World War I and medicine, October 27, 2017

- [Donna Hirst] Can you hear me? This is the second lecture of the History of Medicine Society and we're gonna be hearing about World War I and medicine. I wanted you to know that on the third floor of the Hardin Library there's an exhibit about World War I and medicine. And some of this information is there, but there's additional information that you might be interested in. Over to the, oh, sorry. Over to the right, on the ledge, is a sign-up sheet if you want to get notices about future lectures. I know some of you are already on the mailing list, but if you aren't and you would like to be, you just need to put your name and your email address on it. When you came in, you got a bibliography and a handout with questions. And we're hoping that you have a chance to kind of look over those questions and consider your own relationship to World War I and information about the war so that at the end of the session, we can have some group discussion about that. Our first speaker is Dr. Chuck Hawtrey, who's been in Iowa City for 60 years. And he's Emeritus faculty in the urology department. He's written five separate memoirs. His mentors, or family, and I think it's evident from this research that he has a strong interest in history and people, as they have affected history. An interesting sideline, he's currently working to digitize the Department of Urology's museum collection, pathology and radiographic images, that go back nine decades. So that's a huge project that he's working on. So I will turn it over to Chuck. - [Charles Hawtrey] Thank you all for coming. I'm gonna basically tell you about two people. Oscar Hajos was a patient of mine way back when. And he would come to the clinic and be sitting beside the interview chair. And would be reading the book pass time. The books were all in Hungarian. So that interested me to find out more about his life and so I have a manuscript autobiography that he did, and it's, I'm hoping that as far as the interest in the World War I that the government will publish some of this kind of story. I hope I'm hitting the right button. Donna, I don't know. - [Donna Hirst] A thing that works real easy is, oh, did you get it? - [Charles Hawtrey] No, I don't know. - [Donna Hirst] It's that right there. - [Charles Hawtrey] Oh, okay. Alright. So, the circumstance that got me interested in this, and also encouraged me to collect books that have to do with the war and substantiates the material which you'll see. So for the German surgery picture, German wounded at their casualty stations, and you'll notice by the date that this is only three weeks, approximately, into the war. So people are out random in the sun and the rain. And that would change over time. Now, where I'll click. So he basically wrote the autobiography, and we would chat about it, and then set it aside until we saw each other again. And the, his travels from Budapest, where before the war he worked in a bank, his pattern, his pattern for travel, was the red line, which you see in the atlas drawing. Similarly, the second map I put in here to show the arrows of the Russian front and the Russian troops confronting the Hungarian Army. Sorry. So the army that they faced was an experienced group, and quite strong certainly in terms of numbers. And this confrontation of course led to Mr Hajos' wounding on the Russian-Hungarian battlefield. So. He was a cadet, which meant that he had approximately 50 troops under him. And they came out of training to go to the Russian front. And here they basically did the work, the details of setting up the coastline the battlefield no man's land, similar to what they were experiencing on the Western Front. So he was a charge of his troops, they would be on duty over the night for four hours, while Hajos was to make sure that they didn't fall asleep. And he read paperback novels and would sleep during the day. His circumstance was in his leadership position. They were told that the Russians were out in front of them. And they were weaving through high tall grass and were uncomfortable about knowing where the other platoons were in their circumstance. So he stands up to reconnoiter the circumstance, he probably was standing in a slightly bent position so that he was wounded through the colon and the liver. And fortunately, in that particular sector, they were very rapidly cared for. So the stretcher bearers came, picked him up, and took him to the casualty hospital where doctors evaluate in triage the injured. So he fell to the ground, picked up and carried away, and then was seen by his surgeon. And his surgeon was the professor of surgery at the University of Kiel in Germany. So he was a very excellent gentleman to try to get him to restore his health. And Mr. Hajos was demonstrated for him with his medal, equivalent to our Purple Heart. And that information incidentally came from the BBC in Vienna, which had a picture of the medal, which you'll see in a few minutes. So if we compare the circumstances over time, you see the same casualty setting on the left side of your screen, and the right side shows what it was like a couple of years later. So it is clear that there was organizational difficulties for all of the combatants in the First World War. So, the doctors had very limited ways to tell about what was involved in your wounds. So the entry wounds and the exit wounds through the body would be helpful information. And if there was no exit wound, they could take a primitive plane x-ray and determine where the missile ended up in the body. And so from that they would make decisions. And of course symptoms on the part of the patient might be helpful. They had vomiting, they vomited blood, and your entry wound was oriented such that if you think it went through the stomach, that would be helpful information. And so putting these things together and the absent, and obviously, putting together harmful symptoms that said you're gonna die were distinct possibilities. And of course the farther back the missile was in the body, the more likely it would be to hit major blood vessels, for which they had no way to care for the patient. So what's the likelihood that you're gonna get fixed, or what you're gonna find in terms of the docs. So obviously the intestinal injuries were most common. Followed by the liver, followed by the stomach, kidney, mesenteric vessels, spleen, and pancreas. So the farther back the injury was in the abdomen, the more likely to hit lethal organs. And then the surgical ability to fix these was pretty well discerned. And the use of atraumatic clamps with rubber covers over them could limit the amount of contamination from the wounds like the tear of the intestine. And the difficulties with the patient in part was related to where, what their job was. So if you were in the trenches, you tended to be very constipated. And so if your injury was through the large bowel, you would have bigger tears and large contamination related to the wound so that the surgeons had a reasonable plan of action. And they could, if they saw the patient early, they could care for the patient more expeditiously. Unfortunately, on the Western Front, many of the men lay out in the no man's land for periods of time, two, three, four days. And that was, needless to say, not very helpful for getting well. So what is the likelihood that you would survive an operation done by an expert surgeon, like Professor Anschutz? Interestingly, Wallace in a study which was published in 1970, showed that if you had no injuries within the abdomen, but just got explored to make sure that everything's okay, you had a 93% chance of survival. Good chance. However, if you had a terrible infection, like gas