2 war and medicine

War and medicine 4 war and medicine

CONTENTS

i FOREWORD 126 LAVONNE TELSHAW CAMP KEN ARNOLD, KLaus Vogel AND JAMES PETO Lingering Fever: A World War II Nurse’s Memoir iii Preface War and medicine, past and future 130 STALINGRAD John a parRish WOUNDED BODIES AND SOULS Wolfgang U Eckart 10 WAR AND MEDICINE IN THE MODERN ERA Mark Harrison 152 AbramPORTRAITS Games 28 THE IMPACT OF THE CRIMEAN WAR ON PUBLIC HEALTH 162 DANG THUY TRAM Hugh Small Last Night I Dreamed of Peace

42 SISTER M ALOYSIUS DOYLE 166 WHY THE PSYCHIATRY OF WAR IS TOO The Crimean Journals of The Sisters IMPORTANT TO BE LEFT TO PSYCHIATRISTS of Mercy, 1854–1856 Ben Shephard

46 How varied the image of heart 180 ANONYMOUS trauma has become Living with Personal Dragons The Development Of Cardiovascular Surgery During The First World War 184 CHERYL LYNN RUFF Susanne Hahn Ruff’s War: A Navy Nurse on the Frontline in Iraq 56 Life Without Arms Carl Hermann Unthan and His Motivational 188 ROBERT ACOSTA Work with Disabled Veterans in Germany Army Specialist: Iraq War Service Colleen Schmitz 192 Artist’s Diary, 66 SOLDIERS’ bODIES IN THE WAR MACHINE J4MED, Op Herrick 7, TRIAGE, PROPAGANDA AND MILITARY 03.11.07-26.11.07 MEDICAL BUREAUCRACY, 1914–1918 DAVID COTTERRELL Ana Carden-Coyne 222 DR MANTADOR TAHER 84 MARY BORDEN OPEN THE HOSPITAL DOORS! The Forbidden Zone 226 ADVANCES IN MODERN COMBAT CASUALTY 88 TREATED LIKE FLOWERS CARE WITH A VISION TO THE FUTURE THE INDIAN ARMY AT THE ROYAL PAVILION William Wiesmann, Nicole Draghic, John Parrish HOSPITAL, BRIGHTON, 1914–1916 Kate Forde and Lucy Shanahan 242 NOTES

98 246 BIBLIOGRAPHY PORTRAITSPercy Hennell 250 CONTRIBUTORS’ BIOGRAPHIES 108 SUFFERING AND THE HEALING PROFESSION THE EXPERIENCE OF MILITARY MEDICINE IN 252 INDEX THE FIRST AND SECOND WORLD WARS Joanna Bourke 256 colophon

6i ii WARwar ANDand MEDICINEmedicine FOREWORD

Having described the litany of appalling injuries endured Harvey Pynn of the Royal Army Medical Corps, John Parrish, by his fellow patients in the beds and wards around him, the Director of Center for Integration of Medicine and Innovative FOREWORD narrator of Erich Maria Remarque’s All Quiet on the Western Technology, Boston, and to the artist David Cotterrell, for their Ken Arnold, Klaus Vogel and James Peto Front, 1929, concludes: “Only a military hospital can really sound advice. We thank all the writers who have contributed show you what war is”. It is not just the physical devastation directly to the book and especially Melissa Larner and Nadine suffered by the wounded that is inescapable. A military hospital Monem, who have not only edited and produced it, but also can also show us the full, bewildering range of stark choices played an important role in shaping its contents. We also thank and moral dilemmas that confront those charged with the delivery Wolfgang Eckart for lending pictures from his collection. of medical care during wartime. From the sometimes counter- As mankind’s capacity to maim and kill has increased, intuitive principles of triage, to the arguments over whether our desire to repair and heal has always struggled hard to keep and how post-traumatic stress can be clinically diagnosed, pace. We hope that this book, with its combination of eye- war hugely complicates the already difficult ethics of the witness accounts and historical analysis, will encourage a practice of medicine. wider engagement with the medical and moral complexities This book is published to coincide with the exhibition of that struggle. War and Medicine, organised jointly by Wellcome Collection and the Deutsches Hygiene-Museum, Dresden. Both book and exhibition concentrate on the modern era, beginning with the Ken Arnold and James Peto disasters of the Crimean war and continuing through to the Wellcome Collection, London current conflicts in Afghanistan and Iraq. As mankind has developed increasingly sophisticated weaponry with which Klaus Vogel to harm its enemies, medicine has had to adapt to cope Deutsches Hygiene-Museum, Dresden with the volume and the changing nature of the resulting casualties. The exhibition combines military and medical artefacts with interpretative approaches to understanding the relationship between war and medicine, including historical and contemporary artworks and film. The book brings together very different approaches to the subject. It interweaves the arguments of academics and historians with personal accounts written by those with first-hand experience of trauma and its treatment during or in the aftermath of conflict. It is often argued that, for all the destruction war has brought, it has at least been good for the development of medicine. Set against this is the uncomfortable fact that medical scientists and military leaders have sometimes responded not only to the medical needs of war, but also to the medical ‘opportunities’—leading to unscrupulous experiments and even to genocide. That the nature of the relationship between warfare and medicine is much disputed is borne out by the strong and sometimes contradictory convictions expressed in this book. What is certain, however, is that a great deal of time, money, energy and expertise continues to be directed into areas of research where military and medical interests intersect, and that war and medicine continue to influence one another in ways that are critical to the lives of many—both soldiers and civilians. Finding a way through the maze of issues that surround this subject, in order to realise both the book and the exhibition, has required the hard work and help of many people. There is only space here to thank a small number of them. First and foremost are the curators of the exhibition, Kate Forde and Lucy Shanahan, and their colleagues in Dresden, Colleen Schmitz and Stephanie Neuner. We are particularly grateful for the help given by the medical historians Ana Carden-Coyne, Roger Cooter and Susanne Hahn and by the freelance curator Angela Weight. Thanks are also due to Dr iii8 iv WARwar ANDand MEDICINEmedicine PREFACE

Throughout history, war has inflicted massive physical harm Not all war wounds are visible. Each major war has and has added substantially to the burden of malnutrition and left a signature constellation of symptoms or neuroses that was PREFACE disease. It is ironic, therefore, that war sometimes advances called ‘shellshock’ during the First World War and referred to the practice of medicine. Some of the essays in this book as Post Traumatic Stress Disorder (PTSD) in more recent times. WAR AND MEDICINE, record the complex ways in which the medical profession The physiological, biochemical and psychological causes and has responded to the challenges of war, and has struggled to manifestations continue to be poorly understood and a great PAST AND FUTURE care for the injured against the odds. Others argue that their deal of controversy surrounds this subject. Because of lack John A Parrish discoveries have brought widespread benefit to soldiers and of effective treatments, the victims may suffer for decades civilians, in both war and peace. after their war experiences. Following each of the past six or From a global perspective, the participants in most seven major wars, society and the military have gone through serious conflicts use hand-held weapons to kill and maim and cycles of denial, exaggeration of these invisible wounds, and there is essentially no medical care. Industrialised, developed finally a more permanent form of denial – ignoring and forgetting states have the technical, intellectual and fiscal resources to the victims. Increasing advances in modern neuroscience cause widespread death and destruction from great distances research are creating a platform for a significant increase in and with high efficiency. Those with the most advanced killing the understanding, prevention and treatment of war-related machines are also those able to provide medical care for their psychological wounds. But to realise this potential, significant wounded soldiers. financial and intellectual resources would be required, as well Technological advances continue to increase the as a climate of sustained public concern, and the enlightened destructiveness and lethality of weapons, the dispersion of selection, training and deployment of soldiers. soldiers and medical responders, and the capabilities of health Medical advances will not change the essential nature professionals. However, whatever gains physicians make in of armed conflict. Death or maiming of both combatants and salvaging soldiers and maintaining maximum fighting strength innocent civilians remains the goal. Nations or groups will war are largely swamped by the massive killing of civilians as a against one another and the winner will be the one who can tool of war. inflict and absorb more punishment than the other. War will When one considers the intersection of war and continue to challenge healthcare providers, as well as yielding medicine, the focus is often on the increased capability to care much relevant clinical experience and strong incentives for for individual badly wounded soldiers. But it is the advances biomedical researchers. Individual physicians will continue in preventative health measures, as well as sanitation, hygiene, to make incremental improvements in the care of trauma, processed food and water, window screens, insect repellents, chemical assault and infections. vaccinations and other such measures that have had the Throughout history, when the professions join forces, greatest effect on the quality and duration of a soldier’s life. medicine serves the military and the war machine serves the All of these measures are overshadowed, however, by the state. In time of war, it is the state that decides the magnitude widespread and often lethal social, political and economic and quality of the care of war victims, with some help from disasters spread by war. The technology of killing (and the volunteer agencies. This book chronicles the struggles of willingness to use it) grows much more rapidly than the ability caregivers to serve these efforts to improve care. The goals are to care for victims. This is only to be expected, since it is to maintain fighting strength and soldier morale, assuage the easier to destroy than to repair—and the resources provided angst of citizens unwilling to accept the human cost of war, for destruction by society are greater. and meet a moral obligation to wounded warriors. But we can Nonetheless, the capabilities of military medicine are imagine a world in which the military serves healthcare. The constantly progressing. Current research and development transportation, communication, entertainment and information efforts are leading to an improvement in the proximity of the industries are driving the creation of an enormous exponential wounded to surgical teams. New technologies are advancing growth in technology. The weapons industry helps generate this the control of hemorrhage, the monitoring of the wounded, the explosion of technology, and benefits greatly from it. Medicine treatment of shock, and the prediction, management and is inadequately resourced and motivated and is incapable remedy of sepsis. Tissue engineering will be used to treat of capturing the full technological possibilities available. spinal-cord injuries and replace organs. Sophisticated life-like Fragmented healthcare industries create relatively little push autonomous simulators will provide better training of first in terms of technology. responders, while robotic devices will extract wounded soldiers We can hope that the privileged states will someday from dangerous places and improve prosthetics. ‘Smart’ devices choose to provide the necessary resources to assault the curse will also improve rehabilitation and therapy after wounded of poverty and epidemic death from treatable diseases. The soldiers return home. military establishment could supply the political stability These advanced capabilities will also be useful for and logistical distribution capability to overcome many of the civilian victims of trauma and natural disasters. This ‘dual use’ impediments to improved global health. All things are possible. of technology is becoming more important as terrorism blurs the boundaries between the battlefield and the city square. 10 11 war and medicine WAR AND MEDICINE IN THE MODERN ERA

WAR AND MEDICINE IN THE MODERN ERA Mark Harrison

he mid-nineteenth century he birth of modern warfare coincided Clemance Brophy, 34th is often said to mark Twith the emergence of medicine Regiment, wounded in the advent of modern as a modern profession. Around the the Crimean War, warfare. It was at this middle of the nineteenth century, 31 August 1855. time that war began to be medicine began to assume a form that Photograph by Robert organised on an industrial we would easily recognise today. It was Howlett and Jospeh scale—harnessing the at that time that medical qualifications Cundall, commissioned relentless might of the steam-powered began to be standardised and medical by Queen Victoria. factory.T This began with the Crimean War registers drawn up. But while the medical The Royal Collection (1853–1856) and American Civil War profession now had a legal monopoly to © 2008 Her Majesty (1861–1865) and culminated in the two practice medicine, it retained much of Queen Elizabeth II. great world wars of the twentieth century. its autonomy, having the right to regulate In its mature form, modern warfare was the conduct of its own members. These epitomised by soulless destruction, mass measures helped to consolidate the mobilisation, and by new and terrible profession and boost its public standing, weapons that turned killing into an as did some notable scientific advances industrial process. War became less and such as anaesthesia, antiseptic surgery less about face-to-face combat and more and bacteriology. These enhanced the about killing at a distance, with rifles, capacity of medicine to cure or prevent machine-guns, torpedoes, high-explosive disease, or at least to reduce suffering. shells and poison gas. lthough the modern medical y the time of the Second World War Aprofession owed its existence to B(1939–1945), aerial bombardment several social trends, it was not entirely had come to dominate strategic thinking coincidental that it emerged around the as the ultimate means of destroying a same time as modern warfare. Like modern nation’s productive capacity and morale. medicine, modern warfare was part and Traditional distinctions between service parcel of a new professional society, in personnel and civilians were becoming which status depended increasingly on less relevant when nearly everyone scientific expertise rather than upon birth. contributed to the war effort. Just as warfare was being purged of its 12 13 war and medicine WAR AND MEDICINE IN THE MODERN ERA

charismatic, aristocratic elements, so William Young, Henry medicine was becoming standardised Burland and John with a clearly defined curriculum in which Connery, wounded in scientific training counted more than the Crimean War. the tacit knowledge imbibed within the Photograph by Robert profession. This is not to say that social Howlett and Jospeh class ceased to matter, either in the military Cundall, commissioned or in the medical professions, but that by Queen Victoria. such distinctions became progressively The Royal Collection less important. © 2008 Her Majesty Queen Elizabeth II. ut there was also a more direct Bconnection between modern medicine and warfare. The advent of ‘total war’ drew in much of the adult population, either as combatants or workers, placing manpower at a premium. Every effort was therefore made to prevent sickness and to restore patients to some kind of useful role. As expectations of health and medical care rose, medicine also came to play a more important part in morale. The sanitary reforms of the Victorian era and inoculation against diseases such as typhoid did much to diminish fatalism in the face of even common diseases. At the same time, the curative powers of medicine were increasing. The advent of antiseptic surgery and of anaesthesia made even complex operations—such as abdominal surgery—seem possible. 14 15 war and medicine WAR AND MEDICINE IN THE MODERN ERA

The emergence of new drugs, like care for servicemen became a matter of ightingale’s work in the hospital also responded in a determined manner, A large snake, symbolic Salvarsan for syphilis and sulphonamides acute public concern. Although there Queen Victoria and Nat Scutari has received so much knowing that its actions would be closely of a gas attack, strikes at and penicillin in the coming decades, had had been consternation following the Prince Albert visiting attention that it will already be familiar to scrutinised in the press. a sleeping soldier, First an even more remarkable effect upon massive death toll from disease during the soldiers in hospital, most readers. There is no doubt that she World War. Drawing by public confidence. Needless deaths from French Wars of 1793–1815, there was a injured in the Crimean worked tirelessly to improve conditions he Crimean War also resulted L Raemaekers. disease and wound infection were no sense that such deaths were inevitable, War. Drawing by there: compiling statistics, attending Tin root-and-branches reforms Wellcome Library, London. longer to be tolerated. especially in tropical regions like the John Tenniel, 1855. to sanitation and hygiene, and checking of the army medical services and Caribbean. Nor did most people expect Wellcome Library, London. personally on her patients. She wrote lasting improvements in the health of t the beginning of the Crimean medical care for the sick and wounded continually to Herbert requesting more servicemen. Systematic training was AWar, however, there was only the to be anything other than rudimentary. supplies and clothing, and enlisting his introduced for all new medical officers, faintest glimmer of public concern over By the time of the Crimean War, however, help in overcoming what she perceived as smart new hospitals were constructed, the health of servicemen. When the expectations had begun to rise in line with the obstructive attitude of military doctors. and far more attention was paid to British and French dispatched their sanitary reforms and the proliferation of Similar stories were later told by other sanitation and personal cleanliness. expeditionary forces to the Black Sea in charitable hospitals for the poor. A fusion medical volunteers sent to the Crimea, The results of these reforms were 1854, they gave little thought to medical of humanitarian and patriotic sentiments such as Dr Pirogov, who denounced the impressive, the death rate in garrisons provisions. Sick and wounded men often impelled well-connected individuals in all stupidity of the Russian army doctors in Britain falling from 17.5 per 1,000 in lay at the front, exposed to the elements, the combatant nations to organise medical and their hospital administration. 1857 to 9.3 by 1875 and to 4.3 by 1899; or perished in the unsanitary conditions relief for troops. This was the first war that the number of admissions to hospital also of hospitals at the base. It was not that was extensively reported in the press, and n some cases, these charges may have dropped from 105 per 1,000 per annum generals were particularly callous, or correspondents such as William Russell Ibeen a little unfair, since medical in 1857 to 67 per 1,000 by the end of that military doctors were incompetent, brought the war home in a way that had officers could do little by themselves to the century. Similar falls in mortality— as some observers later claimed. Rather, never been done before. His reports from alter conditions. Indeed, many had tried though not in sickness rates—occurred the nations involved had not fought a the Crimea caused a great scandal and to do so but had failed because they in major overseas stations such as India. large war for some time; war ministers, leading the Secretary at War—Sidney lacked full military rank and because they generals and senior medical officers were Herbert—to implore Florence Nightingale were not politically well-connected. It was he Crimean War had shown that all largely inexperienced in planning the to organise female nurses for the military in this respect that Nightingale’s presence Tgovernments—particularly democratic logistics of a major campaign. hospitals in Turkey. In Russia, too, Grand was to prove vital. Her close relationship governments such as Britain—could Duchess Elena Pavlovna founded the with Herbert enabled her to cut through no longer afford to neglect the health ut, for all its horrors, the Crimean War Community of the Cross, an organisation military red tape and go over the heads of and welfare of servicemen. Indeed, in the Bmarked a new beginning for military that aimed to recruit doctors and nurses commanding officers. Once the scale of coming decades, humanitarian scrutiny medicine. For the first time, medical to help troops at the front. the problem was grasped, the War Office of wars became even more intense. 16 17 war and medicine WAR AND MEDICINE IN THE MODERN ERA

Having witnessed the suffering of the carts. Many observers were also struck by Wounded being treated wounded at the battle of Solferino in the fact that the Prussians had far fewer at Rezonville during 1864, Henri Dunant was determined sick men than the French, particularly the Franco-Prussian that a neutral body should be formed to cases of smallpox. The French had War. Coloured wood provide for the wounded of all combatants, vaccinated very few of its troops and engraving by HIA Closs. regardless of nationality. The International suffered over 200,000 cases of smallpox; Wellcome Library, London. Red Cross movement that he founded the Prussians, who strongly encouraged in 1864 proved to be a powerful force vaccination, suffered only 4,800. in the coming years, and an even more powerful symbol of benevolent neutrality, he Franco-Prussian War was thus mitigating some of the horror of war for Tto prove instructive in all kinds its survivors. By the time of the Franco- of ways: by highlighting the potential Prussian War, its tremendous emotional contribution of civilians to medical work appeal was evident in the numbers of in wartime, in preventive medicine, neutral doctors, nurses and orderlies who and in the evacuation of the sick and flocked to tend the wounded of both sides. wounded. The same was true of the American Civil War. The efficient ut in some cases, their intentions organisation of evacuation in the Union Bwere not entirely philanthropic. A Army provided an inspiration to the number of medical officers from the armed British Army right through to the First forces of other countries volunteered World War (1914–1918). However, the their services, at least in part in order to Civil War is also interesting because it observe the medical work done by the provides an excellent example of how French and Prussians, and to learn from war can stimulate the emergence of it. It was for this reason that the British new medical specialities: in this case, surgeon Thomas Longmore went to France neurology. During the war, some 10,000 in 1870, and what he learned of Prussian soldiers were discharged from the Union casualty evacuation deeply impressed Army with so-called ‘nostalgia’—a him. The Prussians made extensive use delibitating form of depression and of railways to evacuate their wounded, home-sickness—and twice as many with as well as specially adapted horse-drawn ‘epilepsy’ (in reality a stress reaction to 18 19 war and medicine WAR AND MEDICINE IN THE MODERN ERA

battle). This loss of manpower acted as Officers saluting the a spur to therapeutic innovation and the wounded after the diversion of resources to doctors with an battle of Lewinsville, interest in neuro-physiology, enabling American Civil War. them to create specialist hospitals for the Engraving by F Skill. treatment of nervous disorders. Wellcome Library, London. y the end of the nineteenth century, Bpractically all armed forces possessed specialist institutions for training military doctors and for the treatment of servicemen suffering from disease and injury. But it is important not to give an impression of unmitigated improvement. On active service, serious losses due to disease and other medical failures continued to occur. This was particularly true of colonial campaigns, over which there tended to be less public scrutiny. It was one thing to maintain hygienic standards in a military camp and quite another to do so when moving rapidly through tropical rainforest, mountains or desert. To make matters worse, some officers took little interest in sanitation, believing it to be beneath their dignity. During the Spanish-American War (1898) and the South African War (1899–1902), thousands of soldiers fell ill and died as a result of diseases such as typhoid, most of which were regarded as preventable. 20 21 war and medicine WAR AND MEDICINE IN THE MODERN ERA

f these two campaigns provided an medical services. By the beginning of few casualties compared with the tens outside northern Europe. In Gallipoli, Regimental Aid Iobject lesson on how not to organise the First World War, these ideas were Casualties of the of thousands that had plagued military East Africa, Mesopotamia and Salonika, Post, Western Front, a war from a medical point of view, then firmly implanted in the minds of many Dardanelles being campaigns as recently as the one in South as well as on the Eastern Front, operations First World War. the Russo-Japanese War (1904–1905) generals and government ministers, as carried in an open boat to Africa. Well-organised sanitary divisions, were sometimes severely affected by Wellcome Library, London. provided some positive examples to were the political implications of being the military hospital ship mobile laboratories and improvised disease. To be sure, it was not all the follow, at least on the Japanese side. seen to fail in the state’s duty of care Dongola at Anzac, 1915. sanitary equipment for the trenches also fault of commanders: the prevalence of The Japanese had learned a lot from towards its troops. It was not simply Wellcome Library, London. helped to keep the spread of water—and diseases such as typhus and malaria the British and the Germans, both in that expectations regarding health fly-borne diseases to a minimum. But among the civilian population made the terms of medical teaching generally, and medicine were rising in tandem louse-borne diseases such as typhus and task of disease-prevention exceedingly and about the organisation of medical with scientific and sanitary advances; relapsing fever presented more difficult difficult, as did the nature of military care in wartime. They paid a great governments had also forged new problems. Despite disinfecting stations, operations. But the maintenance of deal of attention to arrangements for contracts between themselves and the portable disinfectors and regular cleaning, health also depended greatly on high evacuation and treatment, while insisting people, promising better health care in lice were everywhere in the trenches, and morale and strong leadership. In the on strict hygienic standards. They also return for responsible citizenship. relapsing fever placed a heavy strain on Russian army, the collapse of effective harnessed medical science—particularly manpower. But the armies on the Western leadership contributed to the lapse of the new sciences of bacteriology and uring the conflict of 1914–1918, Front were spared the ravages of typhus, sanitary precautions and thus to high immunology—more effectively than any Dhealth and medicine thus attained a disease that was already endemic on levels of typhus. As the war turned other nation. For the first time in a major a position of central importance. On the the Eastern Front. No theatre managed against the Ottoman Empire, there was a modern conflict, deaths from disease preventative side, governments did their to avoid influenza, however. The deadly similar collapse in morale and discipline, were lower than deaths inflicted in battle. best to ensure that troops were protected strain of the 1918–1919 pandemic swept allowing diseases such as typhus and with such inoculations and vaccinations rapidly through troops on all fronts, there cholera to sweep through the army. Up hile some medical officers as were available, and that all forces being nothing that could be done to until 1916, the Turkish army appears Wsuspected that these claims going into battle received lectures and, prevent it. to have paid almost as much attention to were inflated, they helped to persuade if possible, instruction in the prevention sanitary matters as the British, although governments and commanding officers of disease. Special emphasis was placed espite many thousands of deaths, the record of the British was quite of the importance of medicine in war. upon the responsibilities of officers, Dthere was no public outcry over the poor in theatres such as Gallipoli and In the decade after the war, a number who for the first time were made clearly handling of the influenza pandemic; Mesopotamia. At first, senior commanders of generals even began to write articles responsible for the health of their men. On public morale only seemed to be dented showed little interest in either sanitary on sanitation and strategy, seeing the the Western Front at least, such measures when troops died from diseases that or medical matters, and it was only after possibility of gaining an advantage paid real dividends, and endemic were regarded as preventable. This was these commanders had been removed that over opponents with less developed diseases such as typhoid claimed very very much the perception of campaigns conditions began to improve. 22 23 war and medicine WAR AND MEDICINE IN THE MODERN ERA

n the curative side, military these institutions became increasingly of mental disorders. Or it may be that y the Second World War, most Patient being loaded Omedicine between 1914 and 1918 specialised and began to be run in a Sinking of the hospital the mobile warfare characteristic of Bgovernments had taken the positive onto an air ambulance, benefited from scientific innovations manner resembling a business, with the ship Rewa, 1918. these fronts was less conducive to the and negative lessons of the First World Second World War. such as anti-tetanus serum, which, application of time-and-motion studies Wellcome Library, London. production of shellshock cases than War to heart. In nearly all theatres of the Wellcome Library, London. despite its limitations, helped to control to maximise efficiency. trench warfare. Nevertheless, it was war and on all sides, a huge effort was wound infections. Military doctors increasingly recognised that the many made to keep disease to manageable also became more adept at preventing utside the Western Front, conditions thousands of men who became ill with levels and to evacuate casualties as soon infection through radical excision of Owere more variable. The exclusion malaria in these theatres often suffered as possible. As was the case between damaged tissues, reversing the trend of medical officers from operational prolonged mental disturbances. The true 1914 and 1918, armies tried to treat towards conservative surgery over planning in theatres like Mesopotamia scale of the problem and the fate of such casualties close to the fighting, so that the previous two decades. But, as and Gallipoli led to serious problems patients remains one of the great untold they could be returned quickly to duty Nightingale and others realised during in medical evacuation by land and sea. medical stories of the war. (and also to deter malingering). However, the Crimean War, the most important These problems were aggravated by the advent of air evacuation opened up element in wartime medical care was a severe shortage of hospital barges otwithstanding the problems new possibilities. In North Africa, Italy, administration—something to which and ships, which often resulted in Nexperienced in medical evacuation in Western Europe from 1944, and even most armed forces now gave a great deal troops being transported long distances and disease-prevention outside the in the jungles of Burma and the Far of attention. Arrangements for evacuation in unsuitable vessels, such as those Western Front, the First World War East, aircraft were increasingly used to and treatment of the wounded on the normally used to carry cattle. Another represents an important turning point in evacuate casualties from places relatively Western Front resembled a vast factory interesting difference between medical the history of war and medicine. It was close to the front. This enabled men to that processed the human wreckage arrangements on theWestern Front and the first major conflict in which deaths receive medical care far more quickly of war. Motor ambulances, trains and other theatres is the comparative absence from disease were lower than deaths than before and in larger and better- barges traversed France and Belgium, of facilities for the treatment of nervous due to battle injuries, for all combatant equipped hospitals, which massively transporting thousands of casualties from disorders (shellshock). By 1916, there nations with the possible exception of improved their recovery rates. Later on, the regimental aid posts at the front to were many units on the Western Front Russia and Turkey. In part, this was due in the Korean War (1950–1953) and hospitals at the base or at home. Perhaps to treat these casualties. But outside to the enhanced killing power of modern Vietnam War (1956–1975), the extensive the most vital link in this chain was the Europe there were very few and those weapons—especially high-explosive use of helicopters would render this kind casualty-clearing station, which sorted that were established came late in the shells—but it was also a testament to of evacuation the norm. casualties according to their seriousness war. The reasons for this have yet to be the massive effort made by most military and which undertook preliminary satisfactorily explained. It may be that commanders and their political masters ilitary doctors in the Second World treatments and surgical operations. Like the huge burden of disease in these to conserve manpower and maintain the MWar also benefited from a number other hospitals further down the line, theatres masked the true incidence morale of servicemen and their families. of scientific advances that permitted the 24 25 war and medicine WAR AND MEDICINE IN THE MODERN ERA

more effective treatment of a range of had to look at the abject condition of sick Anti-VD posters, signed diseases and wound infections. The most and wounded men captured by the Allies “Hooper”, 1943–1944. famous of these was penicillin, which at the end of the war to see the difference Wellcome Library, London. became widely available in 1944 after it made. The inmates of German extensive clinical trials among soldiers in hospitals captured between 1944 and North Africa. Penicillin not only treated 1945 were often suffering from severe wound infections, but also those that wound infections, and the majority developed after severe burns, which were responded well when given penicillin. more frequent between 1939 and 1945 Apart from penicillin, perhaps the most than in previous conflicts due to the large important scientific innovation during number of motor vehicles and aircraft used. the Second World War—from a medical Penicillin also enabled one of the most point of view—was the development ubiquitous and difficult military disease of the chemical insecticide DDT. DDT problems to be dealt with effectively was first used by the Allies in the winter for the first time. Sexually transmitted of 1943 / 1944 to control an epidemic infections had always been an enormous of typhus among civilians in Naples. So problem in wartime, but hitherto, military successful was it in arresting the disease authorities had been forced to rely chiefly that it was soon applied to the prevention on preventative measures such as medical of another stubborn infection—malaria, inspections of brothels and chemical which was a tremendous drain on disinfection, knowing that appeals to manpower in several theatres. Despite abstinence were unlikely to be effective. the general availability of synthetic None of these measures worked, however, anti-malaria drugs, by 1944 there had and the STI rate in theatres such as Italy been no real improvement in the malaria rose inexorably. Penicillin thus prevented situation in Italy, and spraying with an epidemic of sexually transmitted DDT commenced as troops moved into diseases from becoming a heavy drain areas that abounded with mosquitoes. on the Allied armies. The effects were dramatic, and DDT was shown to reduce the population of he Axis forces did not have the malaria-bearing mosquitoes for some Tbenefit of penicillin, and one only time after spraying. 26 27 war and medicine WAR AND MEDICINE IN THE MODERN ERA

The same methods—together with a and sailors in most combatant armies more concerted use of anti-malaria were probably such as to imbue them drugs—protected the Allied armies in with a lasting respect for the benefits other theatres such as Burma and the of good hygiene. During the two world Far East. wars, most European and American troops were bombarded with sanitary t was said that DDT gave the Allies a propaganda and had personal cleanliness Icrucial edge over their opponents in literally drilled into them. Many recorded theatres such as Burma. Whether or not their experiences of this in diaries and largely disappeared. Former generations from civilians opposed to recent conflicts it did remains unclear, but it is certain letters, and more than a few admitted French anti-malaria may have grown to expect more from the in Iraq and Afghanistan. There have that without DDT and strict anti-malaria that they had changed their behaviour cartoon, First World War. state in relation to healthcare in wartime, also been several instances of hospital- discipline, the Allied offensives in the because of it, becoming less tolerant of Wellcome Library, London. but they also had a clear view of their acquired infection, which some soldiers Pacific and Burma would have been far dirt around the house and of lax hygiene responsibilities to each other and to the have attributed to low standards of more costly and protracted. But there in restaurants, lavatories and other state. Governments have not given up hygiene in civilian hospitals. Whether was one theatre of the war in which public places. But the true importance on health campaigns—far from it—but or not such claims are justified, the sanitary arrangements do appear to have of the wars in changing public behaviour the sense of civic duty that made such loss of separate facilities for military given the Allies an important advantage. has yet to be fully explored. So, too, appeals effective is much weaker than it patients has led many to ask whether the In the Western Desert of Egypt, in has the relationship between military was. Weaker, too, is the commitment of ‘military covenant’, whereby the state the run-up to the crucial battle of El medicine and its civilian counterpart. some—though by no means all—states looks after its wounded servicemen, Alamein (1942), the British-led force We know that military metaphors and to the health of their servicemen and has disappeared. under Montgomery had a sickness rate forms of organisation were a prominent women. Whereas it was formerly taken less than half that of Rommel’s Afrika feature of civilian medicine and for granted that servicemen would Korps. On the eve of the battle, one in nursing following the two world wars, receive care in specialist hospitals, five German troops was out of action due but it remains unclear how far military where their privacy and dignity would to disease. Remarkably, the Afrika Korps experience was directly applied in be respected, this is sadly no longer took little interest in sanitation, whereas civilian institutions. the case. In Britain, the majority of the British force went to great lengths those wounded in Afghanistan and Iraq to avoid disease with diligent attention e are probably still living with are treated in civilian hospitals and to sanitation and a deluge of leaflets Wthe legacy of the world wars, sometimes in civilian wards. Service and lectures on disease-prevention.The but the sense of social solidarity that personnel have complained that these wartime experiences of soldiers, airmen underpinned medicine in wartime has arrangements leave them open to abuse 28 29 war and medicine THE IMPACT OF THE CRIMEAN WAR ON PUBLIC HEALTH

THE IMPACT OF THE CRIMEAN WAR ON PUBLIC HEALTH Hugh Small

he Crimean War popular author, believing that colourful An Angel of Mercy (1854–1856) provides graphics with simple messages would Florence Nightingale an outstanding example carry more weight than dry figures with lamp, visiting of wartime experience and logical reasoning. Her overriding the sick. Coloured informing domestic objective was to ensure that the lessons mezzotint, by Tomkins medicine, specifically of the war should be applied to the after Butterworth, 1855. preventative medicine. civilian population at home, where the Wellcome Library, London. The process was paradoxical: the failure mortality from preventable disease was Tof the military authorities to adopt the staggeringly high. In her final pamphlet latest practices allowed their value to be of the controversy, published exactly demonstrated to sections of the civilian 150 years ago, she clarified that her main medical profession and the public, which target was civilian public health: “Let had not yet been convinced. us now ask, how was it that our noble army all but perished in the East? And or two years after the end of the war, we shall at the same time learn how it Fa controversy over the cause of the has happened that so many hundreds high wartime mortality from sickness of millions of the human race have by pitted reforming disciples of the pestilence perished before their time.” sanitarian Edwin Chadwick against the conservative army medical staff. Florence Nightingale became the figurehead for THE HUMAN COST OF THE WAR the reformers; her surviving letters, together with pamphlets and statistics ritain and France declared war on from both sides, show how the battle BRussia in March 1854, after the latter for the hearts and minds of the public had invaded the European provinces of was fought. the Turkish Empire (now Moldavia and Romania). In September of the same ightingale presented her statistics year, the Allies invaded Russia’s Crimean Nby deploying her famous ‘Coxcomb’ peninsula with the objective of destroying diagrams, in official reports and in a the Russian naval base and arsenal at book that she commissioned from a Sebastopol. After a siege lasting a year, the 30 31 war and medicine THE IMPACT OF THE CRIMEAN WAR ON PUBLIC HEALTH

general hospitals suffering principally improvement of the health of the army Above: Barrack Hospital, from scurvy, exposure, dysentery, cholera, Above: AB Barton, after the winter of 1854–1855. In Scutari, 1845–1855. typhus and malnutrition. The mortality was Journal of a ship’s February 1855, the conservative-led Wellcome Library, London. particularly high in the first winter: in the medical officer at the coalition government was forced to single month of January 1855, two months time of the Crimean War. resign as a result of its mismanagement Right: Cutting from The after Florence Nightingale arrived at the Drawing showing Scutari of the war; its replacement, a more Illustrated Times, with Barrack Hospital, Scutari (near Istanbul), Barrack Hospital, 1855. liberal government headed by Lord a picture of Florence ten per cent of the whole British Army in Palmerston, was determined to introduce Nightingale, 27 the East died of disease. The army had Right: Plan of civilian standards of administration February 1856. decided to spend the winter besieging Scutari Barrack into the army. Palmerston’s first act as Wellcome Library, London. Sebastopol without proper preparation, and Hospital, 1855. Prime Minister was to send a civilian the conditions were worse for the besiegers Wellcome Library, London. Sanitary Commission with specific than for the besieged. Many of the sick instructions to improve sewers, water were evacuated by sea to the general supply and ventilation in camps and hospitals at or near Scutari, 500 kilometres t the end of the first winter, the army hospitals at Scutari and in the Crimea. from the front line. Some died during the Ain the Crimea became more secure The previous government had been much arduous journey, but the evacuation was and better supplied. Hutted hospitals less interested in these matters: over thought necessary because the army was opened near the front line and a smaller Palmerston’s protests, it had sacked the in a precarious situation and might have proportion of patients were sent to sanitary reformer Edwin Chadwick and had to withdraw from the Crimea at Scutari. The death rate among soldiers abolished his General Board of Health any moment. admitted to hospital declined. However, in deference to landowners who resented as the fighting intensified, the size of the the extra taxes and building regulations he arrangements for treatment of army increased and deaths from sickness that his sanitary reforms entailed. Allies destroyed the naval installations, Tthe sick and wounded came in for remained high in absolute terms. and peace was restored in April 1856. The much criticism in newspaper reports he leader of Palmerston’s Crimean British army in the region numbered fewer from the war zone. Ambulances, drugs TSanitary Commission was Dr John than 60,000 men at its peak, but nearly and hospital equipment were in short Politics and the Sutherland, who had formerly worked 21,000 British soldiers perished in the war. supply, and Nightingale was credited Sanitary Commission for the defunct General Board of Health. Only about 4,500 died as a direct result with introducing improvements when Arriving in the east in March 1855, of injuries; the rest were victims of disease, she went to Scutari two months after the olitical changes at home in Britain Sutherland found the hospital at Scutari having been admitted to regimental or invasion of the Crimea. Pmay have contributed to the to be as filthy as the vilest slums in London. 32 33 war and medicine THE IMPACT OF THE CRIMEAN WAR ON PUBLIC HEALTH

He and his colleagues (who included an to public censure. Nightingale’s position Balmoral after the war. Nightingale ightingale first met Farr in Drawing of the Barrack engineer) employed workmen to remove was an unusual one. During the war, Drawing of Florence used the opportunity to lobby the Queen NNovember 1856, and worked with Hospital, Scutari, the ordure and to improve ventilation, she had been a functionary of the state, Nightingale, in the for the Royal Commission, and also him to analyse the mortality data. She 1854–1855. sewers and water supply. They broke 400 reporting to a senior officer in the Army Barrack Hospital, helped to draft the terms of reference had insisted, against her parents’ advice, Wellcome Library, London. glass panes in the Scutari hospital on the Medical Department. Her published Scutari, 1855. for it as well as nominating several of on studying mathematics under a tutor first day to let in fresh air, the windows job description involved superintending Wellcome Library, London. the Commissioners. in her youth, and Farr now coached her having been sealed to conserve heat. Any female nurses and distributing gifts in statistics. By March the following opposition from the senior army officer donated by the public. The role of ord Palmerston, not sure of whether year, their studies had led them to the in charge could have been silenced by public servant was rare, if not unique, Lhe could obtain authorisation for conclusion that the principal cause of showing him the new Prime Minister’s for a woman at that time—most female the Royal Commission, also asked death during the war had been poor personal instructions to ventilate this reformers acted in the name of private Nightingale to prepare a confidential hygiene in the army hospitals. When building. Some people at home had charities. Even more unusual was her report to the Cabinet as a fallback. To the Royal Commission of enquiry was evidently been aware of the problems confidential job description: she was compile her report, she began to collect finally authorised, with Dr Sutherland as at Scutari for some time. to report direct to the Cabinet on any the mortality statistics of the army, one of the Commissioners, Nightingale defects in the army hospitals. Her and this brought her into contact with decided to make this discovery the qualifications for this were that she had William Farr, a physician and statistical central message of the Commission’s Post Mortem and been superintendent of a hospital in epidemiologist (as we would call it public report. This shifted the blame the Royal Commission London for nearly a year and had studied now) employed at the General Registry from the army to the Cabinet Ministers of Enquiry hospital organisation in France, Italy, Office in Somerset House. Farr was a who had approved the hospital buildings Germany and Egypt. Now, after the war, physician whose career had been kept without evaluating the sanitation—the fter the war ended, some progressive the government wanted her to use her back by his humble background and by same Ministers who had abolished the Aelements close to the Government influence with Queen Victoria and with his focus on the unpopular subject of General Board of Health to save money wanted a Royal Commission of Enquiry the public to overcome army resistance hygiene. Farr had long been interested on public sanitation in Britain. It would to report in public on the defects in to the public enquiry. Nightingale in the mortality of the army, which he make the Commission’s findings much the army’s medical services and to had written to the Queen during the regarded as a controlled environment more relevant to the civilian population put forward suggestions on correcting war asking her to set up civilian post for studying the health of the working than if they had been simply a series of them. Nightingale was the champion offices in the Crimea, so that soldiers man. Earlier studies in this area had recommendations about army medical of those reformers in the army and in could send money home instead of convinced him that hospital hygiene, organisation. It seems likely that government who favoured this public spending it on drink. The scheme had rather than quality of medical care, was Nightingale took this course because enquiry, fearing that the army was worked brilliantly: the Queen was most the most important factor influencing she was influenced by Farr’s belief that incapable of reforming unless exposed impressed, and invited Nightingale to the mortality of patients. public hygiene was being neglected and 34 35 war and medicine THE IMPACT OF THE CRIMEAN WAR ON PUBLIC HEALTH

that armies were a good testing ground the first 12 months of the war in the figure who coordinated the enquiry), was think proudly of the ‘Thin Red Line’, Florence Nightingale’s for measures to protect the civilian on the right. The blue areas represent the Florence Nightingale’s due to their barracks being even more a phrase that had become famous in ‘Coxcomb’ diagram: working population. mortality from preventable disease, the ‘Lines Representing unhygienic than civilian homes of the the Crimean War when a two-deep row ‘Causes of Mortality in red areas from wounds, and the grey from the Relative Mortality period. Nightingale illustrated this with of red-jacketed British infantrymen the Army in the East’. aving decided to make hospital other causes. of the Army at Home the chart above. had stopped a Russian heavy cavalry Wellcome Library, London. Hhygiene her main culprit, Nightingale and of the English charge, something that was thought to pursued her goal single-mindedly and his chart does not conform to Male Population at he chart is a kind of visual elegy be impossible. The thin red lines on with an imaginative use of statistics Tthe modern convention that time Corresponding Ages’. Tfor the soldiers who were being Nightingale’s chart represented these supported by innovative graphics. series data should be presented as Wellcome Library, London. killed every day in peacetime by bad same heroic soldiers, who were now When the Royal Commission Report a column chart on a horizontal time hygiene rather than by bullets. The dying unnecessarily because of bad was published in early 1858, its most axis. By dividing the chart into two poet AH Clough, author of Say Not the hygiene in their barracks. striking section was an appendix halves and grouping each half into Struggle Naught Availeth, was acting containing her graphical representations a circle, Nightingale has added an as Nightingale’s secretary at the time his ‘Lines’ graphic was probably of statistics, a sort of Victorian PowerPoint extra dimension to emphasise the she produced this chart, and the poetic Tthe most influential of Nightingale’s presentation, which she called the ‘before and after’ of the Sanitary features might lead one to suspect that diagrams because it dealt with a ‘Coxcomb’—meaning the gaudy part Commission, downplaying the month- he influenced it. First, the title ‘Lines ...’ situation that was still going on. She of the report that would catch people’s on-month variation. It is an effective makes it sound like a poem, as in Lines sent framed copies of some of her charts attention. Her principal evidence was the communication tool that emphasises on the Death of Bismarck. Secondly, four to the War Office, and it can be assumed data that showed that the death rate from a single key message: that the pairs of bars are presented, when actually that this was one of them. An editorial sickness decreased dramatically after Sanitary Commission saved lives. the message would have been clear in The Lancet described this finding of Dr Sutherland’s Sanitary Commission from one pair alone. This repetition, is the Royal Commission as “surprising had begun its work. Conveniently, this he Royal Commission not only reminiscent of a chorus. The poetic effect and grave”. occurred exactly half way through the Texamined the mortality of the army in is increased by the words, repeated two-year war, enabling her to construct a the war zone, but also that of soldiers in at the end of each line, “English Men, ightingale is sometimes given credit two-part diagram contrasting two periods their barracks at home, where they found English Soldiers ...” like the march Nfor inventing statistical diagrams. of twelve months each. The diagram above that soldiers in peacetime had a much played on a solitary kettledrum at a While this is incorrect, she probably does (now usually referred to as the Coxcomb) shorter life expectancy than civilians military funeral. deserve the credit for being the first to is a revised version, published late in (whereas they should have lived longer use them prescriptively, as part of a call to 1858. The mortality in each of 24 months because the army rejected unhealthy n an emotional level, the red bar action, rather than just descriptively. Her is proportional to the coloured areas; the candidates). This, the Commission’s Orepresenting the soldiers would charts illustrate a cause and its effect, or months are shown turning clockwise, with experts said (briefed by Nightingale, certainly have made some people what she called a ‘law’. 36 37 war and medicine THE IMPACT OF THE CRIMEAN WAR ON PUBLIC HEALTH

these and other alternative explanations. Page from The story of Left: Cutting, “The Hall claimed that the fall in mortality Florence Nightingale: the Nightingale in the after the first winter was due to many heroine of the Crimea, East”, 1855. changes, principally the better weather W J Wintle, 1895. Wellcome Library, London. and better supplies. He may have been Wellcome Library, London. partially right, as even Dr Sutherland Right: Portrait of J Hall, admitted. But Hall compromised his halftone reproduction, arguments somewhat by saying that he by SM Mitra, 1911. had previously made the same sanitary Wellcome Library, London. recommendations that Sutherland had made, though he did not have Sutherland’s power to carry them into effect. This made it appear as if Hall’s quarrel with Sutherland was motivated by a desire to defend his record rather than to pursue the truth, in contrast to Nightingale’s remarks in the Royal Commission Report, which did not try mortality in the Crimean War was to defend her hospital against charges of due to the failure of the army and the particularly poor sanitation. commissariat to provide adequate rations, shelter and rest for the men. r Sutherland replied to Hall with They had been starved, frozen and Dpamphlets of his own, in which he The Controversy provoked angry responses from the worked to death by uncaring senior argued that there was no record of Hall army’s senior medical officers, who felt officers, so the theory went, too weak having made sanitary recommendations. r Sutherland had published his criticised by his detailed descriptions of when they arrived at hospital to respond Hall’s unconvincing response was that Down report into the proceedings the filthy state of the Scutari hospital and to any treatment then available. Sir John he had made them verbally, which of his Crimean Sanitary Commission the camps. Hall, Principal Medical Officer in the Sutherland countered by showing that a year before the Royal Commission Crimea and Nightingale’s old antagonist, Hall and his colleagues had written report claimed that he had reduced the he prevailing opinion among the published two pamphlets criticising Dr reports admitting that the Scutari death rate. His report had immediately Tmedical staff was that the high Sutherland’s report and putting forward Hospital was “crowded and polluted” 38 39 war and medicine THE IMPACT OF THE CRIMEAN WAR ON PUBLIC HEALTH

but offering no solution except to from Lord Palmerston. The argument of evacuate the patients to England. From some medical men like Dr Greenhow was this exchange it seems quite probable that scarlet fever (one of the major causes that the medical authorities in the of premature death) was transmitted Crimea were not well versed in the directly from person to person, not emerging science of building sanitation. through a contaminated environment, In this they were no different from many and that therefore the mortality from civilian medical men. it could not be reduced by sanitarian measures. Nightingale’s argument was hen the Royal Commission’s report that the disease was more likely to be Wappeared, a year after Sutherland’s, fatal when sanitation was poor. another pamphlet appeared, which criticised the Royal Commission’s findings he produced her own pamphlet— and repeated Hall’s arguments about SA Contribution to the Sanitary Crimean mortality. The pamphlet was History of the British Army—in which anonymous, but Nightingale believed that she linked military and civilian it was the work of Hall and his colleagues. ignorance of sanitation: journalist Harriet Martineau to write proportional to the number of patients it It also criticised Nightingale’s new Florence Nightingale England and her Soldiers, an accessible sent to Scutari. No explanation was given finding that soldiers in peacetime had The recently published Correspondence and her brother-in-law version of the Royal Commission report. of how this new data was obtained so long a lower life expectancy than civilians of the Army Medical Officers during Sir H Verney with nurses after the war, but if accurate, it would be a and her conclusion that this was due the Russian War shows how very at Claydon House, he paid for copies of this book, which much more convincing proof that hospital to poor sanitation in the barracks. Among small a number of these Officers Buckinghamshire. Salso contained the famous diagram, to conditions, particularly at Scutari, caused other evidence, it cited with approval the was acquainted with the elements of Wellcome Library, London. be distributed to mechanics’ institutes the high death rate. After this, the public “careful researches” of Dr Greenhow, [sanitation]. In the present (so-called) throughout the country. Finally she debate on the causes of wartime mortality who had claimed in a recent government enlightened time, sound principles of distributed (leaked, one might say) copies of effectively ceased. report that improving the homes of Hygiene are by no means widely spread the confidential report that Lord Palmerston the poor did not improve their life among the civilian medical profession. had requested to at least a hundred of the expectancy. To Nightingale, this was like a leading public figures in the country. This Civilian Fallout red rag to a bull, because it promoted the his pamphlet also included the contained some surprising new data: a anti-sanitarian views of the Conservative Timproved diagram shown on page table of regimental statistics that showed he transfer of experience from the government that had recently taken over 34, Nightingale paid for the popular that the death rate in each regiment was TCrimean War to civilian preventative 40 41 war and medicine THE IMPACT OF THE CRIMEAN WAR ON PUBLIC HEALTH

medicine largely resulted from the and construction. Her 1863 Notes Left: Florence government’s extraordinary decisions first on Hospitals became a standard text The statue of Nightingale’s design to send Nightingale to the war and then for hospital designers, and she was Florence Nightingale for a convalescent to ask her to orchestrate a public enquiry personally involved in advising on the in Waterloo Place, hospital arranged as into the Army Medical Department. As building of many hospitals in Britain Westminster, with cottages, from Notes a result of her experiences, she was able and overseas: St. Thomas’s, Gilbert a veteran of the on Hospitals, 1863. to lend her fame and her energy to the Scott’s Leeds Infirmary, and the Royal Crimean War and Wellcome Library, London. sanitarian movement that had stalled Buckinghamshire Hospital are three children. Drawing with the dismissal of Edwin Chadwick. that survive as hospitals. Her favoured by John Byam Shaw. Right: Title page of This occupied much more of her time “pavilion plan” was a radical departure Wellcome Library, London. England and Her during the15 years after the war than from the monumental hospital style Soldiers by Harriet did her previous interest in hospital previously in favour, and her ideas Martineau, 1859. nursing. Hers was not the only sanitarian were inspired by the shortcomings Author’s collection. initiative of the time; for example, she of the Scutari Barrack Hospital. seems to have had little to do with the boom in sewer construction initiated as t would be hard to quantify the impact a result of the Great Stink of 1858. The Iof the lessons learned in the Crimean metropolitan sewers were a megaproject, War in terms of improvement in civilian but Nightingale’s speciality was bringing health. It is clear that life expectancy the sanitary lessons of the Crimean War in Britain increased from 39 years at to the population at large through village the end of the war to 55 at the time of committees, popular books (including Nightingale’s death in 1910, one of the her Notes on Nursing, a self-help manual steepest rises in recorded history. There is did not constitute the entire sanitarian on the government-policy agenda, but was for housewives), home nursing visits evidence that this increase owed little to movement, but she was without doubt an also embedded in the popular culture. and other grass-roots initiatives that curative medical techniques, vaccination, articulate public figurehead who emerged Whether or not her statistical conclusions are nowadays credited with creating a improved human immune systems, or a at the critical moment in 1858, when can be validated, Nightingale’s lessons revolution in hygiene standards. decrease in the virulence of microbes. Chadwick’s engineering-led approach from the war, which she so effectively There is not much agreement on what to public health had been replaced for presented to a wide audience at all levels he made a significant contribution did cause the increase, the two chief political reasons by one that focused on of society, must share the credit for Sto larger projects, too, through her candidates being improved nutrition and medical research. Within a short time, the facilitating this revolution. pre-eminent role in hospital design better sanitation. Nightingale’s efforts sanitarian movement was not only back he prevailing opinion among the Tmedical staff was that the high mortality in the Crimean War was due to the failure of the army and the commissariat to provide adequate rations, shelter and rest for the men. They had been starved, frozen and worked to death by uncaring senior officers, so the theory went, too weak when they arrived at hospital to respond to any treatment then available. Sir 42 43 John Hall, Principal Medical Officer WARwar ANDand MEDICINEmedicine SISTER M ALOYSIUS DOYLE in the Crimea and Nightingale’s old antagonist, published two pamphlets criticising Dr Sutherland’s report SISTER M ALOYSIUS DOYLE THE CRIMEAN JOURNALS OF THE SISTERS OF MERCY, 1854–1856

Sister M Aloysius Doyle and the Sisters of Mercy were sent on a mission to the East during the Crimean War, assisting Florence Nightingale at the General Hospital, Scutari, from 1854–1856.

