Fighting Fit E-Book

Kevin Brown

• Herausgeber: The History Press
• Kategorie: Fachliteratur
• Sprache: Englisch

Veröffentlichungsjahr: 2008

Beschreibung

The twentieth century saw two world wars and many other conflicts characterised 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.

Leseprobe

In memory of Harry and Ethel Lazenby, Rob and Jennie Brown

When you see millions of the mouthless dead across your dreams in pale battalions go, say not soft things as other men have said, that you’ll remember. For you need not so.

Charles Hamilton Sorley, 1915.

Contents

Title

Dedication

Preface

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

Bibliography

Copyright

Preface

War and medicine make strange bedfellows. The main purpose of war is to injure, maim and kill. Medicine, by contrast, is dedicated to healing and maintaining good health. Opposing as they may seem, these aims are not totally incompatible. If a nation is to maintain its fighting capability, it requires a healthy citizenry. It also needs to have the means of repairing the ravages inflicted by war on the human body in order to return its servicemen to action as quickly as possible, since, in the words of the great medical humanist Sir William Osler, it is ‘strange that man who dominates Nature has so far departed from Nature as to be the only animal to wage relentless war on his own species’.1 In a modern democracy, a state must be prepared to patch up the damage done to its soldiers by warfare in return for its citizens being ready to risk life and limb; as the Home Front has become as much a battlefield as the theatres of war, medical services for civilian casualties have become part of that implicit pact between state and combatant.

The twentieth century has been marked by wars of great savagery in which technological advances have made the killing machine ever more efficient and deadly. That rapid pace of technological advance in medicine has generally kept pace with the developments in the sinews of war. Indeed in many ways, warfare has accelerated changes in medical practice, though not without opposition from diehard conservative practitioners of military medicine, and has encouraged new ways of looking at things that have been beneficial to patients in general. Both war and medicine in the last century have been impelled by a drive to modernity.2 Osler believed that the monster of war had brought the blessings of ‘the enormous number spared the misery of sickness, the unspeakable tortures saved by anaesthesia, the more prompt care of the wounded, the better surgical technique, the lessened time to convalesce, the whole organization of nursing’ and judged that ‘the wounded soldier would throw his sword into the scale for science – and he is right’.3 Yet the picture is not entirely positive. War can impede progress because limited resources are used on the means of waging warfare rather than on drugs or medical care.4 War has also unleashed callousness towards injury and has perverted medicine from its nobler ethics, not only under authoritarian regimes but wherever it may be accepted that the ends justify the means. Medicine is not a noble calling above the society in which it operates: it is conditioned by, and an integral part of, that society.

The intimacy in the relationship between health, medicine and war is reflected in the language used to describe medicine. We speak of the battle against infection, we wage war on bacteria and patients fight for life. At the same time metaphors for illness can be used in a military context. Military planners talk of ‘surgical strikes’. British serviceman liberating France in 1944 were urged to understand that ‘when anyone has been living for a long time suffering from privation or in a concentration camp, and is suddenly let out, it takes him time to recuperate. And France had developed under the German occupation much of the physical depression of a huge sick-room, and much of the mental stress of a huge concentration camp’.5 The Italian futurist artist Virgilio Retrosi depicted the First World War as a giant abscess covering the world with the sores of misery, sickness and taxation.6 Such terminology reinforces the idea of the heroism of medical pioneers and military doctors. It also suggests that in modern warfare, two battles are ongoing simultaneously, the military one of the armed servicemen and the medical one of the doctors, nurses, stretcher-bearers and medical scientists.

This book tells the story of the interrelationship of these two wars over the course of the twentieth century, a subject surprisingly up to now lacking an overview, such as this one, for the whole century. There are tales of heroism and the ideal of the noble warrior, but there are also accounts of the misery caused by warfare and of inhumanity. Yet, there remains in the popular imagination a romantic tinge of heroism attached to the image of the tending of the sick in the heat of battle. Most war films or dramas would be incomplete without a background of ambulances, first aid posts and Red Cross armbands or the heroic figure of the doctor or nurse. Such imagery is often irresistible because so striking. When the opera director Emilio Sagi updated Donizetti’s La Fille du Régiment to a Second World War setting for a 2005 production at the Teatro Carlo Felice in Genoa, he had Patrizia Ciofi’s Marie don a nurse’s headdress to tend the wounded leg of Juan Diego Flórez’s Tonio to make him into a soldier fit to fight and ready for the tenor’s effortless achievement of his successive nine high Cs.7 The nurse always remains the beautiful ‘Rose of No Man’s Land’ and the sick and wounded are similarly handsomely idealised. War is never like that and the casualties rarely suffer as picturesquely as in art. Warfare by its very nature is nasty and brutish even when it is justified. Medicine is often very messy.

