Until the final big push, the First World War (1914–1918) was characterized by heavy casualties in return for negligible gains. This resulted from the shocking novelty of institutionalized trench warfare during the first 2 years of war as a target for the industrialized use of heavy artillery, and the tactic of unprotected infantry against entrenched machine guns as on the Somme, on 1 July 1916, where the British Army suffered its greatest losses until the fall of Singapore in the Second World War. However, there were medical advances made during the war, and the wounded soldiers in 1918 received much better care than in previous wars .
The purpose of this paper is to investigate whether anaesthesia as a speciality benefited in its development from the First World War, and if so, how. Before the war, anaesthesia was an unstructured speciality, practiced by a few full-time anaesthetists. Away from the main teaching centres, anaesthetics were administered by General Practitioners. In general, the full-time anaesthetists gave their hospital services free. They made their living from private practice, relying on the surgeons for their work. Hence, portability of apparatus was essential, and there was little incentive for other developments. Medical students were taught enough about anaesthetics to enable them to get by. Anything more was learned by trial and error. The situation was well summarized by Charles Hadfield, who on looking back on this time when he was a medical student at St Bartholomew's Hospital London, revealed that ‘Anaesthesia was in a static condition, was tactically assumed to have reached its zenith, and no further improvements were expected or even sought' . In many ways, anaesthesia required further stimulation and evolution similar to that which the Crimean and American Civil Wars had brought to anaesthesia in the second half of the nineteenth century [3-6].
The subject will be considered under five heads: the organization of medical services, the training of specialist anaesthetists, the search for appropriate anaesthetic techniques, the extension of the role of the anaesthetist and the development of resuscitative methods, and the aftermath. This study will consider only the Allied armies at the Western Front, since the majority of historical information and post-war developments derive from this area.
The organization of medical services
The increased proficiency of weaponry in the First World War caused the deaths of 780 000 men from the Allied armies, and over 2 000 000 were wounded . Therefore, the need to evacuate and treat an unprecedented number of Allied casualties required changes in the earlier processes of evacuation that relied on regimental stretcher-bearers, field ambulances, and field or general hospitals. Consequently, an enlarged, more effective, and now classical system was developed. Regimental and field ambulance stretcher-bearers transported the wounded to advance dressing stations (ADSs), from where field ambulances carried them to main dressing stations (MDSs). After passing through the MDS, transport took the soldier to a casualty clearing station (CCS), from where the eventual destination was the general hospital, some distance from the fighting . The CCS, however, was the key, where up to 1000 wounded men could undergo essential nursing and surgical care at any one time . This was provided by a medical team made up of six medical officers: a surgical specialist, a second surgeon, an officer in charge of the medical cases and three other medical officers . One of the medical officers was called the ‘anaesthetist', although he may have not witnessed surgery since medical school [9,10]. The creation of such a position was to be vital in securing the opportunity for specialist anaesthesia to grow in the war.
The need for military anaesthetists in the crowded CCSs forced anaesthesia training to progress in the European contingent of the Allied armies. As the war advanced, so did the workload of the CCS: from 1915 to 1917, the percentage of operations performed in CCSs during quiet spells increased from 15% to 50%, and in heavy periods from 5% to 30% . At the Battle of the Somme, for example, some 14 000 casualties moved through the CCSs on the first day, and CCS number 29 at Gézaincourt alone received 11 186 wounded soldiers in the first 3 days of conflict . This presence of casualties required the ‘anaesthetists' to become sufficiently proficient and safe, something which self-education in the CCSs could not provide. On realizing the incompatibility of this with the workload, Captain Arthur Guedel (1883–1956), an American anaesthetist who arrived at the Western Front with the American Expeditionary Force prior to America's official entry, stated: ‘A system of suggestions and instructions in the matter of surgical anaesthesia would go far toward saving money, time and life' . Consequently, he set up schools in Chaumont and Contrexville for medical officers and other students awaiting placements. With his genius for simplification, he trained the students in airway management, and the monitoring of depth of anaesthesia using his chart board description of the signs and stages of anaesthesia. Then, to ensure his instruction was followed in practice, he would rapidly dash between hospitals and CCSs on his motorbike, which became part of his persona.
