The First World War had a huge impact on medicine.

It was one of the deadliest conflicts of all time: the weapons of shells, machine guns and poisonous gas used en mass for the first time resulted in a scale and severity of injuries that had never been encountered before.

The dangers and challenges faced by the armed forces and medical services provoked huge advancements in medical technology and changed the way we practice medicine forever.

In this video, we look at some of the devastating conditions faced by the Royal Army Medical Corps on the Western Front and around the world, and how it rapidly adapted to meet these challenges.

From experimental new medical practises such as plastic surgery, to fundamental advancements such as the use of ambulances, the First World War had a major impact on medicine, far beyond the battlefields in which it was practised.

What was the biggest killer in the First World War?

These photographs show the work of Sir Harold Gillies, a surgeon who developed methods of plastic surgery to help soldiers who had been severely disfigured during the First World War. Gillies’ work was ground-breaking. Using methods of skin grafts and the relatively new technology of X-rays, his work transformed the lives of his patients. Gillies had witnessed first hand the devastating effects of modern weaponry. Despite great progress in medicine since the Crimean War and the Boer War, the casualties of the First World War dwarfed that of previous conflicts, with nearly 10 million armed forces left dead.

Weapons such as artillery and poisonous gas created a scale of injuries that had never been encountered before. And as ever, in the face of this suffering incredible advancements were made that would change the way we practise medicine forever. 
How did the medical services face such devastating injuries? What new developments were able to transform modern medicine? And where did this fall short?

The First World War was the first major conflict in which fewer soldiers died from disease than from enemy fire. Devastating lessons had been learned from the failings in the Crimean War, where casualties mounted up untreated and disease was rapidly spread between the wounded. Newspaper reports of the suffering emerged and caused a public outcry. In the Boer War, 6,000 British troops died from weapons injuries and 160,000 from disease. The typhoid vaccine had been offered to troops before heading to South Africa, but the uptake had only been 5%. In contrast, though it was never made compulsory, typhoid vaccination rates by armed forces in the First World War were at 90% by 1916.

The Boer war at the time of the 20th century had exposed a terrible state of the poor health of would-be new recruits. So by 1914 you see this manifesting in specific requirements for height, weight and chest measurements. There was a desperate demand for soldiers however this became more and more acute as the war went on and as a result of that these requirements did become more lax.

Although not on the scale of the Crimean or Boer war, illnesses and disease were still huge issues for the army. The Western Front spawned ailments like ‘trench foot’, a painful condition brought on by damp feet, and ‘trench fever’, with symptoms similar to flu. On other war fronts, the situation was even worse, and in these environments, disease still caused more deaths than wounding.

This is particularly problematic say France like Salonika in East Africa. Issues of malaria, of cholera, dysentery. And attempts to deal with these local conditions were so important because they had the capacity to knock men out and stop them from fighting. That's what all of the medical care is designed to do it's designed to get men back fighting. A medical officer's list of concerns when it came to illness also extended to things like sexually transmitted infections. It was a widely acknowledged reality that many men were still sexually active at this time either when they were back home or even behind the lines and there were brothels for example and this led to a rise in things like syphilis and gonorrhoea.

And yet, it was not disease or illness that accounted for the huge death toll of WWI. It was weaponry. These scenes are what most people recall when they think of the casualties in the First World War – the devastating effects of new weapons that were deployed for the first time en mass.

Now an injured soldier faced a multitude of life-threatening injuries from all sorts of brutal modern weapons. Chief amongst them were artillery shells and other sorts of weapons projectiles which splintered into pieces of shrapnel, and these accounted for approximately 60% of all wounds. The use of high explosive shells from these big field guns led to especially catastrophic flesh wounds, they were associated with rapid blood loss as well which was a chief consequence of these sorts of injuries. They were made a lot worse by deeply embedded dirt from the mud entering into the body and therefore into the bloodstream and causing infection. Bullets were also a particular danger; machine gun bullets especially entered the body of very very high velocity and caused catastrophic wounds to flesh. They tore through bone, really dreadful injuries.

But there was another new threat on the western front that caused mass fear amongst soldiers. This was of course poison gas. Chlorine gas suffocated men. Phosgene gas caused catastrophic lung blistering injury. Invisible mustard gas caused terror amongst soldiers. Its use by Germany was regarded as barbarous and uncivilised to start with but Britain retaliated by using it too.

"And then the next thing we heard was this sizzling – you know, I mean you could hear this damn stuff coming on – and then saw this awful cloud coming over. A great yellow, greenish-yellow, cloud. It wasn’t very high; about I would say it wasn’t more than 20 feet up. Nobody knew what to think. But immediately it got there we knew what to think, I mean we knew what it was. Well then of course you immediately began to choke, then word came: whatever you do don’t go down. You see if you got to the bottom of the trench you got the full blast of it because it was heavy stuff, it went down."

It was immortalized in soldier-poet Wilfred Owen's poem Dulce et Decorum Est, where his description has a really evocative description of a soldier guttering, choking, drowning. It was also evoked by John Singer Sargent's very famous painting Gassed, in which you see the row of blinded soldiers grasping onto each other. Although it rarely proved fatal, it did cause a terrible amount of suffering.

A hugely significant factor for all of these injuries was the time that it took to retrieve casualties from the battlefield.

The time between suffering a wound and being treated made the difference between life and death, and it was this consideration that really did influence thoughts about how better to treat the wounded as it became clear that this was not going to be a short war.

The trench deadlocked Western Front allowed for the emergence of an effective chain of treatment, taking the wounded from the battlefield into medical care. The first, and often the most dangerous step of this process was the retrieval of the wounded.

