Medicine During World War 1 PDF

Medicine Through Time: The British Sector of the Western Front: 1914‐1918 Learning Outcomes 1. How developments in medicine in the early 20th century contributed to treatment of soldiers 2. Understanding the types of injuries that were experienced by soldiers...

Medicine Through Time: The British Sector of the Western Front: 1914‐1918 Learning Outcomes 1. How developments in medicine in the early 20th century contributed to treatment of soldiers 2. Understanding the types of injuries that were experienced by soldiers in the British sector 3. Understanding of the different developments in surgery and medicine used to treat soldiers 1  The First World War: Western Front Britain declared war on Germany on August 4th 1914 when Germany invaded France through Belgium. The British government sent the B.E.F (British Expeditionary Force) to northern France to try and stop the German advance. By the end of 1914, much of Belgium and northern France had been occupied by the Germans. After the initial fighting, both the British and Germans pulled back their forces and this is when ‘Trench Warfare’ began as both the British and Germans pulled back their forces. It became a defensive war using trenches with some offensive attempts to capture the enemy trenches and land. Between 1914 and 1918, most of the fighting done on the Western Front (France/Belgium) was trench warfare. The British sector (in red) includes the strategic areas of Ypres, Arras, Albert and the River Somme and many of the largest battles in the war were fought in this sector. The medical impact of WW1 There were 2.7 million casualties in the British sector of the Western Front during the war. 1⁄4 (700,000) of these casualties were not seen by medical services because they were killed/prisoners. The remaining 2 million were treated by medical services in France or back in England. Of those treated, 5.6% (150,000) died from their wounds. Therefore the vast majority of those treated survived their wounds and illnesses: a testament to the successes of the medical care during WW1 (of course, many of these might be killed later in fighting). Timeline 1914 ‐1918 Sept 1914: WW1 Begins Oct 1914 1st Battle of Ypres Oct 1914 Motor Ambulances sent to the front. Apr 1915 2nd Battle of Ypres – 1st use of gas Key Events of the Western Front 1915 Lawrence Robertson pioneers use of blood transfusions Apr 1915 Battle of Hill 60 1915 First gas masks introduced 1915 Brodie Helmets introduced 1915 Richard Lewisohn stops blood clotting Dec 1915 Thomas Splint taught to medical practitioners 1915 Richard Weil discovers how to store blood for 2 days 1916 Francis Rous and James Turner discover how to store blood for 4 weeks Jan 1916 FANYs allowed to drive ambulances Jul 1916 Battle of the Somme 1916 Tunnels dug at Arras Jul 1917 3rd Battle of Ypres 1917 Battle of Arras 1917 Carrel‐Dakin method agreed as best method to stop Oct 1917 Battle of Cambrai infection 1917 Transfusions widely used in CCS’s Aug 1917 Gillies opens Queen’s Hospital for plastic surgery 1918 Delousing Stations set up 2 Nov 1918: WW1 Ends  The Four Key British Battles in WW1 The Ypres Salient 1914‐15 The ‘Salient’ was an 1914: The First Battle of Ypres area under British In autumn 1914, the Germans attacked the British control surrounded by positions around east and north east of Ypres. Britain Germans on 3 sides. kept Ypres but lost 50,000 troops. The Germans held the Hill 60: Mines high ground, whilst the The Germans held ‘Hill 60’ south‐east of Ypres which British were in the low, gave them the height advantage over the British. In wetter areas. April 1915, British soldiers mined underneath the hill and literally blew up the German defences so the British were able to capture it. The area surrounding the 1915; The Second Battle of Ypres town of Ypres was the Between April to May 1915 the second battle started. It scene of two major battles, was the first time the Germans used Chlorine Gas on the the First and Second Battle Western Front. British losses were 59,000 men and the of Ypres, as the Germans Germans moved 2 miles closer to the town of Ypres. pushed to take Ypres and get to the Channel ports. The British finally pushed back the Germans in the rainy 1917 battle of Passchendaele. It was a costly victory, with 245,000 casualties. The Somme, 1916 Largest British attack in WW1 which lasted from July to Huge casualties on both sides but especially for the British, November, 1916. It aimed to take ground from the with 57,000 casualties and 20,000 dead on first day alone. Germans. The battle was significant for two reasons, which would help contribute to more casualties in the war: First use of tanks – used but not effective yet. Use of creeping barrage – artillery bombardment that moved towards the German trench as the British approached it. Arras, 1917 The allies (Britain, New Zealand & Canada) built over 2.5 miles of tunnels as shelter to prepare to attack the German line. It was a new tactic used by the Initially the attack in April 1917 was a British. success as the British advanced 8 The tunnels could shelter 25,000 men, contained miles into enemy territory. accommodation, a railway, water and electrical However, by May 1917 the attack supplies and a hospital big enough for 700 beds. had virtually stopped with the Allies suffering 160,000 casualties. Cambrai, 1917 First large scale attack However, the Germans by British tanks to counter‐ attacked after the attack the German front British attack stopped. line. Over 450 tanks were used. All land taken by the No artillery bombardment used, which surprised the British was lost. Germans. The British attack succeeded at first, helped 3 by tanks.  