# Lentis/Disease Prevention in the First World War
## Introduction

World War 1 was the first major war where combat killed more soldiers than disease. In the years before the war, advancements in medicine as well as military practices made this possible. This chapter will focus on these advancements and the systems they were implemented into.

## Vaccines

The use of disease prevention techniques were used for years prior to World War 1. The U.S. military specifically sought out and valued the effects of vaccines. By the start of World War 1, a typhoid vaccine had been developed, and the U.S. army made it compulsory for all soldiers. The French army didn't have an operational vaccine program until the middle of the war, and the British army usually only vaccinated soldiers deployed in tropical areas.
In 19th century Great Britain an anti-vaccination movement began and drew traction. After passing regulations in 1840 and 1853, members of this movement lobbied for reduction in requirements in 1898. This pressure of anti-vaccination interests is thought to have had an impact on the lack of compulsory vaccinations for soldiers fighting in mainland Europe.

## Germ Theory

Germ theory states that disease is spread through physical living pathogens that spread in a variety of ways.
During the U.S. Civil War, the commonly accepted theories included miasma theory and contagion theory. Miasma theory claimed that disease was spread through bad air or miasma. Contagion theory said that disease was spread by touch from an infected individual. Under these theories, armies wouldn't take precautions against practices like placing latrines where they can seep into drinking water supplies. Contemporary theories wouldn't connect problems like the possibility of contaminated water with illness in soldiers.
Germ Theory had been discussed for thousands of years prior to World War I, with many discoveries and scientists help legitimize and promote it. Some of the notable scientists and their experiments include:
* Louis Pasteur, known for his swan neck flask pasteurization experiment. These involved showing a flask of broth with a swan neck would not grow bacteria like a standard vertical neck would. Pasteur concluded that the bacteria could not reach the broth in the swan neck, while they could easily fall into the vertical neck.
* Robert Koch, known for his anthrax experiments and his postulates. Koch inoculated mice with blood from animals infected with anthrax and saw how that caused anthrax in the recipient. Also, Koch proposed 4 postulates to link the bacteria to the disease.
* The bacteria must be present in sick individuals and not in healthy ones.
* The bacteria needs to be grown in culture, separate from a host
* The lab grown bacteria must cause the disease when introduced to a healthy individual
* The disease from the inoculated individual must match that from other sick individuals.
* John Snow, known for his connection of cholera to an infected well. In 1854, there was an outbreak of cholera in a suburb near London. John Snow observed how it clustered around a specific well, where a vast majority of the cases could be traced back to the individual drinking from that pump.
As more people came to support Germ Theory, it enabled more effective and health practices across the board. The other components of this chapter were enabled by the progress of Germ Theory.

## Advancements
#### Antiseptics

Improved mortally rates can be contributed to the use of antiseptics. Used first in 1867, antiseptics are used to kill bacteria and disinfect wounds. Before the introduction of antiseptics a small would could prove fatal by infection. Known antiseptics however were not enough to combat Clostridium perfringens, a bacteria found in the trenches. Henry Dakin was able to create an antiseptic from sodium hypochlorite with help from Alexis Carrol, patenting the Carrel-Dakin Method.. This method saved countless lives during the war.

#### Anesthesia

By the time of the war, anesthetics had improved to the point where doctors could perform longer operations. This allowed more complex procedures to be completed, saving more lives through surgery. The most common forms of anesthesia were chloroform, nitrous oxide, and ether. A mask with gauze containing the drug were placed over the patient's face. Application methods vary but most patients were unconscious in less than 5 minutes.

#### X-Ray

Wilhelm Roentgen discovered x-rays in 1895. Imaging devices were limited to hospitals so soldiers needed to be evacuated to be treated. In 1914 Marie Curie invented a car that contained x-ray equipment. This car could be taken to the front where doctors could use the x-ray equipment in their field stations.

## Open Wound Cleaning
#### Civil War Practices

A major cause of death during wartime before to World War I was primarily due to post-operative wound infections. During the Civil War from 1861 to 1865, prior to the development of concepts such as Germ Theory and Antiseptics, there were many misconceptions on proper wound healing. For instance, during post-operative care, causes of infection such as laudable and malignant pus were often ignored and treated as signs of proper healing. Laudable pus is thick and cream colored and is known to be associated with Staphylococcal infection. Malignant pus is thin and bloody and is known to be associated with Streptococcal infection. As a result of this infection, a type of necrotizing fasciitis known as hospital gangrene was a prominent disease in wartime locations. In order to prevent death due to infection, amputations were common. During the civil war, three out of four battlefield surgeries performed were amputations; out of approximately 175,000 extremity wounds, 30,000 underwent amputation. One common course of treatment for infection treatment was to dissect dead tissue away, treat with bromide (whose effectiveness was unknown at the time), and pack the wound with bromide soaked dressings.

#### Spanish American War Medical Practices

The Spanish American Was was one of the first wars containing a mild implementation of antiseptic treatment. Taking place in 1898, this was marked one of the first uses of Lister's antiseptic method in wound care. During treatment of wounds, antiseptic dressings were used, operating rooms were disinfected, instruments were metal and sterilized, and surgeons made sure to wash their hands prior to surgical procedures. While gloves and masks were not yet used during surgery, other antiseptic techniques helped reduce the rate of infection among soldiers undergoing surgery. Another contributing factor to the reduction of the mortality rate during wars was due to a better understanding of septic shock and its treatment. For instance, the Spanish American war marked one of the first instances where shock as a result of hemorrhage was known to be treated with fluid resuscitation. This resulted in fewer cases in which amputation was used to eradicate disease, decreasing the occurrence of this procedure during wartime.

