The medical examination of millions of men was a necessary preliminary to the mobilization of the belligerent forces of the World War. The deaf, the dumb and the blind, the lame and the halt, the weak and the infirm, the cardiac and the nephritic, those too tall and those too short, the very young and the old, the anemic and the diabetic, those underweight and those overweight, the syphilitic and the gonorrheic, those with hernias and those with hemorrhoids, the tuberculous, the cancerous, the insane and the feebleminded, the infectious and the degenerate; all were discarded, at least temporarily. Of 2,753,922 men examined for the United States during the World War, 468 men per thousand were found defective or diseased; that is, nearly half were found to have a physical or mental blemish of importance sufficient to dictate rejection for military service.
There was a tendency for the volunteer to minimize, the conscript to magnify defects. Remediable disabilities must be detected before they can be corrected and the subject added to available reserves. These examinations afforded the various nations invaluable statistical data concerning the physical and mental well-being of their manhood. The currently recommended physical examination for the early detection of disease was emphasized, if not initiated, by the World War. These examinations also alarmed, for they formed the basis of lamentable commentaries concerning the widespread disease and defect existing in the prime of life among the manhood of the civilized world.
Of 2,500,000 men examined by local and district boards in the United States, 80,834 were rejected entirely for service because they were tuberculous. Fifteen thousand examinees were found unsuitable by reason of nervous or mental diseases.
Preliminary study of the first 1,000,000 men, recording only the major causes of rejection, revealed manifold defects in American men of military age. This information was significant for the following reasons: (a) The military, social, and industrial availability of manhood from 21 to 30 years of age was apportioned; (6) the eugenic and biologic failures inherent in progenitors were indicated; (c) the physical and mental status of our manhood in various sections, among different racial groups, and with varying medical supervision was determined; (d) it informed the medico-military services of the proportion of men available for varying grades of service; (e) it had the social-therapeutic bearing of indicating the possibility of corrections of disease and defect.
From eugenics to gerontology the World War bore influence in the realm of medicine. The social upheaval incident to war had an inevitable effect upon the unborn of those times, and at present we note the effect upon those combatants first to grow old. Due to decreased birth rate, increased infant mortality, the employment of women and the dearth of men, France was facing national extermination during the World War. For this reason the American Red Cross sent over corps of infant- welfare workers under command of leading pediatricians, whose endeavors saved many children for France.
Thus the World War contributed vastly to the statistical data of medicine. It afforded millions of individuals and their families a much-needed appraisal of the state of their health. It supplied governments with important biological, social, industrial, military, and medical information.
Organization and Training
From hamlet to metropolis the professor and the student of medicine gathered to their colors in the World War. England called 11,000 civilian practitioners, France organized the entire profession, and in our Army nearly 30,000 physicians were in uniform. Before the Armistice was declared, opportunity for an international exchange of opinion in methodology was available. The World War was a long and difficult Postgraduate course to thousands of medical men; it enhanced their knowledge and dexterity, and broadened their experience even to the envy of succeeding generations of practitioners.
The World War trained a great number of physicians and surgeons in every domain of medicine with an experience rich though terrible. Upon the disbanding of forces and release of the majority to the civilian population, these medical officers carried that knowledge home to their People, who were thereafter better served. The indelible training gained by dire stress was employed anew for the benefit of all.
The World War afforded unprecedented conditions favorable to controlled mass experiment. The control of typhoid, an ever-prevalent disease, supplied only one instance of convincing proof of the controllability of infectious disease. Not only did the World War afford the opportunity to test prophylactic methods, but it demonstrated the value of this practice to thousands of doctors who applied this knowledge in civil life. Medical discoveries were broadcast to the profession.
The exigencies of the World War enriched medicine with a vast experience otherwise unobtainable. The war brought the regular medical officer, the reserve, and the civilian practitioner into closer contact. Familiarization with each other’s problems enhanced the esprit de corps of the entire profession. After demobilization, many medical officers maintained affiliation as reserves in the various service medical corps.
Among other benefits to medicine from the World War, it may be noted that medical literature throughout the world is laden with thousands of contributions of the war to the advancement of medicine; that the inculcation of order and method derived from discipline added to the poise of doctors; and that the war occasioned progression from the unwieldy administrative sanitary train to the Medical Regiment, which greatly facilitated the evacuation and care of the wounded. Motorized transportation of casualties reduced the time of exposure to shock, pain, and hemorrhage. Initial immobilization and extension of fractures was another method initiated and now extended even to Boy Scout first-aid treatment.
Medical history reveals that, since the Napoleonic Wars, advances in medical science during war were ever greater than within an equivalent peaceful period.
An invaluable training for physicians and surgeons, improved medical corps organization, and great increase of the medical reserve corps were contributions of the World War to the advancement of medicine.
