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Medical lessons learned

October 17, 2013

The British Army campaign in Sudan, 1882–85 – by Michael Tyquin

Just how conservative was the British medical service before World War I? The notion that the British Army often neglected its injured troops in wartime is outdated, but still surprisingly popular. In fact, Victorian army doctors and nurses working in field medicine were keen to learn about and deploy the most up-to-date medical science to aid casualties during the Middle East campaigns of 1882–85.

Sudan, covering an area of more than 25 million square kilometres, was a province of Egypt for most of the 19th century. After decades of corrupt rule from Cairo there was a popular uprising under a charismatic radical Islamist – the Mahdi – in the 1880s. The British government opposed the uprising, and the result was the Anglo-Egyptian war of 1882.

A soldier in Sudan being treated for sunstroke. Wellcome Library

A soldier in Sudan being treated for sunstroke. Wellcome Library

British forces, under General Sir Garnet Wolseley, suffered considerable physical hardship, causing a number of medical crises. Troops lacked fresh drinking water and adequate sanitation, so cholera took a heavy toll. An added problem was that ambulance transportation could not cope with the number of injured troops at a time when many foot soldiers were malnourished because basic army field rations were substandard. These basic healthcare problems increased casualty numbers.

Wolseley was determined to learn from the medical errors of 1882. And, when he led forces back to Khartoum three years later, to relieve the besieged General Charles Gordon (who was killed two days before they arrived), in health matters the British Army was generally much better prepared. Indeed, the British Army led the way in improving field medicine in the desert during extended military campaigns in hostile environments in the Middle East. These medical lessons also anticipated others that would be learned during World War I. The historical neglect of the Khartoum campaign therefore has meant that historians of medicine have tended to underestimate the contribution that Victorian army personnel made to better healthcare during colonial warfare.

Gordon was an iconic British Army leader who had been sent to supervise a complete withdrawal of Egyptian and British forces from the increasingly dangerous and chaotic region. But he disobeyed orders and found himself under siege in Khartoum. After relentless public and media pressure, the British government sent a large force to Khartoum. Wolseley was ordered to capture the Mahdi, retake Khartoum and suppress the revolt. Two army columns planned to advance from Cairo, one going south along the Nile, while another would fight its way west from the Red Sea Port of Suakin.

The harsh desert environment posed significant health challenges: the heat and lack of drinking water had contributed to several British military disasters in 1882. Aside from a few oases, deep wells were few and far between, and were usually poisoned by the enemy or were located in hostile country. But by 1885, most troops were deployed with their own charcoal water filters, which helped keep the incidence of waterborne disease low. Meanwhile, at the port of Suakin four steam-operated water condensers supplied fresh drinking supplies to the expeditionary force there. And whereas basic rations had been substandard, by 1885 they were generally ample and of good quality.

The recently established Medical Staff Corps recognised that medical preparation was an important aspect of strategic planning. In 1885 there was thus adequate medical support and elaborate casualty evacuation schemes – in stark contrast to 1882. Hospital accommodation, for instance, was now based on better casualty estimates. Even so, in the second month of his 1885 campaign Wolseley had to ask for 23 more medical officers and 124 medical personnel to cope with the influx of sick and wounded. The fact that he got more personnel attests to the willingness of senior British Army staff to support the needs of the wounded in the field.

The prevailing illnesses were typhoid fever, dysentery, diarrhoea and eye diseases such as conjunctivitis. Despite advances in science many army doctors still blamed miasmas for the worst epidemics. Untested remedies such as ‘cholera belts’ (strips of padding or quilted material worn to protect the wearer’s back from the intense heat that was thought to cause heatstroke) and ‘spine pads’ (another supposed preventative measure against over-exposure of the spine to hot sunshine) were issued to troops. References to a flannel-belt for preventing diarrhoea and dysentery still appeared in the British Army’s Manual of Sanitation in 1907. Medical officers – perhaps unsurprisingly – remained critical of Army-issue infantry helmets, which they believed offered little protection from the sun, and in this they were probably right. Military doctors had a sound understanding of the seriousness, if not the physiological causes, of fatalities from exposure to heat.

One key lesson learned from 1882 was that the standard British Army bell tent was unsuitable for hospital accommodation in a hot climate. Consequently in 1885 an Indian Army design was used. It featured a large rectangular tent with double roofs for better ventilation and walls with a well- padded inner lining to keep out the fierce heat of the sun. These new tents could also accommodate more patients; this greater capacity complemented the better-organised field medicine.

Along the Nile, in 1885, Wolseley commanded two columns which consisted of over 11 000 troops, labourers and boat handlers. Surgeon General John O’Nial together with officers and men of the Medical Staff Corps provided health support for the combined force. The Army deployed no fewer than 27 field hospitals (ranging from 12 to 500 beds) along the Nile from Aswan to Korti, a distance of over 1250 kilometres. The larger facilities had up to four doctors and 40 staff. In contrast to the modern preference for containerisation, all the equipment for the field hospitals was carried in small boxes – 500 for the larger ones.

Casualty evacuation was done by stretcher, camel, small boat, steamer and railway. Six hospital train carriages were constructed for stretchers to be suspended in by ropes from the floor and sides of the wagons. This reduced vibration and added to patient comfort. On the navigable stretches of the Nile there was a purpose-built hospital steamer that could accommodate 50 patients. This vessel was donated by the National Aid Society.

The deployment of Wolseley’s Nile column posed other challenges: one of these was that it was impossible to employ field hospitals in the traditional way. Instead, personnel and stores had to be distributed among nine 15-metre boats, each of which had a medical officer and medical equipment aboard. Heavy tents had to be left behind and shelter improvised in the stern of each boat for any stretcher patients.

