Angel of Mercy is set in the Canadian Army Nursing Service and the Canadian Army Medical Corps.

World War I marked the first conflict in history where the death toll from battle was higher than that from disease.   This has been attributed to mass vaccination, particularly against typhoid, and to the development of antiseptics.  Antiseptics made surgery safer by reducing infection and made it possible to keep wounds clean.

“Blighty” was a slang term for a wound that wasn’t serious enough to cause death but was serious enough that it earned a soldier a trip home.

Compound fractures had a death rate of up to 80 percent.  However, the ice bath given to Private Wilfred in Chapter 9 likely killed him.  While once a common practice for high fevers, submerging the body in ice water actually causes the core temperature to rise by forcing the body to shiver.  The ice will temporarily lower temperature, but the fever that follows the ice bath will be higher.

Aspirin is capitalized because it was not yet a generic drug.  The patent was held by Bayer.

Throughout the course of the war, 10,000 Canadians were diagnosed with shell shock.

Treatment was in its infancy and ranged from psychotherapy to electrocution of the nerves and limbs.  Sixty-six percent of those diagnosed were returned to active service.  Those who did return home usually received little or no treatment.

“Pudding club” was a Victorian euphemism for pregnancy.

Margaret Sanger coined the term “birth control” in the mid-1910s.  It replaced many euphemisms for contraception.  Access to birth control devices and education was limited in the early 20th century thanks to 19th century obscenity laws.  Sanger did not let this stop her, and she was arrested on more than one occasion.  Sanger believed that smaller families equaled healthier families and that every woman had the right to plan when and how often she had children.  Sanger was inspired by her own work as a nurse tending to women who had had multiple births and miscarriages and those who had attempted self-abortions (with the aid of poison, falls, hangers and other objects) or endured abortions performed by unqualified people.  Her mother whose 18 pregnancies, including seven miscarriages, contributed to ill health and a shortened lifespan also inspired her.

The flu pandemic of 1918 was one of the worst disasters in human history, affecting 500 million people and killing 50 million, most between the ages of 20 and 40.  Mortality was highest among pregnant women, up to 80 percent of whom died.  Older adults seemed to be immune to the pandemic, perhaps due to exposure to the virus during the 1890 Russian flu pandemic.  Those who had fallen ill during the first wave of the virus also were immune and spared to watch the horror that would befall the rest of the population.   Around 50,000 Canadians, both soldier and civilian, would die of Spanish flu by 1918’s end.

Medical Care During World War I

New killing machines led to appalling injury rates.

“These are weapons that reduced human beings to mist in some cases,” Andrew Burtch, acting director of research at the Canada War Museum, told CTV. “They shear off noses and faces. They shred the extremities, they cause massive bleeding wounds in the stomach. They tear people into pieces.”

Nineteen million men, on both sides, were wounded. Of those, approximately 500,000 had limbs amputated at medical units. Despite the high casualty rates, most of the wounded who lived long enough to receive medical care survived.  How is this possible in an age before antibiotics?

A splint developed by an orthopedist during the war increased the survival rate for a broken thigh fracture from 20 percent in 1914 to 80 percent in 1916.

An efficient system moved the wounded from the front.  Stretcher bearers carried men from the field and took them to first aid stations.  Wounded were moved then to a field ambulance followed by a dressing station, a casualty clearing station and finally a base hospital. At any point along the way, a soldier might be treated and sent back to his unit.  More serious cases proceeded to the next step.

In addition, triage was developed to assess who needed the most assistance.  Triage ensured serious cases were treated quickly and before other patients.

Medical advancements made not long before the war also played an important role in saving soldier’s lives.

These include:

• Portable x-ray machines
• Vaccinations for anthrax, cholera, rabies and typhoid
• Antiseptics
• Antitoxins for diphtheria and tetanus
• The identification of blood types
• The discovery that vitamin deficiency caused rickets and scurvy

Other medical technologies improved because doctors treated a high volume of disfigured patients.

• Plastic surgery: Plastic surgery advanced little before the war’s start. Soon, doctors needed to literally reconstruct soldiers’ faces. Techniques were developed to build prosthetic faces and eyes, and to supply blood to reconstructed body parts.
• Prosthetic limbs: New types of prosthetic limbs, produced on a mass scale, were produced that were functional enough to allow men to return to work.

Germ Theory

Germ theory recognizes that some diseases are caused by microorganisms.   Before germ theory was proposed, doctors believed diseases were caused by bad air.

Beginning in the 16th century, however, some scientists began to put forth the theory that something living, yet unseen by the human eye, was causing disease. It wasn’t until the 19th century that science was able to prove these theories correct.

Austrian obstetrician Ignaz Semmelweis observed that women who gave birth with the assistance of a midwife had lower incidents of childbed fever than those who gave birth under a doctor’s care. He discovered the doctors were going from autopsies to births without handwashing. Once strict handwashing measures were put into place, the rates of childbed fever dropped dramatically.

In London, Dr. John Snow developed the science of epidemiology when he discovered the source of a cholera outbreak was a contaminated well.