However, in spite of this training, the ‘anaesthetists' had no security of tenure and were liable to be selected to fill the unenviable shoes of the regimental medical officers who, in 1917, had a mortality rate of 40 per 1000 per month . Consequently, a lot of anaesthesia experience was being lost. This predicament was noticed by Sir Anthony Bowlby (1855–1929), the Advising Consulting Surgeon of the British Armies in France, who ordered the presence of a specialist anaesthetist in every CCS. This meant that anaesthetists could no longer be transferred, other than in the same capacity to help neighbouring CCSs . With such security of posting, the specialist anaesthetists were able to supervise some of the 200 nurses who were specifically trained in anaesthesia in late 1917, and employed in early 1918 [14,15]. To summarize the importance of anaesthetists in the CCSs, the Canadian anaesthetist W. Howell wrote at the end of the war: ‘In a severe action, a CCS is very busy and I cannot imagine any place where the services of a skilled anaesthetist would be more useful' . Crucially, the First World War had established the importance of specialist anaesthetists in the British Army.
The development of anaesthetic techniques
The First World War provided the opportunity for the first major comparison of the effects of anaesthetic agents on the severely injured. Previous studies had focused upon morbidity and mortality rates, but not in distinct groups. The outbreak of the war brought with it an array of subgroups that could be reliably compared by anaesthetists. The easiest, because of the numbers involved, were between patients with and without specific diseases, such as bronchitis, a condition commonly seen because of the cold and wet trench life, as well as high levels of smoking. Accordingly, wards would: ‘Sound like a dog show' . However, the most important comparison was to be in the different severities of shock. This had been the subject of debate in the Crimean War, but never sufficiently quantified.
The study of the effect of anaesthesia on shock was taken up by Captain Geoffrey Marshall (1887–1982, see Fig. 1 ), later Sir Geoffrey Marshall. At the outbreak of the war, Marshall, then aged 27, left the post he held as demonstrator in physiology at Guy's Hospital to serve in the Royal Army Medical Corps (RAMC). His initial assignment was to take charge of a French barge that had been fitted up as a mobile evacuation hospital . As he later recalled, this ideal posting came to an end in 1915 when:
A dreadful old man, who was the senior consultant, Sir Anthony Bowlby, drove up to my barge one day – lovely day – and said, ‘Marshall, we are having an awful lot of deaths in the forward hospitals from shock, and you did a lot of work on the physiology of anaesthesia before the war so I want you to come along and see if you can do anything about these chaps' .
The result was a transfer to CCS number 17 and the start of painstaking observations and reports aimed to accomplish Bowlby's brief. This involved measuring the blood pressure, pulse and haemoglobin concentration in patients arriving at CCSs in different degrees of shock. The averages of these measurements were calculated at intervals before, during and after operations with different anaesthetics and then compared.
Marshall's presentation of his findings at the meeting of the Section of Anaesthesia of the Royal Society of Medicine in early 1917 was a landmark in the history of anaesthesia . The main subject of his attention was spinal anaesthesia, a method advocated to minimize the operation-induced shock in accordance with the anoci-association theory of Crile at the time. Marshall showed that this technique, as it was then used, carried the danger of extreme hypotension up to 40 hours after the anaesthetic, a time that would have been further extended but for the replenishment of intravascular volume with fluids . Similar dangers were witnessed with i.v. administration of alcohol and 6% ether, as well as inhalation of chloroform and ether . However, ether was seen to protect the patient during the operation, which present knowledge attributes to its sympathometric effect upon cardiac output. Therefore, after a chance meeting with the American anaesthetist James Gwathmey (1863–1944), who in 1912 had introduced a nitrous oxide and oxygen machine that contained a sight-feed flow-meter to indicate the amount of nitrous oxide being delivered, Marshall focused his energies on the combined nitrous oxide, oxygen and ether technique, which he administered with an improvised machine that he commissioned from a tinsmith in France . With this, he found that shocked patients survived better than with any other agent or combination of agents, and, when reminiscing on the experiment, he believed: ‘We cut down the mortality from about ninety per cent [in thigh amputations] to something like twenty-five per cent' . Furthermore, he observed that these patients made quicker recoveries, no doubt because the depth of anaesthesia was lighter and consciousness returned quicker.
The main consequence of the success of the nitrous oxide, oxygen and ether technique was to reorganize anaesthetic usage. Since its introduction, chloroform had been the major military anaesthetic and had dominated civilian use in Europe. Marshall's results led to the popularity of chloroform being diminished, save for a minority of situations such as the intermittent relieving of shell shock , assessing cases of malingerers , operations on patients with concurrent chest and abdominal wounds  and in the cases requiring administration of an anaesthetic before being evacuated to a CCS . In the German Army, it was proposed by Professor Schleich that it be carried mixed with some ethyl chloride, so as to be self-administered after injury in order to allow the regimental medical officer to concentrate solely on treatment .