My first day in the wards of the General dead. By degrees we were able to get them The blankets put into the boiling water We beg of the orderlies, who are Hospital, Scutari. Where shall I begin, to bed. Then, of course, we could see lifted out with a tongs and put onto waiting to take them to the dead house, or how can I ever describe my first view? after them better. the canvas, an orderly at each end, to wait a little lest they may not be Vessels were after arriving and the I will try to describe the cholera they wring the flannel out so that not dead; and with great difficulty we can orderlies carrying the poor fellows, first and then the frostbite, these a drop of water remains. A preparation prevail on them to make the least delay. who had, with wounds and frostbite, latter the worst of all. The cholera was of chloroform sprinkled on and applied As a rule, the orderlies drink freely, been tossing about on the Black Sea for of the very worst type, and when once to the stomach; a spoonful of brandy, when they can get it, to drown grief, two or three days, and sometimes more. attacked, the patients only lasted four and immediately after a small piece of they say. I must say their position Where are they to go? Not an available or five hours. Oh, those dreadful cramps; ice, to try to settle the stomach, but is a very hard one. Their work is bed. They are laid on the floor one after you might as well try to bend a piece very seldom it succeeded: rubbing with increasing and such work, death around another, till the beds are emptied of of iron as to move the joints when once mustard and even with turpentine, but them on every side, their own lives in those who are dying of cholera and every attacked. I believe the medical staff did cholera is proof against all. Rarely, continual danger; it is almost for them other disease. Many died immediately their best, and I may say daily, hourly very rarely, anyone got over it, and, as a continuation of the field of battle. after being brought in, their moans risked their own lives, and with little a rule, it was not the weak or delicate When the poor wounded men are would pierce the heart. The taking of or no success. At last everyone seemed who were attacked by this deadly brought in out of the vessels they are them in and out of the vessels must have to be getting paralysed. The orderlies disease, but the strong and healthy, in a dreadful state of dirt; and they increased their suffering very much. indifferent as to life or death. if there was any such out there. One are so weak that whatever cleaning they The look of agony in those poor The usual remedies ordered by day a fine young fellow, the picture of get must be done so cautiously. Oh, the dying faces will never leave my heart. the doctors were stuping, poultices of health and strength, was carried in on state of those fine fellows, so worn out They may well be called the ‘martyrs of mustard, etc.1 They were very anxious a stretcher to my ward. I said to the with fatigue, so full of vermin from the the Crimea’. We went round with hot wine, to try chloroform, but they did not orderlies, “I hope we will be able to soiled clothing and poverty of blood. and relieved them in every way as far as trust anyone with it except the Sisters. bring him through”. I set to work with The doctors gave us a wash, which we it was possible for us to do so. We went Reverend Mother was a splendid nurse, the usual remedies; but the doctor shook found very useful. Most, or I may say to the Catholic soldiers, took the names and had the most perfect way of doing his head, and said, “I’m afraid it’s all all of them, required spoon feeding. of those in immediate danger, that the everything. For instance, the stuping no use, Sister, he won’t do”. When the We had wine, sago, arrowroot.2 Indeed, chaplain might go to them at once. He seems such a small thing, and if not orderlies, poor fellows, were tired I I think there was everything in the was there; but it hastened matters for properly done it does more harm than set to work myself, and kept it on till stores, but it was so hard to get them. him to get the list of worst cases. The good. I will give her way. A large nearly the end, but you might as well We went every morning with the orderlies beds were by degrees getting empty. If tub of boiling water, blankets torn rub iron; no heat, no move[ment] from to get the wine, brandy, and other stretchers were bringing in some from the in squares, a piece of canvas with a his joints. He only lived about the things ordered by the doctors: we gave vessels, others were going out with the running at each end to hold a stick. usual time, four or five hours .... them out according to their directions. 44 45 WARwar ANDand MEDICINEmedicine SISTER M ALOYSIUS DOYLE

The medical officers were kind enough to in. I must say something of my poor And then the poor fellows were so went to him. “Tell me at once what you say they had no one to depend on but the frostbitten patients. prostrate, no matter what care they want. I have worst cases to see after”, nuns. Sometimes, if allowed, a man might The men who came down from the got they could not survive. (he did not appear to be very bad). drink the brandy ordered for the day in ‘front’, as they called it, had only The following is from a letter “All I want to know, Ma’am, is, are you one draught which, of course, would do blay linen suits, no other clothing to written by one of the Sisters at this one of our own Sisters of Mercy from him great harm. An orderly officer takes keep out the Crimean frost of 1854–1855. time, dated Scutari: Ireland?” “Yes”, I said, “your very the rounds of the wards every night, to When they were carried in on the famous own”. “God be praised”, exclaimed the see that all is right. He is expected by stretchers, which conveyed so many to A poor frost-bitten soldier told poor man. the orderlies, and the moment he raises their last resting-place, they often had me that when lying ill at Balaclava Another poor fellow said to me the latch one cries out, “All right, to be laid on the floor, no beds being one night, when he tried to stir his one day, “Do they give you anything good your honour”. Many a time I said “All, ready for them. When one was available, feet, he found them frozen to those of out here?” “Oh, yes”, I said, “Why do all wrong”. The poor officer, of course, their clothes had to be cut off. In most another soldier whose feet were lying you ask me?” “Because, Ma’am, you gave went his way; and one could scarcely cases the flesh and clothes were frozen against his. Many lose all the toes, me a piece of chicken for my dinner, blame him not to enter these wards, together; and, as for the feet, the many, the whole foot and hundreds have and I kept some of it for you”, he so filled with pestilence, the air so boots had to be cut off bit by bit, the died from this frightful frostbite. pulled it out from under his head and dreadful that to breathe it might cost flesh coming off with them, many pieces offered it to me. I declined the favour him his life. And then what could he of the flesh I have seen remain in the It is a comfort to think that these fine with thanks, I never could say enough do even if he did come? I remember one boot. Poultices are applied with some brave men had some care, all that we of those kind-hearted soldiers and their day an officer’s orderly being brought oil brushed over them. In the morning, could procure for them. At this time consideration for us in the midst of in, a dreadful case of cholera; and so when these are removed, oh, can I ever the food was very bad, goats’ flesh, and their own sufferings. devoted was his master that he came in forget it? the sinews and bones are laid something they called mutton, but black, every half-hour to see him, and stood bare. We had surgical instruments; but blue, and green. But who could complain over him in the bed as if it was only a in almost every case the doctors or staff of anything after the sufferings I have cold he had. The poor fellow died after surgeons were at hand, and removed the described and yet, I believe, it is only a few hours’ illness. I hope his devoted diseased flesh as tenderly as they could. giving a fair idea of the reality and master escaped. I never heard. And as for the toes, you could not then the patients: not a murmur .... It was said that the graves recognise them as such. Far, far worse One day, after a batch had arrived were not made deep enough, and that and more painful were these than the from the Crimea, after I had taken my the very air was putrid. There were wounds; and what must it have been when rounds through them, one of my orderlies no coffins, canvas and blankets had to they had both? To my dying day I can told me that a man wanted to speak one Originally published in The Crimean Journals of the Sisters of suffice, though cholera is still pouring never forget the dreadful frostbite. word to me. When I had a little time I Mercy, Four Courts Press. 46 47 war and medicine HOW VARIED THE IMAGE OF HEART TRAUMA HAS BECOME

How varied the image of heart trauma has become The Development Of Cardiovascular Surgery During The First World War Susanne Hahn

he expression attributed our knowledge and our proficiency n the eve of the First World War, as to Heraclitus of Ephesos has been greatly advanced … How Above: Complete Oa result of these and other recent (c 535–475 BC) that “War varied the image of heart trauma has apparatus for Röntgen scientific and technical achievements, is the father of all things” become; how very much larger our Ray work in 1897. medicine was equipped as never before is repeatedly quoted in understanding! I am reminded … of the Wellcome Library, London. to confront the anticipated injuries the history of medicine. diversity of lodged shots that pertain to the heart and vascular system. In It particularly defines the to the pericardium and the heart … It Right: 1896, Willem Einthoven (1860–1927) attitude of leading German military is not only the variety of the injuries to Electrocardiograms developed the electrocardiogram with doctorsT during and after the First the heart that astonishes us, but time of six persons, traced string galvanometer. Together with the World War. and again the amazing fact of what the by means of the string insights of Ludwig Aschoff (1866–1942), human heart is able to endure ... What galvanometer, 1903. Sunao Tawara (1873–1952) and udwig Rehn (1849–1930) is an resilience the heart possesses with Wellcome Library, London. Wilhelm His (1831–1904) into the Lexample. Professor at the University respect to these injuries!1 cardiac-conduction system (a group of Frankfurt and director of the city’s of muscle cells in the heart that cause municipal hospitals, he had in 1896 n 1895, the year before Rehn’s medicine are contradicted by the it to contract) and X-ray imaging, the successfully made use of cardiac sutures Ibreakthrough, Wilhelm Conrad Röntgen evidence, particularly in the field of ECG developed into a subtle method for for the first time to treat a patient with (1845–1923) had discovered X-rays, cardiovascular surgery. In fact, war diagnosing defects in cardiac rhythm a stab wound. This was a breakthrough which were later to be named after in general, and in particular the First and enabled functional statements on in cardiac surgery; operating on the him. The X-ray rapidly developed into World War, greatly impeded medical cardiac activity. The elaborate and costly heart had previously been considered the predominant diagnostic method in developments, since it prevented the equipment was, however, reserved for impossible. During the war, Rehn was medicine. It enabled the size and shape medical profession from fulfilling research facilities and not suitable for promoted to the position of consultant of the heart to be determined, in addition their potential. However, medical widespread use in combat. surgeon and Medical Brigadier to localising foreign bodies. After the developments did play an active part in, General of the Landsturm. In 1922, he war, radiologists agreed that the location and partially determined, the events of t was considerably more straightforward enthusiastically outlined what the war had of foreign bodies “has developed into the war. They impacted, for example, on Ifor the non-invasive methods of represented for him as a heart surgeon: an illustrious chapter in radiographic the physical examinations carried out to blood-pressure measuring inaugurated diagnostics directly resulting from the determine fitness for military service, the in 1896 by Italian paediatrician In this monstrous war there existed world war 1914–1918”.2 systematic evaluation of casualties and Scipione Riva-Rocci (1863–1937) to the opportunity as never before to fallen soldiers by army pathologists, and gain acceptance. Simple cardiac sutures treat heart injuries, to operate and ut these assumptions that the First they even influenced new biological and were also developed further. Ferdinand to carry out autopsies … Thereby BWorld War significantly enriched chemical weapons systems. Sauerbruch (1875–1951) and Johann 48 49 war and medicine HOW VARIED THE IMAGE OF HEART TRAUMA HAS BECOME

von Mikulicz-Radecki (1850–1905) n Germany, too, there were vascular powder. The pre-eminence of these German wounded at developed new techniques of cardiac Isurgeons at work, such as Ernst Above: “With God pointed bullets became clear for the first Diakonissenhaus, surgery in their use of vacuum chambers Jeger (1884–1916), who performed a for Emperor and time in 1904–1905 during the Russo- Frankfurt. Postcard, for operations on the interior of the chest. successful animal bypass operation in Fatherland/Hurrah, Japanese War, when the Japanese, 8 October 1914. This was replaced shortly afterwards by 1913, and Friedrich Trendelenburg hurrah! I went into equipped with these bullets, defeated Courtesy Wolfgang Eckart. Sauerbruch’s innovation of performing (1844–1924). In 1907, Trendelenburg the battle, one bullet the Russian army, who were still firing artificial respiration with compressed carried out the operation on a pulmonary found me, but it was with round-headed amunition. By around air. Both of these procedures averted embolism that was named after him. In for Emperor and 1910, all large armies had converted the dreaded pneumothorax, the collapse experiments on animals he exposed the Reich”. Postcard, to pointed bullets. From a military of the lungs following the opening of heart and, by means of a suction syringe 12 October 1914. perspective, these were considered the chest. introduced into the pulmonary artery, he Courtesy Wolfgang Eckart. extraordinarily effective due to their removed the fatal blood clot. low resistance, their good range and flat ess spectacular but equally Right: Willem trajectory. Because of their relatively low Lsignificant were the rapid advances hus by the start of the First World Einthoven (1860–1927), traumatic impact, they were described made in vascular surgery, which were TWar, the prerequisites for the Photograph by Charles by military surgeons as “humane”. If closely connected to the introduction of treatment of aneurysms (ballooning) R Messelhoff, 1930. they hit the heart or brain they no longer antisepsis by Joseph Lister (1827–1912) of the vascular wall and transplant Wellcome Library, London. spelt the certain death of the soldier but and the further development of suture operations were available. Research offered a chance of survival. The bullets material. Vascular surgery was heavily was also being conducted into were intended to render the enemy unfit promoted by the French surgeon and cardiopulmonary resuscitation, for which to fight, but not necessarily to kill. physiologist Alexis Carrel (1873–1944). new possibilities had arisen as a result of Active at the Rockefeller Institute developments in cardiovascular surgery. ardiovascular surgeons at this time for Medical Research in New York Chad a range of suitable therapeutic from 1906 onwards, he succeeded in echnological advances in weaponry interventions at the ready to treat the performing experimental transplants of Tthat had been made with the respect As early as 1828, elongated bullets anticipated injuries from pointed bullets. animal tissue and organs and specifically to the wars waged at the end of the had superseded spherical amunition in These wounds included a variety of vascular transplants. He perfected nineteenth century would also have a France. These were improved during trauma to the pericardium, shot-graze the vascular suture technique and bearing on cardiovascular surgery. In the course of the century, until in 1898 injuries, bullets in the pericardial cavity introduced cryopreservation for vascular addition to the development of biological round-headed bullets were replaced or lodged in the pericardium and in the grafts. In 1912, he was awarded the and chemical weapons, small-bore arms by pointed versions, which were better wall of the heart, shots through one or Nobel Prize in recognition of his work. with pointed bullets were evolving. suited to the new low-smoke nitrate more cardiac chambers, pericardial or 50 51 war and medicine HOW VARIED THE IMAGE OF HEART TRAUMA HAS BECOME

die on the battlefield or at the initial ligature (cutting off the vessels) was Above: Wounded first-aid station. Thus only very few Above: Field-dressing maintained, early aneurysm operations Germans arriving ever arrive at the field hospital or station, Chambrai, 1915. were dispensed with, and conservative at Lake Konstanz military hospital and still fewer reach Courtesy Wolfgang Eckart. methods were given preference. after internment in a military hospital back home. Then Additionally, even though the location of Switzerland, March a further 44 per cent of those who Right: Damaged bullets or grenade shrapnel lodged in the 1915, in E Nagel, Die come into clinical care will perish as a German helmet, heart or in the major blood vessels had Liebestätigkeit der consequence of infection. However, of First World War. been perfected with the use of X-rays, Schweiz im Weltkriege, those who recover, the great majority Militärhistoriches Museum here too, conditions of war prevented vol II, 1916. retain ensuing conditions involving der Bundeswehr / Meier. widespread practice: inflammation and impairment to the Right: Damaged circulation in the form of pericardial The large majority of these injuries German helmet, First adhesions, adhesions of the surrounding do not reach the stage of X-ray World War. cardiac rupture, as well as multiple gun- area, the diaphragm, the lungs, etc.3 ew developments in vascular examination; in particular, injuries to Militärhistoriches Museum shot wounds to the major blood vessels Nsuturing and operating on vascular- the major blood vessels lead almost der Bundeswehr / Meier. causing fatal haemorrhaging. he infantry suffered the worst wall aneurysms caused by injury were without exception to a quick death Texposure to the hail of bullets. not given the chance to fulfil their full on the battle field or on the front owever, the number and type of Protective Prallab (Ricochet) vests potential in the battle context, since line. Among the millions of gunshot Hactual heart injuries that doctors proved to be of no use. Not until after the “ideal operation of the aneurysm wounds brought about by this war, a of the German military medical service the war was it possible to estimate the is … even under the best conditions substantial number of casualties with were required to treat during the First number of front-line soldiers who had difficult, protracted and, above all, is in injuries to the pericardium and the World War, and from which soldiers died survived heart injuries. Soldiers suffering no way feasible in every case. The basic heart reached military hospitals back in many cases, exceeded all expectation. from a bullet lodged in the heart had the requirements for this are completely home and here were, at last, correctly According to the Handbuch der ärztlichen greatest chance of survival: up to ten aseptic conditions and it is therefore directed to X-ray examination.5 Erfahrungen im Weltkriege 1914–1918 per cent. Around 450 soldiers lived with absolutely out of the question at the (Handbook of Medical Experiences bullets in their bodies without the need front.”4 hese clear discrepancies between the During the World War 1914–1918), for an operation. In fact, operating rarely Tlevel of medical technology achieved written by leading German physicians: improved the situation. But discomfort oreover, not all surgeons had by this time and the actual level of in the cardiac area impaired both their Mbeen trained in the complicated treatment achieved in war—discrepancies By far the largest proportion of capabilities and the future course of techniques of vascular suturing. Thus that countless soldiers paid for with cardiovascular casualties undoubtedly their health. the conventional use of the vascular their lives—were augmented by further 52 53 war and medicine HOW VARIED THE IMAGE OF HEART TRAUMA HAS BECOME

shortfalls that can only be evaluated Landsturm conscripts and civilian doctors. opportunity to gain insight into medicine, nly a few doctors, for example Ernst German stretcher- indirectly. Despite the formidable number Of the 26,292 doctors deployed during the German wounded in they contributed to the popular idea that OWeiß (1888–1940) and Friedrich bearers approaching of heart injuries, only very few individual war, 1,783 (seven per cent) lost their lives. a military hospital war is manageable and that medicine can Wolf (1888–1953), became opponents of the German border cases were deemed worthy of coverage in Postcard, date and minimise its disastrous consequences, the First World War as a result of active near Bale following medical journals during the war. There he resulting stagnation of medical location unknown. thus avoiding a proscription of war and duty at the front. Cardiologist Georg internment in was no further mention of systematic Tdevelopment caused by this alone Courtesy Wolfgang Eckart. effectively becoming complicit in this Nicolai (1874–1964), who specialised Switzerland, November provisions for resuscitation or for organ continued in Germany during the post- and future conflicts. in ECG and was from 1910 professor of 1914, in E Nagel, Die transplantation. Other themes dominated war years, which were characterised the medical clinic at Berlin’s Charité Liebestätigkeit der medical literature during the early war by gaps in personnel and shortages of t is therefore not surprising that hospital, also belongs to this group. Schweiz im Weltkriege, years, above all, the completely new materials. It took years for world-famous Ithe preparations for the Second Defamed for denigrating his own country, vol II, 1916. experience of war on this scale. Particular sites of medical research and teaching in World War from 1935 onwards were he was prevented from resuming his attention was drawn to ‘heart neuroses’, Germany, such as the Medical Faculty made without ever considering the teaching activities after the war. In 1920, where soldiers who to all intents and of the University of Leipzig, to rejoin idea that war ought to be prevented. he was stripped of his venia legendi purposes were physically strong but international scholarly research, and Instead, the focus was on how military (permission to teach) and emigrated to were unable to deal with the physical they only survived this difficult time with medicine could be improved through Argentina in 1922. strain and psychological horrors of the the aid of external support. increasing the capacity of military field war responded with cardiac pain and hospitals and their ability to transfer hus as long as the war continued, arrhythmia (disturbance of the heart he Handbook of Medical Experiences, patients, as well as the introduction of Tcardiac deaths in combat zones beat) that did not seem to be the result of Thowever, did not concern itself psychological training in the prevention took place routinely, far away from all any organic abnormalities in the heart. with these fundamental humanitarian of war neuroses and suicide among the successes of cardiac surgery. In his and scholarly shortfalls. The war was soldiers. But there was also a systematic autobiographical novel on battlefield eading German physicians, including unilaterally and uncritically presented as reduction of provisions for soldiers, and medicine Die Pflasterkästen (The LSauerbruch and Rehn, were entrusted the source of an inexhaustible development from 1939, the killing of the mentally Plaster Boxes), Alexander Moritz Frey with military assignments rather than of knowledge. The majority of German ill, Jews and the elderly in order to (1881–1957) describes the rapid death in civilian research. The losses in the German doctors seemed incapable of reflecting free up hospital beds. Thus the Second 1918 of a clerk of the Medical Corps on the Military Medical Corps resulting from upon the horrors of the war and did nothing World War was no more humane; even Western Front, who was hit in the heart by the war were considerable: ten per cent to confront its disastrous psychological, from a medical perspective it turned a tiny piece of shrapnel from a grenade: of active officers in the Medical Corps, social and economic consequences. out to be a diabolical disaster. Modern 7.9 per cent of medical NCOs, six per While they continued to portray medicine war is a priori the enemy of a profession And it ought to be demonstrated what cent of the auxiliary combat doctors and as a humanitarian element of war, and that takes responsibility for the life and sort of insignificant things can do junior combat doctors, 4.7 per cent of the to depict the conflict as a fundamental health of humanity. away with someone … One morning, 54 55 war and medicine HOW VARIED THE IMAGE OF HEART TRAUMA HAS BECOME

His mouth snatches strongly for air Above: Wounded German once, twice, but equally often by an “The battlefield /where soldiers and nurses ever declining degree of energy. His pain and suffering rise drinking wine, Hilfs- lips turn pallid during the next gasp. / from red blood and Lazarett Ackermann, They glow blue. He has closed his eyes. manly slaughter. / Still, Wittenberg, private That they are now half open again does this is the seeding acre military hospital. not mean he has come back to life. /Of healing charity / Postcard, 19 There is no return; it is the slackening For you, the caring March 1915. of the eye-lids. They are at half-mast daughter!” Postcard, Courtesy Wolfgang Eckart. and will never again reveal a gaze, only 1914–1915. crushed views of the past … Medical Courtesy Wolfgang Eckart. Right: Treatment the younger of the two clerks was Captain Fünfer took hold of what was of wounds, Reserve- injured by a small piece of shrapnel now no more than a body, which was Lazarett Marburg, the size of a lentil. He had heard it, already turning cold … ‘Something very Postcard, 9 the grenade, which exploded in the small has apparently penetrated right February 1918. garden, evidently close to the wall, into his heart’, Fünfer said, expressing Courtesy Wolfgang Eckart. for we heard the crashing of timber his diagnosis in unintentionally and and stone. Soon there is a rumbling of unwontedly absurd fashion.6 hasty boots going down the cellar stairs. They carry and drag the man, who can eing hit in the heart became a no longer walk, between them. What’s Bmetaphor for the manifold physical wrong with him then? Has he been and psychological, in many cases fatal, hit? Where has he been hit? He is not injuries that the First World War had bleeding; his uniform is undamaged— inflicted on humanity. Erich Maria as far as a German uniform can be Remarque (1898–1970) used it in his ourselves. We were 18 and began to in 1918. It is incomprehensible but novel Im Westen nichts Neues (All Quiet love the world and existence; we had plainly apparent; he dies in a few on the Western Front): to shoot at them. The first grenades seconds. Here, it is clear how death that struck, hit us in the heart. We are conquers life, gradually taking hold We are no longer youths. We no cut off from the active, from ambition, with a firm and certain grasp … That longer want to storm the world. We from progress. We do not believe in man is pale, turns ashen, then yellow. are fugitives. We are fugitives from that any longer; we believe in the war.7 56 57 war and medicine LIFE WITHOUT ARMS

Life Without Arms Carl Hermann Unthan and His Motivational Work with Disabled Veterans in Germany Colleen Schmitz

“I saw the first transport of wounded lthough heart problems had forced Opening a door. soldiers and heard their moans. Terrible AUnthan into an early, unfulfilling From Das Pediskript, visions arose before me. How would retirement, he felt a strong sense of 1925. these many thousands endure the duty to do his part for the fatherland Photograph by R crippledom that had befallen them?”1 and show his thanks to the soldiers who Müller, American Photo had sacrificed life and limb. He became Studio, Prague. hese were the thoughts of involved in various initiatives to care 66 year-old Carl Hermann for the injured veterans by sharing his Unthan (1848–1929) as experiences of disability. the disabled soldiers of the First World War began to return home. Himself ON STAGE physically disabled since birth, Unthan set out on a mission to s Untham wrote in his autobiography assistT these German veterans in coping Das Pediskript (The Armless A with their injuries. Fiddler) 1925:

nthan was born without arms Dr Bretter, the head of war hospitals Uand had developed exceptional in Berlin, asked me to send him dexterity in his feet and legs. Through photographs showing some of my self-training, he had learned an array of extraordinary feats; they would be extraordinary skills that enabled him to published in Über Land und Meer [Over be largely self-reliant. Not only could he Land and Sea] for the consolation of the dress and undress himself independently, wounded. I sent him four photographs but he could also fasten a necktie, eat and asked him if he did not think that with a knife and fork, and write legibly lectures and demonstrations, which I with both his mouth and his foot. Most should be very pleased to give, would extraordinary of all, he was a talented be more effective. He was delighted violinist, who had travelled around the with the idea and I gave my first world, giving performances in music lecture at the Königstadt hospital in the halls and circuses. beginning of April 1915.2 58 59 war and medicine LIFE WITHOUT ARMS

ome of the leading doctors in at the end of the performance. “I don’t Corps. He gave a lecture at each Regulating a watch. From SGermany invited Unthan to lecture find anything difficult, but playing the Above: Firing a military hospital. At the Luisenbad, the Das Pediskript, 1925. at their hospitals. Between 1915 and violin has required most practice”.... rifle. From Das medical officer marvelled at the fact Photograph by R Müller, 1918, he gave his demonstrations I made good my promise to visit Pediskript, 1925. that armless soldiers were propelled American Photo throughout the German Empire, Ettlingen in the state of Baden. All Photograph by R Müller, forward more quickly by means of their Studio, Prague. from Berlin, Dresden, Würzburg and citizens of that state who had suffered American Photo leg motion than the arm strokes of the Karlsruhe to Lublin (at that time wounds to their arms or legs were Studio, Prague. soldiers with missing legs.4 Austrian), Bucharest and many smaller assembled in a special hospital, which towns. He demonstrated everything from had originally been built for a military Right: Sharpening undressing to lighting a cigarette. school. The latest improvements were a pencil. From Das IN FILM installed there and all expedients that Pediskript, 1925. nthan’s audiences included both had proved helpful were adopted .… Photograph by R Müller, Lingner wanted for his museum, The Umedics and injured servicemen, Baron von Künßberg, a Heidelberg American Photo Human, a work of world culture, which sometimes totalling as many as 2,000 professor, was heart and soul devoted Studio, Prague. would be exhibited in many cities, at a single event. Statesmen and high- to the care of the wounded. His Manual a film in which I would demonstrate ranking military figures also attended. for the One-Armed was used in all everything achieved via self-help. I hospitals. He invited me to see him and was always ready for anything in the My offer to give a lecture at the Royal introduced me to Dr Eugen Fischer, name of scholarship. I did not ask for Hospital in Dresden was accepted. The Professor of Anatomy in Freiburg, then anything in return other than the cost King was present ... “My word, once director of the Ettlingen Hospital .... of travel and board.5 again!” exclaimed the King after my I had found the doctors and their first [rifle] shot … had cut a lead pencil assistants most interested in their nthan is referring to Karl August in two, as he picked one of the halves patients everywhere, but nowhere did ULingner, the former director of the up from the floor and searched for the I find such warm-hearted and friendly Deutsches Hygiene-Museum in Dresden, other half. Instantly two officers of his devotion as in Fischer and Künßberg, Karlsruhe, where I performed all my who was active in the field of public- suite were crawling about on the floor who, on the day of my lecture, had feats and got Künßberg to take some health education. During the war, the to find it. “May I keep them?” asked been promoted to professor. When photographs of me.... museum increasingly focused on the the King, holding both halves in his I explained to them the effect that In otherwise easy-going Munich, health and medical care of soldiers and hands. “Certainly, Your Majesty, it only swimming has on the circulation care was taken profoundly seriously. disabled veterans. As the masses of costs ten Pfennigs”—“What do you they arranged for the wounded to be Prince Ludwig Ferdinand served as injured and often severely disfigured find most difficult?”, asked the King transported to the swimming-bath in Lieutenant Colonel of the Medical soldiers returned from the front, the 60 61 war and medicine LIFE WITHOUT ARMS

exhibition took place in 1915 and was abandons himself to despair, which Above: Ringing “to bring reassurance and consolation to Above: Preparing to is, unfortunately, very easily, almost a doorbell. Still from all sections of society”.5 dive after a small plate. always unjustly transferred to others.9 Ausbildung der Füsse (!) Still from Ausbildung als Hände, 1975. t is within this context that Lingner der Füsse (!) als hus begins the introduction of © Stiftung Deutsches Hygiene Iinitiated the filming of Ausbildung Hände, 1975. TUnthan’s 1916 book Ohne Arme durchs Museum Dresden. der Füsse (!) als Hände (Training the © Stiftung Deutsches Hygiene Leben (Surviving Life Without Arms). Feet as Hands) with Unthan in 1915. Museum Dresden. He drafted this illustrated handbook Right: Undressing. Here, Unthan demonstrates how to ring a for disabled veterans at the request of Still from Ausbildung doorbell, open and close a door, undress, Right: Swimming orthopaedic doctors participating in the der Füsse (!) als swim, dry off and dress. backwards. Still from ‘1st Conference on War Orthopaedics’ in Hände, 1975. Ausbildung der Füsse (!) Berlin in 1915, where he was invited to © Stiftung Deutsches Hygiene he main part of the film is dedicated als Hände, 1975. with one foot, and picking up objects give one of his lecture-demonstrations. Museum Dresden. public’s initial enthusiasm for the war Tto swimming, which played a © Stiftung Deutsches Hygiene from the bottom of the pool. “With Unthan wrote 78 pages in 20 days. was beginning to wane. Moreover, fundamental role in Unthan’s life Museum Dresden. genuine enjoyment, I collect plates, In 20 chapters he takes readers on a stories circulating about the horrible and was a major component of his coins and even pins from 3 metre-deep step-by-step guide to mastering life’s suffering of soldiers in the field, as well self-help philosophy. water, but never remain under water for new challenges. He gives a descriptive as complaints about inadequate means longer than 2 minutes.”7 account of the most important events of of transport and poor medical care in the That which is beneficial to the his life and then goes on to describe how military hospitals, were adding to this development of the body proves in he masters everyday tasks without arms. shift in sentiment. the same way to be of value to the THE WRITTEN WORD maintenance of it. Therefore, in you nthan also expounds, sometimes in a o temper these fears, various get, you disabled men! Try what I As I have called on many thousands Urather grandiloquent style, on issues Tideological initiatives sprang up began to do and it will work for you.6 of you in the military hospitals, of mind and body, training, enjoyment and throughout Germany. Among others, the I would thus like to visit each possibilities for employment. For him, Deutsches Hygiene-Museum developed hile in the pool, Unthan performed individual in his place of suffering determination and perseverance were various special exhibitions and films, Wa variety of actions such as in order to demonstrate in how many crucial for leading a constructive life with propagating to a broad audience the diving, floating, swimming forwards different ways one can still help a disability. Pity was to be scorned. With state-of-the-art medical services and backwards both on his back and on oneself. [I will find hope] where an a strong will, hard work and a positive for soldiers at the front and injured his stomach, swimming with one leg, able-bodied person can now only attitude, he believed it possible to lead serviceman at home. The first such swimming while holding an umbrella see utter helplessness and quietly a relatively autonomous and happy life. 62 63 war and medicine LIFE WITHOUT ARMS

PHILOSOPHY that lead to one and the same goal are Writing with his countless … However, in one point all right foot. From Das verall, Unthan wished to sensitise of these approaches concur: in the joy Pediskript, 1925. Odisabled veterans, the medical field of each success, even the small ones. Photograph by R Müller, and the general public to the notion This is a joy that is so heart-warmingly American Photo that life with a disability need not be deep that an able-bodied person would Studio, Prague. abnormal. In his various engagements never get to know it in normal life. in the service of war-victim care, he This success—or is it simply work saw his role primarily as a motivator, aimed at success?—brings about a limited to inspiring through example. deepening of the soul, upon which a When asked by a doctor at the onset new standard of values can be built.10 of the war what he could his teach his patients, Unthan answered: “What they n this way, Unthan championed work can learn will differ according to age, Ias a central tool in mastering the new previous occupation and good will. Even challenges facing disabled servicemen. the smallest [task] would fill their time and banish thoughts of suicide”.9 He saw The period of transition, until you have Shaving. From Das his self-help strategies not so much as found your way in the new Empire Pediskript, 1925. methods to be slavishly copied but rather and have regained your psychological Photograph by R Müller, as models of what could be achieved with equilibrium, this ‘difficult time’, American Photo the right attitude. because it has befallen you so Studio, Prague. suddenly, for this I can only offer you To my friends injured in battle, one remedy, which also operates as Far be it for me to ask that you carry an accelerant to help you carry the out that which I have achieved by burden. The magic word is ‘work’. No means of self-help. Not even the way matter how you occupy yourselves, be that has led me to my goal will be it painting a box or carving a wooden imposed upon you. However, I will board, do something! If you only do it, reveal as many methods as possible then you will see your achievements to you, which you should develop and grow. Then you will have conquered follow in your own ways. For the ways the most difficult stage.11 64 65 war and medicine LIFE WITHOUT ARMS

nthan’s ardent wish to motivate and he proceeded with his lecture series Above: Unthan at one Ucoupled with his experience on stage despite declining health. Even in the face of his demonstrations. as a musician made his lectures highly of dwindling savings, he refused to accept From Ohne Arme Durchs entertaining. His demonstrations were money for his work with the disabled, Leben, 1916. often accompanied by a piano and were believing that this would jeopardise the Photograph by A aimed specifically at getting a laugh. legitimacy of his cause. Bruhn, Hamburg. The doctor Hans Würz stated in his book Siegreiche Lebenskämpfer (Victorious in I request that remuneration is the Fight for Life) that Unthan “pours dry disregarded. I have attempted to inspire humour from his feet”.12 everyone, who can still stir themselves, to work and to banish their thoughts of Without fail, I succeeded in brightening suicide. If it becomes known that I have the cheerless faces of the wounded drawn pay, then my influence will likely soldiers to the point of elation. I had dwindle. This would not be favourable gradually become accustomed to the to me.14 sight of the wounds, which initially threatened to make me feel heart sick.13 nthan was awarded a Red Cross UMedal and a Cross of Merit for his war Shaking hands. From ot all medical professionals approved work. When the war ended, the military Ohne Arme Durchs Nof Unthan’s choice to put himself hospitals no longer requested his services, Leben, 1916. on public display. Konrad Biesalski, but various professors of anatomy, surgery Photograph by A a pioneer in the rehabilitation field in and orthopaedics continued to call on him. Bruhn, Hamburg. Berlin at the time, termed people who On his 75th birthday, at the request of his publicly exhibited their handicap in wife, he retired from lecturing. order to make a living Reklamekrüppel (publicity cripples). Unthan’s image stood With all my power I strive to spread in opposition to the new ideas of Biesalski sunshine and roses over the future and others on integrating the disabled into path of your lives. If only a very small society. Such attitudes, however, did not fraction of my wishes are fulfilled and deter him. Invitations to appear at medical illuminate and warm you on your new hospitals continued throughout the war, journey, I will feel royally rewarded.15 6666 67 war andand medicine medicine SOLDIERS’ BODIES IN THE WAR MACHINE