Yet even out of the chaos and confusion of war can emerge unexpected benefits. It is outside the scope of this book to investigate the ways in which military technology and hardware devised for one purpose subsequently can have entirely pacific benefits in a different context for which they were never envisaged, but we ought to be aware of these possibilities. A classic case of this is ultrasound scanning, which had its origins in a sound-wave device to detect icebergs invented by the American Lewis Nixon in 1906 and subsequently developed to detect the presence of enemy U-boats. By the Second World War, sonograms were being used to detect gallstones, brain tumours, breast cancer and rectal obstructions. Then in the late 1950s the Scottish gynaecologist and obstetrician Ian Donald, a veteran of the First World War, moved on from using ultrasound scanning to detect ovarian cysts to producing clear echoes of babies in the mother’s womb to check for foetal abnormalities.8

While this book was being written, the newspapers were full of stories of casualties from the fighting in Iraq and Afghanistan, the deplorable closure of specialist military hospitals, the resultant problems in treating wounded service personnel in the general wards and clinics of the National Health Service, and the psychological problems faced by people returning from an unpopular war that their country perhaps should never have got involved in. It seemed as if the pact promising the soldier that he and his dependents would be looked after medically and financially if wounded or killed, in return for risking his life in his country’s service, had been breeched.9 Yet, with military forces stretched, the role of the army doctor in maintaining the health and physical fitness of the soldiers in his unit remains as important as ever.10 Sometimes it seems as if nothing has been learned from the experience of the last century. It does give immediacy to the themes running through this book and, as always, the past informs the present and the present helps us towards an understanding of history. Yet, however much there might seem to be similarities, it is as well to remember that society a hundred years ago was different from how it is now. What happened in the past was conditioned by a world that is remote from our own and must be understood in its own setting. Medicine, war and society are interrelated and not separate areas of study: to understand one, we need to know something about all and in the context of the times, not by projecting the concerns of 2007–8 back to the 1900s. At the same time, it is by looking at the subject over a long period of time that we can better see the development of war and medicine over a century that has known few periods of true peace.

As ever, many people were very helpful while I was researching this book. I am grateful to Bill Frankland, who has relived the ordeal of his experiences as a prisoner of war of the Japanese in Singapore during the Second World War. Michael Wolach has spoken of the absence of any medical aid during his time in a Soviet camp. Barbara Gammon and Betty Ashton have described their experiences of nursing during the Second World War. Andrew Bamji has kindly given me access to the records of Harold Gillies’s First World War work on plastic surgery at Queen Mary’s Hospital Sidcup and has liberally given his time in discussing the subject with me, displaying his great enthusiasm for the topic. At the Queen Victoria Hospital, East Grinstead, Bob Marchant very generously gave me access to the collections of the Queen Victoria Hospital Museum, showed me around the hospital as it is today and pointed out buildings surviving from when Archibald McIndoe was treating burnt airmen there in the 1940s, as well as sharing his memories of working with McIndoe in the post-war years. Nicholas Baldwin, Archivist at Great Ormond Street Children’s Hospital, has supplied references to child welfare during the First World War. From Ellen Reace, I have learned of the experiences of Londoners evacuated to safer areas to have their babies, and their desire to return to the heavily bombed capital during the Second World War. I have happy memories of discussing the First World War influx of female medical students with James Garner when he was doing his history of medicine dissertation on that very topic. Myer Salamon, Richard Keeler, Neil Handley, Bernard Dixon, Maria Lorentzon, Elise Younger, John Grabenstein and João Carlos Boléo-Tomé, secretary-general of the Fundação Casa de Bragança, have suggested some useful references. Robin Touquet has recommended some leads on more recent military medicine and reminded me of the similarities between military field medicine and the work of modern Accident and Emergency departments. I wish to thank too everyone at The History Press concerned with the commissioning and editing of this, my third book for them.