Ether, on the other hand, enjoyed a renaissance. Over the entire war, the British used 413 198 pounds of it in comparison to 249 341 pounds of chloroform . Much of this was due to the association of ether with nitrous oxide and oxygen, but improvements in its safety were also important. This was particularly aided by Guedel, who, after comparing American to European ether, stated, in a letter published in the American Journal of Surgery: ‘I am beginning to understand why ether in Europe has been slow in displacing chloroform. The ether they are using here is rotten [original italics]' . This resulted in the American Red Cross sending 100 000 half-pound tins of ether and paraphernalia to the Western Front , but also for the British government to add two more tests of purity to those already in place in the British Pharmacopoeia . Moreover, the use of ether was encouraged by apparatus designed by Francis Shipway (1875–1768), later Sir Francis Shipway, which warmed ether and chloroform by pumping the vapours through a vacuum flask containing a coiled tube in hot water by means of hand bellows ; this, by 1916, had been supplied to all CCSs . This technique was demonstrated by Marshall to reduce ether-induced bronchitis in abdominal patients from 54% to 14.7% .
Nevertheless, the biggest change in demand was for nitrous oxide and oxygen. In 1917 alone, 300 000 gallons of nitrous oxide and 78 500 ft of oxygen were received by the Allied Medical Services . By the end of the war, 140 000 oxygen cylinders and 8000 nitrous oxide cylinders of varying capacity were in circulation, but this supply was not matching the demand since steel was being reserved for ammunition rather than for gas cylinders .
The increasing use of the nitrous oxide, oxygen and ether sequence was to stimulate elaboration of the anaesthetic machine. As has been already mentioned, Marshall had designed a machine for his own use, but, in addition, when he returned to London to present his landmark paper, he took his design to Coxeters, the instrument manufacturers. They approved the blueprint and agreed to manufacture the machine. This machine became the standard RAMC machine in the latter parts of the war (see Fig. 2 ) but the company warned him: ‘For goodness sake, publish this because some chap has borrowed our blocks' . The advice was not taken, as Marshall was needed back at the Western Front. This allowed the gentleman in question, Captain Henry Boyle (1875–1941), to attach his name to the machine. Boyle had met Gwathmey in 1912 at the Seventeenth International Congress of Medicine in London, and, on taking on his wartime position with the RAMC at the First London General Hospital, had persuaded the hospital governors to purchase a Gwathmey machine . Using this on the casualties of war, he quickly modified it to British standards, supplemented some of Marshall's innovations and introduced reducing valves. Under these valves, he placed a small spirit lamp to prevent the nitrous oxide from freezing up the valves, albeit with an ether bottle only inches away. In 1919, a description of this super-machine was published , and the celebrity status it gave Boyle confirmed him a career in anaesthesia that was to lead to him, in association with Coxeters, to produce eight evenmore technologically advanced machines by 1933 (see Fig. 3 ). Boyle's name is still associated by some with the vastly different apparatus of today.
Resuscitation techniques and the extension of the anaesthetist's role
Besides improving knowledge of the role of anaesthesia in shock, the First World War aided the strategies for its general prevention and treatment though it would be much later that it became part of the anaesthetist's responsibility. In spite of the researches of Crile into resuscitation, the methods being taught at the outbreak of war were relatively basic. A notebook of a RAMC private in 1914 revealed instruction on the problem amounted to the following: ‘Caused by injury, worry, and severe burns. Patient suffering from shock will be cold, clammy, lips white, pulse feeble, apply warmth, and tuck him up, apply hot w. bottles to extremities, not to touch him. Give stimulants, very little. Give hot drinks [original italics]' . By the end of the war, the methods available for reheating had drastically increased, as ambulances started to be fitted with a system for warming the interior from the exhaust, allowing temperatures of up to 70°F to be reached . This was complemented by the implementation of hot-air baths as far forward in the evacuation tree as the ADS. These comprised cradles that supported a heat generator and blankets, which together would form a tent around the stretcher-prone victim. If placed in such a structure for up to 20 min, the core body temperature of shocked patients was seen to rise by an invaluable 1°C . However, the most notable and influential benefit to all future anaesthetists was the introduction of oxygen into general use. Importantly, this was stated to reduce the quantity of chloroform or ether required, curbed the incidence of post-operation vomiting and alleviated the effects of excessive morphia medication .