#### World War I Medical Practices

During World War I, medical procedure thoroughly implemented antiseptic and disinfection treatment techniques due to the knowledge of topics such as Germ Theory and antiseptics. As WWI mainly consisted of trench warfare, the amount of bacteria that was present to infect wounds significantly increased. However, wound treatment had improved greatly during this war. US surgeons adopted the procedure of debridement, or the removal of damaged tissue, and delayed primary wound closure to ensure that an infection was not present before closure was attempted. This procedure basically eliminated the need for amputation to prevent infection from spreading. Another procedure that was implemented was wound irrigation using sodium hypochlorite and boric acid, known as Dakin's solution. This procedure thoroughly disinfected the wound site, thus making sure that closure of the wound site was only attempted after almost all sources of infection were removed from the wound site.

## Systematic Treatment

While the concept of triage wasn't invented in World War 1, it became much more prevalent in the world of military healthcare. The allied forces in particular set up a structure of medical stations to optimize their effect.
The first layer of this structure was composed of Regimental Aid Posts. These would be embedded in the trench network, fairly close to the front lines. These had little capabilities, normally just cleaning/closing wounds. For any severe injury or disease the patient would be sent back a layer to the Advanced Dressing Station.
Advanced Dressing Stations were typically in the back of the trenches, close enough to be carried from the field care stations on a stretcher. These stations had ability to do some small surgeries as well as hold patients for a few hours. Capacity was relatively low, so if patients needed more care they could be sent back another layer in the chain.
The Field Hospitals were located a fair distance from the trenches usually needing an ambulance to access. These hospitals would have the level of care seen in top civilian hospitals with operating rooms, machinery, and labs for diagnosing patients.
One layer back would be the Evacuation Hospital. This layer wouldn't be a substantial increase in capability from the general hospitals, mostly just an increase in capacity. U.S. soldiers who were not fit to return to combat would also be sent here to wait for a boat back home.
The trench warfare of World War 1 caused armies to be more stationary, which made it easier to put in the system detailed above. Additionally, as the automobile grew in popularity some ambulances changed from horse-drawn to motorized.

## References

* ↑ Cooter, R. (1993). War and modern medicine.
* ↑ Artenstein, A.W., Opal, J.M., Opal, S.M., Tramont, E.C., Peter, G., Russell, P.K. History of U.S. Military Contributions to the Study of Vaccines against Infectious Diseases. Military Medicine. 170, 4:3, 2005.
* ↑ Shanks, G. D. (2014). How World War 1 changed global attitudes to war and infectious diseases. The Lancet, 384(9955), 1699–1707. doi: 10.1016/s0140-6736(14)61786-4
* ↑ Wolfe, R. M., & Sharp, L. K. (2002). Anti-vaccinationists past and present. BMJ (Clinical research ed.), 325(7361), 430–432. doi:10.1136/bmj.325.7361.430
* ↑ Michael R. Gilchrist. (1998). Disease & Infection in the American Civil War. The American Biology Teacher, 60(4), 258-262. doi:10.2307/4450468
* ↑ Berche, P. (2012). Louis Pasteur, from crystals of life to vaccination. Clinical Microbiology and Infection, 18, 1-6.
* ↑ Blevins, S. M., & Bronze, M. S. (2010). Robert Koch and the ‘golden age’of bacteriology. International Journal of Infectious Diseases, 14(9), e744-e751.
* ↑ DONALD CAMERON, IAN G JONES, John Snow, the Broad Street Pump and Modern Epidemiology, International Journal of Epidemiology, Volume 12, Issue 4, 1983, Pages 393–396, https://doi.org/10.1093/ije/12.4.393
* ↑ Michael Keyes, Rachel Thibodeau.(2019)Dakin Solution (Sodium Hypochlorite)
* ↑ Kułakowski A. (2011). The contribution of Marie Skłodowska-Curie to the development of modern oncology. Analytical and bioanalytical chemistry, 400(6), 1583–1586. doi:10.1007/s00216-011-4712-1
* ↑ Reilly, R. F. (2016). Medical and surgical care during the American Civil War, 1861–1865. Proceedings (Baylor University. Medical Center), 29(2), 138–142.
* ↑ https://www.medicalmuseum.mil/index.cfm?p=exhibits.past.spanishamericanwar.page_05
* ↑ Hardaway, R. M. (2004). Wound shock: A history of its study and treatment by military surgeons. Military Medicine, 169(4), 265–269.
* ↑ Manring, M. M., Hawk, A., Calhoun, J. H., & Andersen, R. C. (2009). Treatment of War Wounds: A Historical Review. Clinical Orthopaedics and Related Research, 467(8), 2168–2191. https://doi.org/10.1007/s11999-009-0738-5
* ↑ Nieves, J., Stack, Kathleen, (n.d.). WWI: US Army 1st Division and Sanitary Corps Training in the Western Front, Eyewitness Notes by Col. B.K Ashford 1917-1918 [PowerPoint slides]. Retrieved from https://history.army.mil/curriculum/wwi/docs/AdditionalResources/presentations/WWI-US_Army_1st_Division-Sanitary_Corps_Medical_Training_Western_Front.pdf