Being Wounded

I’ve been working on my essay on ‘Woundscapes of the Western Front, 1914-1918’.  What follows is the section dealing with the act of being wounded, drawn from a series of diaries, letters and memoirs; it’s followed by a section fleshing out the concept of a woundscape which I’ll post in due course [for a preliminary sketch, see here].

Subsequent sections reconstruct the precarious journey of casualties from the point of injury through the aid posts, dressing stations and casualty clearing stations to the base hospitals on the French coast and beyond (for a quick sketch, see here, and for an experimental version inspired by Harry Parker‘s Anatomy of a soldier, see here).

This is very much a working version, so please read it as such – and as always I’d welcome any comments or suggestions.  I’ve added some links and images (most of them from my presentations), though those included in the final version are likely to be different.

I should add that this is one part of a much larger project that also considers medical care and casualty evacuation in other war zones: the Western Desert in the Second World War, Vietnam, and Afghanistan and Syria today.

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John Keegan once remarked that in military histories the wounded seem to ‘dematerialize as soon as they are struck down’. [1] This matters for more than historical reasons, however, because the wounded serve as a testament to what Elaine Scarry insists is ‘the main purpose and outcome of war’, which is to say injuring. This ugly fact, she argues, can be ‘made to disappear from view along many separate paths.’ [2] In order to bring it back, I attempt to have the wounded reappear on – and through – the paths they followed after they were injured. Most of what I have to say is confined to the British Army and its colonial and imperial counterparts from Australia, Canada, India, New Zealand and South Africa on the Western Front. [3]  The details differ in other militaries and other theatres, but the elemental geography of casualty evacuation was a general one.  My focus is confined to the effects of physical injury and I do not directly address what was eventually diagnosed as ‘shell shock’, but it will soon become clear that the trauma of being wounded was far from a purely physical affair and that it was suffused with emotional reactions that played a vital role in rescue and recovery. [4]

Trauma typically ruptures ordinary language – another of Scarry’s astute insights – and it is scarcely surprising that many witnesses to the broken bodies trailing across the battlefields should have turned to metaphor to convey the enormity of the toll.[5] On 1 July 1916, the first day of the battle of the Somme [above], a British officer found his trench ‘blocked with wounded men who were trying to make their way back to the dressing station’, and as Capt Radclyffe Dugmore surveyed the scene he was struck by the mechanical nature of both military violence and military medicine.

 ‘Here was this line of men, who little more than an hour ago were normal men in the finest of health and strength, and now maimed, and with every degree of injury, they painfully made their way back to the human repair department. The well men were rapidly moving eastward in countless numbers, going forward to the assistance of their comrades, while the injured so laboriously dragged their way back, two human streams, the sound and the unsound. Before us, all energies were devoted to destruction; behind us, all human power and skill tried to repair the damage.’ [6]

.The language of ‘wrecks’ was commonplace.  To Sister Kate Luard ‘the wards [were] like battlefields, with battered wrecks in every bed.’   The task of casualty evacuation, explained one medical orderly, was ‘to move these helpless pieces of wreckage, as rapidly and comfortably as may be, to the place where they will in due course be repaired.’ [7]  The language of ‘repair’ was a common one too, and I will return to its significance shortly.

Three weeks after Dugmore’s observation, and not far from his position, a wounded Australian soldier making his way from aid post to dressing station described the same awful scene but in a different, animate register:

‘Ahead of us and behind us as far as the eye could see, a long column of walking wounded slowly made their way through the valley and across the ridges.  From a distance the khaki column resembled a huge brown snake crawling across the country.’ [8]

Hartnett’s pained allusion was evidently not to a serpent entwined around a staff, the classical symbol for medicine; the intended effect was altogether more venomous. [9]  Still more sinister was the common imagery of the shambles and the slaughterhouse. Wilfred Owen described the infantry training camp on the French coast at Étaples as ‘neither France nor England, but a kind of paddock where the beasts are kept a few days before the shambles.’  In the sixteenth century a shambles was an open-air slaughterhouse, and the term was readily extended to the modern battlefield. Watching the stretcher-bearers file past after the Battle of Festubert with their burden of bloodied bodies one Guards officer recoiled in horror: ‘fine upstanding fellows only a few hours before’, they had become ‘nauseatingly repulsive’,  ‘hideously injured carcases.’ Doctors sometimes had the same reaction and resorted to the same imagery.  ‘Although but a middleman,’ confessed Capt Lawrence Gameson at a dressing station on the Somme, ‘one gets sick of blood’s smell and of the endless everlasting procession of red raw human meat passing through our hands.’If the injured survived they were consigned to a Casualty Clearing Station, what one senior medical officer – one of many, as it turns out – called his ‘Butcher’s Shop’, wherein Philip Gibb was nauseated by the ‘great carving of human flesh’.  One chaplain remembered a surgeon who had been working 24 hours without a break: ‘In the middle of it all he turned away from one table and looked up as another one was being carried in, and he shook his head.  He was covered in blood – we all were – and he said, “This isn’t a hospital, it’s a butchery.”’ [10]

Those two imaginaries, the mechanical and the animate, collided most explosively and intimately in the act of being wounded.  Those who wrote about it often expressed their surprise, even disbelief that it had happened to them – pain came later – or registered the immediate sensation of a tremendous blow. On the first day of the Somme it never occurred to Lt Edward Liveing that he had been wounded:

‘Suddenly I cursed. I had been scalded in the left hip. A shell, I thought, had blown up in a water-logged crump-hole and sprayed me with boiling water. Letting go of my rifle, I dropped forward full length on the ground. My hip began to smart unpleasantly, and I felt a curious warmth stealing down my left leg. I thought it was the boiling water that had scalded me. Certainly my breeches looked as if they were saturated with water. I did not know that they were saturated with blood.’ [11]

But when Sgt R.H. Tawney was hit later the same day he had no doubt he had been hurt:

‘I felt … that I had been hit by a tremendous iron hammer, swung by a giant of inconceivable strength, and then twisted with a sickening sort of wrench so that my head and back banged on the ground, and my feet struggled as though they didn’t belong to me. For a second or two my breath wouldn’t come. I thought – if that’s the right word – “This is death”, and hoped it wouldn’t take long. By-and-by, as nothing happened, it seemed I couldn’t be dying. When I felt the ground beside me, my fingers closed on the nose-cap of a shell. It was still hot, and I thought absurdly, in a muddled way, “this is what has got me”. I tried to turn on my side, but the pain, when I moved, was like a knife, and stopped me dead. There was nothing to do but lie on my back.’ [12]

Three weeks later, still on the Somme, Lt Robert Graves had a similar sensation when he was seriously wounded. ‘An eight-inch shell burst three paces behind me,’ he recalled.

‘I heard the explosion, and felt as though I had been punched rather hard between the shoulder blades, but without any pain.  I took the punch merely for the shock of the explosion; but blood trickled into my eye and, turning faint, I called to Moodie [his company commander]: “I’ve been hit.” Then I fell…’ [13]

His friend Lt Siegfried Sassoon’s reaction to being wounded during the Battle of Arras the following year)was much the same.  He too knew at once that he had been hurt, even if he was not sure how. ‘No sooner had I popped my silly head out of the sap,’ he wrote much later, ‘than I felt a stupendous blow in the back between my shoulders. My first notion was that a bomb [grenade] had hit me from behind, but what had really happened was that I had been sniped from in front…To my surprise I discovered that I wasn’t dead.’ [14]

As these accounts indicate, for many wounded soldiers the proximity of death was palpable: space sensibly contracted to their wound, their body and its immediate surroundings.  ‘A man badly knocked out feels as though the world had spun him off into a desert of unpeopled space,’ Tawney admitted: a feeling heightened by the standing order forbidding troops from stopping to aid the wounded during an advance. ‘Combined with pain and helplessness,’ he continued, ‘the sense of abandonment goes near to break his heart.’ [15]  When Pte David Jones was shot in the leg on the Somme shortly after midnight on 11 June 1916, and left barely able to crawl, a corporal hoisted him on his back until a major saw what he was doing and told him:

 ‘“Drop the bugger here” for stretcher-bearers to find. If every wounded man were to be carried back, their firepower would be cut in half. “Don’t you know there’s a sod of a war on?”’ [16]

Many of the seriously wounded stumbled or crawled into shell-holes to wait for their rescuers; some lay out for days.  On the first day of the Somme Pte A. Matthews was escorting German prisoners back across No Man’s Land, that narrow strip between the opposing lines of trenches, when he was shot in the thigh.  An officer dragged him into a disused trench and bound up his wound as best he could before rejoining the advance. While the trench sheltered Matthews from direct fire (‘shells were bursting all around me’), he realised that unfortunately it also concealed him from the view of any rescuers.  Later that day a company runner chanced to see him and left his water-bottle, but Matthews was unable to move – ‘I might as well have been chained to the ground’ – and as night fell all he could do was shout for help.  Nobody came.  He eked out his iron rations and water, but by the third day it was all gone. The next night a group of wounded men making their way back found Matthews, and shared the iron rations they had scavenged from the dead.  They could do no more for him, but promised to get help.  An hour or two later they returned, disoriented,  and set off in a different direction.  The next night they came back again, ‘in a terrible state’, one of them crawling on his hands and knees.  They shared some biscuits and water before setting out once more; Matthews never saw them again.  The next morning a shell-burst buried the biscuits and pierced his water-bottle, and he was reduced to catching rain in his helmet and drinking from pools of water in the trench. He drifted in and out of consciousness until, ten days later, an officer on patrol found him – ‘nearly treading on me’ –  and dug him out before getting him onto a stretcher. When he reached the Advanced Dressing Station at Sailly he was ‘a mere skeleton’: he had been lying out in No Man’s Land for 14 days. [17] This was something of a record; Matthews’s experience combines bad luck and good luck in equal measure, and it is impossible to know how many others succumbed to their injuries while waiting or, perhaps like the party of wounded men who stumbled back to his trench time and time again, never made it to safety.

If they were fortunate the wounded would have others for comfort and company while they waited, but all any of them had for first aid was a field dressing and an ampoule of iodine.  Capt Harold McGill reckoned that  ‘the obsessing fear of the men was death from hemorrhage’ – understandably so in the absence of effective blood transfusion until late in the war – and the field dressing was the first vital response to bring bleeding under control. [18] One soldier explained:

‘The first field dressing which each man carries sewn in the lining of his tunic has saved many lives. Comprising as it does two pads of gauze and cotton-wool and a bandage, it can be ripped out of its case and clapped on to the wound, and so save the injured man, who may have to lie out hours before he can be taken back to a dressing-station, many risks from loss of blood or outside infection.’ [19]

 

Of course, the utility of the dressing depended on the nature of the wound. The same man recalled a lecture from his Medical Officer, who had explained that a field dressing could be used to stop bleeding from an arm or a leg, but ‘if the man was hit in the body or head – well, the doctor shrugged his shoulders in a way that made us think.’ [20]If they were not alone the wounded might also be able to improvise a tourniquet or even a splint with their bayonet or rifle, and if the iodine bottle had not smashed – unlikely, McGill thought: ‘The men reported to me that during the action they had nearly always found their pocket ampoules of iodine tincture broken when the time came to use them’ [21]– they could make a rudimentary attempt at cleaning the wound.