Other doctors experimented with growing and identifying organisms.

Joseph Lister, a surgeon, took germ theory a step further and developed a way to sterilize wounds and medical instruments using carbolic acid. Lister discovered that carbolic acid prevented wounds from developing infection. Beginning in 1867, he advocated the sterilization of operating rooms and instruments, surgeons wearing gloves and for medical instruments not to be made of porous materials.

Prior to Lister’s campaign, surgeons did not wash their hands between surgeries and took pride in wearing bloodstained garments.

Lister died in 1912, but his techniques would save countless lives during World War I.

The Gravesite Record of a Canadian Soldier

Canada and Wartime Medical Care

Canadian Army Medical Corps

The Canadian Army Medical Corps (CAMC) was founded in 1904 and its members served during World War I in France, Belgium and the Mediterranean.

Members of the CAMC sometimes worked dangerously close to the front line and often in primitive conditions.  By the time Armistice was declared in 1918, 21,453 nurses, physicians, dentists, ambulance drivers, stretcher bearers and orderlies had served. Of them, 1,325 lost their lives.  Three were awarded the Victoria Cross, the highest military honor in the British Empire.

Types of Medical Units

During the war, there were several types of medical units.

• Field Ambulance: A field ambulance, despite its name, was not a motorized vehicle. It was a mobile medical unit very close to the front line that treated patients when they were rescued from the battlefield.
• Dressing Station/Aid Posts: These units also were close to the front. They employed a medical officer, stretcher bearers and orderlies. There were two types of units, main and advanced. Dressing stations were under fire from the battlefield and were never intended to provide life-saving surgery, but sometimes surgery was performed out of necessary. Patients were either sent back to their units or on to a casualty clearing station.
• Casualty Clearing Station: Abbreviated (CCS) and designated a number (for example, CCS #10).  These units were located behind the front lines but were close enough personnel often heard bombardments. Casualties arrived from dressing stations, and men treated at a CSS did not stay long-term. They were treated and either sent back to the front or moved further behind the line to a stationary hospital. These units moved frequently but were usually located near a railway line.
• Stationary/base Hospital: Generally in buildings, these provided long-term care.

Conditions at a Casualty Clearing Station

Casualty Clearing Stations were located in tents or temporary structures. The first stations were located in requisitioned buildings but necessity forced the transition to tent cities.

A CCS was staffed with surgeons, nurses, orderlies, a dentist, ambulance drivers and a chaplain. During a major battle, a CCS could treat 1,000 patients daily.

Patients arrived at the CCS either by ambulance, wagon, railroad or on foot. They were received at reception where they were assessed and a medical tag applied to the patients’ clothing.  Patients who were severely wounded or dying were moved to resuscitation, nicknamed resuss, where they were kept comfortable. Others were moved to pre-op.

After surgery, but before being moved to a stationary hospital, patients were moved to the award tent where they were kept under supervision. Patients who were moved to evacuation prior to discharge.

Medical Tag Used During Triage

The School of Nursing Toronto General Hospital

Hettie is a 1913 graduate of the School of Nursing Toronto General Hospital.   By 1913, it was the largest, and among the most prestigious nursing schools, in Canada. Competition for acceptance into the program was stiff and had been since 1894.

In the 19th century, hospitals were where the poor went to die. The middle class and wealthy hired nurses to care for the sick and injured at home. In the days before germ theory and modern sterilization methods, death rates were considerably higher for those nursed in hospitals as opposed to at home.

Public hospitals became more common by 1900 and began serving the middle class. Wards had multiple beds, but a patient could pay for a semi-private or private room. The insane and those with contagious diseases were housed separately.

The Alumnae Association of the Toronto General Hospital Training School of Nurses was formed in 1901. The school then had 347 graduates. Alumnae were given a pin with the image of a pomegranate plant. It bore the words UT Prosem, Latin for “that I may be of service.”

Nursing gained great strides toward being considered a serious profession. In 1904, the Graduate Nurses Association of Ontario was founded. Four years later, both the Canada National Association of Trained Nurses and the International Council of Nurses were established.

Prior to 1913, Toronto General Hospital was located at the corner of Gerrard St. and Sumach St.

During World War I, 180 alumnae served in the war. They trained in Niagara-on-the-Lake, a camp nicknamed Niagara-on-the-Lake General Hospital.

The Student Experience

In 1881, the nursing program was a two-year course. This expanded to three years in 1896. During the third year, students worked in the hospital.

Students studied:

• Practical nursing
• Anatomy
• Physiology
• Surgery and obstetrical nursing
• Communicable diseases
• Eye, ear and throat
• Dietetics

The school year ran from October to July with medical staff serving as instructors.  The school was run by a superintendent. The best known is Mary Agnes Snively. She retired in 1910 and was replaced with Robina Stewart.  Students lived in residences with bedrooms, a dining room and a sitting room. They had strict rules to follow, and morning prayers were mandatory. Graduation was held in July. Students received their diplomas and had a class photo taken. The average class size was 56.

