The doctrine of staged treatment, developed a century ago, became the basis of a modern system of medical support for troops.
The First World War in its bloodshed and duration surpassed all the wars of the XIX century combined. This led to a sharp increase in combat losses. Unfortunately, our rich experience of that war has still been studied very little, in contrast to the countries of Western Europe and the United States. Archival materials are almost completely lost. But Russian military medicine entered the 20th century with significant achievements.
By the beginning of the new century, a decentralized multi-departmental system of medical care was formed in Russia. Along with state health care, it was involved in zemstvo and city governments, private and public organizations, and charitable institutions. There were factory, military, naval, insurance, prison and other forms of medical assistance.
In 1908-1915, the post of chairman of the Medical Council was held by an honorary life surgeon, an outstanding obstetrician-gynecologist, academician of the Imperial Military Medical Academy (IMMA) Georgy Ermolaevich Rein. He proposed to establish the Main Department of Health in Russia. Rhine's project met with resistance from the Pirogov Society and many leaders of rural medicine. However, thanks to the patronage of Nicholas II, Rein achieved a decision to separate the health care system from September 1916 into a special department.
The State Duma insisted on canceling the emperor's decision, and in February 1917 the academician withdrew his bill. Nevertheless, de facto, since September 1916, Georgy Rein was the first and only Minister of Health in pre-revolutionary Russia. As you know, the Bolsheviks six months after the October Revolution began the construction of Soviet health care also with the establishment of the corresponding People's Commissariat.
During the first year of the war, only the officer losses of the Russian army amounted to 60 thousand people, as a result of the 40 thousand pre-war cadres by this time almost no one remained. In September 1915, rare front-line regiments (three thousand soldiers each) had more than 12 officers. In anticipation of large losses and the most difficult tasks set by the war for the medical service, a decision is made to establish a single governing body. On September 3 (16), 1914, by order No. 568 for the military department, the Office of the Supreme Chief of the Sanitary and Evacuation Unit was created, headed by a member of the State Council, Adjutant General Prince Alexander Petrovich Oldenburgsky, endowed with the broadest rights and powers. The order read: “The supreme head of the sanitary and evacuation unit is the supreme head of all bodies, organizations, societies and persons of the sanitary and evacuation service both in the theater of operations and in the inner region of the empire … It unites all types of sanitary and evacuation activities in the state … His orders concerning this activity are carried out by all, without exception, by officials of all departments and by the entire population as the highest …"
Such powers of the Prince of Oldenburg, subject to their full implementation, ensured absolute unity in the management of military medicine, which was unprecedented. While in the theater of military operations, Alexander Petrovich was subordinate to the Supreme Commander-in-Chief, and outside the theater of operations - directly to the emperor. On September 20 (October 3), 1914, by order of the Supreme Commander-in-Chief No. 59, sanitary departments were formed at the headquarters of the armies, the chiefs of which were directly subordinate to the chief of staff of the army, and by specialty - to the chief of the sanitary unit of the front armies.
Having assumed his duties, the supreme chief of Russian military medicine personally got acquainted with the organization of the case on the ground, making a detour of the front, the rear area and the largest centers of the inner region located on the evacuation routes. The Prince of Oldenburg reported to the tsar in his report on September 3 (16), 1915: “The impression from the first detours turned out to be unfavorable. With a very complex organization, the matter was hampered mainly by the lack of proper unity among the leaders … Excessive multi-command, which was actually reduced to anarchy, formalism and a tendency to interdepartmental and personal friction hindered the establishment of proper interaction. In this regard, the prince decided, first of all, to achieve coordinated actions of his department, the Russian Red Cross Society and new public organizations that arose during the war - the All-Russian Zemstvo Union and the All-Russian Union of Cities.
Not being a doctor, the Prince of Oldenburg relied on his closest consultants, among whom were surgeons Roman Romanovich Vreden, Nikolai Aleksandrovich Velyaminov, Sergei Petrovich Fedorov, and other prominent figures of Russian medicine, when deciding fundamental issues. In the apparatus of the supreme chief of the sanitary and evacuation unit, there was a medical department, which included experienced military doctors. According to Velyaminov, the prince always responded extremely quickly to his advice on various issues of medical support for the troops. He carefully listened to the opinion of experts, summarizing their recommendations in the form of orders.