Given the cascading combination of immediacy, difficulty and uncertainty it is scarcely surprising that the space of the wounded should have contracted so drastically. And yet at the same time that space expanded, partly through what had become the taxing task of traversing even a short distance to relative safety, and partly through the tantalizing prospect of a ‘Blighty’, a wound judged sufficiently serious to require evacuation to Britain (and perhaps beyond for troops who came from elsewhere in the Empire). [22]

Arthur Empey came round from surgery at a Casualty Clearing Station to find rows of soldiers lying on stretchers: ‘The main topic of their conversation was Blighty. Nearly all had a grin on their faces.’ [23]  One medical orderly explained that ‘a wound, even when serious, is the messenger of freedom’ – and he had never met a wounded man who wanted to return to the trenches. [24]Another had ‘only heard of one who said that he was anxious to return there, and he was subsequently transferred to No. 2 General Hospital in Le Havre, where the huge numbers of mental cases were cared for.’ [25]

Even so, the extended space of evacuation was a fraught and dangerous one.  Many of the wounded fell in No Man’s Land, in the front-line trenches themselves, or in broken land during the fluctuating tides of advance and retreat in the opening and closing phases of the war. They were injured in major offensives (‘pushes’), in small raids (‘stunts’) and by routine, almost ritualized shelling and firing (‘the morning hate’).  These were the most immediate danger zones in space and in time, extending back towards the reserve trenches and the small towns and villages in the rear.  The wounded were supposed to move within a legal envelope that protected them from further attack.  The Hague Regulations stipulated that ‘all necessary steps must be taken to spare’ – as far as possible – ‘places where the sick and wounded are collected.’  But that possibility was none the less limited.  Firing and shelling were often notoriously inaccurate, casualty clearing stations were routinely located close to batteries and railheads, and it was not always easy to make out the red cross symbol that was supposed to guarantee protection.  In the final months of the war even base hospitals on the French coast were bombed, while hospital ships crossing the Channel ran the gauntlet of mines and torpedoes. [26] If the wounded imagined travelling through an extended space towards safety, then it was a safety rendered conditional by the continued risk of attack. And the journey itself always exacted its own, sometimes deadly toll on the wounded body, which prompted Patrick MacGill to write of being ‘a passenger on the Highway of Pain that stretched from Lens to Victoria Station’. [27]

My purpose is to reconstruct that highway and the relationship between wounded bodies and the journeys they undertook.  Many of those planning for war had a remarkably sanitized view of both.  When one hard-pressed volunteer with the British Red Cross Society, working at a field hospital in Belgium in September 1914, described her pre-war training she recalled

‘the drill and the white-capped stretcher-bearers at home, and the little messenger boys with their innocuous wounds, which were so neatly and laboriously dressed.

The messenger boys’ wounds were always conveniently placed, and they never screamed and writhed or prayed for morphia when they were being bandaged. And shoulders were not shot away, nor eyes blinded, nor men’s faces – well, not much good ever came of talking of the things one has seen, and they are best left undescribed. “These are not wounds, they are mush,” I heard one surgeon say; and then I thought of the little messenger boys and their convenient fractures.’ [28]

 

The wounds were not the stylised, artfully coloured images of the text book and when G.H. Makins suggested that a survey of them ‘forcibly reminds the observer of the water-colour drawings made by Sir Charles Bell’ he was referring to Bell’s extraordinary ability to convey the horrific damage wrought by musket balls and shrapnel during the Peninsular War.  Bell was a military surgeon and his sketches were no less remarkable for their rendering of the agony, despair and sheer terror of the wounded: a far cry, as he noted, from the text-books. [29]

Similarly, schemes for medical evacuation typically displayed an elegant linear geometry, an abstract grid of transmission lines that resembled what Fiona Reid called ‘a modernist dream’ with no catastrophic breaks or nightmare tangles (Figure 3). [30]  This highly imaginative geography of an evacuation machine, carefully oiled and smoothly running, intersected with debates around a politics of speed. [31]  [For much more, and a detailed case study, see my post on ‘The Leaden Hours’ here].  In the first months of the war there were complaints that it was taking far too long for the wounded to be brought from the firing zone to hospitals on the French coast. These reports provoked sufficient public unease for Lord Kitchener, Secretary of State for War, to send Col Arthur Lee to France to investigate.  In a series of private communications Lee conceded that ‘in surveying the scene from London, or studying it upon a map, questions of transport present no very serious difficulties’, whereas once in France it quickly became obvious that getting the wounded to railheads was complicated by intense enemy shelling, and that the railways were under enormous pressure – ‘the wounded must of course give way to food, ammunition and reinforcements for the fighting forces’ – and with many bridges destroyed and signalling systems dislocated the hastily improvised ambulance trains, often little more than cattle trucks filled with straw, had ‘to slowly explore their own way back towards [the hospitals at] the Base.’ [32]  Two years later the politics of speed had reversed; the concern now was that the RAMC had become so fixated on rapid evacuation that the injured were suffering needlessly.  The debate reached its climax when Sir Almroth Wright, Consultant Physician to the British Expeditionary Force, criticized what he saw as the preoccupation with rapid evacuation, ‘hustling the wounded from hospital to hospital’ he called it, and the overwhelming importance attached to ‘the fact that a [Casualty Clearing Station] has passed so many thousands or tens of thousands of wounded through the wards, evacuating these in a minimum of time so as to be at disposal for reception of more patients.’ He claimed that as soon as a new convoy arrived at a base hospital, and as a direct result of ‘the catastrophes which are associated with long journeys’ from the Casualty Clearing Station, ‘amputations and other operations in large numbers have to be performed upon men who had been judged fit to travel’ (my emphasis). Wright’s complaints were summarily – and angrily – dismissed as ignorant and even ‘stupid’ in what was a bitter personal dispute, and the official response doubled down on the machine-like efficiency of the evacuation system.

What flickers in the fissures of these exchanges is the stubbornly, viscerally bio-physical: injured bodies did not present themselves as pristine plates in a medical atlas and their precarious journeys were not inscribed on the paper trails of an evacuation plan.   The relations between the two were not only intimate; they were also reciprocal. The nature of the wound materially affected evacuation.  Treatment times and pathways for ‘walking wounded’ and stretcher-cases were different, for example, and the worst cases were often the last to reach a Casualty Clearing Station and – if they survived – they travelled much further down the line and ultimately back to Britain.  Those journeys in turn affected the wound: rescuing casualties from No Man’s Land was almost always at the risk of further injuries from enemy fire, for example, and as bearers struggled to carry stretchers over shell-shattered ground and through waterlogged trenches, as ambulances bumped and skidded over muddy tracks and torn-up roads, and as ambulance trains clanked and wheezed their way to the coast, the spasmodic jolting greatly aggravated pain and increased the risk of haemorrhage.

To be continued

[1]John Keegan, The Face of Battle(London: Pimlico, 2004), p. 40; Keegan was referring specifically to General Sir William Napier’s account of the battle of Albuera in 1811, but he was also sharpening a general point.

[2]Elaine Scarry, The Body in Pain: the making and unmaking of the world (New York: Oxford University Press, 1985) p. 64.

[3]Regiments were raised from other British colonies in the Caribbean and Africa too, and also in Newfoundland; in some cases colonial and imperial casualties were treated by their own medical services, and in others by the RAMC, though they all worked in close concert with one another.  For a general discussion, which extends to the French and German medical services, see Leo van Bergen, Before my helplesssSight: suffering, dying and military medicine on the Western Front, 1914–1918 (London: Routledge, 2016).

[4]On ‘shell shock’ and, of direct relevance to my discussion, what was known as ‘wound shock’, see Stefanos Geroulanos and Todd Myers, The human body in the age of catastrophe: brittleness, integration, science and the Great War(Chicago: University of Chicago Press, 2018) especially Ch. 2.

[5]Casualty estimates are notoriously difficult, but on the Western Front more than five million from the Allied armies were wounded, most of them from France and the United Kingdom, and more than three million from the Central Powers, principally Germany and Austria-Hungary.  There were also tens of thousands of civilian casualties, from towns and villages close to the front lines but also from long-distance shelling and air strikes much more distant from battlefields whose boundaries were already dissolving.

[6]Captain A. Radclyffe Dugmore, When the Somme ran red(New York: George H. Doran, 1918) pp. 201-2.  Hence too Mark Harrison’s apt description of a ‘medical machine’ assembled on the Western Front: The Medical War: British Military medicine in the First World War (Oxford: Oxford University Press, 2010).  The imagery of two streams was a common one too, and so was its mechanical rendering. ‘One of the most stabbing things in this war,’ wrote Sister Kate Luard, ‘is seeing the lines of empty motor ambulances going up to bring down the wrecks who at this moment are sound and fit, and absolutely ready to be turned into wrecks’: John Stevens (ed) Unknown warriors: the letters of Kate Luard1914-1918(Stroud, UK: History Press, 2014) 8 May 1915.

[7]Stevens, Unknown warriors, 10 April 1917; Ward Muir, ‘An intake of wounded’, in Happy though wounded: the book of the 3rdLondon General Hospital(London: Country Life, 1917) p. 64.

[8]H.G. Hartnett, Over the top(Sydney: Allen and Unwin, 2009) p. 60; Hartnett wrote his memoir in the early 1920s from diaries he had kept during the war.

[9]His own journey was a long and painful one. ‘After tramping five or six miles in search of medical attention,’ Hartnett continued, he and his mates ‘finally reached Albert, where the confusion was even worse if that was possible. Long lines of wounded men along the footpaths and roadways were waiting their turn to get attention from doctors and their assistants, stationed at intervals along the roads, out in the open’ (p. 61).  From Albert he was taken by lorry and light railway to a casualty clearing station and, after his wound had been dressed, by ambulance train to Rouen; then it was on to Le Havre and a hospital ship bound for Southampton.