I must especially mention the assistance of Lluis Martinez, sub-editor of Avui in Barcelona, who has proved himself the most helpful of friends over the last five years, and that of his son Guillem whose native Catalan and Spanish tongues and ability in English has facilitated communication between us. Without Lluis’s guidance about sources and contacts, the chapter on medicine in the Spanish Civil War would have been infinitely poorer. I also wish to thank Miguel Lozano of the Hospital Clinic, University of Barcelona, the family of Dr Frederic Duran, and Montserrat Mira, daughter of Dr Emili Mira.

Without the resources of countless libraries and archives, the research for this book would have been impossible. Even with the benefits of desktop access through the Internet to many journals, which allow references in them to be consulted without leaving one’s seat, there is no substitute for visits to archives and libraries that contain material that is often unique and will never be available online. Such visits may involve more effort and be harder work, but they are so much more rewarding. I wish to thank the staff of the National Archives at Kew; the Wellcome Library; the National Archives and Records Service of the United States; the National Academy of Sciences in Washington DC; the Imperial War Museum; the Royal Society Library; the Musée International de la Croix Rouge et du Croissant Rouge; the Deutsches Hygiene Museum; the National Center for Agricultural Utilization Research in Peoria, Illinois; the Pfizer Records Centre at Sandwich; the Pfizer Information Center in New York; the Rockefeller Archives Center; the Paul Ehrlich Institut; the British Library; the Bodleian Library and the Library of Congress. Long may we all continue to have such unfettered access to such banks of knowledge that are the mainspring of knowledge and scholarship. I have also taken inspiration from visits to medical and military museums throughout the world, too innumerable for all to be mentioned. Their collections of artefacts and interpretative displays can provide that imaginative spark needed to bring the past alive or suggest an otherwise elusive insight.

London, 11 November 2007.

Notes

1W. Osler, ‘The War and Typhoid Fever’, British Medical Journal, 2 (1914), 909–13.

2See R. Cooter, M. Harrison and S. Sturdy (ed.), War, Medicine and Modernity (1998), pp. 1–17.

3W. Osler, ‘Science and War’, The Lancet, 2 (1915), 795–801.

4R. Cooter, ‘War and Modern Medicine’ in W.F. Bynum and R. Porter (ed), Companion Encyclopaedia of the History of Medicine (1993), pp. 1536–73.

5Political Warfare Executive, Instructions for British Servicemen in France, 1944 (2005), p.6.

6Virgilio Retrosi, Guerra (1914–15), exhibited at Estorick Collection of Modern Italian Art, London, ‘Barbed Wit: Italian Satire of the Great War’ exhibition, January–March 2007.

7Gaetano Donizetti, La Fille du Régiment, (DVD, Decca Music Group 074 3146, 2006).

8T. Cassidy, Birth: A History (2007), pp. 175–7. I wish to thank Elise Younger for this reference.

9Independent on Sunday, 11 March 2007.

10R. Holmes, Dusty Warriors (2007), p. 35.

1

National Inefficiency

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.’1 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’2 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’.3 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.4 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.5 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’.6 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’.7

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 1884.8 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’.9 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’.10

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.11

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’.12 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.13

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’.14 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’.15 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’.16 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.17 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.18 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.19 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.20 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.21 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’.22 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.23

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.24 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’.25

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’.26 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’.27 She had a more realistic view of wounded privates, noting that ‘always Tommy was very anxious to get his bullet for the missus’.28 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.29 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 becoming more unhealthy, and the food rationings decreasing. Nothing but a good, sound constitution could have possibly overcome these obstacles’.30

It was little wonder that sick men tried to stay in one of the hospitals in Ladysmith rather than be sent to such a hellhole. In order to prevent journalists from seeing what was happening out there, any press correspondent stricken with enteric fever was allowed to stay in the town though it was compulsory for all other sufferers to be sent to the isolation of Intombi.31 George Steevens, the dashing war correspondent for the Daily Mail, had complained soon after the beginning of the siege that there was nothing to do other than eat, drink and sleep and that unless Ladysmith were to be relieved soon, ‘we die of dullness’, but was destined himself to die a horrible death from typhoid shortly before Christmas 1899 in one of the insalubrious Ladysmith hospitals.32