***Editor’s note:  A special thank you to the Alumnae Association School of Nursing Toronto General Hospital website for being invaluable to Angel of Mercy research.*** 

Canadian Army Nursing Service

The Canadian Army Nursing Service (CANS) was founded in 1901. The first women who enrolled served in the South African (Boer) War.  Three years later, the CANS consisted of 25 women. In 1904, CANS was renamed the Canadian Army Nursing Corps (CANC). Its first matron was Georgina Fane Pope. She was responsible for establishing the corps’ uniform, rules and regulations, and recruitment techniques.

At the start of World War I, there were only five permanent members and 30 reservists. A recruitment campaign was launched. In order to qualify for membership in the CANC, nurses had to complete a training course and take a written exam. This requirement was later waived.

When the first contingent of Canadian soldiers sailed for Europe in autumn 1914, 105 nurses left with them.

Members of the medical corps were noncombatants but that didn’t mean they were not in danger. In June 1917, the hospital ship Llandovery Castle was sunk, and all 14 nurses on-board were killed. The following May, No. 1 Canadian General Hospital was bombed, and five nurses were killed.

27 Facts About the CANC

1. The CANC became part of the Canadian Army Medical Corps during the war.
2. Of the 3,141 nurses who served, 2,504 did so overseas.
3. There were more volunteers than there were openings.
4. The average age of a nurse was 24.
5. Their proper title was “nursing sister.” This is because traditionally nursing had been carried out by those in religious orders. None of the World War I nursing sisters, however, were nuns.
6. The nurses were high school graduates as well as graduates of hospital nursing programs. This makes them highly educated compared to most women at the time.
7. Most were born in Canada or Britain.
8. They were mostly from urban areas, middle class and their fathers were professionals.
9. They were paid $2 daily.
10. Requirements for acceptance were graduation from a recognized nursing college, being single, in good health, and being between the ages of 21 and 38.
11. Women joined out a sense of duty, to expand their job skills, to seek adventure or to escape unemployment.
12. They were given the rank of lieutenant, although they had no power to issue orders outside of the medical corps.
13. Their uniforms were blue with white veils and aprons. This earned them the nickname “bluebirds.”
14. Army nurses also were nicknamed “angels of mercy.”
15. The first medical units were permanent hospitals. Later, casualty clearing stations were introduced closer to the front line, allowing triage to be performed.
16. They served overseas in Belgium, France, Great Britain, Russia, and around the Mediterranean in 30 hospitals and clearing stations. They also served on hospital ships.
17. The medical staff at clearing stations had to contend with more than the enemy. They also experienced primitive working conditions and exhaustion. They fought insects, especially fleas, and rats.
18. Hospitals in the field were equipped to handle 250 patients and were staffed with 16 nurses. Hospitals in England handled 500 patients with a nursing staff of 72.
19. It was very common for staff to be moved from one post to another throughout the course of the war.
20. Duties included changing bandages, disinfecting wounds, serving patients food, disinfecting instruments, changing bedding, emptying bedpans, bathing patients and triage.
21. They usually lived in tents or wood huts.
22. Nurses often left the service because of mental exhaustion.
23. Nurses occupied themselves during their free time by playing sports, dancing, enjoying afternoon tea and traveling while on leave.
24. They were given the right to vote with the passage of the Military Voters Act in 1917. Because overseas military personnel voted earlier than citizens back home, nurses were the first Canadian women ever to a cast a vote in a federal election.
25. The official death toll for nurses was 47. However, some historians believe the real number was 76.
26. Nine nurses received medals for gallantry under fire.
27. Most returned home and eventually married, but some remained in the service.

The uniform of a real WWI nursing sister

10 Facts About World War One Nurses

“In his much-admired book published in 1975,” Baroness Williams of Crosby, the daughter of Voluntary Aid Detachment nurse Vera Brittain says, “The Great War and Modern Memory, the American literary critic and historian, Paul Fussell, wrote about the pervasive myths and legends of WW1, so powerful they became indistinguishable from fact in many minds. Surprisingly, Fussell hardly mentioned nurses. There is no reference to Edith Cavell, let alone Florence Nightingale.”

1. Nurses were not treated equally with doctors, the majority of whom were men.
2. There was a rift between professional nurses and untrained volunteers. The professionals felt the volunteers undermined the legitimacy of the profession.
3. Many early British hospitals were run by aristocratic women who felt they were entitled to the position because of their experiences running grand estates.
4. Nurses worked long hours, often dealing with insects, rats, and the weather, and their position close to the front placed them in danger.
5. Many women’s decisions to serve caused conflict in their families.
6. New medical techniques had be to learned quickly, such as blood transfusions and wound disinfection.
7. Nurses had strict rules of conduct, and breaking the rules could lead to dismissal.
8. The Endell Street Military Hospital in London was run and staffed entirely by women. It cared for 24,000 patients during the war.
9. Nurses served not just on the Western Front but in North Africa, Greece and Romania, on the Italian front and at military-base hospitals.
10. Nurses put duty first, no matter the peril.  A prime example is Edith Cavell.