[10]Wilfred Owen, Collected Letters(ed. Harold Owen and John Bell) (Oxford: Oxford University Press, 1967) 31 December 1917; ‘An O.E.’ [G.P.A. Fildes], Iron times with the Guards(London: John Murray, 1918) pp. 74-5; Lawrence Gameson, Private Papers, IWM Doc 612; Philip Gibbs, Now it can be told(New York: Harper, 1920) p. 374; Capt Leonard Pearson, in Lyn MacDonald, The Roses of No Man’s Land(London: Penguin, 1993) p. 187.

[11]Edward G.D. Living, Attack: An Infantry Subaltern’s Impression of July 1st, 1916 (New York: Macmillan, 1918) pp. 69-70.  He managed to walk out after one of his men applied iodine and a field dressing to his wound, but walking became steadily more painful; eventually, weak from loss of blood, he was placed on a stretcher and wheeled to an advanced dressing station, and from there he was taken by ambulance to a Casualty Clearing Station.

[12]R.H. Tawney, ‘The attack’, Westminster Gazette, 24-5 October 1916.

[13]Graves confessed that his memory of what happened next was ‘vague’. He was not expected to survive, and was taken to a dressing station where he remained unconscious; when his commanding officer went down and saw him lying in a corner ‘they told him I was done for.’But the next morning an ambulance took Graves to a Casualty Clearing Station, where he remained until 24 July when he was put on an ambulance train for a Base Hospital on the coast and was eventually repatriated to Britain. Meanwhile his commanding officer had written to his mother tendering his condolences at the loss of her son.  Robert Graves, Goodbye to all that (London: Penguin, 2000; first published in 1929) pp. 180-2.

[14]Siegfried Sassoon, Memoirs of an infantry officer(London: Faber, 1930).  This is a fictionalised account of Sassoon’s experience on 16 April 1917; he recorded his more immediate reactions in his journal but said virtually nothing about the initial shock of being hit.  He left the trench as ‘walking wounded’ and, after his wound was dressed at an aid post, was driven to a Casualty Clearing Station: Sassoon Journal, Cambridge University Library MS Add. 9852/1/10.h

[15]Tawney, ‘Attack’.

[16] Jones resumed his crawl and was eventually found by a bearer party:  Thomas Dilworth, David Jones and the Great War (London: Enitharmon Press, 2012) p. 117. Tiplady, Soul of the soldier, p. 131 explained the logic behind the injunction: ‘When a man falls his neighbor cannot stay with him. He must press on to the objective, otherwise, if the unwounded stayed to succor the wounded, there would be none to continue the attack.’ This was of course emotionally hard. ‘The grimmest order to me was that no fighting soldier was to stop to help the wounded,’ one sergeant confessed.  ‘The CO was very emphatic about this. It seemed such a heartless order to come from our CO who was … looked upon as a religious man. I thought bringing in the wounded was the way Victoria Crosses were won. But I realized that this would be an order to the CO as well as us from the General and that the whole of the attack could be held up if there were many wounded and we stopped to help them’: Sgt Charles Moss, in Richard van Emden,  The Somme(Barnsley UK: Pen and Sword, 2016) p. 00.

[17]A. Matthews, ‘I was fourteen days in No Man’s Land’, I Was There!pp. 688-691; Capt A.W. French, War Diary (Liddle Collection), 14 July 1916.  For another vivid account of a survivor, see the memoir written after the war by John Stafford describing his wounding on the Somme on 8 August 1916:https://www.europeana.eu/portal/en/record/2020601/contributions_3155.html?q=%22John+Stafford%22.

[18]McGill, Medicine and Duty, pp. 118-9.

[19]Arthur Mills, Hospital Days(London: T. Fisher Unwin, 1916) p. 14.

[20]Mills, Hospital days, p.

[21]McGill, Medicine and Duty, p. 157.

[22]‘Blighty’, a corruption of the Urdu vilayati(‘foreign’ or ‘European’)  was first used by Indian soldiers to refer to Britain in the Boer War; its use became widespread in the First World War.

[23]Arthur Empey, Over the top(New York: G.P. Putnam, 1917) p. 00.

[24]Christopher Arnander (ed), Private Lord Crawford’s Great War Diaries(Barnsley, UK: Pen and Sword, 2013) 30 September 1915.  ‘To these men,’ Crawford added, ‘the relief of leaving the front honourably wounded is inconceivable after months of killing, anxiety and fatigue.’ David Lindsay, the Earl of Crawford, enlisted in the RAMC as a private in April 1915 at the age of 43; in July 1916 he returned to the UK as a member of the coalition government.

[25]M.R. Werner, Orderly!(New York: Jonathan Cape & Harrison Smith, 1930) p. 76.

[26]Stephen McGreal, The war on hospital ships, 1914-1918(Barnsley UK: Pen and Sword, 2009).

[27]Patrick MacGill, The Great Push: an episode of the Great War(New York: Grosset and Dunlap, 1916) p. 254. This was a memoir lightly disguised as fiction; MacGill was wounded at Loos on 28 September 1915, and in the preface wrote that he had ‘tried to give, as far as I am allowed, an account of an attack in which I took part’ (p. 7).

[28]Sarah Macnaughtan, A woman’s diary of the war(London: Nelson, 1916) p. 23.  Similar make-believe drills took place behind the front lines, where they were met with a healthy cynicism by ‘wounded’ and stretcher bearers alike.  ‘After heavy losses we would get reinforcements and this would be followed by a Field Day to break in the newcomers’, explained one orderly with a Field Ambulance.  ‘Men with labels describing their supposed injuries were hidden in unlikely spots and had to be found and dealt with as if actually wounded’: Edwin Ware, Diary,p. 94 [WL:RAMC/PE/1/707].  One private recalled a rehearsal for a ‘special stunt’ in which he played a casualty: ‘My wounds were not too painful to prevent my enjoyment of the spectacle while waiting for the stretcher bearers, who did not seem in a great hurry. Casualties here had their own choice of wounds, and they all seemed to prefer some wound which made it impossible to walk a step, much to the disgust of the stretcher bearers.After some argument with the stretcher bearers who came at last to attend to me, I was bundled unceremoniously on to a stretcher with my mess tin making itself unpleasant in the middle of my back, despite the fact that both my legs had been shattered (in theory)’: Doreen Priddey (ed.), A Tommy at Ypres: Walter’s War(Stroud: Amberley Publishing, 2011) 5-9 December 1916.

[29]G.H. Makins, ‘A note upon the wounds of the present campaign’, The Lancet, 10 October 1914 (p. 905); M.K. H. Crump and P. Starling, A surgical artist at war: the paintings and sketches of Sir Charles Bell 1807-1815 (Edinburgh: Royal College of Surgeons, 2005).  Bell uncannily prefigured the horrors for which his successors were equally ill-prepared one hundred years later.  ‘The cases I have had under my care,’ he wrote in his Dissertation on gunshot wounds(1814), ‘have proved to me that the books we possess upon the subject of field-practice do not even hint at the nature of the difficulties the surgeon has to encounter there.’

[30]Fiona Reid, Medicine in First World War Europe: Soldiers, Medics, Pacifists (London: Bloomsbury, 2017) p. 19.

[31]Derek Gregory, ‘The politics of speed and casualty evacuation on the Western Front, 1914-1918’, forthcoming.

[32]

The Leaden Hours

Ever since I attended a conference at Nijmegen on Transmobilities I’ve followed the current interest in ‘mobilities’, though from a distance and perhaps in strange ways: but I think that the following study contributes to that debate as well as to quite different preoccupations with the intersections of military geography, medical geography and my current research on woundscapes and ‘trauma geographies‘. Let me know what you think.

Modern trauma response pays close attention to what happens in the ‘platinum ten minutes‘ immediately after injury and treats the ‘golden hour‘ to definitive medical treatment as the standard to which casualty evacuation should adhere.  I explored the implications of these metrics for treatment outcomes and survival rates in Afghanistan in ‘the geographies of sixty minutes‘, and as part of my comparative work I’ve been examining the speed of casualty evacuation on the Western Front in the First World War.

The politics of speed

This turns out to be a complicated issue, and one that attracted considerable controversy – both professional and political – throughout the war.  There are summaries in Ian Whitehead‘s Doctors in the Great War and in Ana Carden-Coyne‘s The politics of wounds, but some of the sharpest exchanges (in early January 1917) were sparked by a memorandum from Sir Almroth Wright, Consultant Physician to the British Expeditionary Force, criticising what he saw as the preoccupation with rapid evacuation at all costs.  His charges were summarily dismissed by General Sir Arthur Sloggett, (right, shown in 1917), the Director-General of Medical Services for the British Expeditionary Force – in angry memoranda and meetings and in acerbic private correspondence – as being entirely without foundation and, indeed, ‘ignorant’ and even ‘stupid’ (see RAMC 365/4 here).

Some front-line medical officers were more perturbed than these exchanges suggest.  Surgeon Henry Kaye, for example, addressed the issue in his diary for 24 January 1916, when he sought an explanation for the mortality rates from ‘different classes of wounds’ passing through his casualty clearing station:

‘I should surmise that the only controllable factor is that of transport – ie that a certain percentage of the mortality is due to the transport of seriously wounded men – people are so pleased with the excellence of the transport arrangements (ambulances, trains, and ships) that they forget what a great additional strain any transport imposes on the patients, and are apt to lay approving stress on how quickly they have transported thousands of cases to England, without regarding (or at least mentioning) how many men this express transport has cost their lives. (Diary, Wellcome Institute, RAMC 739/4)

Notice that word ‘surmise’.  Given the joined politics of speed it is surprising that there should have been so few detailed studies at the time.  In their survey of ‘The development of British surgery at the Front’, published in the British Medical Journal on 2 June 1917, Surgeon-General Sir Anthony Bowlby and Colonel Cuthbert Wallace (Consulting Surgeon to the British Army) showed that out of 200 abdominal cases received at one casualty clearing station (CCS), 164 arrived within 12 hours, another 35 arrived in the next 12 hours, and 31 took over 24 hours to reach the CCS (p. 706).  

Another surgeon concluded from these figures that one third of the casualties ‘arrived so late that they had little chance of recovery because of the elapsed time alone’ (Daniel Fiske Jones, ‘The role of the evacuation hospital in the care of the wounded’, Annals of Surgery 68 (2) (1918) 127-132: 130).  In a second tabulation Bowlby and Wallace drew on a different sample of abdominal cases which confirmed that 51 per cent of those who arrived at a CCS within 12 hours survived (at least long enough to be transferred to a base hospital on the coast), but for those who took longer than 12 hours the survival rate fell to 33 per cent (p 716).

If nothing else, these figures confirmed the importance of evacuation rates, but their wide dispersion raised a series of important questions. The Australian Army provided two later studies that attended more closely to the geographies of casualty evacuation – and, to some degree, addressed the dispersion in the figures from Bowlby and Wallace – and for the rest of this post I’ll focus on the most detailed of the two.

