affect entire units at a time – and there remained both a lack of clear understanding about why it was happening as well as very inconsistent approaches to treatment regime. In December 1916, losses to shell shock (mainly on the Somme) created a manpower crisis. Rather than send men way down the line and very often back home, psychiatric units for the rapid treatment of shell shock were established. They were called ‘Not Yet Diagnosed Nervous (NYDN) in part to avoid medical terminology.

Bottle of “Ner-Vigor”, with instructions, in original carton, by the Anglo-American Pharmaceutical Co. Ltd., 1915-1925, c. Science Museum, SSPL.

Bottle of “Ner-Vigor”, with instructions, in original carton, by the Anglo-American Pharmaceutical Co. Ltd., 1915-1925, c. Science Museum, SSPL.

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British Soldiers wearing gas masks 1917. Kodak collection.

Most shell shock cases would eventually be acknowledged as emotional collapses from the stress and horror of this war. Sometimes, however, such men were accused of shirking or cowardice. Many of the 306 British and Commonwealth servicemen executed during the war are now believed to have been shell-shocked.

‘Sidney Stanfield remembers Passchendaele’,From the collections of the Alexander Turnbull Library

The Vest Pocket Kodak Was The Soldier’s Camera – National Media …

One Hundred Years On: The Science Of The Somme | IFLScience

The Battle of the Somme – Battle of the Somme | NZHistory, New …

WW1 Battles of the Somme 1916 & 1918, France

First day on the Somme – Wikipedia, the free encyclopedia

The treatment of wounded and sick soldiers – The Long, Long Trail

 


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  • WeaselKiss

    I have to confess, I couldn’t read it all. It just made me so sad, and pretty angry.
    ‘Internet’ (cough) studies I have done over the last couple of years have told me that WW1 could have been ‘easily avoided’ and as well, there is evidence that a relatively small group of financial elites have basically financed both sides of every major conflict around the world since the Napolianic War.
    Well, I don’t know about that.
    But if any of that is even half true….#angryalldaynow.

    • Isherman

      Its perhaps the sadest of ironies, that throughout the ages conflict has been one of the principal drivers of our advances in science and technology. Even such humble items as a ballpoint pen and the wristwatch owe some measure of debt to the Great war.

      • Chinaman

        Agree Weasel that it makes me angry as well…Dylan expressed that anger many years ago very well with ”masters of war”,here is a small taste..

        Come you masters of war
        You that build all the guns
        You that build the death planes
        You that build all the bombs
        You that hide behind walls
        You that hide behind desks
        I just want you to know
        I can see through your masks.

        You that never done nothin’
        But build to destroy
        You play with my world
        Like it’s your little toy
        You put a gun in my hand
        And you hide from my eyes
        And you turn and run farther
        When the fast bullets fly.

        • Lux

          That’s amazing, and very powerful.
          I have not read that before, thanks for posting.

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