Canadian Nurses Tending to Graves

Medical Care and Soldiers

Trench Diseases

Trench Fever

Type of infection: Bacterial, transmitted by lice

Symptoms: Abnormal sensitivity in the shins, fever, headache, muscle soreness, eye pain

Duration: Five days, but could be reoccurring

Course of the illness: Muscle soreness continues even after fever breaks

Prognosis: Rarely fatal, but too high of a fever can lead to heart damage

Prevention: Cleanliness and eliminating the lice infestation, which is next to impossible in the trenches

Major J. H. P. Graham, of No. 5 Canadian Mobile Laboratory, first identified the disease in 1915. At first, medical professionals disagreed on whether this was a new disease or simply an old one presenting itself in a new way.  Laboratory studies confirmed the former. Researchers discovered that most cases were not caused by the lice themselves but instead from accidentally rubbing louse excrement into irritated skin.

“A private belonging to an infantry regiment was admitted to a casualty clearing station from a field ambulance where he had been detained suffering from a febrile illness of three days’ duration and of sudden onset,” Graham said in his notes.  “The patient’s condition on admission was marked by frontal headache, dizziness, severe lumbago, a feeling of stiffness down the front of the thighs, and severe pains in the legs referred chiefly to the shins.”

In 1917, trench fever accounted for 15 percent of medical evacuations.

Trench Rot

Type of infection: Fungal

Symptoms: Feet turn red then blue; swelling, blisters; area stinks like decay

Duration: Two to six weeks followed by months of recovery

Course of the illness: In advanced cases, leads to gangrene and amputation

Prognosis: Varies, depending on severity

Prevention: Improved drainage in trenches, waterproof footwear, frequently changing into dry socks

Trench foot was a disease well known in the medical field.  It had been plaguing soldiers for centuries, but it became especially problematic in the early months of the Great War when it affected tens of thousands.

“Towards [sic] the end of WWI, the armies developed techniques for preventing Trench Foot,” blogger Perry Walters says on the Kansas World War One Centennial Committee website. “First, they provided an elevated wooden floor in the bottom of the trenches. They enhanced the trench drainage systems, and they also developed a buddy system where each soldier was responsible for his buddy’s feet being dry and clean.”

Armies also instituted regular foot inspections.

Trench Mouth

Type of infection: Bacterial

Symptoms: Swelling of the gums as well as ulcers on the gums, fever, bleeding, bad breath

Duration: If not properly treated, can spread beyond the gums and infect the jawbone, lips and cheeks

Course of the illness: Caused by the bacteria normally present in the mouth growing out of control

Prognosis: Depends on severity of the infection because gum tissue is destroyed. Teeth may fall out.

Prevention: Good oral hygiene, proper nutrition, not smoking, controlling stress

Trench mouth is the gingivitis case from hell.  It is painful and cannot be reversed (true gingivitis can).  During the war, it became prevalent because some soldiers stopped their oral hygiene routines and many ate sugary treats from home.

“In the horrendous conditions amidst the mud and carnage of battle, strategies of attrition involved troops in long  stalemates, with gun care more of a priority than gum care,” the European Federation of Periodontology says.

Today, the disease can be treated with antibiotics, but during the 1910s it was treated with hydrogen peroxide.

Field Dressing

Shell Shock

Post-traumatic stress syndrome (PTSD) was not a diagnosis during World War I, and psychiatry was a relatively new medical discipline. No one knew how intensely stress affects the mind.  Not long after the war began, a new disease began showing up in otherwise healthy soldiers.

The disease, coined shell shock in 1915 although the term was not in common use until later, originally presented itself in soldiers who had been near exploding shells.  For this reason, doctors concluded the disease was physical, the result of brain or nerve injuries caused by shock waves or perhaps poisons  emitted from shells.

Symptoms included:

• Headache
• Ringing in the ears
• Nervous twitches and ticks
• Dizziness
• Amnesia
• Sensitivity to sound
• Uncontrollable diarrhea
• Nightmares
• Hysterical blindness
• Flashbacks
• A blank stare

Many of these symptoms were associated with injuries, but the men had no physical wounds.

Shell shock was something to be ashamed of and commentary on a soldier’s masculinity. Because medical personnel did not understand the causes of shell shock, sufferers were unfairly labeled cowards, trouble makers and unable to get a grip on reality. Some were executed for military cowardice, especially if their symptoms returned after treatment.

Despite its newness, psychiatry increasingly became an accepted form of medical treatment, and doctors recognized war neuroses as a psychiatric condition.

“Military and medical authorities were convinced that many soldiers exhibiting the characteristic symptoms — trembling ‘rather like a jelly shaking’; headache; tinnitus, or ringing in the ear; dizziness; poor concentration; confusion; loss of memory; and disorders of sleep — had been nowhere near exploding shells,” Smithsonian magazine explains. “Rather, their condition was one of “neurasthenia,” or weakness of the nerves — in laymen’s terms, a nervous breakdown precipitated by the dreadful stress of war.”

In time, armies learned how to treat shell shock. Men showing symptoms were allowed a few days rest to prevent a more serious case. If this didn’t work, the soldier was sent to a casualty clearing station for observation and finally to a psychiatric hospital.