From an average strength of 11 371 troops there were 9467 hospital admissions and 598 deaths (mainly from disease) between 18 March and 31 July 1885. These high rates were probably largely due to infection from milk and bowel discharges contaminated by flies. But there were only 13 deaths from heat illness – a figure that was considered to be very low given the environmental stresses every day (route marches etc.). It is noteworthy that hospital admissions, deaths and invalidings were all substantially lower in 1885 than in 1882.

Lessons had been learned, even if more progress in field medicine – broadly defined – was still needed.

Wounds were managed with antiseptic dressings of carbolic and boracic acid lotion and in gunshot wounds these were left in situ for several days. Given that the enemy were mainly tribesmen, most wounds sustained were caused by traditional weapons such as spears and daggers. The desert environment meant that there was little risk of troops contracting tetanus from wounds, but these weapons could still be fatal.

The outside and inside of the hospital ship Ganges. Wellcome Library

The outside and inside of the hospital ship Ganges. Wellcome Library

Around the port of Suakin some 13 000 British and imperial troops were concentrated under the command of Major General Sir Gerald Graham. His Deputy Surgeon General, Oliver Barnett, had a staff of 45 medical officers and 478 men. An environmental health officer was also attached to Graham’s staff. There was a 50-bed stationary hospital and four deployable 100-bed field hospitals. Offshore, three fully staffed hospital ships lay at anchor: the P&O ship Ganges (67 staff and 193 beds); the British–India Company’s Bulimba (150 beds); and the Czarewitch (for troops of the Indian contingent). Some modifications were made in the early months of 1885 and a row of planking was removed along the entire length of both sides of the Ganges and Bulimba to allow better ventilation between the lower decks. Ship-to-shore casualty transport was by means of a steam launch.

The Indian Army contingent was supported by 13 doctors in two field hospitals; the New South Wales contingent had its own medical team of 37, including three medical officers. An additional 600 labourers were brought from India to carry stretcher patients in the field. In Suakin the Army maintained an ice works and all hospitals there had a daily allowance of 50 kg per day. The Ganges had its own ice maker, and there was a suggestion that it be incorporated into an air- conditioning unit. While it is doubtful that this was done, it is a very early reference to the subject of cooling air systems in a hospital environment. Water filters, such as Maignen’s patent ceramic ‘Filtre Rapide’, were standard equipment. These stoneware filters relied on gravity to filter water. Their walls were designed to have greater pull than the flow of the water, allowing bacteria and other contaminants to be trapped in the porous ceramic surface. They are still used today.

Included among the delicacies for sick and wounded soldiers were port, champagne and brandy, which were regarded as medical stimulants.

Male orderlies from the Medical Staff Corps nursed soldiers in the field and in the 300-bed field hospital in Suakin. Several female nurses who had been sent out by the National Aid Society worked in the main hospital and on the Ganges. Most trauma cases here were from gunshot wounds – usually to the bone or arms and legs. The biggest causes of hospital admissions were bowel diseases: typhoid, dysentery and diarrhoea. Heatstroke claimed several victims. The military exploited advances in medical science such as the use of chloroform and antiseptic techniques. Soldiers who could not be returned to the front were sent to the Royal Victoria Hospital at Suez or invalided home.

Overall, the Medical Staff Corps performed relatively well under trying, harsh environmental conditions during the Egyptian campaigns of 1885. Several of its leading officers and medical men were killed in action or fell victim to disease. In response, general healthcare support for all troops deployed had to be better organised so that it could meet the demands of a highly mobile force operating on land and amphibiously along the Nile, in an uncertain military environment in which fresh drinking water was extremely scarce. In this challenging terrain it was fortunate that the enemy was not better armed. One of the key reasons for British Army success in alleviating casualties is that its senior staff listened to the advice of its medical officers rather than its strategic planners. The former quite sensibly recommended troops be withdrawn from Sudan before high summer, when the extreme heat would have caused widespread health problems. Better-organised field hospitals, more mobile field stations on land, and improved water transport along the Nile delta meant that the Medical Staff Corps was flexible and responsive where needed. This type of Victorian military provision in field medicine is recognisably modern, especially given the hostile environments of the Middle East.

There is no doubt that Wolseley struggled against the conservative leadership of the Army. He realised that it was falling behind European powers that were beginning to harness technology and science to prosecute their wars. Yet in the Sudan conflict, medical and logistic officers in Wolseley’s ground forces were not slow to learn from their mistakes or to use new ideas to maintain the health of their troops. The standards that the Victorian Army Medical Staff Corps set itself continued to evolve throughout this period, and this area of military medical history unquestionably deserves more scholarly attention.

The evidence of the Sudan campaigns challenges the outdated popular notion that most Army medical staff bungled or displayed ignorance about the need for better field medicine during Victorian Britain’s wars abroad. In fact, the opposite was happening on the ground. A genuine willingness on the part of the military to embrace and experiment with new ideas was part of military medicine’s contribution in Sudan.

Nor were these campaigns a mere sideshow in northern Africa; they have important lessons for understanding the development more broadly of field medicine before World War I. In particular, they can help us better understand how tropical disease and environmental health threats like heat injury were overcome. Many of the same medical issues – such as air coolants, heatstroke and the need for fresh drinking water – still preoccupy armies in modern theatres of war in the Middle East and Afghanistan, and in training environments from the Arizona desert to Australia’s outback and tropical north.

Dr Michael Tyquin has published extensively on Australian social, medical and military history. His latest book is Gallipoli: An Australian medical perspective. He is an Adjunct Professor at the Centre for Military and Veterans’ Health, University of Queensland – cmvh.org.au.ad – and also works as a consulting historian based in Canberra, where he can be contacted at makinghistory@bigpond.com.au.

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