The Lancet: The legacy of changing attitudes since World War 1

The Lancet is pleased to announce that the following papers will be published as part of a Special Issue on the legacy of World War 1:

• Series: Changing attitudes during and since World War 1 towards:

  o Infectious Diseases

  o Military psychiatry

  o Surgical and amputation-related pain

• Article: Questions raised about antibacterial resistance as dysentery-causing bacterium found to be resistant to penicillin 13 years before discovery of antibiotics

• Comments on Health policy during and since World War 1

World War 1 was a key transition point for medicine. Thanks to Louis Pasteur's findings in the 19th century, rational control and treatment measures were used during World War 1 to combat infectious diseases, even in the pre-antibiotic era. However, the 'flu pandemic of 1918–19, which killed more people than died during the entire war, highlighted weaknesses in contemporary knowledge of infectious diseases. Fortunately, knowledge improved significantly after the War, particularly with the discovery of antibiotics. Drawing parallels with modern issues such as drug resistance and uncontrolled outbreaks, the author of this Series paper argues that more research should be devoted to drug-resistant microbes and the pressing need to develop new antimicrobial drugs.

While vast achievements in psychiatry have been made since World War 1, the psychiatric legacy of the war is ambiguous, say the authors of this Series paper. The authors explore the changing attitudes toward the psychological impact of trauma since World War 1, from its branding as an excuse for the cowardly, to an illness of social maladjustment, and finally to a psychiatric condition caused by the specific environments of World War 1's battlefields. The 'forward psychiatry' movement, which saw shellshocked soldiers rest in clinics on the front line before returning to combat, emerged during World War 1. Thanks to its questionable efficacy, the debate over its use in modern wars remains controversial and as relevant today as it was during World War 1.

Nerve, muscle and bone injury to the limbs from artillery weapons were the most common form of injury to World War 1 soldiers. Amputation was often necessary to save lives but surgeons were unable to offer long term solutions to the post-amputation pain suffered by many of their 41,000 amputee patients. This Series paper compares the results of contemporary and modern understandings of post-amputation pain across wars of the 20th and 21st centuries. It describes the evolution of amputation surgery itself during the First World War, from the guillotine procedure to operations that prioritised nerve and bone health in an effort to minimise pain for the amputee. The paper concludes that despite significant progress in the process of amputation over a century, post-amputation pain remains a complex condition to understand and treat. The aim of ongoing work is to create a new life for amputees "free from the company of miserable pain".

Questions raised about antibacterial resistance as dysentery-causing bacterium found to be resistant to penicillin 13 years before discovery of antibiotics – by Dr Kate Baker et al

The earliest live strain of Shigella flexneri, the bacterium responsible for deadly dysentery outbreaks, was found to be resistant to penicillin despite antibiotics not being discovered until 13 years later, according to this research article and case report. The strain, known as NCTC1, was isolated in 1915 from a WWI soldier, believed to be Private Ernest Cable, who died from dysentery, and its DNA was compared to different strains of shigella bacteria from the past 100 years. NCTC1 had similar genes conferring resistance against penicillin and erythromycin to modern strains, despite antibiotics not being discovered until 1929. Dysentery causes hundreds of thousands of deaths a year in developing nations, particularly in children. It typically occurs in areas with poor sanitation, and particularly where there is displacement of people – both common in conflict areas from 100 years ago and today. Amongst other conclusions, the authors call for research to focus on vaccination development as the best way to combat dysentery in the face of antibiotic resistance.

This Special Issue includes three commentaries on health policy during and since World War 1:

This commentary discusses the expansion of the role of the state as a result of the first and second World Wars, ranging from keeping a supply of men at the frontline by improving healthcare, to caring for injured veterans.

This commentary examines the health impact of forced migration and displacement due to conflict, and draws comparisons with World War 1 and current conflicts such as in Syria and Iraq. The authors argue that poverty and lack of access to health services are among the main reasons for disease outbreak in conflict zones. They go on to suggest ways for nations to support refugees, as well as ways that refugees can support the countries they settle in, should repatriation be impossible.

This commentary documents veteran care throughout the two World Wars, and compares the UK's approach to that of other nations such as Germany and the USA. They argue that while other nations view the welfare of disabled veterans as a state affair, the UK frames the needs of such veterans in terms of charity rather than rights; an attitude which, they argue, was cemented by the Armed Forces Covenant in 2013.

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