Although many men were treated and sent back to the front, the majority did not return to the battlefield. Many continued to receive help years after the war ended while others didn’t develop shell shock until returning to civilian life.

Canadian Soldier’s WWI Identity Disks

Morphine Addiction

When it came to pain relief, the medication of choice was morphine. It was reserved for the most severe injuries as its addictive properties were already well known.  So much so that morphine addiction was referred to by the euphemism “soldier’s disease” as far back as the American Civil War.

Morphine works by relaxing the body, reducing shortness of breath and killing pain. It is derived from opium and has been used as a pain reliever since the early 19th century. By the start of the war, it was available only by prescription, but originally was sold over-the-counter.

Because it is so highly addictive, morphine addiction is difficult to cure, and patients go through many withdrawal symptoms. The majority of addicts will relapse.

Very few other pain medications were available during the early part of the 20th century. The other options were:

Aspirin: Used for pain relief and fever reduction, German pharmaceutical company Bayer lost its trademark on aspirin in 1918. The drug saw widespread use during the Spanish Flu pandemic and may have contributed to the high mortality rate.

Patent Medicines: These over-the-counter drugs were available until the United States and Canada required all drug ingredients be labeled. These drugs were advertised to cure or prevent a variety of ailments, but were not true medications.  The secret ingredients contained in the products were generally herbs, alcohol, cocaine or opium. Some were even radioactive.

Laudanum: Derived from opium, laudanum was popular in the 19th century, but is still available today as a tincture of opium. While it was advertised as a cure for a variety of ailments including menstrual cramps and colic, it was typically used as a pain reliever or a cough suppressant. Other drugs have been derived from opium throughout the years, including oxycodone that was developed in Germany in 1916.

Cocaine: Cocaine has a numbing effect so it was used primarily for dental procedures but also for nose and eye surgeries. In addition, it was used as a spinal anesthesia.

Heroin: Heroin was developed as a cure for morphine addiction. Its developer, an English chemist, didn’t realize or intend for heroin to be more addictive than morphine. It was marketed by Bayer, which lost the trademark in 1919, as a non-addictive alternative to morphine and as a cough suppressant.

A Nursing Sister’s Medals

Burn Treatments

Burns were treated at home using everyday items such as honey, milk, butter, eggs or lard. Ointments such as rose water or oil also were used as was saline.

More serious wounds were covered with bandages. Antiseptics kept infection from developing. During World War I, burns were disinfected using sodium hypochlorite.

Patients with third-degree burns were given morphine or another opiate for pain relief, and dead skin was cut away.

Mustard gas was first used in 1917. Unlike chlorine gas, which could be seen, mustard gas was clear. Victims often were exposed, but didn’t know it for hours or even days. Exposure caused irritation, redness and burning. It also affected the digestive and respiratory systems. Once a soldier was exposed to mustard gas, there was little medical personnel could do.

Treatment was limited to:

• Eyes were flushed with saline, but blindness was common
• Skin was treated with petroleum jelly and bleaching powder
• Gauze soaked in menthol was used to alleviate respiratory distress

Though rarely deadly, mustard gas affected victims permanently, sometimes causing cancer.

Surgery

Since the 1840s, the two available anesthetics were ether and chloroform. Ether numbs the patient but does not cause unconsciousness. Chloroform works more quickly, but there is a higher risk of death if the wrong amount is used. It is applied using a mask, sponge or cloth. Dental procedures were conducting using nitrous oxide.

Shrapnel caused a number of facial injuries. Men lost noses, eyes, lower jaw bones, sometimes even the entire front of their faces. These men were scarred for life, and doctors sought ways to alleviate their suffering. This led to the field of reconstructive surgery.

Dr. Harold Gillies asked for permission from the British Army Medical Corps to establish a facial reconstruction hospital.  Gillies treated thousands of patients with the goal of giving patients as natural a look as possible. Many techniques were discovered via experimentation. Procedures often involved multiple steps that had to be done over a period of years. There were no mirrors in the hospital to hide men from their appearance.

A large number of the surgeries were successful, but unfortunately, many were not. Lessons learned from the setbacks was applied in future surgeries.

Often the psychological scars were worse than the physical ones of men who sustained severe facial injuries. Many had difficulty being seen in public, holding down jobs and maintaining relationships.

X-ray machines were less than 20 years old when the war began but proved invaluable. Portable x-ray machines allowed medical personnel to see what was going on inside a patient’s body before surgery was performed. X-rays could be taken by doctors or nurses, but soon the new position of radiographer was born.

Ether Dispenser

Treating Bone Fractures

In the early 20^th century a broken bone could be a serious, if not deadly, injury.

People knew from ancient times to immobilize broken bones with a splint or a brace. Later, bone setters were used to move the bone into place before immobilization. The location of the fracture determined how difficult, and how painful, the procedure would be.

Wrapping the bone in plaster began in the 18th century. Limbs were often put in traction, pulling the bone back into place, before being set.

