MILITARY NURSING THROUGH THE AGES

 

BY

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ANNE THOMPSON,

ROYAL RED CROSS

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Although there is, apparently, no record of any sort of established nursing service in early times, there is no doubt that with all armies some provision was made for the wounded on the battlefield.

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3400 B.c.-1200 B.C.:

 

Sixty centuries ago, in Crete, the standard of hygiene was definitely high, and it is safe to infer from this fact alone that there must have been some interest in, and arrangements for, the maintenance- of health.

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3500 B.C. Onwards:

 

In Egypt, medicine was held to be of divine origin, and the medical practitioner and his attendants were more in the nature of priest and his satellites. It is probable, therefore, that attention of the sick and wounded on the battlefield was provided by the soldiers themselves.

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2500 B.C. Onwards:

 

The ancient civilizations of Chaldea, Babylonia and Assyria produced a period of great intellectual development, and also instituted a legalized medical service. It was a period of wars, massacres and pestilences, hence it is obvious that the highly qualified medical man must have had assistants of some sort, and having regard to the subservient position of women, it is most probable that these assistants were men.

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The ancient Indian cultures produced a most comprehensive system of rules for the preservation of cleanliness within and without, founded on the belief that prevention of disease is more important than the cure.

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Definite instructions are laid down for the nurse, which might well stand for the present day, as this extract from the Charaka-Samhita will show:

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"Nurse: Knowledge of the manner in which drugs should be prepared or compounded for administration, cleverness, devotedness to the patient waited upon, and purity (both of mind and body) are the four qualifications of the attending nurse." .

 

And again: "That person alone is fit to nurse or to attend at the bedside of a patient, who is cool-headed and pleasant in his demeanour, does not speak ill of anybody, is strong and attentive to the requirements of the sick, and strictly and indefatigably follows the instructions of the physician."

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During the reign of Asoka, public hospitals, which were schools of medicine, were erected along all the normal routes of travellers, and skillful physicians and equipment were supplied at the expense of the State.

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Our knowledge of the medical and hygienic customs of the Jews is taken mostly from the Old Testament: with their frequent wanderings, and captivities, it is safe to assume that much of their knowledge was acquired from other nations. The net result was a most comprehensive ritual which covered strict supervision of foods including inspection of meat, dietetic restrictions, laws of hygiene, segregation of those suffering from communicable disease, and subsequent disinfection. They were the first people to deal with infection in a rational manner.

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Information regarding the medical and nursing work of China is of a later period, though ShenNung known as the father of Medicine-ruled for a long period 'between 2000 and 1000 B.C. That their knowledge" was intricate and advanced there is no doubt, though some of their theories are rather startling to us. One of their greatest contributions was massage, an art in which they excelled. This art was not brought into use in Europe until A.D. 1800! 

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The early phases of Greek medicine are much like those of other nations, but the god-like attribute of medicine was probably more pronounced.

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Aesculapius, the son of Apollo, was the great god of medicine, and the many temples raised in his honour provided a system almost of hospitalization. The priests of these temples were the physicians, and the many attendants and servants no doubt supplied the nursing care.

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500 B.C. and After:

 

It was with Hippocrates that the era of scientific medicine begins, and with it, in all probability, the foundation of improved nursing arrangements. He it was who rejected the supernatural origins of disease and taught that it was caused by a breach of natural laws. His disciples were instructed in all the details of what we now term "nursing technique," and also in the value of observation of the patient's condition.

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250 B.C. Onwards:

 

Early data of Roman medicine is scanty; but there is evidence (somewhat legendary, it is true) that Greek medicine was introduced in the year of pestilence, 239 B.C. However, it is with the Romans that we have our first records of Army nursing. There is no doubt that every previous civilization must have had some system of caring for the sick and wounded of its Army, but, apparently, it was

haphazard and of a rough and ready nature, as no records have been traced.

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Rome, however, instituted a definite system of hospital and services for its armies. It was an essentially militaristic nation, and its armies roamed over large areas, many of them" almost barbarian in "nature. Therefore, the Army was equipped most comprehensively for the care of its own sick and wounded.

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The fighting man was issued with the equivalent of a "field dressing," and had rudimentary instruction corresponding to first aid. Doctors were attached and though they did not rank as officers, they had certain rights and privileges.