The foremost of medical historians declared:
For medicine the greatest triumph of the war was in the direct application of the science of infectious diseases to military sanitation, in this case the group sanitation of armies of millions. This is the first war in history in which the mortality from battle casualties has exceeded that from communicable diseases. Mortality from disease was four times greater in the Civil War than in the World War. From 1914 to 1919, the Germans lost 1,531,048 men by wounds against 155,013 by diseases. Typhoid prophylaxis and improved sanitation decreased the incidence of typhoid fever twentyfold in the American Army of the World War as compared with the Spanish-American War. The British alone gave more than 2,000,000 prophylactic anti-tetanus injections, and thereby decreased the mortality from tetanus over 50 per cent; American results were even more favorable.
Smallpox vaccination was compulsory in the American, French, British, Belgian, Italian, and German forces; not strictly so in the Austrian, which up to and including 1916 had 45,000 cases of smallpox. Universal vaccination against smallpox and typhoid fever, the widespread use of antitetanus serum, and required venereal prophylaxis resulted in a great reduction in mortality and morbidity rates as compared with other wars.
Precautions in sanitation practiced in the World War proved a direct relationship between the excellence of general sanitary conditions and the admission rate for disease. Trained epidemiologists appointed to concentration camps in America were a boon to our forces.
The progress of medical science during the World War cannot be spoken of more eloquently than by the following figures:
Total deaths from dysentery:
American Civil War...................... 63,898
Spanish-American War.................. 6,382
World War.......................................... 44
Despite face masks, prophylactic sprays, limitation of public gatherings, use of cubicles and protective vaccination, there was no appreciable limitation of the killing pandemic disease influenza. We still face this challenge.
It is pertinent that when national or sectional disaster threatens, be it war, flood, storm, earthquake, or strike; when the military are called they insure prophylactic inoculations, rigid sanitary precautions, isolation of carriers and the infectious, disinfection and disposal of excreta, water purification, protection from rats, flies, mosquitoes, lice, fleas, and poor or spoiled food.
There was a potential saving of 128,574 lives from the ravages of typhoid, malaria, and dysentery in the World War in comparison with the Civil War. The World War taught that sanitary science safeguards soldiers and sailors.
Hippocrates wrote, “War is the only proper school for the surgeon.” All subdivisions of the surgical art have ever advanced scientifically with war. The interns of contemporary years owe much to the experience they attained by attendance upon World War veterans.
The second greatest achievement of medicine attained during the World War was the conquest of wound infection. Deaths from wounds were reduced by more than half in the World War as compared with our Civil War.
Though Larrey, surgeon of Napoleon’s army, had practiced excision of wounds, this procedure as rediscovered and extended by Grey-LeMaitre in 1915 came to be known as debridement—the excision of devitalized tissue followed by immediate suture. Debridement was the greatest legacy of the World War to surgical principles, indeed the greatest advance ever propounded.
One of my professors, a reserve army, surgeon, related that following certain costly engagements a hoe actually was required as a preliminary in the cleansing of the deck of his surgery.
Technique, asepsis, and antisepsis in war time differ not from that of civil practice. The ghastly wealth of material presented by the World War trained many of our prominent surgeons so intensively and extensively that the world looks to America for the ultimate in surgery today!
Millions were killed or maimed in the World War. Over 10,000,000 of Germany’s armies were treated during the war (including readmissions) with a survival of 97 per cent. Paradoxically, noncombatants prolonged the titanic struggle, for the enemies’ doctors did their noble best as did our own.
The first disciples of a new branch of surgery were initiated by the World War; traumatic surgery as a specialty was incepted. Wonderfully intricate new operations were performed. Blood vessels were sutured. Operative technique and diagnostic acumen reached a zenith.
The tremendous number wounded in the World War presented surgeons with Multifarious and intricate problems, the study and solution of which advanced every province of surgery.
It is recorded that the Germans found venereal diseases the first in frequency during the World War. The services of 98,000 men were lost to the British in the year 1917 as a result of venereal disease, and at one time during the World War 18,000 men were constantly away from their organizations undergoing treatment. Up to 1917 a million men were treated for syphilis or gonorrhea in the French Army. In 1917 there were 71,955 admissions for venereal disease in the United States Army, resulting in 875,553 sick days. The venereal diseases were such a Menace through loss of man power that General Pershing, in General Order 77, filed their incidence with the personal records of organization commanders as a basis for determining the commander’s efficiency and the suitability of his continuing in command. The recent laudable campaign to eradicate the scourge of the Venereal diseases is antedated by that instituted as a compulsory measure during the World War, with such good effect that one authority states the percentage of failure of 100,000 venereal prophylaxes given at Base Area Number 2, Bordeaux, France, was only 1.7 per cent.
