Medical War Pt. 2



Hello everyone and welcome to History of the Great War Premium episode number 27. Last episode we looked at the lead up to the war and the evolution of the British Army Medical Services during that time. We also spent quite some time talking about the complications of rounding up enough doctors to be sent to the army without completely robbing the civilian sector of necessary physicians, this problem will also be a big topic for us today. I initially became interested in this topic after reading Doctors in the Great War by Ian Whitehead, and that interest just cascaded into more than a week of almost constant research into the topic around the holidays. The reason that it hooked me the way that it did was because it was a critical topic, but also one that would also apply to us today. Our society, much like that of Britain in 1914, is not in any way prepared to lose half of our doctors in a pretty short amount of time. But I do want to reassure everyone that we will be getting to the discussions about medical care both at the front and behind it in the next episode, and the one after that. Today we will be focusing on the the specifics of how the British got fully trained male doctors to the front in the last two years of the war. We will then also look at how the British handled Medical Students, a critical decision point both for maintaining the supply of doctors during the war but also making sure that there was a pipeline of doctors for when the conflict was over. We will then close out this episode by looking at female doctors and nurses. In both cases the women who just wanted to contribute and assist in the war would be in a constant battle trying to convince the male dominated military and government that women were fully capable of providing valuable care near the front lines, and eventually the women would win this battle, but it would be a long slog.

Our story begins right where it ended last time, at the start of 1916. Between 1916 and 1918 the British Army would go from employing around a quarter to well over half of all of the doctors in the British Isles. The introduction of the draft in early 1916 required even more doctors to be brought in and to facilitate this effort a new national organization was created to determine doctors that could be drafted into military service. These doctors would be of military age, and would be replaced by other, generally older, doctors. At first these doctors were not themselves conscripted into military service, and hence the government did not have total say in what they did or where they went, but when there were problems finding replacement doctors for those drafted into service this policy was rethought. In the middle of 1916 it was decided that older doctors between the ages of 45 and 55 would be drafted into service, they would be commissioned as medical officers just like their younger colleagues, however they would be restricted to home service. This allowed for this pool of older doctors to be mined for manpower to be sent out wherever needed in Britain so that younger doctors would be able to go to the front. For many of these older men this was acceptable, they wanted to contribute, although some would find their new workloads more than they could handle.

One interesting wrinkle, and something that we touched on last time but I wanted to talk about a bit more, was the topic of patients and how they were handled with all of this shifting of doctors. Much like the United States today, people were generally free to choose their own doctors, and they could move from one to another if they wanted and one was available. This made many men who were called away to service very nervous that when they got back all of their patients would stick with their temporary doctors, if possible, instead of coming back to them when they returned. The Times would have a letter from a doctor who had most of his patients slowly siphoned away by another doctor who did not join in the war effort “I had to leave my practice to my colleagues who promised to keep a note of all my patients consulting them, and forward me half the fees received. I have never received a single penny. When I placed the matter before the Branch President, BMA, he wrote to my nearest colleague with a view to his taking up the whole of my practice. The reply he received was to the effect that it was quite impossible, as his practice was increasing by leaps and bounds. In the meantime, by a curious coincidence, my own has disappeared.” In general the patients themselves did not always stick with their doctors later, even though most would say that they would do so when their doctors returned. Another doctor would say that “[E]ven friendly colleagues often forget to ask a newcomer if he has been previously attended by the absentee, whilst naturally they never dream of putting the question to one of their old patients who return to the fold after an unaccountable absence of several years. Another factor not allowed for by the Committee is that many of the patients think that they get better treatment at first than at second hand, and therefore not only seldom volunteer the information, but often deliberately conceal it.” There were some schemes that would try to prevent these kinds of situations from occurring, for example the insurance companies tried to help out by preventing doctors from taking on another doctors patients after he returned from the front for a period of time, but none of them were totally successful. These concerns were most acute for urban doctors where there was greater availability, with rural doctors having at least some protection just due to geography.

