THE HISTORICAL BACKGROUND
• The Crimean War – Florence Nightingale
• the American Civil War
• the Boer War
• World War I
WORLD WAR II
• From battlefield to base hospital
GREAT BRITAIN
• Queen Alexandra’s Royal Naval Nursing Service
• female medical officers, Royal Naval Volunteer Reserve
• Queen Alexandra’s Imperial Military Nursing Service
• Territorial Army Nursing Service
• female officers, Royal Army Medical Corps
• Princess Mary’s Royal Air Force Nursing Service
• female medical officers, Royal Air Force
• Voluntary Aid Detachments
UNITED STATES
• Army Nurse Corps
• Army Air Force nurses
• Navy Nurse Corps
• female medical officers
• American Red Cross
BRITISH COMMONWEALTH
• Canada
• Australia
• New Zealand
• South Africa
SOVIET UNION
SELECT BIBLIOGRAPHY
THE PLATES
HISTORICALLY, THE CARE AND TREATMENT of the wounded and sick during military campaigns had always been haphazard. The number of physicians and surgeons available to armies had always been absurdly small, and the crudest sort of nursing was provided, if at all, by the soldiers’ women among the camp followers. As the ‘age of enlightenment’ dawned in the 18th century the degree of medical care differed from nation to nation, but was generally characterised by scientific ignorance and a waste of human life. Although medical and surgical advances were pioneered over the next 150 years the quality of care remained extremely patchy. The great majority of deaths were due to disease; but a high mortality rate among the wounded was inevitable, given the minimal arrangements for bringing the casualties to treatment. If they did reach the surgeons alive, many were carried off by post-operative shock or sepsis due to lack of anaesthetics, ignorance and poor hygiene.
The 18th-century Austrian army had an exceptionally well-planned medical service for its day; the dedication and foresight of Baron Larrey, chief surgeon to Napoleon’s Imperial Guard, became legendary; but it was not until the Crimean War (1854–56) that nursing reforms, based on post-surgical care and hygiene, were pioneered in the British service by Florence Nightingale at her hospital at Scutari.
The Director-General of medical services, Sir Andrew Smith, was a humane and energetic man, and on paper his preparations for the campaign were admirable; but lack of resources and administrative incompetence sabotaged his plans, with calamitous consequences. The catalyst for the improvement in this, as in other fields, was William Howard Russell, the correspondent for The Times. At a time when journalists were beginning to provide the public with eyewitness reports that were in stark contrast to the sanitised official bulletins, Russell’s despatch of 12 September 1854 was wholly damning of the British medical services. It convinced the Secretary of State at War, Sidney Herbert, that nurses were needed in the Crimea; and that the ideal person to lead them would be an old acquaintance of his, Florence Nightingale. Miss Nightingale thus became the first officially appointed British military nurse, serving with the Army but not a part of it.
The social prejudices of the day restricted the active roles of women in society; and while nursing slowly gained a general public acceptance, military nursing was slow to achieve the same recognition – war was felt to be a strictly male domain. The necessary education was open only to the upper classes, but it was considered unbecoming for a lady to lower herself to the menial tasks and rough company required of military nurses – these tasks were best left to men, and thus were all too frequently just left… . Nevertheless, the situation slowly improved, largely due to the Victorian middle-class ethos of charitable public service.
The next half-century saw constant advances in medical science and improvements in patient care, which were to reduce the heavy mortality rate from wounds and sickness – and thus to increase the rate at which men could be returned to active duty, with advantages obvious even to the least compassionate. The role of nursing in this equation was soon appreciated by all; but recognition of the need for a large and organised military nursing service was still masked by the dedicated efforts of idealistic amateurs.