The Trench System Trenches were first dug by the British and French Armies in Northern France in 1914. The aim of trenches was to act as a barrier to stop the rapid advance of the German army. At first trenches As the war went on, trenches became part of the were temporary ‘stalemate’, used to defend & launch attacks. and built quickly using sandbags Trenches became more complex with bunkers, and shovels in drainage, hospitals and accommodation. Important! existing ditches. Trenches were different Trenches also became more dangerous with from one place to another They would need machine guns, concrete bunkers and barbed across the Western Front. to be constantly wire used as defenses. repaired due to So not every soldiers had the the weather and With this evolved new weapons such as tanks, same experience in the constant gas, machine guns, artillery and airplanes to fight trenches. bombing. on this terrain. Cross Section of a trench This is a typical British trench on the Western Front. Key Features Firebay Where troops did their shooting, they would be protected by sandbags Duckboard To prevent soldiers from standing in water. Possibly preventing trench‐foot Firestep Allows the soldiers to fire towards the other trench. Trenches were 2.5 m deep Parapet Low protective wall Ammunitio Area in which ammo was kept near the n shelf firestep Dugout Area dug into side of the trench where men could take protective cover The Trench System This shows the main features of the Trench System from the Western Front, they were often quite different but they were mostly laid out this way. No Man's Land was between the two trenches, punctuated by shell holes, death and destruction. Frontline Trench Where attacks were made Support Trench from, the most dangerous 80m behind the frontline area. Only 15% of a trench. Troops would soldiers time was here. retreat here if under attack. 10% of time here. Reserve Trench 100m behind the support trench. Where troops Communications Trench would be mobilised to Trenches that run counter attack the enemy between other trenches, if they captured the front linking them together. line. 30% of time here. 45% of a soldiers time was actually spent away from the trenches. The Trench System Advantages: Disadvantages: Simple to make and cheap to build Hard to attack as had to cross no man's land (the area between the two trenches) Easy to defend with few men using which has been destroyed by shell fire and was a mass of mud and craters barbed wire, artillery, concrete Trenches were very dirty and unhygienic as there was no running water or flushing bunkers and machine gun fire toilets. Provided some shelter/protection In summer sewage, dead bodies & heat led to horrific smell and disease everywhere. 4 In winter bad weather led to flooding and frostbite (6000 cases in December 1914).  Conditions on the Western Front The constant bombing and shelling often left the Western Front a landscape of craters, mud and water. All roads had also been destroyed, making it very difficult to cross and transport the wounded. This caused issues in both transporting wounded men away from the front line and communication. Key Problems on the Western Front No Man's Land Trench System The land was dangerous and the The trenches were clogged up with wounded could only be collected at men and equipment. This made it hard night. for stretchers to manoeuvre whilst under fire. The destroyed terrain was muddy, contained stagnant water filled The numbers of wounded also craters with rotting corpses and overwhelmed the medical unexploded munitions and chemicals system. waste. Transport Problems and Solutions If you were injured you needed to be moved ASAP away from the trenches where they could provide better medical treatment and cover from shelling. 4 man stretcher bearers would carry the wounded away from the front line once they were in a stable condition. They carried the wounded during day and night, often under enemy fire. The faster a man could be evacuated and treated, the greater the chance of survival. Horse‐ Drawn Ambulance Wagons Motor Ambulances Originally the decision was made not to News of this reached Britain and The Times send motor ambulances to the frontline: appealed for donations. As a result enough money they used horse‐drawn instead. for 512 ambulance was raised. By October 1914 the first motor ambulances reached the frontline sent by the Red Cross. Solution However, the worse the terrain the less effective This was a mistake as horse‐drawn motor ambulances were. Therefore, horses carriages could not cope with the number continued to be used, sometimes up to 6 in of wounded, whilst the shaky transport horrendous conditions. often made injuries worse. A lack of ambulances meant many men were left to Train, barge and ship ambulances die. To reach the final destination, Base Hospitals on the French Coast, the Royal Army Medical Corps (RAMC) used specially designed ambulance trains from November 1914. Stretchers could fit down the side of the carriage and some contained operating theatres, hundreds were evacuated. However, they were criticised for damaging the war effort as trains were blocking supply routes in France and Belgium. As a result, canals were used. These were comfortable, slow but 5 could often transport the wounded straight to ships back to Britain.  