Conditions in the hospitals were bad enough at the height of the typhoid epidemic but were made worse by the actions of Colonel Exham, the Principal Medical Officer who, desirous of being able to present a neat list of supplies at the end of the siege, had forbidden the issue of such meagre comforts as sago, arrowroot and brandy to the sick whilst ensuring that these were diverted for the use of journalists, civilians and senior officers.33 At the same time Exham was obsessed with the tidiness of the field hospitals, prompting Major Donegan, who was in charge of the 18th Field Hospital, to complain ‘God almighty! We have four doctors for 120 patients scattered over three churches and thirty-six tents, and the P[rincipal] M[edical] O[fficer] only worries whether the men’s clothes are neatly folded, or if their boots are in line.’34

Bad as the ravage of typhoid was at Ladysmith with its grim average of ten deaths a day, it was to be far worse at Bloemfontein after its occupation by General Roberts in March 1900. Almost 1,000 troops were to die in the epidemic which had been partly caused by many of Roberts’s troops drinking water from the Modder River, heavily polluted by the corpses of men and horses killed in the recent Battle of Paardeburg fought there. Neglect of elementary hygiene compounded the problem. Where attention was paid to adequate sanitation, it was possible to control typhoid. At 6th General Hospital, Naauwpoort, a simple and effective sewage system had been devised by the Royal Engineers who had also provided pumps for an adequate water supply. Moreover, the hospital staff had incinerated all soiled dressings and the excreta of typhoid patients, thereby ensuring that ‘up to date we have passed over 2000 patients through No. 6 General Hospital, and there is not a case of enteric fever to be traced to the surroundings of the hospital’.35 Less care was taken at Bloemfontein. Soon there were funeral processions through the dusty streets of the town every afternoon mocking the recent triumphal entry of the army that was now burying its dead with the minimum of ceremony.

Arthur Conan Doyle working in a voluntary hospital at Bloemfontein saw the outbreak of enteric fever at Bloemfontein as ‘a calamity the magnitude of which had not been foreseen and which even now is not fully appreciated’. In one month alone, 10–12,000 men had gone down with ‘the most debilitating and lingering of continued fevers’ and over half of the doctors, nurses and medical orderlies attending the sick had themselves caught the disease.36 William Burdett-Coutts, a journalist and Unionist MP, denounced in the columns of The Times the scandal of the failure of the Hospital Field Service:

hundreds of men to my knowledge were lying in the worst stages of typhoid, with only a blanket and a thin waterproof sheet … between their aching bodies and the hard ground, with no milk and hardly any medicines, without beds, stretchers or mattresses, without linen of any kind, without a single nurse amongst them, with only a few soldiers to act as orderlies and with only three doctors to attend on 350 patients.37

Yet despite it being ‘obvious that for many years the department of healing has not advanced pari passu with the department of maiming’,38 the Army Medical Department was unwilling to co-operate with civilian volunteer hospitals notwithstanding it being recognised that such hospitals as the Portland Hospital offered superior standards of care and accommodation to anything provided by the Royal Army Medical Corps.39 Perhaps co-operation was not as great as it may have been because of a feeling that the private hospitals were getting in the way of the army organisation and that ‘they should not be allowed to force themselves up towards the Front in the place of organised military hospitals’.40 Jurisdictional rivalries only worsened the lot of the sick and dying.

All these deaths from typhoid could so easily have been prevented had the troops been vaccinated. Only a few years before the outbreak of the war a vaccine against typhoid fever had been developed by Almroth Wright, professor of pathology at the Army Medical School at the Royal Victoria Hospital at Netley overlooking Southampton Water. Yet, despite it coming from an army medical establishment that was gaining a reputation for its research, the military authorities were suspicious of the new vaccine and even more so of the man who had produced it. Wright was an abrasive, acrimonious figure made for controversy who made no concessions to his critics however much he may have antagonised them and biased them against his ideas. There had been resentment against his appointment to the post at Netley in 1892 when this relatively unknown thirty-one-year-old civilian with as yet little experience in the field of pathology had been given the job in preference to older, more experienced army officers.41 By this time, despite having followed an erratic career path that had veered from the humanities to the sciences and from law to medicine before he finally chose to concentrate on medical research, he was already acutely conscious of his own ability and impatient of anyone who disagreed with him. It was an attitude that was later to earn him the nicknames of ‘Sir Almost Right’ and ‘Sir Always Wrong’ from his many opponents who did not share his own extremely high opinion of himself.42 He was not averse to telling the president of one military tribunal to which he was giving evidence that ‘I have given you the facts, I can’t give you the brains.’43