Amputations had a 75 percent mortality rate in the 18th century. Infection was the main cause of the high mortality. Methods of controlling bleeding often led to other severe problems that caused death.

Even those who did not have their limbs amputated, but suffered from severe factures, often died of infection.

Surgery was a worse-case scenario and generally was reserved for open fractures and severe compound fractures. In the 19th century, wires, metal plates and screws began being used to stabilize some fractures. The use of these instruments greatly reduced the need for amputation, but those who survived often had a limp or physical deformity.

Soldiers who were shot in the femur suffered an 80 percent mortality rate in 1914. Techniques used for fracture treatment, such as the use of antiseptics and stabilizing wounds before transport, reduced the mortality rate to 20 percent by the war’s end.

Field Surgery Kit

Blood Transfusion

Doctors had experimented with blood transfusion since the 1600s. These early transfusions were from person to person, and sometimes didn’t work.  Doctors weren’t sure why until blood types were discovered in 1901. Six years later transfusions began being administered according to blood type. Matching blood types dramatically ensured the success of a transfusion.

In 1914, a successful anticoagulant was discovered. Finally, blood could be stored. The first successful blood transfusion of the war was performed in October 1915 by Canadian doctor Lawrence Bruce Robertson at a casualty clearing station.

Robertson published his experience in a British medical journal the following year. With the aid of fellow physicians, Robertson was able to persuade the Royal Army Medical Corps that blood transfusions needed to be given routinely.

The first blood bank was established in 1917 with blood successfully stored for 21 days.

Nurses see off soldiers after demobilization

Other Medical Care

Insane Asylums

Institutions to house the mentally ill began in the Middle Ages. The word “bedlam” is derived from the nearly 800-year-old Bethlem Royal Hospital, which is still in operation.

By the Victorian era, mental illness was accepted as a disease, and this meant it was treatable. What was considered a mental disorder, though, was not fully understood. People often were committed for conditions that had nothing to do with mental illness.

Reasons that could get a person committed included:

• Madness
• Epilepsy
• Learning disabilities
• Schizophrenia
• Being an unruly or opinionated woman
• Being dangerous or violent
• Vagrancy
• Depression
• Anxiety
• Being suicidal
• Mental exhaustion
• Giving birth to an illegitimate child
• Post-partum depression
• Alcoholism
• Shell shock

The number of people who were committed increased over the course of the 19th century. By the dawn of the 20th century, asylums were overcrowded and understaffed, despite laws that regulated how they should be run. Many patients were forgotten by their families, and abuse was common.

Treatments for mental illness included:

• Beatings
• Cold baths
• Withholding food
• Isolation
• Mercury pills
• Bleeding
• Inducing vomiting

Many patients didn’t survive their treatment and were buried on the asylum grounds.

Not all treatments, however, were inhumane. Patients at the better institutions were allowed some measure of autonomy and were rewarded for good behavior.

More effective treatments included:

• Art therapy
• Occupational therapy
• Hypnotism

In the late 19th century, reformers began advocating for change.

Former asylum patient Elizabeth Packard wrote three books on her experiences. She was committed by her husband, a minister, for disagreeing with him on theology in 1860.  Illinois state law stated a person must have a public hearing before he or she could be committed. The exception to the law was a wife; she could be committed by her husband without question. Packard was released three years later and eventually took her husband to court.  She later championed women’s rights and human rights.

Reporter Nellie Bly, considered a pioneer of investigative journalism, voluntarily committed herself in 1887 to investigate the treatment patients receive in asylums.  Her book Ten Days in a Mad-House is based on her New York World articles. Bly’s investigation led to an inquiry by a New York assistant district attorney as well as changes to the Department of Public Charities and Corrections which funded New York City’s asylums.

The work of these women and others, in addition to new medical discoveries, helped changed conditions at insane asylums.

Early 20th Century Dentistry

Dental schools got their start in the mid-19th century.  Before this, dentists had “day jobs” and performed rudimentary dentistry on the side.

French surgeon Pierre Fauchard is considered the father of modern dentistry.  He developed many treatments we take for granted, including braces and fillings, a century before the first dental schools opened.

Dental assisting became a profession in the 1880s.  In those days, assistants were called Ladies in Attendance.  Their jobs included not only assisting their employers but greeting patients and ordering supplies.

Dental hygienists were first employed in the late 1910s.

The 1870s witnessed the invention of the electric dental drills as well as the hydraulic dental chair.  Previously, drills were powered by hand, and drilling was a painful and time-consuming process.  There were attempts at drills powered by clockwork or pedals, but they were slow and noisy.

Dental X-rays were first used in 1896, only a year after the X-ray’s invention, allowing dentists more accurate diagnoses.

Forceps began being used for dental extractions by the early 20th century.  They replaced the dental key, an instrument that often broke teeth or injured the mouth.

The drug that is marketed as Novocain was invented in 1905.  A local anesthetic, the drug became popular with dentists as a replacement for another common dental drug – cocaine. Cocaine also was used as a local anesthetic and allowed teeth to be extracted without pain.  Physicians were aware of the addictive nature of cocaine by the early 20th century, but the drug was readily available.