This related to the evacuation scheme in operation for what became known as the Battle of Menin Road (20-25 September 1917). The image above is Paul Nash‘s celebrated rendering of The Menin Road, which he completed in February 1919.  Nash served on the Ypres Salient from February 1917 as a second lieutenant, but a few months later he missed his footing in the dark, fell into a trench and broke a rib.  He was evacuated to England, and returned to the Salient in November as an official war artist. (There is a fine discussion of Nash’s art and its relation to the war in Paul Gough‘s A Terrible beauty: British artists in the First World War; for The Menin Road in particular, see pp. 150-62 ).

Third Ypres: the first two phases

The Battle of Menin Road was the third phase of ‘the Third Battle of Ypres’ (July-November 1917) that culminated in the fall of Passchendaele (the name by which the whole series of offensives is often known).  The object of the campaign was to seize control of the line of low hills – ‘the ridge’ – running south and east of Ypres.

The first two phases were directed against Pilckem Ridge (31 July to 2 August) and Langemarck (16 to 18 August).

For the medical services there were two pressing problems.  The first was the retrieval of casualties by relays of stretcher bearers.  The terrain had been reclaimed from marshland by an elaborate system of drains but these were destroyed by savage and relentless artillery bombardments, and  Colonel A.G. Butler explained that ‘with the rains – expected in the autumn – the low, flat countryside reverted to primitive morass’ (Official History of the Australian Army Medical Services in the War of 1914-1918, Vol. II: The Western Front, p. 184n).  Confounding the Allies’ expectations, however, the rains broke at the end of July.  The conditions were frightful, the casualties horrendous, and on 1 August Lt John Warwick Brooke took what turned out to be an iconic photograph that caught the intersection of the two: no fewer than seven bearers struggling to carry a stretcher through the thick, plastering mud-slime near Boesinghe:

That same day Private Walter Williamson was ordered to a ruined building – he had no idea what it used to be – where his Regimental Medical Officer had established an aid post:

The place had simply been battered with shell fire and the road ploughed up, but this had now settled down to one horrible level surface of water and oozing mud….

Stretchers with their pitiful burdens were brought out from the inner recesses of the ruins, and we were detailed each four to a stretcher … containing a badly wounded lad who was only conscious enough to feebly moan to us to put him straight in the boat [to ‘Blighty’]. We heaved the stretcher to our shoulders, and started off that long remembered journey down the St Julien road. In addition to being weak and tired, our uneven heights made carrying difficult, and it must have been torture for the poor occupant of the stretcher. In the best places, the road was nearly knee deep in mud, and shell holes could not be located except by testing each foothold. Planks had been put down in places where the whole width of the road had been blown up, but these were now floating aimlessly about, and any attempt to use them would have resulted in a spill, and hurling our burden into the mud. Rain still poured down unceasingly and the road was being shelled viciously. We could not well duck at the shells, with a badly wounded man dependent on steady shoulders, and all we could do was to plod through and trust to good luck…

The road was a gruesome nightmare, bodies lay in the mud all along the road and burial parties were busy collecting them as best they could. Dead mules, horses, wrecked guns, limbers and all the terrible debris of battle lay in the mud. We were getting now, that we could not carry the stretcher more than a hundred yards at a stretch, and each time we rested, we found it more difficult to heave it up again, but we plodded along with red hot shoulders and cracking backs, sometimes having to get nearly waist deep to find a foothold across some huge hole that stretched from one side of the road to the other’ (Doreen Priddey (ed), A Tommy at Ypres: Walter’s War).

They eventually succeeded in delivering the poor man to a motor ambulance, which would have taken him to a dressing station or a casualty clearing station.  

The walking wounded didn’t fare much better, and the distinction between them and stretcher cases was by no means clear-cut or constant, as the experience of Private Alfred Warsop makes horribly clear.  Hit by shrapnel in the jaw, arm and chest, he passed out and when he came round ‘a doctor was just finishing bandaging me up and he said, “Get a stretcher for this man as soon as you can.”‘  Realising there were unlikely to be enough bearers available to carry him through the mud, he decided to walk out:

‘I persuaded a first aid man to put his hand in the middle of my back and hoist me on my feet. I tottered out determined to get down to the Menin Road or die in the attempt –on this occasion no idle phrase. It was all slippery mud, shell holes and trenches. I soon found that I had lost nearly all sense of balance with both arms useless. No doubt I was able to make that journey because I was suffering from shock and not feeling things as you normally would’ (in Steel and Hart, Passchendaele: the sacrificial ground)

Similarly, Gunner Walter Legg recalled coming to the aid of a badly wounded young soldier – carrying him to a shell hole and applying a field dressing, then helping him stumble to the aid post:

‘I remember vividly that with each step he took, blood oozed out on to the loose loop of his braces and fell drop by drop on his trousers.  From where we were I could see the forward dressing station about a quarter of a mile to the rear…  We managed to make progress a few yards at a time.  We’d shelter for a bit in a shell-hole, and then if the shelling seemed to be easing up we’d crawl into the next one and wait there for a bit, then try and get to the next one a yard or two away.  After a couple of hours … we’d only gone thirty or forty yards…

It took us ten hours to cover that quarter-mile to the dressing station, and when we got there we were absolutely drenched to the skin and thick with mud’ (in Lynn MacDonald, They called it Passchendaele).

The second problem emerged as soon as the injured reached a road: their transfer to a main dressing station or casualty clearing station was often slowed because the roads were in a poor condition, many of them full of craters and badly degraded by the constant traffic of convoys and marching columns, but also because the ambulances had to struggle against the flow, yielding to fresh troops, ammunition and supplies moving in the opposite direction.  The priority was clear. ‘The conditions of warfare demand … that wounded men shall be got out of the war,’ wrote one senior medical officer, so that supplies of reinforcements, ammunition and food to the fighting line are not interfered with’ (Col. H. M. W. Gray, ‘Surgical treatment of wounded men at advanced units’, New York Medical Journal 107 (1917)).

To regulate the flow, elaborate arrangements were made to control the direction of traffic, sometimes with special routes designated for ambulances.  The map below shows the traffic circuits established by the Fifth Army around Ypres by 27 July 1917:

[Roads shown in red could be used in both directions; roads shown in blue only in the direction indicated; roads not coloured were not to be used by lorries and could be used by ambulances or light traffic; there was ‘no restriction placed on Motor Cars containing Officers on duty’.]

Despite the slow journeys faced by wounded soldiers, the casualty clearing stations were hard pressed to keep up with the tide of injured bodies.  This was particularly true for those fed by by broad-gauge train from dressing stations in Vlamertinghe and Ypres.  That was how most of the nominally ‘walking wounded’ arrived at the CCSs at Remy Siding on the night of 31 July/1 August.  ‘They consequently arrived in very large batches,’ Major-General Sir W.G. Macpherson explained, ‘instead of coming down in small numbers at a time by lorries and charabancs.’  This overwhelmed the CCSs and delayed the departure of ambulance trains to the base hospitals, which could not leave until the casualties had been cleared, and the congestion was compounded because the trains bringing them in used the same siding as the ambulance trains waiting to come up and load: eight of them were scheduled in the first 24 hours (Medical Services, General History, Vol. III, pp. 160-1).

On that first day US surgeon George Crile, working at No 17 British CCS at Remy Siding, described how

‘The stream of wounded began to increase in volume, slowly at first, then rapidly, until the entire Remy Siding was swamped.  By the night of August first, every bed, every aisle, every tent, every inch of floor space was occupied by stretchers – then the rows of stretchers spread out over the lawn, around the huts, flowing out towards the railway…

The operating rooms ran day and night without ceasing.  Teams worked steadily for twelve hours on, then twelve hours off, relieving each other like night–day–night shifts.  There passed through the Remy Siding group of [three] CCSs over ten thousand wounded in the first forty-eight hours.  I had two hundred deaths in one night in my service.  The seriously wounded piled up so fast that nothing could be done with them, so I told the sister to administer as near an overdose of morphine as was possible to keep them alive but free of suffering’ (Autobiography, pp. 301-2).

It was the same everywhere.  Here is another American surgeon, Harvey Cushing, writing in his journal at No 46 British CCS near Proven at 0230 the next morning:

Pouring cats and dogs all day – also pouring cold and shivering wounded, covered with mud and blood…. The pre-operation room is still crowded – one can’t possibly keep up with them; and the un-systematic way things are run drives one frantic. The news, too, is very bad. The greatest battle of history is floundering up to its middle in a morass, and the guns have sunk even deeper than that. Gott mit uns was certainly true for the enemy this time.

Operating from 8.30 a.m. one day till 2.00 a.m. the next; standing in a pair of rubber boots, and periodically full of tea as a stimulant, is not healthy. It’s an awful business, probably the worst possible training in surgery for a young man, and ruinous for the carefully acquired technique of an oldster. Something over 2000 wounded have passed, so far, through this one C.C.S. There are fifteen similar stations behind the battle front (From a surgeon’s journal, p. 175).

(In his biography of Cushing, Michael Bliss remarked that having such a great surgeon perform brain surgery at a CCS – with exquisite care and meticulous attention to detail – was ‘like a master chef working at McDonald’s’, but Crile told Bowlby he was a model technician and advised him to organise the other surgical teams to handle the overflow).

The combined toll of these two phases in July and August was sobering, but they advanced the line to the east of Hooge (or, more accurately, to what was left of it: ‘even the road was untraceable,’ Charles Bean explains, ‘and the village site was only marked by a cluster of mine craters’ (Official History of Australia in the War of 1914-18, Vol. IV: The A.I.F. in France [sic]: 1917).  With that, the offensive appeared to have ground to a halt – literally so – and the German High Command concluded that Third Ypres was over.

The third phase: Menin Road

They were mistaken.  On 25 August British field command had been transferred to Lt General Herbert Plumer who devised a new, more measured plan for the third phase, which involved four short steps across a narrow front, separated by breaks to bring up the guns and supplies.  It would be spearheaded by Australian and New Zealand troops, with British and South African support.