gangrene in the muscles and tissue because you laid out in the field for three days, your likelihood of survival would be very low, 9%. So it was a terrible war in terms of survival. And as you can see, they had a limited number of patients with colon injuries like Mr. Hajos, and about half of the patients lived. And if you considered all injuries that led to an exploration, still 50-50 chance of surviving the onslaught of your injury. So this is a medal that Mr. Hajos received for his injuries. Unfortunately, the difficult thing is to find evidence that the patients had some therapy to address the problem of infection. And the two substances available were sodium hydrochloride 10% solution or the phenol carbolic acid. Both of these medications needed to be washed out. So they would treat the area, suck out all the feces, and then they'd have to wash with the antimicrobial treatment and then wash it with saline. Which was about all they could do to treat infection. And survival also depended upon basically what you had for anesthesia, and ether was predominantly used. And it was fortunate they did that, because ether tends to sustain your blood pressure up, whereas the - [Audience Member] Chloroform. - [Charles Hawtrey] Chloroform. Chloroform would depress your blood pressure. And they didn't measure blood pressure, they usually measured the pulse. So there's, that's my first memoir. Mr. Hajos had a much, even more graphic history. And maybe we can take care of that in the discussion at the end. But the second person that I wanna talk about is my father, who was 18 years of age in 1918. And two years before that circumstance, a cousin in the British Army was injured, and died in France on Somme Offensive. And his story, my father wanted to avenge by joining the Army and going to Europe. So he badgered his parents, which he had to get permission from his parents to be able to enlist. So here he is at age 17 going on 18 in his Boy Scout uniform. And I think it's emblematic that it looks, with the exception of rank, it looks exactly like the Doughboys' uniforms. So there's a number of books that helped me understand all of that. So Lieutenant Ralph, who was a mining engineer, working in Russia in 1914, came home, quit his job and came home, and enlisted and fought in the Somme Offensive. And this, the information in the cartoon is a record from the Imperial War Museum in Great Britain. And what's amazing, they could be this defining in terms of where he was at the time he died. So. So the circumstance, basically, was that a letter came to the family telling of his death, and then my father went on about his regaling his parents, trying to get into the Army. So after his birthday, on the 30th of March, 1918, he finally talked his parents into allowing him to join the Army. Since my grandfather was a station agent in Omro, Wisconsin, he had a free pass, and so did every one of his family members. So my dad gets in the train close to Milwaukee. They sign him up and pass him through. He goes to Chicago. And he again was checked out and passed through. And then he goes to Jefferson Barracks in St. Louis, where my father meets the real Army. And he's recording all of these events in a little notebook that he's carrying in his pocket. And he says that the Army gave him a hard test. And then they made him stand in the nude for eight hours. And then finally, he meets that muck-a-muck doctor who discharged him from the Army. Two years later, when he's at Milwaukee Normal School, getting a degree, he writes a theme paper about his experiences. The reason that the doctor discharged him from the Army was due to immaturity. Thank the good Lord for that. Or I wouldn't be here to tell you these stories. So. The circumstances basically, what did we learn about wound care in this particular conflict? And it's a mixed bag to say the least. But they had a fairly intelligent way of deciding whether the patient had bodily fluids intact in that so that they could operate. And if they could get the patient to the clearing, the casualty clearing station, very quickly, they had a pretty good chance of helping. And the sad part, of course, is that the readings that my father could do in newspaper all glorified war. Never said anything about the casualties, the morbidity of the situation, and the death of so many persons. So, that's my memoir. And we'll move on to the second part. - [Dan Bonthius] Thanks a lot for inviting me. It's a real honor and privilege to talk at the History of Medicine Society. And like Donna said, I had a strong interest in the history of medicine ever since my first days at medical school, 30 years ago, when Dr. Palmer Howard, who the annual History of Medicine dinner is named after, and Dr. John Martin, who the Rare Book Room is named after, and Dr. Dick Kaplan, who's here tonight, who taught me the importance of what you call the real literature, which was not just the medical literature, but real books written by famous authors. And that's stuck with me ever since, and I've had a strong interest in the history of medicine ever since. And I remember very vividly discussions that I had with those three giants in the history of medicine back in medical school, where we talked about a subject that was very interesting to me, and that was moments in history that were unique and that presented physicians with challenges that were epidemic in scale and potentially catastrophic in their impact, and things like the bubonic plague in Europe, Yellow Fever in Philadelphia in the 18th century, and gas warfare in Europe during World War I. And to understand why gas warfare was used in World War I, one first has to understand something else that sort of preceded it slightly. And that was the invention of machine gun. Up until World War I, the concept was that, people had this thing called the elan vitale, which is a vital force that each person had, especially soldiers. And vital force was the idea that a person with a fighting spirit was more important than any weapon that could be brought against him from the other side. and the corollary of that idea was that armies should go on the offensive when they are confronting each other. And it's gonna be the offensive army that's gonna win the battle, win the war, so that all the concepts that the generals on both sides had preceding World War I and right up into large parts of it was that they should attack each other and throw themselves against the defending army. And that that was gonna be the way to win the war. What a lot of people did not realize was that the machine gun was a very, very formidable force against anybody who had any amount of elan vitale. And that an army of 500 soldiers being thrown against a single wimpy cowardly soldier with a machine gun was probably gonna come up on the short side. That is, the machine gun was gonna win that war, or that battle. And so, eventually, the generals came to realize that after many, many months, in fact years, and some generals never did learn that concept, and some generals continued to throw thousands and thousands of their soldiers against a defending army all the way through World War I, with catastrophic consequences. But many people did eventually learn that concept. And what they learned was that the defensive position was actually the advantageous one, rather than the offensive position. And in order to have a defensive position, certainly at least on the Western Front, it required trenches. Because these, on the Western Front, large parts of that Western Front were open plains. They would be sitting ducks for gunfire, unless they dug themselves into trenches. And so elaborate large trenches were dug throughout the Western Front to carry these soldiers