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Every camp had its valetudinarian, with complete staff composed of administrators, doctors, and "those who wait on the sick." These last were probably slaves, but in their duties would correspond to the modern orderly. In the medical care of ‘the Army, Rome spared no expense. On the return of the Army to Rome, the sick and wounded were "boarded out" for each house of any size had its own valetudinarian, which normally was used for the sick of the household. The care of the sick in the house was the responsibility of the lady of the house and her female slaves. This custom may, therefore, constitute the origin of female nursing of the Army's sick.

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A.D. 390:

 

Later, the first hospital was built in Rome by Fabiola, but this was probably a public hospital for the poor; certainly not for the all-important soldier, who continued to receive the more specialized treatment of the valetudinarian.

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The introduction of Christianity caused a great set-back to medicine which was pagan in origin with its conception founded upon and closely Linked with the worship of the pagan gods. With the advance of Christianity, the obliteration of all signs of pagan worship was a natural result.

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Yet it was the more fervent Christian followers in the early days who established various methods of administration to the sick, which have grown through the ages to the present system of hospitalization, medical and nursing care, health visiting, etc., etc.

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The care of the sick was lifted to a higher plane, and each congregation had its "deacons" and "deaconesses" whose avowed duty it was to go outside the limits of their own homes and care for the sick. An exact date is difficult to ascertain, but there is no doubt that by the fourth century, organized care of the sick was an established fact and from then on one can trace the course of

nursing to present times.

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With the establishment of religious orders, the care of the sick became more 'and more the responsibility of members of these communities. There is little if any, mention of medical and nursing care for the armies of the world, though one can gather that where a battle was fought in the vicinity of such an establishment, succour “was given to the wounded, after the battle, by the members.

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It was not until the twelfth century that the era of the true hospital begins, and with this we find various religious orders, whose main duty was the care of the sick, and, from the military point of view, the establishment of the Order of the Knights Hospitallers is the most important. The Crusades constituted the direct reason for the founding of the military nursing orders. With the capture of Jerusalem and the establishment of a Christian Kingdom in 1099, the Order of St. John sprang into prominence the origin is somewhat obscure, some historians giving the credit to some Italian merchants, who in 1050 established two hostels at Amalfi for the use of pilgrims, though others give the credit to Peter Gerard.

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The Order was divided into three classes, Priests, Knights and "Frieres Sergeants," or serving brothers, who did the actual nursing . The Order grew large and powerful, but with the conquest of Palestine by the Saracen, the Knights had to abandon all their possessions, and a few escaped to Cyprus.

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Thereafter, their history was as romantic as it was varied. They held Rhodes from 1310 to 1522, when it was captured, and they were compelled to leave. The Emperor Charles V then gave them Malta, where they stayed from 1530 to 1798, when, they were turned out by Napoleon. Their significance in nursing history is great. The Crusading spirit lent it a lustre which attracted the greatest in the land. The prestige was high, and influenced and stimulated all subsequent hospital organizations.

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As the Knights were generally very wealthy, they were in a position to equip and maintain their hospitals far better than any other community. There was a female branch of the Order, equally as old as the mens and while in Jerusalem the Sisters nursed, but after their evacuation from Palestine

to Europe there is little or no evidence of their having continued their nursing. The influence of the Knights Hospitallers spread across most of Europe, the Order of Teutonic Knights being a large and important subsidiary Order. A third great military nursing Order, which also rose to importance during the Crusades, was that of the Lazarists or Knights of St. Lazarus, whose main object was the care of lepers. With the decrease in the incidence of leprosy in Europe, this special need diminished, till in 1490 Pope Innocent VIII closed the Order and handed the possessions to the Order of St. John.

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The progress of nursing through the Middle Ages depended almost entirely upon religious and secular orders, and was carried out almost entirely by women, and there is no doubt that these secular communities advanced the practice of nursing in no' small measure. Little is known, however, about the military nursing of these days, and it would seem ‘that the nursing of the sick and

wounded of the Army was largely dependent upon either the good services of other soldiers or upon the camp followers-the .motley collection of women of loose morals but of generous and kindly nature, which followed the Army wherever it went. Their professional knowledge was obviously non-existent, though possibly with time and all too much practice they attained a certain amount of skill. It may be added that even as late as 1846 their use was advocated by William Fergusson, the then Inspector-General of Military Hospitals in England. In fact, their presence was allowed only on condition that they nursed the sick and wounded.

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There is no doubt that nursing as such was at a low ebb during the seven tenth and most of the eighteenth centuries. Conditions for nurses were such that only the poorest types would accept the work. The late eighteenth and early nineteenth centuries began to show greater advances than ever before.