Plumer took the next three weeks to prepare the ground for the first of his graduated steps, which was the Battle of Menin Road.  The road had been what one NCO called ‘the artery of the battlefield’ during the limited advance of the summer (Corporal J. Pincombe, in Lynn MacDonald, They called it Passchendaele, p. 144), and it remained a live fire zone.  ‘They had to keep the Menin Road open,’ recalled one driver with the Royal Artillery,

‘because it was the only way you could get up to that sector with horses and limbers, and it was shelled day and night.  The Germans had their guns registered on it to a T, and the engineers had to keep filling up the shell-holes … and keep the traffic going’ (Driver J. McPherson, in Lynn MacDonald, They called it Passchendaele, p. 177)

Paul Ham describes the scale of the preparations:

Plumer packed every ounce of energy and action into those few weeks. Within the next seventeen days, 156 trainloads carrying 54,572 tons of matériel arrived at the railheads, all of which had to be trucked, entrained, dragged or carried on mule-back to the front.  Light tramways were hastily reconstructed and roads rebuilt out of wooden planks. Shell holes were filled in and stamped down; gun emplacements firmly laid; telephone lines unrolled and buried; rations and medical supplies prepared and brought forward –all of which proceeded within range of German shellfire. Miles of duckboards were laid, latticing the drying plain, connecting little islands and ridges of high ground in the hardening mud. The men trained all day, rehearsing new platoon tactics, pillbox flanking manoeuvres and how to coordinate their advance with the creeping barrage, worked out to mathematical certainty (Ham, Passchendaele, p. 245).

In the interval the ground dried out and the terrain ‘changed from a morass into a desert’ (Bean, AIF, p. 748).  But it was still immensely difficult terrain, riddled with shell holes and all the hideous detritus of war.  In a letter written from Vlamertinghe on 17 September Hugh Quigley painted a bleak picture:

‘The country resembles a sewage-heap more than anything else, pitted with shell holes of every conceivable size, and filled to the brim with green, slimy water, above which a blackened arm or leg might project.  It becomes a matter of great skill picking a way across such a network of death traps, for drowning is almost certain in one of them (in Martin Marix Evans,  Passchendaele: the hollow victory).

The next map shows the line two days later, on 19 September – the night before the new offensive began:

Plumer’s plan called for clockwork precision.  The infantry were to advance behind a devastating rolling barrage, whose opening curtain would fall just 150 yards (130 metres) in front of the troops; after three minutes, as the troops moved up, it would roll forward at 100 yards every four minutes for the first 200 yards, and then at a rate of 100 yards every six minutes until the first objective, the Red Line, was reached: a distance of 750 metres.  The barrage would then halt for 45 minutes before rolling on at 100 yards every eight minutes until the Blue Line was reached: a further 400 metres.  After a pause for two hours the barrage would advance again at the same rate to the Green Line, the last objective of the day: a further 200 metres.

The slow rate of advance – compared to other rolling barrages – and the short distances eased the difficulty of picking passages through the pock-marked terrain, but there was little room for error or misstep.  Observing a rehearsal, Captain A.M. McGrigor recorded that

‘it did bring home to one how appallingly mechanical everything is now, and how every man must conform to the advance of the barrage.  Initiative and dash must to a certain extent be fettered as every forward movement is worked out so carefully and mathematically’ (in Robin Prior and Trevor Wilson, Passchendaele: the untold story)

Planning for casualties

These precise timings were complemented by similar calculations in the accompanying plan for medical provision drawn up by General Arthur Sloggett, perhaps still smarting from and certainly still contemptuous of Wright’s criticisms (above), and Surgeon-General G.B.M. Skinner (Fifth Army), which was intended to remove the extraordinary frictions that had bedevilled the evacuation chain during the summer.  Butler makes the parallel explicit: ‘The machinery for clearing our own casualties had to move with the same clockwork precision as that designed by us to create them in the enemy’ (Australian Army Medical Services, p. 211).

Their plan was guided by two imperatives.

(1)  Casualty Clearing Stations  The first was to bring casualty clearing stations as close to the line as possible.  This entailed a continuation of the system that had emerged during the summer.

In July and August three CCSs had been deployed just five miles from the front at a railway siding at Brandhoek, located just off the main Ypres-Poperinghe road, and offering direct rail access for hospital trains to the base hospitals at Boulogne and Calais.

Sister Kate Luard was thrilled with the experiment, writing in her diary that ‘we … shall be near enough to the line to get them from the dressing stations direct, without long journey and waits which is what the C.C.S.’s are out to prevent nowadays.’  She arrived at Brandhoek on 27 July, and while she was delighted at what she found (not least because she would be working at a specialist CCS for the treatment of abdominal wounds) she again emphasised the experimental nature of the location:

The hospital had only been pitched since last Saturday and it was already splendid. This venture so close to the Line is of the nature of an experiment in life-saving, to reduce the mortality rate from abdominal and chest wounds. Their chance of life depends (except where the injuries are such as to be beyond any hope of recovery) mainly on the length of time between the injury and the operation. As modern Field Surgery can now be carried out under conditions of perfect asepsis, the sooner the infection always introduced into every wound with the missile is dealt with, and the internal repairs carried out, the more chance the soldier has of life. Hence this Advanced Abdominal Centre, to which all abdominal and chest wounds are taken from a large attacking area, instead of going on with the rest to the C.C.S.’ s six miles back….

Sir Anthony Bowlby turned up later. ‘How d’you like the site this time? Front pew, what? front row dress-circle.’ It is his pet scheme getting the operations done up here within an hour or two of getting hit, instead of farther back or at the Base. That is why our 30 Medical Officers include the largest collection of F.R.C.S.’ s [Fellows of the Royal College of Surgeons] ever collected at any Hospital in France before, at Base or Front, twelve operating Surgeons with Theatre Teams working on eight tables continuously for the 24 hours, with 16 hours on and 8 off.

The location was ideal for rapid medical treatment; but as was often the case, the railway line also made it an optimal location for artillery batteries and ammunition dumps.  When Harvey Cushing visited Brandhoek two days later he observed that ‘the three CCSs were ‘necessarily alongside both road and railway, for hospitals and ammunition dumps must compete for sites of the same kind – and hence they are likely to be heavily shelled.’  And as Colonel A.G. Butler confirmed in the official history of the Australian Army’s medical services, ‘the site had the grave disadvantage that some British 15-inch guns were near by, and huge supply and ammunition dumps covered the adjoining area’ – all, as he concedes, ‘legitimate and obvious targets for German artillery’ (Australian Army Medical Services, p. 188).

It was quiet when Bowlby and Cushing visited, but the medical staff did not have long to wait before their fears were confirmed.  On 30 July Luard wrote:

‘Soon after 10 o’clock this morning [the Germans] began putting over high explosive. Everyone had to put on tin-hats and carry on. He kept it up all the morning with vicious screams. They burst on two sides of us, not 50 yards away – no direct hits on to us but streams of shrapnel, which were quite hot when you picked them up. No one was hurt, which was lucky, and they came everywhere, even through our Canvas Huts in our quarters. Luckily we were so frantically busy that it was easier to pay less attention to it. The patients who were well enough to realise that they were not still on the field called it ‘a dirty trick.’ 

It is doubtful that the CCSs were the intended target (and they were treating many German prisoners).  Rather, as Sister May Tilton recorded, the area was ‘a huge city of canvas, batteries and ammunition dumps’ – the question of co-location constantly dogged casualty clearing stations and base hospitals alike (see here) – and throughout the next month Brandhoek was subjected to regular shelling and air raids.

On 2 August Luard wrote that ‘it made one realise how far up we are to have streams of shells crossing over our heads’ – from the German lines and from the British batteries around Brandhoek – but the danger was also a more proximate one.  Here she is a few days later:

There is a cheery little Military Decauville Railway for ammunition only, running immediately between our Compound and the main Duck Walk cutting our Hospital in two, and you are always having to wait to cross the rails while a series of baby trains puff through loaded to the teeth with shells, or coming back with empty cases.

The attacks intensified, and on 14 August Tilton wrote that last night

‘No one slept, day or night staff. Our bell tents were dugouts. They had lowered us considerably and sandbagged the outsides so heavily, we felt quite comfortable. It needed a direct hit to get us…’

At 10.30 pm ‘the Gothas [bombers] were over’ and ‘shells were bursting quite close’, but the British batteries responded with alacrity: “Big Bob” [the 15-inch guns] set our tents rocking and vibrating with his fierce and mighty roar.’

On 18 August Luard was outraged at German attacks on hospitals – but she was specifically referring to those in the rear:

He [‘Fritz’] played about all night till daylight. There were several of him. He went to C.C.S.’ s behind us. At one he wounded three Sisters and blew their cook-boy to pieces. The Sisters went to the Base by Ambulance Train this morning. At the other he wounded six Medical Officers among other casualties. A dirty trick, because he has maps and knows which are hospitals back there. Here we are in a continuous line of camps, batteries, dumps, etc., and he may not know.

That last sentence was crucial, but the CCSs at Brandhoek were subjected to sustained shelling throughout the day on 21 August, and two days later Sister Elsie Grant wrote to her sister from Brandhoek with no hesitation in assigning blame:

‘We have been shelled out three times but this last time was too dreadful. Those brutal Germans deliberately shell our hospital with all our poor helpless boys but really God was good to us we had four killed but it was just miraculous that there were not dozens killed. Of course we (the sisters) were put into dugouts as soon as the shelling got bad but I can’t tell you how cruel it was to leave those poor helpless patients. In a few hours the whole hospital was evacuated & one consolation we saw our last patient carried out before we were sent away.’

Two of the CCSs were immediately moved back to ‘Nine Elms‘ (below), five miles behind Poperinghe, while Luard’s remained to provide treatment for walking wounded until it too was evacuated in early September.

Throughout these attacks and dispersals, the CCSs had continued to work at full capacity to deal with the thousands of casualties.  But by September the closest CCSs for the Battle of Menin Road were now all much further back: at Nine Elms, at Remy Siding, and three other groups near Proven known in the British Army’s ironic Flemglish as ‘Mendinghem’, ‘Dozinghem’ and ‘Bandaghem’.  Cushing explained:

The place…  is called “Mendinghem.” This was originally a joke and was to have been “Endinghem”; but this on second thought was changed as being too much even for the Tommy. The army has a professional name maker, I may add. Mendinghem is already on the printed maps and there is in this district a “Bandagehem” and “Dosinghem” which I have not located as yet.

They are all all shown on this map:

These relocations did not end the raids, and the official British medical history by Major-General W.G. Macpherson includes a detailed list of enemy shelling and bombing of CCSs from 3 July to 29 October (pp. 163-4); Mendinghem and Dozinghem were repeatedly attacked. According to Cushing, the staff at Dozinghem were particular upset ‘because General Skinner had ordered an electric Red Cross to be shown at night – a good mark to shoot at’ (A surgeon’s journal, p. 193).  In fact, Macpherson concluded that these attacks

‘were of so exceptional a character as to give rise to the belief that they were deliberate.  The medical units were indicated by the usual red cross signs on roofs of huts, and also on large squares on the ground such as could be seen by aircraft.  The positions of casualty clearing stations had also been notified to the enemy’ (Medical Services, General History, Vol. III, p. 162).