First aid
Underestimation of the scale of the war and combat losses led to the fact that in the first year there was an acute shortage of bed networks to accommodate a huge flow of wounded and sick evacuated from the front. By November 1 (14), 1915, the capacity of this network expanded. By the end of the war, the number of hospital beds exceeded a million and was quite sufficient. The average bed turnover is 70 days.
The bed network of the military medical department accounted for only 43.2 percent of the total capacity, and 56.8 percent fell to the share of the Red Cross and other public organizations. The distribution of beds between the theater of operations and the hinterland of the country turned out to be not entirely rational. Two-thirds were deployed in the rear and only one-third at the fronts, which predetermined the "evacuation at any cost" system that prevailed throughout the war.
The main stages of the medical evacuation of the wounded and sick were:
-forward dressing station, deployed by means of the regimental infirmary in the rear of the regiment, - providing first aid to the wounded, conducting surgical operations for health reasons, feeding the wounded and sick;
the main dressing post deployed by the division's dressing detachment behind the dressing posts as close to them as possible, but outside the sphere of fire (its removal, like the forward dressing detachment, from the front line was not regulated, but usually the forward detachments were deployed 1.5-5 kilometers from the line front, and the main ones - 3-6 kilometers from the forward dressing points) - the provision of urgent surgical and general medical care, temporary accommodation and care of the wounded before they are sent to the next stage. Sorting the wounded into four categories:
returned to service, following to the rear on foot, evacuated to medical institutions and non-transportable. The percentage of the wounded here being operated on, according to Nikolai Nilovich Burdenko, ranged from 1 to 7. Vladimir Andreevich Oppel and a number of other front-line surgeons insisted on a greater expansion of the operational and surgical activities of the main dressing points. In their opinion, the percentage of operability here could be raised to 20 with the strengthening of divisional dressing points at the expense of the forward detachments of the Red Cross and other public organizations. In practice, this has rarely been achieved;
- Divisional infirmaries, two of which were deployed in the rear for the wounded and sick who did not need long-term treatment, by the decision of the divisional doctor and commander - treatment for those who hope for recovery, surgical and general hospital care. Most often they were used to treat lightly wounded and sick;
- the head evacuation point deployed at the head railway station by order of the chief of the sanitary unit of the front armies (later the right to move them was given to the chiefs of the sanitary departments of the army headquarters); medical institutions of the rear area, referral of infectious patients according to the instructions of the chief of the sanitary unit of the armies.
Circumstances forced to form additional stages of medical evacuation:
- dressing and feeding points, organized in winter and with a significant length of evacuation routes, most often by forces and means of public organizations;
- army receivers deployed at railway stations and in nodes of unpaved evacuation routes and in the order of "improvisation" by means of military medical and public medical institutions in cases when the wounded and sick were evacuated from military formations to several railway stations that could not be provided with head evacuation points.
This general scheme for organizing the treatment and evacuation of the wounded and sick in different armies and fronts under various conditions of the combat and rear situation changed and, as a rule, was not fully maintained.
First aid was provided by a company paramedic. The search for the wounded and their removal from the battlefield, first aid and delivery to dressing points were assigned to regimental and divisional porters, the number of which was quite sufficient by state. In each regiment (16 companies) there were 128 of them (eight in a company), in four regiments - 512, in the bandaging detachment of the division - 200 people. Thus, the division had 712 porters, excluding the artillery brigade, where there were six, and two orderlies in each battery. Despite this, the timely and complete removal of the wounded was not always ensured, especially in heavy battles, under adverse terrain conditions and poor weather conditions. In such cases, the removal of the wounded was often delayed for several days. Large losses among the porters were made up with difficulty.