SOLDIERS’ bODIES IN THE WAR MACHINE TRIAGE, PROPAGANDA AND MILITARY MEDICAL BUREAUCRACY, 1914–1918 Ana Carden-Coyne

arly in 1914, the British reveals how wounded soldiers found an Austin Osman Spare, War Office estimated imaginative way of expressing their view An Aid Post, drawing in that 50,000 beds would that their bodies had become mere cogs coloured chalks, 1918. be needed to care for in the military machine. Wellcome Library, London. the sick and wounded. Unprepared for the scale of warfare, the Royal Instituting Medical Army Medical Corps was soon facing Logistics: Transport massE casualties on an unprecedented and Triage scale. As the year drew to a close, more than 73,000 wounded patients had he Army Medical Services dealt returned to Britain for hospitalisation. Twith the mass casualties by This situation placed enormous stress developing bureaucratic systems of on logistical, professional, medical treatment. Controversies, however, and personal contingencies regarding such as professional tussles between the effective evacuation and treatment civilian practitioners and regular of the wounded. Military medical military medical staff and conflicts over bureaucracy—procedures and policies the safe transportation of the wounded, for overseeing both medical staff and undermined their efficiency. The role of patients—became a critical development triage—a system to sort the wounded by of the war. severity of injury in relation to treatment time and resource allocation—meant his chapter considers the logistics that some doctors encountered new Tof transporting the wounded, and ethical dilemmas that challenged the significant role that triage played their Hippocratic ideals, since it was in the war. It shows how accusations “practically impossible” to attend to of neglect against the RAMC were met all cases.1 with a propaganda campaign to counter this image, and explores how civilian he RAMC system divided labour, physicians employed in the RAMC came Tresources and infrastructure into into conflict with the system. Finally, it three zones: Collecting, Evacuating 68 69 war and medicine SOLDIERS’ BODIES IN THE WAR MACHINE

and Distributing. The principle of the the frontline. In his 1915 diary, RAMC Carriage of the wounded Collecting Zone was to mark out an area Captain DWJ Andrews reflected upon the in the trenches, First where the wounded were taken from the pressure and tragedy of triage at the RAP: World War. battlefield to one of the Regimental Aid Wellcome Library, London Posts (RAPs)—a small underground All moribund cases we kept, it being clinic or temporary structure, as seen in useless to send them on. It was a Austin Osman Spare’s painting, An Aid trying time. For the patients are all Post (see page 66). such young healthy lads, and it is rather nerve racking to see them cut ollecting the wounded was a off in the prime of life to satisfy the Chazardous procedure that often whims of governments.2 endangered the lives of rank-and-file stretcher-bearers, as shown in Gilbert ven in the heat of frontline duty, Rogers’ heroic painting opposite, which Etriage could make hardy medical shows a group struggling to retrieve a men reflect on the cost of war. RMOs wounded man from a shell hole. and surgeons often found these decisions personally taxing. Triage also impacted earers rescued patients and delivered upon stretcher-bearers and orderlies. Bthem to the Regimental Aide Post Though they worked “splendidly”, (RAP), where the Regimental Medical Andrews recalled, “the majority of them Officer (RMO) dressed wounds, and made were quite unused to such sights”, and triage decisions about who should be experienced great stress in administering transported to the Advanced Dressing these life-or-death decisions.3 Station (ADS), based on the extent and severity of injury and whether it was uring battle periods, surgeon Henry Gilbert Rogers, Stretcher treatable. The triage process was repeated DKaye noted the “delirium of work” Bearers of the Royal at the ADS, where the Medical Officer and how it affected patients: “it was truly Army Medical Corps, oil decided who would be transported further piteous to see the state those men were on canvas, 1919. on, who would remain, who would be in”.4 As the war dragged on and casualties Wellcome Library, London. returned home and who might be sent for peaked, a vicious cycle of exhaustion a short rest before being ordered back to developed, and the low success rates 70 71 war and medicine SOLDIERS’ BODIES IN THE WAR MACHINE

of some operations further demoralised to die in order to give those less badly Motorised field hospital, staff. Some RMOs became depressed, wounded the chance of recovery … First World War. turned to alcohol, or were sent home with Poor abandoned ones! We trust that God Wellcome Library, London.. “their nerves gone”; others developed especially covered you with His wings, “unhealthy” stress reactions.5 Although and that your people at home never medics often imagined that they would knew the tragedy of your last hours.8 never get used to the conditions of war, over time they became desensitised to t the RAP, treatment was basic: what was happening around them. Kaye Aarresting haemorrhage, splinting admitted feeling “oppressed” by his fractures and cleaning wounds with patients, given the likely outcome of antiseptic. Often, systems were ad their injuries.6 hoc. Sometimes the wounded did not even see an RMO in the first phases of hen a decision was made triage. For instance, when the RAP was Wthat a patient was “too bad to occupied, men could be sent straight touch” or was too close to death for to the ADS having undergone neither intervention, he was “detained” by the diagnosis nor bandaging and pain he introduction of this bureaucratic smothered groans of those who were Field Ambulance at the Main Dressing relief. At the No 8 Casualty Clearing Regimental Aid Post, Tprocess was meant to aid efficiency given a white showed me that the Station (MDS), which meant trying to Station, the Field Ambulance appeared First World War. and treatment; however, the patients distinction was of great moment to make him “comfortable” before he died. “indifferent”, “none of the fractures” Wellcome Library, London. understood the significance of the labels these men.10 Physicians could not waste time and arrived cleaned, and “many cases came only too well. Journalist Basil Clarke resources on attempting to revive such down bleeding”.9 recorded the conversations of men lying white label may have indicated a cases.7 Nevertheless, RMOs were often on stretchers in a Beauhamel cellar, which A less serious injury, but it also uncertain about these wartime decisions; hen the triage decision had served as an RAP. The wounded “lay signalled to its recipient that he was not for some, triage lingered on as a troubled Wbeen made, a Regimental Label anxiously speculating as to their fate”: going home to “Blighty”. memory. In 1922, the yearbook of the describing the injury was attached to 44th Field Ambulance recalled: the patient’s jacket. A white label meant I was watching the distribution of AP trenches were often so a light case, whereas a red and white pleasure and pain such as only a Rnarrow that stretchers had to It was always sad, after big pushes, label indicated a serious one. The labels wounded Tommy can know. But be tilted or patients lifted by blanket, to see at RAP’s and ADS’s bad cases, produced at the RAP could be amended the glittering, glad eyes of the lads which could distress both the such as abdominals, put on one side at the ADS or further behind at the MDS. who received a red ribbon and the injured and the bearers. 72 73 war and medicine SOLDIERS’ BODIES IN THE WAR MACHINE

troop replacements. After a series of road conditions. A soldier wounded three Hospital Tag of Private Diagram illustrating the scandalous reports of patient neglect by times said, “I would a thousand times Walter Percy Bray, scheme of evacuation the RAMC, intense political pressure prefer to be driven by a woman”; others 1915–1924. of sick and wounded had been placed on evacuation speeds. commented that “they bump less” and 14 Wellcome Library, London. in Macedonia, 1 The wounded were continually moved “look out for every pebble in the road”. Subject to continual bombardment, the he Evacuating Zone included two September 1917. on stretchers, wagons, trolleys and Collecting Zone was dangerous, generating TCasualty Clearing Stations (CCS) and, Wellcome Library, London. ambulances, which was often detrimental hile patients complained about fear and uncertainty among patients. further behind, the Stationary Hospital. to recovery. Whilst medical propaganda Wjolting rides across ragged terrain, RAPs were destroyed, and site-relocation Patients were evacuated along routes claimed that the best motorised transport physicians worried about blood loss, caused confusion for stretcher-bearers, who called the ‘lines of communication’, by was being used, in some theatres of war shock and cold. This was why the choice wandered around trying to find them. In road, railway and canal. camels and other animals were used, of site for the CCS was so important: emergencies, RMOs improvised makeshift or men had to improvise, sometimes good roads ensured the smooth transport RAPs from blankets tied to trees or he third area, the Distributing Zone, pushing the transport by hand. of the wounded. amongst the rubble of buildings. Twas where the wounded received their final treatment, and referred to t home, politicians boasted that s the war continued, the CCS shifted ield Ambulance teams of bearers and hospitals at the base, overseas or at Arescue speeds were within four Afrom an amorphous, temporary Fmedics worked between the RAP, home. The simple structure of the three- hours, and hospitalisation within 12 and mobile structure to a more stable the ADS and MDS. The ADS might be zone model was not always implemented, hours. Back at the front, however, one with a greater range of equipment far away from the RAP, which could however, especially with constraints Captain Kaye commented that “people undertaking multiple roles. Later in the drastically affect the patient’s survival. on mechanical transport and medical forget what a great additional strain war, staff from several Clearing Stations At Sanctuary Wood (Ypres), the distance manpower. Evacuation plans were drawn any transport imposes on the patient were pooled into one locale, assisted was five kilometres and the journey up by hand and colour-coded, but in … this express transport has cost their by mobile surgical teams, but the great could take up to five hours. At the ADS, practice could be complicated and lives”.12 He wrote in his diary that length of the frontline did affect its the RAP label was replaced by the Field inefficient. although the motor transport had “done proximity to the Evacuating Zone. Medical Card, which allowed for notes. wonders in this war”, from the patient’s However, this system could also cause he question of transporting patients perspective, “the abiding recollection et senior officials in the RAMC confusion. Private Walter Percy Bray’s Tin ambulances and by road was a of the worst part of the whole business Yappeared not to comprehend fully card, for instance, had a diagnosis of fraught one throughout the war. Some in the wounded man’s mind is his time the stressful conditions of warfare and anaemia recorded on one side and scarlet Commanding Officers complained in the ambulance”.13 Patients often mass casualties. Captain Andrews fever on the other. Medics regularly that patient evacuation was secondary preferred female ambulance drivers, recalled how the Assistant Director of complained about such inconsistencies.11 to the transport of munitions and who took more care with the hazardous Medical Services had insisted on drilling

74 75 war and medicine SOLDIERS’ BODIES IN THE WAR MACHINE

Above: Evacuating Propaganda and wounded men on an Above: Horse Professional Conflict improvised trolley railway ambulance line from No 3 CCS, transport,1916. rom the outset, transportation of the Pushviller, to an Wellcome Library, London. Fwounded had been politically and ambulance train, 1916. ethically sensitive. Rumours circulated Wellcome Library, London. Right: Stretcher cases that casualties were often left for days being carried on a light in No Man’s Land, before medical Below: Women railway near Feuchy, assistance arrived. In many cases this motor ambulance during the Battle of was true, especially since wounded drivers, 1916. Aras, 29 April 1917. men often crawled into shell holes for Wellcome Library, London. Wellcome Library, London. protection and then fell unconscious.

o defuse public anxiety, media Tcampaigns were conducted to a group of field surgeons for “An Urgent promote an image of the RAMC as a Aseptic Operation”, with everything modern machine, capable of speedy and sterilised and the officers gowned and painless evacuation. Although modern washed. Andrews thought this “utterly machines produced horrific injuries, absurd”, given the conditions at the new technology and medical science front.15 Compounding the pressure were seen as delivering innovation to the on resources and training time, the wounded body, which was highlighted Field Ambulance became “a dumping in medical propaganda as modern ground for Medical Officers” who were progress. The British Medical Journal often insufficiently skilled.16 Indeed, enthused that the Collecting Zone had many senior medics raised the issue “an atmosphere all its own—bracing, of competence and training, asserting suggestive [and] thrilling” for the that Medical Officers were unaware of physician.17 Newspapers and illustrated treatments and procedures, and that the magazines featured stories on medical flow of information was slow to reach advances, asserting the superiority of across the three zones. the Allies. In October 1914, the medical 76 77 war and medicine SOLDIERS’ BODIES IN THE WAR MACHINE

correspondent for The Times reported wrote to The Times, asserting his ith sentimental images of tender antiseptic application, bandaging, a “Removing the Patient on floating barge hospitals, which could confidence in the Army Medical Services: Hospital ward on a Wnurses, committed doctors, and hastily-written label tied to the man’s After Surgical Attention”, be boarded “without disturbing the French canal barge, their “untiring devotion and forgetfulness breast, and the wounded one is borne in “How the Wounded wounded man”.18 For the peace of mind of the public, First World War. of self”, Knutsford reassured the public of off and away” to the ADS.22 Supporting were Brought Home”, and especially of those who have Wellcome Library, London. the humane treatment given to wounded this testimony, the editor offered his own The Great War Magazine, hotographs of mobile operating units relatives wounded, I do ask to soldiers. This RAMC propaganda also praise for “The Medical Army” and its February 1917. Pand other technological innovations be believed when I say that the reached the patients, raising their “masterly organisation”, jeering: “Who 23 Wellcome Library, London. were also published. Patients were shown arrangements, as far as my hospital expectations of care and treatment, which says the British cannot organise?”. being treated gently and professionally, experience permits me to judge, are were often disappointed in reality. Stories and the extent of individual care was amazingly perfect.20 of devoted service concurred with images ountering rumours of high rates of stressed: “everything was arranged for deployed in humanitarian advertising and Camputation, The Times reported maintaining perfect steadiness, as the espite vouching for high standards fund-raising literature, such as in the Red that “conservative surgery” was being patient was lifted into the mobile unit by Din the hospitals, he admitted: Cross poster The Greatest Mother in the practised, and that Sir Alfred Keogh five attendants”.19 “I cannot, of course, speak as to the World, 1918. had appointed Senior Consultants for all treatment of the wounded at the front”, major operations, averting any chances cross Britain, ambulance trains were but felt sure that all complaints were he objective of medical propaganda of “serious mutilation” by inexperienced Aexhibited as the epitome of modern dealt with appropriately. Knutsford Twas to maintain public morale. surgeons. Even so, heated debates were technology and efficiency, equipped with praised the evacuation procedure of the Critics of the RAMC were blasted as raging within medical and surgical all the latest devices. However, when RAMC for “smoothness and perfection “irresponsible”, “biased” and ignorant circles as to what was the best way to Captain Andrews loaded 989 wounded of the whole organisation”. Closing his of the facts, as well as “venomous treat wounds and retard the growth of men onto a train at Bethune Station, letter, he made an interesting comment: and harmful”.21 Advocates like Lord infectious bacteria that led to gangrene Northern France, he was appalled that military medicine was anything but Northcliffe highlighted the heroism of the and amputation.24 they had to share one blanket between disciplinary, and was close to the RAMC. Writing for The Times, he spoke four, that several carriages were without civilian model: of their bravery and listed the number n 1916, a confidential memo was sent by lights, and that most of the second-class of medics wounded, killed and missing. Ia group of prominent civilian surgeons carriages were unclean. The whole spirit … [was] not the He also praised their “chivalry” in claiming that patients were tolerating awful military ‘go there,’ ‘Come here,’ ‘Do forsaking “lucrative practices in London, conditions, for fear of appearing to lack n the public domain, however, officials this,’ but … everywhere there prevails or Melbourne, or Montreal, in a great rally “pluck and self-sacrifice”. Physicians, Imade powerful statements of support for a tone of sympathy, kindness and of self-sacrifice”. In marked contrast to too, felt pressure to conform to military the RAMC. Returning from a hospital tour gentleness, which makes one’s heart surgeons’ diaries, Northcliffe extolled the practices and to keep silent or risk being of Boulogne and Calais, Lord Knutsford beat a little faster. RAP as a place of “lightning diagnosis, accused of “unpatriotic” attitudes.25 78 79 war and medicine SOLDIERS’ BODIES IN THE WAR MACHINE

nother problem was that the entry Pensions to determine a soldier’s Arank for physicians was as low medical discharge, the degree of as Lieutenant, a position with little incapacity and the extent of pension autonomy that elicited “grumbling” he might be awarded. Yet accurate and “crankiness”.29 Officials responded records were difficult to keep with derisively to such complaints: the “God large volumes of surgical cases and given Surgeon always has a grievance lengthy operative periods. and these are the men who cause the trouble”.30 Medics might be summarily ther doctors felt frustrated that the moved from one field hospital to another, Osystem did not seem to function at to the extent that the Surgeon General, all; patients arrived at the CCS from Sir William Watson Cheyne, investigated the Field Ambulance with their wounds a range of complaints from consultant incorrectly recorded, suggesting that surgeons. Colonel Burtchaell’s response MOs were time-pressed, or that stretcher- was to dismiss the surgeons as “men who bearers without medical knowledge are no good”.31 were filling in cards. In Britain, senior Although surgeons argued for more To succour the wounded, that they surgeons complained that the wounded Armoured ambulance specialists to be employed in the service, might with greater celerity return to ivilian medical staff often regarded were returning to civilian care “without breakdown in the Colonel Charles Burtchaell retorted that wound or be wounded on a subsequent Cmilitary red tape as a hindrance even the briefest of case notes”.32 The Caucasus, 1911. such “extreme care” only encouraged the occasion … shifted the plane of the to the delivery of effective medical assembly line of wound management 26 Photograph by Montague patient “to concentrate on his maladies”. whole grim business from the illogical care. Lord Charnwood’s 1917 report, meant that each patient was treated Henry Knapp. Wellcome Given the rising instances of shellshock to the insane.27 however, disputed this claim, arguing by many different RMOs as he was Library, London. and severe incapacity from wounding, that continuity of treatment could not transferred from RAP to CCS to various the Armed Forces were concerned about ar propaganda emphasised the be guaranteed without it, and that base or home hospitals. This affected manpower shortages and maintaining Wdefence of British liberalism, case sheets, special reports and index how his medical history and consequent even wounded soldiers in its rotation and yet physicians were prevented cards had to be completed by men condition were understood. system. Medical and surgical staff felt from challenging the logic of the system with medical qualifications (rather conflicted about their professional and or the orders given. As Kaye noted: than administrators). The function of ureaucracy also generated national duty, which were sometimes at “our democratic principles of which we bureaucracy was not just medical; it Bprofessional and class tensions, odds. As Captain Harold Dearden wrote hear so much certainly do not extend to also served as proof of treatment, used such as those between civilian experts in his autobiography: the Army”.28 by Medical Boards and the Ministry of with command positions and army 80 81 war and medicine SOLDIERS’ BODIES IN THE WAR MACHINE

culture. The institutional machine could received. However, they could also be AE Forringer, The Left: Captain Bruce not tolerate challenges or indifference to resistant to this system, which confronted Greatest Mother in the Bairnsfather, “The the system and its hierarchies of power, them with a system of power and authority World. Lithograph on Eternal Question”, and officials found it hard to accommodate over their bodies, calculated as units and paper, 1918. cartoon, 4th London those outside who had little rapport with valued only when functioning as useful Collection Imperial War General Hospital Gazette, its structures and their significance. components in the war machine. They Museum, reproduced with Christmas Supplement Equally, civilian surgeons—and patients responded by asserting their own form of kind permission of the British Edition, 1916. too—could not always respect the logic of empowerment through cultural means. In Red Cross Society Wellcome Library, London. the military machine and its undervaluing hospital magazines, poems, diaries and of the individual. At a deeply human memoirs, those wounded in service to Right: “I don’t want level, civilian doctors, conscripts and the state reframed their experiences and to be massaged!!!”, volunteer citizen soldiers maintained a resisted ‘the system’ with their creative Cartoon, RAMC 1127/1, desire for civilian relations that imaginations and wit, portraying the First Eastern General respected individuals. medical machine with dark humour. Hospital Gazette, no. 19, December 1915. o an unprecedented extent, then, atient cartoons were a remarkable Wellcome Library, London. Tthe Army Medical Service had to Pfeature of the cultural and medical contend with its new character as a history of the First World War. They social community of civilians and reveal an image of medical bureaucracy regulars who were often in conflict, rather from the patient’s perspective. Many than a hierarchical structure founded countered the propaganda by turning upon the acquiescence expected in a the public image of the military hospital administrators. Captain Upcott, ‘Sergeant I really don’t know anything military institution. upside down. Instead of an ordered, safe Commanding Officer of the 37th about it, but can you tell me the name and congenial space for healing—as CCS recalled: of this flower?’ He was scandalised at described in media campaigns—the my flippancy. I don’t believe he has an Patients in the Medical hospital was depicted as brutally I fear I shocked Sergt. Andrews this unofficial side to his nature’.33 War Machine industrialised, often in the hands of evening; he pounced on me just as I incompetent medical staff and merciless got in with some fatuous enquiry about uch incidents struck at the troubled atients were largely ordinary soldiers bureaucrats. Cartoons often showed cruel a memo from DDS and T relative Sheart of these new social relations P—volunteers and conscripts—who treatment and even surgical experiments to GRO something or other. I said, being created within military medical valued the treatment and the care they being conducted on patients. 82 83 war and medicine SOLDIERS’ BODIES IN THE WAR MACHINE

When you feel you’d like to start an an amputee screams at the nurse: “I of mechanised procedures described Offensive again, when the 200th man Opposite and above: Don’t Want to be Massaged!!!”. as “Labour-Saving Devices”. The of this sort comes up and asks you for: Capt C Rhodes ironic captions undercut the meaning ‘your name, your age, your next of kin, Harrison, “3rd LGH ome soldiers felt belittled by de- of the scenes: the patient is “carefully how long in the Army, do you keep labour-saving devices Slousing procedures—where they were assisted” to the Receiving Ward, but white mice, if not, why not etc etc etc. for the reception of stripped of their uniforms and forced to the image depicts his rough handling wounded”, cartoon, wear blue hospital gowns, depriving them by an orderly. Next, the patient is tied nstitutional authority was just as The Gazette of the of their dignity and status as wounded to the bed and force-fed with “light- Istrictly adhered to in the wards as 3rd London General heroes. Patients complained that in refreshment”. Then he is tied with a it was in the barracks: patients had to Hospital, Territorial being conveyed from one treatment rope and conveyed through a series of ‘stand to’ when doctors came in, could Force, Wandsworth, site to another, and in having uniforms machines that violently undress, bathe be reported for misdemeanours or ‘CB’ February 1916. removed, personal items were stolen or and dry him. Still bound, the half-naked (confined to barracks), which might Wellcome Library, London. mislaid, so that insiders nicknamed the patient is forcibly re-dressed by lasso, include cleaning latrines or being RAMC ‘Rob All My Comrades’. and then is carted by wagon to the ward. deprived of a meal. Those with suspected The final image of “perfect peace and ‘SIWs’ (self-inflicted wounds) might ust as writers and artists of this period quiet” includes a nurse yanking his arm endure unofficial harsh treatment, such Jimagined soldiers as mechanised or to read his pulse and a medical officer as being refused meals and medication. weapon-like—an image designed to scrutinising his details.36 Medical staff had the power to get the reveal modern war as dehumanising— patients into trouble, even for talking patients and medical staff portrayed hat the military medical authorities RAMC surgeons and MOs were during ‘lights out’. One anonymous story the soldier’s body in the same way. But Ttolerated—even encouraged—this represented as ‘hacks’ or drunks—cutting described an argumentative patient who whilst The Times praised the “precision” carnival of gallows humour suggests off their own fingers, practising on tree challenged the hierarchy: “even with a of “the machine” as the standard of that such representations were treated stumps with saws, and inflicting pain with Sergeant—ye Gods! Brave fellow! In any British military medicine, patients often as a pressure valve for tensions within giant needles. The pressure imposed on other patient such a liberty of thought, or presented a very different view.35 the British system of military medical patients to recover quickly and return rather free expression of it, would have logistics, some of which—such as to the front was also lampooned. In one given offence to many.”34 n one cartoon, military discourses of triage—were subsequently imported into cartoon by Captain Bruce Bairnsfather, I‘saving labour’ are ridiculed as an civilian medicine. a wounded man appears exhausted and rustrations with the bureaucratic industrialised disregard for the human exasperated by “The Eternal Question”. Fregime could lead to defiance of body: a wounded man is put on a The caption reads: treatment. In another patient cartoon, conveyor belt and goes through a series 84 85 WARwar ANDand MEDICINEmedicine MARY BORDEN

MARY BORDEN THE FORBIDDEN ZONE

But no it was impossible. In They were strapping his iron arms this war such things didn’t happen. and legs to the narrow table. Someone Men were killed, haphazard—maimed, lifted his heavy head. Someone pulled his torn to pieces, scattered by shell fire, great bulk into position and bound him to plugged full of shrapnel, hit square the table with strong leather bands. sometimes by rifle bullets, but not shot “Don’t do it!” I shouted suddenly. neatly through the roof of the mouth “Leave him alone.” I was appalled by his with a revolver. immense helplessness. Mary Borden, the daughter of a wealthy They were whispering as they bent They went on with their business businessman from Chicago, set up a hospital unit over him. Monsieur X frowned, pinched his of getting him ready. They didn’t hear on the Western Front on the outbreak of the lips together, looked down at the great, me. Perhaps I had not shouted aloud. First World War. Awarded the Croix de Guerre gentle unconscious carcase sideways. “You don’t understand”, I cried. “You’ve by the French government, she remained with “But how?” I asked. “Who?” made a mistake. It wasn’t fear. It was the unit until 1918. “Himself. He shot himself through the something else. He had a reason, a mouth. It’s a suicide.” secret. It’s locked there in his chest. “Suicide!” I echoed the word vaguely, Leave him alone with it. You can’t bring He was a man of the soil, of the dark a pick-axe, deeply gashed. His closed as if it contained a mystery. There was him back now to be shot again.” earth, with the heavy power of the eyes were caves under bushy cliffs, his something queer, out of the ordinary, But they clapped the ether mask earth in him. The bright sun shining battered mouth a dark shaft leading down about it, shocking to the surgeons over his face, stifling his enormous on his massive unconscious bulk made into a cavern where a hammer was beating. and orderlies. They were ashamed, stertorous breathing, and with that he the darkness of his lost consciousness Because he was so big, his worried, rather flustered. “But why began to struggle—the dying ox. Life, visible. He seemed to lie deep, distant, helplessness was the more helpless. But suicide?” I asked, suddenly aware of roused by the menace of the suffocating withdrawn in a shadowy abyss ... But his one could feel life pounding powerfully the extraordinary fact that a personal gas, sprang up in him again—gigantic, immense body continued, in spite of his in his body—senseless life, pounding on, tragedy had lifted its head above the furious, suffering, a baited bull. It began absence to hum and drum like a dynamo, pumping air into his lungs, keeping his dead level of mass destruction. It was plunging in him, straining, leaping to get like a machine whose tremendous power heart going. Yes, he would be hard to this that shocked them. He’s not young, out of his carcase and attack its enemies. takes time to run down, and his breath kill, I thought. Even a bullet in the I thought, cutting the bandage round the A leather thong snapped, a fist shot out, came whistling and spurting through his head hadn’t killed him. rough unconscious head with its shock of knocking over bottles and basins. There rough bruised lips like escaping steam. I counted his pulse. It was strong matted red hair. A peasant, probably— was a crash, a tinkle of broken glass, a The old stretcher-bearers lifted and steady. very stupid—an ox of a man. scramble of feet, and suddenly through the him again grunting, and brought him in “Shot through the mouth. Revolver “Why suicide?” I asked aloud. confusion I heard a thin soft anguished to us and hoisted him with difficulty on bullet lodged in the brain.” Monsieur “Panic”, answered Monsieur briefly. voice cry as if from a great distance, to the narrow white table, in the white X was reading the ticket that had been “Fear—he tried to kill himself from fear “Rosa, Rosa!” It came from his chest; it room full of glistening bottles and pinned to the man’s blanket in the of being killed. They do sometimes.” sounded like the voice of a man lost in shining basins and silvered instruments, dressing station behind the front line. “This one didn’t.” a cave. It came from under his heaving among the white-coated surgeons and But how? I wondered. How queer, I “No, he didn’t succeed, this big one. side where the bushy hair grew thick nurses. His head hung over one end of the thought. Shot in the mouth—through the He ought to be dead. The bullet is here and strong—a hollow heartbroken voice, table, and his feet over the other, and roof of the mouth. He must have been just under the skull. It’s gone clean issuing from his blind unconscious mouth, his great freckled arms hung helpless asleep in the trench with his mouth open. through his brain. Any other man would in a long cry—”Rosa, Rosa!” Twice again and heavy down at either side. Thick And I imagined him there, sprawling in the be dead. He’s strong, this big one.” he called Rosa before they could clap the curling bunches of red hair, wiry and muddy ditch, an exhausted animal with his “You’ll extract it?” ether mask down again on his face. vigorous, grew out of his enormous chest. great stupid mouth open; and I saw a figure “But certainly.” It was a neat operation and We stripped his body. It lay inert, a crawl in beside him and put the barrel of “And he will live?” entirely successful. They took the mountainous mass, with the rough-hewn a revolver between his big yellow teeth. “Perhaps.” bullet out of the top of his head, brick-red face tipped back. His sightless Fool, I thought. You fool—you big hulking “And what then?” bandaged his head up again, and carried face reminded one of the face of a rock brute beast—going to sleep like that in “He’ll be court-martialed and shot, him away through the sunny afternoon to in a sandstone quarry, chiselled with utter careless weariness. Madame, for attempted suicide.” be put to bed. 86 87 WARwar ANDand MEDICINEmedicine MARY BORDEN

“He will surely die in the night”, answer. He said nothing. He seemed not Rosa let him down, or perhaps she died. I spoke to the nurse who was I said to myself, and I went again and to notice. Meekly, docile as a friendly Perhaps he simply wanted to go to her. going on duty for the night. “When Rosa again in the night to see if, happily, trusting dog, he let her bandage him “He must have had a letter in the pulls off his bandage tonight, leave he were dead; but always, standing beside up again, and the next morning I found trenches—a letter from Rosa or about it off”, I said abruptly. She looked the shadow of his great bulk, I could him again sitting up in his bed in his her. He’s not a young man. He is forty at me a minute, hesitating. She was hear him breathing, and once I thought clean head bandage staring in front of or more—an enormous brute with red hair highly trained. Her traditions, her I heard sighing on his shrouded lips the him with that dark look of dumb subhuman and hands like hams. A farmer probably. professional conscience, the honour of name of the woman—Rosa. suffering. And the next night the same One of those slow plodding gentle brute her calling loomed for a moment before “He can’t live”, the night thing happened, and the next, and the men, faithful as dogs. His voice was her, then her eyes lighted. “All right”, nurse said. next. Every night he tore off his bandage, broken-hearted, high and hollow like a she said. “He can’t die”, I whispered to and then let himself be tied child’s voice, when he called to her. I thought when I stood at the foot myself. “Life is too strong in him, too up again. Like a child that is lost. “Rosa! Rosa!” of Rosa’s bed next morning and found him hard to kill.” “If his wound becomes infected If you’d heard him. And here you are staring at me that I detected a look of He was much better next day. I he’ll die”, said Monsieur X angrily. with your military regulations asking recognition in his eyes, perhaps even found him sitting up in bed in a clean “That’s what he’s trying to do”, me to save him for you so that you can a faint look of gratitude, but I could pink flannel night shirt, staring in I answered. “Kill himself again before shoot him. You expect us to tie up his not be sure. His gaze was so sombre, so front of him. He didn’t answer when I they can shoot him”, I added, “to save head every night and prevent his dying deep, that I could not read it, but I said “Good morning”, or take any notice them the trouble”. so that you can march him off to trial could see that he was weaker. Perhaps it of me. He hadn’t spoken to anyone during I dared not speak to the man whom and stand him up against a wall. was his increased pallor that made his the day, the nurse told me, but he was I thought of day and night as Rosa, But what was the good of arguing eyes so enormously dark and mysterious. very obedient and ate his soup quietly, having never learned his name, and he against army regulations? We were at Toward evening he grew delirious, but “as good as gold”, she said he was. “A never spoke to me or anyone. His eyes, war. The General could do nothing. The he tore off his bandage all the same, remarkable case”, Monsieur X said. “He which he now always turned on me when I man must be made an example, so that in the middle of the night. He managed ought to be dead.” But there he was came in, forbade me to speak to him. They these epidemics of suicide could be to do that. It was his last effort, his sitting up eating his meals with an stared into mine with the understanding kept in check. I didn’t dare go back to last fumbling desperate and determined excellent appetite. of a brute mortally wounded, who is not Rosa. I went to the door of the hut and act. His fixed idea prevailed through his “So he knows what will happen?” I allowed to die, so I went to the General, called the nurse. Down in the centre of delirium, his will triumphed. It was asked, following the surgeon to the door. and, actuated by some hysterical impulse, the long row of beds I could see Rosa’s enough. He was unconscious next morning “But certainly. They all know. pleaded for the man’s life. great shoulders and his huge bandaged and he died two days later, calling in Everyone in the army knows the penalty.” “But, Madame, we have epidemics of head. He looked like a monstrous baby in his weary abysmal heart for Rosa, though The suicide did not turn his head suicide in the trenches. Panic seizes his white bonnet and pink flannel shirt. we could not hear him. or look in my direction. He was still the men. They blow their brains out in a But I knew that his big haggard eyes staring straight ahead of him when I came panic. Unless the penalty is what it is— were staring, and I remembered that his back and stood at the foot of his bed. to be court-martialed and shot—the thing face had been a little paler each day, Who are you? I wondered, and who is would spread. We’d find ourselves going that it was not brick colour any more, Rosa? And what can I do? How can I help over the top with battalions of dead but the colour of wax, that his cheek you? And I stood there waiting, miserably men. The same penalty applies to men who bones stood out like shelves. spellbound by the patient brute who at wound themselves. That’s the favourite He’s killing himself in spite last turned on me from his cavernous eyes device of a coward. He puts the muzzle of us all, I thought. He’s succeeding. a look of complete understanding, and of his rifle on his foot and fires.” It’s hard work, it takes patience, but then looked heavily away again. I argued. I explained that this he’s doing it. Given a chance, he’ll That night when the orderly was man was not afraid of being killed, but pull it off. Well, he’ll have his chance. dozing and the night nurse was going of not being killed, that his luck was I almost laughed. I had been a fool to on her round from hut to hut, he tore out when the enemy missed him; that he go to the General and plead for his the bandage from his head. She found had been kept waiting too long, had shot life. That was the last thing he wanted him with his head oozing on the pillow, himself in despair because the Germans me to do for him. That was just the Originally published in “Nurses at the Front: Writing the Wounds and scolded him roundly. He didn’t wouldn’t shoot him; and a woman called wrong thing. of the Great War”, Doubleday Press. 88 89 war and medicine TREATED LIKE FLOWERS

TREATED LIKE FLOWERS THE INDIAN ARMY AT THE ROYAL PAVILION HOSPITAL, BRIGHTON, 1914–1916 Kate Forde and Lucy Shanahan

The Indians have come. Ever since the of every window of which stretched remarkable chapter in Brighton’s history. World War they played an important role news of their intended coming was first a glowing dark face, with bright Ambulance outside As one journalist put it “the Oriental not only in facilitating the exchange of published all Brighton has been agog eyes and shining teeth, bearded the front entrance of Pavilion is emphatically now the abode human emotion, but also in the effort to see the arrival of the warriors from and turbaned! Think of that line of the Royal Pavilion, of Oriental people”.4 to represent the war in propagandist the east who have been shedding their khaki puggarrees (turbans). There Brighton. terms. The individuals featured in these blood in the defence of the British was something comic as there was Collection of the rom December 1914 to January images were not named, identified and Empire to which they belong.1 something romantic, in the sight.2 Royal Pavillion and F1916, over 2,200 members of the sealed in albums or frames; nor would Museums, Brighton. Indian Army were treated for war-related their personal histories have been n 5 December 1914, ecord numbers of newspapers injuries in Brighton. The following reconstructed in the language of family the residents of Rfeaturing the reports of their arrival chapter is only a partial account of anecdote. Instead, their stories were Brighton caught were sold and several reprints were that time, inspired by the compelling collapsed into a grand narrative that their first glimpse required to meet the unprecedented photographic material and contemporary sought to highlight Britain’s military of wounded Indian demand. It was not simply the presence newspaper reports housed in the archive might by connecting its imperial legacy soldiers evacuated from of these foreign heroes on British soil of Brighton History Centre at Brighton with its new role in the Great War. the western front. The that so captured local attention, but the Museum and Art Gallery. The very arrival of these “exotic Sons of the east”, fact that, at the request of the King and existence of this material suggests an hen Indian reinforcements were Oamong them Sikhs, Punjabis, Bengalis, Emperor George V, hundreds of them awareness of medicine as spectacle, and mobilised to join the war in W Pathans and Gurkhas, had been much were to be cared for in the magnificent a belief in its power during wartime to September 1914, it was the first time anticipated since the Corporation of setting of the Royal Pavilion—that inspire troops and civilians alike. It is that the Indian Army had been required Brighton had announced that they were grand icon of Brighton. Commissioned important to highlight the fact that these to fight in Europe. They were initially to be nursed back to fitness in the British in 1815 by the Prince Regent (later photographs were commissioned for destined for Egypt, but were diverted seaside town, long renowned as a health King George IV), the Pavilion was an official guidebook and as a series of at the last minute to Flanders, where resort and leisure destination. transformed by the architect John Nash, postcards published to mark the opening back-up forces were urgently needed. together with Frederick Crace and of the hospital as a sight-seeing venue for As a result, they were poorly provisioned he initial disembarkation of Indian Robert Jones, from a Palladian villa into the public in 1916.5 In other words, they and not acclimatised to the punishing Tsoldiers generated much curiosity and an architectural extravagance of domes, were not conceived as formal portraits winter weather, equipped only with excitement amongst the local community: minarets, balconies and pagodas in the but sold as mass-produced souvenirs. lightweight khaki uniforms intended for Indo-Saracenic style.3 To contemporary In the pre-electronic age, postcards the North African climate. Propelled As the train steamed into the station observers, this building seemed an were the economic mainstay of Europe’s into some of the most violent fighting you saw their heads craning out of authentic and irresistibly theatrical vast and diverse printing industry, and near Ypres in November and December, every window. Imagine a train out location for the unfolding of a brief but immensely popular. During the First the Indian Army suffered heavy losses. 90 91 war and medicine TREATED LIKE FLOWERS

Meanwhile, they were subjected to Much of this loyalty may be attributed to Pavilion grounds, Dome relentless rain and bitter cold, which an acquiescence derived from the long- in background. resulted in many cases of frostbite, standing legacy of British reign in India. Collection of the trench foot and gangrene, in addition Additionally, the British had gone to great Royal Pavillion and to the innumerable injuries caused by lengths to convince the Indian people Museums, Brighton. machine-gun fire and high explosives. that the war was also their war—or the To compound their suffering, many of “defence of their hearths and homes”.7 the Indians were afflicted by the added This included employing incentive tactics hazard of unfamiliar European diseases such as promises of valuable land to celerity and drew extensively on local its luxurious eastern decoration would such as measles, mumps and influenza. Indian officers and men who demonstrated Indian soldiers resources and manpower. Completing have a positive impact on the soldiers’ There was also the risk of contracting the greatest valour or izzat—to bring gathered in beds in the job in less than a week, Brightonians recuperation. As one member of the War bronchitis and pneumonia as a result of honour to their family or caste by fighting the Dome, Brighton. were justifiably proud of this unique Office explained, it would “have an effect being exposed to the damp and cold of bravely on the battlefield. One further Collection of the achievement: “It is surely the most on their minds beyond ordinary English the trenches for extended periods of time. motivation was the country’s hope of Royal Pavillion and perfectly arranged hospital of its kind, comprehension”. But another reason The Indians were heavily involved in attaining dominion status. To this end, Museums, Brighton. which has ever been established in this can be gleaned from his next comment: the ambitious attack at Neuve-Chapelle, Mahatma Gandhi, as leader of the Indian or any other country.”9 “They will write letters home, telling the main British-Indian sector on the National Congress, openly supported of the magnificent place where they are Western Front, and were amongst those the British war efforts and actively eorge V, a man reputedly more being cared for, and the news will spread exposed to (and unprotected from) poison encouraged Indians to enlist in the army Ginterested in stamps than in art, throughout India and do an immense gas when it was used for the first time by and to contribute to the war fund. seems nonetheless to have understood amount of good.”11 This suggests an the Germans in May 1915. Shocked and the Pavilion’s power and to have attempt to re-emphasise colonial ties by unprepared for carnage on such a scale, t had originally been planned that appreciated the intrinsic theatricality of promoting the high standard of medical one man wrote home: “This is not war; it Iwounded Indian soldiers would be the opportunity presented to him.10 The care granted to Britain’s allies. It was is the ending of the world.”6 hospitalised in France, but the number Royal Pavilion, an architectural fantasy felt that this might assuage the potential of casualties escalated to such an extent that had reflected George IV’s nostalgia for resentment amongst the Indian espite this, there was an ardently that alternative arrangements had to be for absolute monarchy by linking it to the civilian population, whose husbands, Dpowerful sense of allegiance and made. In November 1914, the Royal growth of Britain’s empire in the East, sons, fathers and brothers were obligated personal duty to George V amongst the Pavilion was closed to the public and was the perfect stage on which to re- under Imperial rule to risk their lives Indian troops, who frequently mentioned taken over by the War Office.8 The task inforce the idea of colonial power in the in a disconnected war for a remote him in their letters; a royal message or of adapting the buildings for medical twentieth century. The professed reason cause in a remote country. As part of visit was considered to be a great event. purposes was undertaken with great for renovating the Pavilion was that this same effort, 20,000 copies of the 92 93 war and medicine TREATED LIKE FLOWERS

commemorative guidebook in English, ecent developments in the practice ll notices were printed in Urdu, Pavilion gardens and promenading along Royal Pavilion Gurmurkhi and Urdu were secured for Rof anaesthesia meant that it was Royal Pavilion Kitchen. AHindi and Gurmukhi. Special the sea-front. 12 Operating Theatre. distribution in India. possible to explore wounds more Collection of the areas were designated for religious Collection of the thoroughly. This required vast quantities Royal Pavillion and worship, with lawns being allocated to umerous articles acquainted Royal Pavillion and he Pavilion, together with the of dressings, which were very expensive Museums, Brighton. the Sikhs and the Muslims on the grass Nreaders with “these faithful dusky Museums, Brighton. Tnearby Dome and the Corn and consequently led to improvised plot in front of the Dome, facing Mecca. warriors of King George” by offering Exchange, provided 724 beds. The substitutes. These included sawdust pads Separate mortuaries and particular details of their military tactics, forms of Drawing Rooms, Saloon, Music Room and dressings made of muslin-covered funeral rites were also observed; Hindus religious worship, and food and drink and Banqueting Room as well as the Sphagnum Moss, a plant that had been and Sikhs were cremated on the Downs, requirements.14 Finally, during the Dome were all used as wards, while the used in this way for centuries due to its the site now occupied by the Chattri, an first week of February 1916, and after smaller rooms functioned as isolation absorptive and extremely acidic nature, Indian memorial to the dead. the majority of the patients had been rooms or offices. All wards were mixed, inhibiting the growth of bacteria and discharged, the Pavilion was opened to with different religions and castes fungi. Other modern innovations provided nitially, once the Indian soldiers had the public so that they might inspect how sharing the facilities, although separate at Brighton were radiant-heat baths and Iarrived at Brighton there was—for the state apartments had been renovated wards were set aside for officers. various electrotherapy treatments believed one journalist at least—frustratingly to accommodate the foreign visitors. to help stimulate the nerves and muscles, little to be seen of them: “Every possible By 9 February there had been over lthough the majority of cases were particularly in cases of paralysis. entrance to the Pavilion grounds is 10,000 visitors. Agunshot wounds, owing to the guarded by the police, and sometimes recent introduction of the high-velocity ontemporary documents record how by the military, while carpenters have ith its wildly imaginative bullet, a wide range of conditions were Cevery effort was made to ensure that been busy all the week boarding up Wcombinations of Chinese, Indian, treated, particularly those caused by the provisions being made to accommodate all possible crevices where the curious Gothic and neoclassical elements, the effects of explosives to the lower different faiths in the field were extended public may possibly peer in ... Most of the Pavilion is a superlative example and upper extremities as well as gas- and strictly adhered to in the Pavilion us feel that the town deserves a little of nineteenth century architectural poisoning, gangrene and psychological Hospital. This included separate water more spectacle for its money.”13 Over ‘Orientalism’.15 In the context of the First trauma. In order to carry out the taps for Hindus and Muslims in each ward; the course of the year during which the World War, the decision to reinvent the necessary surgical procedures, two segregated bathing houses and latrines; soldiers underwent treatment at Brighton, Pavilion as a military hospital for Indian operating theatres were installed at the nine kitchens providing discrete cooking this appetite for spectacle was fed by soldiers has significant political symbolism. Pavilion, one in the Prince Regent’s and washing-up facilities for Muslims, numerous descriptions, illustrations and Representations of the Pavilion from kitchen and one in the Church Street meat-eating Hindus and vegetarians, and photographs of the luxuriously equipped this time seem to offer ‘proof’ of Britain’s entrance to the Dome, which also had special arrangements for the ritual killing medical facilities and wards, as well supremacy, its ability to civilise and an X-ray room attached. and storing of meat. as images of the Indians resting in the conquer through supposedly enlightened 94 95 war and medicine TREATED LIKE FLOWERS

ambulance is parked directly beneath Hospitals require a surrendering up of the no truncated limbs, awkward prostheses Above the onion dome of Nash’s entrance Royal Pavilion patient’s body to the enlightened practice or facial deformities obviously on display. Convalescent Sikhs. porch, while a few Indian patients stand Ward Three, Saloon. of modern, usually western, medicine. In Instead, it is the idea of a ‘noble race’ that Collection of the aside on the driveway (see page 89). Collection of the the case of the Indian army at Brighton, is being brought sharply into focus. Royal Pavillion and } The vehicle is the focal point of this Royal Pavillion and this submission is even more problematic Museums, Brighton. image, its undecorated bulk asserting Museums, Brighton. because the convalescing bodies of the rom a historical perspective these itself against the elegant proportions of soldiers represent not only the individual’s Fpostcards refer to a language of Below the architecture, dwarfing the graceful surrender but the subjugation of one scientific or anthropological portraiture Convalescent Dogras. minarets and causing the structure nation to another, by armed force. originating in the daguerreotype era, Collection of the to appear even more fantastical. The withWestern photographers training their Royal Pavillion and ambulance fits perfectly however, almost even of the postcards in the collection cameras on native people in order to Museums, Brighton. colonial rule, its beneficence towards its as if it had been designed to occupy this Sat Brighton present the various construct a sense of the ‘exotic’. However, occupied nations, and its commitment to space—a potent symbol of modernity ethnic groups who fought alongside the partly because of the undiscriminating the practice of modern medicine. gesturing towards Britain’s superiority as British: ‘Punjaubi mahommedans’, ‘Jats’, nature of photographic technology itself, a medical as much as a military power. ‘Gurkhars’, ‘Pathans’, ‘Sikhs’ and ‘Dogras’. the images of the Indian soldiers do not he postcards produced to document The images of the pavilion interiors are simply work as reflections of colonialist Tthe Indian soldiers’ recuperation similarly incongruous: the steel-framed hotographed in groups of around principles. The randomness captured at Brighton served as tokens to remind hospital beds with their white sheets P12, they stand or sit somewhat stiffly in these photos, the light falling on a those who purchased them of their visit float beneath the great vault of the Dome, in the pastoral setting of the pavilion particular corner of the room for instance, to the transformed pavilion. Whether illuminated by the sparkle of gigantic gardens. Wearing hospital blues and or the enigmatic expressions of the they remained in their owners’ safe- chandeliers and the coloured glass set turbans, some with bandaged limbs or patients, should permit a more complex keeping or were posted to distant into the roof. using crutches, they are assembled as interpretation of this material.17 addresses, these souvenirs functioned elements of a picturesque collection, as fragments of authentic experience, here is an atmosphere of medical representatives of their country. The onetheless, it is apparent that providing an opportunity for people to Tausterity contrasting with opulence, photographer has been careful to frame Nthe ideology of empire is at work possess some tiny aspect of the original a pleasure palace newly concerned with these men within the massive sculpted both in these photographs and in the encounter.16 pain. For the viewer, one of the intended pillars of the Pavilion and to create paternalistic tone of Brighton’s local consequences of seeing such images is pleasing symmetrical compositions. press with its repeated references to “our t is interesting to note a certain to marvel at the unseen power, namely Unlike so many images of wounded men Indians”. Perhaps unsurprisingly it is Irhetoric of power that haunts these Britain’s military authorities, which had from this period it is not a sense of tragic the soldiers’ bodies that often become images. In one exterior shot, an brought about such a metamorphosis. loss that is foregrounded here; there are central to contemporary reports: 96 97 war and medicine TREATED LIKE FLOWERS

They are good patients, these Indians: seen, extended to the troops convalescing photographs and warrant a much longer of itself as a colonial power occurred at they lie quite passive, and but for their at Brighton, both informally, through the Royal Pavilion Ward discussion than is possible here. the very point when that power seemed open eyes one could have imagined local press, and through the more formal Five, Music Room, most under threat. With no end to the them lifeless. Of the hundred men who path of the censor, who translated and after the Indians had he wealth of information that was war in sight, and with British and French were brought across the platform only passed (or rejected) thousands of letters been discharged. Tgenerated about the Indians’ year-long casualties outnumbering German, two or three, by some contraction of that the Indian soldiers wrote home Collection of the stay in Brighton illustrates a common Britain’s authority was being seriously the forehead or twitching of the lips from Brighton and many other military Royal Pavillion and belief that knowledge of foreign cultures undermined. With the 1857 Indian showed signs of pain.18 hospitals in Britain: Museums, Brighton. was a demonstration of, and route to, rebellion still in living memory it is enlightened colonial rule. Victorian clear that the decision to turn Brighton t was a convention of the time when Do not be anxious about me. We are ethnographic collections, such as Henry Pavilion into a military hospital was at Iwriting about the plight of wounded very well looked after. White soldiers Wellcome’s Historical Medical Museum, least partly an exercise in nostalgia, soldiers to praise their enduring stoicism; are always besides our beds—day and were a manifestation of this attitude. permitting a wistful glance backwards however, given the unique position of night. We get very good food four times Wellcome himself stated that “the man at Britain’s historic influence over the Indians as foreign subjects fighting a day. We also get milk. Our hospital who understands native peoples and their India. But the decision also implies a for a British cause, the reference to their is in the place where the King used to habits, customs, superstitions, their beliefs, sense of nationalistic bravado masking valour is undermined by the description have his throne. Every man is washed and fears, has an enormous advantage a degree of disquiet about the course of their submissiveness. once in hot water. The King has given over the man who does not”.21 The staging of contemporary events. The arguments he central yet ambiguous place of strict order that no trouble be given of events in Brighton, together with the made in favour of treating the Indians Tthe Indian army within Britain’s to any black man in hospital. Men in visual and written accounts that ensued, at Brighton concentrated on the colonial order has been discussed by hospital are treated like flowers, and offered an elaborate demonstration of advantages of accommodating them in historian David Omissi, who points the King and Queen sometimes come familiarity with Indian life and customs, an authentically ‘Eastern’ royal palace. out that in 1857 the British had been to visit them.20 at the same time as accommodating them They did not need to make explicit almost driven from the subcontinent by within a definitively British framework. that this episode was actually part of a the rebellion of their Indian troops. He The existence of these letters, however This was an example of the ‘knowledge’ therapeutic strategy designed to restore explains that “because of the essential compromised, together with the that underpinned imperial dominance and the morale of the nation at a critical time. yet potentially dangerous role of the ambiguities they present, contributes became the mode by which the Indians Indian forces in colonial India their towards a more nuanced version of this were persuaded to know themselves: as activities were more closely scrutinised episode than is communicated by the subordinated to Britain. and more carefully recorded than those fervent nationalism of the contemporary of most other elements of the indigenous reports or the silent images. These t is notable that this attempt to re- population.”19 This scrutiny, as we have are stories from the other side of the Iinforce the United Kingdom’s sense 98 war and medicine

PORTRAITS Percy Hennell The following photographs of patients before and after various stages of plastic surgery were taken by Percy Hennell between 1939 and 1945 using a remarkable technique that involved the superimposition of three layers of film. The light-fast colour has not faded in 60 years.