Macpherson, wise after the event, commented that Brandhoek ‘had always been regarded as too far forward’ – he claimed the CCSs were only there at the insistence of the Fifth Army commander and his Director of Medical Services – and concluded that the whole affair showed ‘that a journey of twenty minutes to half-an-hour to a more secure locality farther back is not likely to be so great a risk to the patient as his retention in a more forward position which is in danger of being shelled by the enemy’ (p. 156).

(2)  Direct evacuation  The retreat of the forward CCSs placed a still greater premium on the second imperative, which involved another experiment, a concerted attempt to expedite the movement of the wounded to the rear.  In practice, this resolved into marking and co-ordinating evacuation routes for bearer teams and ambulances, minimising treatment at all intermediate dressing stations (even the administration of anti-tetanus serum had to wait until a casualty arrived at the CCS), and separating casualty streams from the Advanced Dressing Stations (ADS) into the three circuits shown on the diagram below:

I’ve seen many similar maps – the war diaries of Field Ambulances are full of them, either superimposed over or based on trench maps, and Regimental Medical Officers were accustomed to draw up their own annotated sketch maps showing the location of aid posts and the routes to be followed by the regimental stretcher bearers – but this one is unusual because it extends beyond the immediate recovery zone and (following directly from the emphasis on direct evacuation) includes a series of timings from the front line all the way back to the CCSs at Remy Siding.

As the map shows, ‘walking wounded’ made their own way to the collecting point at Hooge on the Menin Road and then (by ambulance or light rail if space were available, otherwise on foot) to the ADS designated for them in Ypres.

The more seriously wounded were brought to the same collecting point by regimental stretcher bearers in a series of relays; this was estimated to take between 10 and 40 minutes during the day and around 60 minutes at night.  The casualties were then transferred by motor ambulance to the ADS for stretcher cases, just across the road from the ADS for walking wounded (below).

The location of the two ADSs made sound logistical sense, but they were uncomfortably close to heavy artillery batteries and naval guns and were repeatedly shelled.  Together the ADSs acted as the hub for what the Medical History calls the ‘elaborately detailed’ system of onward evacuation (Australian Army Medical Services, p. 202):

  • Those who could withstand the journey – a further 80-120 minutes, according to the map – followed Circuit A (‘long distance’) to the CCSs at Remy Siding; 58 per cent of stretcher cases followed this route.
  • Those suffering from shock, gas or haemorrhage followed Circuit B (‘short distance’) to the Main Dressing Station at Dickebusch, a journey of 20-30 minutes; 27 per cent of stretcher cases followed this route.
  • Those who needed immediate surgery were sent direct to Remy on Circuit C  – a journey of 90 minutes – and 15 per cent followed this route.

It’s not clear how these timings were established: they were almost certainly estimates written in to the plan rather than observations after the event.  But there is a clear consensus that, if that were the case, the estimates were realised and according to official historian Charles Bean the first day of the battle itself ‘went almost precisely in accordance with plan’ (AIF in France, p. 761).

The Battle of Menin Road

It started to drizzle during the evening of 19 September, and when it changed into steady rain and the dust turned back into mud there were understandable jitters.  But shortly after midnight the rain eased and Plumer was determined to press on.  Zero hour was 0540 on 20 September, when ‘the whole of the British artillery and machine-guns, breaking in with the suddenness of a great orchestra, gave the signal for the attack to start’ (Bean, AIF, p. 757).  Frank Hurley, the Australian Official Photographer, was there to capture the scene, but his words (Diary, pp. 87-8) are as evocative as his photographs:

We were just walking along the Menin road in the twilight, near Hellfire Corner, when our barrage began. Simultaneously from a thousand guns, & promptly on the tick of five, there belched a blinding sheet of flame: & the roar – Nothing I have heard in this world or can in the next could possibly approach its equal. The firing was so continuous that it resembled the beating of an army of great drums. No sight could be more impressive than walking along this infamous shell swept road, to the chorus of the deep bass booming of the drum fire, & the screaming shriek of thousands of shells. It was great, stupendous & awesome.

The walking wounded were the first to pass through the collecting post, followed by the stretcher cases.

There were delays in moving them down the Menin Road (below; the first photograph is another Hurley), but according to the officer commanding the 3rd Field Ambulance these were ‘due to the amount of traffic – ammunition limbers, lorries, etc. – which held up the ambulance waggons.’  There was ‘practically no delay by enemy shelling on the road, which we all so greatly feared.’  (They were wise to do so; the reprieve was short-lived and  the German batteries soon re-registered on the Road). 

The Red Line was secured at 0611.

By 0700 the first walking wounded started to arrive at their Advanced Dressing Station, followed by the first stretcher cases at 0900 (again, the photographs below are by Hurley):

 The Blue Line was secured at 0815 and the Green Line at 1015.

At first the light railway was used to clear cases from the ADSs to the CCS, but the service was disrupted (in part by enemy shelling and part by a backlog at Remy) and lorries took over until the trains were restored by mid-morning.  In the first 24 hours 2,200 Australian and 1,000 British wounded passed through the twin ADSs; the proportion of walking wounded to stretcher-cases was roughly 3 : 1 (though, as I’ve noted previously, the distinction between the two was by no means hard and fast) (Australian Army Medical Services, pp. 208-9).

Further down the evacuation chain at the CCSs at Remy Siding casualties started to arrive ‘so rapidly as to cause some embarrassment’ but the stations started to take in by turns – a standard practice – and this successfully relieved the congestion: thereafter casualties arrived in a steady stream.    

Meanwhile stretcher bearers were moving up as the line advanced and new relay posts were being established.  From 1800 a light railway ferried the walking wounded directly from Birr Crossroads via the MDS to the CCS.

The official history has nothing but praise for the execution of Plumer’s plan, and Bean attributed the success of the first day to the artillery: ‘The advancing barrage won the ground; the infantry merely occupied it’ ( AIF, p. 761).  It is perfectly true that the German troops fell back under the sustained barrage, and that their counter-attacks were all repulsed, but this one-liner does an extraordinary disservice to the infantry that ploughed forward.

The medical history tells a more cautious story, and Butler emphasised that ‘throughout the day shell-fire was severe in the captured area’ – a situation with awful consequences for the troops and for the regimental stretcher-bearers who came to their aid.

Again Frank Hurley captures the dreadful scene that same day with a visceral immediacy:

I pushed on up the duck board track to Stirling Castle – a mound of powdered brick [below] and from where there is to be had a magnificent panorama of the battlefield. The way was gruesome & awful beyond words. The ground had been recently heavily shelled by the Boche & the dead and wounded lay about everywhere. About here the ground had the appearance of having been ploughed by a great canal excavator, & then reploughed & turned over and over again. Last nights shower too made it a quagmire; & through this the wounded had to drag themselves, & those mortally wounded pass out their young lives.

The shells shrieked in an ecstasy overhead, & the deep boom of artillery sounded like a triumphant drum roll. Those murderous weapons the machine guns maintained their endless clatter, as if a million hands were encoring & applauding the brilliant victory of our countrymen. It was ineffably grand & terrible, & yet one felt subconsciously safe in spite of the shell burst & splinters & the ungodly wanton carnage going on around.

]
I saw a horrible sight take place within about 20 yards of me. Boche prisoners were carrying one of our wounded in to the dressing station, when one of the enemy’s own shells struck the group. All were almost instantly killed, three being blown to atoms. Another shell killed four & I saw them die, frightfully mutilated in the deep slime of a shell crater. How ever anyone escapes being hit by the showers of flying metal is incomprehensible. The battlefield on which we won an advance of 1500 yards, was littered with bits of men, our own & Boche & literally drenched with blood (Diary, pp. 91-3 ).

And this, as Paul Ham reminds us, ‘was a battle that had gone well, in which everything had proceeded according to the plan’ (Passchendaele, p. 305).  The total British and Dominion casualties on that one day were around 21,000, expended in order to advance one and a half miles and to hold an area of 5.5 square miles.

Hurley recognised the extraordinary sacrifices made by those bringing in the wounded (above), and that same evening he wrote of his admiration for ‘the magnificent work of the stretcher bearers who go out in the thick of the strife to succour the wounded.’  Many of them were killed or injured, and by the end of the day one subaltern with the 3rd Field Ambulance reported that he had

ended up with four fit squads, fifteen men wounded, five missing and five worn out. Bearers all thoroughly done up.’

Not surprisingly, it was difficult for the bearers to find (let alone recover) all those who had been wounded.  On 28 September Harvey Cushing was operating on a British soldier at Mendinghem and asked him his division and regiment:

“Oxford Bucks; 20th Division, sir.”

“How can that be, they went over on the 20th, a week ago?”

“I went over with ’em, sir.”

He actually did, and has been lying for a week in a shell hole, until, during the attack of yesterday, someone found him. He said he had eaten nothing, for his bully beef went “agin” him and he wasn’t hungry — indeed thought he had been out of his head for two or three of the days. Then when it got dark he used to holler, but no one came….

He doesn’t seem to think his escapade anything out of the ordinary …  I asked him if he was in the barrage of yesterday morning and whether he knew there was an offensive under way. No, he just heard a terrible rattle and crawled up to the edge of his shell hole and waved his hand: some stretcher-bearers came along and took him away—that’s all he knows (A surgeon’s journal, p. 214).

You might think he was an outlier to all those accounts of rapid evacuation, physically and statistically, but he plainly wasn’t the only one.  And as the phased advance continued, so conditions deteriorated and the dangers increased.

By 4 October the rains returned with a vengeance, and as the battle for Passchendaele ground on and the toll mounted so one nightmare day became indistinguishable from the next.  The carries became longer and longer; bearer parties found it harder and harder to find their way in a landscape (or what Samuel Hynes calls an anti-landscape) devoid of any permanent markers; even those areas stitched together by duckboards became dangerously slippery:

From 8 to 11 October, one medical officer reported,

‘the work was so heavy that for a large part of the time 6 men had to carry one stretcher – 8 and even 12 men were used in parts. Under these conditions the stretcher-bearers rapidly became exhausted, and absolutely so after 24 hours’ work. Usually they were relieved after 24 hours, but owing to the universal shortage some 36 and even 48 hour shifts were done. About 200 bearers (ambulance and infantry) were continually at work’ (Australian Army Medical Services, p. 234).