At Netley, he had developed a diagnostic test for Malta Fever and a vaccine against this prolonged, relapsing illness. So confident was he that this vaccine would work that he tried it out on himself and then injected himself with live organisms only to find that the vaccine did not work after all.44 When he had recovered from a long and distressing bout of Malta Fever, he turned his attention in 1896 to the problem of producing a vaccine against the much more serious typhoid fever. It had taken great personal courage for Wright to test his vaccine against Malta Fever on himself, yet there were even greater dangers in injecting a human being with this virulent organism, the typhoid bacillus, in however attenuated a form. Still firm in his belief in the principle of vaccination and encouraged by the success of Waldemar Haffkine in using heat-killed bacteria in an anti-cholera vaccine, he developed a heat-killed vaccine which he tested on himself, his colleague David Semple and sixteen trainee medical officers. These young officers were accustomed to military discipline and to obeying orders but were also inspired by their charismatic chief’s confidence in what he was asking them to do. The initial effects were alarming. The officers concerned soon felt faint and suffered from vomiting and a loss of appetite. The worst affected of them remained weak and ‘looked somewhat shaken in health for some three weeks after’.45 Wright, having learned his lesson with Malta Fever, decided against infecting himself with typhoid to see whether the vaccine did actually work, but injected one intrepid young man with live typhoid bacilli with no ill effects. More extended clinical trials following a typhoid outbreak at Maidstone Insane Asylum in 1897 and with the Indian Army in 1898 also gave encouraging results but were too sketchy and incomplete to confirm Wright’s faith in his vaccine.46 The outbreak of the Boer War offered just the opportunity he needed to try out his vaccine in wartime conditions and give him the chance he craved to make a difference to the health of the troops.

Unfortunately, the new vaccine was not received by serving military medical officers with the same enthusiasm Wright had shown for it. Only 14,628 soldiers actually volunteered to be inoculated, which amounted to no more than four per cent of the total. There was little support and much suspicion from the army doctors. There was a general history of popular hostility to compulsory vaccination, which had raged ever since Edward Jenner had first developed his smallpox vaccine at the end of the eighteenth century with many doctors opposed to the very idea of inoculation.47 Moreover many of them actually believed that anti-typhoid inoculation caused the fever in the first place; and the severity of the reactions to it, which could leave a man unfit for duty for several days, only reinforced military hostility to inoculation.48 Wright explained such adverse reactions as representing a ‘negative phase’ in the treatment, a period immediately after inoculation when immunity was diminished before it could be enhanced. Since this made men more vulnerable to infection in the short term, it meant that inoculation must take place before they were exposed to infection and made it potentially dangerous during an epidemic. Wright also recommended a second booster injection to increase protection, but this advice made it even more of a deterrent to the adoption of the vaccine. Some wooden cases containing supplies of the vaccine were even dumped over the sides of troopships leaving Southampton Water within sight of Wright at Netley to be returned to him by the coastguards.49

Those doctors who actually inoculated soldiers during the voyage out to South Africa were to report adverse reactions made worse in some cases by seasickness. One civilian surgeon was able to round up 200 volunteers aboard SS Sicilian, but two of them fainted ‘with fright’ immediately after the needle was injected. Within ninety minutes, nearly all the men injected began to feel ill, some with cramp in the abdomen, others with nausea and violent vomiting or diarrhoea, and all with a rise in temperature. It was to be three days before any of them began to recover. The surgeon concerned was also inoculated and was soon ‘unable to move hand or foot without assistance’ while the ‘two glands in my groin were swollen to the size of pigeon’s eggs’.50 Such strong reactions, though actually very common, were put down by some doctors to the sera being too strong.51 It was no wonder that many men did not volunteer, even if their regimental medical officers recommended the injections, when they saw the effects on their comrades.