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Reformers like John Howard (1727-1789) and Elizabeth Fry (1780-1845) worked indefatigably to improve general conditions for patients, and consequently their attendants. It needed the Crimean War to bring home to the world the necessity for improved conditions in the Army.

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Army hospitals were in a deplorable state. Soon after the outbreak of the Crimean War, ugly rumours began to reach England of the neglect and mismanagement: one report from the special correspondent of The Times (October 9 and 12, 1854) said that in the hospitals were "neither surgeons, dressers, nurses, nor the commonest appliance of a workhouse sick ward." Later, having noted that the French had the ministrations of the Sisters of Charity, he demanded, "Why have we no Sisters of Charity?"

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Sidney Herbert, the Secretary of War, and Florence Nightingale, took up the challenge. His letter on the subject to Florence Nightingale, with a request for help in sending a staff of women to Scutari, is worthy of special note. "There is," he wrote, "but one person in England that I know who would be capable of organizing and superintending such a scheme. . If this succeeds, an enormous amount of good will be done now, and to persons deserving everything of our hands: and a prejudice will have been broken through and a precedent established which will multiply the good to all time." With the acceptance of the post by Florence Nightingale, military nursing took one of its longest steps

forward.

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The difficulties she encountered, the prejudices she had to overcome before she set off on October 21, 1854, with her little team of thirty-eight nurses are too well known to need further description. But the revolutionary aspect must be fully appreciated. WOMEN nurses in the British Army! Quite unthinkable! But the step was taken, and the gain to nursing in the Army in particular, and modern nursing in general, is beyond measurement.

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The conditions on the arrival of Florence Nightingale and her nurses were indescribably bad. Equipment of any sort was practically non-existent, sanitation was appalling, and everything covered with filth and vermin.

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A quotation from a nurse's letter is enlightening: "Generally speaking, the chief medical officers resolutely closed their eyes to the great want in the hospitals of every comfort for the patients : they would have said, from time immemorial a prescribed course has been resorted to in order to meet certain exigencies, and, if it did not meet them, it was supposed to do so: which was, they persisted, so far as they were concerned, the same thing." (One knows this attitude even in these enlightened times.) 

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Gradually, by almost superhuman efforts, improvements took place. Comforts (which were really necessities) were bought out of funds which had been given to Florence Nightingale for the benefit of the soldiers, and The Times instituted a fund which was administered by an official who was sent out and who worked in close liaison with her.

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In addition to the nursing, she also instituted a scheme for the care of soldiers' wives. Another reform was the introduction of recreation and reading rooms, schemes which have stood the test of time and are still of incalculable value to the welfare of the Army. 

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Also, at her own expense, she fitted up a house to enable doctors to carry on their scientific studies. This small experiment was destined to be the nucleus of the Army Medical School. The general improvement is, perhaps, best shown by the rate of mortality which fell from 42 per cent to 22 per thousand. In spite of her magnificent efforts: she was not given official status until February of 1856, when she was called "General Superintendent of the Female Nursing Establishment of the Military Hospitals of the Army."

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After her return in August 1856, she continued to work unceasingly for the improvement of conditions in the Army. The total number of nurses by the end of the war was 125, and this formed the nucleus of the present Military Nursing Service. Closely linked up with the advance in Military nursing during this period is the inception of the "Red Cross." With the many wars, various organizations for aiding soldiers had sprung' up, but were chiefly for supplying material comforts. In many instances, however, the voluntary helpers concerned found themselves nursing the sick and wounded because of the lack of trained nurses.

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French and Italians against Austria:

 

The founder of what is known now as the Red Cross was a Swiss, Jean Henri Durant (1828-1910), who organized a band of amateur helpers after the battle of Solferino (1859). He published a book

describing the sufferings of the miserable wounded of both armies, and then travelled widely to advertise his scheme for the prevention of such miseries. As a result of his activities, especially after a talk in person at the International Statistical Conference in Berlin, a member of the Geneva Society of Public Utility invited various governments to 'an International Conference to be held in Geneva in October 1863.

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The outcome of this was the famous Convention of Geneva which was signed in 1864 by twelve Powers. The distinctive mark for medical personnel was to be a red cross on a white field-the flag of Switzerland with the colours reversed.

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The ultimate outcome was the International Red Cross Society as it was finally named. As regards its nursing activities, the Convention of 1863 mentioned only men nurses, but by 1869 the scope. Was more general, and resolutions were passed for the instruction in nursing of anyone who wished to serve from patriotic motives.

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The degree of training varies in different countries from elementary nursing (this mainly in countries having an established military nursing service) to full and complete training to constitute the supply of trained personnel for the Army in time of war.