all in them. And so what happened then was that all along the Western Front, it became a very static front, where things were not changing over time. Everybody was dug in, and the defensive was the thing that was winning the war. But you can't really win a war on the defensive. You have to somehow break through and defeat the enemy. And so both sides became very, very desperate to figure out a way how to break this stalemate. And the Germans then, at this town here, near this town here in Belgium called Ede, devised a plan. And that was, about eight months or nine months into the war, they, on April 22, 1915, released from their trenches 168 tons of chlorine gas. And chlorine gas, then, chlorine is a gas that is denser than air, so that once you release, it will stay near the ground, it won't just evaporate into the atmosphere. So the Germans waited for a day when the wind was blowing right, that is, toward the west, and they released these large amounts of chlorine gas which were carried by the wind across no man's land and into the trenches and the shell holes on the opposite side. And these defending British soldiers that saw this coming, initially they were just kind of puzzled by it. And then they became alarmed by it, and they smelled it, and they realized that this was some kind of lethal attack against them. Those that could broke and ran. The only ones that really survived that were gonna be the ones sort of on the perimeter of that attack. They then described their experiences later, they describe this wave of fear that they had and how they, some of them were able to run away from that. But many of the defending soldiers were not able to run away from it. And on that day, there were 20,000 casualties in the British ranks, and 5,000 of them were fatal. And so, it was learned that gas actually could be a very, very effective weapon in this war. But, the Germans did not take advantage of this to the extent that they could have and should have. And why they didn't is actually an interesting point in history. The person who sort of came up with the idea for gas warfare and for the use of chlorine and how to produce large quantities that can be used on a military scale was this professor, Fritz Haber, a German chemist, who actually was a very, very good chemist. And he devised this plan. But he was a Jew and he was a civilian. And those two disabilities so prejudiced him in the minds of the German general staff that they did not put stock in the idea that an important new military concept could come from someone like him. So they really didn't exploit it to the extent that they could have, they didn't follow up with more poison gas that day. They didn't really have a very large supply of it. And they didn't really release it along a very big front. It was only along about four miles of front. So into that four miles of front the Germans poured people and they did make some definite headway, they gained some miles there. But not to the extent that they could. And that golden opportunity for the Germans was then lost and was never regained again. Because quite quickly, the defending soldiers were outfitted with gas masks of their own that could defend against the chlorine gas. Now initially when this happened, though, of course they didn't have gas masks. So they had to devise what they could. So at first the chemist of Britain and France worked on this very quickly, and they said to the soldiers in the field that what they could do is they could take a bottle, find a bottle, and break off the bottom of the bottle, fill that bottle with dirt, and then breathe through, with your mouth through the top of the bottle, and exhale through your nose. That's what they suggested to do. And it really didn't work well, the soldiers couldn't get this to work. For one thing it was hard to find a bottle on the Western Front. Secondly when they tried to break the bottom off the bottle, that was very hard to do without breaking the entire bottle apart. And secondly, when they filled it with dirt, they couldn't breathe through the bottle. So these chemists had sort of a distorted view of what this would really be like and it didn't work at all for the soldiers. But the soldiers did come up with a plan of their own that actually did work. They took handkerchiefs, and they could put just a little bit of dirt in a handkerchief and wet it down with some water and they could breathe through that if there was a chlorine gas attack. Luckily, chlorine is probably the easiest of all war gases to defend against. And so that actually was quite effective. Meanwhile, back in the factories of Britain and France, gas masks were being produced then in mass quantities. And the first gas masks were made of flannel with some kind of semi-plastic viewing holes here that people could breathe through, or rather that people would see through. And then this flannel was soaked in a kind of photographic hypo that would allow people just to breathe through this kind of hood they wore, like this. But this gas mask was not adequate for the kinds of gases that would be developed as the war progressed. As the war progressed, new and more lethal gases were produced constantly. And so, there was an evolution of gas masks to keep up with these gases. And ultimately there were quite sophisticated gas masks that were made that had charcoal and other kinds of antidotes against the gas in the air. They were carried around then in canisters by soldiers. The results are necessary, because to have gas masks for all the animals on the front. Because horses were hugely important in World War I, and they had to have gas masks so that the horses could breathe. And so they usually modified these gas masks for the horses from the human gas masks. Another thing that happened then on the Western Front was the dreaded gas bell. This was a bell that was rung in the trenches whenever gas was detected as a weapon that's being thrown against them. People carried around their gas masks, and when they heard the bell go off, that meant put your gas mask on. So the British and the French were initially, initially they said that they were repulsed and horrified by the fact that the Germans would stoop to using gas in war. And this is a newspaper printed in Britain shortly after the first gas attack. It's the Daily Mirror, it says, "Devilry, They Name Is Germany. "Soldiers trapped by a gas cloud "lie unconscious in the trenches." Even though they were repulsed and shocked and horrified by it, they were not too repulsed or horrified or shocked to use it themselves. And so, about two months later, the British launched from their trenches, when the wind was blowing the right direction, chlorine clouds that blew the other way and induced very heavy German losses. And so began gas warfare back and forth. Germans responded with phosgene, which is a gas that is actually 10 times more poisonous than chlorine gas. And importantly, it was capable of penetrating Allied gas masks at the time. And so began this kind of back and forth evolution of war weapons. Particularly gas masks and gases. Each step being made to try to up or outpace the other side. And an example of this was the development of sneeze gases. These were deployed to force the removal of the enemy's gas masks, thus rendering them vulnerable to the lung irritants that they would send over shortly afterwards. So eventually, over 50 chemicals were deployed as war gases in World War I. And these 50 different chemicals could be broken down into four basic groups. And these were, number one, the lacrymators, those were eye irritants, the sternutators, those were nasal irritants, suffocants, which were lung irritants, and vesicants, which were skin irritants. And