Medical War Pt. 1

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Hello everyone and welcome to History of the Great War Premium Episode number 26. This episode begins our four part series on the medical side of the war. As we have discussed many times before the first world war was a conflict on a scale that had never before been imagined. There would be 20 million men wounded during the conflict, and this would require medical care on a scale never before imagined. In this series we will look at the men and women who did their best to put back together what the battlefield had torn apart. We will begin our story before the war, in the mid-1800s and then carry it through to 1918. During that time we will see how the doctors and nurses treated the horrible wounds suffered on the battlefield. Our discussions will not be restricted just to the treatment of injuries and other critical pieces of the medical war are also important. Much like the manpower problems that the armies had the medical professions around Europe had similar problems, thousands of doctors would have to be pulled out of civilian society, views would have to change on the roles of female nurses and doctors, and new and more efficient organization and transport systems would have to be developed. Overall, the medical services of the First World War would rise to all of these challenges. They would be able to take advantage of new techniques and ideas like germ theory, vaccines, antiseptics, and blood transfusions and apply them on an unbelievable sacle. These innovations, driven by the urgent need to keep men in the trenches, would pave the way for new treatment methods and new ideas that would have long lasting effects after the war. Today we begin far before the men entered the trenches in 1914, instead our story starts with the British Army on its way to Crimea in 1854.

The war in Crimea is as good of a place to start as any because, at least for the British, it was the last large conflict they would participate in before the world shifted into new medical ideas like germ theory and antiseptics. During this conflict the medical officers that accompanied the army would be attached to the various regiments, with each infantry regiment having a surgeon and an assistant. These medical officers were not actually real officers, with most of the military men considering them more civilians than actual soldiers, this would be one of the items that would be changed by the Crimean conflict. During the Crimean war there were many complaints about the medical care and sanitation provided to the British units, which rose to prominence due to the work of Florence Nightingale and many others. This complaints prompted a Royal Commission to be set up after the war which would bring about several different chantes. One of these changes was the change in status of the surgeons and assistants to instead be Medical Officers, who would be given the same pay and same rank as regimental infantry officers. These changes resolved some of the power issues that were experienced by the new Medical Officers, but it did not completely fix the situation. Another data point on the way to the first world war was the Franco-Prussian war. While the British stayed out of that conflict, they still had observers on both sides and seeing the performance of the French and Prussian militaries made the British leaders reconsider their medical situation, and caused them to seek more improvements.

The quest to improve on these medical services would encounter two major issues which would plague the British army for the last decades of the 19th century. The first was the problem of rank and authority for medical officers in the army. Even though the medical officers had been given better rank and pay after the Crimean War, this did not sovle the issues around them having real world authority in the actual army units. This lack of real authority hindered the ability of medical officers to properly influence unit practices, which was especially important around sanitation. The doctors would go on campaigns with the army, and they knew that there were areas where sanitation improvements could be made which would have positive effects on unit performance but it was difficult to get the Army officers to listen to them and to then act on their suggestions. This problem would require a culture change within the army before it would be resolved. The second major problem was just getting doctors into the army in the first place. With the budget for the British Army always tight, it was difficult to lure doctors out of civilian practice. All they had to look forward to in the army was a lack of leave and pay, and then a serious lack of ability to continue their studies which would put them at a serious disadvantage if they ever left the Army. These types of downsides turned many doctors away from the military path.

These problems would be swept up into all of the other problems that the British army had during the Boer War. That war, and the embarrassment that it caused for the British Army, would cause several investigations and commissions to be launched into almost every possible area of the British armed forces. One of these areas was medical care. The first problem was that the army had simply went into the war without enough doctors, and those that they had were then stretched far too thin. Very few people would criticize the medical officers for their work ethic, and even third party observers would speak highly of their efforts, but no amount of work could make up for their numerial shortfall. This and other issues resulted in the 1901 Royal Commission on the South African Hospitals. The commission would recommend several changes and then also the appointment of a committee to make sure that the changes actually happened. Ian R. Whitehead in his book Doctors in the Great War would summarize the commissions decisions like that “1. The staff of the RAMC may be permanently enlarged and due provision may be made for its further necessary and speedy enlargement in times of great wars. 2. Inducements may be offered to ensure a continuous supply to the corps of sufficient men of good professional attainment; and 3. The men who have joined may be kept as a body thoroughly acquainted with the general progress made in professional subjects, and at a high professional standard of efficiency.” These changes would result in the creation of the Medical Advisory Board which oversaw changes to pay, the creation of study leave, and the establishment of a medical staff college. These changes made Medical commissions far more appealing to young doctors, and 1902 saw more competition for commissions than in any previous year.