As a result of the low number of troops inoculated, it was impossible to perform any accurate statistical analysis of the results of using the vaccine. Wright, who was sceptical about statistics at the best of times, had no doubt about its value and advocated the compulsory vaccination of troops against typhoid. His many enemies in the military hierarchy, headed by David Bruce, discoverer of the cause of Malta Fever and one of the disappointed candidates for Wright’s chair in pathology, were hostile to any form of inoculation let alone any involving compulsion. As a result, the army board advising the War Office on scientific issues recommended that voluntary inoculation be suspended and that it should only be resumed if Wright prepared a detailed proposal ‘showing exactly on what lines and with what precautions he would propose that the system should be carried out’.52

An Army Medical Services committee on anti-typhoid inoculation was established in 1904 after Wright had mobilised medical and scientific support against this decision; it concluded that ‘the practice of anti-typhoid inoculations in the army has resulted in a substantial reduction in the incidence and death rate from enteric fever among the inoculated’ and recommended resumption of voluntary vaccination for troops.53 However, the critics of vaccination enlisted the support of the statistician Karl Pearson, who attacked the rigour of Wright’s methods of analysis.54 Wright, who had left the Army Medical Service in 1902, was to spend the next decade fighting for official recognition of the value of vaccination that he believed could have saved so many lives in South Africa.55 It was only once William Leishman, Wright’s successor at the Royal Army Medical School now based at Millbank, London, had undertaken further research into the effects of anti-typhoid sera that vaccination was reintroduced on a voluntary basis in 1912.56

However, it was not only among the British armed forces that the inadequate response to the treatment of infectious disease was to provoke a scandal.57 Boer women and children incarcerated in the first concentration camps of the twentieth century were to suffer from the ravages of epidemics just as much as the men who were fighting, although measles rather than typhoid was to be the bigger killer. These camps were General Kitchener’s response to the Boer guerrilla warfare that characterised the last phases of the conflict. They were established as refuges for Boer women and children made homeless by the burning of farms thought to be harbouring the commandos. It was a policy which freed the Boer men from the distraction of looking after their families and added to the determination of the ‘bitter enders’ to carry on what was by now a hopeless struggle. Those families who tried to stay in their farms seemed to be ‘very badly off’ and were short of sugar, salt and matches. If they left home to seek refuge in a camp, their homesteads were burned in line with the policy ‘to destroy everything likely to be of material use to the enemy’ if it had not been purloined by British soldiers, with ‘a most brilliant reputation for looting’, first. Even many an army doctor ‘became somewhat of an adept at fowl-snatching’.58 For some Boer families the camps were at first refuges as much as prisons, but not for long.

Soon death from malnutrition and disease swept through these badly sited, unhygienic camps. At the camp at Mafeking women were washing clothes in excrement-fouled water, the latrines were not properly disinfected and slop water was just emptied next to the tents. There was no mortuary despite a rising death rate. Fresh meat and vegetables were not available as part of the rations, even though they could easily have been bought from the nearby town. However, it was not just the negligence of the British Army that was to blame for creating such unsanitary conditions.59 The Boer women were also blamed by observers for having ‘a horror of ventilation’ which directly caused ‘the pestilential atmosphere of the tents’ which could best be described as ‘stinking’.60 Farming families accustomed to leading healthy if isolated lives had not built up resistance to infectious diseases. By the end of the war, well over 20,000 women and children had died in the camps, a quarter of all women and children from the Boer Republics.61

Conditions at Heilbron were made even worse when the army interned a group of Boer families infected with measles in a camp unable to cope with the influx of the sick, many of whom were housed in ‘miserable sheds or stables, and one hovel was one surely meant for a pig or some poor native and yet a young girl, dangerously ill lay in it’.62 Such a policy outraged the suffragette Millicent Fawcett, the leader of an all-women committee appointed by the British government to enquire into conditions in the camps: ‘There is barely language too strong to express our opinion of the sending of a mass of disease to a healthy camp; but the cemetery at Heilbron tells the price paid in lives for the terrible mistake.’63

Conditions in the camps had first been exposed by the Quaker Emily Hobhouse who had been horrified at what she had witnessed during her visit to them between December 1900 and May 1901:

I began to compare a parish I had known at home of 2,000 people where a funeral was an event – and usually of an old person. Here some twenty to twenty-five were carried away daily … it was a death rate that had not been known except in the times of the Great Plagues … the whole talk was of deaths – who died yesterday, who lay dying today, who would be dead tomorrow.64