I'll show you examples of each of these. The lacrymators are the tear gases. These would induce temporary blindness through irritation of the corneal nerves. And they would also induce intense ocular pain and copious secretory tears. So people who were gassed with a lacrymator would have these intensely painful eyes that would water incredibly. And it was not uncommon then in World War I to see trains of soldiers all lined up together following each other along with hands on each other's shoulders 'cause they've been exposed to a lacrymator or sometimes a different gas that would injure a person's eyes. Now the second group of gases was the sternutators. These were nasal pharyngeal irritants. These actually were not gases technically, they were solids that were dispersed in the form of smokes. And they would collect in the upper respiratory passages and irritate nerve endings of the nose and the throat. And this produced violent sneezing, vomiting, and coughing, and the main goal of all of this was if a person was wearing a gas mask and was coughing and gasping and throwing up, they would remove their gas mask. And then, they would then send over a lung irritant that would, the patient or the soldier would then breathe in the lung irritant, and that was then what would kill the soldier. So it was a very kind of nefarious and evil kind of way of thinking about things. Now the suffocating gases were those gases that were used to directly kill. These were mostly chlorine and phosgene, those are the most important. And those gases reacted with an injured lining epithelium of the respiratory tract, which led to edema and necrosis of lung tissue and ultimately to suffocation of their victims. Now these two gases were very similar to each other, but they also differed in a couple important ways. Chlorine acted instantly. So a person who was exposed to chlorine, as anybody who's even walked into a swimming pool room in a hotel, you know how kind of instantly irritating that can be, when they've got just a little too much chlorine in there. That produced an immediate sense of shock and gripping of the throat and chest. And this was quite a famous photograph made of World War I, during World War I, showing actually a soldier who is being exposed to chlorine gas or fought chlorine gas and gripping his throat in agony. The second gas was phosgene, it was 10 times more toxic than chlorine, and importantly, it produced no immediate irritation. So people who were exposed to phosgene just smelled kind of a pleasant odor, actually, it did not cause this big irritation. But that actually was the whole point of it. Without causing irritation, the soldiers would continue to breathe it in quite readily. And even though they had no immediate sense of injury, they had a huge problem coming, and that was minutes or late hours later, they had sever pulmonary edema, from which many of them died. And in fact phosgene was the biggest killer of World War I in terms of war gases. Probably 10 times as many people died of phosgene as of all the other war gases put together. It was just so lethal. Now a final group of gases were the vesicant gases, these were the skin irritants. Mustard gas is the most important of those. It produced blistering lesions of the skin, eyes, and upper respiratory tract, and it was a thick, oily liquid. Again, it wasn't technically a gas. It was a thick, oily substance. And it would penetrate the cells and hydrolyze to produce hydrochloric acid. But this conversion to hydrochloric acid was a slow one. And therefore, people who are exposed to it didn't suffer any immediate discomfort. They just felt like kind of a liquid oily substance on their skin. It wasn't until hours later that they started to get symptoms, and those first symptoms were reddening of the skin, followed by blistering and necrosis of the skin. And here you can see a picture. I think this is an American soldier in World War I who has these big blisters on his skin like this. And he was exposed to mustard gas. Here is an example of a volunteer who had mustard gas exposure at various concentrations. You can see the concentrations of gas are written down below here, ranging from .06% up to .01%. And what you can see are these terrible blisters that formed within a couple of days after the mustard gas exposure. So these skin lesions could lead to intense wounds on the skin of affected soldiers. Here you see a soldier who had large parts of his skin exposed to mustard gas, and he is losing large amounts of of it here. It also in many cases left horrific permanent scars on people, including on their face. And here you can see two kind of famous cases of this, where these soldiers were exposed for quite a long time to mustard gas, they weren't in a situation where they could quickly get it washed off, and therefore they lost large amounts of their skin, and it just formed these horrific scars. Now the mustard gas differed from other war gases in a couple other important ways. First of all, because its target included the skin, there was no gas mask that could protect against it. And in fact, there was no uniform or any other clothing that could really protect against mustard gas. It was a gas that could, it was a liquid that could just penetrate virtually anything except maybe very thick canvas, alright? So if you were gonna be exposed to mustard gas, you had it on your clothes, it was gonna go through your clothes, and it was gonna get to the skin. It did not have to necessarily go through gas masks. And also, because it's a heavy, oily liquid, it volatilizes very slowly, and it's a persistent gas. So it did not just blow away the way that all the other gases did. You know, with the other gases, if there was wind, within minutes, the wind would blow those gases away. But mustard gas would persist, sometimes for weeks, wherever it was. And that meant that, well it meant several important things. But one thing it meant was that if a area underwent heavy bombardment with mustard gas, then that sector would be uninhabitable for weeks afterward. And here you can see again a picture of a soldier that had very very extensive wounds from mustard gas, and once again animals suffered tremendously on the front, because they were also exposed to mustard gas. So, the use of war gases then created not only new problems strategically for the generals on the field, but it also created new problems the physicians in the field. Prior to the use of poison gas, blood loss, trauma, exhaustion, and disease were the four major things to worry about in terms of physicians. But after the advent of gas warfare, suddenly respiratory failure and chemical burns became major items that the physicians on both sides had to worry about and learn about. Also, because of mustard gas's physical properties, that is because it was a liquid and an oil that persisted, this caustic fluid could be transferred to the position with a medic. Thus a wounded soldier was not only a patient, but he became a threat to the medic or the doctor taking care of him, 'cause he was carrying with him a lethal substance that could easily be transferred to anybody taking care of him. So this changed the doctor-patient relationship in the field. Now, American field arrangements were taking care then of gas casualties. Sort of consisted of three tiers, which are listed here, and shown schematically here. There were regimental stations, electing stations, and hospital centers. These were the regimental stations, the collecting stations, and then the hospital centers farther to the rear. So the stations between these three were based on the distance from the front and the nature of the care that was provided. So the regimental stations were those