This was not the only concern for doctors in the military. Another problem would felt strongest by older doctors in uniform, these doctors had generally already established themselves in a practice and an area, and probably had established their own patient list before being called away. since they were being called away for an indefinite amount of time, if they came back and their practice did not continue they faced possible financial ruin and the inability to support their families. They would also receive the same pay as Medical officers who were straight out of med school. These youngest doctors had it best, they were gaining incredibly valuable experience with no real downside since they were not leaving behind anything that could fall apart. They were better able to bank their army pay until after the war was over, allowing them to start their careers after the war with a bang. Meanwhile the older doctors could lose everything if their practices did not recover on their return. For one group there was only upside, for the other only downside. Both of these groups were then heavily disliked by those who had served as medical officers before the war, in the professional army. The newcomers were often given higher ranks and more pay than those who had been in the service before the war, with this inequality being felt strongest by the doctors in territorial units who had been called up very soon after the war started. It had been impossible for many of these doctors to properly prepare their civilian practices for their departure, like many later volunteers could, and they were set to serve for the duration of the war, instead just for a short period like the wartime volunteers. This is actually something I forgot to mention earlier, many of the medical officers who volunteered after the war began only had a one year enlistment period, after which they could choose whether or not to renew for another year. This would become an important factor as fewer and fewer doctors were available.

All of these doctors were then understandably concerned when they felt like they were not even needed at the front. The general ebb and flow of conflict was foreign to many doctors, and this meant that when there were periods where the Army had more doctors thatn needed there were overarching generalizations made about how many doctors the army needed in total. There would be lengthy periods where there would not be much for many medical officers to do, and this made them start to question why the army required their services. One Medical Officer would say “I have now just completed my year, and if I had to do all the work that I have done in that time again I could easily fit it into one month and have plenty of time for recreation or study. It can be no question of my having fallen on a soft job as I’ve done practically every sort of job in my time, both at home and in France, with the exception of work in a C.C.S., where I believe the Medical Officers generally overworked.” This type of concern, even if it was just part of military life, made many doctors far less likely to re-up for another year once their first was complete, and this would very soon be a problem. The entire concept of allowing the Medical Officers to opt out of another year of service began to be questioned in 1917. This questions would ramp up after August when the War Officer would be told that the supply of new Medical Officers had been abandoned. This revolution would be the final straw that would lead to the creation of a Commission of Inquiry and after the commission was complete they would have a few recommendations. The first was a reduction in the number of Medical Officers with a field ambulance, with those officers to be replaced by men who were not doctors, and then they also believed there could be some savings on Ambulance Trains, again by substituting non-doctors in for Medical officers. In both of these cases it was mostly just a recognition that some of the jobs being done by Medical Officers could be done by nurses and trained aids. While this moves did help alleviate some of the problem, the ability of Medical Officers to leave after their annual contract was still considered a problem. This meant that in December 1917 a new rule was created. After that date any Medical Officer that relinquished his commission on expiration would be immediately called up into military service for the rest of the war. So while the ability to decline a new contract still existed, exiting the armed forces was no longer an option. While this would once again help, the German spring offensives would force the British to extend Medical Officer conscription to doctors aged up to 55. These older doctors were then used to fill spaces at Base Hospitals while younger doctors were moved closer to the front. In many ways the British Medical Services were lucky that the war ended hwen it did. If the war had continued into the next year they may have found it difficult to find enough trained Medical Officers to fill the ranks if only because of the arrival of the Spanish Flu, a topic for another episode.

We turn now to our first group of people to discuss today that were not certified male doctors when the war started, and this first group is medical students. Much like other groups of young people in Britain, when the war started many medical students wanted to assist in the war effort as soon as possible. For many of the men this meant volunteering for service in the army, and for women volunteering for either nursing or medical groups like the Red Cross. Many of the male students made it to the front, and their exodus from medical schools was seen as a serious problem. In total there were 1,000 fewer students in medical schools by the end of the first year of the war. The War Office first advised medical students who had joined the armed forces that the best way to do their duty was to return home and finish their studies as soon as possible. When this did not bring as many students back as hoped, the War Office took more drastic measures. In 1915 most medical students serving at the front, who had been in their last two years of school, were brought back and instructed that they had to finish their studies. With many men in society who had not volunteered being accused of cowardice in 1915 when medical students were brought back to school they were allowed to wear military uniforms. This let everyone know that they were doing what their country needed, which was very helpful to student morale.