Toothbrushes and Toothpaste

Toothpaste was introduced in the 1870s.  Fauchard had correctly identified sugar as a cause of tooth decay, and there was greater understanding that taking care of one’s teeth was beneficial.  Toothpaste takes its name from the first products, pastes sold in tins, jars and boxes.

Toothpaste sold in a tube, called dentifrice, appeared a decade later and was common by the early 20th century. Fluoride toothpastes began being sold in 1914, and all toothpastes contained soap until mid-century.

The earliest toothbrushes were a bone handle with animal-hair bristles.  Handles eventually were made of synthetic materials.

Toothpaste and toothbrushes were commonly sold in catalogues, such as Montgomery Ward.

Dental floss went on the market in the late 19th century.

Common Diseases

Rheumatic Fever

Rheumatic fever is a complication that can result from streptococcal infections such as strep throat and scarlet fever.  Contributing factors were poor eating habits and cold climate.

Symptoms include:

• Fever, can be mild or up to 104 degrees
• Join pain
• Joint swelling
• Fatigue
• Nosebleeds
• Rash
• Twitching limbs

• The fever was most common in children and young adults.

The fever was most common with young people and could reoccur, causing damage to the heart.  People who died of rheumatic fever generally did not die from the fever itself but from heart failure.

Antibiotics used to treat strep prevent the onset of the disease. Before the advent of antibiotics, all a family could do was keep a patient comfortable.

Today, rheumatic fever is categorized as an autoimmune disorder.  This is because the illness seems to run in families and often is accompanied by an auto-immune response.

The term rheumatism is a generic term that was extensively used in previous generations.  It was used to describe inflammation or stiffness of the joints, including arthritis.

Tetanus

Tetanus, also known as lockjaw, affected farmers and gardeners in the early 20th century.  Popular belief is that rust causes tetanus, but it doesn’t.  The bacteria that causes the disease is found in soil, manure, dust and saliva and enters the body through a cut or a burn.  The incubation period can last anywhere from three to 21 days.

Symptoms include:

• Muscles spasms or stiffness that begins in the jaw
• Fever
• Rapid heart beat
• Sweating
• Tightening of the vocal cords
• Difficulty breathing
• Muscle spasms that can last for several minutes and involve the entire body, some severe enough to break bones
• Headache
• Trouble swallowing

About 10 percent of cases are fatal. Starting in the 1890s, the disease was treated with an antitoxin. A vaccine was developed in the 1920s.

Tuberculosis

Tuberculosis, also known as consumption, was a common disease in the 19th century. So common, in fact, that sanatoriums were opened for treatment of the disease. These institutions exposed patients to fresh air and provided proper nutrition.  However many patients died.

Tuberculosis is caused by bacteria and is spread through coughs and sneezes. It most commonly affects the lungs. Public campaigns were organized to stop spitting and encouraged people to seek medical attention.

Symptoms include:

• Fever
• Blood tinged phlegm
• Weight loss
• Fatigue

Tuberculosis claimed the lives of many in the Victorian and Edwardian eras with a death rate of up to 50 percent for those showing symptoms.  Most people who have tuberculosis are asymptomatic.

Cholera

Cholera. The mere mention of the word was enough to cause fear in 19th century communities. Symptoms sometimes present themselves the same day a victim is exposed to the bacteria. The disease kills the healthy and weak alike.

Cholera is caused by a bacteria spread by food or water contaminated with feces. Basic sanitation and water purification can keep infection at bay.

Symptoms include:

• Diarrhea
• Vomiting
• Muscle pain
• Dehydration

During the 19th century, there were several cholera outbreaks. In 1854, Dr. John Snow was the first to track the spread of a disease and find its source. He correctly concluded that an outbreak in London was caused by a contaminated well. The pump caused 500 deaths in 10 days. Once the handle was removed and the pump could no longer be used, the number of new cases stopped.

Before the discovery of the cholera bacteria, people believed the disease was caused by bad vapors and often burned tar to cleanse the air.

A cholera vaccine was developed in 1892, and the final epidemic in the United States occurred in 1911.  Cholera had a death rate of up to 50 percent.

Typhoid Fever

Typhoid fever is a disease pandemic in areas without a clean water supply. It iis caused by bacteria and is spread through water or food contaminated by feces. In the Victorian era, before plumbing was common, and in the Edwardian era, in areas that still relied on outhouses, the disease was a daily threat.

Public health campaigns encouraging people to wash their hands helped reduce the number of cases. So did the gradual replacement of horse-drawn vehicles with the automobile, eventually eliminating fecal matter in the streets.

Typhoid had a death rate of up to 30 percent.

During World War I, soldiers were vaccinated against the disease, making it the first war in which deaths from combat were greater than those from disease.

Symptoms include:

• Fever
• Abdominal pain and digestive problems
• Rash
• Bloody nose
• Extreme fatigue

Typhoid Mary

Sometimes people carry the disease but are asymptomatic, meaning they can spread the disease to others without being aware of it. The best known of these carriers was Mary Mallon, otherwise known as Typhoid Mary. Mallon was a cook who was linked to 53 cases, including three deaths, and was forcibly detained twice under quarantine.