Medical Problems on the Western Front. Trench Foot Trench foot was a major problem caused by standing in waterlogged trenches with no change of boots or socks. In the first stage, the feet would swell, go numb and the skin would turn red or blue. The condition could get worse quickly, leading to gangrene and amputation of limbs! In the cold, wet winter of 1914‐15 cases of trench foot were serious. The 27th Division of the British army experienced 12,000 cases of trench foot. Attempted Solutions To prevent the impact of trench foot, medical Attempts were made to pump out officers ordered soldiers should carry 3 pairs of trenches to reduce waterlogging socks and change them twice a day. They were and add duckboards, but constantly also encouraged to rub whale oil into their feet. bombing made this hard Trench Fever (PLO) Flu-like symptoms with high temperature, headache and aching muscles which was spread by lice. Men could be ill for up to a month. Estimated half a million men on the Western front were affected by trench Fever. Attempted Solutions Delousing stations were set up on the front; clothes were disinfected, men were bathed and sprayed with chemicals to prevent lice. As a result of this, there was a decline in the numbers experiencing the condition. Shell Shock Symptoms included tiredness, headaches, nightmares, loss of speech, uncontrollable shaking and complete mental breakdown. It is estimated 80,000 British troops experienced shellshock Called NYD,N (Not Yet Diagnosed, Nervous) as a code by the army for shellshock. Attempted Solutions This condition was not understood at the time, some soldiers who experienced shell shock were accused of cowardice and any were punished, some even shot. Craiglockhart Hospital in Edinburgh was set up and dealt with 2,000 sufferers. New Wounds Gas Attacks The First World War introduced a wide range of wounds for medical staff Gas caused great panic as soldiers were to attend to. For example, high explosive shells and shrapnel (fragments unprepared for it. It wasn’t a major cause of of metal) were responsible for 58% of wounds whilst bullets were death. Only 6000 soldiers died during responsible for another 39%. 60% of shrapnel wounds WW1. were to the arms and legs. There were 3 types used in the war: A common treatment was Chlorine: Ypres 1915 amputation. Over 41,000 Caused death by suffocation. Before The high number of head had their limbs gas masks, soldiers soak cotton pads wounds led to the steel amputated. in urine and pressed them to their faces Brodie Helmet being introduced. It reduced fatal Phosgene 1915 head wounds by 80%. All Used at Ypres. Faster acting soldiers were given it. than chlorine, killing an exposed person within 2 days. Gas gangrene could not be cured. It Mustard Gas 1917 Most injuries often got could often kill in a Odourless gas that worked infected due to the day. within 12 hours. Caused internal bacteria in the soil, and external blisters and could causing gangrene. The pass through clothing to burn skin. Artillery, gun fire and bombs impact of gangrene was Solution could break bones, pierce reduced by tetanus British soldiers were given Gas masks vital organs and destroy injections from the end of 1914. tissue. Many never made it from July 1915, which became more 6 to hospital. sophisticated over time.  Medical Progress up to WW1 In the years before WW1 many breakthroughs had occurred in medicine. These were the foundation for medical treatment and advancements in the British sector of the Western Front. These included aseptic surgery, x‐rays and blood transfusions. X‐Rays Blood Transfusions X‐rays were discovered by accident in In the 19th and 20th centuries, blood loss was a huge problem 1895 by Wilhelm Roentgen. in surgical operations that had got more complex. Blood loss often caused shock and death, which limited progress. As early as 1896 radiology (x‐ray) James Blundell did the first experiments departments were set up, like on human to human blood transfusions Birmingham General Hospital where Dr. John Hall‐Edwards was one of the first doctors to use x-rays to locate a needle He developed techniques/equipment in a woman's hand. so that transfusions were possible by the start of WW1. Problems with x‐rays Also, Karl Landsteiner discovered blood Health risks from x‐rays were not understood. Radiation groups in 1901, e.g. A,B,AB and O, and O levels were 1,500 times stronger than those today, so was the universal blood group. patients could lose hair or suffer burns. This