While the big changes before the war would come as a result of the Boer War, there were still some alterations to the British medical services in the decade before 1914. Some of these were just administrative, like the creation of the Field Ambulance, the purpose of which we will discuss in a future episode. Some of the changes were based around training, like the creation of new training material and better ways of spreading that training to both new and currently serving doctors. This allowed for a unified system of training to be present for all of the medical officers in both regular and territorial units. While these changes were a move in the right direction the much bigger change was the army’s view on preventative medicine. During this time there was a new emphasis put on maintaining a high standard of hygiene, a viewpoint partially influenced by the experience of Japanese units during the Russo-Japanese war. There was also a huge swing in how the British military establishment viewed inoculation. After a trial set of inoculations were done in India, and after that trial proved that they were very successful at keeping more men healthy, the army leadership was persuaded to offer them to all soldiers. They would never make these measures necessary, although there were many leaders who wanted to, but the majoirty of soldiers in the lead up to World War 1 would receive protection against as many diseases as possible. All of these advances helped to greatly reduce the number of sick and incapacitated soldiers in the army. In 1912 it was estimated by the Director of Army Medical Services, that these efforts kept over 6,000 men in fighting shape who otherwise would not have been, and that was 6,000 in the small British pre-war army, so a pretty hefty difference.

While the improvements before the war setup British Medical Officers to be more prepared when the war started, nothing could truly prepare them for what was about to happen. That did not mean that many doctors were not ready to do their duty to their country. Much like all young men around Britain, doctors volunteered in large numbers. Many doctors who wanted to volunteer, but were rejected for any number of reasons, found a way to assist by joining the Red Cross or other medical organizations. With this initial surge of enlistment the areas of Britain reacted differently. On one side you had England in the south, here there was not much organization and coordination around the doctors who were volunteering for the war. This meant that many fully trained doctors volunteered to join the infantry, and were allowed to go to the front. In the north, in Scotland, there was far more organization about how doctors were a were not allowed to join in the service, and there was also a stronger attempt to make sure that their civilian duties were properly covered. The Scottish setup the Scottish Medical Service Emergency Committee with the stated goal of working with doctors all over Scotland to find way to make sure that doctors who wanted to could join the army and their civilian duties were properly covered by other physicians, including older doctors who were asked to come out of retirement.

Most of the disorganization in some areas of society ws due to the fact that like most of the British Army, the medical services believed that the war would be a short one, and because of this did not think that it was necessary to take the proper steps or organize the available medical manpower. There were some in the British government who believed that the war might be a long one, but it would be some time before other in teh government would be brought around to this belief. When this shift occured they had to begin to construct some kind of system, especially when it became clear that all of the Territorial units would have to serve overseas. The Territorial units had originally been created as a home defense force, and they were not eligible for overseas service. Once the war started in 1914 this restriction would begin to change, and very quickly Territorial units would begin to serve either in the British garrisons all around the world, or in combat units around Europe. This was problematic for the Medical Officers of these units because while they were attached to territorial units they were often civilian doctors as well, maintaining a practice and a group of clients. These civilian practices could not just be abandoned. This was also not a small number of doctors, with somewhere around 2,000 physicians falling into this scenario. This would result in a special exemption being made for these doctors, and when their units were called up their were given the option of either going with it overseas or staying home. These concerns about what to do about making sure that civilians still got the care that they needed would be a very serious topic for the rest of the war.

When we look at Medical Officers during the war, we should remember that each one of them was a doctor trained as a civilian and who had in almost all cases either owned or worked at a civilian practice. These men, just like the doctors today, could not just be removed from society, they were needed to make sure the civilian populace stayed healthy. Because of this requirement, along with the requirements for these men in the army, there were many efforts to try and develop a system where when these doctors were removed and sent overseas somebody would be available to look after their patients. This was most critical in rual areas where there might only be one doctor available to a large geographical region. In some cases there were olde, retired, doctors who could cover for the younger doctors who were leaving, but this could not make up the entire shortfall. There would be many doctors in 1914, and really for the entire war, who would stay at home because there simply was not a good system for somebody else to come in and make sure that their patients were cared for. There was also a continual fear that those doctors who did stay home would actually benefit from the situation, they would be able to build up their client base while other doctors were away, this was a concern particularly important to urban doctors who did not have the same relationship with their patients as doctors in rural areas. The government decided to kick the problem down the road a bit by letting civilian doctors who had volunteered for service stay home as long as possible, letting them continue their practices while their units were being trained, but this was just a bandaid and the problem would rear its ugly head once again when these men began to ship overseas by the millions in 1916.