Photographs courtesy the Antony Wallace Archive of the British Association of Plastic Reconstructive and Aesthetic Surgery (BAPRAS). 100 101 war and medicine PERCY HENNELL—PORTRAITS

The right forehead The left eye and shows the result of surrounding flesh was reconstructive surgery. lost in a war wound. A head injury and The flesh has been surgery had left a reconstructed with a depression, which has flap of skin taken from been filled out with the scalp. The bandage a graft. covers the donor area. A further surgical procedure will be needed to complete the repair. 102 103 war and medicine PERCY HENNELL—PORTRAITS

A wound to the right jaw Severe burns to the has damaged the lower neck resulted in branches of the facial scarring that almost nerve. The right lower fixed the chin to the lip is paralysed. chest. The scarring has been removed and new skin and flesh has been grafted from the patient’s stomach. 104 105 war and medicine PERCY HENNELL—PORTRAITS

An airman with healing, The left side of the partial-thickness burns jaw is fractured and to the face. The rest of the flesh above it is the head was protected wounded. External by his helmet. fixation with pins and a dental appliance have been used to immobilise the fracture. 106 107 war and medicine PERCY HENNELL—PORTRAITS

Scarring of the face Fracture of the facial from burns. The eyelids bones and burns. are deformed by the scarring and the sight is endangered. 108 109 war and medicine SUFFERING AND THE HEALING PROFESSION

SUFFERING AND THE HEALING PROFESSION THE EXPERIENCE OF MILITARY MEDICINE IN THE FIRST AND SECOND WORLD WARS Joanna Bourke

Militarised Medicine very ill he must be. He wishes me Richard Caton to write & tell you all, because he Woodwille, When n 1916, the night before joining said he could not do it. he says he Night Sets in The Sun the army, Wilfred Willett held cannot come back to his Wife like is Down, 1910s. his weeping wife in bed and that, but I tell him you will be glad Wellcome Library, London. wondered, “Should I ever sleep to see him anyhow … He worries so with her again? or should I be much about things.2 limbless or faceless next time? I would meet her in heaven but uch anxieties and torments would not in what state?”1 War threatened major Svanish with any armistice. Idevastation upon the male body and Willett’s fears of physical disintegration he First and Second World Wars were shared by millions of men during Tthreatened major devastation upon wartime. The so-called healing profession male and female bodies, propelling the was charged with inspecting and medical services into the forefront of assessing new soldiers such as Willett the warring enterprise. Every person and then taking care of their physical who signed up would have had contact and mental well-being during their with the medical services, even if only time of service. Willett survived his war during the process of recruitment and (barely), as did Lieutenant Arthur E during the regular medical inspections. Kaye, though he found himself severely For a significant minority, contact with injured in hospital during the First World the medical branch of the military was War. On his behalf, a nurse wrote the more extensive. During the Second following letter to Kaye’s mother: World War, for instance, over a thousand British medical units were mobilised and Your son Lieut Kay [sic] asked me to British medical services attended to five write to you & tell you the worst—poor million patients. The dead were beyond boy he has had his left Eye knocked help, but the hundreds of thousands out—& his right leg Amputated, he is of British servicemen and women very ill indeed, beside the Eye & leg who were physically dismembered his jaw is fractured, so you see how or psychologically fractured found 110 111 war and medicine SUFFERING AND THE HEALING PROFESSION

did not require amputation. In some Medical Officers accompanying the “Nurses and midwives Patient with many sectors of war, diseases had a more fighters and setting up Field Ambulance are needed. The wounds, 1916. devastating impact than wounds. Over or Dressing Stations (really First Aid wartime job that can be Photograph by Albert Norman, half of soldiers who died in Macedonia posts) a short distance behind the front your career.” Second Wellcome Library, London. and Italy during the First World War, for lines. This was where stretcher-bearers World War, poster. instance, were admitted with illnesses as took the battle-wounded for immediate, Wellcome Library, London opposed to wounds. This was in contrast emergency treatment. From the clearing to the situation in France, where only stations, men would be transported to ten per cent of soldiers who died had General Hospitals at some distance from been admitted to hospital suffering from the fighting. The most important change illness. Just before the Second World during the Second World War was that War, 222,000 officers and over 419,000 these routes became more flexible, and servicemen in other ranks were still extremely mobile units were introduced, being paid disability pensions for either allowing surgical teams to operate closer wounds or illnesses contracted during to the front lines. their time in service. An unknown number were still suffering from the edical officers were not only nightmares and ‘shakes’ of shellshock. Mresponsible for men in combat zones. Their job was inextricably linked ho were the physicians responsible up with military administration. In Wfor the medical well-being of men addition to ministering to urgent surgical and women serving in British forces? and medical needs, they also assessed During both world wars, the Royal Army the health and strength of recruits, themselves dependent on the physicians, adequate preparation for the physical Medical Corps (established in 1898), held medical parades, examined feet nurses and a wide variety of other devastation of the two world wars. All along with various nursing services, and penises, and inspected sanitary medical personnel. parts of the body were at risk: head, were primarily responsible for the facilities. Crucially, physicians were at shoulder, arm, chest, intestines, buttock, medical care of military personnel. the heart of the entire system of military othing in British history (neither penis, leg, foot. Over 41,000 men had The structure of their provisions was discipline: their primary function was Nnineteenth century wars nor the grim their limbs amputated during the First simple. Carefully delineated ‘routes’ of to return men to their military duties. injuries perpetrated upon the human World War. Thousands more suffered medical help were formalised during In the words of John Rawlings Rees, body within factories or mines) was severe injuries to the arms or legs that the First World War, with Regimental member of the Directorate of Army 112 113 war and medicine SUFFERING AND THE HEALING PROFESSION

Psychiatry during the Second World War, fragile tissue and bones. The risk of A field ambulance “The medical officer in the army has physical mutilation was not identical in behind the firing line. to think in terms of groups and group all fields of war. During the First World Field surgery in the welfare rather than of the individual War, for instance, the risk of infection Dardanelles. 1915, patient.”3 Like other military officers, was much higher in France than Captain J Pearson. medical personnel in wartime feared elsewhere, and medical officers rapidly Wellcome Library, London the consequences of indiscipline. Thus, learnt to treat every wound as septic. It reflecting on his service during both wasn’t until the Second World War that the world wars, medical officer Charles the new age of antibiotics dramatically Huxtable mused that: “Sometimes, I reduced death rates through infection. have pangs of remorse, but it doesn’t do Penicillin was invented by Alexander to dwell on past mistakes. If you relax Fleming in 1928, but it took until 1943 and give favours to one man, there may for the drug to be mass produced. Blood be a flood of others”.4 Medical officers transfusions were also being used on a tended not to question the right of their mass scale by that date. Clearly, delays military superiors to command the men in obtaining medical help also increased as they saw fit. As Sigmund Freud put risk of severe mutilation or death. On nearly half within another six hours. As sinuses” of war wounds and the fact it, war-time physicians “had to play a the Western Front during the First Advance dressing a consequence, fewer than five per cent that he was unable to operate on “clean, role somewhat like that of a machine gun World War, a wounded soldier typically station in the field, died of their wounds.7 unbroken flesh”. He candidly admitted behind the front line, that of driving back took between eight and twelve hours First World War. that he relished making incisions those who fled. Certainly, this was the to reach a Casualty Clearing Station Wellcome Library, London hysicians and nurses faced through unblemished skin; the torn and intent of the war administration”.5 and, at Gallipoli, soldiers might face a Pformidable problems in dealing filthy wounds of battle were not to his voyage of two to three days before being with the number of casualties on the taste. The “neat techniques” in which admitted to hospital. As Major Stanley front lines. Unhygienic equipment, poor the “aesthetic result” was paramount Surgery and its Argyle lamented in his diary in May lighting, the scarcity of water, and the had to be rejected in favour of “crude Discontents 1915, “Is it any wonder that many limbs short supply of operating instruments, unfinished ways”.8 Surgeons who failed are amputated and some lives lost that needles, ligatures, supports and crutches to adapt to wartime contingencies were he first priority, though, was to deal would otherwise have been saved?”6 severely lowered standards of medical pronouncing a death sentence on their Twith the immediate effect of those In contrast, by the Second World War, care. The eminent surgeon Dr Alexander patients. Even with the more mobile machine guns, shrapnel, poisonous gases one-fifth of soldiers were operated on MacCormick was said to have despaired surgical units of the Second World War, and other weapons of destruction upon within six hours of being wounded and over the “filth, sepsis, pus-running speed was paramount, sometimes making 114 115 war and medicine SUFFERING AND THE HEALING PROFESSION

it more sensible to amputate limbs than corner selling matches”. “Those honest Wounded soldiers on to attempt complex and time-consuming worried eyes of Thomas Jones” were stretchers eating a procedures. As one commanding “looking at me; they are looking at you”, meal, 1940s. officer informed a surgeon who seemed the appeal began: Wellcome Library, London determined to invest slightly more time in operating in order to avoid having to And around and beyond his bed, as far amputate a limb, “If I give you time, I’ve as vision can reach, there are thousands got three men out here on the floor who of other beds; thousands of other eyes, will die and maybe this one will die too. honest and worried. War cripples— He’s better without a leg than all of them soldiers, sailors, our men, women of the should be dead”.9 services, munition workers, children of the Home Front … Not begging—they urvival was paramount, but medical are too brave to beg; just wondering … Sresponsibilities did not stop when the Are we going to get that treatment? And wounded left the wards. They faced long what about employment, without which periods of recuperation in hospitals and the human spirit sinks from self-respect local clinics. Artificial limbs had to be into the darkness of bitter despair?10 Blood transfusion. fitted; vigorous health, regained. No-one Wellcome Library, London expected that the wounded would return ublic rhetoric judged soldiers’ to physical—let alone psychological— Pmutilations to be “badges of their health quickly. In the early days of both courage, the hall-mark of their glorious the First and Second World Wars, the war- service, their proof of patriotism”, as wounded were spoken about in patriotic Help for Wounded Heroes, 1920, put it.11 and sentimental tones. Typically, on 20 The disabled soldier was “not less but April 1941, the Central Council for the more of a man”, the Liverpool Chronicle Care of Cripples broadcast an appeal for crooned.12 Time and again, the mass people to give money to help those men, media claimed that “broken warriors” women and children wounded in battle deserved reverence. or during the Blitz. It told the story of a limbless soldier who fretted about whether his sentimentalisation of the war- he would end up “left behind on the street Tdismembered did not last. Those 116 117 war and medicine SUFFERING AND THE HEALING PROFESSION

The ShellShocked neck with a bolo knife, and the blood Three wounded spurted high in the air before the body soldiers, 1940s. econd only to the public anxiety fell. And the horrible smells! You Wellcome Library, London Sabout wartime dismemberment was know I can hardly see meat come the concern expressed about mental on the table.17 collapse, whether called ‘shellshock’, ‘war neurosis’, ‘hysteria’, or ‘combat rivate E Lucas also described his exhaustion’. For many British soldiers, Psense of enduring horror. In a halting, who remained in hospital after the war person, and in particular the child, who the traumas of combat were almost distressed paragraph scrawled in a nurse’s found that many of the privileges they is threatened with crippling as a result unspeakable. “My nerves are shook scrapbook, he described (with almost had enjoyed before the Armistice were of accident, of tuberculosis, or infantile up, severe head-ache now and again no punctuation): removed. A navy man who was crippled paralysis, or other illness is every bit when my mind is on the affair”, is how as a result of war service, complained: as important as the person or the child Private Arthur Hubbard described his showers of lead flying about and big who is injured by a German bomb”.14 psychological crisis in a letter to his big shells its an unearthly sight to see The hospitals had many patriotic After both wars, this sentiment gained mother in July 1916. His breakdown was them drop in amongst human beings. visitors and supporters during the dramatically in strength. With the distaste triggered by being ordered to slaughter The cries are terrible, I escaped being years of the war, when the nation was for soldiering following the war, the heroic brutally three unarmed German prisoners hit but… got buried once that caused in peril, but since the Armistice this image of the war-disabled on the field of who had “cried for mercy”. It made his me to have fits… and trip to France band had dwindled down to just a few. battle came to lose its potency. They were “head jump”, he sighed.16 Other men is nice but not when the murderers Many of those people who during the portrayed as both child-like victims and found that their days as well as nights are killing anyone children included, war, visited the hospitals with gifts, prematurely aged. In either case, they were tormented with nightmares. In the and destroys Churches May the Lord and took the men out for long drives, were useless in the face of the growing words of a young officer known only as put an unholy curse on them for ever and to entertainments, gave up—at the post-war needs to restore the economy. In ‘Captain B’: and ever The sights cannot cannot be signing of the Armistice—what they the words of Harry Smith, a character in a explained in writing. Writing is not my were pleased to call their ‘war-work’.13 play called The Unknown Warrior, 1923, The chief trouble now is dreams—not line. No fighting either. For they that who had been given a job making toys: exactly dreams, either, but right in the wants to let them fight Because I will ven the main charities devoted to the “I’m fed up with making silly toys. It’s middle of an ordinary conversation the never like it no no never.18 Ecare of disabled people began warning not work for a man—but we’re not men face of a Boche that I have bayoneted their donors that too much attention was now, with half our insides and half our comes sharply into view, or I see o one really knows how many being paid to the war-maimed. As early limbs gone; it’s a good enough job for us, the man whose head one of our boys Nmen experienced long-term terror as 1941, one charity insisted that: “The I suppose”.15 took off by a blow on the back of his like Privates Hubbard and Lucas or 118 119 war and medicine SUFFERING AND THE HEALING PROFESSION

Captain B Poor psychiatric training compensation?”19 In other words, military and the hurried nature of diagnosis psychiatrists made their diagnoses Field dressing; in wartime conditions dampened with economic and administrative bandaging the wounded, enthusiasm for accurate record-keeping. repercussions firmly in mind. First World War. The statistics were also skewed by Wellcome Library, London variations in nomenclature (a headache hat were doctors to do, then? might be labelled ‘combat exhaustion’, WThe first thing psychiatrists and ‘concussion’, or ‘malingering’), differences other physicians were required to do was in evacuation procedures (for instance, ‘screen’ recruits thought to be susceptible a sudden increase in cases of trench to breakdown. The list of men who should foot might cause wholesale eviction of not be allowed to enlist included such psychiatric patients from the hospital), diverse groups as epileptics, homosexuals and the presence of a wound in addition and those suffering from venereal disease, to emotional collapse (in which case, the to those with a history of insanity in their wound would take precedence). Decisions family, men frightened by trains, and were also made with pension requirements men incapable of micturating in public.20 in mind. The psychoanalyst William Undeniably, though, the chief screening between 20 and 50 per cent during the psychiatric services available to the Needle, who served during the Second device consisted of ensuring that people the 1939–1945 war were labelled armed forces to be adequate again. World War, recalled being bewildered who had a “neuropathic or psychopathic “psychiatric casualties”. The military by the pressures placed upon him to soil” were identified.21 Clinical services realised that something had he purpose of treatment was to restore diagnose men suffering from war neuroses psychologists had a duty to ensure to be done—and quickly—to reduce Tthe maximum number of hysterical as “constitutional psychopaths”. The that men with a dubious psychiatric levels of psychiatric breakdown. As and neurotic men to duty as quickly reasons for this were many, he discovered, family history were identified and a result, clinical psychology received as possible. In the words of the author but “fear about the national debt” was excluded from military service. a significant boost. In 1916, the first of “Psychiatric Activities During the “uppermost”. After all, his colleagues Consultant Psychologist was appointed Normandy Offensive, June 20–August argued: “why qualify a man for pension espite these procedures, it was to accompany the Consultant Neurologist 20, 1944” (1946), psychiatrists were rights by attaching the label of neurosis Dclear that large numbers of men with the British Expeditionary Force. not to concern themselves with ‘cure’, to him when the facts indicate that his were being rendered militarily useless Unfortunately, by the time of the nor with solicitude for the psychic pain symptoms are of life-long duration? due to psychiatric breakdown. Overall, 1939–1945 war, the lessons learnt in [the patient] would have to endure to Why not designate him constitutional around 25 per cent of all discharges the earlier conflict had been forgotten: serve a few more combat days, nor psychopathic state, which rules out during the 1914–1918 war and it took until the middle of the war for even with speculations on the eventual 120 121 war and medicine SUFFERING AND THE HEALING PROFESSION

malingering. Most famously, during the Sicilian campaign in the Second World War, General George Patton visited a hospital where he met a man suffering from battle neurosis. In Patton’s words:

I said, ‘You mean that you are consequence to his personality. Military ‘exhaustion’) as providing sufficient although the medical officer should show malingering here?’ He burst into tears Patients’ recreation psychiatrists had only one aim and that cause for breakdown. Malingerer’s guide, sympathy, the patient “must be induced and I immediately saw that he was an room, Second floor, was to determine whether a man retained disguised as a book to face his illness in a manly way”.23 hysterical case. I, therefore, slapped King George V Military “additional combat usefulness”, the his shift had inevitable consequences of matches, 1944. Treatment was summed up in terms of him across the face … And told him 22 Hospital, Stamford author concluded. Tin terms of treatment. If breakdown Wellcome Library, London three principles: immediate treatment, to get up and join his unit, and make Street, London. was a ‘paralysis of the nerves’, then continued proximity to the battle (based a man of himself, which he did. I am Wellcome Library, London. here was considerable debate massage, rest, dietary regimes and on the belief that the further men were convinced … that, had other officers Tabout how this was to be achieved, electrical treatment were invoked. If it removed from the fighting, the less had the courage to do likewise, the however. A medical officer called was the result of psychological trauma, chance that they could be transformed shameful use of ‘battle fatigue’ as an Charles Myers had coined the term then the ‘talking cure’ (especially back into combatants), and constant excuse for cowardice would have been ‘shellshock’ in 1917. Along with many group psychotherapy), hypnosis and reassurance of rapid healing. Either way, infinitely reduced.24 other medical officers in the front lines rest would speed recovery. From 1942, sufferers had no choice but to recognise at the time, Myers had assumed that Exhaustion Centres were set up, in the stigma of cowardice and acknowledge ot all medical officers shared shellshock was the result of a physical addition to preventative policies such that their reputations as soldiers and men Nthis view, of course. As the more injury to the nerves arising out of as limiting the amount of time a man had been dealt a severe blow. sympathetic author of Men Without incidents such as being buried alive or spent in combat without rest-periods. Guns, 1945, patiently explained, exposed to heavy bombardment. But, Drugs (such as insulin, anti-depressants “simulated psychoneurosis is really very quickly, it became obvious that and tranquillisers) were also widely Malingering a form of the affliction. A man who everyone was at risk, including those employed. In all instances, occupational is willing to be branded a neurotic— who had never been anywhere near the training and the inculcation of ne of the problems faced by medical as having cracked—is, to a degree, front lines. As a consequence, medical ‘masculinity’ were regarded as essential. Oofficers was that they shared with neurotic.” Someone who shoots officers increasingly began emphasising As the medical superintendent at other military officers the suspicion himself “has reached what they call psychological factors (including simple Bootham Park (York) put it in 1920, that men in mental wards were actually his emotional threshold”.25 122 123 war and medicine SUFFERING AND THE HEALING PROFESSION

moved to a room by myself and this was Opposite, above and not nearly as nice as being in a ward right: Self-inflicted with six and eight other chaps.29 wounds, First World War, Lieutenant Colonel reudian ideas in particular were G J S Archer, RAMC. Fthought to clothe the sufferer in a Wellcome Library, London mantle of disgrace that had been absent evertheless, one of the jobs of shattered nerves was becoming when more somatic explanations were Nphysicians within the military very prevalent. accepted. Pathologising emotional was exposing malingerers; indeed, as reactions to killing, and ascribing one army surgeon responded when hen he suspected that the doctors psychological weakness to men who asked if he was a doctor: “No … I am Wdistrusted him, he stepped in front disliked (or disapproved of) military a detective”.26 After all, some men did of a truck, crushing his foot.27 Others life, made it even more difficult for malinger in order to escape combat. simulated diseases or bought specimens combatants to discuss their experiences As Private Edward Casey (a Cockney of saliva containing tuberculous in war with their families and friends serving with the Royal Dublin Fusiliers) bacilli or small samples of gonorrhoeal when they returned admitted: “I started to scheme, how the discharges from their mates. Even more castigate them as cowards or weaklings. hell can I work my ticket and get out simply, a stick of cordite, extracted from Lieutenant AG May, for instance, refused he medical profession, however, of this bloody war … I admit I am a a .303 rifle cartridge, would cause a high to accept the slur of cowardice that he Tinvented signs by which the coward—a bloody, bleeding coward— temperature and symptoms of an erratic believed had been fixed to him with the malingerer could be distinguished. and I want to be a live coward [rather] heart condition if chewed. As the author diagnosis of shellshock. He had been They attempted to identify groups of than a dead blasted hero”. He faked of “Malingering—A Study”, published in shot during the Messines-Wyteschaete men who were to be regarded as the most madness. As a result, he also had to The Military Surgeon in 1941 lamented: push and had been sent back to England. prone to dissimulate. This took many pretend to be hypnotised. In his words: “It is indeed devastating to recognize, as In his words: forms—including the sweeping assertion we must, that all men are not possessed that particular ethnic groups (Irishmen The Doctor who put me to sleep, of manhood, and that the ‘yellow streak’ A few days later I started to have and Lowland Scots) were untrustworthy. examined me again, I had to tell him down the backs of some of our fellows is uncontrollable jerking and shaking of Doctors also speculated about how to everything I remembered before the invisible to the unaided human eye.”28 my legs. I was quite upset because I identify malingerers by certain physical barrage. Talking and telling him lies, was unable to stop it. The doctor came signs. Malingerers looked cunning, they while he wrote every word I spoke, in f course, patients were not passive; and told me I had shellshock but I overacted, and the symptoms were vague a book, telling me my complaint of Othey often resisted attempts to didn’t believe this. That afternoon I was and diffuse. 124 125 war and medicine SUFFERING AND THE HEALING PROFESSION

f these techniques did not work, beds, military and civilian, be Isuspects could be tricked into devoted for the genuinely ill, The Guinea-Pig revealing their true selves. The use wounded and disabled.31 magazine, 1950. of ‘truth drugs’ was recommended. Printed with permission from Intimidation was considered legitimate. iven such sentiments (and as the Queen Victoria Hospital Physicians could start by “informing the Gconcern with military morale NHS Foundation Trust, simulator that one was fully aware of the reached hysterical levels), it is not East Grinstead. deception and that he will face serious surprising that doctors tended to charges unless he gives up his symptoms suspect every soldier who reported Willett, the young man with whom we them in wartime. Physicians faced at once and returns to duty”, advised sick of being a ‘skrimshanker’. started this essay, was wounded during immense pressures to change their own another medical corpsman.30 They could the war and paralysed. He had been values to pull them in line with those threaten to put the men on the extremely a student doctor prior to the war and, of the military. Conditions of work in dangerous and emotionally fraught Conclusion: in talking to another doctor in the modern conflicts provided scant time duty of stretcher-bearing. It was even War’s Aftermath hospital, discovered that two military for introspection. The military as an valid to inform patients that unless they surgeons (he dubbed them ‘Thread and institution was exceptionally powerful quickly improved, they would be shot ilitary medicine was more Frog’) were experimenting on wounded and provided very strict limits within for cowardice. M‘military’ than ‘medicine’. Some soldiers. “I couldn’t stick [Frog’s] and which they could operate. Surgically, physicians expressed doubts about their Thread’s bloody experiments”, he cursed, they were saving lives. They were he justification for such techniques role. The authors of Shell Shock and Its adding: “You’d have thought the war was doing an onerous and often dangerous Tin wartime was obvious: malingering Lessons, 1919, for instance, admitted being fought just to give them healthy duty. Many were haunted for the rest endangered other men. This fear was to feeling uneasy about declaring that specimens. Once up in the theatre they of their lives by what they had seen. expressed by the authors of “The Military a man who suffered shellshock after didn’t care a bit about the case. Electric In the end, however, military and Malingerer” in The Military Surgeon experiencing the horror of having to stimuli, ligatures, anything; like frogs in medical disciplines enjoyed a symbiotic in 1943: kill another human being had “lost the phys. Lab.”34 The presence of a large relationship. Medicine did not simply his reason or senses”. His senses were and docile community of experimental serve the military, but was crucial in Now that we are engaged in a war “functioning with painful efficiency”, subjects was too great a temptation for actually defining and expanding military which is literally a struggle for our very they dryly observed.32 Others expressed some medical officers. power so that the armed forces could lives, we cannot tolerate the malingerer reservations about the callousness induced control and direct the emotional as well or countenance his parasitism in our by the endless exposure to what one owever, the majority of medical as the material lives of its recruits with concerted effort. Ours is a selfish doctor called so much “saddening Hpersonnel had little difficulty greater effectiveness. attitude in demanding that hospital raw living flesh”.33 Similarly, Wilfred in adapting to the demands made of 126 127 WARwar ANDand MEDICINEmedicine LAVONNE TELSHAW CAMP

rope and slept under a blanket that they Usually they were formed by a group of LAVONNE TELSHAW CAMP shared with four other soldiers. They volunteers from medical schools and were malnourished, ravaged with disease hospitals. The physicians and nurses, LINGERING FEVER: A WORLD WAR II NURSE’S MEMOIR and had no spirit of aggressiveness that as well as technicians and other a soldier needs. Stilwell took these personnel necessary to the functioning men and their officers and transformed of a hospital, were carefully selected them into a healthy army. He clothed and were particularly well qualified them, fed them, inoculated them against for the highest type of medical work. disease where vaccines were available, The esprit de corps and the morale of and hospitalised them in American these groups was especially high, as hospitals when they needed treatment. they were identified with the prestigious Not all the Chinese soldiers were institutions they represented. They had fortunate enough to fall under the aegis worked as a team in the civilian world As a young staff nurse at New York Hospital, of Stilwell and the Americans. Some of and were enthusiastic about exercising LaVonne Telshaw responded to President them were replacements, poorly equipped, their skills in the combat areas of Roosevelt’s plea for nurses to serve in military poorly nourished and totally untrained. war, or anywhere our fallen soldiers hospitals. After her basic training at Fort China had been fighting the Japanese needed their special expertise. When since it had been invaded in 1937. They these units were called to active duty, Dix, New Jersey, she was sent in 1944 to were tired of war, but were beginning they were given a period of military the fourteenth Evacuation Hospital in Assam, to realize that until the Japanese were training to familiarize them with army caring for soldiers in the China-Burma-India driven from the mainland of Asia, they routines and procedure, then placed theatre of war. would never be free people. Many of the under the command of regular army patients at the Fourteenth Evac. were officers. The 14th Evacuation Hospital casualties of the campaign to take North was established by the University of THE fourteenth learned that they had returned to Burma. Those wounded in battle were far Southern California and the 20th General EVACUATION HOSPITAL their military units without benefit of outnumbered by those who had fallen to Hospital was initially made up of medical discharge. tropical disease. physicians, nurses, and technicians My first assignment at the Fourteenth Prior to arriving at this isolated Many of the staff at the hospital, from the University of Pennsylvania. I Evacuation Hospital was to a ward hospital, I had not realised what role men and women who had been associated did not belong to this kind of group, filled with Chinese patients, perhaps the Chinese played in the theatre’s with the Chinese Army for a long time, but was sent overseas as a replacement fifty men. The Chinese Army provided me military operation, nor did I know about were squeezed dry of compassion. They for a nurse who had been at the 14th with an interpreter, a real necessity, the urgency that America felt about considered these soldiers as “hopeless, Evac. since its inception. She had the considering the communication problems keeping China involved in the war. Had unreliable, corrupt, thieving sons-of- distinct advantage of belonging to an that I faced. Yang Jei-pen was a serious this enormous country succumbed to the bitches” and seemed reluctant to go assemblage of professionals that had young man, well educated by oriental occupation by Japan, the United States out of their way to offer treatment. It trained and worked together for many standards, and very helptful in keeping could not have fulfilled its mission was nearly impossible for me to get a months. Her daily life was supported by the names of the patients sorted out. with Asia. The commanding general of medical officer to look at a patient. the fellowship and camaraderie of her Unfortunately, he was not there all the CBA, General Joseph W Stilwell, Many of our doctors had been in the peers and their long association with the time, and the Chinese ward boy had been responsible for taking these Pacific campaign for an extended time each other. On the other hand, she had who lived in the ward spoke little Chinese peasants and turning them and were shipped to the CBI for yet been exposed to the horrors of combat English. I had a difficult time keeping into an effective fighting force in the another long tour of duty. Theirs was injuries, had worked lengthy hours the Wongs and the Wangs, the Hos and retaking of Burma from the Japanese. In a malignant apathy towards Chinese under appalling circumstances and had the Hus straight in my mind, which made Ramgarh, India, he trained several units patients, for they saw in these men a been in the theater for such a long giving medications and keeping records of Chinese soldiers, equipped them as callous attitude toward human life, time that her health was compromised a nightmare. I quickly learned the well as their American counterparts, and and they felt that their compassion and her vitality depleted. I came Chinese numbering system, numbered each gave them the humane treatment that they was wasted. This had not been the case without a “life support system,” a man’s straw pallet, called a chwáng, and had not known before. Recruits who came earlier in the campaign. There had been newly graduated nurse, with very little identified the patient by the number on to the Chinese army had been victims a splendid esprit de corps, but month experience beyond what I had learned as his chwáng. Alas, they switched chwángs of press gangs, forced into military upon month of intolerable conditions had a student, thrown into an organization whenever they felt like it, and laughed service because they could not buy wrung the juices of empathy from their that was corroding from lack of spirit uproariously at their ability to confuse themselves out of it. Tied together with very souls. and breaking down from an exhausted and frustrate me. I found it impossible rope, they were marched to base camp During World War II, the hospitals will to perform. Society had insulated to keep an accurate census. Sometimes and given three weeks training before that provided medical services to our me from the “real” world. All my young when I came on duty a half dozen being thrown into combat. Many of them armed forces were first established as life had been given over to learning, patients would be missing, and I later marched in sandals made of straw and separate institutions in the States. to getting as much education as I could 128 129 WARwar ANDand MEDICINEmedicine LAVONNE TELSHAW CAMP

afford, seeking a place for myself in searched for a clearing where they little foolish to the veterans who had I hadn’t the vaguest idea what was my chosen profession, which, in those could land. Many of these patients were been there for many months. After a few bringing such apparent joy. They held years did not enjoy the almost limitless seriously and acutely ill, suffering encounters with the reality of nursing the rice bowls up to their chins and boundaries that it does today. Thrust from exhaustion, malnutrition, typhus, in a thatched hut, of seeing patients with two chopsticks held close together into the strange and alien environment malaria and amoebic dysentery. After sell their medications, of watching they shoveled the rice into their of Assam, working with Chinese months of horrendous conditions of rats run under the chwángs, I was mouths, down to the very last grain. patients—I had to make all kinds of jungle warfare, some of the men were considerably subdued and had a better Afterward they drank tea and smoked. The adjustments in every region of my mind, more dead than alive by the time they appreciation of the attitudes that way to a Chinese patient’s heart was just to survive. It was my intention to reached the hospital. The two sections prevailed. through an American cigarette. do a good job, to exercise my nursing of the 14th Evacuation Hospital which The long basha that housed the Even in throes of illness these patients expertise where it was needed, be it for were equipped and staffed for seven patients was similar to all the other could not quite understand why the the sick Chinese or for our own military hundred fifty patients, now had two buildings in the compound. The floor was American nurses tended to their needs. patients, but I began to feel that thousand eight hundred sick or wounded packed-down dirt that promptly became They giggled when I checked a pulse nobody really gave a damn. There were soldiers, American and Chinese, and mud where the rain fell from leaks in rate; they thought it humorous that many men and women like myself in World even some British and Indians. Not all the roof. The patients’ chwángs, lined I would place a stethoscope on their War II who found themselves unprepared casualties could be evacuated from this up on either wall, were raised a foot or chests to listen, and they had not the for their roles but they learned quickly guerilla action by air; many of them so off the earthen floor. At one end of slightest idea what I was listening and functioned far better than they ever were brought in after days of struggling the building a small room, partitioned for. They watched every move I made, had dreamed they could. through thick forests, swollen rivers off with a woven bamboo wall, was the perhaps with distrust. Sometimes when I The 14th Evac. was built originally and streams, and mountainous terrain nurses’ station. Here I kept the meager gave them medicine, they would take the for seven hundred fifty patients. During that required death defying efforts to equipment needed: medications, needles tablets in their hands, and later walk the campaign to recover North Burma from traverse. Doctors, nurses and enlisted and syringes, a few treatment trays, all the way to Ledo to sell it to the the Japanese, the 14th was asked to men worked fourteen and eighteen and the patients’ medical records. Just local citizens who prized the quinine establish a branch hospital to receive hours a day. After the battle to take outside this room was basin of Lysol and the atabrine, for they too suffered casualties from the 5307th Provisional Myitkyina, the patient population began solution on a little table where I could from malaria. Unit (Special) code named GALAHAD, to level off, but there was still much immerse my hands after ministering to later known as Merrill’s Marauders for work to be done. It was at this time an infected patient, dressing a purulent Col. Frank Merrill, its commanding that my group arrived to relieve some wound, or cleaning up an ulcerated officer. These three thousand combat of the staff. A great number of the mouth. I chuckled to myself, thinking of troops penetrated deep behind enemy remaining patients were Chinese, full the impeccable aseptic technique that I lines, pushed through the putrefying of worms and other parasites, venereal had been taught to use .... jungle to flank the Japanese. Casualties, disease, tuberculosis and dysentery. The I enjoyed that time of day when disease and fatigue ravaged heir ranks. morale of the hospital unit was on a the cook brought in the tea and rice. As fast as the planes could evacuate precipitous decline. Those patients who could ambulate on the wounded, they came in and filled I had the temerity to approach their own steam would gather, squat on the beds. There were no helicopters, my nursing job in this ward of disease- their haunches and wait for their rice just some L-5s with courageous pilots ridden men as though the outcome of the bowls to be filled. Their conversation, who were willing to risk being picked war depended on it. We women, fresh always punctuated with great bursts of Originally published in “A World War II Nurse’s Memoir”, off by the Japanese Zeros while they from the states, must have looked a laughter, made me feel good, even though McFarland & Company, Inc Publishers. 130 131 war and medicine STALINGRAD

STALINGRAD WOUNDED BODIES AND SOULS Wolfgang U Eckart

Introduction he medical situation in the Urban warfare; Russian Tencirclement of Stalingrad, however, soldiers, in Stalingrad, or decades, the has received little attention until now.1 Second World War. encirclement of the city of Reconstructing it from the extant files DHM, Berlin. Stalingrad by the Germans and from the retrospective literature and the battle that took tells us much about the experience place there (22 November of the siege. It also tells us about the 1942 to 4 February 1943) political and military leadership and its was one of the most contempt for humanity, a leadership that, traumaticF events of the Second World in the service of propaganda, accepted War in the German collective memory. the destruction of the Sixth Army in It marked the beginning of the collapse Stalingrad against all military reason, of the front in the occupied part of the hiding the fate of the trapped soldiers in Soviet Union, and was thus a turning point lies and declaring the situation a “large- in the war. It also marked the beginning scale experiment in starvation”. of desperate attempts on the part of Hitler’s leadership clique to lie their way hen the encirclement of Stalingrad out with propaganda, as exemplified by Wwas completed on 22 November Joseph Goebbels’ infamous speech on 18 1942, it enclosed approximately 300,000 February 1943 in the Sportpalast, Berlin. German soldiers and those allied with But above all, Stalingrad marked the them. Some 100,000 to 145,000 of these betrayal, suffering and senselessly wasted “fell in battle, froze to death, starved, lives of the German soldiers in the East succumbed to epidemics and other and that of their despairing relatives at diseases”.2 Between 29,000 and 45,000 home. Hardly any other event of the war, wounded, ill and healthy men—the not even the Allied landing in Normandy, numbers cannot be established with has had such an influence on the flow of any certainty—were flown out of German literature after 1945 on the war the encirclement before they could in the East, a flow of various political be captured, often under dramatic colours and intentions that still circumstances. More than 90,000 men continues today. were captured prior to, and especially 132 133 war and medicine STALINGRAD

since often the intestines and stomach packed blood, direct transfusion, or by Tank fight near German troops were multiply perforated, which would means of infusions of physiological Stalingrad, June 1942. charging up a hill have required special care. But care sodium chloride and nutrient solutions, Ullstein Bild— near Stalingrad, of these life-threatening wounds was at least, as long as these could be Nowosti Collection. October 1942. impossible. It simply took too much sufficiently thawed out. By the beginning Ullstein Bild— time and often met with failure. Nearly of December 1942, however, it was no Granger Collection. every abdominal-wound operation kept longer possible to get sufficient supplies “a whole team busy for one and a half of medicines and blood substitutes after, the capitulation on 2 February again confronted the medical corps with to two hours”, and entailed a mortality through. The infusion solution Tutofusin, 1943 and became Soviet prisoners of war. problems for which it could not have rate of approximately 50 per cent.3 in particular, was soon in dramatically The majority of these exhausted troops been prepared, since the eventuality of Operations of this kind were therefore short supply. Blood-group tests were also were wounded, suffering from frostbite, large-scale retreats or even of long- soon put aside in favour of others with a lacking. The work of the surgeons within disease and extreme malnourishment. lasting encirclements had not been taken better success rate. Since soldiers with the encirclement was therefore reduced into consideration. Primarily, these abdominal wounds usually needed to be to purely operative activity. Post- difficulties were those of supply, caused transported lying down, and therefore operative care of the patients, decisive for Wounds And Diseases— by inadequate transportation. Medical required considerable space, few, it may survival, was no longer a consideration. Medical Care materials from the stores on the Eastern be assumed, were flown out. Front, such as that at Charkov, could not mong the illnesses observed in edical care among the German land be brought to the main front because the urgeons often worked for days on Athe encirclement was infectious Marmies in the course of the early transport was being used instead to take Send to the point of exhaustion, with hepatitis, cases of which increased in phases of the Second World War was fresh units and ammunition to the front. only brief breaks. But it was not just frequency with the duration of the siege. considerably hampered by inadequacies For the same reason, the wounded could the direct surgical treatment of the Daily life was characterised by influenza from the start. The medical units stationed no longer be transported in sufficient soldiers that was difficult. Soon after infections and all kinds of diarrhoea, at the rear had a great deal of difficulty time and quantity to the hospitals in the encirclement was completed, the mostly harmless gastroenteric colides. in keeping up with the combat troops. the rear. The main problems for the problem of post-operative treatment These were not, as a rule, cases for This was particularly true of the attacks medical care of the soldiers trapped of the wounded became acute. To hospital treatment, but soldiers with on Poland, the Benelux countries and within the encirclement were the large relieve pain, morphine was given, or jaundice and dysentery had to be treated France. The experience gained in number of wounded and the constantly its substitutes Pantopon, Dilaudid and in the clinic. In particular, soldiers these battles did prove useful for the growing cases of severe frostbite. Eugodal, as long as supplies lasted. with ‘Balkan anamnesis’ had frequent preparations to attack the Soviet Union, Abdominal gunshot and shrapnel In the first days of the siege, loss of recurrences of malaria, which had even but the battles at Moscow and Stalingrad wounds posed the greatest challenge, blood could be compensated for with prior to the encirclement, together 134 135 war and medicine STALINGRAD

with infectious jaundice cases, led to and ill, and were chronically crowded, German troops in men being unfit for duty. In view of the are known to us. At the beginning of Stalingrad, October season, however, fresh cases of malaria December, a large first-aid station to December, 1942. within the encirclement were no longer was set up directly beside the airstrip DHM, Berlin. expected. This was also true of steppe at Pitomnik, which served as the (pappataci) fever, a highly febrous viral rendezvous and first-aid location for the disease transmitted by mosquitoes, most severely wounded men, who were which had considerably weakened the to be flown out. An establishment with troops during the late summer and the a similar function, although of smaller autumn. Typhus cases in larger numbers, size, was at the auxiliary airstrip at and cases of other such diseases, did Basargino. A large hospital base existed not occur until after capture for the most at Gumrak (for a time the site of the part. Within the encirclement itself, headquarters of General Paulus) from it cannot be said that there was any the beginning of December 1942 serious outbreak of infectious disease until the start of the Soviet January until capitulation. offensive. Medicines, bandages and other medical material—altogether some 100 altogether, according to estimates, these trains were sometimes “heavily Medical Facilities tonnes—were delivered to this hospital Red Army soldiers there were about four to five thousand damaged”, even “plundered”, by base from a medical supply distribution fighting in the streets of injured men. This number, however, marching battalions and men on leave. ll the receiving stations for the centre that had been set up in buildings Stalingrad, might have been considerably smaller Locomotives provided for the hospital wounded, the main first-aid belonging to the Sovkhoz Karpovka October 1942. if the transport of wounded had been trains were sometimes sent back, Astations and smaller medical and which was directed by one Staff Ullstein Bild— carried out without hindrance prior to resulting in delays of up to stations of the divisions were either Apothecary Bruch. Nowosti Collection. the closure of the encirclement. Instead, 18 hours. Interference of this and lost one by one as the encirclement there were traffic jams, blockages and similar kinds resulted in “damage and tightened, or had to stay in constant orries were available for the other obstacles. On 18 November 1942, loss” that could “no longer be made movement, only to be completely Ltransport of the wounded; their only four days before the encirclement good”.4 The situation worsened with the destroyed following the commencement number was still designated as sufficient came into effect, Surgeon-General closure of the encirclement, since there of the Soviet offensive of 10 January at the beginning of December. At this Renoldi was forced to point out that was a constant stream of wounded and 1943. However, the larger medical point in time, the number of wounded things were going grievously wrong ill from the already overfilled hospitals facilities within the encirclement, and ill at Gumrak, for example, was with the transport of wounded in the of the western military areas, which had which took on thousands of wounded 1,437, while in the encirclement hospital trains. On their return trips, to be evacuated one after another. 136 137 war and medicine STALINGRAD