The infusion of fluid in the resuscitation of patients was also assessed and improved upon. Again, a lot of credit for this must be given to Marshall, for it was he who noticed in autopsies that the giving of three pints of fluid subcutaneously to shocked patients was useless as the fluid remained in the axillary folds . Accordingly, the custom of giving fluids i.v. received momentum in the war and, by the end of it, i.v. infusions had become an integral part of medical management at all the evacuation stations. Originally, normal saline was the fluid used, but this was found to stave off shock for only half an hour. Therefore, the introduction in 1916 of a six-per cent solution of gum acacia in 0.9% sodium chloride solution by Professor W. Bayliss was significant. This being a colloid, exerts an oncotic effect on the extravascular compartment, transferring fluid into the intravascular. Interestingly, i.v. treatment of severe post-anaesthetic vomiting was also developed in this war, as a pint of 2% solution of bicarbonate of soda was reported in the Official History of the Great War to have been introduced . Evidently, this was an important therapeutic treatment, but it also heralded the origin of the fluid charts that are a substantial administrative medical procedure today.
Efforts to restore and establish blood transfusion as a definite therapeutic treatment for shock were extremely successful in the First World War. This became a practical procedure following the discovery of the ABO blood groups in the decade before the outbreak of the war . Direct blood transfusion received fresh impetus from the employment of Fullerton–Dreyer–Bazett paraffined cannulae and rubber tubing at the Boulogne Base in the latter half of 1916 . This did much to aid the ease of the procedure, but could not hide its other disadvantages: first, the inability to gauge the amount of blood transfused; second, the difficulty of applying it at the front, and in hospitals in busy times with many casualties; and third, the risk of infection to the donor . Instead, the war hastened the development of indirect blood transfusion, which avoided the problems of direct transfusion by collecting blood in suitable calibrated containers that was later transfused into the recipient. For this to succeed, clotting had to be prevented, and the war witnessed the introduction of several methods, of which the most successful was the use of the anticoagulant sodium citrate. Developed by the Belgian, Albert Hustin in 1914 , its introduction was perfectly timed. Major Edward Archibald of the Canadian Army Medical Corps first demonstrated the ease of the method , and in 1917, the American, Captain Oswald Robertson of the Third Army, designed and introduced a new apparatus , which allowed indirect blood transfusion to sweep the board.
The availability of stored blood also helped to establish the first resuscitation teams. Experimental work by Rous and Turner of the Rockefeller Institute found that blood could be preserved for a number of weeks in an iced solution of dextrose and sodium citrate . This led to Robertson testing the concept at a CCS in the Battle of Cambrai in November 1917, when he demonstrated that blood could be stored up to 26 days . Such a possibility was seized upon by the Australian, Major Alan Holmes à Court, in the development of his transfusion teams, whose roles were to hasten access to casualties suffering with severe shock, continued haemorrhage or shattered limbs . These teams were attached to major ADSs, and among the personnel were two medical officers. One was designated in charge and expert in performing rapid urgent surgery, blood transfusion and general resuscitation. The second would be a medical officer experienced in nitrous oxide and oxygen anaesthesia, resuscitation and cross-matching of blood donors . On receiving authorization to proceed, the numbers of these teams grew hastily because of successful results. A report on 14 October 1918 detailed that, in the previous 2 months, 948 operations, 52 blood transfusions and 62 gum acacia and other i.v. infusions had been performed, and it also remarked that: ‘Severely shocked patients arrive in the CCS in much better condition than would otherwise be the case' . Thus, on incorporating these roles of shock treatment in post-war trauma care, the status and capabilities of anaesthetists dramatically increased, albeit without total knowledge of the pathophysiology of the condition they were treating.
Comments published by contemporaries do much to reveal the effects of the First World War on the development of anaesthesia. According to the anaesthesia chapter of the Official History of the Great War:
In conclusion, it may be noted that the art of administering anaesthetics was greatly developed during the war, with immense benefit to both the patient and the surgeon. The increased supply of special apparatus contributed very greatly to this result and the administration of warm ether vapour and of nitrous oxide and oxygen instead of chloroform saved very many lives .