It’s not my purpose here to chart the unfolding geography of casualty evacuation in any detail – it was modelled on the plan for Menin Road but constantly adapted to the changing circumstances: ‘the medical scheme for each battle was an extension, at most a variant, of that for the preceding one; they were built up, as the line advanced, in the general “arrangements” described’ above: Australian Army Medical Services, p. 212) – but one stretcher-bearer epitomises the wrenching experience as well as anybody.  Frederick Noyes was with the 5th Canadian Field Ambulance, which was posted to Ypres on 1 November:

Who could ever forget those two weeks of the Passchendaele show? Looking back now it all seems like one long, weird, and terrible nightmare of water-filled trenches, zigzagging duck- walks, foul slime-filled shell-holes, half-buried bodies of dead men, horses and mules, cement pillboxes, twisted wire, shrieking shells, flying humming metal, crashing aerial bombs, stinking mud, water-logged and blood-soaked stretchers – a Slough of Despond such as even a Bunyan couldn’t conceive of.

That long, wearisome “carry” from Tynecot to Frost House was like a never-ending Via Dolorosa to all who made the journey. Passchendaele was the Somme multiplied and intensified ten times over. Dark, wet, hopeless days were followed by almost endless, cold, marrow-congealing nights of despair and exhaustion. Every man was soaked through to his skin the whole time we were there, and the added weight of his sodden, muddy uniform and equipment seemed to sink him deeper into the prevailing mire. After the first few hours we moved about like so many dazed automatons, stumbling, staggering, blundering along the heaving duck-walks and erupting roads – almost too stunned to care whether we lived or died and totally indifferent to the volcanoes of smoking shell-craters about us. The hours and days and nights seemed to merge with one another into a cruelly indefinite whole and it is doubtful if any man was afterward able to distinguish one Passchendaele day’s experiences from another (Stretcher bearers at the double! p. 177).

From geometries to geographies

It’s now possible to return the evacuation map and its clockwork timings that set my discussion in motion.  Maps like these display the system of evacuation as a linear geometry – an abstract grid of transmission lines that resemble what Fiona Reid in her Medicine in First World War Europe: Soldiers, Medics, Pacifists calls ‘a modernist dream’ – with no catastrophic breaks or nightmare tangles.  Many official and semi-official accounts endorsed this view of ‘the cogs of the evacuating machine’, beautifully oiled and running smoothly.

But it should now be clear that this is a representation of a space that never existed beyond the paper landscape on which the military offensives were themselves planned (cf. my ‘Gabriel’s Map’, DOWNLOADS tab).  Casualty evacuation was not only a geometry but also a geography; it was confounded by the bio-physical terrain through which the wounded were moved, and threatened by the savage continuity of military violence.  Routes constantly had to be changed, particularly for bearer parties, and aid posts and dressing stations were endlessly re-located as medical officers struggled to adapt to changed circumstances: improvising their own posts, sketching their own maps.  By extension, the analytical mapping of casualty evacuation cannot be limited to a cartography but necessarily extends to a corpography (see also ‘Corpographies’, DOWNLOADS tab) for, as Reid emphasises, the stories the wounded told of their journeys were, like so many of their injuries, ‘complicated and messy’.  There was a vital reciprocity between those journeys and the bodies that made them, and I’ll elaborate on that in later posts about the woundscapes of the Western Front.

Coda

On 22 September Harvey Cushing operated on a British soldier with a serious head injury, who had been wounded the previous day.  He had reached the Field Ambulance at 1230 and was admitted to the CCS at Mendinghem at 0647, whereupon he ‘got lost somehow in the crowded wards’ and was finally lifted on to Cushing’s table that afternoon.  Nothing unusual about any of that, except for Cushing knowing the time when his patient had reached the Field Ambulance.  He observed in passing ‘that they are noting the hour as well as the date since our discussion of last Tuesday’ (A surgeon’s journal, p. 209).  His journal records that meeting, presided over by General Sloggett, but there are no details of the discussion to which Cushing refers.  It’s all the more remarkable given the debate over the politics of speed – and the fact that the medical plan for Menin Road was all about minimising data recording and administration before the casualty was admitted to the CCS.

This leads me to the second Australian Army study I noticed at the start, which was carried out by the 7th Australian Field Ambulance on the Somme in July 1918 [see Appendix 16 of FA War Diary here].  It provides a useful counterpoint to the Battle of Menin Road.  Here too the objective was ‘to get the men as quickly as possible to the CCS’ and this too included minimising the number of dressings and treatments en route.  But where the plan for Menin Road also restricted data recording at the ADS and the MDS for the same reason, except for deaths and cases treated and returned to duty, the 7th FA added a layer by recording the time each casualty arrived at each station on the field medical card pinned to his tunic (below).

The corresponding scheme of evacuation is shown in the following sketch:

750 cases were recorded; 200 of these were retained at one of the intermediate stations (either because they were lightly wounded or because they needed emergency intervention); and of the remainder evacuation times were remarkably constant.  Including treatment and travel, it took casualties 1 hour 45 minutes to be brought from the Advanced Ambulance Post (where motor ambulances collected the casualties from the regimental stretcher bearers) to the Main Dressing Station at Saint Acheul, and a further 2 hours 15 minutes (including treatment at the MDS) before they reached the CCS at Crouy: the total elapsed time of 4 hours to travel those 22 miles was reduced for some ‘special cases’ to around 3 hours.

These travel times were maintained outside any ‘push’ (a major offensive) or a ‘stunt’ (a raid).  The FA provided statistics for two stunts that punctuated the steady process of attrition and these – unlike the schemas I’ve been describing thus far – incorporated the time it took stretcher bearers to retrieve casualties from the field and bring them to an aid post.  The first stunt kicked off at 0310 on 4 July; the time from the Advanced Ambulance Post to the CCS was more or less unchanged (around 3 hours 30 minutes) but factoring in   the time from the field to the Advanced Ambulance Post the first casualties took 5 hours 45 minutes to reach the CCS from the point of injury, and as the troops advanced further forward this increased until it took 9-10 hours for stretcher cases to reach the CCS.  The second stunt started at 2030 on 7 July, and the darkness combined with rain to change the calculus: it now took 4 hours 30 minutes to 5 hours to transfer casualties from the Advanced Ambulance Post, and the first casualties took around 7 hours to reach the CCS from the point of injury; others must have taken much longer though no details were given.

Trauma Geographies

I’ve been invited to give the Antipode lecture at the RGS/IBG conference on 29 August.  Here’s the abstract:

Trauma Geographies: broken bodies and lethal landscapes  

Elaine Scarry reminds us that even though ‘the main purpose and outcome of war is injuring’ this ‘massive fact can nevertheless ‘disappear from view along many separate paths.’ This presentation traces some of those paths, exploring the treatment and evacuation of the injured and sick in three war zones: the Western Front in the First World War, Afghanistan 2001-2018, and Syria 2012-2018. The movement of casualties from the Western Front inaugurated the modern military-medical machine; it was overwhelmingly concerned with the treatment of combatants, for whom the journey – by stretcher, ambulance, train and boat – was always precarious and painful. Its parts constituted a ‘machine’ in all sorts of ways, but its operation was far from smooth. The contrast with the aerial evacuation and en route treatment of US/UK casualties in Afghanistan is instructive, and at first sight these liquid geographies confirm Stephen Pinker’s progressivist theses about ‘the better angels of our nature’ [see also here]. But this impression has to be radically revised once Afghan casualties are taken into account – both combatant and civilian – and it is dispelled altogether by the fate of the sick and wounded in rebel-controlled areas of Syria. For most of them treatment was dangerous, almost always improvised and ever more precarious as hospitals and clinics were routinely targeted and medical supplies disrupted, and evacuation impossible as multiple sieges brutally and aggressively tightened. Later modern war has many modalities, and the broken bodies that are moved – or immobilised – in its lethal landscapes reveal that the ‘therapeutic geographies’ mapped so carefully by Omar Dewachi and others [see here and here] continue to be haunted by the ghosts of cruelty and suffering that stalked the battlefield of the American Civil War in the years following Lincoln’s original appeal to those ‘better angels’.

The presentation will tie together several strands I’ve laid out in posts on Geographical Imaginations; the next installment of my analysis of siege warfare and geographies of precarity in Syria will appear shortly.

Losing sight

May Jeong – whose excellent investigation of the US air strike on the MSF Trauma Centre at Kunduz I’ve commended before – has a new, equally enthralling extended report over at the Intercept on the sole survivor of a US drone strike in Kunar province in eastern Afghanistan on 7 September 2013: ‘Losing Sight‘.

It’s a long, rich read, but there are two issues I want to highlight.

First, May captures the stark, bio-physical horror of an air strike with an economy and force I’ve rarely seen equalled.  As I’ve noted before (see here and here), many critical analyses emphasise the bio-convergences that animate what happens behind the digital screens of the kill-chain and say remarkably little about those that lie on the other side.  It’s all too easy to lose sight of the embodied nature of remote warfare, though in another powerful essay Joseph Pugliese argues that it’s often not possible to speak of the corporeal at all in the face of such catastrophic violence: ‘The moment of lethal violence transmutes flesh into unidentifiable biological substance that is violently compelled geobiomorphologically to assume the topographical contours of the debris field’ ( ‘Death by Metadata: The bioinformationalisation of life and the transliteration of algorithms to flesh’, in Holly Randell-Moon and Ryan Tippet (eds) Security, race, biopower: essays on technology and corporeality (London: Palgrave, 2016) 3-20).

So here is May describing the strike on a pick-up truck in the early evening as it ground its way along a rough road through the Pech Valley; inside the cabin were the driver, three women and four young children, while seven men were crammed into the back along with sacks of flour they had bought to take back to their village.  There were a couple of miles from home, Gambir, when five missiles hit the truck in a 20-minute period.  Minutes later a second truck – which had been racing to catch up with the first – arrived close to the scene.  The driver (Mohibullah) scrambled up a small hill with a local villager:

[T]hey saw the husk of the pickup, strafed and lit up in flames. They hurried toward the fire.

When Mohibullah arrived at the blast site, he saw that of the 17 bags of flour he had helped load onto the truck, just two were intact. The rest had splayed open. There was a sick beauty to the scene — white powder over blood-red carnage.  These were men and women Mohibullah had grown up with, but he couldn’t recognize any of them. Their mangled body parts made it difficult to ascertain where one person ended and another began: spilled brains over severed limbs over ground flesh…

At first, it was just Mohibullah, another driver named Hamish Gul, and three villagers from Quroo who came to help. Most people in the area knew to stay away. The ghanghai [drones] often attacked again. Even so, the five of them worked at untangling the dead bodies — among them Aisha’s mother, father, grandmother, and little brother — and stacking them in neat rows atop the bed of Mohibullah’s truck.