stations just right behind the front, right? These were right behind the front lines, often located in a tent or a trench. And it was here that medics supplied first aid before sending soldiers to the collecting stations a couple miles back. And this is a picture then of a nice neat regimental station. Most of them did not look this nice. Most of them were chaotic places, where they were dug into the ground, where they would hope to survive shrapnel and shells that were flying over them. And it was here, the medics supplied first aid before sending soldiers to the collecting station. If there was gas in the area, the first pass at the regimental station was to fit the patient with a gas mask and try to send them on. So if the soldier had been gassed with a pulmonary irritant, then at these regimental stations, what they would do is they would loosen the victim's clothes, they would administer ammonia ampule, and they would evacuate these soldiers as fast as they could by stretcher or ambulance to the collecting station behind. And the goal here was to deliver the patient into the hands of a physician before the onset of serious pulmonary edema. So that was if it was a pulmonary irritant. If it was a vesicant, which was the skin lesion, the skin gases, then the first step of the medic was completely different. Now the first step of the medic was getting yourself protected more by putting on protective gloves, they were made of canvas and saturated with oil or soap in an attempt to keep that mustard gas away from the medic. Once that was done then splashes of mustard gas were removed from the soldier with kerosene. Their eyes, nose, and throat, were washed with bicarbonate solution. And mustard gas victims, unlike the pulmonary gas victims, were not transported by stretcher or ambulance. They had to walk to the collecting station, a couple miles to the rear. And the reason for that was number one, mustard gas they knew was gonna be a much slower pathogenesis, so they had more time to do that. Secondly, they did not want to contaminate their stretchers or their ambulances with mustard gas that was being carried by those soldiers. If it was a lacrymator or a sternutator, then these soldiers usually got no first aid at all, and instead the role of the medic there was to simply reassure the blinded or the gagging soldier that his condition is temporary. Which it is not necessarily that easy a task to do when you have a panic-stricken soldier who thinks he's just been blinded or killed essentially by gases. So a little farther to the rear were the collecting stations, as shown here. These usually consisted then of several large tents, as shown in this picture. And this was the acute care hospital, where soldiers moved for recovery or died at. This was the crossroads where they gassed soldiers were either gonna make it or not make it. And these soldiers often arrived in large waves. That was just the nature of gas warfare. Unlike more traditional weapons that would sort of hit individuals one at a time, the war gases would hit hundreds of thousands of soldiers at a time. And therefore, they had to be evacuated, as much as they could be, anyway, all at once. And so these collecting stations would suddenly have to cope with the onset of hundreds of patients hitting them all at one time. So in order to do this, they had a very very highly organized system there that consisted of departments. And these departments included a receiving department, a bathing department, a department for the slightly gassed, a department for the seriously gassed, a department for observation, and a forwarding department. And these were formidable organizations. They could move soldiers around and get them to the right spot very, very quickly. And I wish I could tell you about each one of these, 'cause they're actually very, very fascinating. But I'm only gonna really tell you about one right now, and that is the receiving department. So each wounded soldier entered this formidable system at the receiving department, where somebody was there to say, okay, this is what you've got, you go to this area over here. And here then, a physician had to judge whether a soldier had actually been gassed or not. And this was actually kind of a new thing also. 'Cause always previously, you know, in history, if a soldier had been wounded, it was pretty obvious. He had a great big shrapnel wound in his shoulder, or you know, bullet wound through his abdomen. So it was obvious. In the case of the gases, it was not so obvious. There were not gonna be entry wounds or exit wounds on most of these people. Instead there was a history that they had. Or maybe they had symptoms. But they didn't have necessarily externally visible wounds. And so this became a big challenge for the doctors who were in that receiving department to try to decide what to do. To try to decide first of all was this person even gassed or not. And this was not a trivial issue. Because a lot of the people who were showing up with a story of being gassed weren't necessarily being gassed. And one of the commanding officers there on the Western Front wrote this at the time, he said, "There is no doubt that many men have claimed that they "were gassed in order to get out of the front lines, "that a still larger number thought they were gassed "and were suffering from conditions which might "be called gas mania, and that others smelled the odors "produced by the explosions of ordinary shell and became "panic-stricken in the belief that they were gassed. "If facts were known considering our gas casualties, "they would not be over 1/3 those actually reported." So this guy at least believes that 2/3 of the patients showing up at those collecting stations were not actually gas victims at all. Farther to the rear was the base hospital. This was located then far behind the front lines. And this was the point at which severely gassed patients went to slowly recover. There they were segregated between wards according to the type of gas injury that they had. And those included then a mustard gas ward and a pulmonary ward. And oftentimes there would be another ward for patients who were more the surgical patients. But on the mustard gas ward then, the treatment consisted of treating people with boring ones like zinc oxide or something. And the blisters of these patients then were opened with the fluid absorbed onto gauze, with very careful attention paid to the fact that they don't wanna let this fluid contact the neighboring skin or their own skin. 'Cause those bubbles, those blisters, were filled still with mustard gas and hydrochloric acid that could injure the patient or them. And then< on the pulmonary ward, attempts were made to relieve the pulmonary edema. And the way that they did this was they knew first of all that pulmonary edema is a fluid, right, that's leaking into the lungs. And so one pretty effective way of minimizing that is to minimize the amount of fluid that's available to go into the lungs. And the way to do that is to take blood out of the patient. And so any patient that had what looked like pulmonary edema, the first thing they would do is remove one or two pints of blood from that patient in order to reduce the pressure in the pulmonary arteries on the lungs, and therefore reduce the edema. Now another way to handle it in addition was to give intervenous glucose. That way, the glucose in the blood would act as an osmotic agent, it would pull liquid out of the lungs into the vasculature. They also gave cardiac stimulants, because the heart failure was a very common concomitant of this, and to stimulate the heart to beat better would move fluid out of those lungs and bring it back into the venules and out of the