The 20th century saw two world wars and many other conflicts characterized by technological change and severity of casualties. Medicine has adapted quickly to deal with such challenges and new medical innovations in the military field have had advantages in civil medicine. There has thus been interplay between war and medicine that has not only been confined to the armed forces and military medicine, but which has impacted on health and medicine for us all. These themes will be examined from the Boer War to the dawn of a new century, and a "war against terror;" the experiences of individuals as doctors, nurses, and patients, are highlighted, with personal, sometimes graphic, first-hand accounts bringing home the realities of medical treatment in wartime.
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About the Author
Kevin Brown is the author of Penicillin Man and The Pox.
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Health, Medicine and War in the Twentieth Century
By Kevin Brown
The History PressCopyright © 2012 Kevin Brown
All rights reserved.
It started off as a Boys' Own adventure both for the troops and for the young doctors seeing active service in the early days of the Boer War that broke out in October 1899. The young newly qualified medic was urged to seize his 'chance of seeing actual fighting, and, maybe, of proving himself to be something more than a non-combatant' and was reminded that 'a chance such as this does not often come of widening one's view of life, of foreign travel, of active service and of good pay into the bargain.' What no one at the time could know was that the new century so soon to dawn was to be a century of total war in which health and medicine were to assume great importance for good and ill, nor that this colonial adventure straddling the 'Century's corpse outleant' was to prefigure the relationship between medicine and warfare in the years to come. For the time being though, a recruit could happily claim that 'we live in tents, comfortable enough, though everything is covered with dust' and complacently boast of 'what a brotherhood our profession is! Although I know none of the men here, almost all of us have mutual acquaintances'. This spirit of supreme confidence of a quick victory by an efficient modern army against a weak force of Boer farmers shared by army doctors and soldiers alike was soon to meet its nemesis in the form of three British defeats in the aptly christened 'Black Week' of December 1899. Few could have foreseen that it would be another two and a half years before the might of the British Empire, represented by over 400,000 British troops, could prevail over a seemingly insignificant enemy. Wars in the coming twentieth century were rarely to go according to predictions either in duration or outcome.
Despite initial appearances to the contrary, the Boer commandos were actually better armed in many ways than the British Army at first. They could call upon an impressive arsenal of modern Mauser 0.276 rifles, Krupp cannons and French Creusot siege-guns, not to mention a stock of more ammunition than they could hope to use. Moreover, 'these hard-bitten farmers with their ancient theology and their inconveniently modern rifles' turned out to be unsurpassed as horsemen and even more superb as marksmen, easily able to pick off British officers at 1200yds. The resultant gunshot wounds were clean and it was soon found best to leave them to heal themselves as far as possible. Vincent Warren Low, tending over 300 wounded in a small field hospital in one week from the Battles of Paardeburg and Driefontein in February 1900, noted that 'the most striking feature of the ordinary modern bullet wound is its asepticity' and that 'assuming no complication existed, both [entrance and exit wounds] healed in the course of a few days under a scab, and, as a rule, gave rise to no inconvenience, though occasionally a little pain and stiffness existed in the course of the track of the bullet'. A Canadian Scout had been wounded by a Mauser bullet a week before reporting sick and this 'had not prevented him riding some 20–30 miles daily'. Low ascribed this to the shape, structure and size of the bullet, although many of his fellow surgeons were more inclined to put it down to 'the dryness and asepticity of the South African atmosphere' despite the fact that shell wounds invariably suppurated and shrapnel wounds tended to drive small pieces of shirt or khaki uniform into the wound which also caused infection whereas 'the wedge-like modern bullet made as clean a perforation of the clothes as it did the skin'.
That it was possible to wait for a wound to be treated by a doctor for sometimes considerable periods was partly owing to the fact that each soldier now carried a 'first field dressing' for immediate use at the height of battle. These packages contained a couple of sterile dressings in waterproof covers, comprising gauze pads stitched to a bandage, together with a safety pin. The Prussian Army had been the first to use such dressings and they were an item of standard issue to British troops from 1884. Soldiers in the Boer War and subsequent wars of the twentieth century were able to apply the dressings to themselves if they were not too badly wounded or to their comrades to stave off infection. Yet many soldiers would be seen 'with their dressings a long way from their wounds'. Nevertheless the field dressing also allowed regimental medical officers in the midst of battle to collect 'their wounded in the nearest sheltered positions they could find, which owing to the hilly nature of the ground was usually close to the fighting line; here they were dressed and attended to, and no attempt was, or could be, made to move them further to the rear until the fighting had ceased'.
It was perhaps just as well that the majority of the wounds could be left undressed for some time as the rapid pace of many of the battles on the veldt meant that the sudden evacuation of a casualty clearing station or field hospital might become necessary at short notice. Lieutenant Wingate was giving chloroform to a wounded officer being operated upon during the Battle of Paardeburg when the Boers began to shell the hospital tents and 'two bullets whistled through the operating tent over our heads'. With barely time to finish operating upon their patient, the doctors had to abandon their tented hospital, load their wagons with the wounded under fire and travel two miles before it was safe to stop and 'dead beat, with all our wounded except two poor fellows who died en route, we camped or rather laid down on the veldt and slept'. For the exhausted and wounded soldiers there lay ahead a night of intense thirst since the enemy had control of the nearby river and had captured the hospital's water carts.