Starvation Within or colds, began to prove fatal. I knew Soviet propaganda German POWs The Encirclement that, until now (around Christmas handbill for German cutting a loaf of bread time). according to the findings of soldiers in Stalingrad, (Russian propaganda oon after the closure of the Surgeon-General Renoldi, such December 1942. photograph). Sencirclement, the remaining illnesses had ended fatally in 56 Photo AKG Images. DHM Berlin. physicians began to notice a remarkable cases. The word ‘starvation’ was not increase in cases of death whose causes written on the certificate of death, could not be explained by wounds, just ‘acute illness’.6 disease or frostbite. In fact, the real culprit was the lack of supplies, n view of this, on 15 December 1942, especially of food, which made itself Ithe Army doctor in Morosovskaya, felt as soon as the encirclement was outside the encirclement, gave the complete. It was thus probably quite pathologist Hans Girgensohn the clear that these were cases of death by task of clarifying the causes of death starvation; of course, this would only of unwounded soldiers within the have been very quietly and privately encirclement. The pathologist was acknowledged, if it was mentioned at flown in on 18 December and was met all. Officially, it was “assumed” that the at Pitomnik airport by Stabsarzt Dr deaths were caused by “hypothermia Seggel, who took him to the army field and exhaustion”; naturally, none of the hospital near Gumrak train station. physicians in the encirclement dared to Girgensohn describes his accommodation talk of starvation.5 Günter Toepke also as “luxurious” in comparison with the describes this in his Stalingrad memoirs: normal conditions in the encirclement. It was: The army doctors observed the state of health of the troops quite exactly. an earthen bunker dug into the clay Swelling of the extremities could be of the steep Balka ravine, with a seen in many of them already. These wooden wall at the front; inside were starvation oedemas were the natural two double field bunks with sheets (!), result of the insufficient nourishment. a table, and an iron heater, which was Otherwise mild illnesses, such as flu fed with wood from the house ruins 138 139 war and medicine STALINGRAD

was the discovery that even short-term of this division had been decorated General Field Marshall high-caloric nourishment would not have because in the autumn of 1942, hoping Friedrich Paulus, meant the rescue of those starving, but to hoard supplies before the rainy, muddy Commander in chief of on the contrary their rapid deaths. The periods that entailed severe interruptions the 6th Army in 1942. pathologist reported on this: of supply, they had already reduced Photograph AKG Images. the rations of their units. When, in the It happened quite often that a soldier encirclement, the remaining supplies … would tell the non-commissioned were distributed as evenly as possible of Stalingrad. The wounded lay in a in the snow at minus 30 degrees Celsius officer of the rounds, ‘I am feeling fine, to all units, it was this “well-supplied” temporary wooden barracks building, and with strafing by enemy planes. “Hot I want to eat something now’ (a small division that became the “preferred squeezed together.7 water was brought repeatedly from a piece of tinned fatty meat, which was casualty of starvation, in view of its small bunker, to let me thaw out my flown in with precedence because of already malnourished soldiers”. he divisional physicians informed frozen fingers in their rubber gloves.” its high caloric content); when the non- Thim by telephone of the fatalities The extreme frost caused quite different com came round again, the man would t was not only German soldiers who requiring examination. He then went to problems. Frequently, the corpses to be be dead. The necropsy then regularly Idied of starvation in and around the location given, together with his two examined were frozen as hard as boards. showed, in the mesentery of the small Stalingrad. Hunger also hit the Soviet autopsy aides. They had to be thawed out with a great intestine, which was completely free of prisoners of war in particularly cruel deal of trouble before an autopsy could fatty tissue, that the lymphatic vessels fashion; before Christmas, some 3,500 in The trips to the sections in the 30 to even be considered. were stuffed full and yellow with the prisoner-of-war camp at Voropnovo 50 km diameter encirclement were the absorbed fat, in a way otherwise near Gumrak were packed together in difficult. We had to improvise and to ltogether, Girgensohn carried out seen only in anatomical injection an inadequate space. Around Christmas find unconventional ways to do things. A50 necropsies between 19 and 31 preparations. The commencement of 1942, Captain Toepke, who was By way of an operating theatre, an December. In 25 cases, the signs of digestion had overtaxed the circulatory deployed with the quartermaster of the earthen bunker was provided; if it was death by starvation were present. In system and led to death. Army top command six, reported to the a village, a room in one of the huts these cases, the proof lay in the total Army paymasters on the position of the was temporarily emptied; perhaps a “disappearance of the fatty tissue”, the he dissections also brought to light prisoners of war: railway wagon or a tent was available. “atrophy of the heart and liver”, the Tthe results of a mistaken decision “disappearance of skeletal musculature”, that had been made long before the Both have confirmed that the situation n one occasion there were three and the “swelling of the right chamber closure of the encirclement. The majority is no different in the prisoner-of-war Oautopsies to be carried out, one after of the heart”. Perhaps the most of those dead from starvation were in the camp (presumably Voropnovo). It is another; this had to be done in a trough discouraging result of the autopsies 113th Infantry Division. The paymasters quite intolerable to see this misery 140 141 war and medicine STALINGRAD

without being able to help. Swollen find a mountain of corpses of Russian extremities can be seen in most prisoners of war, nearly naked, thin as prisoners. Typhus is spreading; every skeletons, the skin already blackish- day about 20 fatalities lie about in brown, all thrown together in a heap. the camp. The weakened bodies had They must have lain here for some no more resistance left. The cause time already, having starved to death of death was given on the death or been tortured to death.9 certificates here, too, as (just) typhus.8 irgensohn, too, had had the grammes “per head a day”. The Army morning of 1 January 1943, Girgensohn n fact, the commander-in-chief of Gopportunity to see and dissect Junkers airplane being top command had avoided ordering this handed the report to Stabsarzt Seggel, Ithe Sixth Army, General Paulus had Soviet victims of starvation. He reports prepared for a rescue reduction in the period before Christmas who sent it directly to General Paulus. ordered the release of the prisoners that, after the autopsy of three Soviet flight into Stalingrad. for psychological reasons. “Various units Five days later, Surgeon-General of war on 14 January in view of this prisoners of war, who had been active had, nevertheless, been forced to carry Renoldi expressed his opinion of situation; however, he was unable to as volunteer workers, the “young officer out this reduction before Christmas, the situation in a letter to the Chief determine whether this order had been of the unit” enquired about the cause owing to the desperate situation.” Quartermaster of the Sixth Army: carried out. The poet Erich Weinert, a of death. Upon hearing the diagnosis In addition: German volunteer with the Red Army, “starvation”, he was quite taken aback. Since the beginning of December had been at the front at Stalingrad since This could not be right: “They receive at midday a litre of soup could be 1942, the army has been carrying out 2 December 1942. In a note in his diary the same rations we do—three slices of issued. It was made without the a large-scale experiment in starvation. from 25 January 1943 he reports a bread and a half-litre of good horsemeat addition of any fat, usually of pulses. In The quantities established then—and horrific find in liberated Gumrak: soup (water with four to five small cubes the evening there was tinned food, or, still valid now—contain about half of meat)!”. This statement was not depending on the place, a second, thin the nourishment needed by a working Early this morning a walk through correct, as shown by Toepke’s memoirs. soup dish, thus decidedly calorie-poor adult. There is no doubt that one Gumrak. Some houses are still food. The result was a rapid can expect soldiers to get along with smoking, hit yesterday by German he nutritional situation for the and general loss of strength among such nourishment for a limited time bombardment. The whole landscape TGerman soldiers in the encirclement the troops.10 without serious consequences, when nothing but ruins and corpses. Snow worsened dramatically after Christmas, circumstances demand.11 during the night had half-covered while Girgensohn was still carrying n New Year’s Eve of 1942, the the horrible scenes. Here and there out his post-mortems. An order dated Opathologist wrote his concluding he report only hinted at the bare skulls, hands or feet sticking 26 December 1942 reduced the bread report, which clearly identified those Tdeficiencies of the nutritional up through the snow. In a ravine we rations from 100 grammes to 50 who had died from starvation. On the situation in the encirclement and 142 143 war and medicine STALINGRAD

recommended 3,200 calories per day Last Hope—The Wounded medical stations further on behind the lines examined and transported to the airstrip per man, which was still too little. Are Flown Out Of was another matter. Bottlenecks occurred by a medical company of some five or The concept of the “experiment in The Encirclement both in the transport from the airfields six physicians. There the ‘passengers’ starvation” is nevertheless surprising. It and in the further transport by rail. It is were placed on a list; then the “planes, cannot be established whether Renoldi ith the closure of the encirclement impossible to establish exactly how many as soon as they had been unloaded, meant this ironically or whether he Won 22 November 1942, the last ill, wounded and healthy men were taken had to be reloaded immediately with actually conceived of the situation in options for transport by land vanished; out of Stalingrad between 19 November wounded”. When possible, last-minute the encirclement as a physiological the wounded and ill could only be flown 1942 and 24 January 1943. The numbers medical treatment was given for the short experiment. Examples of this kind of out. Those whose wounds were slight were given in the literature lie between 29,000 period of transport. This, according to thinking are known from the First World flown as a rule to Morozovsk, those more and 45,000. Estimates of the numbers the Army Physician for the Sixth Army, War. But in the midst of the all too seriously wounded to Tatsinskaya. Airstrips flown out of the airfield at Pitomnik functioned “excellently within the concrete catastrophe of the Sixth Army were available within the encirclement at between 19 November and 2 December shortest possible time”.14 Every wounded in January 1943, such an idea would Pitomnik and Basargino (until 14 January exist: “some 2,000 wounded and ill”.12 The man apparently had a certificate from have been quite out of touch with reality, 1943) and at Gumrak (until 16 January daily performance of the transportation for the unit administration, on which his even cynical. For what was happening in 1943). A small, temporary airstrip at wounded depended on enemy air activity, name and the type of wound were noted. front of the eyes of the highest-ranking Stalingradski, a few kilometres from the and could vary considerably. Within the Prior to take-off, the correctness of this medical officer in the encirclement city itself, existed for a few days after the encirclement, counting was carried out information was supposedly checked by a of Stalingrad was no experiment in surrender of Gumrak. Although this airstrip under “normal” transport conditions, and doctor. Despite this, men pretending to be nutritional physiology, but a large-scale was constantly under bombardment, it what was counted was “what was loaded, wounded probably got through. After such supply disaster caused by dereliction on was possible nonetheless for a few supply not what arrived”.13 The aircraft were cases began to show a marked increase the part of the army command and quite planes to land and then take off again, fully generally overloaded, landed and took off among the officer corps, officers were certainly without any claims to scientific laden with wounded. The last aircraft left under bombardment, and, when they flew only permitted to fly out after personal validity. Intentional and systematic Stalingradski on 23 January 1943. in good visibility, were constantly beset examination of their cases by the Army experiments of this murderous kind had by Soviet fighters. At least 495 transport Physician. An exact examination at peak indeed been carried out, but in German he ill and wounded reached the aircraft are known to have been lost, times, ie when transport was favourable camps with Soviet prisoners, where, as Tairstrips in different ways; many came which would indicate several thousand and more than 1,000 wounded were being early as the summer of 1941, the daily in vehicles, many more on foot, and some victims among the aircrews and wounded. flown out daily, was hardly possible. In caloric intake was already less than the even crawled. For those flown out, a safe such cases the doctors responsible for minimum needed for existence, but landing in Morozovsk or Tatsinskaya meant t Pitomnik, the wounded, who were the transfer were personally responsible still above that in the encirclement rescue from immediate danger to life and Atemporarily placed in Luftwaffe to the Army Physician for the validity of of Stalingrad. limb; rapid transport from these airfields to bunkers and shelters, were collected, the permit of leave. 144 145 war and medicine STALINGRAD

officer corps—had been ordered into the direction of Stalingrad. Parts of these DR Fitzpatrick, Gate to the encirclement personally by General disorganised columns also reached the Stalingrad, American Paulus, was completely out of his depth airfield at Pitomnik and contributed to cartoon, 1942. with the organisation of transport from the worsening of the situation there. Ullstein Bild— the medical stations of the division at the Granger Collection. airfield. His adjutant cooperated closely ncreasing pressure from the Soviet with quartermaster corps to “ensure Imilitary, but also rumours of the an exact overview of the transport of imminent fall of Pitomnik, then destroyed the stream of wounded”;17 but what use the fragile balance at the airfield. Army could this be, when neither air-transport Engineer Commander Seile reports on capacity nor shelter close to the airfield the increasing tension at the airfield. were sufficient to “transport thousands of On 12 January, he wrote, the airfield sick and wounded”?18 The fact that the was abandoned “for no visible reason”. shelters at the airfield were “bursting at The departure from the airstrip had the seams with wounded” was not only resulted in “scenes that were not exactly owing to the lack of flights to take them encouraging”, and “not justified by ccasionally a search for ‘shirkers’ at to the statement of the Army out, but also to the incompetence of the anything”, for “far and wide” there was Othe airfield of Pitomnik was carried Physician. Prior to this, everything Army Physician.19 not yet a Russian to be seen. Nonetheless, out in the form of ‘purges’, as can be was ‘under control’.16 What was “the air was suddenly full of panic”; seen from an entry in the War Diary of kept ‘under control’ was, of course, he situation worsened dramatically “showing no inner discipline, obeying the quartermaster section of the Sixth a disastrous evacuation emergency, Twith the start of the Soviet offensive no other law than that of primitive self- Army for 29 November 1942: “Among which set in quite soon after the from 10 January 1943. On 12 January, preservation”, everyone was “in wild flight the wounded at the airfield at Pitomnik a encirclement was complete. The increased military pressure from the to the rear”.20 search for shirkers and malingerers was daily number of wounded exceeded west necessitated the evacuation of the carried out, resulting in some 150 to 200 the transport flight capacity of the main first-aid stations in Dimitriyevka, ust what the “scenes that were not soldiers being returned to the troops.”15 Luftwaffe many times over. Karpovka, Novo-Alexeyevka and Jexactly encouraging” were cannot Barbukin. Hundreds of the most severely be reconstructed in detail. The only Situations of panic or dramatic bviously Renoldi, who was wounded were evacuated from each certainty is that the airfield and the bottlenecks did not occur until Oresponsible for the transport out of of these positions with all available bunker of the medical company, about immediately before the ‘final the encirclement, and who—according vehicles, and under most difficult 500 metres distant, were so crowded evacuation’ of the airfield, according to rumours among the trapped medical circumstances, towards the east, in with wounded days before the evacuation 146 147 war and medicine STALINGRAD

that there was little hope that any had been flown to Stalingrad-Pitomnik taxiing aircraft in their despair, without of the encirclement, with temperatures would be flown out. The impending as a member of an aircrew (not as a Soviet soldiers waiting for them to be unloaded. The of minus 30 degrees Celsius, and a lack involvement of the airfield in the front pilot). Prior to take-off and the flight embracing after the crush was “beaten back with slats”; of space for the wounded.24 “Under lines, hunger, frostbite, wounds, the back, the soldiers nearly took the surrender of German one man was killed and one officer had these circumstances, what with the stress of selection prior to being flown aircraft by storm, and at take-off some troops, 31 January 1943. “all the fingers on one hand cut off”.23 icy cold and the even icier wind off out, and the obvious fate that awaited the threw themselves … screaming into Ullstein Bild— the steppes, any attempt at treatment men when the airfield was captured—all the propellers or held onto the landing Nowosti Collection. he situation of those desperately had to seem senseless.” The wounded, appear to have been causal factors for gear of the Junkers.21 Thoping for rescue at the last temporary sick and starving froze to death in their the chaotic conditions just prior to the landing strip in the encirclement at hundreds. The progressive decrease in surrender of the airfield at Pitomnik. enoldi observed the evacuation Stalingradski, available until 23 January bodily strength of all soldiers, including When the rumour of approaching tanks Rof the airfield at Basargino on 1943, was the same. On 23 January, a the medical personnel, meant that even occurred simultaneously with the take- 14 January. Despairing attempts, Junkers 52 aeroplane was just able to before Christmas: off preparations for two aircraft that undertaken with the men’s last strength, take off from Stalingradski, under direct would probably be the last to leave, the to reach transport aircraft still flying fire. A last take-off attempt took place the in the field hospitals no normal final psychological barriers were broken out had taken place at this airstrip, too. following day. The aircraft never left the interment could be carried out any down. Violent attempts were made to Reports from Luftwaffe men, mostly ground and fell into Soviet hands. longer, because the personnel … storm the last aircraft directly before and pilots, on the situation at Gumrak also were not able to dig into the hard- even during take-off. As eyewitnesses exist. These give an idea of what scenes frozen earth with spades and picks. have confirmed, violence was used in must have taken place there among the Retreat Of The Wounded The dead were laid on the bare turn to allow it to take off. Whether an despairing wounded men. On 17 January Into The City Centre ground and covered with snow. express order to shoot was ever given to 1943 “wounded, who could no longer the ground personnel remains unclear, be taken along, and who lost their heads he accommodation for the wounded n 8 January, Lieutenant-General but this is not improbable in view of altogether” prevented a plane from Tcould be called “sustainable” (under OKK Rokosovski, the commander- the situation. The events in Pitomnik taking off. Luftwaffe officers stopped the the circumstances) at the relatively well in-chief of the Soviet troops on the have not been preserved in document storming of the aircraft with submachine built-up northern front, indeed in the city Don front, sent a message to General form; statements by witnesses and the guns. Only a few “severely wounded”, area of Stalingrad itself, too, according Paulus, in which he expressly referred memories of those directly involved are who “had secured a place in the aircraft to the preliminary opinion of Captain to the situation of the German sick and few. But this little is clear enough. Gisela before the totally exhausted men, Toepke, even after the encirclement wounded in the encirclement: Girgensohn, the wife of the pathologist, because of their physical condition”, was complete; but the situation at the reported the experiences of her uncle could be flown out.22 On 19 January western front of the encirclement was The position of your trapped troops Walter Vleugels, who told her that he: “lightly wounded men” stormed the “catastrophic” from the very beginning is difficult; they are suffering from 148 149 war and medicine STALINGRAD

hunger, disease, and cold. The provision, which must have been quite great effort, limping forward with partial darkness was relieved grim Russian winter has hardly obvious to those involved, especially the sticks, and with their frozen feet only by a few Hindenburg lights; the got started. Heavy frosts, cold medical personnel, that contributed to wrapped in bits of straw and the stench of blood, pus, and excrement winds, and snowstorms are all yet the worsening of the situation. Directly remains of blankets.27 was very intense”.29 to come. But your soldiers are not following the commencement of the equipped with winter clothing January offensive came the inhuman radio message of 24 January 1943, ew, if any, of these places of refuge and find themselves in difficult order to surrender first-aid stations Asent to the army of the Don, told of Foffered anything more than a little circumstances that render medical into “enemy hands” after doctors and the chaotic conditions: warmth and a brief feeling of safety. aid well-nigh impossible … All nursing personnel had left. Thousands Cellars full of wounded who would never wounded, sick, and frostbitten of wounded soldiers were thus quite Horrific situation in the city area receive medical aid formed lines as long men can expect medical help.25 deliberately left to freeze to death, proper, where roughly 20,000 as the streets under the sea of ruins since they could not even keep the wounded are searching for shelter in that was Stalingrad. With the tightening aulus, remaining “true to the most primitive fires going without help. the ruined houses, with no medical of the noose, the remains of the Sixth PFührer”, refused, and with that “Under these circumstances, every care. Among them as many starving Army flooded into the cellars even in sealed the fate of the soldiers entrusted man who could somehow manage once men, frostbitten men, and scattered the city centre, like an “invasion of to him, creating the prerequisite for the more to pull himself together dragged men, generally unarmed, as weapons bleeding misery”.30 J Wieder writes of final destruction of his army. himself”in the direction of Gumrak, had been lost in combat. Heavy an “underground and ghostly empire”, Pitomnik and Stalingrad.26 A “dying artillery fire on the entire city area.28 extending underneath the “eery stony ith the commencement of the army” flooded towards the ruins desert” of Stalingrad. “Every hole in the WSoviet offensive from 10 January, of Stalingrad: ot all soldiers reached the city of ground, every bunker, every cellar, each the situation for the wounded and NStalingrad, that last doubtful refuge and every room offering shelter was filled sick in the encirclement worsened. The scattered men, the starving ones, from death or capture. The dying army to bursting”.31 Although the danger of an impending the freezing ones, the sick … the was vanishing even on its way into the offensive ought to have been clearly remains of the shattered and shrunken ruins of the city, leaking away in driblets he largest of these cellars of recognisable even before the refusal units, columns and others, with into holes, caves, bunkers and ruins. On Tdeath, one below the former Local of the Soviet offer of capitulation, no vehicles slowly pushed and pulled all routes of the retreat some 20,000 men Headquarters Centre at the Heroes of the preparations were made for an increase by men. Wounded, ill, and frostbitten crept into their final shelters; even these Revolution Square, and one beneath the in the number of wounded, not to men. Emaciated figures were among were fought over by the dying, trying to building housing the Red Army Club, mention for a rapid evacuation in the them, with coats, tarpaulins, and rags find a little warmth and comfort. “Entire each contained over 1,000 wounded. direction of Gumrak and Stalingrad. wrapped about them, wretched pictures packs of men”, reports Waasen, “had In the cellar of the theatre some 800 But it was not only this glaring lack of of misery, dragging themselves with gathered together like dying animals; the sheltered; in the Timoshenko Bunker 150 151 war and medicine STALINGRAD

several hundred found refuge. The Others were less fortunate. The building A German plane shot Timoshenko Bunker was an extensive of the former Local Headquarters German POWs down over Stalingrad, 2 underground system of shafts, whose Centre, filled with sick and dead, was in Stalingrad, February 1943. chambers and corridors were “stuffed bombarded into flames in the final days February 1943. Ullstein Bild— full” of sick and wounded during the last of January and burned—a monstrous DHM, Berlin. Nowosti Collection. days of the encirclement, as Hans Dibold crematorium—down to the foundations. reported in his memoirs. “Without Only a few escaped. pause” they n many houses and cellars serving pumped new wounded into the Ias a last refuge for the wounded, the seemingly endless system of corridors. victors of the battle found mountains of For several days then the entrance corpses, and a few survivors, after the to the corridors lay in no-man’s-land capitulation. The American journalist between the fronts. Then the Russians Edgar Snow, who saw Stalingrad on 4 came, took away those sick men who February, two days after the capitulation, could still walk, except for a few, and reports on such a find in the ruins of the removed the lighting.32 former Red Army Club, which had been with excrement and filth. We stepped and central encirclements of Stalingrad, converted to a field hospital: back, aghast. When we looked at and two days after this the rest of the ibold himself spent the last hours the place from where the figure had army in the northern sector had also Dbefore capture in the cellar of the In a distant corner we found a heap come, we saw a small opening into capitulated. Over 90,000 soldiers were former GPU building, where he set up of half-naked Germans, the corpses the cellar level below. Bending over taken as Soviet prisoners of war. a kind of first-aid station and waited of wounded men, who had apparently this, a disgusting stench rose up to for the Red Army soldiers to arrive. In been thrown there by other occupants us; evidently others were still alive he capitulation did not end their the packed cellar, reports Dibold, “the too weak to bury them or burn them. down there. The Russians were so Tsuffering. The second day of soldiers lay on the floor” or “on, under, Many of the dead had rags wrapped busy burying their own dead that they February 1943 simply marked a stage in and among bedframes and pallets”.33 By around their hands and feet … all of had not yet been able to bring in all the odyssey of suffering of the wounded, the end, the sick men had lost all will “to them looked half-starved …While we surviving Germans.35 sick and exhausted men of a maltreated do more than what was required by the were staring at this horrible scene, army through a “dark valley” leading to needs of the moment”. 34 The doctor and a figure seemed to detach itself from our days before the journalist’s the Soviet prisoner-of-war camps, where many of the wounded entrusted to his the corpses; it staggered towards the Fexperience, the remains of the Sixth countless further numbers fell victim to care were captured shortly afterwards. back of the room, which was filled Army had capitulated in the southern the vicissitudes of the camps. 36 152 war and medicine

POSTERS Abram Games The following posters by Abram Games were commissioned by Her Majesty’s Stationary Office, London, in the early 1940s, as part of a campaign to improve health and hygiene during the war years. 154 155 war and medicine Abram games—posters 156 157 war and medicine Abram games—posters 158 159 war and medicine Abram games—posters 160 161 war and medicine Abram games—posters 162 163 WARwar ANDand MEDICINEmedicine DANG THUY TRAM

DANG THUY TRAM LAST NIGHT I DREAMED OF PEACE

At the age of 24, Dang Thuy Tram volunteered to serve as a doctor in a National Liberation Front (Viet Cong) battlefield hospital in the Quang Ngai Province. Two years later, she was killed by US forces. Her diary was written between 1968 and 1970.

20 july 1968 The community and his son accept on his pale lips. It was a very painful very fast (140 to 150) but I am hopeful. that I did everything I could, but I injury, but he did not whine or moan. In the end, he cannot survive. The days are hectic with so much work am still painfully disappointed. Why He worried about one thing: being able Having lost so much blood, he lacks the piling up, critical injuries, lack of did he die? Was it my technique? It to continue fighting. During my visits strength to recover. Oh, Bon, your blood staff personnel; everybody in the clinic wasn’t that. Although it was my first with him in the patients’ ward, I often has crimsoned our native land, flowing works very hard. My responsibilities amputation, I stayed calm and adhered brushed his hair with my fingers and down the length of the road to battle. are heavier than ever; each day I work to the surgical protocols. Then why? whispered to him: “Don’t worry, little Your heart has stopped so that the heart from dawn till late at night. The volume Was it the unsuccessful plasma brother. You can certainly still hold a of the nation can beat forever. of work is huge, but there are not transfusion? I don’t know what to say: gun well enough to fight the enemy.” Bon dies, his eyes closing gently enough people. I alone am responsible we got the vein, then missed it again Another day, I saw Bon in a as if to sleep. Sitting by his side, for managing the clinic, treating the and again because of the old man’s marching troop, an AK-4782 on his brushing his hair, I think he is still injured, teaching the class.1 More than continuous thrashing. What a tragedy! shoulder. He saw me from afar and with us. Then my tears fall onto his ever, I feel I am giving all my strength Why can’t I draw any lesson from shouted cheerfully, “Greetings, Doctor! hair. No! Don’t die! You will live and skills to the revolution. The wounded this untimely death? Report to Doctor: My arm is as good as forever in my heart and in the hearts soldier whose eyes I thought could not new!”. He waved his arm to show that the of your comrades who have fought at your be saved is now recovering. The soldier 9 january 1969 joint functioned normally. I laughed side in this life-and-death struggle whose arm was severely inflamed has .... happily when I saw the healthy hue on .... healed. Many broken arms have also healed Bon is 21 this year, 21 years, with his cheeks and the playful grin on the All these successes are due mainly to the seven battle injuries. This young scout- face of that liberation soldier. nurses and me working day and night at platoon leader has made an unforgettable Today, Bon is back at the clinic 13 march 1969 the patients’ bedside .... impression on me. again, very pale. He lies motionless The first time I saw Bon, he was and silent, without a single moan. His Another comrade sacrificed his life. admitted into the clinic with a minor leg is lacerated, mauled by a mine, his The wound went all the way through his 5 october 1968 injury in his leg. After a few days he clothes soaked with blood. With love, abdomen. His condition was not good left, even though his wound was not fully the other comrades and I try our utmost after the operation, and worsened over I lost an amputation patient. He was healed. Over a month later, I re-admitted to treat him. time. Perhaps there was an internal sixty years old but still strong, a him at the clinic. This time the wound After the amputation of his leg, hemorrhage caused by some undiscovered veteran Party member who had been in the was in his shoulder. He had lost a lot Bon smiled and said, “Now survival is 80 shrapnel cutting a vein. After a joint fight for 23 years. His family and the of blood, so he was very tired and pale. per cent certain”. diagnosis, the common opinion was not to clinic staff tried their best, but we When he regained consciousness after the In private, I still worry because perform a second operation. Privately, couldn’t save the old man. surgery, a playful smile bloomed again Bon lost so much blood. His pulse is I hesitated. In the end he died. 164 165 WARwar ANDand MEDICINEmedicine DANG THUY TRAM

I developed a severe headache, his entire body. This is Khanh, a 20 innocent forehead of that beautiful observation assignment, Thanh was shot thinking about his death. Why did he year-old man, the son of a sister girl. Looking at her, I want to write a right at the stream on the path that led die? Was it because of my indecision? cadre in the hamlet where I’m staying. poem about the crimes of war, the crimes to my house. The enemy wounded brother Very probably. If I had been decisive, An unfortunate accident caused the that have strangled to death millions Xuat and then they landed to take him he might have had a ten percent bomb to explode and severely burned of pure and bright loves, strangled away. His torn pants were left at the chance of survival. I conformed to the the man. Nobody recognises him as the to death the happiness of millions of site... In less than three months, the majority’s opinion and dropped something cheerful, handsome man he once was. people, but I cannot write it. organisation has lost three people! worth doing. Today his smiling, joyful black eyes My pen cannot describe all, even The grave is not yet finished, He died with a small notebook have been reduced to two little holes— though this is one case I feel with all but people are already carrying Thanh in his breast pocket. It held many the yellowish eyelids are cooked. The my senses and emotions .... back. A day has passed, but blood pictures of a girl with a lovely smile reeking burn of phosphorus smoke still still seeps from his body, soaking the and a letter assuring him of her steely rises from his body. wrapping sheet red. I cannot see his resolution to wait for his return. His mother weeps. Her trembling 30 july 1969 face clearly, but only a pair of closed On his chest, there was a little hands touch her son’s body; pieces eyes and pale face. Alive, Thanh had handkerchief with the embroidered of his skin fall off, curled up like At midnight, brother Ky arrives from weaknesses that I didn’t like, but now, words “Waiting for you”. crumbling sheets of rice cracker. His the South Wing and gives me painful shoveling earth to cover his body, I Oh, that girl waiting for him! younger and older sisters are attending news: the enemy has mounted a surprise cannot hold my tears. That’s the way it Your lover will never come back; the him, their eyes full of tears. attack on the clinic. Young sister Lien is. Try to love and care for one another mourning veil on your young head will be A girl sits by his side, her was shot and killed while leading the when we are still alive, but when we are heavy with pain. It will mark the crimes gentle eyes glassy with worry. injured to escape. Ky doesn’t know who dead, crying is only tears on a lifeless committed by the imperialist killers and Clumps of hair wet with sweat cling survived from the soldiers and who died. mound of earth. my regret, the regret of a physician who to her cheeks, reddened by exhaustion and Within three months, the clinic could not save him when there was sorrow. Tu (that’s her name) is Khanh’s was attacked four times .... a chance .... lover. She carried Khanh here. Hearing that he needed serum for a transfusion, 29 march 1969 29 july 1969 Tu crossed the river to buy it. The river was rising, and Tu For the first time, I dig a grave to bury The war is extremely cruel. This didn’t know how to swim, but she braved a comrade. The shovel hits a rock, and morning, they bring me a wounded the crossing. Love gave her strength. sparks fly like the flame of hatred in soldier. A phosphorus bomb2 has burned The pain is imprinted on the my heart. Yesterday, returning from an Originally published in “Last Night I Dreamed of Peace”, Random House. 166 167 war and medicine WHY THE PSYCHIATRY OF WAR IS TOO IMPORTANT TO BE LEFT TO PSYCHIATRISTS

WHY THE PSYCHIATRY OF WAR IS TOO IMPORTANT TO BE LEFT TO PSYCHIATRISTS Ben Shephard

hat will be the of civilians on the battlefield, the use of psychological roadside bombs and improvised explosive Chronic movements due cost of the Iraq devices, a high ratio of wounded to dead, to shellshock, 1916. War? In their a high proportion of reservists deployed, Photograph by Albert Norman. book, The Three and above all, long (and repeated) tours of Wellcome Library, London Trillion Dollar duty—all of which are reliable predictors War, the Nobel of high psychiatric casualties because Prize-winning economist Joseph Stiglitz they cause heavy emotional debris. Wand his co-author Linda Bilmes put Furthermore, the shortage of available the overall medical bill for American manpower has forced the Pentagon veterans of the war at 660 billion dollars, to drop its admission standards for with the lion’s share going on mental recruits, lowering the intelligence criteria health problems. This appalling statistic and issuing ‘moral waivers’ to people will surprise no one familiar with recent in trouble with the law; post-Vietnam history. It represents the price America experience tells us this will create is paying, not just for a bad war, but for problems down the line.2 three decades of bad psychiatry.1 whole societies had to live through The “medical method of handling”, it o a bad war will have an aftermath. traumatic events—combat, bombing, was found, undermined the individual’s irst, the war. More or less from the SBut Stiglitz’s enormous bill has as being captured as prisoners of war, losing ability to take responsibility for himself. Fbeginning, the fighting in Iraq has much to do with the society to which Iraq loved ones, German occupation. This Second, it was thought wisest to leave contained ingredients that, history tells War veterans will return, the culture of was not Freud and ten neurotic women people to cope on their own; to respect us, magnify the incidence of psychological trauma created by modern psychiatry in Vienna—this was entire societies. Out the culture and the defences within casualties. At the macro level, there within which they will try to readjust, of this experience, a broad consensus it—humour, singing, alcohol, sex, ritual, has been poor political leadership, bad and the extraordinary dissemination of was forged. Doctors and psychiatrists ceremonial, religion, and so on—and, generalship (until the arrival of David the concept of Post-Traumatic Stress found, first, that it was best not to where necessary, re-inforce them. This Petraeus), an ill-defined military mission Disorder over the past 30 years. To see medicalise this process; not to give it was not a culture of denial. It was one with no clear exit, and divided public this in its proper perspective we need to medical names. That was the lesson of that assumed that most people are opinion at home. All these elements go back in history, to 1939.3 ‘shellshock’ in the First World War, when healthy, robust and resilient and can have thrown into doubt the value of the the public and the newspapers were come through pretty horrible experiences soldier’s task. At the operational level, uring the two World Wars in the allowed to think that there was an actual with social support. But, third, it was at the fighting in Iraq has seen the presence Dfirst half of the twentieth century, medical condition called ‘shellshock’. the same time accepted that there would 168 169 war and medicine WHY THE PSYCHIATRY OF WAR IS TOO IMPORTANT TO BE LEFT TO PSYCHIATRISTS

be casualties. The thinking was: in the Blitz of 1940. The policy adopted then fear was one they shared with all other the Ministry of Health had no money Patient has his cigarette first instance, just give them rest and tell was worked out, at a conference in patients and with the emergency workers, for such conferences.) But I do believe lit for him, 1940s. them they are exhausted; get them back 1939, by a group of doctors who had and that it was important that they return that in relying more on the culture than Wellcome Library, London. to work or soldiering and rely on them all been through the First World War. to their normal work and resist the on medicine, this generation of doctors to cure themselves. If that didn’t work, It consisted of four strategies, which temptation to exaggerate the experiences made a wise decision. for the more serious cases there was a can be summarised as follows: through which they had passed. In other range of treatment techniques—in the words, civilians were not allowed to hat about that culture? Nowadays, First World War, hypnotic abreaction 1 Don’t use quasi- medical words like break down. Social pressure was used to Wwe tend to see it in very stereotyped and dream analysis; a generation ‘shellshock’ either to the patient or in reinforce the idea that there was nothing terms derived from old movies—stiff later, with the arrival of barbiturates, the media. wrong with them. Meanwhile, the media upper-lips and so on. In some ways, it pharmacological sedation, sometimes promoted a powerful ‘London can take it’ was a little comical. There was also often combined with drug abreaction.4 Fourth, 1 Don’t pay pensions for ‘war mood, which carried people along. a strong racial element within it that the strongest predictor of outcome was neurosis’; don’t reward the neurotic. we would find unacceptable today. The thought to be the patient’s pre-morbid am not saying that this was a golden great strength of this culture, however, personality not the level of exposure. 1 Keep psychotherapy to a minimum Iage of psychiatry—the era of ECT was that it offered the ordinary person Intelligence was also regarded as an and rely on social pressure. and of leucotomy; a period when people a simple, straightforward, clear model important factor.5 with learning difficulties, or young girls of how to carry himself in adversity: he 1 Use personnel selection to keep who got pregnant might find themselves knew, for example, that to weep in public t is sometimes said that medicine at vulnerable people out of the forces. confined to a mental hospital for life. was to show weakness. And, although Ithis time was unaware of trauma. In There were wartime failures, too: most this code of behaviour is sometimes fact, the textbooks of the time (such as n line with this approach, civilian air- notably, with those who returned from depicted as a form of social control that written by Sir David Henderson Iraid victims in 1940 were simply told Japanese Prisoner of War camps. The imposed from above (like the British and RD Gillespie) contain many calm, that they were exhausted, that there was tough regime applied to the London Empire and the ‘Public Schools’ system) wise pages on trauma—which is hardly nothing wrong with them and that they Blitz patients was passionately opposed it was, in Britain at any rate, as much surprising since their authors usually should go back to work; very few were by some younger doctors at the time, rooted in popular working-class culture had wide experience of war and its given pensions at the time and elaborate who thought it was heartless and cruel. as in middle-class social conformity. aftermath—they just don’t emphasise it.6 treatment was discouraged. All of this (When the psychoanalyst John Rickman One of its most important attributes, resulted in the very brisk treatment tried to organise a conference of of course, was a distaste for psychiatry. hat did this mean in practice? One given to air-raid victims. Patients at psychiatrists, he was bluntly told by the “The majority of men, especially in this Wobvious example is the handling of the London Hospital were told that Psychiatric Consultant to the Emergency country”, a British officer wrote in 1946, psychological casualties in the London their reaction was due to fear, that that Medical Services, Dr Bernard Hart, that “are healthily devoid of any interest in 170 171 war and medicine WHY THE PSYCHIATRY OF WAR IS TOO IMPORTANT TO BE LEFT TO PSYCHIATRISTS

psychiatry (which) is regarded as a a dissenting subculture, the world of the queer interest for queer people”. There bohemians of the early twentieth century was also, he thought, “a revulsion against … and the countercultural Left of the the invasion of mental privacy which 1960s”. Conservatives have argued that is unavoidable in prolonged “while some good things came from these psychiatric investigation”.7 changes, most notably, perhaps, the assault on racial injustice—most of its n the late 1950s, these social values, results had been dismaying and socially Iwhich had long been under strain, destructive”; others feel the gains have that, because Vietnam was an unpopular ne reason for this was that the issue began to break down; they have outweighed the losses.8 Wounded servicemen war, soldiers afterwards came to feel Oof the Holocaust had belatedly, continued to erode ever since. At the arriving from Vietnam guilt about what they had done there; or nearly two decades after the liberation of same time, the epicentre of our culture he effect of this shift in values first at Andrews Air that anti-war psychiatrists projected onto the Nazi death camps, begun to influence began to shift to America—and to Tbecame apparent in Vietnam. The Force Base. veterans their own feelings about the war. psychiatry, as physicians in New York, Nashville, Memphis, Detroit, Hollywood great unresolved mystery of the Vietnam Photograph Library Boston, Chicago and Detroit became and Orlando as much as to New York War is the extraordinary contrast between of Congress. ietnam divided American society— involved in a campaign for survivors’ or Boston. The net result has been the psychological literature at the time Vand American psychiatry. By and large compensation against the West German a change in the role of emotion and —which, by and large, has a note of the dominant figures in the profession, the government. Historians may argue over stress in Anglo-Saxon public culture, complacent satisfaction (“psychiatric grand, articulate, Ivy League doctors, were whether the Holocaust was a unique which has been lucidly summarised by casualties are lower than in any previous against the war—“outside the tent pissing aberration or just one of countless the American historian Alan Brinkley. war”)—and the torrent of writing in the in”, in Lyndon Johnson’s famous phrase— examples of genocide and savagery in “Where once society organised itself two decades after the war, which mostly and it was left to the hacks working for the twentieth century. But in the context around a cluster of powerful and claimed that Vietnam veterans were the military to defend (and apply) the of psychiatry, no such debate ever took widely shared values, many of them more damaged, more screwed up, than traditional line. In order to prove that place. The Holocaust was admitted to the emphasising restraint, self-discipline survivors of any previous war. There have America’s veterans were uniquely screwed trauma equation in the late 1960s and and personal responsibility”, Brinkley been many conflicting explanations for up, the anti-war psychiatrists seized on the early 1970s by American psychiatrists has written, “now it is dominated by this—that the Army psychiatrists were rhetorical weapon of trauma: they moved who would have felt it impossible to a new and more permissive ethos that too smug, careerist, and far in the rear trauma centre stage, made the pathological exclude it. And their patient population emphasises personal fulfilment, desire to know what was really happening; that the norm and, in the process, threw provided them with solid and tangible and identity”. A “set of essentially the widespread availability of drugs led away the hard-won store of knowledge evidence of the after-effects of trauma— bourgeois standards, rules and truths” to a numbed state of mind from which accumulated during the twentieth century. of the “survivor syndrome”—nightmares, has been displaced by “what was once many soldiers only emerged years later; They knew better. flashbacks, depression, anxiety, and 172 173 war and medicine WHY THE PSYCHIATRY OF WAR IS TOO IMPORTANT TO BE LEFT TO PSYCHIATRISTS

so on—which had a profound effect on St Louis, Missouri. These doctors psychiatric condition which only them. Thus, the Holocaust experience wanted to replace what they saw as the Patient suffering from in 1980 had been fully discovered created a new professional model: current chaos in psychiatry with a more war neuroses. From and named. the psychiatrist as patients’ advocate, consistent, uniform kind of medicine Arthur Frederick Hurst, helping a group of wronged victims to based on generally agreed, scientifically Medical Diseases of the ecause Post-Traumatic Stress win reparation. This popularised the idea replicable, systems of classification—a War, 1918. BDisorder, as set out in the new bible of a general, loosely defined ‘syndrome’ nosology based primarily on symptoms. Photograph by Edward of psychiatry the DSM-III, created a among a group of patients, made the (This tidier world was of course more Arnold. Wellcome standardised model of how victims idea of delayed emotional after-effects convenient for the drug companies and Library, London. respond to trauma—a “single common of trauma respectable, and put guilt, the medical insurers.) Far from being syndrome that appears to be the final, especially survivor guilt, on the agenda. deflected by this paradigm shift, a group common pathway in response to severe Most important of all, it shifted the of psychiatrists working with Vietnam stress”—it made it possible for doctors balance between trauma and victim; War veterans brilliantly exploited the working with Vietnam veterans to unite thereafter the emphasis was more on opportunity it provided—to establish with those treating other forms of trauma victimhood and less on endurance. in the new Diagnostic and Statistical and stress—rape, child-abuse, road Manual (DSM-III) the classification of accidents, torture—to create a ‘trauma t is worth emphasising, however, that Post-Traumatic Stress Disorder, intended movement’, which soon acquired an Ithis is the only aspect of European to cover the problems of the veterans ideology. It aimed to bring into the experience in the twentieth century that and to help them secure assistance from open society’s “collective secret” and American psychiatry has ever really government and insurance companies. but by medicine, the media and the law- to reverse decades of wilful ignorance taken on board. They did it by a shrewd combination of all over the world. As Derek Summerfield of traumatic acts and denial of post- lobbying, solid argument and emotional has written: traumatic suffering. ietnam; the Holocaust: as if blackmail. And so, in 1980, PTSD Vthat wasn’t enough, American was born. The mental health field rapidly ut the trauma movement was not just psychiatry at this time also underwent accorded PTSD the status of scientific Babout theory; it was going to transform a dramatic paradigm shift—away he authority conferred by the truth, supposedly representing a practice. Greater “consciousness of from the psychoanalytic approach TAmerican Psychiatric Association’s universal and essentially context- trauma”, it was believed, would make dominant since the Second World War imprimatur played an important part in independent entity. This was to possible a greater ability to treat it. And towards a more biological, ‘scientific’, the astonishingly rapid acceptance of say that from the beginning of here, nearly all the traditional wisdoms ‘objective’, neo-Kraepelinian model, Post-Traumatic Stress Disorder, not just history people exposed to shocking were stood on their heads, the old promoted especially by a group in within the American medical community experiences had been liable to a culture ignored. 174 175 war and medicine WHY THE PSYCHIATRY OF WAR IS TOO IMPORTANT TO BE LEFT TO PSYCHIATRISTS

Now they said: checklist of its symptoms for everyone medical understanding, bringing with it it is glued together by the practices, to read. Symptoms mattered. new treatment techniques. technologies, and narratives with 1 You must not leave the traumatic which it is diagnosed, studied, treated, victim alone. Armed with the new 1 Finally, thanks to America’s guilt he ideology of PTSD did not simply and represented and by the various insights into trauma, you must give him at sending thousands of young men Tconquer Western Europe. It was interests, institutions, and moral active preventive treatment—debrief into a dirty, un-winnable war, millions exported to the Soviet Union and to arguments that mobilized these efforts him. (‘Debriefing’ techniques, developed of dollars were spent on research to the Developing World. By the 1990s, and resources. in the 1980s, required trauma survivors establish the biological causes of western ‘experts’ working for international to be formally gathered together to trauma, which suddenly became the agencies were using ‘trauma programmes’ oung’s book, The Harmony of talk through their experiences in biggest growth area in psychiatry. that assumed that there was a “universal YIllusions, had a wide impact. It the presence of a trained counsellor. trauma response” that could be measured reminded psychiatrists of something they By working through the traumatic hy was PTSD so rapidly accepted by giving victims a checklist of symptoms seemed temporarily to have forgotten— emotions, they would be able to resume Wall round the world? In Britain, developed by American PTSD doctors. that they were social beings, working their lives without having trapped circumstances played an important UNICEF workers surveyed 3,000 Rwandan within a social context. It also coincided traumatic memories. Large numbers of part. What had been for two decades children using the ‘Impact of Events with growing evidence that the clinical people with no direction in life began a medical backwater was suddenly Scale’ and the ‘Grief Reaction Inventory’, practices developed by the ‘trauma retraining as ‘trauma counsellors’.) transformed in the 1980s by the concluding that they had high levels of movement’ were not working. Falklands war and the extraordinary PTSD requiring immediate treatment. 1 It was not previous personality spate of man-made disasters—train he PTSD doctors were like spoilt that mattered; it was the magnitude wrecks, aeroplane crashes, oil-rig s it turned out, however, the Tteenagers discovering sex for the first of the stressor. fires—that killed over a thousand people Aearly 1990s constituted the high- time: they thought no one had ever done it in less than four years, all of these water mark of the trauma movement. before. Most had little clinical experience 1 Intelligence was not an important horrors reported in detail on television. Soon afterwards, theoretical and of their own and few made much attempt factor. (The issue of intelligence had By the end of that period, most of the practical problems began to appear. to understand the overall clinical record become politically incorrect and main London psychiatric hospitals had On the theoretical side, the American of the past. However, by the late 1990s, unmentionable because the American established ‘trauma clinics’. The role anthropologist Allan Young was the these doctors had acquired some clinical Army had not given intelligence tests of the media was also important. Long first person to put PTSD into its proper experience of their own. They found: to troops sent to Vietnam.) reliant on getting new medical stories historical perspective. He concluded that: from America, it took the rhetoric of the 1 That debriefing didn’t work. It 1 And not only did you give the trauma movement at face value: PTSD The disorder is not timeless, nor does was better to “respect the patient’s condition a name, you published a was presented as a great breakthrough in it possess an intrinsic unity. Rather coping strategy”. 176 177 war and medicine WHY THE PSYCHIATRY OF WAR IS TOO IMPORTANT TO BE LEFT TO PSYCHIATRISTS