lungs. And then fourth of course they would administer oxygen. So, on these wards, where patients had pulmonary edema and were drowning virtually right in front of the eyes of these physicians, it was a very painful thing for these physicians to watch. They felt very very helpless in many cases. And so, they did things sometimes that they probably knew weren't gonna work, they certainly knew better medically, were probably were not gonna be functional. But they were desperate, and so there were cases where physicians would inject oxygen into patients subcutaneously, intermuscularly, or rectally. And after the war was over, the War Department issued some printed material. This is kind of a history of gas warfare in the Great War. And this document states very dispassionately, these methods of oxygen administration were not found advantageous. There was one sort of happier ending that dealt with the attempt to get oxygen into patients. And this happened in the collecting station, where it was found, or where the protocol was to have beds arranged in a row in these collecting stations. And oxygen supply to each row was provided by a branching overhead pipe. So there was a pipe carrying oxygen along this row of beds. And at each side along the bed, there would be kind of a tributary pipe coming off that went to each patient. And curious factors noted that the cases at the end of the row tended to do poorly. And investigation revealed that such cases were receiving a dearth of oxygen, the supply being exhausted by soldiers in the more proximal beds. And so, they changed their arrangement from a single overhead pipe to a multiple tube attachment. And this saved the day then for the soldiers at the end of the row. Now, one of the people who was really up to his neck in the issues of gas warfare in World War I was Colonel HL Gilchrist, he was the medical director of the American Expeditionary Forces in Europe. And so he, along with others, but he certainly, was confronted with these problems that they were not prepared to deal with. One of these problems was, of course, all these patients who were exposed to mustard gas. And so he heard from the French that they were using chlorine to remove mustard gas from the soldiers' uniforms. And so he thought about this, and he thought, well, if they can use chlorine to remove mustard gas from their uniforms, maybe we could use chlorine to remove mustard gas from our soldiers. And so he devised this idea of these portable tunnels of chlorine gas for treatment of mustard gas. And he got the approval of the high command in America to pursue this idea. And what he would do then is he would fill tents, small tents, with high concentrations of chlorine gas. And then he would take the soldiers who had the mustard gas exposure, and he'd give them a gas mask and put them into the tent filled with chlorine. And it failed completely, actually, because number one, the chlorine gas was not concentrated enough to remove mustard gas from a soldier's skin or uniform. But it was concentrated enough to penetrate their gas mask and make them hypoxic. And so a lot of those soldiers came out of those tents blue and coughing and gasping and very unhappy with Gilchrist. So that failed. However, he did have one particular success, and that was he came up with the idea of a mobile degassing station. And these were big three-ton trucks that were moved around on the front wherever mustard gas was being released by the Germans. And what these trucks had was they had tents that could be erected very, very quickly, with 24 shower heads attached to them, and a great big tank, filled with like 3,000 gallons of warm water. And what would happen was that they would then rush these soldiers into these mobile degassing stations. And this invention worked so well that they were able to move about 24 soldiers through there every three minutes. And by doing that, they could essentially decontaminate about 700 soldiers with a single tank of water. So that was a great success. So the gas casualties in the First World War were approximately, well, a little over 91,000 people got killed. And a little over a million got injured by gas. About 1,462 Americans were killed, and more than 71,000 Americans were injured. So these are pretty bad numbers, but they sort of pale in comparison to the total numbers that were killed in World War I. I mean, in World War I, there were more than 10 million people killed. And so the numbers killed here and injured are small compared to those that were inflicted by the more conventional weapons. However, really I think the most important effects of the war gases were psychological rather than physical. And that is, these war gases made it much, much more difficult for people to do anything as a soldier. You had to wear these contraptions all the time. It was a harassment to have to wear them. They were difficult really to breathe through, difficult to operate through machinery. The war gases caused extreme anxiety for people who were on the receiving ends of it. So I think that a lot of the shell shock and anxiety disorders that arose in World War I were greatly contributed to by the use of war gases. They caused horrific and permanent wounds on people and greatly disfigured their faces. And one other very important thing about World War I that the war gases contributed to greatly was the depersonalization and dehumanization of the individual soldiers. At the beginning of the war, like I talked about, there was this idea of this elan vitale, this idea that a person could be a very charismatic and brave and effective soldier. And as an individual, he could really help bring about the winning of the war. And with the, as the war progressed, people lost that sense of identity. And everybody kind of started to look alike. Everybody was dirty. There were no special uniforms. Everybody had gas masks on most of the time. And therefore they lost their personal identity, and they lost sort of the individual sense of themselves and of their comrades. And I think that that contributed greatly actually to the psychology of World War I. Alright, that's it. Thank you. - [Janet Schlapkohl] Hi, thank you so much for having me here today. I have attended so many of the lectures that are held and I've always enjoyed them very much. So it's a real thrill and a privilege for me to get to be able to present here for you today. What do you know, it's the standard clicker. I may be the ideal person to make this presentation, because I have absolutely no standing in the medical community, and also none with the military, so I have absolutely nothing to lose by presenting something that may be somewhat controversial. Shell shock as commonly portrayed in literature, film, and even scholarly essays perpetuates a perception that's been generated by military authorities that the cause was psychological. Medical evidence to the contrary has been reframed, refuted, or dismissed. This evidence of this deception was first played upon a wounded and grieving population during the First World War. But make no doubt, it absolutely still continues today. For over 150 years, doctors have had the scientific evidence necessary to prove the existence of great injury caused by forces occurring without obvious physical injury. This evidence included medical reports of a condition known as railway spine. 