The hospitals set up immediately behind the lines were often housed in tents during the First World War, including wards and operating theatres.

This was particularly true of Casualty Clearing Stations, with base hospitals further away from the fighting sometimes making use of existing or more permanent buildings.

A casualty then travelled by motor or horse ambulance to a Casualty Clearing Station. These were basic hospitals and were the closest point to the front where female nurses were allowed to serve. Patients were usually transferred to a stationary or general hospital at a base for further treatment. A network of ambulance trains and hospital barges provided transport between these facilities, while hospital ships carried casualties evacuated back home to ‘Blighty’.

As well as battle injuries inflicted by shells and bullets, the First World War saw the first use of poison gas. It also saw the first recognition of psychological trauma, initially known as ‘shell shock‘. In terms of physical injury, the heavily manured soil of the Western Front encouraged the growth of tetanus and gas gangrene, causing medical complications. Disease also flourished in unhygienic conditions, and the influenza epidemic of 1918 claimed many lives.

Roman Wound Care

Care of the injured soldier is as old as war.  And war is as old as history.  Perhaps older.  People were fighting and hurting one another back into the old stone age, long before organized societies and armies.  Military medicine goes back a very long way.  In fact, to the very first civilizations.  From around 4000 BCE to around 1500 BCE, organized civilization arose separately in Mesopotamia and Egypt; the Indus River valley, present-day Pakistan and India; the Yangtze River valley in China; and the Americas, meso-America and the Andes.  All were agriculturally based, and featured organized governments and armies supported by hereditary ruling and military castes.  Without exception, all were warlike.

Even in the ancient world, all armies had to care for their wounded.  But the civilizations themselves varied widely in their underlying medical institutions.  Some cultures had such rudimentary medical care that wounded soldiers were given hardly more than token care, others had fairly sophisticated treatment of wounds. Roman military medicine most closely approached what we have today.  The Roman army had organized field sanitation, well-designed camps, and separate companies of what we would now call field engineers. They had a much better grasp of sanitation and supply than anyone else before, or for a long while after.  They had medical corpsmen, called immunes. They practiced front-line treatment, with evacuation through well-organized supply and logistics chains.  Because of their improved sanitation, their armies suffered somewhat less from the epidemics which swept military camps.  But that was only by comparison with their opponents.  Two-thirds of their casualties were still due to disease.  Their world-view included no such thing as bacteria or protozoa.  Immunizations were two millennia in their future.  And, perhaps most important, their practices did not outlive their empire. 

After the Romans, medical care on the battlefield became disorganized, almost an afterthought.  In the Middle Ages and the Early Modern period, medical care was done by whoever was nearby.  This meant local surgeons, camp followers, servants, and whoever else would volunteer or be conscripted.  Armies were small.  The famous battle of Crecy, for example, in 1346, was fought between an English army of 10,000 men, and a French army of 20,000.  Camp sanitation was totally unheard of, and disease ravaged armies of the day.  Until the 20^th century, at least twice as many soldiers died from disease in camp than from wounds on the battlefield.

What is military medicine?  Today’s military medicine is an amalgam of trauma care, infectious disease treatment, preventive medicine, and public health.  All of these are important.  Trauma care includes not only the treatment of wounds, but also the rescue of injured soldiers, their evacuation, and the provision of a graded system of care from the front line to hospitals far in the read.  

Equally important is infectious disease care and preventive medicine. Anyone who has been in military service can testify to the large number of immunizations they received.  These have controlled the diseases that caused most of the casualties in previous centuries.  Those that cannot be controlled by immunizations can be treated.  Today’s antibiotics and other treatments are vital in military medicine.  Unhappily, antibiotics were not available in World War I, and diseases such as pneumonia, dysentery, and tuberculosis continued to claim victims.

Public health, including environmental medicine, is recognized as a crucial part of military medicine.  Disease agents such as mosquitoes can be controlled.  Water supplies are routinely treated.  Human waste is controlled and not allowed to spread disease.  Environmental medicine is a large part of this.  Wars are not usually fought in nice places.  Even when they are, as in Flanders and northeastern France, those places quickly become adverse environments.   

French Soldier in a Trench

The First World War was fought largely in the trenches of the Western Front.  That’s not the full story, but it was a dominant part of the war, and remains the public image.  Trench conditions were miserable from a military standpoint, but a disaster for public health.  Sanitation was so bad that after a week or two in the trenches, troops had to be rotated back of the lines to be deloused, thoroughly cleaned, and provided with fresh clothing and equipment.  Even so, disease was common, and wound contamination universal.  

Wounds were usually contaminated with the mud of the trenches.  Tetanus immunization was available, and wounded soldiers were routinely given tetanus toxoid.  Wound care was much better than during previous wars.  It emphasized debridement of devitalized tissue and thorough cleaning with antiseptic solution (Dakin’s solution).  Aseptic technique was (usually) used in operating rooms.  General anesthesia was available.  Bowel injuries could be routinely repaired.  Intravenous fluids were available, as were blood transfusions (sometimes).  Radiography had only been invented some 16 years before, but was deployed on the battlefields by 1914.  As an index of how much things had changed, mortality following amputation had been 25% in the American Civil War, and was 5% in World War I.  Deaths from wounds dropped, but deaths from disease dropped even further.  Far fewer soldiers died of disease as a percentage of total deaths than ever before.  And this was despite the influenza epidemic of 1918-19, which claimed many victims at the end of the war. 

Aid Station in a Trench Dugout                  

Even acknowledging all of the difficulties imposed by trench conditions, the casualty care system was still much better than in any previous war.  Specialized military units, called ambulances were charged with picking soldiers from the battlefield and transporting them to aid stations, and then to field hospitals.  For further evacuation, hospital trains were staffed with nurses and orderlies, and equipped to care for even difficult wounds. There were base hospitals and convalescent facilities both on the French coast and in England.  As the American Army deployed to Europe in 1917-18, hospitals, doctors, nurses, and ambulances went with them.

The First World War claimed 9 million soldiers, and 7-10 million civilian lives.  Civilian casualty estimates vary widely, and the true figure is probably unknowable. In 1918-20, over the course of the influenza epidemic (misnamed the Spanish flu), some 20 to 40 million people died. Half of all American soldier deaths from disease were due to influenza, many in training camps in the United States.  Did the war cause the flu epidemic?  Perhaps so.  Certainly, it created the conditions in which the epidemic began and spread.  The question has been debated ever since.  Whatever its cause, the flu epidemic killed more people than the war itself.