The Army Nursing Service finally came into being in 1889, and had 800 trained nurses by the end of the Boer War in 1902. At this time the Royal Army Medical Corps probably led the world in its standards of medical knowledge – not only clinical, but also administrative, logistic, and across the whole related field of sanitation and hygiene. During the Boer War (1899–1902) survival rates among the wounded were far higher than a generation before. Nevertheless, although foreign observers were sufficiently impressed to urge the copying of British practice in their own armies, a subsequent royal commission found that under the burden of numbers of casualties, particularly from disease, practice had fallen short of theoretical standards. For every one of the 22,000 troops treated for wounds, 20 were hospitalised suffering from disease – some 74,000 came down with enteric and dysentery alone, and at unit level standards of hygiene were still lamentable. As a result of the commission’s findings, effective reforms at all levels were driven through in 1905–10 by the Director-General, Sir Alfred Keough, and the War Secretary, Lord Haldane, and the whole chain of evacuation was reorganised.
In the United States, thousands of women came forward to tend the wounded during the Civil War (1861–65). ‘Nursing’ at this time largely meant providing for general welfare rather than medical care, however – bathing and feeding patients or laundering linen. Civilian volunteer nurses worked in hospitals behind the lines, provided by charitable and church organisations; actual medical care was provided by soldiers of the Confederate and Union Army medical departments, whose shortcomings were much the same as in armies the world over. Some 30 years later the Spanish-American War (1898) found the US Army Medical Department severely undermanned, and the shortage of qualified male medical orderlies led to the recruitment of female nurses qualified in medical care and graduates of civilian nursing schools or institutions. These women were not a part of the Army but were termed ‘contract nurses’, many being under the control of voluntary organisations rather than the Army. It was 1901 before the US Army established its own permanent military nursing service.
The unprecedented numbers of casualties suffered during the Great War (1914–18) would once and for all confirm the necessity of having fully trained nurses as a permanent part of the military medical organisation. Although the sheer numbers of casualties to be treated were overwhelming, the actual ratios of recovery reflected well on both recent advances in medical capability, and also on the practical and psychological benefits of care by qualified nursing sisters. (In 1914–18 the percentages of deaths among those who were admitted to British medical units were 7.61 per cent of the wounded and 0.91 per cent of the sick. The important distinction is that these impressive recovery figures applied only to those who reached medical care.) The chain of evacuation – though often delayed and distorted by the horrific local conditions – took a casualty from his Regimental Aid Post, to a Collecting Post, to Advanced and Main Dressing Stations, and a Casualty Clearing Station, before further distribution, if necessary to a large General Hospital with specialist facilities. (From the Western Front, some 40 per cent of wounded and sick were evacuated back to Great Britain.)
Under pressure of numbers and the types of multiple wounds encountered, the Casualty Clearing Station soon lost its purely ‘sorting’ role, and both expanded and moved forward towards the fighting line. It acquired specialist facilities and a staff of nursing sisters, and in some cases could take up to 1,000 patients. A broad generalisation would be that by 1916 the benefit had been recognised of surgical intervention earlier than had previously been thought wise; and this required the forward movement of those facilities in which nurses were stationed.
The many thousands of women who followed the vocation of nursing were thoroughly trained and usually highly efficient. At a time when women’s place in society was a subject of constant debate, educated women were well aware that the professional respect of male colleagues was hard-earned, and set themselves extremely high standards. Their work in forward areas was often undertaken in unavoidably squalid conditions. No concessions were made for a nursing sister’s sheltered upbringing or her youth; she was expected to face the most appalling sights and distressing responsibilities with calm competence, and was subject to strict discipline. Casualties’ memoirs make clear that the great majority of nurses rose to these demands, making an unforgettable impression on those for whom they cared.
The decline of the military in the post-war era saw the reduction of the military nursing services to, in most cases, a mere handful of sisters; reliance was placed on a reserve of qualified nurses to be drawn from the civilian sector in time of need. This expectation of availability led to some strain during the early part of World War II, when Britain’s cities were suffering heavily at the hands of the Luftwaffe and civilian nurses found themselves heavily burdened by huge numbers of civil casualties. The shortage of nurses was met by the Voluntary Aid Detachments, whose service to civilian and military nursing during World War II is often overlooked but was absolutely essential. The VADs were further supplemented in British service by specialist Auxiliary Territorial Service ranks; and in the United States the Women’s Army Corps provided hospital aides trained in a variety of employments, as did many other organisations.