The venereal disease problem in the American Expeditionary Force was combated by propaganda, education, prophylaxis, segregation, early and intensive treatment. Time has added little to this great lesson in preventive medicine first taught by the World War. The value of venereal prophylaxis was a lesson learned and fostered by the soldier and sailor who informed friends and associates at home that the choice between infection and prophylaxis was highly in favor of the latter. Therefore, the first great antivenereal disease campaign was a contribution of the World War to the advancement of medicine.
Segregation and Specialization
In 1914 the British inaugurated a system of segregation. It was observed that soldiers with mutilated faces were reluctant to associate with others not similarly defaced. They were morose, depressed, so conscious of their affliction that they refused to visit home or to mingle with other wounded, who involuntarily shuddered. In consequence a hospital was established at Sidcup, England, and later a Maxillo-Facial Service Hospital of the United States Army Medical Department, where facial mutilations were thenceforth admitted. The jack-o’-lantern faces benefited notably with the combined care of the best plastic surgeons and prosthetic dental officers. The latter combination to this day affords the most advanced assistance in certain cases of arrested malignancy of the face and jaw. These unfortunate wounded promoted a closer liaison between medical and dental officers, as well as provided the impetus to establish highly specialized institutes where the advocates of such nicely refined service foregather. Fracture, cardiac, diabetic, arthritic, tuberculous, venereal, and mental were other special hospitals established following the above precedent. The bona fide specialist is the most highly developed of the men of medicine.
Segregation hospitals and individual specialization were furthered during the World War.
Aside from ancient Chinese stinkpots and Greek fire, serious chemical warfare originated with the Germans in the World War in direct violation of The Hague Congress, 1899. The Allies promptly provided protective preparations. American chemists, before war concluded, daily produced more toxic gases than all other countries together. Probably knowledge of this fact influenced the Germans in accepting defeat. The cataclysm of the World War stimulated the art and science of medicine to aid the humanities, for as each new diabolical agent of torture and destruction was designed, its preventive, catalyst, antidote, or checkmate followed apace. Ingenious mechanico-chemical masks appeared soon after gas was first delivered.
Physicians converted the atrocious weapon gas into an agent of succor. Chlorine was later used to combat respiratory infections rather than men. The widely publicized oxygen tent evolved from efforts to employ oxygen to treat gassed cases during the World War. Gas, perhaps the most dreaded innovation of the World War, was eventually used to help and not harm mankind; therefore, an outstanding horror of the war contributed to the advance of medicine.
During the World War many soldiers suffered with a strange new disease, their greatest complaint being tender and painful shin bones, particularly at night.
This disease was nonfatal when uncomplicated, but it was infectious, debilitating, relapsing, and febrile. An American commission finally demonstrated that the body louse was the vector, and the cause is believed to be a virus of the Rickettsia type. Since spontaneous generation has long since been discredited, this disease existed unrecognized as an entity until Graham of the British Expeditionary Force first described it as trench fever in 1915. Trench fever was thought to be endemic in Russia, whence it was disseminated by German and Austrian troop movements to all fighting fronts. It was estimated that one third of all sickness in the British Army during the World War was caused by this disease, and in 1917 60 per cent of all patients in British hospitals had trench fever. A later student posed the speculation: How much sooner and in whose favor the World War might have terminated had it been possible to quickly control this persistent recurring disease that hospitalized soldiers for months.
Uncleanliness and overcrowding enhance the spread of the louse-borne diseases. These conditions prevailed in the World War as they do elsewhere today. The unwitting soldiers afforded the clinical material, a new disease was described, the vector was demonstrated and another malady was conquerable—a contribution of the World War to the advancement of medicine.
In 1916 there appeared in France and Austria another apparently new malady which was described by Von Economo. Though some investigators believe this disease identical with the “sleeping sickness” of 1712 and the “nona” of 1890, it was certainly a new disease in the United States, where it first appeared during the winter of 1918-19.
Epidemic encephalitis is a toxinfectious disease that manifests an affinity for the central nervous system, causing diffuse degenerative and disseminated inflammatory lesions which occasion marked clinical complexity. An ultramicroscopic virus ls thought to be the causative agent, the nasopharynx the portal of entry.
Typical cases present three stages: (a) somnolent-ophthalmoplegic (75 per cent develop ophthalmoplegia); (b) hyperkinetic; and (c) myasthenic (Parkinsonism). In 10 per cent, serious progressive sequelae affect the nervous system. The mortality averages 25 per cent. Puzzling cases of fever with drowsiness, somnolence, lethargy, and stupor or delirium incite suspicion, particularly if epidemic. Differences in the localization of inflammatory foci, virulence of the infection, and intensity of intoxication cause wide variation in the clinical aspect of the same case as well as different cases.