1 That a patient’s previous diagnostic systems will be taken up by the and popular journalism. The experience face of this onslaught. Firstly, it is now personality, not the magnitude of the broader society; and that to publish a list of trauma has become intertwined with accepted that there is a cultural element traumatic stressor to which he was of symptoms and then offer compensation the values of the entertainment industry, in the response to trauma and some of exposed, determined outcome. to those who suffer from them is and what used to be seen as the normal the universalising fervour of the 1990s, tantamount to an invitation to malingerers, experiences of life are now seen as when symptoms checklists developed 2 That trauma did not necessarily fantasists and highly suggestible people quasi-medical traumas. in San Francisco were confidently cause neurosis. to develop those symptoms. exported to, say, Rwanda, has subsided. ver the last decade, the intellectual Secondly, since 2000 there has been a 1 That intelligence is important. o, did the psychiatrists offer a Oinitiative has passed from the new emphasis on ‘resilience’. In 2006, Scollective apology? Rewrite their proponents to the critics of PTSD. the American Psychiatric Association 1 That “giving it a medical name” textbooks? Of course they didn’t—in Many of its fundamental assumptions announced that “a traumatic event alone might undermine the individual’s this litigious age. Anyway, by then it have come under sustained attack, is not a sufficient cause of PTSD and ability to take responsibility for himself. was too late; the damage was done, the not just from psychiatrists, but from PTSD is not the most frequent response genie out of the bottle. While the PTSD anthropologists, historians and to traumatic events”, without, of course, 1 That America’s Vietnam veterans doctors had been completing their philosophers, even as the definition of accepting responsibility for previously had not benefited from the “invention education, trauma had been vectored PTSD in the DSM has undergone three asserting otherwise. of PTSD”. Far from curing the into the society by the media and seized revisions, losing in the process even problems of Vietnam veterans, the on by the law. Counsellors were busily more of its coherence. For example, the ut, for all that, the concept of PTSD provision of outpatient clinics had spooning half-digested PTSD down ‘traumatic stressor’ causing the damage Bremains unassailable. Much of the increased the number of those with their clients’ throats. Latterly, smarter was defined in 1980 as being “outside response to criticism comes in the form PTSD. American society had offered journalists and lawyers have realised the range of usual human experience”, not of reasoned intellectual debate, but its ex-servicemen the role of the that PTSD is just a phrase that brings no but by 1994 it had widened to include of personal abuse and moral blackmail. ‘dysfunctional veteran’ and thousands magic bullet; but in the popular culture almost any traumatic experience. One Why is this? Partly, it is chauvinism: an were happy to take it.9 that idea is still propagated. ‘Trauma’ study found that, as a result of this American belief that no one understood has become one of the staples of daytime category creep, 90 per cent of adults in this problem before 1980. But, more n other words, this medical generation television and magazines, the cheapest the Detroit area had been exposed to at importantly, the current of political Ihad spent 20 years learning what most form of drama. The emotions provoked least one traumatic event, yet only 9.2 advocacy that lay behind the creation European doctors knew in 1950—that by fear and stress have long since ceased per cent had developed PTSD.10 of PTSD in the first place has been many patients are suggestible; that it is to be private and shameful; now they reignited by the Iraq War. Opponents often better not to medicalise problems; are commodities to be traded in the ainstream American psychiatry and supporters of President Bush are that doctors need to be wary of how their marketplace of deregulated television Mhas given some ground in the once again using the issue of military 178 179 war and medicine WHY THE PSYCHIATRY OF WAR IS TOO IMPORTANT TO BE LEFT TO PSYCHIATRISTS

Opposite Vietnam Veterans Memorial, Wahington, DC. Photograph Todd Gipstein collection: National Geographic

media, lawyers, veterans’ groups and the the time of writing, veterans’ groups and Above Vietnam general public, for all of whom it serves sympathetic clinicians are fighting to get Veterans Memorial, a useful purpose. PTSD, we are told, is proper psychiatric treatment for Iraq War Washington, DC. the one psychiatric diagnosis patients veterans, but their care is being held up Mediaimages/Photodisc, like, because it takes away personal by the number of Vietnam-era patients courtesy Getty Images. responsibility for one’s psychological choking the system. Meanwhile, a review state and shifts it to an external ‘event’. of treatments for PTSD carried out for The media reporting of the Iraq War has the National Academy of Sciences by routinely reiterated the long-questioned a panel of nine eminent psychiatrists (and inherently absurd) finding of a has concluded that the evidence does 1988 survey that one in three Vietnam not make it possible to say whether or veterans have PTSD—inherently absurd not any of the treatments for PTSD are psychological casualties as a political econdly, the dominant model of how because many fewer than one in three effective.14 So what will all the billions weapon. It has become unthinkable that Strauma works, which in the 1970s soldiers served in the front line there.13 of dollars be spent on? psychiatrists who have three decades of was neo-Freudian, has long since emotional and bureaucratic investment been decked out in the clothing of ll in all, it is not just America’s in PTSD should abandon the diagnosis modern neuroscience; this enables the Aforeign policy chickens that are now; to do so would be to lose faith proponents of PTSD to offer bold (and now coming home to roost. We are also with the Vietnam veterans whom they so far unprovable) hypotheses in the seeing the consequences of allowing have championed for so long and to language of modern neuro-babble.12 psychiatry (and the professional undermine the bureaucratic raison interests of psychiatrists) to dictate d’etre of the institutions that pay hirdly, PTSD is now embedded in the social policy. The contradictions that their salaries.11 Tculture. It has been taken up by the this can produce are now apparent. At 180 181 WARwar ANDand MEDICINEmedicine ANONYMOUS

anonymous LIVING WITH PERSONAL DRAGONS IN YOUR DAILY LIFE

This veteran of the Vietnam War wishes to remain anonymous

At the present time, I have a Veteran’s Through therapy I am learning and I do not allow people to get close that I have had many good ideas but have Administration Service Connected to recognise many of my PTSD problems to me. This way I do not expose myself never followed through with them to disability rating of a hundred per (Dragons) that I was not aware of before to inquiry about the war or the part completion. The fear of success can be cent based on PTSD. The primary trauma starting. These symptoms... have been that I played in it. overwhelming .... accrued within a 48-hour period while so much a part of my life that I did For the last 30 years I have not During several times of great on active duty in Vietnam. During this not recognise them as being out of the lived a normal happy life. stress or anger, I have lived in time I, along with my unit, was bombed ordinary. Since November 1996, I have I have repeatedly moved around the isolation away from everyone, preferring by our own B-52s. Ended up walking next emotionally continued on a downward country looking for the ‘right’ place to live in the mountains. I am much more to an unexploded 750-pound bomb. Then spiral fighting this ingrained PTSD. to live, never being happy in any one comfortable living in small towns and walking into an ambush that took most of I will emphasise my deficiencies place for longer than two years. I’ve even more so in a rural setting like a the lives within my unit and watching in the areas of work, family relations, been married three times. I’ve had 20 farm or ranch with no neighbors close by while rescue helicopters were being and lack of anger management, plus plus live-in girlfriends plus hundreds to my family or me. shot down trying to remove me and other other areas. I am unable to accept of short-term/one-night relationships. Anger is the main controlling wounded from the battle zone where I had authority in the workplace, which is It seems that anytime a woman tries to force in my life and I use it as a tool received combat wounds .... very stressful to me and I get feelings be close to me emotionally I push them to protect myself from harm, which has Since leaving the Army, I have that it’s necessary for me to change away and I look for someone else. I accrued or may accrue in my life since found life difficult and trying. Many jobs because of the lack of satisfaction try to find contentment, satisfaction Vietnam. This perceived danger can times over the last 30 years and even where/when I have worked. and happiness with women but all it happen even in my life today and has more often in recent times, I have Even though I’ve had many personal turns into is sexual gratification and been reflected in daily events as simple felt that ending my life would be relationships, lasting several months, escapism... as yelling at people for blocking an best solution for me. After losing my I still feel that I am isolated from I am always looking for a better aisle at a store while I’m trying to teaching job at a college I returned to people and the communities that I have life, the right woman to be my wife, a pass by. the travel industry where I have been lived in. I feel that every time that better job, or place to live. I have, I must admit that I do spend time employed for most of my adult life. But someone has tried to be a friend, I push for many years, believed that I won’t confused as to the date, place or time only after a short time (three months) them away so that they don’t learn of my live past the age of 62. It’s my belief that I’m in. Finding it necessary to rely I lost this job because of an angry past or for fear of losing them later that I will not retire like normal on others for appointments, I’m usually outburst on my part. I have looked as it happened so many times during my people do .... at least a day or two off but it’s not back on my life and feel that I have tours of duty in Vietnam .... Within this 30-year time frame I uncommon for me to be at least a year accomplished little in my life, my For most of my life I have lived have had and lost many jobs, quitting off when trying to remember events in my depression has taken its toll, and I’m within a closed world. I have only one most of them, and I have never been life. While teaching, it was necessary very tired because of this depression. true friend, who is also a Vietnam vet, successful in the business world. I feel for my secretary to keep track of events 182 183 WARwar ANDand MEDICINEmedicine ANONYMOUS

I needed to go to since I would forget from service there. When PTSD became I had many, many leaches on me. I spent where I was supposed to be.... a recognised disorder... I personally almost an hour looking for leeches then I have been in combat situations feel that not enough effort was made to burning them off of me with cigarettes. over six times. Since going into the evaluate Vietnam Veterans for PTSD. First, flashbacks: I experience Denver PTSD program even more events I do have a BA degree in them. They can occur for no reason and their related flashbacks have been geography. The major difficulty is that and without warning, coming from added to my memory as each recollections it is very non-specific in subject out of nowhere, or during times of happen. Each flashback event presents content and has not provided me with stress. Secondly, sounds: Sometimes me with their own images and many are useful tools for outside employment with a backfire, helicopter fly-bys, now on a daily basis. Most flashbacks after graduation. But now I feel so hail bouncing on a roof, close hitting are vivid when they occur. With people discouraged and depressed in life I will lightning or distant thunder will dying, trees blowing apart and my fears not go any further in my education. This produce a flashback. I return to Vietnam and terror. Some are seen as incomplete is based on my lack of concentration, and my experiences come back to me. events and I’m not seeing all that had retention of material, memory problems, Thirdly, smells have an effect on me: happened nor with other people in them. plus personal concern in my ability to There are several smells that can cause Other visions are only images viewed study and learn. an event but the most forceful smells through a small window of the fight. Many During my time in Vietnam I got are: diesel fumes from truck exhaust or nights I find it hard to go to sleep, into the habit of going to sleep on my the smell of vomit .... stay asleep or I wake up with cold sweat left side. The reasoning for this is to I wish to list here my aversion of nightmares that I do not remember. get my heart as close to the ground as being in any crowd or people in general. I have to live with anger and possible. We had the feeling that during I do not like, nor enjoy crowds of irritability on a daily basis. I am an attack the first rounds from the VC people. This includes movie theaters, now dealing with frustrations over my would be high so I wanted to protect cafeterias with long lines, long lines ‘missed’ life, a life that I’ve craved myself as best I could. That is one of any kind, sporting events, or malls. for and will never have now because of habit that has carried over to today and A simple example of this is that I did my age. I am bitter with the government I still make every effort to go to sleep not go to any of my school graduations and the Veterans Administration for the on my left side .... while in college. It seems that I’m lack of insight into PTSD and the effects One of the most vivid dreams and always on guard! that it has had on my life as well as recurring dreams deals with my exposure others that experienced Vietnam and to leeches after being hit and lying in the reactions of people upon my return a rice paddy for a night. When I woke up 184 185 WARwar ANDand MEDICINEmedicine CHERYL LYNN RUFF

at one another and said, “This surgery the rhythm with which I was squeezing CHERYL LYNN RUFF is over. We can’t help this man the bag. Eventually and very gradually, anymore.’ I stopped squeezing the bag. My patient Ruff’s War: NAVY NURSE ON THE FRONTLINE IN IRAQ I looked at Commander Fontana and said, was dead. I could only pray that his “It’s over? What am I supposed to do?” death was a peaceful one. “You’ve got to let him die, Cheryl”, he I then asked the OR nurse to get said, and began backing away from the Commander Fontana to come back into the table. OR and officially pronounce the death of The only thing that was keeping this man. When she returned, she said, this man alive was my effort to “Cheryl, the doctors can’t come back ventilate him continuously by squeezing in right now. It’s your call”. This the anesthesia reservoir bag. I was task was way beyond the normal scope of breathing for him, and his life was duties and responsibilities for a nurse Cheryl Ruff had spent 25 years in the US Navy, literally in my hands. anesthetist, but we were not functioning providing patient care in naval hospitals around The surgeons stopped the in normal times. I pronounced his death, the world, before she was sent to the frontlines procedure, moved away from the table, and as I completed my anesthesia record of the 2003 war in Iraq as the only female nurse/ and removed their gowns. Still, I could I wondered who, if anyone, would ever anaesthetist in the Bravo Surgical Company. not stop squeezing the bag. This was read it. I was emotionally exhausted and They followed directly behind the First Marine not something one learns in anesthesia physically spent. Expeditionary Force as it entered Iraq at the school, and I was not prepared for such When Iraqi civilians or EPWs died a gut-wrenching, decisive, and final act. or arrived at the camp dead on arrival, onset of Operation Iraqi Freedom. The OR nurses began cleaning up, and we would take whatever identification we all the surgeons had left, but I still could find on them and send it to the continued squeezing the bag. I could Iraqi government. Their remains were APRIL—JULY 2003 and anesthetising agent/vapors to the not stop myself despite the continuous taken to a trench on the far side of patient. In essence, I was breathing for decline of this man’s oxygen saturation the road that bordered the camp. They As soon as the choppers began to arrive, the patient .... levels. I realised that he was dying, were then placed there with deep respect I was ready to administer anesthesia in One of my patients was an Iraqi that his brain was being deprived of in accordance with their religious OR (Operating Room) number two. Both man who had been shot in his abdomen. oxygen, and that nothing more could customs. The precise location of their Lieutenant Commander Sheppard, my battle His colon had been ruptured, and his be done to save his life. Still, I remains was recorded using the global buddy and fellow nurse anesthetist, and abdominal cavity was filled with human continued to squeeze the bag. positioning system, and that location I had been assigned as the anesthesia waste. For some reason I could not A few of my colleagues entered was reported to the Iraqi government. providers for this OR designated to maintain adequate oxygen saturation the OR and said, “Cheryl, the surgeons Following the demise of my patient, I care primarily for those with chest, for him despite my constant manual aren’t coming back. We’re done; it’s could do nothing more than watch as the abdominal, and head injuries. OR number ventilation. A chest tube had been over”. Still, I continued to squeeze the corpsmen gently and respectfully removed one would care for those who had inserted and connected to suction, bag. I needed time to convince myself this man from the OR and took him to his sustained orthopedic injuries. We knew and there was no evidence that the that I had no choice but to stop this final resting place, the trench on the most of the wounded would have multiple patient was bleeding from a thoracic man’s life. I was fully in charge of him other side of the road. injuries, but if the primary wound had injury. Still, I knew something was not at that moment, and my action was the Despite the heart-wrenching been sustained to the chest, abdomen, right. The patient’s oxygen saturation only thing sustaining his life. experience I had just endured, my work or head with secondary wounds sustained level, which should have been 95 to 100 As I sat there, I experienced was far from complete. More casualties to the limbs, the patients would have percent, had fallen to 89 percent .... a memory flash from a time when I was arrived, and we soon realised that this surgery performed in OR number two. If A decision to stop the abdominal stationed on board the USNS Mercy. We war was not one in which only the fighting the primary wound was orthopedic, the procedure and open the thoracic area had talked about what we would do if troops were being killed and injured. A individual would have surgery performed was made. It was a drastic decision, the ship was hit by enemy fire and we had nine year-old boy arrived with half of in OR number one .... but a necessary one. Once the chest no way of taking our patients to safety his face blown off. Where he once sported I performed my first anesthesia was opened, we saw a tennis ball-sized before the ship sank. We did not want a nose was now nothing more than shredded procedure using field medical anesthesia hole on the upper portion of his right them to experience the abhorrent death by tissue. His right eye was gone, as was equipment that consisted of a vaporizer lung, and he was oozing blood. I was drowning, so we developed a plan where we most of the right side of his face. He with tubing that extended from the ventilating him, but the oxygen was not would dose the patients with morphine to was in excruciating pain, had only half a vaporizer to a mask placed over the entering his bloodstream; instead, it provide them with a peaceful death before mouth, yet he cried, screamed, and called patient’s nose and mouth. Midway was being blown out through this large, they went down with the ship. out for his mother. Even though he spoke along the length of this tubing was a gaping hole in his lung .... That memory gave me the strength I a different language from our own, the reservoir bag that I would manually Once the surgeons saw this needed. I administered ten milligrams of cry for “Mom” was universal. We knew what squeeze in order to provide oxygen devastating, fatal wound, they looked morphine to my patient and began to slow he wanted and what he needed, and we did 186 187 WARwar ANDand MEDICINEmedicine CHERYL LYNN RUFF

everything we could to comfort him. of how the injuries occurred were horrific. viewed this person whom I was breathing diminish tensions between our troops I saw this young boy in the We provided care to our wounded marines, for as a fellow health care ‘civilian’ and the EPWs for whom we provided care. triage area, where he was being EPWs, and noncombatant civilians, never provider. He had lied, and we realised At no time, whether they were in a evaluated by anesthesia because of turning anyone away and providing the that we could not be as trusting of chopper, the OR or the postoperative his seriously impaired airway. We same standard of care for all.... those coming to us for care as we wanted ward, were the Americans and EPWs housed had little pediatric equipment On our One day a middle-aged Iraqi man to be and that we needed to keep our together. To prevent cross contamination Authorised Minimum Medical Allowance was brought into OR number two after guard up. of potential infectious diseases List (AMMAL) because children are not having sustained a significant injury Initially I thought, “How dare inherent in the various cultures, we considered to be frequent victims of war. to his arm from a blast. We were told this man lie to us?” and it made me separated the anesthesia equipment we Fortunately, a small endotracheal tube that he, along with two other foreign angry. Still, I knew I could not allow used and designated the items either was located, and Captain James Chimiak, nationals, had attempted to run through my feelings to overtake my duty and ‘EPW’ or ‘American.’ We never used the an anesthesiologist, expertly inserted a marine barricade. The other two men responsibility to render the best care same anesthesia equipment on EPWs that it with his skilled hands. The vision of riding in the vehicle with him had been I was capable of providing. I put my we used on our American troops.... that helpless, innocent, mangled child killed instantly. As we prepared this emotions aside and continued to provide Bravo Company continued to care still haunts me and will remain with me man for surgery, he told me he was him with the same professional standard for a total of 667 patients, 63 of whom forever in my dreams and in my nightmares a civilian pharmacist. I was amazed of care afforded to all who were brought required more than one hundred intricate .... at how well he could both speak and into OR number two. The general survived and convoluted surgical procedures. The By early morning on the second day comprehend the English language. He was the surgery, and because of the change injuries were traumatic, bloody, and after our arrival at Camp Chesty, both well educated, and he discussed with me in his status from foreign national to debilitating, but no member of the US OR number one and OR number two were the actions, indications, and compound EPW (Enemy Prisoner of War), he was armed forces brought into the ORs for set up and ready to receive patients. structure of various medications I transferred to the recovery ward and, surgery died. They all survived and were Once again, both ORs were austere. Each was administering to him. I did not like the other EPWs, shackled to his cot transferred to an EMF. featured a dirt floor, two OR tables question his story or his alleged status and watched by a marine armed with an We had worked long and hard placed head-to-head, and poor lighting. as an Iraqi civilian pharmacist, for M-16 rifle. and were pleased with our success rate. Neither room had air-conditioning for he seemed well versed when it came to Our feelings of resentment We were also proud that we had the several days. With the temperature often pharmaceuticals. Still, I found it toward the EPWs for whom we provided opportunity to be working in the service reaching 110 degrees during the day, we curious that someone who seemed to care grew as we witnessed the horrible, of our country and especially proud that would open the tent flaps when we were not understand English to the degree he did devastating wounds and injuries we were able to save the lives of so performing surgery just to let in some would choose not to heed the marines’ sustained by our young American fighting many of our brave American fighting men. air and diminish the stifling heat of the command to stop when approaching the troops. As health care providers and interior. Unfortunately, when we opened barricade. human beings, we fought to curtail the flaps, we could not prevent flies, After I had administered these feelings of resentment and hate. bees, and mites from entering. Although anesthesia to him and while the surgery Despite this tumultuous emotional we tried to keep the OR environment as was taking place, other members of our battle that raged deep within us, the clean as possible, flies were everywhere, company inventoried his clothing and care we provided to the patients who buzzing over surgical fields and open personal effects. When they found his were brought to us would continue to be wounds. All our patients received hefty identification, they were shocked, as equitable for all. doses of antibiotics .... was I. He was a three-star general in We did make a few logistical The wounds we saw and the stories the Iraqi Republican Guard. I no longer modifications in care provision to Originally published in “Ruff’s War”, Naval Institute Press.

188 189 WARwar ANDand MEDICINEmedicine ROBERT ACOSTA

robert acosta army specialist: iraq war service

At the age of 20, Robert Acosta, from Santa Ana, California, served as an Army Specialist in the US Iraq War Service, from April to July 2003.

APRIL—JULY 2003 here and there. It wasn’t like neighborhood of Abu Ghraib .... As we three or four cars out of the way, a shootout type of thing. drove, we both kind of noticed there and he is running people over. We get I joined the army for a few reasons. I I didn’t care about Iraq. I was was no military presence. We were the on the airport road, and there are more wasn’t doing well in high school, so I in the army. We were just focused on only humvee in this neighborhood, and and more people there. Someone on the dropped out. I was working little jobs, doing what we had to do and then going I was like, “Fuck this. Let’s make divider tries to flag us down, and my whatever, using drugs and stuff. I was home. When we were in Kuwait, soldiers a U-turn and go back”. People were friend made a sharp left and took him going nowhere fast and just wanted to were passing out left and right because starting to come out of their houses out, and that guy was literally right get out. There were no opportunities, there wasn’t enough water. We had to go and staring at us. We tried to get back in front me on the car all messed up. and I didn’t want to go to school. to other units and steal their water. onto the airport road, but then the There were so many people, and I didn’t even want to finish high Once we got to Iraq, it was even worse; car in front of us stopped, and then they were all after us. It was fucking school. It was boring. You could tell the water wasn’t coming in.... It was there were people standing on each crazy. We were in traffic just knocking the teacher didn’t care, and I got really unorganised. I didn’t get my body side of the vehicle. All of a sudden people off the road. My friend is yelling discouraged. A good friend of mine had armor until a week before I got injured. through my window, which was open, I at me, “You’ll be all right”. At that just come back from boot camp, and he We had old flak vests. They then gave us see it—a grenade was thrown into our point, I was, like, fucked. I said, was talking about it. I wasn’t doing new ones, but they didn’t have plates. vehicle, between the driver’s seat and “Tell my family I’m sorry”. I was in anything, and so that’s why I joined. We made our own armor with cans. We’d me. I grabbed it. I knew what it was. I no pain. He is yelling at me to stay I signed up when I was 17, in flatten them out. You get mad, but there grabbed it with my right hand and threw awake, but I was so up, I remember every October of 2000, but I had to wait is nothing you can do about it. You it out, but I fucking dropped it back detail. because I had to get my GED. I finally can’t bitch to your chain of command in the humvee. I reached down again and I started getting dizzy, and I got that, then had to wait some more. because they would tell you just deal grabbed it, and it popped. I almost got thought, “this is it. I am dying in this I left for boot camp in August 2001, with it, so you just dealt with it. it out. My hand was gone automatically. shithole”. We finally got out of there a month before 9/11. I was 18. After The day I got injured was my My leg was all fucked up. I was still and hauled ass on the airport road. The 9/11, I was like, “Shit, we’re going to day off. I was hanging out .... We conscious. My friend didn’t get hurt at vehicle died at the gate of an airforce war”. We flew into Kuwait City in April decided to go out and pick up some all. We started shooting. I tried to fire base. My friend gets out and says, 2003. Things had seemed to be dying stuff for my soldiers... We were going a round. It was the first time I’d fired “Don’t worry. You’ll be fine.” He runs down; they were saying it was the end of to buy sodas and ice, which is like a gun in Iraq. So there is this car in over to that gate and tells them I’m the war. I was an ammunition specialist gold out there. front of us; people are yelling. It’s hurt. He comes back, picks me up because and was finally doing the job I was So we go and drive out, past the fucking chaos, dude. I’m like, “Let’s my legs are broken, and throws me on trained for. I was stationed at Baghdad airport, and on to the airport road, get the fuck out of here”. I put my hand his back. He then carries me to the Airport and the area surrounding it. which was called ‘IED (improvised out the window because I don’t want to gate and tells the guys to take me to We mostly had indirect fire, a rocket explosive device) alley’, and the see it. My friend hits it, pushes about the hospital. 190 191 WARwar ANDand MEDICINEmedicine ROBERT ACOSTA

The whole time I was cursing out didn’t want to take them. I’d get really an outcast. I didn’t feel I fit into seeing things on the road. My other the airforce guys who took me to the frustrated. I really wanted to kill society, and I get depressed because of hand hurts because I overuse it. I was hospital. One guy was trying to hold my myself. I just didn’t know how. It was a it. At school, everyone was staring at wigging out. Not getting my benefits cost hand. I wanted water, and they wouldn’t hard time. I was really unhappy. I would me, and people were always asking about me $500 just on bounced checks. Then give it to me. I wanted a cigarette. cry. I couldn’t sleep at night. I still my hand. Sometimes, it’s too much: I the Washington Post called me, and I Those guys got a Bronze Star for driving can’t sleep for shit. I feel really went this semester. I went to all my told them everything. The article comes me two minutes to the airport. My friend antsy all the time. It’s weird—at night, classes for one day, had a fight with out, and the next day, the chief of got nailed. They said that it was his I’m paranoid. I sleep with a gun by me. my girlfriend, and then dropped out. I staff of the VA called me. I told her I fault we went out there. He got 45 days It’s with me wherever I go. It’s not stress out too easily. couldn’t even live. Then the next day I extra duty without pay. They said it normal. It just sucks. It’s hard, dude. I don’t wear the electric got a check. Two weeks later, I get this was our fault. The E-7 who gave us the I feel I got caught sleeping one time, prosthetic. It’s heavy, it makes you check in the mail and a letter that says vehicle said we just took it, which was and it ain’t going to happen again. sweat, and then it slides off. It’s they’re bumping up my rating from 100 a lie. I was put in for a Bronze Star, The president came twice, and I really uncomfortable. I really liked percent to 120 per cent disabled. A few but it was rejected. My leg sucks; it’s left. I didn’t want to meet him. the hook. It was easier to use. I got so weeks later, they bumped it up to 200 messed up. They almost had to cut it off. I feel he and his whole mad one day at Walter Reed, I threw the percent because of the PTSD. There was a big hole in my leg, administration lies and puts our lives prosthetic against the wall. I hate that I go every Wednesday for therapy, like two inches. in jeopardy. He didn’t want to meet me. stupid thing. I wear the hook when I but I mostly go to be with the guys. It In Baghdad, they told me my hand’s I went home in January 2004. I had play pool, but it draws more attention. doesn’t help one bit, but afterward, gone, but the doctor said he was going the whole hero’s welcome ceremony at I’m more comfortable without it. we all hang out and smoke cigarettes to try and save my leg. I lost a lot of the courthouse, and that was cool and I had a fake hand, too. I wore outside. That’s all I do with the VA. blood. I was really mad. I was yelling everything. The spotlight was on me.... that a lot for a while. It was light. I had a job for a while when I got at everybody. My legs above my knee took My girlfriend... was very supportive. If If I wore a long-sleeved shirt, you back doing fiber optic cable splicing. a lot of shrapnel. Every time they moved it weren’t for her, I wouldn’t be here. couldn’t tell. Then a finger broke off of The guy I worked for even wanted to send me, my leg hurt so much. My hand never Still, sometimes, I’m like, “Why am I it, and I had it taped up with safety me to school. But he was a born-again hurt. here?”. She is always there to tell me pins, and it looked really ghetto. To Christian, and he was trying so hard to They sent me to Walter Reed otherwise. So I was really close to her get another, I’d have to deal with the convert me, and I couldn’t deal with Hospital. I was there for seven months. when I got home. I clung to her. VA (Veterans’ Association), and I can’t having a job and the responsibility. I hated it, but the nurses and doctors My girlfriend is in college, and deal with it. I liked being in the army until are amazing. I don’t even know how she went to study in Spain. I started The VA fucked me over. They sent Iraq. I was a really good soldier. I did many surgeries I had. It seemed like drinking and taking pills. I would drink me a letter telling me my claims were everything I was told. Every now and every week, I was having a couple of all day long, all night. Sometimes I denied for my leg and PTSD, my hearing, then, I go to the list and see who died. surgeries. My throat was real sore wouldn’t sleep, just drink and take and a lot of shit. They said nothing I’ll see people’s names that I know. because they had to put a tube down my pills. I needed to get away from that. was wrong with my leg. I flipped out. I It’s sad, man. throat each time. I had money saved up and met her in have a bar in my leg. I have a lot of I didn’t want to live anymore. I Spain. We went to nine countries, and ringing in my ears. Sometimes I can’t was done. I was 20 years old and all I stopped the pills. hear; sometimes it’s fine. They tried fucked up. I was really depressed; I I was going to school for a while, to say my leg would get better, but didn’t want to do anything. They told me but it was hard being home and doing it’s gotten worse. I don’t like crowds. Originally published in In Conflict, Iraq Veterans Speak on Duty, Loss, and I needed to be on antidepressants, but I normal everyday shit. I feel like such I almost crashed my car because I was the Fight to Stay Alive, by Yvonne Latty, Polipoint Press. 192 war and medicine Artist’s Diary J4MED, Op Herrick 7, 03.11.07–26.11.07

David CotteRrell

In November 2007, artist David Cotterrell travelled to Helmand Province, Afghanistan, as a guest of the Joint Forces Medical Group. For three weeks, he observed the work of military medical staff at the main field hospital at Camp Bastion. His documentation forms part of the research for a new body of work commissioned by the Wellcome Trust for the exhibition War and Medicine. The following passages and images are extracted from his personal diary and photographic records. 194 195 war and medicine artist’s diary

03/11/07 Leaving Brize Norton The ramp opens to reveal the orange light of Bastion. The sun is setting and vast amounts of dust have been thrown into the air by the landing. 05.25: Waiting in departure lounge of RAF Brize The diffused glow of the sun appears to ignite the Norton. After wake up call at 04.00, breakfast at 4.30, sky. In the distance I see a burning plume of smoke I have successfully checked in for my C17 transporter (apparently the 24-hour waste fires). flight to Kandahar. I am the only passenger. Dressed in combat trousers, desert 05/11/07 First Briefing boots, body armour and with a 20 kilogram bag as hand-luggage I am relieved to be ready and in the right place. My worries about failing to wake up are swiftly I should have left yesterday. If all had averted at seven am when the lights in the tent gone to plan, I would be waking up in Kandahar crackle to life. I am surrounded by activity. I decide (KAF) about now, instead of listening to News24 to embrace the challenge and swing out of bed and contemplating 11 hours in the hull of a giant to take a long-needed shower. The shower block supply plane. After a night without sleep, packing, ‘Ablutions’, like everything else, is semi-communal. rendering and emailing, I had managed to misjudge I feel conspicuously unfit and I try to pretend that time. In denial, as always about the impossibility of my ponytail is not noticeable. traversing London, I had arrived just an hour before 9.30 am, I have an invitation to attend departure. OK for easyjet but not acceptable for the ‘ops’ briefing at the MED GRP CP and after RAF airways. Turned away and Lt. Col. Copanni’s bombarding the adjutant with questions return with masterplan was casually disregarded.1 him to sit in on the daily senior briefing.3 Acronyms At 6:30, I am called to board the RAFC17. describe all units, events and places. I imagine A small woman appears, looking flustered, and the briefing is confidential, but even if it weren’t, suggests I follow her. After a negotiated pause to I would need a code book to decipher the language buy reading material I find myself going through of common usage. security/passport control. This consists of a pair of “Enhanced threat of VBIED reported by double doors leading on to the runway. I demolish RC FOB Delhi” = Enhanced threat of Vehicle- the back shelf of the waiting Renault Clio as I dump Bourne Improvised Explosive Device reported my camera bag and we drive across the airfield to by Regional Command, Forward Operating meet my transport. The crew are already aboard and Base, ‘Delhi’. preparations have obviously been continuing for a After the meeting finishes I meet Colonel while. I am led up the steps of the squat plane and McGroom. He is the Group Commanding Officer motioned toward one of the canvas jump seats fixed (CO) meaning that he is in charge of medical to the side of the fuselage. Earplugs are waiting for services for the whole of Helmand. A silver-haired, me and the baggage that I was fretting about earlier immaculately turned out soldier, he takes time is ratchet-strapped to the floor in front of me. out of controlling operations across the whole Half a million rounds of palletised province to brief me on the network of services and ammunition is cargo netted around me. operations that Camp Bastion is part of.

04/11/07 Arrival In Bastion TM = Team Medic; CMT = Combat Medical Technician; MERT = Medical Emergency Response Team; MERTE = Medical Emergency I find myself sitting amongst a squad of Royal Marine Response Team Enhanced; A&E = Theatre; ITU Commandos. They appear incredibly young. One = Intensive Treatment Unit; CCAST = Critical of them, who looks like a teenager, is wearing a Care Air Support Team/AEROMED; BZZ = Camp Commando knife in his chest webbing. It is hard to Bastion; KAF = Kandahar; Selly Oak Hospital— reconcile my recognition of this student-aged man Hedley Court Rehabilitation Centre. with the eight-inch blade fastened at the ready on his armour. After a strange propeller-powered 45 We are interrupted by an officer leaning over to minutes I wake to realise that we had all been lulled mention, “Sir we have a T2 coming in, ETA 18 into a fitful sleep by the drone of the engines. I minutes.” The colonel replies with a quick “Thank hastily—too late—put my helmet back on, before the you” and continues his briefing. LM has time to chastise me. The marines smile with The meeting ends with a brief handshake recognition at my amateurish lapse in protocol.2 before the Adjutant once more appears to escort me. 196 197 war and medicine ARTIST’S DIARY

An insurgent has been captured and MERT Half the doctors expect me to produce a have brought him for treatment. It seems that he was painting, a significant number would prefer that a suspected mortar commander and has been shot in I wasn’t in the way and a few like the idea of me the leg. We photograph the helicopter approaching documenting their skills for posterity. and find ourselves coated in dust as the Chinook By 11:00 am the helicopter has not returned, “wheels down” (WD). I begin to hear little bits of news. The casualty may The ambulance crew is waiting on the be in a minefield. It will take at least another hour Helicopter Landing Site (HLS) (The ambulance looks for the other soldiers and engineers to inch their like a second-world war vehicle from the film Ice cold way toward him. He has self-administered morphine in Alex) and within seconds they have transferred and is conscious. I find it impossible to imagine: the prisoner and are making the 300-yard journey two hours with a mine injury awake and unable to to A&E at 15 mph (the camp speed limit). move. At 1:00 pm the Chinook finally arrives. As it I make my way on foot to the A&E entrance. swings into the HLS the sand washes over the waiting A crowd of medics has formed. The colonel is already Land Rover ambulances, and medics run from both waiting in the background. The crowd is bigger than vehicles to meet and make the exchange. The soldier normal as it includes several Royal Military Police is wheeled across. I watch from a distance with a (RMP) officers waiting with side-arms to escort the telephoto lens. By the time I have walked past the suspected Taliban fighter. He is blindfolded when he QuarterMaster’s (QM’s) office to the entrance, the arrives and is searched carefully with metal detectors ambulances have arrived. As always, a crowd of some and before being allowed entrance. I stand back as of the NHS’s most highly paid and skilled consultants he is wheeled into A&E. A team of about ten people are waiting in DPM clothing.4 A group involved is waiting. Notes are taken in triplicate as X-rays are in ‘Resus’ and triage are already forward as the taken digitally and he is stripped and prepared for stretcher emerges. The others stand back, waiting for surgery. The wound is not life threatening and within indications of their respective tasks. ten minutes he is being wheeled, already sedated, He is taken to Resus. Awake, in pain and into theatre. The MASH-style theatre is an amazing bloody. The doctors adopt varying roles. One doctor venue. Under canvas like the rest of the hospital the stands with a nurse and an administrator at a lectern theatrical lighting of the operating spotlights adds taking notes of every observation. Others direct the to the incongruity of surgeons with blue gowns over X-ray team, manage the unwrapping of the field Disruptive Pattern Material (DPM) uniforms. We dressings, check the vital signs, look for internal stand well back beyond a striped line on the floor, bleeding and try to calm the soldier. He is young; I attempting to understand from a distance what is suspect, a commando and from the York’s regiment. happening in the bubble of intensity at the far end From overhearing the doctors, I find his name is of the dome tent. ‘Jono’ Lee. He is from Lancashire—Bolton. His right leg has been bandaged in three field dressings—each 06/11/07 First Operation one can absorb a litre of blood. His foot is unwrapped and clothes are cut away. It strikes me that all the kit fetish that follows the FOB postings is discarded. The At ten am a 9-liner starts to come through the boots, the webbing, holsters and DPM are cut into “Jchat” system: a T1 casualty (meaning evacuation pieces, and the blood-soaked pieces are deposited needed within an hour or less—life threatened). into a black plastic bag for incineration. People purposefully begin to manoeuvre themselves. The most obvious injury is to his foot. Bone The MERT consultants seem to look a little more and flesh hang from its centre. The heel protrudes like soldiers than doctors. They slope off to their about two inches below the base of his sole. The X-ray unit, the Command Post (CP) staff return to their explains. There are no fragments of shrapnel. The desks and the surgeons head out for their cigarettes. force of the blast has travelled through the armoured I rush to my tent to assemble a selection of vehicle into his foot and with devastating effect has lenses. I feel a little vulgar; my role is sinister, an forced the bones from the base of the foot upwards. ambulance chaser with a camera. I am here to consider The neat lattice of bone and tendon has been rotated ‘War and Medicine’—the role of healthcare in combat. and pushed away from his heel. The anaesthetist I have never been in the military and have never seen is beginning his work. The soldier keeps shouting an operation. I am a trauma tourist desperately trying “Sir!” as he deliriously looks around “Don’t take to justify my role—to others, but more difficultly—to my legs”, he appeals. “Have I got my legs?” He myself. The camera keeps me busy; it gives me a doesn’t believe the doctor who reassures him that function in the room, but it is not my purpose. the remains of both are still attached to him. 198 war and medicine 200 201 war and medicine ARTIST’S DIARY

I am wearing a heavy X-ray apron and find attacked; SIED in Lashkagar.6 The abstraction of in Kajaki and Sangin.9 Beautiful landscape and much blood and gore in my short time at the hospital. myself welling up. The activity seems further away Bastion is becoming a problem. poetic views end with a photo of a flight of steps. He is carried into a room at the back of one of and I find myself cold and sweating profusely. I I speak to Col McGroom after ‘Prayers’. “That’s where he died”, Ron says wistfully. “You the wards accompanied by the RMP’s, the Padre and struggle to stop myself fainting. I mustn’t faint. He says he is helpless to make anything happen knew him?”, I mutter. I hope Ron didn’t hear me. a few nurses, Col Goulbourne and me. I am the last His right leg has multiple fractures and and asks me to present a slide show the next morning.7 At least he never acknowledged my ignorant to pass through the plastic curtain. One of the RMPs the knee is crushed. His left leg is also broken. I walk past the ‘Watch-keeper’ and ask if statement. I realise soon after that the young man looks accusingly at me. He speaks to the Col. “Do He is still conscious as they wheel him to theatre. he can explain his role. He has been expecting me. was his brother-in-law—his sister’s husband. He you know this man?”, he says about me, as if I am out My dizziness eases to the extent that I manage to follow He sits me down and talks through the emergency died seven months ago in Afghanistan. of earshot. Col Goulbourne explains and I am brought Jono into Theatre 1. Theatre 1 is a tent, like the rest of ‘Jchat’ system. “Medic” calls out from the software at in by one of the nurses. The room is small and I stand the hospital, but it is illuminated with dramatic lighting intervals as if the real cries of pain are synthesised 09/11/07 T4 shrinking a metre from the soldier. JM Alderton and inside, a new team waits. The surgeons wear gowns across the region. He agrees to let me film him as he (Jake), Lance Corporal Royal Engineers. over their DPM and plastic covers over their desert electronically monitors and directs the evacuation of I can’t help but stare at Alderton. The boots. Two surgeons and a consultant anaesthetist a casualty. At 7:15, I wake up to see the pod nearly empty doctor checks for signs of life. Pulse, light in the work over Jono. He is put to sleep, and intense but We don’t have long to wait. The electronic with Col Goulbourne hurriedly leaving. I check my pupils. He uses my torch (and I am grateful to unhurried activity takes place to untangle the mess of chatter suddenly becomes more intense. Red lines watch. Something strange is happening. have a small purpose) and touches a cloth to the bone and skin. Pieces of bone come off the base of his of text scroll down the screen: two T2 casualties. I go to CP suspecting a problem. 2 T1s man’s cornea. He is formally pronounced dead. The feet in the surgeon’s hands. He cuts away the last bits I leave the cameras rolling and retreat to Simon’s and a T4. I assume a T4 is a light injury. I am RMP steps forward, with a camera, and begins to of muscle and skin symbolically attaching the bone office. An hour later the Watch-keeper’s patient wrong—T4 means dead. I don’t know what to purposefully and efficiently photograph the body fragments to the soldier and places them in a steel tray. work is rewarded: WD at Bastion—two Afghan do. My problems of appropriate behaviour are from several angles. The kindly look on his face The foot is emptied of dead tissue and takes on children and their dignified elderly-looking father insignificant compared to the enormity of the belies no acceptance of my presence and I still the form of a near empty bag of skin. The toes are still appear from the ambulances. events taking place. I find myself feeling clumsy sense his distaste at having a voyeur in the room. attached and have the appearance of some remaining I am struck by how beautiful they are. and self-conscious. I go to see the Regimental There are strange pauses—the RMP’s circulation. I pray that the surgeons will decide that The son has shrapnel to his face and is in pain. Sergeant-Major (RSM). He is a kind and darkly batteries die in his flash unit. And the nurses use the foot will survive. One of the doctors continues to The daughter has a wound to her leg and looks funny man. He is the right man to ask. He will the time to check that I am OK. I am embarrassed search for signs of a pulse in his toes. Despite their like aliens have abducted her. She is wide- coordinate the treatment and reception of the fallen by their concern but relieved. Although I feel appearance, the surgeon suspects that they are no eyed and confused. All three are covered in a soldier. He says he thinks I should be there and to wrong, they don’t seem to mind me being there. longer salvageable. One of the doctors suggests to me thick layer of desert dust. I leave them as they speak to Col Goulbourne. I eventually find myself The RMP finally finishes and the body that the best case for him will be to lose the lower part are stabilised in Resus, unable to face another standing next to the Colonel still not knowing his is prepared for identification. His face has been of his right leg. I listen quietly but am horrified. operation so soon. name. I explain that the RSM has asked me to compressed at the right side. Blood has dried Strips are cut in his calves on the four Instead, I head over to the ‘Super Kitchen’ speak to the Col. Not flinching at my peculiar turn around his eyes and nose. He is lifted off the clear chambers of his muscle cavity to stop the swelling from mess tent for ‘scoff’. I meet the force protection of phrase, he says in answer to my question: “Yes, bag with a ‘documents attached’ plastic label onto cutting off the blood supply. The macabre effect of his lads with their sergeant. I am invited over and get alright, but no photos please.” a neighbouring table. He is extremely heavy and flayed legs is heightened by the theatrical lighting. to speak with Lieutenant John Dolphin. We agree to Almost out of habit, I nearly protest but pull seven people assist in the move. His body is wet and By 3.30, the operation is nearly complete; meet up next day. I am quietly proud to be sitting myself together in time. With cameras and lenses still his face partially blue. It seems that once again he the wounds are left open and packed with gauze. No with soldiers without the aid of my medic hosts. hanging off me, I am embarrassed to find myself lined was on “top cover”. The NVGs worn work well, but amputation will happen here. They will allow Jono to Once again I find the surreal holiday-camp up with the padre and others to receive the body. make distance hard to judge. The Warrior had driven return to Britain as he is. The decision will be made in ‘Entertainments’ sergeant and am invited to try The two T1s arrive first. Thankfully they’re off a bridge and landed upside down in a river. Jake Selly Oak. Layers of plaster are applied to his legs and driving a collection of huge military vehicles. I serious but not life-threatening. A broken arm and Alderton had drowned in 12 inches of water.10 he is transferred to intensive care, ready for evacuation.5 select a ‘Warrior’ armoured-personnel carrier and head injuries. After they have entered the hospital A clean body bag is unpacked and he is Two more injured patients are waiting heavy ISO container-carrying army lorry.8 the last ambulance arrives. Wrapped in a clear again lifted from table to table. They struggle to get for theatre. Unsurprisingly, I find the Warrior quite plastic bag within an open dirty green body bag is his feet in the bag and it becomes obvious that he difficult to control with the driver blind (shutters) the soldier. There’s enormous dignity offered to the is too tall. Farcically, he is moved twice again to fit 07/11/07 Loss Of Momentum down. I direct through intercom, crushing cones and dead man. The ambulance crew, assisted by two other him into a larger bag. The sodden plastic remnants of over-steering. The low-loader is more successful. soldiers, gently lift the stretcher from the ambulance his original packaging are cleared away and we are After bouncing, crunching and stalling around the and place it on to the trestle base prepared at the rear asked to leave. A captain from Alderton’s company I feel dislocated and aimless. I am not certain if my camp, I successfully dock and pick up a trailer, entrance to Resus. With the sun beginning to bake, (rear-based force) has arrived and is led in by the anxiety comes from my ethical fears of delivering gaining something close to surprised praise from the the noise of the generators drifts away. Padre and RSM to make the official identification. a facile response or from thwarting of adolescent convoy driver. We bow our heads and the Padre—Padre After a few minutes he has been led away and we fantasies. I am not certain of my own intentions. Again I feel guilty for the playful interlude Barrett, a mild and friendly Methodist preacher— are invited back in. and return to the hospital. I somehow feel like says a short prayer. I feel shaky as I gaze at the With great care his stretcher is lifted onto 08/11/07 Watchkeeper I’m working when I’m smoking with surgeons or unkempt and skinny frame of the soldier. His clothes its trolley and wheeled out into the daylight. A drinking coffee with the ambulance drivers. are soaking wet and hang clumsily from him. He has short walk around the back of the hospital, with Ron shows me a slideshow on his laptop.9 developed a wispy full beard of inch-long red hair. concerned checks that there are no passers-by Next morning I resolve to miss breakfast. I arrive at I mishear and don’t really understand what I’m He has a blue tint to his pale and dirty skin. I suspect to witness the scene, leads to a line of neutral the briefing but am distracted. Inkerman is being looking at. It’s a series of photos of a young soldier he is from Inkerman. This place has delivered so refrigerated ISO containers. 202 203 war and medicine ARTIST’S DIARY 204 205 war and medicine ARTIST’S DIARY