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The activities of the "Red Cross" were not by any means confined to nursing. The administrative bodies have built up one organization after another.to meet some particular need, with the consequence that during· the recent war the personnel of the armies, whether sick or wounded or fit, were able to depend on them to an unprecedented degree.

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DEVELOPMENT OF THE MILITARY NURSING.

 

It should be remembered that up to the period now under review there was no such thing as a "trained nurse."

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Probably the first instance of an organized training was that of the well known Kaiserworth. This institution, founded in 1836 in a very small way by Pastor Fliedner near Dusseldorf, introduced a definite system of training for its "deaconesses." Most of the nursing lectures were given by the Pastor's wife Frederike. The movement expanded and aroused considerable interest in other 

countries. Visitors came to study its methods and later experienced deaconesses were sent to start similar institutions in other localities . Elizabeth Fry, Florence Nightingale and Agnes Jones all spent some time there and built up their ideas for nurse training on similar lines.

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In 1855 public opinion in England was resolved that there should be some concrete mark of appreciation of the work of Florence Nightingale in the Crimea. The result was the formation of the Nightingale Fund which was to be used by her to establish and control an institution for the training, sustenance and protection of nurses.

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By the time she had reached 'England in July 1856, the Fund had reached the sum of forty-four thousand pounds sterling. A Royal Commission on "The Health of the Army" was set up in 1857 to

inquire into the terrible conditions in military hospitals. Scutari had demonstrated beyond all doubt that there was room, and great need, for women nurses in British Military Hospitals, and that a different and better type of women was needed to create the new order of nurses. They needed to be educated women willing to devote their lives to their work. They needed instruction in all the branches of science that enter into nursing and practical knowledge of ward and sickroom work.

Medicine and surgery were making great advances during this period and it became increasingly evident that the nurses must have the necessary knowledge to appreciate what was being done for the patient, and to be able to carry out instructions intelligently.

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The time was ripe for the introduction of the professional nurse of good character, with education and intelligence. Florence Nightingale set herself to found an institution on her own lines to impart the necessary training. She chose St. Thomas's Hospital, where the Resident Medical Officer, Mr. Whitfield, was fully in sympathy with her schemes, which was certainly not the case with

many other medical men. Also, she spent considerable time and thought with her matchless organizing ability to carry out a scheme for Army nursing, and managed against some

opposition to arrange that women nurses should be employed in the General Hospital at Fort Pitt, Chatham, to look after the soldiers sent home from the Crimea. 

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On May 19, 1856, the foundation stone of the Royal Victoria Hospital was laid at Netley by Queen Victoria and a little later the Herbert Hospital (now the Royal Herbert) was started at Woolwich. Each of these hospitals was staffed with a Lady Superintendent and six to ten nursing sisters. In 1860, the Army Medical School was transferred from Chatham to Netley and the nursing staff under the supervision of Lady Jane Stewart Shaw was also transferred .

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In 1866 nurses were appointed to all Military General Hospitals, but it was not until 1881 that an Army Nursing Service was formed. Later in 1883, it was ruled that all military hospitals having one hundred beds or more should have a nursing staff. Originally, all nurses served a probationary period at Netley, and were then drafted to other stations. They were responsible for the nursing of their

patients, for giving them their medicines, food, etc., and also for the training of the orderlies in their wards.

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This last is important, for it throws a light on the fact that previously the orderlies had had no training in nursing duties.  In 1884 a "Code of Regulations for the Female Nursing Services of the Army" was published, arid it was then established that all Army nurses must have received previous training in a civil hospital.

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At the outbreak of the South African War, 1899, the Army Nursing Service was:-

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1 Lady Superintendent (at Netley).

19 Superintendent Sisters.

68 Sisters.

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By the end of the war 22 general hospitals of 520 beds each had been established in South Africa alone. The Army Nursing Service had been augmented in various ways. Princess Christian's Army Nursing Service Reserve, composed of civilian nurses, with full or partial training, supplied a large number of the nurses required. Queen Alexandra (then Princess of Wales) arranged for the despatch of a draft from the London Hospital, and some were sent by various Colonies . Later many of these, were absorbed into the Regular Service, while a large number remained on the Reserve.

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Just as the Crimean War had brought home the need of nurses in the Army, so, the South African War proved the necessity of a thoroughly well-organized nursing service. It proved how an efficient, well-trained, well-organized service would in every way help to increase the efficiency of the Army Medical Services at all times. With trained women, the nursing orderlies were in a position to learn to carry out their duties with knowledge and efficiency. 