When the Derby Scheme was enacted, and it required men to attest to future service, there was a special bit of rules around medical students. Essentially those students in the final half of their schooling could simply attest that when their studies were complete they would make themselves available as Medical Officers, if they did not agree to this they could be called up at any time. Those students who were in their first half of schooling were liable to be called up to general service at any time as well. For female students the situation was different, since theyw ere not liable for being called up they generally just continued their studies as normal. It is likely that if the war had continued another few years they would have been involved with the war effort in some way, or more of a way than they were, but that did not happen.

These rules and regulations left one group of former students a bit in the lurch, those who had been in the first half of their studies but who had volunteered as soon as the war started. These students were often not called back from teh front since they were early in their studies, but for many, if they had not volunteered in 1915 they would have been in the last half of their studies by the time that the Military Service Acts came into place. This unfortunate timing seriously damaged their future employment opportunities, since many of their former classmates were by 1916 almost done with medical schools and about to start a difficult, but very rewarding, tour as Medical officers instead of infantry soldiers. Here is one father discussing this specific situation for his son, I think the last two sentences really say it all. “My only son … accepted a commission in 1914 when in his second year. He has now been on foreign service for over two years, and … looks like serving … two more years. By that time he will be twenty-four years of age and will still have four more years before he can qualify, not to speak of the year or two of hospital work before he will be fit to succeed me. Meanwhile, those students in his year who, quite as fit as he, but endowed with less patriotic feelings and more concern for their own individual welfare, resisted their country’s call, are now enjoying complete immunity from service, together with good hospital appointments as unqualified house-surgeons (at £90 a year) and are within a year of being able to take up practice. One wonders whether patriotism really pays. Still I do not envy them or wish my son had emulated them.”

Our second group fo individuals are female doctors. The War Office simply refused to even consider the idea of women doctors serving overseas, instead they wanted them to serve in hospitals in Britain to free up the men to go to the front. While the British were a bit more backwards in their views on this subject, there were other countries were female doctors were called up to serve at or near the front, and in these situations they performed splendidly. One example of this was in Serbia, where women worked right up at the front, saving both injured men and helping those suffering from diseases. Another area where the War Office refused to take women seriously was the area of commissions. As we discussed last episode the path for Medical Officers to get proper commissions was a long one, but the War Office drew the line befoer giving them to women. Instead the women were classified as “attached” to the Medical Corps, but were not actually part of it, and their pay did not rise above that of an infantry Captain. It was not just vanity or greed that caused the female doctors to desire these commissions, though a bit more pay would have been appreciated. The problem was that not having sufficient rank meant that they did not have the authority to efficiently carry out the jobs that they were already performing. This meant that the British were not doing a good job of utilizing what was becoming a valuable resource, training medical personnel, just becuase they were female.

While the British Government did not allow female doctors close to the front, they found another way, through the Red Cross and other civilian organizations. These organizations were more than happy to employ female doctors, and in these roles they proved they were equal to their male counterparts. Here is a lengthy qutoe from Dr. Elizabeth Courtault who worked in a hospital in Viller Cotterets northeast of Paris “There came an order for the hospital to evacuate.… Then came an order that heaps of terribly wounded were expected, and we could stay on. We were glad. It seemed horrid to be told to go and leave things behind us. All the night we were hard at it and working under difficulties. Terrible cases came in. Between 10.30 and 3.30 or 4 a.m. we had to amputate six thighs and one leg, mostly by the light of bits of candle, held by the orderlies, and as for me giving the anaesthetic, I did it more or less in the dark at my end of the patient… air raids were over us nearly all night and sometimes we had to blow out the candles for a few minutes and stop when one heard the Boche right over. Next morning [30 May 1918] about 11 a.m. we were told the whole place must be evacuated, patients and all…. So during the day we did have a strenuous time. Patients had come in all through the night, some practically dying, all wanting urgently operating upon. But we had to stop operating, dress the patients’ wounds and splint them up as best we could, and all day ambulances came up and we got patients away.” Unfortunately for many female doctors, and nurses as well, with the end of the war instead of the situation improving at home because of the proof of their abilities, they would often find the same sexist feelings as before 1914.