Sometimes men were retrieved simply by their own comrades who might pick them up and carry them if that were possible but as the war went on the importance of stretcher bearers became incredibly important. They faced the gruelling job of going out into the battlefield under fire - not armed - to retrieve the injured out of a war zone.

"No one will ever realise the effort it meant to get these men over this terrible marshy muddy ground. Sinking down knee deep was quite mild at times. On this occasion there were four fellows of my size and we come out of the trench, and a loop of barbed wire caught around my feet. Now your first instinct is for the man on the stretcher so as I went down on my knees, my hands went up like that, to keep the stretcher level. And while I was like that, two bullets pinged off my tin hat. Now if it hadn't been for that loop of wire those two bullets would have been between my shoulder blades and I wouldn't be here now."

If a soldier was able to be retrieved, a system of triage kicked in. Some men could be patched up and sent back into battle, and for emergency life and death cases, primitive surgery was possible at aid posts. Much more commonly, injured men would be labelled up for evacuation and moved back down the line.

Now usually this meant ending up in what was called a casualty clearing station. This is effectively a field hospital often in tented accommodation with an array of nurses, doctors and surgeons. And it's just worth making clear is the furthest point on the front line where nurses and female doctors were allowed to work. However for the more long-term wounded their journey continued. The chain of medical care meant that they could be moved, usually by ambulance vehicles, horse-drawn carriages, by trains even, to base hospitals well behind the lines. For more long-term care and ultimately for the very long-term wounded that meant convalescence care back in Britain itself. That was also the case for troops who had travelled thousands of miles to fight for Britain from its Empire, and a very famous example of this was the use of the Brighton Pavilion for a hospital for Indian soldiers.

This slick system of casualty dispersal on the Western Front saved many many lives, and the evolution of this system can still be seen today in A&E rooms and the use of ambulances – things that today seems so fundamental.
However, it was an entirely different ball game on other global fronts where the chain of medical treatment was not nearly as well organised.

On other fronts like Gallipoli, there simply was no safe space behind the lines. At all times all men including stretch-bearers were under fire. Trench warfare allowed for this chain of medical care but in the likes of Gallipoli, arrangements were far less satisfactory and in that case there was a failure of planning as well, a failure to plan for the number of casualties, a failure to plan for evacuating the wounded by sea, and ultimately this was subject to a subsequent investigation.

One area in medical services that had vastly improved since previous conflicts was the integration of the medical services into the military. In the Crimean War and the Boer War, doctors and other medical staff suffered greatly from a lack of authority and there was even a perception that doctors were incapable of understanding operational realities. 
It took until 1898 for an integrated Royal Army Medical Corps to be established. Medical officers were finally given sufficient rank that allowed them to work effectively within the armed forces. By the start of the FWW, medical services were fully integrated into the army, with the eventual deployment of a medical officer in each battalion. By 1918, over half Britain’s doctors had been on active service.
Women were also vital to the medical machine, with thousands serving as nurses - in Casualty Clearing stations, base hospitals and in convalescent care back home. Many more served as ambulance drivers taking the wounded to hospitals. (For more on this topic, watch our video on the role of women in the First World War.)

But the war gave rise to a whole number of innovations, not just in procedures, but also specific medical treatments.

In terms of some specific treatments there are some standout examples of developments. One of those was the Thomas Splint which has barely changed in all the years that it's been used but its application in the First World War really changed the treatment of otherwise fatal injuries to the femur particularly. Preventing infection taking hold in wounds was another huge concern. This was a time when antibiotics did not exist and therefore other methods had to be found. The use of a solution to put into wounds the Carrel-Dakin solution was an incredibly important advance.

Furthermore, the use of X-rays was fully established as a diagnostic tool. Pioneered by Marie Curie, mobile X ray units were in put into use along the Western Front, Curie organised a fleet of vehicles for the units and trained female drivers. They gave surgeons a huge advantage as they no longer had to operate blindly.

Another huge advancement was improvements in blood transfusions– there were efforts to innovate blood banks, and the speed of getting blood from a donor to a patient was vastly improved.

And as mentioned before, the improvements in preventative medical care cannot be overstated.

So medics were encouraged to focus on preventing minor ailments this came down to sanitation was a huge concern preventing pests like lice and rats spreading disease and illness to keeping toilets or latrines clean keeping men clean by providing things like communal baths. And the use of vaccination was a very important tool in defeating typhoid.

Yet despite these advancements, there were still big gaps in knowledge and practice. So what was less effective? One key issue was a lack of awareness about the impact of war on mental health

There was the first understanding of what became referred to as shell shock, the neurological, disturbing nature of living under constant threat of danger. It was acknowledged but there was a lot more work to be done.

Another issue that would take many years to resolve was the lack of rank given to female doctors as mentioned previously was detrimental in their care as it undermined their authority.

Nearly one million people died on active service with the forces of Britain and its Empire. It’s estimated that over 2 million of their forces were wounded.

When the surgeon Harold Gillies returned to England from France, he went about establishing a facial injury ward in Cambridge Army Hospital. After the first fortnight of the Battle of the Somme alone, over 2,000 men were transported to the ward for surgery. The Queen's Hospital in Sidcup opened in June 1917, the first hospital devoted to facial injuries. Many of the methods developed here during the war out of sheer necessity are still used in modern reconstructive surgery today.

Many improvements were yet to come, including antibiotics for infection, vascular surgery to prevent limb loss. But the First World War undeniably led to dramatic improvements in medicine far beyond the battlefields in which it was practised.

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