Epidemic encephalitis has been pandemic; it occurs sporadically and epidemically throughout the world. Watson believed the disease long epidemic in the Far East, whence it was spread as a result of contact with Asiatic and occidental troops on various fronts during the World War. This important and serious new disease was described and studied during the World War and the advance of medicine continued.
The universal experience of the Allies attributed the appalling percentage of 90 of each 100 aviation casualties to defects among pilots. Within the first year of the World War, the British attributed 60 per cent of aviation fatalities to defective Physiological requirements of personnel; whereas the enemy accounted for 2 per cent. Casualties at training centers far exceeded those of aerial combat. This costly situation demanded remedy. An entirely new subject was introduced when the British established a special Care-of-the-Flyer Service, whose function was the selection and medical supervision of the aviator. Justification for such a service was written in the saving of life on a broad scale, for the second year of the war brought a 200-per cent decrease in fatalities, and a 300-per cent saving was approached the third year. American medical officers played an important role in this new specialty, which came to be known as Aviation Medicine. Thus one of the youngest and most promising of Aesculapius’ progeny was a war child closely resembling professional kin such as physiology, internal medicine, cardiology, ophthalmology, psychology, otology, neurology, psychiatry, and research.
Mars was the godfather of Aviation Medicine which was conceived during the World War.
Shell Concussion and War Neurosis (“The Wind of the Ball”)
Four centuries past the great French Army surgeon Pare noted that “the wind of the ball” caused physical injury to soldiers actually untouched by cannon ball. Burr, an American Army surgeon in the War of the Rebellion, first described war neurosis. These distinct conditions were confused until the experience of the World War finally decided the differentiation. The balls of former wars were far less destructive than the shrapnel and high-explosive shells of the World War. French officers declared they had seen German soldiers thrown 30 feet into the air by the explosion of their “75’s.” Many dead found at the site of explosion bore no external evidence of a wound; but petechial hemorrhages of the brain, bloody cerebrospinal fluid and rupture of the lung or hollow viscera were found at necropsy. The impact of violent air and gas compression, enormous atmospheric increase and ensuing vacuum were responsible for the structural trauma.
The greatest number of true functional cases of war shock differ little, if at all, from typical neurasthenia, psychasthenia, hysteria, or neurosis. War neurosis is an exhaustion of the nervous system by the physical and mental stress incident to the conditions of war. Borderline cases partaking of the characteristics of both war concussion and war neurosis were encountered.
The World War contributed the means of this important differential diagnosis to the advancement of medicine.
The experience of the World War contributed to the differentiation and prognosis of organic and functional cardiac disease. Haldane’s oxygen apparatus originated through necessity for a treatment of poison gas. Local anesthetics were popularized. Remarkable success was attained in the treatment of burns with ambrine (paraffin-resin solution of Barthe). There developed improved localization of projectiles by Hirtz compass, the electro-vibrator of Bergonie, and radiologic methods. Osier described the etiology of trench foot disease. Baer conceived the maggot treatment. Bohler greatly improved various splints for fractures. Rogers’ hypertonic saline treatment for cholera and heat cramps was discovered. Leiper discovered the cause of bilharziosis; Christopherson, the curative treatment. (Military hygienists have always been pre-eminent in the discovery of insect vectors.) War edema was found the result of living on a diet containing insufficient protein and excess fluid; polyneuritis was not uncommon. The study of avitaminosis was stimulated by the plight of starved children and prisoners. Almost all that is known of gas gangrene was learned. Longitudinal sinus disease, a new concept in internal medicine, was admitted. The diagnosis and treatment of dysenteries progressed. An unheard-of field presented in psychiatry; reconstruction and rehabilitation of neuropsychiatric cases were undertaken with an impetus theretofore unknown. The Binet tests were introduced to recruiting service. The Germans found malaria the disease second in incidence during the World War, and Hoffman in Russian-Poland carried out provocative activation of latent malaria infection by splenic faradization. This alternate heating and chilling of the body effectively indicated latent infections and carriers—a measure of obvious value. The treatment of shock improved. The value of blood transfusion in operation, hemorrhage, the anemias and septic diseases was appreciated. Intrathoracic surgery, previously a noli me tangere area, was developed. Wonderful prosthetic devices for artificial limbs were improvised. The training of mangled defectives for future life efficiency began.
Since the World War medical knowledge has increased and daily continues to gain, but the necessity of crisis sped medicine during the World War with a spurt of growth paralleled in the development of the individual at certain ages. Mere enumeration of miscellaneous progress reveals that not an age of the human life span but was affected and not a phase of medical science but was benefited by the contributions of the World War to the advancement of medicine.