While female doctors had some difficulting getting the credit they deserved, the same cannot be said for the nurses at the front. By the early 20th century nursing was a long-established, well-regarded, and greatly valued aspect of medical care. Everyone knew that good nursing meant saving lives. During the war nurses would work at every hospital in Europe, they would also be present in Casualty Clearing Stations, some would get even closer to the front. Mary Borden, who would serve as nurse during the war, would describe here job like this “It was my business to sort out the wounded as they were brought in from the ambulances and to keep them from dying before they got to the operating rooms: it was my business to sort out the nearly dying from the dying. I was there to sort them out and tell how fast life was ebbing in them. It was my business to create a counter-wave of life, to creat ethe flow against the ebb. It was like a tug of war with the time.”

As everyone in the hospitals and clearing stations became more and more busy the role of the nurses continued to grow larger and larger. It began with the move to have nurses to much of the dressing work. Traditionally this dressing would have been done by surgeon’s assistants, but there were simply not enough of those to go around and so the nurses were trained in how to manage wounds by keeping pressure on them, applying proper bandages, manually compressing arteries with their fingers, or utilizing pressure points to stop the flow of blood. In many of these situations the nurse became the life saver, not just an ancillary individual in charge of taking care of convalescing soldiers. Many nurses would also be asked to make critical clinial discussions in pressure filled moments, because they were the only ones available. In a somewhat funny development in November 1917 there was an announcement from the Director General of British Medial Services that nurses would now be invited to train and anaesthetists. This was a great move, except for the fact that in many hospitals nurses were already acting as anaesthetists, and they had been for some time. In all of these situations nurses stepped into roles where they were needed, to make sure that lives were saved.

Nurses, just like Medical officers and soldiers served in many theaters outside the Western Front. In many of these areas the experience was different than in France and Belgium. An additional hardship for these nurses outside the Western Frotn was a general lack of supplies, forcing them to make due with what was available and be innovative with their treatments. In places like Egypt a huge problem was that the dust and sand could get everywhere, and it would often carry micro-organisms that could cause infections. Eva Lea was a nurse at Lemnos in September 1915, Lemnos being the primary base of operations for the Gallipoli campaign, and the first stop for many wounded who had been evacuated from the fighting. She would say this about her experience “1. Flies, flies everywhere. 2. You can’t bathe because the sea is full of scum and dead horses. 3. Only 1 pint of water is allowed to each one for all purposes as it is so scarce and has to be taken there. 4. Food is awful. 5. Work to much. 6. No butter, only goat’s milk, no shops, no news, in fact the only good thing about it as far as we can hear, is the beautiful sunsets and sunrises and that the climate is cooler. It is still very hot here and we have all been a bit bowled over by it.”

While every effort was made to keep the nurses out of any combat situation, what they were doing was still dangerous. The biggest concern was infection. The long working hours, the stress, and the working conditions meant that infection could quickly overwhelm a nurses already reduced immune system. There were also small infections that while not life threatening were annoying. One of these was called septic finger which would occur when fingers became cut or scraped, something that could easily happen, and then they would get infected. In many of these cases the problem was not critical, but it made it more difficult to use those fingers. I think the best way to close this episode is to look at three first hand accounts from nurses during the war. The first will be a nurse who was in a train carrying wounded from the First Battle of Ypres in 1914. “We were tackling a band woudn in the head, and when it was finished and the man was being got comfortable, he flinched and remarked, “that lead is a beast’ We found a compound franctured femure put up with a rifles for a splint! He had blankets on, and had never mentioned that his thigh was broken. It too had to be packed, and all he said was ‘That leg is a beast’, and ‘That leg is a Beast’” The second is from an unknown Western Front nurse “I have many times felt myself in a tight corner during the war, but never in such a one as this when I stood in the middle of one of the wards filled with over 200 of the worst gas cases I have ever seen, and only a few hurricane lamps to give us a little light. i remember the feeling of despair that came over me, and the relief we all felt when the early hours of the morning brought us light at last.” And here is Sister Eveline Vickers Foot who would describe patients suffering from cholera in June 1917 “Cases woudl die on the stretcher 12 hours after they were taken ill. WE dressed in rubber costumes with masks, overalls, and rubber boots. The vomiting was so terible we had to have masks, Jacanet across nose and mouth, with a wad of wool soaked with a strong smelling antiseptic.” Next episode we will dig into the details of the treatment techniques and technologies that doctors and nurses were using to treat the wounded and to slow the spread of disease in the armies.