This supports the impression that the war improved the safety of anaesthesia and scope of surgery. The improvements in choice of appropriate agent and resuscitation techniques had a direct benefit in reducing the doleful mortality lists of the First World War. In addition, F. McMechan, in his introduction to the American Yearbook of Anesthesia and Analgesia, 1917–1918, stated: ‘Some of the anaesthetic methods, introduced to expedite military surgery, are finding a place for themselves in civilian practice, for the benefit of all concerned' . This is important in demonstrating the relationship between the First World War and anaesthesia in two ways: first, it confirms that wartime advances in anaesthesia were proving advantageous for civilian use; second, the very production of a Yearbook to record the experiences of military anaesthetists showed that the speciality had become important and large enough to support publications devoted solely to the subject of anaesthesia.
In the Western world, the post-war period saw the incorporation of all the major anaesthetic lessons from the war: choice of anaesthetic, Boyle's machine, fluid therapy and transfusion. The publication , and then widespread adoption of Guedel's chart of the signs of anaesthesia provided some landmarks by which to steer (see Fig. 4 ). Some pre-war and newly trained anaesthetists returned to civilian life with an increased interest in the speciality. Among these was Guedel, who became a founder of the American Society of Anaesthesiologists, developed the pharyngeal airway, introduced the Guedel Laryngoscope, and investigated divinyl ether and cyclopropane.
Finally, perhaps the biggest influence that war brought to British anaesthesia was to bring two men into the profession. They were Ivan Magill (1888–1986, see Fig. 5 ), later Sir Ivan Magill, and Stanley Rowbotham (1890–1979), who, in 1919, were both posted to the Queen's Hospital for Facial and Jaw Injuries at Sidcup, in Kent. This, as Magill later remarked ‘was more by chance rather than by choice' , but it was here that Major Harold Gillies (1992–1960), later Sir Harold Gillies, had established a plastic surgical unit to repair the shattered faces and jaws of war victims. The site of these operations meant that anaesthetic maintenance was difficult: anaesthetic by rectal ether-oil was too light at the start of operations and too deep in the middle; Silk's nasal tubes often severely hampered the surgeon; intratracheal insufflation with Kelly's apparatus would produce an uncertain depth of anaesthesia, pose a fire hazard, and the mixture of blood and ether that was blown out through the mouth sorely tried the patience of the surgeon and anaesthetist . It was the mixture of blood and ether that resulted in Gillies remarking: ‘Maggi, you seem to get this anaesthetic into the patient alright, don't you think you could devise some method of getting it out, so that I am not anaesthetized?' . In response to this plea, Magill and Rowbotham introduced a second tube that allowed free expiration to occur and the pharynx to be packed. This procedure led to the invention of the Magill forceps and to various modifications of insufflation apparatus , but also to the use of a wide calibre rubber tube for anaesthetic mixtures. Magill thus hit upon the means of providing to-and-fro respiration (see Fig. 6 ) . This was the starting point of endotracheal intubation, a procedure that has revolutionized the administration of anaesthetics.
Clearly, it is rather morbid to believe that anaesthesia has benefited from war because of the large numbers of injured and shocked soldiers. However, this gloom can be offset with the evidence seen in this paper that some of the knowledge of anaesthesia gained from such suffering has allowed future anaesthetists to treat civilians and soldiers better than previously possible. Although there were no wonder drugs or a drastic change to the structure of anaesthesia in Britain brought about by the First World War, the war was a turning point for anaesthesia as it catalysed its rate of development to that being observed in its neighbouring fields such as surgery, pharmacology, and microbiology. Consequently, anaesthesia should be added to the list of medical ‘successes' that have origins in war. Although the lessons of war will never be worth the cost, history shows that, for anaesthesia, lessons were learned.
I am grateful for the financial assistance from the Association of Anaesthetists of Great Britain and Ireland Student Elective Bursary, the John Blair Trust, the Royal Society of Medicine Section of Anaesthesia Student Bursary and the University of Birmingham Medical School. For allowing me access to the their collections, I am indebted to the trustees of the Army Medical Services Museum, the Imperial War Museum and the Wellcome Library for the History and Understanding of Medicine. Furthermore, I am thankful for the general correspondence with Drs Thomas Boulton, Geoffrey Noon and David Zuck as well as to Miss Harriet Rollinson for reviewing the manuscript.
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*Based on a presentation on the occasion of the final of the John Bullough Prize 2005 at the Sixth International Symposium on the History of Anaesthesia in Cambridge University in September 2005.