50 years before the start of the First World War, in 1862, a London physician wrote, "The probability, nay, the certainty, "that the delicate substance of the cerebral hemispheres "is capable of being seriously injured "by external violence must be conceded. "The symptoms of railway spine," he says, "vary in degree and kind, from insensibility "of a minute's duration to a state "of mental incapacity which lasts for years." Railway companies disputed every symptom. A patient suffering from railway spine shared what brain injured soldiers experienced. "He is perhaps attended by one or more medical men," said the doctor, "who are constantly directing "his attention to his symptoms, "visited by others who frequently "do not hide their disbelief in his statements." Doctors paid by railway companies claimed that the patient was shamming and had a preexisting defective mental constitution, hysteria. The government got involved. Editors of the medical journal Lancet summed that up. The whole system of government inspection and of parliamentary committees in reference to railway accidents is a gigantic sham, as those in authority very well know. Doctors discovered how a party with a significant financial resources was effective in relabeling a diagnosis and shifting the blame onto the patient. They would encounter this again with shell shock. Again, before the First World War, in 1900, reports of brain injury from blast forces came from a member of the Royal College of Surgeons, reporting from the Boer War. "A private of the Second Royal West Surrey Regiment, "whilst in the firing line was knocked senseless "by the exploding in close proximity of a nine-inch shell "The patient is very nervous and shaky, "suffering from twitching, giddiness, "noises in the head, dimness of sight and some deafness. "The reflex are exaggerated, "with tremors of the hands and tongue. "A large number of such cases have come before me "where after six months of complete rest and every care, "patient's nervous system shows no signs of recovery. "There is nothing for it but to invalid them "out of the service as permanently unfit." The Boer War was a war of bombardment. Soldiers in trenches carved into rocky ground were shelled with high explosives coming from artillery produced by the German manufacturer Krauss. The Germans sold the Boers their artillery. Krauss also made the infamous Big Bertha guns used in the First World War. The doctor observed, the clinical fact of most interest undoubtedly is the large number of cases of functional impairment associated with physical symptoms akin to nervous shock or those observed after railway accidents. During the early part of the war, in 1914 and '15, evidence for brain injury caused by blast forces overwhelmed medical journals. In one, the author wrote, "The present war has considerably added to our knowledge of injuries caused directly and indirectly by high explosives." He describes, "a big shell explodes "and the men nearby are rolled over by the concussion "without being struck by any of the fragments. "They get up, feeling rather stunned, "but in the course of a few hours "or a day or two, they collapse and die without presenting any obvious injury. "There are hundreds of instances of acute neurasthenia "suddenly induced by the shock "of explosion in previously normal men. "And indeed, this compels the idea of structural damage. "And pathological evidence, as far as it goes, "confirms that assumption." A French neurologist stated, "The proven near proximity to the explosion "is sufficient to cause organic changes "in the brain and spinal cord "by the compression and decompression of gases, "the result of the detonation of the explosive." In February, 1915, the term shell shock appeared. The author of this article in the Lancet was Charles S Myers, who would be used and abused by the military while being paraded as an expert on shell shock. Charles Myers is often described as a medically-trained psychologist. But, let's see if I can press right, for this, from a historical tape. - [Narrator] Dr. Charles Myers, a pioneering psychologist. - [Janet Schlapkohl] But after he qualified as a physician, he went into academia and saw no patients. In his book, Shell Shock on the Frontier, 1914 to 1918, he describes his work. The analysis of primitive Australian music from a unique series of phonographic records donated to the university. As a doctor, as a very young man, he'd been part of an expedition to the Torres Strait to study native music and native hearing. Other members of the expedition tested the natives' threshold for pain. When war broke out, Myers was too old, 42. So he joined a private hospital, funded, as they could back then, by the Duchess of Westminster in France. And in October of 1914, he did begin work there, as a registrar. He says, my first duties consisted in preparing lists of the 200 patients with names, ranks, etc. And he helped the commander with his correspondence. When given charge of some cases, he noted, that was when the difficulty arose. After a few days' trial, I saw that it was advisable to be asked to be relieved of them and I gave myself up to the dull routine of a registrar's work. The troubles he attributed to self-seeking jealous younger medical officers. He was efficient at the registry. When the director general of the Army visited the hospital, Myers noted proudly, they were brought round to my registry and shown the advantages of the method. In December of that year, he collated his patient's notes, and with the commanding officer he wrote a paper about trench foot. But, at that time he also saw for the first time from his book one of those cases of functional mental and nervous disorder which afterwards proved so plentiful and came to receive the name of shell shock. He tried a slight hypnosis on one. There is no question in my mind that his heart did go out to these men. He noted, "By this time, it was clear to me that my "previous psychological training and my present interests "fitted me for the treatment of these cases." He submitted his observation about these three cases, clearly though indicating brain injury caused by blast forces, what he called shell shock. That same year in January he met with Dr. Aldred Turner, territorial medical officer, who gave him a letter to take to the director general of the Army Medical Service, recommending that Myers, quote, "Join them by undertaking "the psychological work in this district," in France. He received the temporary rank of captain, and then he traveled to England with said letter during the first through fifth of February. He met with the director general, ostensibly delivered the letter, and returned to France. One week later, after the publication of his paper, he received another message from the territorial officer, Aldred Turner, asking for his exact qualifications in order to send another letter to the director general, whom he had just visited and delivered a letter. What exact qualifications were they looking for? Whatever they were, he met them, and by March he was promoted to major, found himself then overwhelmed with far-reaching duties, including giving evidence in court marshal cases. He wrote, "I vainly pointed out, "I had no special asylum experience, "nor had I specialist knowledge of neurological diseases." But then he added, "An Army medical officer has to obey commands. "They arose in my case partly from ignorance "on the part of those who issued them." His orders were clear. Eventually, he wrote a confidential letter to the director of medical services, quote, "Calling his attention to my being "called upon to undertake work vis-a-vis "the diagnosis of lesions and organic diseases "of the brain and cord which I felt unqualified to perform. "But no action was taken." The military prefers no mention of war or shells or forces or blasts in diagnoses, allowing instead a sort of pseudoscientific and sometimes even patently absurd definition. Scrubber's gait. Tight-rope walker's gait. But during the war, medical reports of injury to the brain caused by shell explosion continued. So