Gleaming stainless-steel slabs are inside in the activity I hope the camera may offer me rollers. Four ambulance drivers struggle and strain some perspective. to slide Jake’s body into the steel bunk. The job is It rolls and I stand back. The beds in Resus complete. The RSM and QM close, lock and seal fill. X-rays, clothes cut away. Cleaning away the dirt the container and we walk back to the Hospital of battle and consultants comparing notes. MERT Management Cell (HMC) away from ‘Rose Cottage’. medics arrive, covered in dust and in full body On the way, I speak briefly with Padre armour, to brief the Resus staff. They appear as if Barrett. I am beginning to realise that I may never parachuted into A&E. lose the images viewed this morning. Periodically, the senior medics pause and convene to compare priorities. I am impressed by 09/11/07 Major Incident this restraint. A scene of violent injuries is dealt with in a strange professional way. Any one of the cases would be life-threatening. Here they seem to At about 4:00 pm the hospital fills. Clerks are be received as routine. rushing to don surgical gowns. Rumours are As I stare across the bewildered bearded spreading. Hell at Inkerman (commonly renamed men in the distance, the first priority becomes as ‘incoming’) 2 T1s, 2 T2s + 1 T3. A ‘major’ visible. As the clothes are cut away the bizarre incident is declared. eight more wounded may also and gory scene is unwrapped. There is a gap in be on their way. There are only two theatre teams. his legs. His thighs appear missing. I feel sick, Triage is going to be vital. Both MERT teams have as I mistakenly fear his groin may have also been been scrambled, all staff on standby have been destroyed. Bloody rags and gauze are piled around called in. A level of disorganised well-meaning his legs and in the distance I see figures frantically activity is visible in all locations. With ten minutes attending to his mangled body. I withdraw to meet to go before expected WD at Bastion, order is the surgeons grabbing one last cigarette before the impressively restored. At Resus all four bays are casualties become their charge. ready. Staff wait by each bed. The surge ward is I follow them in belatedly, feeling a prepared for a further four. The QMs and CMTs little exhausted from observing so much in one are waiting at A&E entrance, manning a line of day. Alone, I walk past Theatres 1 and 2. Col stretchers, and the RSM calls us all to attention to Goulbourne is coming out. “Horrible wounds”, he offer a severe but necessary briefing. says sympathetically. “Go in if you want.” I enter An update on status is given, nonessential through the curtains. The strangely damaged legs staff are hurried away. The order of events is given. are exposed beneath blue surgical paper, the theatre This is the first Major incident ‘Mass Casualty’ for light accentuating the red of his raw wounds. the hospital squadron. It is what they have trained “Blast injuries”, I am advised by a kindly for, but there is some uncertainty as to the point at theatre nurse. It feels wrong being here, but the which capacity will be reached. nurse seems to recognise my unease and says In Inkerman, the landing zone is still hot. quietly, “It is so wonderful what you are doing The Apaches have spent 20 minutes attacking fire here—you are always welcome”. points before the Chinooks can land. I feel humbled by the scene. Surgeons work Eventually we hear the sound of the on Fletcher’s leg and other wounds. The others do not helicopters and in less than a minute, ambulances appear to be serious, but the legs are a terrible mess. begin ferrying patients—one per vehicle. Paramedics The thighs appear to have been ripped away. It seems are already working on casualties before they enter impossible that anything can be salvaged, but the the A&E. surgeons continue working, painstakingly removing The Squadron Quartermaster Sergeant infection-causing shrapnel, clothing and dirt. (SQMS) and his staff search the soldiers for I am shown the X-rays on the screen; ammunition and weapons. All are stretchered. amazingly, the bones of the legs are intact. It seems Leg and chest wounds. I notice two men’s chests that this offers the surgeons some hope. They will displaying the flutter of Ascherman chest seals try to save his legs. rhythmically rising as air escapes their collapsed The surgery lasts over an hour and the lungs. One of the soldiers is wearing two CAT floor is red with blood. He has lost nearly all his own tourniquets and has had his boots tied together, and is having a total transfusion. It seems that the trapping an improvised splint. risk from this can be rejection. If a transfusion has I set up the camera on Hi-definition to happened before, he may have too many antibodies watch the unfolding drama. As I migrate around and fail to accept the new blood. 206 207 war and medicine ARTIST’S DIARY 208 209 war and medicine ARTIST’S DIARY

The surgery continues—the gaps in his legs jumps out. “I’ve been looking for you”, he says. “I dilemmas we were facing. Padre Connolly had an During take-off and the flight, I am struck are now clean and packed with gauze. They will believe you came to see me earlier when I was out.” interesting self-critical but confident approach to by the kindness displayed by the nurses in armour. remain open until he arrives in Britain. Fletcher is It is true that I had found myself wandering in to the his work. He had long-since rehearsed these issues; Even Fletcher is reassured and comforted in his to remain sedated. I feel overwrought and tearful. church a few hours earlier. At the time, I had still and it enabled him to honestly and openly voice fitful sleep. Operations on the other casualties continue. I believed I was on the way to Sangin and in a slightly his awareness of the inherent contradictions he We descend in darkness to Kandahar and as can’t see any more and I find myself sitting with maudlin moment had heard music and followed it faced. “The Taliban are bad people … I don’t like the ramp opens we feel the aircraft spinning around. the Resus nurses, having a cup of tea and a few inside. It is a cliché to seek redemption and faith war … I believe that fighting should end … What A majestic sight comes into view. The open ramp of moments of well-needed calm. in times of fear or trauma. I was feeling both and the soldiers are doing is necessary … They should a C17 is waiting, framing an illuminated strategic The next eight casualties are stable at had found myself enacting the stereotypical route to receive support like any others.” The simplicity and team. The C130 backs up to its larger sibling until 50 Inkerman and will wait there until the morning. religion. It wasn’t entirely cynical. I had wanted to sincerity defeats my bloody-minded attempts to voice yards of tarmac separates the two worlds of tactical and Tonight the toll was one shot at Sangin, four Injured speak with Padre Barrett since I first arrived and felt doubt and I think we both leave satisfied that we have strategic care. As I stand up, the loadmaster lopes over at Inkerman and two left dead at the scene. Not the that I had a dual reason. played our roles. to me in his low-slung boiler suit. “Sorry I was rude longest day, but certainly the hardest.11 Professionally, I had wanted to understand before. I thought you were press. No hard feelings.” how chaplains could reconcile themselves with the 10/11/07 CCAST I nod, “No problem.” I politely ask to 10/11/07 Captain Brittan brutality of military conflict. photograph the transfer, taking advantage of the Military padres are not simply co-located LM’s surprise contrition. I am graciously waved off. NGOs with a benevolent purpose. They wear 11.30 pm: Ventilated, paralysed and sleeping, he Standing on the runway between these two The next day I am feeling burnt out. I have been uniform and serve the military as well as God. is packed into a cocoon of wires and tubes, ready great transport aircraft, I watch the stretchers being here less than a week. Another five casualties They serve as councillors, confidantes, moralists for transit. There are four other ‘aeromed’ patients ferried across, illuminated by an honour guard of have arrived by the time I wake up. Leaving an and (as with the medics), to “maintain the fighting travelling tonight. I am introduced to them, but my ambulances and Toyota pick-up trucks. empty tent again, I drift to the CP to find out what capability” of the soldiers. focus is CCAST. Partly because their work is the most I feel a strange sense of calm as the patients, is happening. I am constructing a logic for my I imagined men of God standing between challenging, but also because I feel embarrassed by strapped into the stretchers and protected by an presence, which involves attempting to document armies, not with them, and find the compromise (or the watching stares of the conscious patients. assortment of Day-glo equipment, are received by each stage from arrival to repatriation. It is a shared concern) mystifying. As we exit the hospital tent structure with the C17 strategic CCAST team. I feel that some of tenuous logic but it helps me to justify my presence However my academic art project was Fletcher, his four ‘opos’ have already been ferried the tension has passed away. They are crossing a and provides a structure for my documentation. looking fragile. I had seen cruelty and pain greater to the flightline. We leave the bland uniformity of threshold on the runway between combat and care. I follow this process through and speak than I had previously imagined and needed to see the fluorescents and enter the spot-lit drama of the Their guilt about leaving the friends and duty, which with the surgeon, Lazrado. He agrees for me to Padre as so many soldiers do—as a neutral friend. ambulance bay. appears so present at Bastion, appears to be left in film an operation. These ops used to be called Padre Connolly seemed to think that people The mass of lines and tubes almost conceals the Hercules. As the stretcher crossed the halfway ‘elective’. Relative to the T1s, they are, but by were concerned about me after the last few days the mummified soldier. The bulk of the equipment point between craft, it crossed a threshold. The any normal standards they would be emergencies: and really had been working for me. I agreed to fights against the confined space of the ambulance. gravitational pull of home overtakes the longing shrapnel wounds, bullet wounds, broken bones. his surprise offer to have a ‘brew’ with him in 20 Five medics gingerly slide Fletcher’s life-support for the immersive FOB community. Powerless to These planned procedures are operations where minutes back at the chapel. equipment past the snags and handles of the Land resist, there is no shame for the soldiers. Their the patient will not die if delayed for 24 hours. 11:00 pm: I arrived and the chapel was Rover ambulance. I sit in the front and we move off injuries answer any enquiries. The comfort, care Captain Paul Britton is scheduled for later that empty. I unzipped the door and went inside. I at the regulation 15 miles per hour. and cleanliness of the civilian world beckons. The morning. He was wounded at Inkerman and evacuated prayed for a few moments. It has been a long time The camp is silent. The only activity is the CCAST envoys welcome their cargo, outnumbering at 4.30 that morning with shrapnel embedded in his and I began to feel self-conscious. I had forgotten distant cinematic drama of a Hercules free-spinning the patients three to one, and envelop them in the shoulder and hand. He had been injured at the same how to pray and it felt contrived. its props. I jump out of the van and run at least a warm light of the C17 cathedral. time as last night’s casualties, but had refused to leave I read through small Christian booklets with hundred metres, dragging cameras and lenses to greet his squad. A fire-support commander, he had been extracts from scriptures, which seemed to have been the waiting patients. The Hercules looked magnificent. 11/11/07 Remembrance Day in charge of a small (now depleted) team controlling compiled to support the army’s ethical codes— Resplendent, glowing in its own dust-storm. The ramp mortars, air-strikes, artillery and ‘javelin’ missiles. honour, loyalty, discipline, courage, etc—and felt lowered, it reveals a dull Meccano-style infrastructure, Britton has a shaved head and full beard. my academic interest rising again. Padre Connolly dark green and dusty, illuminated with green light. I am barely conscious. Heat, sleep-deprivation and Lazrado asks him if he minds being filmed. The arrived. I was ready to see him but it was a strange Beams and ratchets stretch from floor to ceiling, the dehydration are taking their toll. I leave Simon as he response causes hilarity amongst the nurses: ‘Just greeting. I don’t think either of us was certain of only clue as to its medical configuration. returns to his work and I decide to struggle through make sure he gets my good side.’ who was interviewing whom. The stretchers are loaded in the half-light a coffee. I still feel a strong motivational guilt and I set up the camera and step back. I can’t We sat over cups of instant coffee, trying and suspended from the beams, at varying heights. resolve to use the next few hours to try to pursue face another operation and leave as the camera to find some distance to view the events of the last They appear as fruit in a canopy. Brightly coloured the hidden health services of the military. Quite observes for me. few days. I was struck that he seemed to genuinely plastic machinery and LED monitors glow as the unrealistically, I decide that now would be a fine think that I should be offered support in the same ramp closes. point to interview the community psychiatric nurse. 10/11/07 Padre way that soldiers serving in much more arduous and The loadmaster appears irritated by my Behind the elaborate tent structures of the lengthy periods deserved. presence. “You can take photos. Just make sure hospital, there is a shabby little tent. I felt uncomfortable but grateful. I was neither me nor my boys are in shot, OK?” Duly A forlorn structure. You can imagine the I have a few hours and wander to my remote smoking shaken and did need some perspective on what I had reprimanded, I join the welcoming CCAST team as indignant Community Psychiatric Nurses (CPNs) spot. On the way I pass the tent chapel and a Padre seen. We grilled each other on the parallel ethical we strap into the webbing at the sides of the plane. begging for an upgrade to the modern ‘pods’. 210 war and medicine 212 213 war and medicine ARTIST’S DIARY 214 215 war and medicine ARTIST’S DIARY

‘Taff’ the CPN opens the canvas flap and invites I assume will be closed shortly. For now, it causes me in. “Crap, isn’t it?” he begins. “You can take a real problems. The Chinook neatly holds 24 soldiers, photo of this. I’d like that. I’m going to rip up that but add Bergens, rifles, post, medical equipment, walkway—no bloody privacy.” He motions to the and space becomes limited.12 Bergens are thrown well-used walkway beyond his kingdom. The tent forwards. One drops through the trap door, followed contains a canvas chair and campbed garnished with by the LM. The squaddies around him grab his a “Do Not Disturb” sign. We speak for an hour about harness and drag him back aboard. His humour is the TRIM diagnosis system for battlefield trauma and not improved, and when I motion with the camera for the aftercare. permission, he simply raises his hand and looks away. I wake for dinner disorientated, hoping that When we take off, the hatch is still open nobody has witnessed my laziness. I head over to and we use our feet to brace bags and objects from the CP and tinker with my photos on the laptop. Col falling 1,000 feet. As we rotate to leave Bastion, Goulbourne is waiting and makes me promise to have a we stay low, coating runners and vehicles with our viewing that evening. Duty-bound I return at 9:00 and downdraft. As we hover between ISOs, I see a bar have a strange time, with the Colonel kindly confiding appear through the hole and with a loud click an in me. He shows me images of his family and talks underslung load is attached. I see an arm pull away lovingly about his children. I feel his homesickness and we are airborne, dragging several tonnes of behind the cheery exterior. Colonel Goulbourne is cargo in a net beneath us. always well-presented in his ironed DPM and it is nice We fly across tracts of desert scarred by to see the man as well as the role. I manage to ring paths and occasional compounds. Distance is home. Jordan seems tense and I struggle. I would love entirely abstract. The FOBs and Patrol Bases reassurance and warmth, but I sense her anxiety. She (PBs) are separated by hostile landscape covered is worried about money. Struggling with the pressure of by armoured patrols, Mines, suicide bombers, work and single parenting. I want her to feel supportive Improvised Explosive Devices (IEDs) and Taliban. of me and to prop me up, indulging my angst with Inkerman is only six kilometres from Sangin, but the sympathy, but instead I realise how immersed I have journey is only undertaken in absolute emergencies become. Elijah is grumpy and angry that I am away. and even with preparation and heavily armed Kezia, as always, wants to tell me everything she can convoys can take over 90 minutes. Lashkagar, as think of. I feel guilty. I am too far from home and too with the FOBs, is an island of British security within early in my trip to be able to offer reassurance, but I the sea of unknown threats. On the Helmand map recognise my selfishness and it helps me to pull away it looks like a long way but I never see a scale in from the self-righteous position that I have allowed miles. Distances are measured in ‘helo’ flight times. myself to adopt. Unsatisfied but less self-obsessed, I 20 minutes is ‘Lash’ and I enjoy every second. finally take a full night’s sleep. My first helicopter journey—I search for detail in the alien landscape to be rewarded by occasional 13/11/07 QIPS green fields, where irrigation has revitalised the dormant desert. We arrive at Lash, landing hard and surrounded by dust. “Go!” motions the LM—”Leave The briefing prayers are followed by a strangled your bags.” We dutifully run out and stagger around slow meander to pack and prepare by the 12:00 pm in the draught of the rotors. I can make out bags deadline. Inevitably, I am running by 11.55. Not being thrown out and run back to grab my Bergen. late, but tight, I meet a young private wearing a Red Just in time, my attempts to struggle back to the Cross. “I am your taxi, sir. Heli-flight line?” helicopter bear fruit. As I grab my bag and run off We watch two Blackhawks disappear into the the Chinook for a second time, the ramp closes and horizon before we are mercifully beckoned forward to it is airborne—off to a further unknown destination. board one of the two waiting Chinooks. Heads bowed, I am here to see overlap territory: Civil- we march to the open ramps. The engine exhaust Military Co-operation (CIMIC)—a strange and scalds our faces and dust rasps as we stand waiting hidden facet of the war. We have come to Lash for the LM’s permission. I had assumed that soldiers to deliver 10,000 pounds sterling of medical bowed their heads to avoid the rotors. Now I believe equipment, which we have brought with us on the it is to save their faces from the debris. helicopter as a gift to the Director of Health and An angry loadmaster shouts at us to get on. to witness the process of Quick Impact Projects A level of chaos is achieved as people fumble under (QIPs). These are Helmand Executive Group (HEG) pressure to strap in before being shouted at to move sanctioned proposals for “early wins” (ie projects again. There is a trap-door hole in the floor, which that may have immediate impact when complete). 216 217 war and medicine ARTIST’S DIARY

The agenda is military—to gain “consent”; social George is supremely confident and at ease escapist heart-throb to the women soldiers. The The door-gunner raises her hand and shouts good as a method to support military success. with himself. We meet a little later near his office. Padre smiles with bemused embarrassment. to stay still. In pitch-blackness, we don’t know if we Near is as close as I got. He emerged from behind a Alone that evening, I make a plan. I must have arrived, have been hit or are waiting for a safe 14/11/07 Ramp Ceremony keycode protected door and we talked candidly but document the rest of the hospital. I spend several landing zone. Major Russell, suspects “Keenan”. away from his office. I never quite found out what hours once again trying to ring home. And once again We are airborne again after 15 minutes of cold, noisy George did, but it was fascinating to talk with him. my phone-card fails. I walk through the darkness to ignorance and once more flying erratically through the We are due to leave at 1:00 pm. I have my head- I suppose at this stage, I was looking for something the J1 cell and try to find a way to make a call while night. Within 30 minutes another dramatic landing mounted camera ready and at last feel I may get a simple to understand. I basically wanted to know Op Minimise is not in force.13 Without resolution, at awaits. We are at the FOB. Dust spills in, baggage is chance to use some of the specialist equipment I if there was any rational plan behind what I had 2:00 am I give up and email a short message home passed forward and we are aggressively ushered out. have been dragging through theatre. seen. George explained the systems of governance promising to ring soon. On the ground, a pile of Bergens and parcels has been But first we have an appointment. Lance- that should exist and the few that do, and skilfully, constructed. We are thrown on to it. “Stay Down!” , Corporal Jake Alderton is due to be repatriated today. without ever fully condemning or endorsing the I8/11/07 Sangin14 shouts a soldier. We grip the bags and each other to The journey begins from Camp Bastion with a ‘Ramp role of the British, we managed to discuss progress stop the rasping wind of the Chinook from scattering Ceremony’. I have never witnessed this, but I am and infrastructure. It is interesting that Ron joins people or equipment. We have arrived in Sangin. The told that it is a very moving tribute. Over a thousand half way through this improvised interview. I We arrive at the dormant Chinook and 20 soldiers Helo disappears into the dust-filled night-sky. In the soldiers and support staff pay tribute to the body introduce George to Ron and Ron to George, but I plus over 50 mailbags are crammed aboard. It is scrum, my finger is skinned by a boot and I find that as it begins its journey back to Britain by Hercules am conscious that the conversation remains only obvious that mail has not been a priority over the past one of the bags that I have been pressing into the dirt transport. Although the journey doesn’t pass through directed at me. Ron sits, interested but quiet, as few weeks. The rotors remain silent and we sit in the is actually an Afghan Nantional Army (ANA) soldier. Lashkagar, a parallel ceremony is held here. Nikki George explains the limitations of the military in calm darkness of the helicopter as the door-gunner Medical supplies cascade from crushed boxes and we (my CIMIC host) has rushed to get permission for effecting lasting change. The discussion finishes Anna puts on extra layers of body-armour. We are all are still not allowed to move. “Second Helo coming in. me to photograph the ceremony. I am grateful and after George’s fourth cigarette as he jumps up and still expecting to miss the flight window. Finally the Torches Off!”, shouts a voice. “IR Beacon set up.” with cameras hanging from my neck, we rush to join declares that he must return to his work—still LM, Anna and the pilots appear ready and a painful The roar of an incoming Chinook approaches. the ranks of over a hundred soldiers waiting in near without really explaining what his work might be. whine signals the first attempt to start the engines. Its silhouette is bearing down over us. It appears silence. Nikki hurriedly directs me to a vantage point As he leaves, I recognise the intensity of The unfamiliar sound stops abruptly and we assume to be about to land on top of us, but instead we are to one side of the parade. I hold the camera to my the engagement. I had probably heard more about that the crew were simply testing equipment, until we simply choked by its down-draught and once more face and the shutter clicks. I drop the camera to my the politics, history and problems of Helmand in see the LM putting out fires in the ceiling of the rear blinded by dust. After no more than a few minutes, waist, ashamed. Stares from the civilian FCO workers that 30 minutes than in the preceding ten days. of the helicopter, tracing burning fuel-lines. it has disappeared and I get up, stumbling around are directed at me. I must look just the same as the Ron explains George’s lack of interest in him. “He There is a silence for a few minutes. Wearing in the darkness with a red-light trying to find my reporters that I saw insensitively running around the thought I was your minder”, he explained. armour and helmets, wedged against our webbing seats Bergen. I retrieve it and find I am alone. My eyes Remembrance Day parade. I want to explain that by mailbags, it is hard to turn to see what is happening are filthy, but beginning to adjust to the night. I Jake Alderton is real to me. I saw him arriving dead in 16/11/07 KBR and a quiet sense of passive ignorance is achieved. search the landscape and see the outline of a figure Bastion. I will never forget his face. I do understand It is only when the door-gunner shouts over us to the at the top of a dirt track. “You lost? This way mate”, the significance of this ceremony, but I sense it is too LM, “You’re not really going to try again after putting he calls. He leads me into the base, past razor wire late to contradict the symbolism of my behaviour and A Hercules is taxiing ready for take off, the hypnotic a fire out, are you?” that we realise what is happening. and bales, before jumping on a quad bike to retrieve equipment. I feel dirty, like press at a funeral. drone washes over the base. I decide that a few “Don’t worry”, comes the response. “Just low pressure the piles of supplies scattered around the landing I don’t attempt any further photographs more vehicular photographs for my collection will in the fuel pumps.” We see the LM hand-pumping the site. I can barely contain my excitement. and join the rear of the parade in silence. There is justify a pause and set down on a rampart with a fuel-lines to manually increase pressure. A second The base is lit by the roving torches of its an unsatisfying sermon. I think I want a profound long lens. It is not long before a KBR pickup truck attempt is made—this time a flash comes from the rear inhabitants and appears to be a grand, semi-destroyed explanation for the death, but instead there is a begins to approach from the horizon. It is coming for of the cabin and the passengers recoil. The crew starts house of some sort. Through a mud wall with poorly brief reading. This isn’t the place for answers. me. I decide to wait. It stops in front of me. A large calling to see if there is an engineer on the craft and fitting wooden door, I enter a courtyard and see soldiers American in dark glasses steps out and begins to ask our hopes seem to be dying with the failing Chinook. drinking tea and queuing with plastic plates outside 14/11/07 FCO me to explain myself. He is suspicious, but satisfied. After a painful period over-hearing the LM getting what I assume is the cookhouse. Steps lead up to “We know who you are”, he assures me—“You’re not advice over the radio and glimpses of ground-crew a stone verandah, where various men seem to be hard to spot”. engineers across the piles of mail-bags, a last attempt surveying the new arrivals. I climb the steps and am A man with a dark beard and civilian dress to fire the engines is made. Unbelievably, the Chinook greeted by a man smoking a pipe. “Padre Hallam”, the introduces himself to me at the Naafi. I had 16/11/07 Film Night comes to life, deafening and angry. It is now dark and figure introduces, “Would you like a wet?”15 I have no overheard him speaking about politicians with a after an eternity on the ground, the crew, with NVGs idea who I am talking to as all the men around me seem colleague and have managed to raise the courage fixed, carry us airborne into the night sky. to be wearing head-torches, illuminating my baffled to look up from my coffee and acknowledge the After dinner, I am invited by the Padre to his I attempt to appear calm, but am ecstatic. expressions, but rendering me blind to my surroundings. discussion. He recognises my name and explains weekly film show. This week, playing in the chapel, We are on our way. After about half an hour of I gratefully accept the tea and begin to try to understand that he was expecting to bump into me. He is it is Casino Royale. There is a tangible feeling a very bumpy and cold flight, I smell cordite. I my surroundings. “You need somewhere to sleep?” I George from the Foreign and Commonwealth Office. of excitement amongst the audience. I am one of am convinced that the door-gunner is firing. The nod and am shown an empty camp-bed in a sandbagged I remember now that Jemima Montagu from Kabul half a dozen male visitors sitting at the back, but helicopter lurches around the sky. After a bizarre room covered in Pashto and English graffiti. Six other had emailed me and suggested I might get in touch the chapel is full. The audience giggles and coos series of manoeuvres, we appear to dive to earth beds are arranged in the room. “You’re welcome here”, with him—“a bit Bond”, I think she had said. at Daniel Craig. For an hour and a half he is the and land heavily. Sangin, we assume! I’m told, as I, gratefully lower my rucksack. 218 war and medicine 220 221 war and medicine ARTIST’S DIARY

POSTSCRIPT

These diary extracts document a For many, their experience at Bastion is short, emotional journey through an only vaguely remembered. Soldiers are unfamiliar context: from the RAF dragged from unresolved firefights by base, Brize Norton, to the Forward helicopter, have morphine administered in Operating Base, Sangin, from novelty to advance of arrival, and may leave theatre institutionalisation. They contrast my still sedated via night flights to waiting angst and self-conscious embarrassment families and civilian healthcare. For those with the absolute confidence of those involved, the process of rationalisation I was observing—individuals who had and acceptance often begins in Britain. little time to prevaricate or to hesitate. Within military culture, each person has I left the field hospital regiment at the a clearly defined rationale and function. end of November. Most of the medics The living environment is embedded would not return home until spring of within the work environment. Uniform 2008. The soldiers and civilians that is worn at all times and being off-duty they had treated would have long since means being on standby. passed through the evacuation chain and dispersed to local healthcare, their The scribbled diary reveals the intense regiments or to begin lives as civilians. fatigue that I experienced during a short period of time as an observer. During my month-long stay in Helmand, Days rolled together and the inexorable two British soldiers died, 29 were arrival of patients at Camp Bastion’s field wounded in action and there were 74 hospital caused a sense of disorientation. admissions to the field hospital. 71 I witnessed neither the instantaneous Aeromed evacuations were recorded violence that caused their injuries nor and an undisclosed number of civilian, their long-term recovery, which may insurgent and Afghan National Army take years to complete. My desire to soldiers were treated. I arrived back in head ‘forward’ to Sangin was an attempt Britain feeling a great sense of anger. I to contextualise the trauma I had seen was frustrated by my previous ignorance treated. It became enormously important of the frequency of injury. Soldiers are to me to seek a privilege that many of surviving wounds that would often have the medical practitioners were denied: been fatal in previous conflicts. Body- to meet with the Commandos and to armour, medical training and proximity understand where they were being of advanced surgery to the front-line brought from and seemed to wish to have led to a “disproportionate” number return to. of casualties surviving. In the media, we hear about the deaths, with only Field hospitals are islands between occasional reference to the wounded. contrasting environments: between I came home assuming the violence I the danger and dirt of the Forward had witnessed in Afghanistan would be Operating Bases and the order and the focus of the news. But Reality TV, convention of civilian healthcare. In local politics and other less dramatic the tented hospital of Bastion, dramatic events occupied the headlines. For me, episodes in individual narratives were the incongruity between what I had seen being repeatedly enacted. Thanks to the and what was presented as the public initial lifesaving treatment at the point face of conflict was, and continues to be, of wounding, the speed of extraction and profound and irreconcilable. the extraordinary skills of the doctors and nurses, most of the injured survived. David Cotterrell, August 2008 222 223 WARwar ANDand MEDICINEmedicine DR MANTADOR TAHER

DR MANTADOR TAHER OPEN THE HOSPITAL DOORS!

Mantador Taher was just finishing his medical training in Baghdad, Iraq, when war broke out in 2003. As a newly qualified doctor, he bravely volunteered to work at Kerkh General Hospital under the most difficult and violent conditions. He is now Medical Doctor at the Ministry of Health in Baghdad.

A few days before the war in Iraq began, new Iraq in a very optimistic way. We who were completely burned, people with and eventually left the country. I heard in April 2003, the medical school in students returned to the medical school no arms, people with their legs only about doctors killed by the militia which I was a student decided to give and graduated in August 2003. Everybody attached to their body by a small piece and al Qaeda inside their clinics and us an obligatory vacation; they told us was excited about being doctors in the of skin. I was shocked. The power went hospitals, and even in their homes in to go back home and to stay there until new free Iraq. off, we were running out of medicine and front of their families. I myself was the end of the war. I said goodbye to my The first hospital to which I was fluids, the oxygen cylinders were empty, threatened by patients’ relatives and friends, not knowing if I would ever see assigned was Kerkh General Hospital and it was extremely chaotic. By the end even the patients themselves. With a them again. in Baghdad. The day before, there had of that day it was quiet again, but we gun to my head, I gave 15 defibrillator About a week later, when the war been a large explosion in front of had only been able to save a few people; shocks to a dead person because his son had started, I volunteered as a senior Alzoora Zoo, caused by a suicide-bomb most of them died because of the lack was convinced that this would bring medical student to work in one of the attack. All the new doctors assigned of fluids and resources to perform him back to life. On another occasion, biggest general hospitals in Baghdad. to the hospital were asked to help the emergency operations. angry relatives tried to kill me with AK I never imagined that so many doctors wounded. So my first day as a doctor was When I sat down, I noticed that weapons because their family member, who would have decided to stay in the a nightmare, as were all those that my white coat was soaked with blood. had suffered a severe asthmatic attack, hospitals. Almost every one was packed followed. For most of each day, there I remembered a girl of seven years old had died due to lack of oxygen and with health-care professionals and I was no power, and because the emergency who had suffered a hundred per cent medication for his illness. couldn’t get a room in the hospital in rooms were flooded with endless wounded burns and had been admitted to the Burn The exodus of senior doctors put which to sleep, so I worked during the patients, all the interns had to be on Ward. I was staring down at my coat us junior doctors, fresh out of medical daytime and returned back home at night. 24-hour call for emergencies. and my female colleague told me that school, in a situation where we had to In the beginning, there were very A couple of weeks later, there the girl had just died. I looked up at perform complicated surgical operations few civilian casualties; most of the was another bombing in Baghdad. At first, her and asked, “Why? Why has all this that would ordinarily be undertaken by wounded were military. This situation after the explosion, it was very quiet, happened?”, and I cried. So did she, and more experienced doctors. The workload persisted until 9 April 2003, when the and then the sirens became progressively that doctor is now my wife increased for the doctors who remained, Multi-National Force entered Baghdad and louder and people were screaming and Things became worse when the and we were only able to listen to took control of the city, and the Iraqi shouting, ‘Open the hospital doors!’ relentless violence spread over Baghdad patients for a few minutes and then soldiers exchanged their uniforms for About 200 wounded and dead people arrived and to other cities. The state of write out a prescription. The shortage civilian clothes to avoid recognition. at the hospital all at once. We had one lawlessness extended to the hospital of power and medicine forced the The sun of freedom rose again in Iraq emergency room, whose door fell off, and wards. Doctors, who were easy targets, hospital in which I worked to close its for the first time in 35 years. there were only about 15 to 20 doctors were threatened, kidnapped or killed by operating theatre. But the emergencies Everybody was happy (or so I in the hospital at that time. A horrible desperate patients and their relatives, were nonstop. It was a totally thought) and I began to think about the picture still sticks in my mind of people and the vast majority left their jobs ridiculous situation. My six years in 224 225 WARwar ANDand MEDICINEmedicine DR MANTADOR TAHER

medical school had not taught me how to The Multi-National Forces are don’t have to. Just to see that the work in a hospital with no electricity, also playing a vital role in improving clinics are open and providing health no medication, no oxygen and with a gun the health system in Iraq by increasing services to the Iraqi people is the pointed to my head. security and giving all kinds of support great reward.” Additionally, because the hospital to doctors and health professionals. The pattern of violence in Iraq in which I worked was located in a I have met and worked with them, and could be described as a curve. Beginning Shiite area, all my Sunni friends left I believe they are here to help us. in 2003, it reached its peak in 2006 it to work in a Sunni area, and because Doctors have been sent for training in and the first half of 2007. In late my wife is Sunni and I am Shiite, the United States, the United Kingdom 2007 and 2008, specifically after the we were forced to work in different and other countries. Medicines and American Army surge, there has been a hospitals to avoid being killed. medical supplies have been continuously dramatic drop in violence and better However, even as a Shiite, I found it sent to hospitals all over Iraq. security. Doctors are coming back to necessary to make a faked ID with a The American Embassy in Baghdad, the hospitals. This has improved health Sunni name because I had to pass through and specifically the Health Attaché services, and I hope it will continue to Sunni areas on the way to the hospital. Office, are also crucial, creating a link do so. Recently, the situation has between the United States Government improved a little. The Iraq Ministry and the Iraq Ministry of Health. They of the Interior has responded to our have undertaken many large-scale health demands by simplifying and expediting projects, one of which is to build 142 gun-licensing procedures for doctors, Primary Healthcare Centres all over allowing us to obtain licensed weapons Iraq, as well as helping to build new much faster than others. I went early hospitals, or to renovate and maintain one morning with my father’s 9mm pistol most of the existing ones. Words will to get a licence and I never imagined never be enough to thank those people, that I’d find so many doctors wanting the who put their lives in great danger just same thing. While I was waiting in line, to assist us. I remember once asking I kept asking myself, “Will I ever use the Health Attaché, “Why don’t you put this gun, even if someone tries to kill signs up at the Primary Healthcare me?”, and I realised that I couldn’t do Centres that you’ve built so that the it because I value human life—even that Iraqi people will be aware of your great of bad people. achievements here?” She replied, “We 226 227 war and medicine ADVANCES in modern combat casualty care with a vision to the future

ADVANCES IN MODERN COMBAT CASUALTY CARE WITH A VISION TO THE FUTURE William Wiesmann, Nicole Draghic, John A Parrish

“War is the father of all things.” advancements such as hospital facilities SAVe: Simplified Heraclitus ( 535–475 BC) in theatre, progress in resuscitation Automated Ventilator. methods and the treatment of shock, the Courtesy AutoMedx Inc advent of blood transfusions, antibiotics, Germantown MD Background more effective surgical procedures, and preventative health methods including rom the earliest recorded improved nutrition. The one exception has histories of warfare to been the remarkable reduction in death the present day, the in military combatants due to infectious needs of the battlefield illness and disease, primarily through and the lessons learned the introduction of the prophylactic use from it have in many of antibiotics, and improved hygiene and ways contributed to sanitary conditions, resulting in significant improvements in health care. Medical reductions in non-combat disease-related advancesF are well chronicled in historical deaths. The accelerated pace of weapons accounts and literature. In fact, it was development has often exceeded or equalled his plague research conducted during the the challenge of delivering lifesaving health Peloponnesian War that helped establish care on the battlefield. Each war has its Hippocrates as the ‘father of medicine’. own signature wound, and subsequently, diagnostic tools and treatment methods may hile these lessons have inevitably need to be modified and/or developed to Wled to advances in health care that improve clinical outcomes associated with arguably might have occurred regardless, these injury patterns. they have indisputably developed at a far faster pace under the pressure of he success of modern medicine has, war. Ironically, in the experience of the Tfor the first time in recorded military American military, the combat mortality medical history, shown dramatic reductions rates from the Civil War through conflicts in battlefield mortality, yet this reduction as recent as the Vietnam War have is associated with a long-term impact on remained relatively constant, in the 20 quality of life; today’s soldiers are returning per cent range, despite improvements and with catastrophic brain injuries, physical 228 229 war and medicine ADVANCES in modern combat casualty care with a vision to the future

American Casualty Ratios Influenced By Medical Progress

Conflict Battle Deaths Wounds Not Mortal % Injuries Resulting in Death

American Revolution 4,435 6,188 41% 1775–1783

War of 1812 2,260 4,505 33% 1812–1815

Mexican-American War 13,283 4,152 76% 1846–1848

Civil War (Union Only) 364,511 281,881 56% 1861–1865

Spanish-American War 6,400 1,662 79% 1898–1899 mutilations from limb and burn injuries, data supports the notion that because HemCon Bandage emotional disorders and heightened risk the majority of casualties occur on the World War I 116,516 204,002 36% in use. of infection. The lessons from this conflict battlefield in the pre-hospital environment, 1917–1918 Photograph by LTC John and impact on military and civilian health strategies that focus on in-hospital or McManus, MD. Courtesy care are yet to be fully realised, yet in-theatre hospital care are less likely to HemCom Medical will undoubtedly help shape future result in significant reductions of mortality World War II 405,399 671,846 37% Technologies Inc, medical research. following combat injury. 1941–1945 Portland, OR. hile it is not the purpose of this he introduction of better methods Wchapter to chronicle all of the Tof controlling haemorrhage through Korean War 36,516 103,284 26% medical advances that have occurred in hemostatic bandages and superior 1950–1953 the history of warfare, it is instructive to tourniquets on the battlefield, as well as the consider some well-documented examples far-forward placement of surgeons and the from more recent American conflicts rapid evacuation chain, has significantly Vietnam War 58,198 153,303 27% to understand the evolution of warfare improved outcomes following combat injury 1964–1973 medicine, its impact on modern medical in Iraq and Afghanistan. These advances care on the battlefield, and how these in battlefield medicine have resulted in the developments could lead to global health- lowest fatality rate in modern warfare. Gulf War 299 467 39% care advances in the twenty-first century. 1990–1991 owever, there is still considerable careful analysis of combat casualty Hroom for progress. Unlike in previous Adata following the Vietnam experience conflicts, the severe injuries that are OEF 542 2,205 19% highlighted a number of important now survivable on the battlefield have Operation deficiencies in battlefield healthcare and serious consequences, including long-term Enduring Freedom has essentially led to a revolution in the disabilities, for surviving soldiers. These are (began 2001) way the American military approaches challenging but realistic facts that must be a the care of injured soldiers; the Wound priority in battlefield medicine research. Data and Munitions Effectiveness Team OIF 4,122 30,409 11% (WEDMET) database has helped to direct urrent research suggests that the Operation Iraqi Freedom military medical research, logistics and Cbattlefield medical care of the future (began 2003) medical tactics since Vietnam. This will evolve rapidly to greater and more 230 231 war and medicine ADVANCES in modern combat casualty care with a vision to the future

comprehensive capabilities to quickly How has military medicine In response, the American established the increased need for treating wound diagnose the nature and severity of improved heath care? The application of the hospitals for maxillofacial surgery, infections, resources were dedicated to the battle injury and accurately direct Thomas splint. From which established the team approach to investigating and purifying penicillin, life-saving therapies sooner and more he American Revolution witnessed the Mitchener & Cowell, reconstructive surgery. Chemical warfare resulting in its mass production and effectively than has ever been considered Tfirst command-ordered immunisation Medical organisation resulted in mask development and treatment wide use. The first mobile field surgical possible. The American military has programme when George Washington and surgical practice in of chemical wounds. Chemotherapy grew detachments were established during implemented a longstanding R&D ordered inoculation for smallpox. In response air raids, 1939. out of studies researching the toxic effects of this conflict. investment in military medicine, including to problems in removing the overwhelming Wellcome Library, London. mustard gas. During the First World War, the infectious disease research, preventative number of wounded from the battlefield, the idea of triage as a medical procedure was orean War innovations included the vaccine development, psychological first ambulance corps was created during implemented, and automobile ambulances Kfirst use of a helicopter in medical research, protective gear and diagnostic the Civil War. A three-tiered evacuation were utilised for quicker patient transport. evacuation and MASH (Mobile Army and point-of-care devices. system was developed, with 1) a field Surgical Hospital) units that provided high- dressing (Aid) Station located next to the he Spanish Civil War provided a testing level surgical care as close to the battlefield ecause of its exigent circumstances and battlefield, 2) a field hospital located close Tground for new weapons and tactics. as possible. Battle surgeons began to treat Bgreater and timelier need than those of to the battlefield, which utilised local It was the first time sulpha drugs were vascular injuries on a routine basis, which the civilian experience, military medical barns or houses for emergency surgery administered in surgery. The widespread prevented traditional military amputation. requirements drive the development of and treatment, and 3) a large hospital use of antibiotics and antiseptics resulted Although not specifically developed for research and the advancement of adaptive, located away from the battlefield for in a dramatic decrease in infection rates. military medical use, during the Korean practical medical devices to support prolonged treatment. Only 342 of 42,000 soldiers underwent War Kolff-Brigham dialysis machines were military missions in austere, far-forward amputations despite still primitive instrumental in the treatment of injured environments. Often, these advances uring the Spanish American War, surgical conditions. The first large-scale American soldiers. Deaths due to renal will ultimately have direct application Dresearch was developed to fight employment of mobile surgical teams and insufficiency decreased by 50 per cent. to civilian healthcare, particularly in malaria, making the building of the blood transfusions using stored blood also civilian trauma cases. In fact, the military Panama Canal possible. occurred during the Spanish Civil War. n Vietnam, the counterinsurgency is often the first to use new healthcare Iwarfare forced rethinking of casualty technology; between three and five per cent he First World War introduced the he Second World War provided a great evacuation; the helicopter provided the of mainstream medicine is derived directly TThomas splint, which reduced mortality Tclinical laboratory; the common use greatest flexibility in patient transport. or indirectly from warfare. Beginning with due to compound fractures from 80 per cent of blood transfusions, DDT, aeromedical Although the Korean War utilised the American Revolution, each military in 1916 to eight per cent in 1918. evacuation, anti-malarial drugs and the helicopters in medical evacuation, conflict has resulted in advancements and The military tactic of trench warfare management of burns were tested and their size precluded carrying more than improvements in medical care. produced large number of facial wounds. evaluated during this conflict. Due to two patients in external pods attached 232 233 war and medicine ADVANCES in modern combat casualty care with a vision to the future

Undoubtedly, lessons learned in these technologies, but also in the full medical conflicts have brought about improvements spectrum, fostering research in prosthetics, in civilian care, especially transport focused and improved rehabilitation, as and triage. However, civilian trauma well as the recognition and requirements management usually involves emergency of mental-health issues. medical care provided at a single facility. Due to the more remote and fluid location of the battlefield, trauma management must Future be adapted to treat the wounded soldier. the promise of regenarative medicine