Frederick Treves, surgeon to Queen Victoria and now in charge of the No. 4 Field Hospital, was shocked by the sight of the casualties from the Battle of Colenso on 15 December 1899, men whom a few hours earlier he had witnessed marching off with a devil-may-care attitude only to return 'burnt a brown red by the sun, their faces ... covered with dust and sweat ... blistered by the heat' and their 'blue army shirts ... stiff with blood.' All of them 'seemed dazed, weary and depressed'. Although he was an experienced surgeon, the horrors of war still turned his stomach as he surveyed the men lying on stretchers covered with tarpaulin as slight protection against the rain that had now started to pour down; one man paralysed by a bullet in his spine was trying vainly to move his limbs, other men were kicking around deliriously on the wet grass to which they had fallen from their stretchers, and the piles of discarded bullet-riddled helmets and blood-soaked uniforms littered the ground. For him, there lay a ceaseless round of amputation ahead.
There was not even time to remove the dead and, during one hectic operating session, Treves noticed what seemed to be a corpse lying below the operating table. The man had been shot through the face and his 'features were obliterated by dust and blood', leaving only his blood-clotted moustache visible. Treves was taken aback to see 'this apparently inanimate figure' raise his head and open his eyes to see what was happening when an amputated limb fell onto him. For most of the casualties there was not to be such a happy ending even if they actually reached the operating theatre in good time.
Transport was a major problem bedevilling the British Army during the war in South Africa, but it was perhaps at its most grievous in its effects on the care of the sick and wounded. Liaison between stretcher-bearer companies and the field hospitals was often poor, with bearer companies simply dumping the wounded at the short-staffed field hospitals where they might be left waiting a long time for treatment. There was no simple line of command to link these two units responsible for battlefield medicine. Moreover, many of the stretcher-bearers were not specially trained orderlies but were 'the outlaws, who are useless for regimental work, and handed over to the M[edical] O[fficer] to carry his bags about'. Such 'useless ignorant fellows' could kill their patients 'by the clumsy jerky way' they carried the stretcher. One medical officer who saw a soldier who had been wounded in the abdomen die on a stretcher lamented that he 'could not make the men, who were untrained, understand the stretcher was to be carried absolutely level and not jerked'. It was felt throughout the army and even into the corridors of the War Office that 'probably nothing has come more prominently under the notice of army medical officers in this campaign than the necessity of combining the field hospital and the bearer company into one unit under one commanding officer'. A model for this was the New South Wales Ambulance, which comprised a unified field hospital and bearer company, 'everything necessary for the performance of its special duties', and had proved itself to be efficient.
However, little could be done to make the ox-drawn ambulance wagons without springs comfortable for the men travelling in them. William Burdett-Coutts, war correspondent for The Times, complained in April 1900 that 'many of the wounded were sent back to Kimberley in bullock wagons, and we can well imagine the excruciating suffering caused by such a method of conveyance'. It was remarkable that there were very few accidents involving them on the march from the Modder River to Pretoria following the British reverses of the aptly named 'Black Week' of December 1899, although there were doubts about their true value when their weight and the number of animals they required to pull them was compared with the relatively few sick and wounded they could carry. Indeed General Buller considered them so unsuitable for the stony terrain of the veldt that he recruited a team of some 2000 volunteer stretcher-bearers as a substitute for them, mainly from British-born Uitlander refugees from the Boer Republics. With them were 800 volunteers from the Indian community of Natal led by a twenty-eight-year-old barrister Mohandras K. Gandhi, keen to show loyalty to the British Empire in the non-belligerent role of stretcher-bearer. The medical horrors of war and seemingly needless death were to reinforce Gandhi's innate pacifism.
Altogether some 22,000 British troops were to die during the war and more than five times that number were to be wounded or incapacitated by disease. However, of those soldiers who died, two thirds of them were the victims not of wounds inflicted in battle but of infectious disease. Above all, it was typhoid that proved the greatest killer in this war rather than the armed warrior. War and typhoid, often known as enteric fever, were old companions. In the Spanish American War of 1898, one fifth of the United States armed forces had contracted it and six times the number of soldiers who died in combat died from the fever. Out of 107,973 soldiers, there were 20,738 cases of typhoid with 1,580 deaths. In the majority of the volunteer regiments involved, the disease tended to break out within two months of the men going into camp and was the result of poor sanitation, flies carrying the contagion and dusty conditions. This pattern was to be all too familiar during the war in South Africa where the disease also struck standing camps rather than troops constantly on the move. The infection was also spread by the 'plagues of flies' so common on the veldt 'for it was a most difficult task to prevent them from settling on the sore lips and gums of men, and then inoculating any food or drink they might come into contact with'. Of the 557,653 officers and men serving, 57,684 caught enteric fever. There were 8,225 deaths from it compared with the 7,582 men who died of wounds.