military authorities stepped up their campaign to reassure the public. The name of this author should be familiar to you. If the percentage of soldiers suffering a traumatic brain injury as a result of service was known, it would be impossible to recruit new troops. And having a psychological cause allows for a preexisting condition, which releases the military from the obligation of providing a pension. By 1916, Dr. Myers had been promoted to Lieutenant Colonel. And by 1917, he wrote that he was, quote, "So worn out with worry over the condition of my work, "I put in a request for prolonged leave "or offered my resignation." But they did not let him go. Instead, after several months, he was asked to serve in the war office. The director general commented, "How gladly I should welcome "you along does here, because your matured experience "of farming affairs will help to regulate the wilder spirits "who lack the due sense of proportion." Someone close to him said this. - [Recording of Woman's Voice] My father was very, very concerned about conditions out there. And he moved about from hospital to hospital and in many cases he went up to dressing stations very close to the firing line, and saw these men who dreadfully came out from the firing line, and he was pleased he was so near, because he could undertake treatment for straight away after their disasters with bombs. - [Janet Schlapkohl] She understood her father to believe that the disaster was from bombs. After the war, Parliament asked a committee of inquiry to be formed for the sole purpose of investigating shell shock. The report was published in 1922. Dr. Myers declined being part of the report. The editors wrote, "Unfortunately, we have been unable to obtain any reliable "statistics covering cases of shell shock. "It would have been desirable to record the number of cases "of the disorder or to supply cables giving the figures. "The committee has failed to obtain this information." Much statistical material was unavoidably lost during the progress of the war, and other material of a statistical kind buried in the archives of the War Office and other departments is at present inaccessible. It could not in fact be obtained without a prohibitive amount of labor and expense and the expiration of time, which would have postponed our report until the official history of the war is published. We are satisfied that we can cover the terms without statistical evidence. 39 questions were asked of their witnesses, 20 about detecting preexisting mental conditions. Only question number 15 asked under what conditions they had seen shell shock or mental breakdown. And out of 12 conditions, only one was high explosives. This official military report, frequently quoted, has no statistics, no references to medical publications, no hospital records, no followup studies, only anecdotal summaries from hand-selected military men, selected by one person. This did not stop them, however, from making recommendations. "No soldier should be allowed to think "that loss of nervous or mental control provides "an honorable avenue of escape from the battlefield. "No case of psychoneuroses or of mental breakdown, even when "attributed to a shell explosion or the effects thereof, "should be classified as a battle casualty." Though it was recognized that such a role would inflict hardship on individuals, it was thought to be a wise one from the point of view of maintaining morale in fighting troops. And finally, this. "Genuine concussion without visible wound as the result "of shell explosion cases were relatively few." They do offer this information for new recruits. And finally. This from an Army training video for medical hospitals and doctors. And finally, this from an Army training video for medical hospitals and doctors. - [Narrator] Today's soldiers and Marines are the best educated and most highly-trained military force that has ever existed. Their mission exposes most of them to IEDs, mortar fire, rocket-propelled grenades, and other explosives. These weapons and devices all produce the phenomenon we refer to as blast. But we are just beginning to learn about the blast injuries. We are just beginning to learn, we are just beginning to learn about the blast injuries. - [Janet Schlapkohl] In my opinion, 150 years is long enough. I show you this today so that you will somehow go out and be active and talk to people, thank you very much. - [Donna Hirst] Approximately two weeks ago, our speaker on World War I and nutrition withdrew from the panel. I had created an exhibit about World War I and medicine, and had some information about nutrition. And so I decided I would go ahead and pull together my notes. But I am not a World War I expert or an expert on nutrition, or a historian. My claim to fame is that I am a librarian. And as such, I know how to do research and organize information under fire. in 1916, the staple food of the British soldier was pea soup with horse meat chunks. The hard-working kitchen teams were trying to locate local vegetables. When they couldn't, weeds, nettles, and leaves were used to flavor the soups and stew. By the winter of 1918, flour was in such short supply that bread was being made with dried ground turnips. Two industrial vats were assigned to each battalion for food preparation. Every type of meal was prepared with these two containers. And so over time, because they couldn't be washed well between meals, everything started to taste the same. Pea and horse-flavored pea was something that soldiers had difficulty getting used to. Food transportation was another issue. By the time food reached the front, bread and biscuits had turned stale, most of the produce had spoiled, soldiers had to crumble the hard food that they had received, add potatoes, raisins, and onions to soften them. The concoction would then be boiled in a sand bag and eaten as a sandy stale soup. One widely used but widely disliked ration was the canned soup machanache. They know it better. It was a thin watery broth containing sliced turnips and carrots. Macanache was endured by famished soldiers and detested by all. One soldier summed up the Army's attitude toward it by saying, "Warmed in the can, macanache is edible. "Cold, it's a man killer." The government did not want the Germans to hear how desperate the food situation was. The British Army had to be depicted as happy, well-fed, strong-minded, whose morale was resolute. An Army announcement that British soldiers were being given two hot meals a day caused widespread outrage among the soldiers. The Army subsequently received over 200,000 angry letters from the soldiers, demanding that the grim truth be made public. A total of 3,241,000 tons of food was sent from Britain to the soldiers fighting in France and Belgium during World War I. The British Army employed 300,000 field workers to cook and supply the food. At the beginning of the war, British soldiers were given 10 ounces of meat and eight ounces of vegetables a day. As the size of the army grew, and the German blockade became more effective, the army couldn't maintain these rations. And by 1916, this had been cut to six ounces of meat a day. Later, troops that were not on the front line only received meat nine out of every 30 days. The daily bread ration was cut. The British Army attempted to give the soldiers 3,574 calories a day that the dieticians had indicated they needed. But people working in the area argued that soldiers during wartime needed a higher calorie limit than that. In World War I, three types of rations were developed. The reserve ration, the trench ration, and the emergency ration, also known as the iron ration. The first attempt to make an individual ration for issue to soldiers was.