Alfred Milner, British High Commissioner for South Africa, although privately blaming the scandal on military mismanagement, was so angered by Hobhouse’s rhetorical mission to publicise the scandal, that he arranged for her to be arrested and deported when she attempted to return to South Africa in October 1901.65

However, by that time Mrs Fawcett’s Ladies’ Committee had been sent out by the War Office to investigate the conditions in the camps. Unlike Hobhouse, who was often dismissed as hysterical in her response to the camps, all of these practical and down-to-earth women, including two doctors and a nurse, believed that the war was just and that in wartime unpleasant measures might have to be taken against enemy civilians. Yet, they were appalled by what they saw and recommended relief measures including the provision of trained nurses in the camps, improved rations and proper equipment for the sterilization of the linen used by typhoid patients, though their interest did not extend to the native Africans who had also been interned.66

Just as Hobhouse and the Fawcett Commission’s reports had galvanised action to improve conditions in the camps, it was Burdett-Coutts’s revelations of ‘the growing scenes of neglect and inhumanity, of suffering and death, which have been the lot of the British soldier in the closing chapter of this war’67 that provoked the usual governmental response to any official scandal, the appointment of a royal commission ‘to consider and report upon the care and treatment of the sick and wounded during the South African Campaign’ under the chairmanship of Sir Robert Romer. Evidence was taken from officers of the Royal Army Medical Corps (RAMC), civilian surgeons and the sick and wounded themselves. The commission found that the scale of the war had taken the authorities by surprise and that the RAMC had come under great pressure and had neglected sanitation in the field, but its conclusion that in general the Corps had generally overcome its own very considerable shortcomings was certainly a whitewash that bore little relationship to the reality of what had actually happened.68 The evidence pointed towards a breakdown of the army medical organisation especially with regard to sanitation, transport, the response to infectious diseases, and manpower, however brave and dedicated individual officers may have been. The whole question of the failure to introduce inoculation against typhoid was ignored.

Yet the outcome of this commission should have come as no surprise to anyone, for there was a feeling within the RAMC that ‘this war is the first occasion on which the existing medical organisation has been tested, and in spite of the reduced scale, it has stood the test remarkably well’.69 E.W. Herrington, a doctor at Bloemfontein, had no doubts after a visit from the Hospital Commission that:

I do not think that the RAMC will come badly out of the enquiry but will, in the future, have their hands greatly strengthened. They were not able to do impossibilities and did their best with what material they could seize upon, whilst no one could foresee that there would be such a terrible outbreak of enteric after Paardeburg, or that the disease would be of such virulent a type.70

Nonetheless, the RAMC had come very close to breaking down under the pressure of war. When the war broke out, the Corps was only one year old, having been formed as recently as June 1898 from an amalgamation of the Medical Staff Corps, made up of medically trained soldiers, and the doctors of the Medical Staff. Up to this time the Staff Corps, men of ‘regular, steady habits and good temper … possessed of a kindly disposition’, had had no officers while the Medical Staff of the Army Medical Department were all officers without any men to command.71 Only with the formation of the RAMC were medical officers given the same status and rank as other officers within the British Army but they still continued to be looked down upon as inferior by both the army and their fellow civilian doctors to whom medical military service was seen as a last resort for medical men unable to afford a footing in general practice or even to find a paid appointment with the poor law authorities. Recruitment to the Corps was also deterred by the inferior terms of service offered to army doctors within the armed forces even if they enjoyed officer status. Whereas an eighteen-year-old cavalry subaltern was paid £400 a year in allowances to enable him to maintain two servants, two horses and stabling, the £200 salary and £70 allowances paid to an older, medically qualified RAMC subaltern was not enough for him ‘to keep up a smart civilian and military kit and subscribe freely to everything that is going on’.72 If better doctors were to be recruited, the army had to offer them more attractive conditions of service and more authority in enforcing health and sanitary regulations. It was little wonder that on the outbreak of the Boer War the new Corps was still undermanned and its inadequacies had been only too visible, but the experience had offered salutary lessons which were to be heeded over the next few years.