Typhoid victims are often infected by eating food or drinking water contaminated by the bacillus Salmonella typhi, which had only been identified as recently as 1880 by Carl Eberth and Edwin Klebs. Once the bacillus reaches the small intestine, it multiplies and enters the bloodstream. After some ten to fourteen days the symptoms begin to manifest themselves, often starting off with a fever, headaches and pains in the muscles and joints that make rest difficult if not impossible. Constipation in the early stages of the illness may be followed by watery green or bloody diarrhoea. By the second week of the infection, the patient is often too weak and dizzy to get out of bed when stricken with diarrhoea, with the result that the bedclothes are frequently soiled. Meanwhile, the fever, accompanied by fits of shivering, increases until it reaches 104°F or even higher. The skin is hot and dry, the lips scab-encrusted and the tongue blackened. Not surprisingly, the patient often begins to ramble mentally. In many cases the intestine wall is perforated and there is massive gastrointestinal haemorrhaging, the major causes of death from typhoid. In 1896 Ferdinand Widal had devised a blood test for the diagnosis of typhoid fever but there was to be no effective treatment for the dreaded disease until the discovery of the antibiotic chloramphenicol in 1948. For the late nineteenth-century patient the infection meant great suffering with no hope of any effective treatment; for the doctor of the age it represented a failure in the therapeutic tools at his command. William Osler, the great doyen of medical humanism, was in no doubt that 'typhoid fever has been one of the great scourges of armies, and kills and maims more than powder and shot'. Writing in 1914, on the eve of a conflict in which this was to change, he despaired that 'the story of recent wars forms a sad chapter in human inefficiency'.
The Hospital Field Service in South Africa soon found it impossible to cope with the horrors of an outbreak of typhoid that shocked the public at home already reeling from news of military setbacks and heavy battlefield casualties. An epidemic spread through besieged Ladysmith, the hot, dusty railway junction walled in by a ridge of hills in which around 13,500 British troops were trapped. Three field hospitals were set up within the town and an isolation hospital for typhoid cases set up in a no man's land at Intombi, beyond the perimeters of the town to which typhoid cases were sent. Out of a garrison of 13, 500 these hospitals treated 10,688 cases of sickness between November 1899 and February 1900, during which four months 393 people died of the disease. At first, when Sir George White and his men had flocked into Ladysmith at the end of October, the hospitals had seen mainly battle casualties. One nurse, Miss Charleson found those early days heady ones as 'trembling from want of rest, strangely excited at the thought of seeing – for the first time – the wounded from a field of battle ... by the dim light of many lanterns, I traced a moving mass of ambulances carrying the wounded and the dead' from the Battle of Modderspruit. An improvised hospital was set up in the town hall and the nurses handed out warming cups of hot Bovril to the wounded. Meanwhile in the operating theatre, surgeons operated on hopeless case after hopeless case: 'alas for the brave Gordons, many of them with their heads shattered by shells, or with hair matted with gore, and faces grey with suffering'. Such horrific injuries did not stop this nursing sister from taking a romantic view of the dying wounded hero, the death of Commander Egerton of HMS Powerful, prompting her to write in her diary on 2 November 1899 that 'his face was pale and peaceful, a tender heroic smile was on his lips, and his eyes had no pain in them, only a look of satisfaction for having done his duty, and a glory in dying for his country'. She had a more realistic view of wounded privates, noting that 'always Tommy was very anxious to get his bullet for the missus'. As the siege went on and typhoid raged, her romanticised view of war was to be greatly modified.
The hospital at Intombi Sprut had been established for the isolation of typhoid and dysentery sufferers. By agreement with the Boer General Piet Joubert, hospital trains bearing a white flag were allowed to transport patients there each day. Once there, they were forbidden to return to Ladysmith. Intombi was a 'dismal spot' and when it rained the camp became a swamp. Nurse Charleson was 'obliged to wade from one marquee to another in a very short dress, shod with long gun boots and with a waterproof bag on my head' when tending her patients. It was no better in dry conditions when the heat of the sun made conditions in the tents unbearable. The patients were deliberately deprived of what medicines and comforts were available in Ladysmith by the military authorities in charge in order to save them for the defenders within the besieged town. Nurse Charleson's diary recorded her despair about being 'shut up in that hollow with so many sick and wounded, surrounded by high mountains in which our enemies were seated with their long-reaching guns; we were indeed to be pitied'. She noted that 'daily the camp was guns; we were indeed to be pitied'. She noted that 'daily the camp was becoming more unhealthy, and the food rationings decreasing. Nothing but a good, sound constitution could have possibly overcome these obstacles'.
Excerpted from Fighting Fit by Kevin Brown. Copyright © 2012 Kevin Brown. Excerpted by permission of The History Press.
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Table of Contents
1. National Inefficiency,
2. Medicine in Khaki,
3. Business not as Usual,
4. Spanish Rehearsal,
5. Healing for Victory,
6. Road to Utopia,
7. Behind the Wire,
8. Trauma and Terror,