meant donor and patients could be matched. Roentgen's x‐ray machine contained a glass tube which was However there was a main problem: fragile. X-rays took about 90 minutes to complete, a long time. Blood could not yet be stored so had to be used straight Big x‐ray machines were being developed but immovable. away and the donor of the blood had to be connected directly to the recipient of the blood. Aseptic Surgery Joseph Lister’s methods has laid the foundations for aseptic surgery after Louis Pasteur’s publication of his germ theory in 1861 and by 1900 most operations were carried out using these methods. It had a huge impact on reducing infection in surgery Aseptic Surgery included All medical equipment was steam sterilised whilst the room was air sterilised to kill germs All medical staff had to hash before entering the surgery and wore clean gowns and rubber gloves 7 @mrthorntonteach The Evacuation Route Because of the large number of casualties, the RAMC needed a quick and efficient system to get the wounded from the frontlines to a safe area where they could be treated. This system was called ‘The Chain of Evacuation’ The chain of evacuation There were four main stages of the chain of evacuation but the order of these stages was not necessarily the same for each casualty. The walking wounded would make their way to the RAP or they would be carried by stretcher bearers. Stretcher bearers would carry basic medical supplies and there were usually 16 men per battalion (1000 soldiers), so there were not enough. 1. RAP: Regimental Aid Post Located within 200 metres of the frontline, in communication trenches. The purpose of the RAP was to give immediate first aid and get as many men back to the front as quickly as possible. They could not deal with serious injuries – these were sent to ADS. Led by a Regimental Medical Officer with some stretcher bearers. 2. Dressing stations (ADS and MDS) There was usually an Advanced Dressing Station (ADS) within 400m of the RAP and a Main Dressing Station (MDS) about half a mile away, usually in tents or bunker to provide protection from enemy shelling. They could only look after men for a week. They were staffed by 10 medical officers, stretcher bearers and nurses too. In total, they could deal with about 150 men but often in battles like Ypres (1917) they dealt with 1,000 causalities in 2 days at Hooge. 3.Casualty Clearing Stations ( CCS) Around 7 miles away from the front, close to the railway and for ambulance wagons. They had several doctors, contained operating theatres, x-ray machines and wards. They could deal with up to 1,000 casualties at a time. At the Third Battle of Ypres the 24 CCS treated over 200,000 causalities with only 4% dying. The CCS treated the most critical injuries close to the front. This was important as it would stop gangrene infection and so men could be sent back to the front. The CCS had a triage system to assess the wounded into three categories: The walking wounded ‐ patch them up and send back to the front. Those in need of hospital treatment ‐ move to a Base Hospital. No chance of recover y‐ make them comfortable. 4. Base Hospitals Situated near the ports on the French/Belgian coast on trainlines and canals. They had operating theatres, x-ray machines, laboratories and even specialist centres for treating gas poisoning and head wounds. These specialist wards allowed doctors to become experts in treatment of particular wounds. They could treat upto 2,500 patients at once. From here, most patients were sent back to England, those with ‘Blighty Wounds’. As the war went on, the efficiency of the system improved significantly and by the end of the war, 67% of 8 men that visited to the CCS were sent back the front again.  Arras Underground Hospital In 1916, tunnelling began under the town of Arras with a fully working hospital built in 800m of tunnels. It was nicknamed Thompson's Cave after an RAMC officer. It was essentially a Dressing Station close to the front, where soldiers would move through the chain of evacuation. The hospital included: waiting rooms for the wounded 700 spaces for stretchers to be used as beds an operating theatre a mortuary electricity and a water supply The hospital was abandoned during the Battle of Arras, 1917 when it’s water supply was destroyed by a shell. The role of the RAMC and FANY The Royal Army Medical Core (RAMC) was the The First Aid Nursing Yeomanry (FANY) branch of the army responsible for medical care. was the first women's voluntary It organised and provided medical treatment to organisation to send volunteers to the the wounded and sick whilst being responsible Western Front. for keeping men healthy. The first 6 women went in 1914 and over 500 women volunteered to provide frontline medical support. Throughout the war, its numbers FANY helped by driving ambulances, driving supplies to increased due to amount of wounded. the frontline and setting up a mobile bath units that In 1914, there were 9,000 men and could bathe up to 40 men an hour! by 1918 they had 113,000 who were One unit ran the Calais ambulance doctors, stretcher bearers etc unit, with 22 drivers and 12 Well trained nurses from Queen ambulances. Alexandria were allowed to join, but only 300 of them in 1914. By 1918, there FANY paved the way for VAD were 10,000 and many volunteer cooks, (Volunteer Aid Detachment) nurses cleaners and washers. to help medical services. 