For the evacuation of the wounded and sick, the infantry division in the state relied on 146 two-wheelers (in the infantry regiment - 16). During the war, the number of standard horse-drawn ambulances was increased to 218, which made it possible to improve the transportation of victims on unpaved evacuation routes. By the beginning of the war, the automobile ambulance consisted of only two vehicles, but by July 1917 there were 58 military autoanitary detachments on the fronts, in which there were 1,154 ambulances. In addition, the fronts were served by 40 autoanitary detachments of public organizations with 497 vehicles. The pack medical transport was not prescribed by the mobilization plan and its formation began only in 1915, when it was urgently required to ensure the evacuation of the wounded and sick in the Caucasus mountains and the Carpathians. Created 24 pack medical transports (in January 1917, 12 of them were at the stage of formation).
The evacuation of the wounded and sick has reached an unusually large size (complete information about this is not available). From August 1914 to December 1916 alone, over five million sick and wounded officers and soldiers were delivered from the front to the rear medical and evacuation institutions, which amounted to almost 117 thousand people a month. Of the arrivals, two and a half million people (43, 7 percent) were sent to the inner regions, not counting those who left by direct transit trains. More than three million people were in hospitals in the rear areas until the final recovery. The mortality rate among soldiers here was 2.4 percent for the sick and 2.6 percent for the wounded; mortality among sick officers - 1.6 percent, among wounded - 2.1 percent. About 44 percent of the sick soldiers were returned to service, 46.5 percent of the wounded, about 68 percent of the sick officers, and 54 percent of the wounded.
On the fronts by February 1917, in addition to the Caucasian one, 195 mobile field hospitals and 411 reserve hospitals of the military medical department, as well as 76 field hospitals, 215 forward detachments and volunteers, 242 horse-drawn ambulances and 157 disinfection detachments of the ROKK and other public organizations functioned. In the inner region, medical and evacuation work was carried out by distribution and district points.
To ensure the evacuation by rail, the mobilization plan provided for the formation of 100 military ambulance trains. In fact, during the period of mobilization, only 46 were formed; by September 12 (25), 1914, there were 57 trains of the military department and 17 sanitary trains of public organizations. However, already at the beginning of 1915 there were more than 300 trains, and in December 1916 there were about 400 of them.
To send infectious patients, special sanitary trains were allocated, which unloaded infectious patients to infectious hospitals deployed in large cities of the front and inner regions, with a total capacity of 12 thousand beds. The ROKK was involved in the evacuation of the mentally ill; they were transported in specially equipped wagons. There were departments for the mentally ill in military hospitals and medical institutions of public organizations. Often, the mentally ill who arrived from the front were sent to civilian psychiatric hospitals.
On September 15 (28), 1917, there were the following number of regular places for the wounded and sick at the fronts: in the infirmaries of the formation - about 62 thousand, in the army region - over 145 thousand, at the head evacuation points - more than 248 thousand, in the inner region - 427 thousand, in total - about 883 thousand, not counting places in the teams of convalescents. If we take the size of the active army at that time for 6.5 million people, then the number of regular beds will be quite sufficient, because the annual casualty losses of the active army did not exceed 1.2 million people.
New challenges and major achievements
In 1917, the chief field health inspector of the Russian army, Nikolai Aleksandrovich Velyaminov, wrote instructions on organizing assistance to the wounded at the front. Based on the experience of the war, Vladimir Andreevich Oppel developed the doctrine of the staged treatment of the wounded and sick in the war, which became the starting point in the creation by Boris Konstantinovich Leonardov and Efim Ivanovich Smirnov of a staged treatment system with evacuation by appointment.
Oppel defined three main tasks of the medical service in the war: the return to service of the largest possible number of wounded in the shortest possible time, the maximum reduction in disability and the preservation of working capacity, and the preservation of the life of the largest number of wounded. The essence of staged treatment was formulated by Vladimir Oppel as follows: “A wounded person receives such a surgical aid whenever and wherever and when a need for such aid is found; the wounded man is evacuated to such a distance from the battle line, which is most beneficial for his health."
Efim Smirnov considered Oppel's concept as lifeless in a war. "In Opel's definition of staged treatment," wrote Smirnov, "there is surgery and competent surgery, there is a wounded man, but there is not a word about the war, about the combat situation, and this is the main thing." This shortcoming of Oppel's teachings was corrected later, but its essence is the close combination of evacuation with treatment, their merger into an indissoluble process formed the basis of the modern system of medical and evacuation support for troops.
