by Lucy Inglis
Cushing’s diary entry for April 1915 continued, ‘When we got back to the Ambulance the air was full of the tales of the asphyxiating gas which the Germans had turned loose on Thursday – but it is difficult to get a straight story. A huge, low-lying cloud of greenish smoke with a yellowish top began to roll down from the German trenches, fanned by an easterly wind.’ This was, of course, the beginning of the German use of mustard gas, causing terrible burns, as well as eye and lung injuries. ‘The smoke was suffocating, and smelled to some like ether or sulphur, to another like a thousand sulphur burning matches . . . [the men were] either suffocated or shot as they clambered out of the trenches to escape’.6
Mustard gas, a new invention by German chemists, would have horrific consequences for those fighting. The First World War introduced many technological and scientific innovations to the theatre of war, and mustard gas, flamethrowers and tanks were only a handful of them. Shellfire accounted for many of the more horrific injuries, and Cushing relates the story of trying to save a young man whose spinal cord had been severed by a piece of debris. Gunshot wounds, burns, and other such injuries must have presented many dilemmas in the face of dwindling pharmaceutical stocks. In the same month Cushing was writing, it was reported that there were limited holdings of Turkish opium left, but they were being offered to the market ‘at a greatly inflated price’.7 The British authorities deemed that neither Indian nor Chinese opium were of sufficient quality to convert into morphine successfully, and attempted to source it from Iran.
In the meantime, the need for other drugs that Germany had produced so well was becoming pressing. Salvarsan, used to treat syphilis, was no longer available, and as German trademarks had been suspended, British pharmaceutical companies were busy trying to create a copy. It was soon available under the trade name Kharsivan and rapidly shipped to the front lines.
It wasn’t only large British pharmaceutical companies like Burroughs & Wellcome & Co. that contributed their expertise to the war effort. Forty of Britain’s universities and technical colleges were called upon to take a wide range of German pharmaceutical and chemical branded products and find their active ingredients. This was done by students, postgraduates and staff, ‘freely and cheerfully’.8
Voluntary medical staff were vital in this war, from doctors and nurses to stretcher-bearers. There were no field medics, and immediate comrades were forbidden from helping the fallen, but ordered to press on. One stretcher-bearer, known only as Tom, remembers watching the men go over the top at Arras, ‘Wave after wave in perfect order, marching into the jaws of death.’9 The wounded had to make their own way if possible, or wait for help from the stretcher-bearers who would give rudimentary care then haul them back to the dressing station or waiting ambulance. It could be between one and four miles from the front line back to the rendezvous, often on impassable terrain. They carried minimal pain relief with them, and their golden rule was not to jolt or drop the stretcher. This was not always easy, as ‘We had to step on these dead soldiers to keep from going in the water and mud so deep and throwing the [wounded] off the stretcher.’10
By 1917, medical care had vastly improved, but morphine supplies were still low. Not so low, however, that it had been reserved only for human patients. At the Battle of Gallipoli, Jack McCrae and his dog, Windy, were both wounded in the leg by the same shell and brought into the shelter together. Windy was granted a medical card and patched up at the hospital, and after that, they were inseparable. Perhaps somewhat too inseparable: Windy would whine outside the medical tent when his master was working, and attacked anyone who wasn’t in khaki. One day Windy was poisoned, and he suffered for two days, until Jack and Harvey Cushing euthanized him with ‘two or three hypos of morphia’. Windy was buried in the grounds of an old Jesuit college with full military honours.11
The treatment of leg wounds was one of the areas of huge improvement during the war. In the first year, 80 per cent of soldiers suffering a broken thigh bone died, but thanks to Robert Jones bringing his uncle’s invention, the Thomas splint, to the battlefield, where the thigh is stretched then held by traction, by 1916, 80 per cent of the wounded survived.