9  New Techniques in the Treatment of Wounds Major problem for the RAMC Amputation was dealing with infections If antibiotics or wound excisions failed to stop the spread of caused by gas gangrene. infection, the only way left was the amputation of limbs. By 1918, over 240,000 men had lost limbs to simply prevent their death. Wound excision or debridement This was cutting away the dead, damaged and infected tissue from around the wound to reduce infection. This needed to be done as quickly as possible to prevent infection spreading. All shell/bullet fragments were also removed It was not possible to perform After the excision the wound needed to be closed with aseptic surgery in the Dressing stitches, often antiseptics were used to kill infection. Stations and Casualty Clearing The Carrel‐Dakin method Stations for two reasons: 1. The contaminated Antiseptics such as carbolic lotion were inefficient when conditions treating gas gangrene. 2. The large number of By 1917, the Carrel‐ Dakin method was the most effective wounded men solution. This involved putting sterilised salt solution in a New methods had to be found wound through a tube. to match the problems facing The solution only lasted for 6 hours and had to made as soon medics on the Western Front. as it was needed. This was a problem if large numbers of soldiers needed treatment. Source A From the diary of B. C. Jones, 1915‐16. Jones served with the Royal Field Artillery in France until 1915. 7 December. A German shell hit the dugout of our telephone pit I remembered no more until I woke up in Bethune Casualty Clearing Station Number 33, where I find I have been severely wounded. Left hand blown off, left arm ripped up 12 inches. Scalp wound 6 inches wound on over side of knee 5 inches 9 December. Operation on upper arm for gangrene successful) 12 December. I remain here for 8 days then removed to St Omer by hospital barge very comfortable. I am then removed by train to Etaples. I am sent to England on the Hospital Ship. Return to Nottingham where I am in bed until the end of February. 3 June 1916. I am eventually transferred to Brighton where I am operated on and re‐amputated. Awaiting Roehampton for artificial limb The Thomas Splint In 1914/1915 men with a gunshot or shrapnel wound in the leg would have a very small chance of survival (20%). The current splint that was used to secure the leg did not work. It did not keep the leg straight so by the time injured soldiers reached the Casualty Clearing Station, it caused blood loss, shock, gangrene and usually amputation if they survived! Hugh Thomas invented the Thomas Splint, which was tested in a hospital in London. This split kept the leg straight so the bone healed in the correct position. From December 1915, medical practitioners on the front were trained in on how to use the Thomas Splint. Survival rates from this type of wound increased from 20‐80%. 10  New Techniques in the Treatment of Wounds Use of mobile X‐ray units X‐rays were used from the start of the war. They were mainly used to show shrapnel and bullets. If they were removed this would help stop infection. There were a number of weaknesses: Two x‐rays would be taken from X‐ rays could not detect all objects in the body, different angles and this would such as fragments of clothing in the wound. help the surgeon identify the location and shape of the The length of time it took to perform an x‐ray. shrapnel, making it easier to Tubes in the x‐ray overheated quickly, meaning extract. it could be only used once an hour. To combat 6 mobile vans were used this, three machines were used in rotation. throughout the British sector of The mobile vans took a while to set up and the the Western Front, called ‘Petit picture quality was poorer than in Base Curies’ after Marie Curie who Hospitals but they could still see shrapnel. created them. Blood Transfusions The Blood Bank at Cambrai In the British Sector blood transfusions were introduced by Due to the identification of different blood groups and the Lawrence Robertson in 1915 in the base hospital at Boulogne. use of type O as a universal donor there was less risk of using the wrong blood type during transfusions. He used the human to human method to There were still problems of there not being enough blood prevent shock of as it could not be stored. blood loss in As the war continued, some advances were made: casualties. Many In 1915, Richard Lewisohn found that by injured soldiers adding sodium citrate to blood stopped it recovered using this clotting so it could be stored. method. In 1916, Francis Rous and James Turner By 1917 blood transfusions were being carried out in the found that adding a citrate glucose solution Causality Cleaning Stations because they had been so to the blood meant it could be kept successful at the base hospitals. refrigerated up to 4 weeks. Geoffrey Keynes, doctor and lieutenant in the RAMC In preparation for the Battle of Cambrai, 1917, Oswald designed a portable blood Robertson stored 22 units of blood in the first ‘blood depot’. transfusion kit that was used 20 Canadians were treated using the blood, 11 survived. to provide blood transfusions closer to the frontline. This was first time blood was used to treat soldiers in shock and it showed This kit could store blood which could be used to take blood its potential to save lives. closer to the front line, meaning soldiers received blood sooner, stopping their bodies going into shock. Blood at CCS’s cold not be used to make a huge difference to the survival From 1915, Keynes was using his kit across the Western Front in of those injured on the frontline. Casualty Clearing Stations on the front. 