To assist in the doctor shortage the British government would ask for help from Canada and Australia. This resulted in an official request for help being given to the two governments. This brought many doctors to Europe, with over a quarter of all Australian Doctors serving in the army by mid-1915. There were also some arrangements made with Belgian doctors who had escaped the country during the German invasion. These doctors were brought back to Britain and would serve as civilian doctors for the rest of the war. There were only about 60 of them but even this token of assisstance was welcome. While these arrangements would help ease some of the manpower problems, they did not come close to fixing them, and in the back half of the war the British would have to continue to struggle to find enough doctors. Already in mid-1915 a quarter of all of the doctors were in the army and it was estimated that the growing army would push that number up to a half by mid 1916.

Even if there were administrative challenges back home, there were already doctors at the front and in the fighting. These were both the career Medical Officers from the professional army and the new volunteers, like Doctor McKenzie “My life during the last three years [general practitioner] has been the happiest part of my life, although at times the work was too heavy. I have always wanted to get into the Army because I wanted to feel that I had offered my life for my country and whatever happens I shall be more glad than I can say that I have managed to help in this great struggle.” Another doctor would say that “I left England filled with the anticipation of cutting off legs and arms upon the stricken field, amidst a hail of shrapnel and machine gun bullets.” Once these doctors were at the front they often found the situation very different from what they had imagined it would be. Here is Colonel Arthur Lee who was sent to France to report back to Kitchener on the situation, he would file this report sometime around the Battle of the Marne “The RAMC staff at that time were undoubtedly overworked and overstrained. There were probably not enough Medical Officers in the first place, and many had been killed or wounded (I still doubt that there are enough to cope with the situation that may arise after the next heavy fighting and am of the opinion that more should be sent at once). I have frequently seen Medical Officers who have been working for such prolonged periods, without sleep or proper food, that they are not in a fit condition to attend to serious cases. And yet, in the absence of anyone to relieve them, they are bound to go on and do so with admirable spirit.” The doctors also found that they were often medically unprepared for the situations they were soon to be in, situations that we will discuss in episode 3 of this series.

I want to close out this episode with just a quick discussion of how the British went about assigning doctors to the front. If you think about how doctors are organized today there are all kinds of specializations. From general physicians, to cardiologists, to podiatrists, pretty much every area of the body has some kind of special doctor for it. Things were a bit different in 1914 in terms of the specialities, but the principal was the same. All of the doctors had different experiences, skills, and knowledge and utilizing the strengths of each one was key to getting the most out of the available pool. The information about each doctor was compiled in great detail by various committees appointed by the government to oversee medical recruitment, and this information was made available to the military, there was just one problem, it was not really used that much. The problem seems to have stemmed from the make up of the British army before the war. Before 1914 the British army had been a professional one, and it had reasonably high physical fitness standards, and if somebody fell below these standards, or something went wrong, they could just be removed from active duty and sent to a civilian hospital. After the war started, this was not really possible, the standards became more lax and this meant that men who would not have been accepted into the prewar army were now at the front. These men brought with them certain medical requirements that now had to be met. These requirements could be very simple, the army now needed more opthalmologists to get glasses for soldiers, they needed far more dentists to deal with dental situations, these were problems that had not been greatly considered by the British army before the war. Therefore when teh war started the administrative apparatus did not have a way of properly assigning specialty doctors to specialty positions. This resulted in many specialists being sent to the army and then just assigned to the normal pool of available Medical Officers. If these officers were not immediately needed somewhere they would just be attached to a base hospital where there was almost always something to do. Then when a Medical officer was needed closer to the front the hospital would be notified and a doctor would be chosen. There was rarely any real requirements for this choice, it was solely up to teh head of the hospital and they could do it at random if they liked. This type of system frequently resulted in specialists not necessarily working in their specialty even if that specialty was needed. These organizational problesm would be at least somewhat addressed in tiem, but these types of inefficiencies would plauge the British Army for most of the war. Next episode we will take a look at the last half of the war and also talk about some of the special groups that assisted in medical care in the form of medical students, female doctors, and nurses.