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In 1902, the details of a new nursing service were formulated. Queen Alexandra displayed the keenest interest in this. "Queen· Alexandra's Army Nursing Board" was formed, and Her Majesty permitted the new service to be named "Queen Alexandra's Imperial Military Nursing Service." She also became its first President.

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The total number was about 300, with a Matron in Chief at War Office and two Principal Matrons, one at War Office and one in South Africa.

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The Great War (1914-1919) required an enormous increase in staff, which was largely supplied by the Reserve which had been placed on a firm basis in 1913. In 1914, no less than 2,223 nurses were enrolled and by 1919 the figure had reached 10,404.

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This number was further augmented by V.A.D.s of the Order of St. John of Jerusalem and the B.R.C.S., a total of 8,495 being employed to take the place of Royal Army Medical Corps orderlies. 

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Between the 1914 -1919 war and the recent world war, many changes have taken place. In 1921 a service for Military Families Hospitals was established but this was amalgamated with the Imperial Service in 1927. In 1926 the Military Nursing Service for India was also amalgamated. This, besides opening up a much wider field for the Army Sister, entailed a large increase in the establishment which in 1939 (before the war) consisted of:-

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(A) A Matron in Chief (at War Office).

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(B) A Chief Principal Matron (in India).

 

(C) Six Principal Matrons.

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(D) Thirty-six Matrons.

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(E) Sisters, approximately 570.

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From the commencement of the reorganization of the Army Nursing Services, improvements in the training of the R.A.M.C. orderlies naturally followed. Various sections were formed and though all orderlies were required to have the rudiments of nursing knowledge, the nursing orderly was now in a position to acquire a satisfactory and comprehensive training. The success of this has been amply proven by the fact that the General Nursing Council accepts Army training and allows those qualified to sit for their State Registration Examination without further training.

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PROGRESS IN INDIA.

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It was in the year 1926 that the first nursing service for the Indian Army was formed. It was named the Indian Military Nursing Service and was composed of

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12 Matrons,

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18 Sisters

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25 Staff Nurses 

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Fifty-five in all a woefully small number to be responsible for the hospital nursing of the Indian Army,

and for the supervision, instruction, and training of the nursing section of the Indian Hospital Corps.

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Their scope was necessarily limited by their numbers, but their existence has been so amply justified during the recent war that their post-war position should be much more favourable. The Indian nursing orderly has also proved an unqualified success. The Service, which is the outcome of the war, is known as the Indian Army Medical Corps and the personnel have benefited greatly by their travels and experience with the Army. Many are fully trained nurses and hold Commander rank.

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They have worked side by side with the RA.M.C. wherever the two armies have fought together The enormous increase in numbers of both LM.N.S. and LAM.C. has perhaps done more for the advancement of nursing as a profession in India than any other single factor: There is no doubt that conditions were, and still are, in a desperately low state chiefly due to lack of recognition of the very real necessity for trained nurses. 

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But, during the war, the temporary LM.N.S. who volunteered for active service, many of them with training far below. the accepted standards elsewhere, the untrained cadets of the Auxiliary Nursing Service, and the LA.M.C. have had the opportunity of working with some of the best physicians and

surgeons in the world. The progress made in Medicine during the war was immense and its application was concentrated very largely on the treatment of the sick and wounded of the Army.

This provided most valuable training which was unavailable in many civilian hospitals.

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GENERAL.

 

The work that has been done during the present war by the Q.A.LM.N.S. and its Reserve, the T.AN.S., the LM.N.S., and AN.S., by the nursing orderlies of the R.A.M.C. and LA.M.C. and the V.AD.s who volunteered in thousands, is too well known to require any amplification.

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Where the Army went, the nurses went, women and men, trained and untrained. The nursing orderlies had the privilege of going farthest forward, they were right in the battle line, and their magnificent record of work and heroism under all conditions and circumstances is beyond description.

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The Q.As were not far behind. They went as far forward as they were allowed, much farther forward than has ever been permitted in previous wars. They served with Field Ambulances on the Tiddin Road and in Arakan: and were once referred to as "The most forward young women in Burma.Theirs

also is a record of which they can be eternally proud. Both the Q.A and the RAM.C. and the LM.N.S. and LAM.C. appear to have a gift for getting on with any patient, of whatever nationality. They have had ample experience during the recent war of' patients .of every type, every nationality, every creed and colour, men, women, children, friend and foe, yet always the result was the same: A well-nursed, comfortable, happy patient.

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No nurse could wish for more.

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