The First World War put forward a number of fundamentally new tasks for military medicine in connection with the emergence of new means of armed struggle - chemical warfare agents, aviation and tanks. On May 18 (31), 1915, the Germans used phosgene for the first time in some areas of the North-Western and Western Fronts. More than 65 thousand people suffered from poisonous gases (among them was the writer Mikhail Zoshchenko). More than six thousand of the victims died in the military area. In the 12 largest gas attacks, the total death rate of victims has reached about 20 percent. The initial means of protection against poisonous gases were bonfires, which lifted them up, pieces of cloth moistened with water and applied to the nose and mouth. The production of protective dressings impregnated with hyposulfite was quickly established. In June 1915, the Prince of Oldenburg reported: "Only about eight million armbands have been sent to the army."
The position of the medical personnel of the active army during the first gas attacks was truly desperate. Doctors, paramedics and orderlies did not know first aid measures and did not have any means of protection. The removal of the victims from the battlefield during the gas attack, their rescue seemed almost impossible. Any attempts led to the death of the orderlies.
The production of more advanced protective equipment was slow. The industry committee selected a filter gas mask based on the use of activated carbon from several samples. The first batches of these gas masks went to supply the officers and non-commissioned officers, then the soldiers also received them. Subsequently, the poisoned were carried from the battlefield by divisional porters to special shelters, medical assistance was provided to them at regimental and main dressing points, in divisions' infirmaries and hospitals. During the evacuation, the victims usually changed their clothes and underwear.
The sanitary-epidemic state of the Russian army during the war years was relatively safe due to the rather rational organization of anti-epidemic measures. From August 1914 to September 1917, the army suffered from typhoid fever, dysentery, cholera, typhus, relapsing fever and natural smallpox. None of the acutely infectious diseases became threatening. Russia in this war did not know major epidemics of infectious diseases either in the army or among the population. Of the non-communicable diseases, scurvy was the most common. Over the years of the war, over 300 thousand people were hospitalized with this diagnosis.
Accurate information about the combat sanitary losses of the Russian army during the First World War is not meant due to the inconsistency of the reporting data during the period of the spontaneous mobilization of the army and the Civil War. On the day of mobilization, the total strength of the Russian army was about one and a half million people. In total, up to February 1917, about 15 million people were mobilized. The cash composition of the active army on September 1 (13), 1917 was determined by the figure of 6 million 372 thousand people, in addition to this, there were 2 million 678 thousand in public organizations serving the army.
The main achievements of Russian military medicine during the First World War can be considered:
-creation of mobile surgical teams, groups and other types of mobile reserves;
-increase in surgical activity at the main dressing points;
-the emergence of specialized medical care (eye teams, departments and hospitals for maxillofacial wounds, medical institutions for lightly wounded);
-the rapid development in the army of the road ambulance transport;
- the origin and development of the army level of the medical service with receivers on the railway and in the nodes of unpaved evacuation routes;
-creation of a well-equipped railway ambulance transport;
-the introduction of compulsory vaccinations against typhoid fever and cholera, as well as a marching disinfection chamber and laboratory equipment at the front;
-creation of an extensive network of isolation and checkpoints and observation points on the railway and waterways of evacuation;
- the formation of infectious diseases hospitals - barriers on the routes of communication from the spread of the epidemic;
-organization of bath and laundry service for troops on the fronts (during the positional period of the war);
- the origin and development of means of protection against chemical warfare agents;
-creation of movable stocks of medical equipment in divisions and corps;
-relatively widespread use of X-ray units in the field;
-development of the doctrine of the staged treatment of the wounded and sick in war conditions.
Unfortunately, views on World War I changed significantly during the Soviet period. From domestic and fair it has turned into an imperialist one. For many decades, everything was done to destroy the memory of her in the people's minds. Meanwhile, more than a quarter of the casualties of the killed imperial Germany were received in battles with the Russian army.