After the first detention, Mallon promised to stop working as a cook.  However, she found a job working for a hospital under an assumed name, and when health department officials confronted her, she fled.

Her second detention last more than 20 years until her death in 1938. Mallon died of pneumonia.

Pneumonia

At the turn-of-the-20th^–century, pneumonia was the leading cause of death, and 40 percent of those who died were under the age of five. Adults, of course, were not immune. Women were susceptible to pneumonia because their tight corsets made it difficult for their lungs to function properly.

Pneumonia is an inflammation of the lungs caused usually by bacteria or a virus. Those with underlying medical conditions or a weakened immune system are more vulnerable.

Symptoms include:

• Cough
• Fever
• Fatigue
• Difficulty breathing
• Chest pain
• Phlegm
• Fluid on the lungs
• Bluish skin tone

The lungs of a patient might experience what is called crackles, a distinctive sound.

Diphtheria had a death rate of up to 10 percent. Death rates for contagious diseases were dropping as the 20th century dawned thanks to sanitation, clean drinking water, hygiene, pest control and vaccination.

Diphtheria

Diphtheria is caused by bacteria and is spread from person to person. In the early 20^th century, diphtheria was among the top 10 causes of death. Death rates, however, were dropping. An antitoxin was developed in 1890 and was used on patients the following year. It worked by neutralizing the toxins produced by the Corynebacterium diphtheriae bacterium.

Sometimes the antitoxin, which was taken from horses, was contaminated and caused illness. This led to a push to regulate pharmaceuticals and also for the development of a vaccine.

Symptoms include:

• Coughing
• Fever
• Sore throat
• Swollen lymph nodes
• Headache
• A membrane covers throat

The membrane also can cover the esophagus and lungs. People who die of diphtheria are literally strangled to death by their own bodies. In the late 19^th century, tracheotomies began being used to help sufferers breathe.

Disease complications include heart damage.

Great Race for Mercy

In the winter of 1925, a diphtheria outbreak struck Nome, Alaska. The town was cut off from the rest of the territory by winter ice. The area’s only doctor was low on antitoxin because his expired supply had not been replenished before winter.

Several children grew ill, and a handful died. The area’s Native Americans had no natural resistance to the disease. It was feared many more would die. Nome needed more antitoxin or it would have an epidemic on its hands.

A telegram went out requesting antitoxin. The winter ice meant antitoxin could not be delivered via road or boat. It could only come one way – via sled dog. A relay of 20 sleds raced against time and the weather, but successfully delivered the serum on Feb. 20. The event is commemorated annually with the Iditarod Sled Dog Race.

Spanish Flu Pandemic of 1918

The Spanish Flu Pandemic of 1918 was one of the most devastating in human history. Despite the name, the virus did not originate in Spain. Spain was neutral in World War I.  As a consequence, its newspapers were not censored, and reporters spoke openly about the disease’s spread.

The pandemic began in spring 1918 and ended in summer 1919:

• The flu came in three waves. The first in the spring of 1918, the second in August and the third in autumn. The second two waves were more virulent than the first.
• Pregnant women had the highest death rate, up to 70 percent.
• People who contracted the flu during the 1890 pandemic were less affected by Spanish flu. Those who survived the first wave of Spanish flu also were immune to the second two waves.
• Every part of the globe was affected, even isolated islands.
• It is estimated up to 100 million people died globally, making the death toll higher than the war.
• It killed more people than Black Death in the Middle Ages.
• It is believed stress and malnutrition caused by the war contributed to the death toll.

Most patients passed away from secondary infections, particularly pneumonia.  Death came quickly, often within days or even hours, as the lungs filled with fluid and suffocated the victim to death.  The person’s skin would turn blue from lack of oxygen.

Makeshift hospitals were constructed in some areas to handle the influx of ill, but medical personnel soon became overwhelmed. Many doctors and nurses fell ill themselves.

The sheer number of ill and dead hampered society.  In many industries, there weren’t enough workers to keep businesses running.  Funeral homes, for example, were so understaffed they had difficulty finding people to bury the dead.

Places where a large number of people congregated, such as cinemas, schools and churches, were closed in an effort to curtail the disease’s spread.

People were encouraged to wear masks, and public-service ads advised the best ways to avoid spreading the disease.

In addition to the high pneumonia rates, the flu differed in other ways as well.

• It killed mostly healthy, young people.
• The cause of death was often the body’s overreaction to the virus.
• Usually ill people stay home, but on the Western and Eastern Fronts, healthy people stayed put while the ill were transported to hospitals. This exposed others to the virus.
• The death toll was 20 percent. In a typical year, the flu kills less than one percent of those affected.
• Entire families were wiped out.

The deadliest month in the pandemic was October 1918.  In many communities, residents violated quarantine when they poured into the streets to celebrate Armistice the following month. In that moment, joy overtook the fear of contagion.

Return to the reader’s guide.