Other notable innovations were in antiseptic practice and anaesthesia. Dysentery and other gastric diseases were endemic in trench warfare, which, when living thigh-deep in water, could turn a scratch into blood poisoning rapidly. Better understandings of infection, and the liberal application of antiseptics made from coal tar, improved chances of a healthy recovery in a time before penicillin. Anaesthetic came as either nitrous oxide, ether or chloroform, and through the war, delivery methods improved markedly, so that there was far less chance of the patient dying on the table. Britain was the main producer of chloroform during the war. Also in use for the first time were battlefield blood transfusions, and the design and resilience of the hypodermic needle had improved dramatically, with graduated glass syringes encased in metal for accurate dosing and safety, and easily changeable needles. By the end of 1917, the Ford factory in the US had built and shipped to France 2,350 newly designed ambulances.12
In 1918, just as the war was coming to an end, Britain secured a new line of opium, from Iran, although there was some uncertainty as to exactly where it was coming from. Requirements for a sufficient quality seem to have fallen by the wayside, as Britain marched into its fourth year of war with casualties that had been unthinkable in 1914. Germany too was now suffering shortages, not of chemical and synthetic drugs, which it was still producing in huge quantities, but of most botanicals, and there’s some evidence they were trying to grow opium poppies during this time.13
The conclusion by pharmacists regarding First World War shortages is that the Allies were woefully underprepared for the medical needs of the wounded, and understocked with medicines of all kinds. But the decision to suspend all Germany’s medical trademarks early, the voluntary help given by British chemists in universities around the country, and the money poured into development of synthetic drugs meant that by 1917, most battlefield medical needs could be taken care of. The one shortage, which mirrored Germany’s own, was the lack of opiates.
Harvey Cushing’s war ended in November 1918, after the Armistice. He returned home to the US to practise neurosurgery, using techniques he had invented at war. He also identified what is now known as Cushing’s disease, won the Pulitzer Prize, and is one of the fathers of neurosurgery. His last days in France were full of relief, as, ‘In the farmyard courtyard below chanticleer crows, guineas and geese cackle, porcs grunt and the beagles bark excitedly’, but he admitted he would miss the war and the opportunity to learn that it granted him: ‘There is nothing quite like this combination in civil life – no comparable incentive.’14
The Great War is perhaps only great in terms of numbers, with approximately 18 million dead and 23 million wounded on all sides. While no country could have prepared itself for such prolonged carnage, the opium question remains: whether the prohibition ultimately had a significant effect on supplies, and whether the decision not to use Indian and Chinese opium was a sensible one. There are few sources regarding shortages from the time, and most of the pharmacological records are believed to have been pulped to make paper in the Second World War, a scant twenty-one years later.
Other records, however, survived, such as the diary entry by Private Daniel Sweeney of the 1st Lincolnshire Regiment, on surviving the Battle of the Somme: ‘These are places where hundreds of men have said their prayers who have never said them before . . . I was wet to the skin, no overcoat, no watersheet . . . I was in an open dugout and do you know what I did – I sat down and cried.’15
The Second World War
‘We sewed up orange peels as they were supposed to be a realistic substitute for human flesh. At least we learned how to thread a needle properly and could bring the edges of the orange peel together even if they were a bit mismatched.’16
On the battlefield, the one great difference in terms of medical care between the First and the Seco
nd World Wars was the field medic. As it had in the First World War, America took its responsibilities in this department very seriously, and established Camp Campbell (which became Fort Campbell in 1950) on the Kentucky and Tennessee border, where medics were trained to a high standard, orange peel notwithstanding. They were exceptionally well equipped in terms of ambulances and personal supplies. A typical medic’s kit would consist of morphine tartrate syrettes, iodine swabs, ammonia inhalants, bandages and adhesive tapes, safety pins, tourniquets, and myriad other antiseptics and coagulants, all of which had been thoroughly explained at Camp Campbell. One medic wrote that ‘We learned which injury to treat first and how to stop the flow of blood, how to sew and protect damaged tissue, and how to administer morphine and blood plasma.’17 Contrary to popular belief, ordinary soldiers did not carry morphine in the Second World War unless they were in parachute regiments, and then only a single dose.