11  New Techniques in the Treatment of Wounds Increase in head injuries Approximately 20% of all injuries in the Western front were to the head, neck and face. As the war went on new methods of treatment for head injuries were developed such as ssurgery to the eye, face, ear, nose and throat, and brain and plastic surgery. Brain Surgery Plastic Surgery Injuries to the brain were almost always fatal at the start A New Zealand ear, nose and throat of the war because: surgery, Harold Gillies developed the very few doctors had experience of neurosurgery use of plastic surgery during the war. before the war. infection in the head was common and it was difficult Gillies was interested in how to replace to move men through the chain of evacuation. and restore those parts of the face that had been destroyed. An American neurosurgeon called He devised new operations to Harvey Cushing developed new overcome problems: techniques. Delicate surgery could not be He experimented with use of completed in France, so Queen's magnets to remove metal Hospital in Kent opened in 1917 fragments from the brain. Using skin grafts (taking skin from He also used a local anaesthetic one area to graft onto the wounded (patient awake but wounded area) area numb) instead of a general Using jaw splints, wiring and metal anaesthetic (patient asleep) to replacement cheeks for facial avoid brain swelling. reconstruction Cushing operated on 45 patients in 1917 and 71% After the Battle of the survived, compared to the usual survival rate of 50%. Somme in 1916, Gillies personally dealt with Improving experience and observations of different about 2,000 cases of facial patients quickly led to improvements in treatments. damage. By 1915, 7 hospitals in France specialised in plastic surgery, especially head injuries. In total, over 12,000 plastic surgery operations were carried out throughout the war. Observation New Method Men who were Some Casualty Clearing Stations operated on quickly became specialist brain surgery were more likely to centres. survive. During the Third Battle of Ypres, all head injuries went to the CCS at Mendinghem. It was dangerous to Patients would stay at the CCS move men quickly for three weeks after surgery. after an operation. Injuries may be All head wounds would be hiding more severe carefully examined. injuries. There was a move from ether and chloroform anæsthetics to gas and oxygen which was safer and gave better results. 12  Sources which could be used to follow up information Type of Source What can be learnt from this type of source? National Army Service Records for Dates of service; where soldiers fought; record of wounds, individual soldiers treatments and hospitals admitted to, discharge records, (NB many were destroyed during death record. a WWII bombing raid but many survive and are available from the National Archives) Pension record cards (currently Details of war related wounds, sickness and injuries and post‐ being digitised) war medical board results. National newspaper reports Battles, number of injuries, deaths etc. recorded, eye‐witness accounts, government statistics – should be fair but may be one‐sided. Propaganda often published as fact. Censorship relaxed during war. Government reports on aspects Departmental overview of aspects of the war – spending on of the war munitions, problems with transportation etc. Medical articles/journals by Although BMJ is produced for medical professionals it doctors and nurses who took part provides an insight in the medical care of soldiers e.g. articles in the war e.g. British Medical like ‘Head injuries in War’, ‘Some notes on Trench Fever’. Journal Recollections of the work undertaken – injuries of soldiers, conditions, chain of evacuation, new techniques and technology etc. Personal accounts of medical Often emotive accounts – detailing feelings and thoughts as treatments by soldiers, doctors, well as facts. Only give one person’s view of events or a nurses or others who were snapshot of what was happening at one particular time or involved e.g. letters, diaries place in the war. Photographs Show images of what is happening at that exact moment in time although could be staged and not necessarily typical of conditions across the Western Front or throughout the war. Hospital/RAMC records Date of admittance, records of injuries and care given, discharge notes, death records, new techniques attempted. Army statistics Numbers fighting in each battle, killed or injured. 13