The years between the end of the Boer War and the outbreak of war in 1914 were ones of reform for the army medical services just as they marked a period of army reform in general under the War Secretary Lord Haldane. The status of the military doctor was regularised and it was suggested that candidates for the RAMC should be ‘British subjects of unmixed European blood, not more than 28 years of age, and shall possess a recognizable qualification to practice’. The medical officers were given responsibility for all medical and sanitary services in their area. Salaries and the status of army medical officers were raised and provision made for study leave.73 In 1904 the director-general of the Army Medical Department was raised to a rank immediately below that of an adjutant-general, which ensured that his voice would be heard when it came to military planning. The Royal Army Medical College was transferred from Netley to London in 1907 ensuring that it was more in touch with wider developments in the medical world of the capital and was no longer regarded as a seaside holiday for men taking courses there. The veteran bacteriologist Alexander Ogston was very concerned that there was no provision ‘for the formation of a Sanitary Corps, consisting of officers specially charged with the duty of carrying out proper sanitary measures in peace and war, and a staff of men trained to ensure the requisite measures being carried into effect’.74 In 1906 a school of sanitation was opened at Aldershot for the training of regimental officers and non commissioned officers that could form the nucleus of hygiene detachments. Military hygiene courses also became a regular part of the syllabus for army doctors. Field ambulances replaced the old stretcher-bearer companies. Research was commissioned into water filters and water sterilizing carts.75 The need for a medical reserve to cope with greater needs in the event of war was met by the formation of a territorial army unit modelled on the RAMC. This reorganisation under the aegis of the director-general Alfred Keogh was to shape the RAMC into a much more effective medical service, one that was at last prepared to fight the Boer War so recently over. Sir Frederick Treves gave his approval to the removal of ‘the grave defects brought to light in the Report of the South African Hospital Committee’ and predicted that ‘it will be the finest service in the world in time’.76

Army nursing did not escape rationalization in the rush to repair the deficiencies revealed by the war. An Army Nursing Service had been formed in 1881 and this had been supplemented by Princess Christian’s Army Nursing Service Reserve from 1887, but women still lacked any status as regular members of the armed forces and were not supposed to nurse close to the battle zones. The Boer War demonstrated the need for the employment ‘of nurses in fixed hospitals for the care of the wounded and of fever and dysenteric patients, and such others as can properly be nursed by females’.77 A committee under the chairmanship of St John Broderick recommended the amalgamation of the army and Indian Nursing Services to form Queen Alexandra’s Imperial Military Nursing Service ‘under the immediate control of Her Majesty Queen Alexandra as President’.78 However, Queen Alexandra was determined to be consulted and have her way on everything, from the size of buttons on the uniform to the role of the Lady Superintendent or Matron-in-Chief.79 The Queen’s interest was often counter-productive and a trial to any one who opposed her well-meaning but always regal interference. Lord Haldane as Secretary of State for War was not the only person to consider her a nuisance when he came up against her in replacing Princess Christian’s Army Nursing Reserve with the rationalized Queen Alexandra’s Imperial Military Nursing Service Reserve and establishing the Territorial Army Nursing Service in 1908. Exasperated by his dealings with the Queen, Haldane complained that ‘she is about the stupidest woman in England’.80 However, there was nothing he could do to counter royal influence in army nursing.81

Military medical and nursing reform was part of a wider obsession with ‘National Efficiency’ which reverses in the Boer War had brought to the fore, though their origins lay in an underlying unease that economically and militarily Britain was being overtaken by an armed, vigorous and prosperous German Empire. The fear was that if the mighty British forces could be brought to the verge of defeat by simple South African farmers, they would stand no chance against a well-disciplined, well-equipped and well-trained German Army. If Britain was to survive it had to modernise itself. Linked in with such fears of national decline were the revelations of the deplorable physical condition of many of the men volunteering for service in South Africa. Over a quarter of volunteers at some recruiting depots were rejected as unfit for military service. The journalist Arnold White revealed that at Manchester three out of five recruits failed to meet the low physical standards of a minimum height of 5ft 3in, a chest measurement of 33in and a weight of 115lb. At York, Leeds and Sheffield, forty-seven per cent of recruits failed to meet these standards and twenty-six per cent were additionally rejected on account of defective vision or hearing, decayed teeth, ill-health or ‘dull intellect’.82 Major-General Sir John Frederick Maurice argued that such statistics suggested that the environmental conditions in which the working classes lived were seriously depleting the reserve of fit men from which the soldiers were recruited.83 All of this was to influence debate on social policy for many years to come.84