Things were different off the battlefield as well. Before the war began on 1 September 1939, Winston Churchill on behalf of Britain, and the US army on behalf of America, had been stockpiling medical supplies, taking note of the lesson from the First World War. The American army had even produced a handbook about how they were intending to make sure each theatre of war, such as the Pacific, was to be supplied. Manufacturing facilities were set up to last five years, or ‘the course of the emergency’, whichever was shorter.18 Britain had made similar, if not quite so lavish arrangements.
Advances in medicine had been astonishing. Alexander Fleming had accidentally discovered penicillin in 1928, and although his work was lost for a decade, a group of students at Oxford University rediscovered it. Then, in 1941, experiments with penicillin were shown at a symposium attended by Pfizer representatives, and the company picked it up for trials and mass production between 1941 and 1944, when the war was underway.
Sulfanilamide, patented in Austria during the First World War but not used, was an anti-bacterial powder – ‘sulfa powder’ – that could be sprinkled into wounds to stop infection instantly. These two drugs, along with morphine, were the mainstays of medicine during the Second World War.
Between the wars, Germany had gone through a golden age of pharmaceutical production. In 1926, they were the top morphine-producing country in Europe and the top heroin producer in the world, in terms of both quality and quantity. Between 1925 and 1930 German companies produced 90,620 kg of morphine, more than 41 per cent of the total global production.19 The pharmaceutical giant Merck was now the leading business in the world in both opiates and cocaine, which it had first extracted in 1862, and the Nazi government even had an expert policy group for the two drugs, the Fachgruppe Opium und Cocain. Like the rest of Europe and America, Germany had adopted a much sterner attitude to opium and cocaine in the first part of the twentieth century, but it had a remarkably relaxed attitude to synthetic drugs, probably because drug companies were innovating faster than the legislature of the fragmented governments of the Weimar Republic could keep up.
The vast majority of these drugs were stimulants. Dr Fritz Hauschild, who developed Benzedrine for IG Farben, had been hugely impressed with its effect on the athletes at the 1936 Olympic Games. First synthesized as an asthma cure in 1929, amphetamines had proved a popular stimulant. Hauschild wanted to design an even better form, and synthesized a very pure methamphetamine, branded as Pervitin, which became tremendously popular throughout Germany when it was released to the market in 1937. In wartime, though, Pervitin tablets had a different and very efficient use, promoting aggression whilst lessening fatigue. Air crews took them on flying missions and they became known as ‘Stuka tablets’. There were reports in the media of ‘heavily drugged, fearless and berserk’ German paratroopers.20 The German military’s peak period of methamphetamine usage was during the Blitz, when the Wehrmacht issued 35 million 3-mg methamphetamine tablets in three months.
British stretcher-bearer and medic Tom Onions may have wished for some methamphetamine on the day of the Normandy landings on 6 June 1944, when he recalled coming in on an amphibious vehicle towards the beach: ‘I had all my medical stuff, a stretcher, 600 rounds of ammunition for the machine guns and two mortar rounds. When the ramp went down, there was none of this Iwo Jima stuff running onto the beach in light order . . . We were struggling.’21
At the time, the British government was carrying out extensive testing on depression and fatigue in soldiers, hoping to avoid the appalling psychological fallout of the previous war. They took a keen interest in amphetamines, particularly Pervitin. The RAF, concerned by the rising number of flight crews consuming stimulants, conducted various long-range bombing trials using both amphetamine and methamphetamine, and found that pilots responded slightly better on the former because they had a greater sense of well-being. In late 1942, each member of the flight crew on bombing missions was issued with two 5-mg Benzedrine pills. Amphetamine use was rolled out across the army in the same year, although it was never implemented in the navy.