Medical Challenges nvestigations into the regenerative Iproperties of stem-cell therapies and he Iraq War has allocated the most adjuncts to stem-cell therapies including Torganised and sophisticated trauma growth factors and cellular mediators that care in history. This, coupled with can restore lost organ function, reduce to landing skids; in Vietnam, ‘Hueys’ are designed to enable damage-control improved body armour, has yielded the inflammatory scarring, and regenerate Medics from Second transported six to nine patients. Vascular surgery near the front lines, and are capable unprecedented survival rates (nine out tissues that have previously been lost show Brigade Combat Team surgeries became routine, and the use of of treating major chest and abdominal of every ten soldiers wounded survive, promising preliminary results. In America, participate in a pre- whole blood as a resuscitation solution was wounds, continuing haemorrhage, severe compared to 7.5 of ten in Vietnam). Yet the Wake Forest Institute for Regenerative deployment medical a factor in reducing death due to shock. shock, respiratory distress, amputations, these advances come at a price; no other Medicine has successfully engineered evacuation exercise at major organ fractures, crush injuries and war has created so many seriously disabled bladders, urethras, heart patches and the Yakima Training he War in Iraq’s medical contribution closed head wounds. veterans. The rate of amputation, TBI blood vessels. The Tissue Engineering Center, Washington, Tis two-fold: medicine has focused (traumatic brain injury), and PTSD (post- Advanced Technology Team (ATT) at the 2006. on prevention and wellness as well as mprovements in body armour and traumatic stress disorder) is higher than in Center for Integration of Medicine and Photograph by Sarah improved care. To reduce the time between Ihaemorrhage-control techniques have any previous conflict. Innovative Technology (CIMIT), Boston, is Underhill. Courtesy of the occurrence and treatment of battlefield also resulted in a higher survivability investigating the development of a tissue- US Army casualties, improved medical evacuation than previous conflicts. Increased pre- ach war has presented its own medical engineered liver replacement and the use vehicles, modularised combat support deployment screening and preventative Echallenge. This war has clearly of heart-cell injection to restore muscle in hospitals and forward surgical teams have medicine have resulted in a reduced identified and mandated concrete progress patients with congestive heart failure. The been utilised. The forward surgical teams disease rate in deployed soldiers. not only in preventative and protective National Regenerative Medicine Foundation 234 235 war and medicine ADVANCES in modern combat casualty care with a vision to the future

is heading research supported by the DOD Shock and survival lthough haemorrhage-control devices since the start of the Iraq War, the HemCon Bandage. to grow limbs for injured soldiers. The A company commander Acan control external bleeding, there is no American Army has increased the training Courtesy HemCon complex genetic responses in conjunction he use of modern, aggressive and from the Second Infantry effective countermeasure to control internal time for combat medics to 16 intensive Medical Technologies Inc, with the latent activation of endogenous Tintelligent fluid resuscitation in cases of Division carries a bleeding in the pre-hospital environment. weeks, which provides the skill level of a Portland OR. stem cells and growth factors, which permit shock, including low-volume resuscitation ‘casualty’ during the Surgical intervention is required to staunch civilian emergency medical technician or the salamander to regenerate a lost limb, in order to maintain adequate organ nuclear, biological and internal bleeding, but death often occurs ambulance medic. has given hope that these silent regenerative perfusion without over hydrating or creating chemical section of the before transport to a surgical facility is mechanisms can be activated in humans. volume overload, which can lead to serious Expert Field Medical feasible. Investigators at the CIMIT are A great deal of important investigative consequences in pulmonary function, will Badge training at Fort studying the potential of a portable insufflator How to train the ‘life savers’ work has yet to be completed that will improve outcomes from these injuries. The Lewis, Washington, 2006. device to control abdominal and thoracic have direct application to the improved anticipated redevelopment and deployment Photograph by Spc. Leah R. bleeding preoperatively. The method urrently, medic training consists of survival of battlefield casualties, including of freeze-dried plasma coupled with red- Burton, courtesy of US Army. uses carbon dioxide to reduce the rate of Ca combination of classroom, field restoration of lost bone, tissue, muscle and blood-cell infusions that are capable of bleeding. Preliminary tests suggest that instruction and mannequin training, the even brain tissue. But the high prevalence correcting blood-clotting abnormalities this technique may be useful in the pre- majority of which is in the field. The of extremity injuries, and direct damage to following uncontrolled haemorrhage and hospital management of abdominal injury to chaotic nature of the battlefield makes it the spinal cord following explosive injuries reducing irreversible shock are likely to effectively temporise bleeding until transfer difficult to assess patients; yet survival is have stimulated renewed interest in novel make their appearance in the months and to the operating room. dependant upon the medic’s skill level. ways to improve peripheral nerve and years to follow. If the medic incorrectly inserts a chest spinal-cord damage. One method is the more tube or IV, or misses an internal injury, intelligent use of resuscitation strategies everal new haemostatic agents are in The new medic the patient will not survive transport to a to reduce collateral damage to oxygen- Suse by the American military. HemCon treatment facility. starved tissues and mitigate inflammatory Medical Technologies manufactures bandages istorically, care rendered in the first hour responses administered in the early minutes from chitosan, a naturally occurring, H(the ‘golden hour’) following injury has ew highly realistic simulation systems following injury. Another is the investigation biocompatible polysaccharide derived from been considered most critical to survival. Nare being developed by researchers, of the application of ‘growth factors’, shrimp shells, which stems the flow of blood. Today, the critical timeframe is considered to including CIMIT, to train combat medics in which stimulate nerve, muscle, skin and Z-Medica makes a pourable product that be the initial five to ten minutes. the treatment of traumatic injuries under immune function and regeneration, as well uses zeolite-based agents. TraumaCure has battle conditions. The Combat Medic as ‘cytokines’, regulatory proteins derived recently developed another granular mix for edics and combat lifesavers are Training System’s (COMETS) prototype from immune cells, which are promising use on gaping wounds. The Army has also Moften tasked not only with treating mannequins mimic combat war wounds to accelerate the restoration of lost tissue issued a one-handed tourniquet, which can single serious casualties, but also multiple with extreme realism, replete with spurting following injury. be self-applied by the soldier. casualties simultaneously. In response, blood, sucking chest wounds, and shrieks 236 237 war and medicine ADVANCES in modern combat casualty care with a vision to the future

uses single-knob, hands-free operation to injuries. IEDs, which cause ultra-high- SAVe: Simplified NIRVANA: Non- deliver precise, measured breaths. Weighing velocity fragmentation injuries, often to Automated Ventilator Ionizing Radiation roughly three pounds, the SAVe is small and the extremities, are frequently packed Courtesy AutoMedx Inc, Vision for A New Army. durable enough to be stored in a medical kit with contaminated soil or other objects, Germantown MD Courtesy Spectral Energetics or on far-forward evacuation vehicles. which increases the likelihood of secondary Inc, Beavercreek OH infection. The average wound from an IED ther dramatic improvements in requires five surgeries. Othe ability to deliver mechanical support for ventilation and circulatory support are anticipated through the use Acinobacter of servo-controlled or robotic controlled of pain. Unlike the plastic models familiar time of transfer to a CONUS facility was devices that not only deliver information cinetobacter baumannii, a bacterium from CPR class, these mannequins, with 45 days; in Iraq, an injured soldier can about the status of the patient’s care but Afound in soil and water highly prevalent imitation blood and synthetic skin, truly be transported to an Echelon four trauma also simultaneously correct for variances in Iraq, has resulted in numerous wound, simulate the human body, and provide centre in Landstuhl, Germany, in as few in the patient’s response to treatment. respiratory and bloodstream infections realistic representations of trauma wounds as 12 hours, and be back in America for Greater emphasis is being placed on the in injured soldiers. These infections are and responses to therapy, and thus enable complete care within three days of the accelerated development of drugs and challenging to treat due to extensive training on complex medical conditions original event. treatment modalities that reduce systemic antimicrobial drug resistance, yet they in a field-like setting. Sensors record all metabolism, reduce oxygen consumption, are occurring with increased frequency in treatment and responses, providing the user ombat injuries requiring respiratory oxygen demand, and glucose utilisation, military medical facilities treating soldiers with immediate feedback on care delivered. Cmanagement are often lethal if not thus reducing overall free-radical generation returning from Iraq. Acinetobacter spores treated within a few minutes after injury. and improving longer-term survivability. can survive on surfaces for up to 20 days, Currently, bag-valve mask units are used on increasing the likelihood of infection Transport and survival the battlefield, but their operation requires amongst other patients. constant and steady manual pumping, which It’s all about infection he changing battlefield has precipitated does not guarantee consistent air delivery. Timprovements in transport. Warfare A new portable ventilator, The SAVe acteria infection remains a serious Sepsis has shifted from formation/trench fighting (Simplified Automated Ventilator) could Bcomplication of war trauma. New to a more urban and fluid battlefield, provide the critical difference in survival therapies must be investigated to prevent ntibiotics are the standard treatment which facilitates a faster access to medical outcomes for injured soldiers requiring and treat multi-drug-resistant microbes, Afor sepsis, but because of the delay in treatment. During Vietnam, the average immediate airway management. The SAVe particularly for soft tissue blast and thermal drug effect, potentially fatal inflammation 238 239 war and medicine ADVANCES in modern combat casualty care with a vision to the future

EDs have intensified the need for matter in the brain. With this technique, CIMIT Prototype Iprotection against the blast wave itself. it may be possible to identify and track ‘band-aid’ monitor Blast waves can cause serious injuries, variations and changes in the brain Courtesy CIMIT, Boston, MA. from pulmonary haemorrhage to progressive resulting from PTSD and TBI, as well as to brain trauma. Current ceramic body armour differentiate between the two disorders. is only effective against projectiles, such as shrapnel and bullets. Preliminary research supported by CIMIT to test the feasibility What has Star Trek taught us? of using machine-augmented composites (MAC) as blast armour demonstrated that n television shows and movies, high-tech the MAC material mitigated blast by 9.5 Idevices and therapies seem capable per cent. of treating any illness. Dr McCoy waves a device the size of a cell phone over a he Preventing Violent Explosive patient’s body and seconds later, the patient TNeurologic Trauma (PREVENT) is cured. The blind Chief Engineer Geordi Program is investigating methods to La Forge wears a special neural implant continues to spread. Researchers from in Iraq with implications for long-term protect soldiers from TBI resulting from visor in order to see. Diffusion Tensor Children’s Hospital Boston are developing health concerns. There is a dramatic rise IED explosions. This program focuses Imaging of the brain. a sort of ‘artificial spleen’ that can be used in both open and closed (concussive) head on evaluating the physics of interaction hile some of the Star Trek devices are Courtesy of BWH Surgical in tandem with antibiotic therapy. This injuries due to increased use of improvised between an IED blast and the neurological Wstill futuristic, they no longer seem Planning Lab, Boston MA. device temporarily removes blood from explosive devices (IED). Although Kevlar system to determine the components unimaginable. The military has recognised the body via a catheter, filters pathogens helmets have reduced the number of fatal responsible for neurologic injury, and that the future of battlefield medicine will out of the blood, and returns the cleaned penetrating head wounds, force momentum developing improvements in personal require pre-hospital support devices with blood back to the body. Work is underway can result in a severe concussive injury. protective armour and new therapeutic greater diagnostic and decision-making to increase the prototype’s capacity and According to the Defense and Veterans interventions for injured soldiers. capabilities. Although medical care is most efficiency, with support from CIMIT. Brain Injury Center, about 900 soldiers have critical within the first few minutes following suffered a serious debilitating traumatic esearchers at Brigham and Women’s combat injury, and delay in recognition and The brain unmasked TBI; additionally, an estimated 300,000 RHospital are investigating the use of treatment can exacerbate the condition, soldiers have suffered milder forms of Diffusion Tensor Imaging (DTI), a relatively there are limited pre-hospital diagnostic raumatic Brain Injury (TBI) is a TBI, including brief loss of consciousness, new imaging technique that provides a capabilities available to validate common Tpredominant cause of injury for soldiers disorientation or cognitive lapses. detailed three-dimensional map of white battlefield injuries. Additionally, a medic 240 241 war and medicine ADVANCES in modern combat casualty care with a vision to the future

may be diverted by other obvious injuries he Digital Diagnostic Glove is another uch of this has to do with modern research headed by Johns Hopkins CIMIT Prototype ‘band- as well as other simultaneous casualties. Texperimental prototype diagnostic Digital Diagnostic Glove Melectronics, sensors and miniaturised Applied Physics Laboratory has created aid’ monitor Experimental prototype diagnostic ensemble under development. This Courtesy Sekos Inc, devices, which can be used to diagnose a prototype prosthetic arm that allows Courtesy CIMIT, Boston, MA. ensembles are under development to device is worn by a battlefield medic on Germantown, MD. treatable conditions that are often lethal for unprecedented movement. The arm identify and confirm militarily trauma the hand and connected to a body-worn if unrecognised, such as pneumothorax, provides sensations that allow wearers currently undetectable in the field. computer system. A medic can gather haemothorax and hidden haemorrhage. actually to feel the sensation of holding temperature and blood oxygen levels, Improved diagnostic tools will enable objects as well as temperature in their he Defense Advanced Research blood pressure, respiration and heart-rate early triage, treatment and transportation prosthetic hand. Because it swings freely TProjects Agency (DARPA) is information on multiple patients in the of injured soldiers, and facilitate the like a natural arm, it does not upset sponsoring the Non-Ionizing Radiation field, and track their progress, even during management of multiple casualties balance while walking. While work is Vision for A New Army (NIRVANA) hazardous conditions such as heavy fire. simultaneously. Ultimately, it is anticipated still needed to perfect weight and power project, whch offers the potential to This system links to a series of critical that these devices will be used in nursing- to ensure wearer comfort, these arms are bring hospital diagnostic capability right diagnostic sensors and arrays, comparing home facilities and as an adjunct to home- an example of a major breakthrough in to the scene of injury. NIRVANA is a the ‘normal’ values and ranges against healthcare for chronic illness management. prosthetic research, and offer a greatly small, handheld electromagnetic-based those continuously read for each vital improved quality of life to amputees. interrogation device designed to detect sign measured, and recognises signals, The Bionic Man and quantify free fluid (air, water or blood), patterns and critical vital-signs changes in order to identify the presence of life- and responses to therapy. Alarms alert the he war in Iraq and Afghanistan has Conclusion threatening lung and chest collapse with user or standby personnel to unsafe and Tresulted in over 1,000 traumatic sufficient accuracy to permit the on-site life-threatening conditions. amputations. Limb-loss has occurred twice hile it is too soon to determine insertion of a chest tube by non-physician as often in Iraq than in any conflict of the Wthe impact of the War in Iraq and medical personnel in situations where his research suggests that the past century, except for Vietnam, for which Afghanistan on the future of medical and X-ray is not available. Tbattlefield medical care of the future there are no good statistics. As of February mental-health care, it is easy to see how will evolve rapidly to greater and more 2008, the DOD reported 1,031 amputees, these developments will improve the IMIT has developed prototype comprehensive capabilities for quick of whom 730 have suffered major limb overall casualty survival rates in the near Cminiaturised, body-worn ‘band-aid’ diagnostic assessment of injury and the amputations, primarily the result of IED future. If history is any guide, our future monitors equipped with sensors to introduction of therapeutic interventions injury. This has spurred the development generations will benefit in ways that we can monitor heart rate, respiration, motion earlier in the combat cascade designed not of the ‘Bionic Man’. Improvements in only glimpse today and will result from the and temperature for the American military only to reduce mortality, but to improve prosthetics and cybernetics are narrowing focus and determination to advance the to provide remote surveillance and outcome and survivability and reduce the gap between prosthetics and actual body protection of soldiers from the catastrophe improved triage. morbidity following combat injury. parts. Although still under development, of warfare. 242 243 WARwar ANDand MEDICINEmedicine NOTES

1984, pp. 201–202. and Co, London, 1922, p. 37. 27 Harold Dearden, Medicine and Duty: A 10 The King and his wife Queen Mary made SUFFERING AND THE 7 Erich Maria Remarque, Im Westen nichts 9 Kaye, 9 November 1915, p. 33. War Diary, Heinemann, London, 1928, p. vii. formal visits to the pavilion twice during HEALING PROFESSION: NOTES Neues, Kiepenheuer & Witsch, Cologne, 10 Basil Clarke, “How the Wounded Were 28 Kaye, 22 April 1916, p. 216. the 14 months that it served as a hospital, THE EXPERIENCE OF MILITARY 1987, p. 84. Brought Home”, The Great War: the Standard 29 Committee Interview with Sir J Rose on 9 January and 25 August 1915. On each MEDICINE IN THE FIRST AND SECOND History of the All-Europe Conflict, ed. HW Bradford, Consulting Physician, Etaples, 5 occasion the couple inspected the premises WORLD WARS Life Without Arms: Wilson, vol 8, 24 February 1917, p. 326. September 1917, p. 3. and interacted with the Indian patients, Joanna Bourke Carl Hermann Unthan and 11 Private Percy Bray, war diary, RAMC 30 Committee interview with Surgeon General giving the local press great opportunities for 1 Wilfred Willett, “Memoirs”, 81, Imperial His Motivational Work with 1673, Wellcome Collection. Sir Anthony Bowlby, Colonel Sir Wilmot yet more colourful reporting. War Museum archives. SISTER M ALOYSIUS DOYLE: Disabled Veterans in Germany 12 Kaye, 24 January 1916, p. 109. Herringham, consultant physician, Surgeon 11 The Argus, 24 November 1914, quoting a 2 Lieutenant Kaye, “Papers and Letters”, THE CRIMEAN JOURNALS OF THE Colleen Schmitz 13 Kaye, 1 November 1915, p. 22. General Macpherson, “Meeting at General “distinguished officer” from the War Office. letter to Mrs Kaye from Nurse J Badger, 29 SISTERS OF MERCY, 1854–56 1 Carl Hermann Unthan, Das Pediskript, 14 Laura Doan, “Primum Mobile: Women Headquarters”, 2nd Echelon, Hesdin, France, 12 A short history in English, Gurmukhi and January 1917, IWM 82/11/1.Capitalisation Sister M Aloysius Doyle Robert Lutz Verlag GmbH, Stuttgart, Second and Auto/mobility in the Era of the Great RAMC 1165/2/3, Wellcome Collection, p. 6. Urdu of the Royal Pavilion, Brighton, and and punctuation as in the original. 1 A flannel or piece of cloth soaked in hot edition, 1925, pp. 267–278. War”, Women: A Cultural Review, 17, 1, 31 Committee Interview with Colonel a description of it as a hospital for Indian 3 John Rawlings Rees, The Shaping of water, wrung out and applied to wounds, 2 Unthan, Das Pediskript, p. 268. 2006, pp. 34–35. Burtchaell, p. 3. soldiers, King, Thorne & Stace, Brighton, 1915 Psychiatry by War Chapman and Hall, Poultices were used much like compresses 3 Unthan, Das Pediskript, pp. 270-75. 15 Andrews, 30 July 1915, p. 3. 32 Fripp, Ogsten, Perry and Horder, 1916. 13 The Brighton Herald, 5 December 1914. London, 1945, p. 19. to draw out toxins and deliver heat and 4 Unthan, Das Pediskript, p. 270. 16 Notes by Dr Buttar. Interview with 33 Captain Harold Upcott, war diary, 1 April 14 The Brighton and Hove and South Sussex 4 Charles Huxtable, From the Somme to circulation to the assigned area. 5 Karl August Lingner, Introduction Captain Hebb, RAMC, TC, CO 17th Field 1918; RAMC 1101, Wellcome Collection. Graphic, 8 July 1915. Singapore, Costello, London, 1987, pp. 29–30. 2 A type of starch made from the powdered to Ausstellung für Verwundeten-und Ambulance’, 16 September 1917, p. 1; 34 Anonymous Patient, “A Quaint 15 Even in a cursory examination of the 5 KR Eissler, Freud as an Expert Witness: pith of the sago plant and used in puddings; Krankenfürsorge im Kriege, 1915, p V. RAMC 1165/2/3, Wellcome Collection. Character”, FEG Hospital Gazette, vol 1, no representation of race such as this, it is worth the Discussion of War Neuroses Between A plant from which a starch is prepared and 6 Carl Hermann Unthan, Ohne Arme durchs 17 “The Royal Army Medical Corps and Its 6, 22 June 1915, p. 98. citing Edward Said’s classic text, Orientalism, Freud and Wagner-Jaugegg, translated by used for nutritional and medicinal purposes. Leben, G Braunsche Hofbuchdruckerei und Work”, British Medical Journal, 18 August 35 The Editor, “The Medical Army”, The Routledge and Keegan Paul, London, 1978, C Trollope, International Universities Press, Verlag, Karlsruhe, 1916, p. 48. 1917, p. 217. Times, 4 October 1916, p. 9. which critiques exoticising Western constructs Inc, Madison, Connecticut, 1986, pp. 60–61. How varied the image of 7 Unthan, Ohne Arme durchs Leben p. 50. 18 “Barge Ambulances. Floating Hospitals 36 Captain C Rhodes Marrison, “3rd L.G.H. and assumptions about the Orient. 6 Major Stanley Argyle, “War Diary”, part heart trauma has become 8 Unthan, Ohne Arme durchs Leben p. 5. for Wounded”, The Times, Thursday 15 Labour-saving Devices for the Reception 16 The memorabilia documenting this episode I, entry for 12 May 1915, Australian War The Development Of 9 Unthan, Das Pediskript, 1925, p. 268. October 1914, p. 9. of the Wounded”, The Gazette, February was intended, as Susan Stewart has remarked of Memorial archives. Cardiovascular Surgery 10 Unthan, Ohne Arme durchs Leben, pp. 5–6. 19 “How the Wounded Were Brought 1916, p. 131. the souvenir, to “move history into private time” 7 Richard A Gabriel and Karen S Metz, A During The First World War 11 Unthan, Ohne Arme durchs Leben p. 6. Home”, The Great War Magazine, Part 132, The simple purchase of a postcard provides History of Military Medicine, Greenwood Susanne Hahn 12 Unthan quoted in Hans Würz, Sieghafte February 1917, p. 326. TREATED LIKE FLOWERS: evidence of a lived experience, connecting Press, Westport 1992, pp. 254–255. 1 Ludwig Rehn, “Die Kriegsverletzungen Lebenskämpfer, Munich, 1919, p. 24. 20 Lord Knutsford, Letter to the Editor, “Our THE INDIAN ARMY AT THE ROYAL the individual with a momentous occasion or 8 Dr Robert Scot Skirving, Memoirs of Dr des Herzens und des Herzbeutels”, in 13 Unthan, Das Pediskript, p. 271. Wounded in France. Efficient Treatment”, PAVILION HOSPITAL, BRIGHTON, remarkable sight. Susan Stewart, On Longing: Robert Scot Skirving 1859–1956, ed Ann Otto von Schjerning (ed), Handbuch der 14 Unthan, Das Pediskript, p. 279. The Times, Tuesday 10 November 1914, p. 9. 1914–1916 Narratives of the Miniature, the Gigantic, the Macintosh, Foreland Press, Darlinghurst, ärztlichen Erfahrungen im Weltkriege 15 Unthan, Ohne Arme durchs Leben, p. 2. 21 Percy Dunn, FRCS, “Healing in the Kate Forde and Lucy Shanahan Souvenir, the Collection, Duke University Press, 1988, p. 231. 1914–1918, vol VI; “Chirurgie”, Erwin Payr Field. Work of the Army Medical Service. The authors would like to thank Joyce Durham & London, 1993, p. 138 9 MR Werner, Orderly!, Jonathan Cape, New and Carl Franz (eds), Johann Ambrosius SOLDIERS’ bODIES IN THE Great Achievements”, The Times, Thursday Collins at Brighton Museum and Library for 17 It has been observed that “no photograph York, 1930, p. 66. Barth, Leipzig, 1922, pp. 799, 815. WAR MACHINE: 21 September 1916, p. 3. her advice and assistance. is so successful that it filters out the random 10 Emlyn Williams, “Appeal for the Central 2 T Deneke, “Die Verletzungen des TRIAGE, PROPAGANDA AND MILITARY 22 Lord Northcliffe, “The War Doctors. Their 1 The Brighton Herald, 5 December 1914. entirely”. Christopher Pinney and Nicolas Council for the Care of Cripples”, in News Herzbeutels, des Herzens und der großen MEDICAL BUREAUCRACY, 1914–1918 Life Under Fire”, The Times, Wednesday 4 2 The Brighton Herald, 19 December 1914. Peterson, Photography’s Other Histories, Letter. Circulated by the Central Council for Gefäße’ in ibid, vol IX; “Röntgenologie”, Ana Carden-Coyne October 1916, p. 9. 3 ‘Indo-Saracenic’ is derived from Saracen, Duke University Press, Durham & London, the Care of Cripples, 7 (July 1941), p. 5. Rudolf Grashey (ed), Leipzig, 1922, p. 198. 1 Major Blackwood, RAMC, ‘Treatment 23 The Editor, “The Medical Army”, The an archaic name for Muslims. 2003, p. 7. 11 HH Thomas, Help for Wounded Heroes, 3 Hermann Merkel, “Schuß-und of Wounds from First Trench to Field Times, Wednesday 4 October 1916, p. 9. 4 The Brighton Herald, 5 December 1914 18 The Brighton Herald, 19 December 1914. Essential Limb Co, London, 1920, p. 1. Stichverletzungen des Herzens, Herzbeutels Ambulance’, Royal Army Medical Corps, 3rd 24 M Anne Crowther and Marguerite W 5 A short history in English, Gurmukhi and 19 David Omissi, The Sepoy and The Raj: 12 “The Disabled Soldier”, Liverpool sowie der großen Gefäße”, in ibid, vol VIII; Corps Medical Society, p. 230. Dupree, Medical Lives in the Age of Surgical Urdu of the Royal Pavilion, Brighton, and a The Indian Army, 1860–1940: Macmillan Chronicle, 27 June 1917. “Pathologische Anatomie”, Ludwig Aschoff 2 Captain DWJ Andrews, RAMC, war Revolution, Cambridge University Press, description of it as a hospital for Indian soldiers, Press Ltd, London, 1994, p. xviii. 13 GH Slade, Two Sticks, Mills and Boon, (ed), Leipzig, 1921, p 463. diary, 30 August 1915, p. 7; RAMC 2021, Cambridge, p. 347. King, Thorne & Stace, Brighton, 1915. 20 Isar Singh (Sikh, 29th Rifles) to a friend London, 1923, p. 96. 4 A Kappis, “Ueber Schußverletzungen Wellcome Collection, London. 25 Confidential Memorandum, Sir Alfred 6 David Omissi, “India and the Western (50th Punjabis, India), 1 May 1915, 14 Rt Hon Ernest Brown, “Fractures in der großen Gefäße”, Deutsche Medizinische 3 Andrews, 30 August 1915. Fripp, Sir Alexander Ogsten, Sir Cooper Front”, at www.bbc.co.uk/history, accessed Brighton, cited by David Omissi, Indian Wartime”, in News-Letter. Circulated by the Wochenschrift 40 (1914), p. 2120. 4 Captain Henry W Kaye, RAMC war diary, Perry and Dr TJ Horder, 1916; Sir Charles July 2008. Voices of the Great War: Soldiers’ Letters, Central Council for the Care of Cripples, no 5 T Deneke, “Die Verletzungen des Saturday 3 July 1915, p. 71; RAMC 739/5 Burtchaell Papers, RAMC 446/13, 7 Michael O’Dwyer (Governor of the 1914–1918, Macmillan Press Ltd, London, 6 (April 1941), p. 5. Herzbeutels, des Herzens und der großen Wellcome Collection. Wellcome Collection. Punjab), India as I knew It: 1885–1922, 1999, p. 59. 15 M Creach-Henry and D Marten, The Gefäße” in Otto von Schjerning, op cit, vol 5 Kaye, 14 July 1915, p. 91. 26 Committee Interview with Colonel Constable & Co, London, 1925. 21 Cited by John Mack in “Medicine and Unknown Warrior, Society for Promoting IX; “Röntgenologie”, Rudolf Grashey (ed), 6 Kaye, 24 May 1916, p. 242. Burtchaell, Army Medical Corps, “Meeting 8 The Brighton Workhouse was also rapidly Anthropology in Wellcome’s Collection” in Christian Knowledge, London, 1923), p. 5. Leipzig 1922, p. 198. 7 Kaye, 23 September 1915, p. 189. on the Evening of Arrival in France, transformed into the Kitchener Indian Ken Arnold and Danielle Olsen, Medicine 16 Private Arthur H Hubbard, “Letters 6 Alexander Moritz Frey, Die Pflasterkästen. 8 With the Forty-Fourths. Being a Record 1st September 1917, Hotel Delveaux, Hospital, and other substantial premises in Man: The Forgotten Museum of Henry Written May—November 1916”, Imperial Ein Feldsanitätsroman, Kiepenheuer, of the Doings of the 44th Field Ambulance Boulogne”, 1917, p. 4; RAMC 1165/2, York Place were made available. Wellcome, The British Museum Press, War Museum archives. Berlin, 1929; reprint, Leipzig & Weimar, (14th Division), Spottiswoode, Ballantyne Wellcome Collection. 9 The Argus, 28 November 1914. London, 2003, p. 215. 17 Quoted by Harvey Cushing, From a 244 245 WARwar ANDand MEDICINEmedicine NOTES

Surgeon’s Journal 1915–1918, Constable 33 Captain L. Gameson, “Diary”, 56, 13 Army physician quoted in Alexander dang thuy tram: database”, Journal of Anxiety Disorders Base, Sangin, which preceded the treatment and Co, London, 1936, p. 489. Imperial War Museum archives. Kluge, Schlachtbeschreibung, Walter-Verlag, last night i dreamed of peace 21 (2007). I was witnessing at Bastion’s field hospital. 18 Miss Dorothy Scholes, “Papers of Miss 34 Wilfred Willett, ‘Memoirs’, 104, Imperial Olten, 1964, p. 132. 1 In addition to providing medical treatment, 11 See, for example, “D.G. Kirkpatrick, 8 ISO containers are the shipping containers Dorothy Scholes”, scrapbook belonging to War Museum archives. 14 Alexander Kluge, Schlachtbeschreibung, Thuy taught young medical workers, mainly Final editorial”, Journal of Traumatic widely used for containerised transport. Dorothy Scholes, nurse at a military hospital, p. 132. in basic nursing skills. Stress 18 (2005), pp. 589–593; Journal of They are widely used by the military for Edward Hall Collection, Wigan Archives STALINGRAD: 15 KTBOQu. for the Sixth Army, Stalingrad, 2 Phosphorous rounds were fired by artillery Traumatic Stress 20 (2007), pp. 449–493. transporting cargo, accommodation and Service. Punctuation and spelling as in original. WOUNDED BODIES AND SOULS 29 November 1942, BA-MA RH 20-6/794. as ‘markers’ to locate targets. Although 12 Rachel Yehuda is the leading modern construction within theatre. 19 William Needles, “The Regression of Wolfgang U Eckart 16 Army Physician, quoted in Kluge, op lethal, they were not designed to be used as researcher into the psychobiology of PTSD. 9 Major Ron Russell hosted, guided and Psychiatry in the Army”, Psychiatry, 9.3 1 See Wolfgang, U Eckart, “Von der Agonie cit, p. 219. lethal weapons. When a target was marked For a general critique, see Raymond escorted me through the majority of my stay (August 1946), p. 176. einer mißbrauchten Armee—Anmerkungen 17 Kluge, p. 219. with phosphorous, it might then be bombed Tallis, “The neuroscience delusion”, Times in Helmand. 20 Sir George H Savage, “Mental Disabilities zur Verwundeten-und Krankenversorgung im 18 Kluge, p. 219. with napalm. It is not clear whether the Literary Supplement 9 April 2008. 10 Night Vision Goggles. for War Service”, The Journal of Mental Kessel von Stalingrad”, in Wolfram Wette, 19 Renoldi in a telephone conversation with young man was hit with a phosphorous 13 Richard A Kulka et al, Trauma and the 11 Lance Corporal Fletcher made a Science, Lxii.259 (October 1916) p. 656. Gerd R Ueberschär (eds), Stalingrad— Toepke on 15 December 1942, in Toepke, round or burned as the result of an accident. Vietnam War Generation, Brunner/Mazel, remarkable recovery. I met with him at 21 Frederick W Mott, War Neuroses and Shell Mythos und Wirklichkeit einer Schlacht, op cit, p. 56. New York, 1990. For critiques, see A Hedley Court rehabilitaion centre in August Shock, Henry Froude, London, 1919), p. 110. Fischer, Frankfurt, 1992, pp. 108–30, on 20 H Seile, Die Tragödie von Stalingrad. Der WHY THE PSYCHIATRY OF WAR Young, The Harmony of Illusions. Inventing 2008. Now an outpatient, he had managed 22 Lieutenant Colonel Philip S Wagner, which the present contribution is based. Untergang der 6. Armee, Verlag “Das andere IS TOO IMPORTANT TO Post-Traumatic Stress Disorder, Princeton to keep his legs, rebuild the strength in “Psychiatric Activities During the Normandy 2 Hans Dibold, Arzt in Stalingrad. Passion Deutschland”, Hannover, 1948, p. 9. BE LEFT TO PSYCHIATRISTS University Press, Princeton, 1995 and BG them and had just finished a four-mile run. Offensive, June 20–August 20, 1944”, einer Gefangenschaft, O Müller, Salzburg, 21 G. Girgensohn, née Vleugels, in a letter to Ben Shephard Burkett and G Whitley, Stolen Valor, Verity 12 Bergen is the common name for the Psychiatry, 9.4 (November 1946), p. 348. 1949, epilogue, p. 215. I would like to thank the author, Freiburg, 11 January 1992. 1 J Stiglitz and L Bilmes, The Three Trillion Press, Dallas, 1998. standard military issue ruck-sack. 23 George Rutherford Jeffery, “Some Dr Gerd R Überschar (MGFA, Freiburg im 22 Captain Mayer, Squadron Leader 9/K.G. Dollar War. The True Cost of the Iraq 14 E Kanter, Shock and Awe Hits Home. US 13 ‘Op Minimise’ is the military code for Points of Interest in Connection with the Breisgau) for his help in the search for files. 27, 21 January 1943, report on the loading Conflict, Allen Lane, London, 2008. Health Costs of the War in Iraq, Washington, suspended non-essential communication. Psychoneurosis of War”, The Journal of 3 V Orator, Leitfaden der Feldchirurgie im conditions at Gumrak, BA-MA RL 30/3. 2 See TE Ricks, Fiasco. The American Military DC, 2007; Committee on Treatment of All internet / email and telephone access Mental Science, lxvi.273 (April 1920), p. 140. Bewegungskrieg, Johann Ambrosius Barth, 23 Radio message from the aircraft Odysseus Adventure in Iraq, Penguin, New York, 2006. Posttraumatic Stress Disorder, Treatment of is blocked for soldiers. Only operational 24 General George Patton, cited in John Leipzig, 1943, p. 24. 17 (pilot Oberfeldwebel Schmidt), 19 January 3 See B Shephard, A War of Nerves. Soldiers and Posttraumatic Stress Disorder: An Assessment communications are still available. This Laffin, Surgeons in the Field, J M Dent and 4 Surgeon-General Renoldi to HQ, Sixth 1943, airfield at Gumrak BA-MA RL 30/3. Psychiatrists in the Twentieth Century, Harvard of the Evidence, Washington, DC, 2007. occurs whenever serious casualties or deaths Sons, London, 1970, p. 285. Army, Stalingrad, 18 November 1942, 24 Toepke, op cit, p. 80; for the following University Press, Cambridge, Mass, 2001. are reported. The policy is rigorously enforced 25 De Witt Mackenzie, Men Without Guns, Bundesarchiv Militärarchiv, Freiburg, RH quotations see pp. 78–80. 4 The resolution of a neurosis by reviving Artist’s Diary, J4MED, Op and is designed to ensure that next of kin are The Blakistan Co, Philadelphia, 1945, p. 30. 20-6/792. 25 Quoted in Stalingrad: die ersten repressed or forgotten ideas of an event. Herrick 7, 03.11.07–26.11.07 only able to hear news from official channels 26 William Wallace, “The Vision of 5 The true number of physicians trapped within authentischen Berichte der russischen Generäle 5 B Shephard, “‘Pitiless psychology’: the role DAVID COTTERRELL rather than through rumour or the press. The the Soldier, With Special Reference to the encirclement of Stalingrad cannot be Rokossowski–Woronow–Telegin Malinin sowie of prevention in British military psychiatry 1 Lt Col Copanni from the Permanent restriction remains in force until confirmation Malingering”, Journal of the Royal Army established today. Certainly there were more russischer Kriegsberichterstatter, Steinberg, during the Second World War”, History of Joint Head-Quarters had been involved of communication with families has been Medical Corps, xxxvii.1, July 1921, p. 43. than the 23 medical officers listed by Manfred Zurich, 1945, pp. 24–5. Psychiatry, 10 (1999), pp. 491–514. in planning and scheduling my training, received—normally within 24 hours. Op 27 John William Roworth [Edward Casey], Kehrig, but rather fewer than 600, the number 26 HM Waasen, Was geschah in Stalingrad— 6 DK Henderson and RD Gillespie, Textbook preparations and deployment to theatre. Minimise was intermittently in force for a “The Misfit Soldier”, 32 and 41, Imperial recalled by Hans Girgensohn, who was flown Wo sind die Schuldigen?, Mirabell Verlag, of Psychiatry, Oxford University Press, 2 The LM (Load Master), is a member of the great deal of the duration of my tour. War Museum archives. See Joanna Bourke into the encirclement as an army pathologist. Zell am See/Salzburg, 1950, p. 52. London and New York, 1950. flight crew on rotary or fixed-wing flights 14 In 2006, British and Canadian troops (ed), Introduction to the The Misfit Soldier, 6 G Toepke, Stalingrad wie es wirklich war, 27 J Wieder, Stalingrad und die Verantwortung 7 Quoted in Shephard, A War of Nerves, p. 164. responsible for the cargo. established a Forward Operating Base on Cork University Press, Cork, 1999. Kogge-Verlag, Stade, 1949, p. 83. des Soldaten. Mit einem Geleitwort von Helmut 8 Shephard, pp. 396–397. 3 MED GRP CP (Medical Group Command the outskirts of Sangin. It is within the 28 Lieutenant Colonel Albert Groves Hulett, 7 Hans Girgensohn, “Als sie einfach Gollwitzer, Second ed, Nymphenburger Verl.- 9 See LS O’Brien, Traumatic Events and Post): the main tent accommodation for the poppy-growing region of Helmand province “Malingering—A Study”, The Military starben—Vor dreißig Jahren: Von Handl, Munich, 1962, pp. 87–8. Mental Health, Cambridge University management and administration of medical and has been the scene of heavy fighting Surgeon, 89.2 (August 1941), p. 138. Hungertod, wagte in Stalingrad niemand 28 Army Commander-in-Chief 6, 1a, to Army Press, New York, 1998; R Yehuda and services at Bastion. with Taliban insurgents. 28 Lieutenant AG May, “Personal zu reden”, in Die Zeit, 6, 2 February1973, Group ‘Don’, 24 January 1943, BA-MA RH A Macfarlane, “Conflict between current 4 DPM (Diffusion Pattern Material): the 15 ‘Wet’ is the Marine term for tea. The Experiences of the War Years 1915–1917”, p. 44. All subsequent quotations from 19 VI/12. knowledge about [PTSD] and its original common abbreviation for camouflage fatigues. marines pride themselves on the retention of p. 32, Imperial War Museum. Girgensohn are from this source. 29 Waasen, op cit, p. 52. conceptual basis”, American Journal of 5 Jono Lee’s foot and lower leg were naval rather than army terminology. 29 Captain Alfred O Ludwig, “Clinical 8 Toepke, op cit, pp. 83–4. 30 Theodor Plivier, Stalingrad, 3rd ed., Psychiatry 152 (1995), pp. 1705–1713; amputated at Selly Oak subsequent to Features and Diagnosis of Malingering 9 Erich Weinert, Memento Stalingrad. Aufbau-Verlag, Berlin, 1946, p. 211. B Raphael, “Does debriefing after evacuation from theatre. He was heard on in Military Personnel. Use of Barbiturate Frontnotizbuch, Worte als Partisanen. 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sites as diverse as a castle in the Czech Republic to a ill, health education, medicine and war, and medicine Medicine, November 2008—February 2009 (London) decommissioned nuclear bunker in Hampshire. Working during the National Socialist era. She has also curated and April—August 2009 (Dresden). contributors’ in many media, including photography, video, audio, major exhibitions on the heart (1995) and the brain (2000). interactive media, Artificial Intelligence and device control, he customises existing technologies to assert new Lucy Shanahan is a Curator of Temporary Exhibitions biographies use values. His work has been shown both nationally Mark Harrison is Professor of the History of Medicine at the Wellcome Collection and co-Curator of War & and internationally. Cotterrell is Professor of Fine Art and Director of the Wellcome Unit for the History of Medicine, November 2008—February 2009. She was at Sheffield Hallam University, and is represented by Medicine at the University of Oxford. He is the author previously Exhibitions Organiser at the Institute of Ken Arnold has worked in a variety of museums on Danielle Arnaud contemporary art. of several books and articles on disease, medicine and Contemporary Arts, London. both sides of the Atlantic. He joined the Wellcome Trust war, including Medicine and Victory: British Military in 1992, after completing his PhD on the history of Medicine in the Second World War (Oxford University museums. He now heads the Trust’s Public Programmes Nicole Draghic is the senior technical research Press, 2004), which won the Templer Medal Book Prize Ben Shephard is the author of A War of Nerves: Soldiers department, running events and exhibitions for analyst and technical writer supporting both research- awarded by the Society for Army Historical Research. and Psychiatrists in the Twentieth Century (Harvard Wellcome Collection. He regularly writes and lectures contract activities for the USMRMC, DARPA, NASA, UP, 2001) and After Daybreak: The Liberation of Belsen on museums and on contemporary relations between NIST, USSOCOM and numerous technical government (Jonathan Cape, 2005). After reading history at Oxford, the arts and sciences. He also serves on a number of support groups including the BioSTAR group, CIMIT, Melissa Larner is co-editor, with James Peto and he was a producer on the BBC’s The World at War series advisory boards and committees. His most recent book the Johns Hopkins Applied Physics Laboratory, Harvey Nadine Monem, of War and Medicine. A freelance editor and then spent two decades making documentaries is Cabinets for the Curious (Ashgate, 2006). Mudd College, the Oregon Medical Laser Center, and writer, she was also co-editor and contributor to the about history and science. He has held visiting-research Washington University and the University of Cincinnati. Wellcome Collection’s BMA award-winning The Heart fellowships at Yale and New York Universities, gave the She has written extensively on technology development (published with Yale University Press, 2007). She has Lees Knowles Lectures on military history in 2006, and Joanna Bourke is Professor of History at Birkbeck in neurotrauma, resuscitation technology and tissue edited numerous books, catalogues and articles on the is currently a Visiting Research fellow in the Leverhulme College, University of London. She has published seven engineering, and has recently co-authored the leading arts and culture for Tate Publications, Phaidon Press, Changing Character of War programme in Oxford. He is books, on Irish history, gender and the body, the history chapter on telemedicine in Expedition and Wilderness Riding House Editions, the Serpentine Gallery and frieze preparing a book on refugees after the Second World War. of psychological thought, modern warfare, the emotions, Medicine (Cambridge University Press, 2008). magazine, amongst many others. and sexual violence. Her books have been translated into Chinese, Italian, Portuguese, Spanish, Catalan, Greek Hugh Small is a former management consultant who and Turkish. An Intimate History of Killing: Face-to-Face Wolfgang U Eckart studied medicine, history and Dr John A Parrish is director of CIMIT, Center for has written books on Florence Nightingale and the Killing in Twentieth Century Warfare (Granta) won the philosophy at the University of Munster. Since 1992 Integration of Medicine and Innovative Technology Crimean War, and frequently lectures and broadcasts Fraenkel Prize in Contemporary History (1998) and the he has been Professor of the History of Medicine at the (a Boston-based consortium of major teaching on both subjects. His study of Florence Nightingale Wolfson History Prize (2000). Fear: A Cultural History University of Heidelberg. Previously, he was professor hospitals and engineering schools committed to included important new research into her analysis of was published by Virago in 2005. Rape: A History from and director of the Department of Medical History facilitating improvements in healthcare through wartime mortality and the development of her interest 1860s to the Present, was published by Virago in 2007. at Hannover Medical School. From 1996 to 1998 he technology. A graduate of Duke and Yale Universities, in public health. His parents were both doctors and he was President of the German Society for the History of he trained in internal medicine and dermatology. grew up in a house in Harley Street opposite the site of Science. His research and teaching activities include He was a battlefield doctor in Vietnam and Chair of Florence Nightingale’s hospital. Dr Ana Carden-Coyne is Lecturer in War/Conflict medicine and colonial imperialism; the history of Dermatology Department at Harvard Medical School. He Studies at the Centre for the Cultural History of War tropical medicine; nineteenth- and twentieth-century has more than 300 publications to his name, including (University of Manchester). She works on war medicine, medical missions; medicine and war; and the history six books. He is a member of the Institute of Medicine, KLAUS VOGEL is Director of the Deutsches Hygiene- memory and commemoration, the history of the body, and ethics of medical experimentation. National Academy of Science, and the Science Advisory Museum, Dresden. Having studied Cultural Sciences disabilities, and the ethics of representation. She Board, National Space Biomedical Institute. and Educational Sciences he worked in management. co-edited Cultures of the Abdomen: A History of Diet, He has been at the Deutsches Hygiene-Museum since Digestion and Fat in the Modern World (with Christopher Kate Forde is a Curator of Temporary Exhibitions at 1991, firstly as the Head of Exhibitions and, since 2000, E Forth, Palgrave, 2005); a special edition of European the Wellcome Collection, London, and co-Curator of James Peto is Senior Curator of Public Programmes as Director. Since 2007 he has been Honorary Professor Review of History entitled ‘Enabling the Past: New War & Medicine, at the Wellcome Collection, November at the Wellcome Trust and one of the curators of the at the School of Fine Arts in Dresden. Perspectives in the History of Disability’ (with Julie 2008—February 2009. She has held posts at Arts Council exhibition War and Medicine at Wellcome Collection, Anderson, 2007), and her monograph Reconstructing the England, Tate, and the Metropolitan Museum, New York. November 2008—February 2009, as well as co-editor Body: Classicism, Modernism and the First World War of this book. Previously he was Exhibitions Curator at Dr William P Wiesmann has dedicated his career will be published by Oxford University Press, 2009. Her the Whitechapel Art Gallery and Head of Exhibitions to the research and development of innovations to current project is Men in Pain: Injury, Disability and Susanne Hahn has been director of the Heimerer social- at the Design Museum, London. improve medical care in trauma, military and emergency Masculinity in the First World War. care training school in Döbeln, Saxony, since 2000. medicine. He served as a medical researcher for the US Previously, she was exhibition curator at the German Army at the Walter Reed Army Institute of Research, Hygiene Museum, Dresden. Following her training Colleen M Schmitz is Curator and Head of the rising to research director for combat-casualty care at David Cotterrell studied at Central St Martins College in medicine and her postgraduate studies in Internal Exhibition and Registrar’s Office at the Deutsches the US Army Medical Research and Matériel Command. of Art and Design, Winchester School of Art and Chelsea Medicine, she also worked as a GP and a lecturer. Her Hygiene-Museum in Dresden. She is also the project He is founder, president and CEO of the BioSTAR School of Art. His work has often been constructed academic publications and lectures have covered the leader from the Hygiene-Museum for the collaboration Group, a collective of companies specialising in specifically for certain environments, in response to history of suicidal tendencies, the care of the terminally with Wellcome Collection on the exhibition War & lifesaving advances in equipment and technologies. 252 253 war and medicine INDEX

INDEX 254 255 war and medicine INDEX 256 war and256 medicine COLOPHON colophon

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