After the First World War, when morphine and diamorphine were in such short supply, there had been extensive testing on finding a powerful, yet non-addictive painkiller. In 1939, Otto Eisleb of IG Farben discovered dolantin, which is less potent than morphine, and they were soon mass-producing it, but subsequently found out that it was as addictive as morphine. Between 1937 and 1939, chemists working for Hoechst AG, Gustav Ehrhart and Max Bockmuhl, working towards the same aim, synthesized methadone. The disruption of the war meant that methadone was not tested or developed much further immediately, but it was approved for use in the United States in 1947.
The Allies, having suffered shortages before, were well supplied this time, and there had been one significant breakthrough: the syrette. Invented by the Squibb Corporation, it was a sealed unit of one dose of morphine with a small, fine needle. It had been pioneered by the company in the 1920s as a single half-grain dose insulin unit for diabetics, but was particularly suited to warfare as it was small, sterile and disposable. After use it was pinned to the wounded soldier’s collar or clothing so that they were not accidentally overdosed on arrival at the clearing station.
Not everyone, however, wanted pain relief. Henry Beecher, an anaesthetist, was at the Battle of Anzio in 1944, and observed that three-quarters of the wounded declined pain relief when offered and reported little or no pain. Beecher later surveyed male patients after surgery and found that 83 per cent of patients reported pain and requested pain relief. He recorded that it seemed ‘the intensity of the suffering is largely determined by what the pain means to the patient’ and that ‘the extent of wound bears only a slight relationship (if none at all) to the pain experienced’.22 This is now referred to as the Anzio Effect.
There were many, though, who did need large amounts of morphine, and, unlike in the First World War, when hope was gone it was freely given. On one occasion, a doctor noted that ‘Despondently I arranged for him to have a large dose of morphia to ease his pain and instructed the stretcher-bearers to place him in a corner to die.’23 When the doctor arrived the next morning, however, the soldier had lived through the night and recovered.
Before America entered the war in December 1941, it had been making extensive preparations to make sure that there were no morphine shortages, despite continuing to formally ask Mexico to cease growing opium poppies: ‘Both the Treasury Department and this Department regard the illicit production of opium poppies in Mexico and the recent trend towards increased production as a menace to the health of our people. It would appear that Mexico, replacing the Far East, from which supplies are no longer available, is fast becoming the principal source of opium entering the United States.’24 However, Edward Heath of the Drug Enforcement Agency was ‘concerned our supply of opium or morphine would be cut off because the world was at war. So we needed a supply close by.’25 The US government came to an agreement with Mexico to open up the Sierra Madre Occidental mountain range to poppy cultivation, and even sent over advisors to help the local people get started. �
�The Sinaloan mountains were crowded with unofficial instructors from both countries, who taught the local people how to grow poppy.’26 The US returned to its position of superiority after the war, and continued to pressure Mexico to stop producing heroin, but by then it was institutionalized in the Sinaloa mountains, funded in part by the American war machine.
The Camp Campbell medic’s war ended soon after the liberation of Dachau. He recorded that, on 26 April 1945, ‘strange people wearing ragged clothing began straggling to the 12th Division’s rear . . . Up close we saw that they were emaciated; their bodies were just skin over bone. They spoke in high-pitched, almost birdlike voices. They carried nothing. They could hardly put one foot ahead of the other. Their only clothing was thin, striped rags although the air was cold.’ A fortnight before, the medic had attended a downed spotter plane that had been hit with a shell just behind the observer’s seat. He treated the observer for a ‘sucking chest wound’, plugging it as best he could with a vaseline bandage, and attended to the pilot’s severe head injuries. This had been the medic’s daily experience for the past year. As he approached Dachau he could see smoke: ‘The German guards had herded a bunch of captives into a barracks and set it on fire only minutes before.’27 The German soldiers were not only destroying prisoners, but evidence of all that went on at Dachau, including the medical testing on inmates without consent. The doctors working at Dachau specialized in developing drugs geared towards the immune system and aimed at eliminating malaria, typhus and typhoid, amongst others.