Astonishingly, there was one survivor, but she too had been brutalised beyond recognition:

Mohibullah did not recognize the girl — her face had been “scrambled, she didn’t have her nose.” She still had both of her legs, but he wasn’t sure if her torso was connecting them to the rest of her body. It wasn’t until she asked in a frail voice — “Where is my father? Where is my mother?” — that he understood her to be his 4-year-old niece Aisha

A neighbor named Nasir held Aisha together for the drive back to Gambir. During the 2-mile journey, Aisha did not make a sound. Life seemed to be slipping away from her. Nasir assumed she would be buried. But when they arrived in Gambir, Aisha turned her head and asked for water. Her voice was so full of intent that they decided to rush her to a hospital in Asadabad.

Read those paragraphs again to see what Pugliese means.

Now the second issue starts to come into focus.  They reached Asadabad Provincial Hospital at 10 p.m., but the duty nurse could do little for Aisha:

Her stomach was missing, as were parts of her face and her left arm. He registered her into the hospital database, writing “acute abdominal injuries” next to her name, treated her with basic first aid, and sent her to the nearest hospital in Jalalabad, 57 miles away.

Aisha reached Jalalabad Public Health Hospital shortly after midnight, where her burns were dressed.  But here too there was little the surgeon could do; she had multiple head injuries, had lost one of her hands, and had major internal injuries.  A helicopter was called to take her to Kabul but it couldn’t land; a second helicopter arrived at midnight – 24 hours after she had reached Jalalabad – and ferried her to the French military hospital at Kabul Airport.

That hospital was a NATO Role 3 hospital, which had been run by the French since July 2009; by the summer of 2013 43 per cent of the procedures carried out by its staff had involved orthopaedic surgery.  Half of these were emergency surgeries; just 17 per cent of the patients were French military personnel and another 17 per cent were Afghan National Army or other ISAF soldiers,  while 47 per cent were Afghan (adult) civilians and 17 per cent were children.

Like other Role 3 hospitals, the facility was tasked with ‘damage-control’, for which it could call on three surgical teams rotation with a general surgeon, (abdominal, chest or vascular surgery) and an orthopedic surgeon as well as an ophthalmologist,  a neurosurgeon and an ENT or maxillofacial surgeon (I’ve taken these details from O. Barbier and others, ‘French surgical experience in the Role 3 Medical Treatment Facility of KaIA (Kabul International Airport…’, Orthopaedics and Traumataology: Surgery & Research 100 (6) (2014) 681-5; see also Christine Joubert and others, ‘Military neurosurgery in operation’, Acta Neurochir 158 (8) (2016) 1453-63).

While Aisha was being treated the hospital was visited by Afghan President Hamid Karzai.  Here is May again:

There, Karzai was confronted with a girl who had lost her sight, her nose, her lower lip, the skin on her forehead, the skin on her torso, her left hand, and nine members of her family, including her grandmother, her uncles, her aunts, her cousin, her mother, her father, and her baby brother.

“I cannot describe what I saw there,” Rangin Spanta, who served as national security adviser under Karzai and accompanied him to the hospital that day, told me from his home in Kabul. We were sitting on a rattan set on his front porch. In telling this story, Spanta covered his face and wept. “Still I have my trauma.” Spanta had lost five family members in the war, but the sight of Aisha, a girl who had been reduced to a “piece of biological construct,” gave him “the feeling that this was a kind of a nightmare.” Spanta, who had seen the guts of suicide bombers splattered across his car window and has visited double, triple, and quadruple amputees, said Aisha was the “most shocking thing I’ve seen in this war.” Karzai asked the attending doctor why her face was covered. “Because there is nothing there” was the answer.

That a high proportion of patients the military hospital were Afghan civilians was by no means unusual for a Role 3 facility, but as I’ve noted before ISAF had strict Rules of Medical Eligibility.  Afghan civilians who were injured during military operations and/or needed ‘life, limb or eyesight saving care’ – both of which applied to Aisha – could be admitted to the international medical system.  But as soon as possible, Afghans were to be treated by Afghans and so, after surgical intervention, they had to be transferred to the local healthcare system.



That system was – is – often rudimentary, which is why Aisha was passed from Asadabad to Jalalabad before reaching Kabul.  And returning someone in her post-operative condition to that system was obviously fraught with danger.  Here is Emily Mayhew in A Heavy Reckoning describing the dilemma for doctors at the Role 3 hospital at Camp Bastion in Helmand province:

Some of the most difficult decisions taken by the Deployed Medical Director related to local patients, Afghans civilians, their families and others. Locals made up the majority (probably as much as 80 per cent) of the patients cared for during the lifetime of the hospital. During the war there were no Afghan hospitals with the technology or capability to ventilate patients with severe chest wounds, therefore leaving Bastion meant death. So anyone intubated who could not be returned to Britain had to stay at Bastion until they could breathe unaided, which sometimes took days or weeks. They were discharged only when it was certain they could survive away from Bastion: probably in a local hospital that was under severe stress, and which could only provide medical care for two or three hours a day, where the rest of the time they would be looked after by their families.

I’ll return to this in a later post, because in some cases those local hospitals have been supplemented and even supplanted by more advanced medical facilities operated or supported by international NGOs like Emergency or MSF.

But what is extraordinary in Aisha’s case is that her pathway did not follow any of these routes.  Karzai had asked both the French and the Germans to help, but they deferred to the Americans who insisted that she be taken to the United States for further treatment.  ‘Twelve days after the strike,’ May reports, ‘Aisha was gone’: but nobody ever told her relatives what had happened to her.  Every attempt they made to find out was rebuffed.

Months later her uncle was informed that she was at Walter Reed hospital in Maryland; she had been sponsored by an American organisation, Solace for the Children.  According to its website:

Each Summer Solace for the Children Summer Medical Program brings children from areas affected by war to the United States so they may receive medical care unavailable to them in their country. We currently focus our efforts on children in Afghanistan. Each fall, applications are accepted for treatment. Our office in Afghanistan typically receives more than 50 applications they must review and qualify. Youth are qualified for services based on need and health condition. They are then placed with a host family for approximately 6 weeks while receiving the medical care they require. After care, youth return to Afghanistan with a better quality of life, brighter future and hope for peace.

While ‘there was no official relationship between the U.S. military and Solace,’ May was told by the charity’s director Patsy Wilson, ‘individual members of the military often reached out to Solace, which had been the case for Aisha.’

“We just get calls. We get calls from the military all over Afghanistan,” she said. She repeatedly deferred to the military, stating, “I am sure they don’t say we kidnap children.” Wilson also expressed doubts that Aisha had been injured in a drone strike, despite the claims of scores of villagers interviewed by The Intercept. “We do not necessarily believe Aisha was in a drone strike, but I know that is one of the stories,” she said. When pressed for details, she said, “I have been told not to discuss that,” adding, “We have no facts. There are no facts.”

Those last sentences are becoming all too familiar, but in this case ISAF not only acknowledged the ‘IM [international military] aerial attack’ but carried out its own investigation into the civilian casualties.  It has never been declassified.

War Stories

The video from our War Stories event in Vancouver last month – including Farah Nosh‘s narration of her wonderful photographs, a superb capsule genealogy of PTSD from Ann Jones, my discussion of casualty evacuation over the last hundred years, a drama staged by veterans from Afghanistan and directed by George Belliveau, Contact! Unload!, and a lively Q&A with the audience moderated by Peter Klein is now available here.

war_stories3b-page-001

My lecture, Precarious journeys, has also been carved out for the Peter Wall Institute website here. The idea behind the event was, in large measure, to think through the multiple ways in which modern war is narrated, which is why we had such a rich and diverse portfolio of performers and why I take the turns I do…  Regular readers will probably recognize that the arc of my presentation draws on my current research on evacuation from the Western Front in the First World War, on evacuation from Afghanistan today, and on my admiration for Harry Parker‘s Anatomy of a Soldier (see my ‘Object lessons’ here and the slides available under the DOWNLOADS tab).

More in an interview with Charlie Smith from the Georgia Straight here.

Wounded

Somme medical dispositions.001

This summer London’s Science Museum is staging an exhibition that is of direct relevance to my current research on casualty evacuation from war zones over the last hundred years:  Wounded: Conflict, Casualties and Care.  It opens on 29 June and is designed to commemorate the centenary of the Battle of the Somme:

57,000 casualties were sustained by British Forces on 1 July 1916, the first day of the Battle of the Somme, creating huge and unprecedented medical challenges. Wounded: Conflict, Casualties and Care, a new exhibition opening at the Science Museum on 29 June, will commemorate the 100th anniversary of this battle and the remarkable innovations in medical practices and technologies that developed as a result of this new kind of industrialised warfare.

During the First World War ten million combatants were killed, but double that number were wounded and millions were left disabled, disfigured or traumatised by their experiences. The challenges were immense. For medical personnel near the front line treating blood loss and infection was the immediate priority in order to save lives. However medics also encountered new forms of physical and mental wounding on a scale that had never been seen before, creating huge numbers of veterans returning home with serious long term care needs.

At the centre of the exhibition will be a remarkable collection of historic objects from the Science Museum’s First World War medical collections, illustrating the stories of the wounded and those who cared for them. From stretchers adapted for use in narrow trenches to made-to-measure artificial arms fitted back in British hospitals, medical technologies, techniques and strategies were pioneered or adapted throughout the war to help the wounded along each stage of rescue and treatment. Visitors will also see unique lucky charms and improvised personal protective items carried by soldiers on the frontline alongside examples of official frontline medical equipment.

I’m looking forward to seeing this over the summer.  The organisers note that:

 Warfare has changed dramatically over the last one hundred years, but similarities remain with the military medical challenges faced today, both through the experiences of the wounded and in their treatment and care. The Wounded exhibition team has worked closely with two UK charities that were formed during the First World War, Combat Stress and Blind Veterans UK, to draw out these parallels and share the personal experiences of soldiers wounded in more recent conflicts.

You can find some of my preliminary thoughts on casualty evacuation from the Western Front here and here, and on twenty-first century casualty evacuation in Afghanistan here and here.  Some of the differences between the two systems are summarised in this slide from a presentation on the project I gave in 2014.

WOUNDS OF WAR Vancouver Jan 2014.001

Much  more to come!

Bodies on the line

The more I think about corpography (see also ‘Corpographies under the DOWNLOADS tab) – especially as part of my project on casualty evacuation from war zones – the more I wonder about Grégoire Chamayou‘s otherwise artful claim that with the advent of armed drones the ‘body becomes the battlefield’.  He means something very particular by this, of course, as I’ve explained before (see also here).

But let me describe the journey I’ve been taking in the last week or so that has prompted this post. Later this month I’m speaking on ‘Wounds of war, 1914-2014‘, where I plan to sketch a series of comparisons between casualty evacuation on the Western Front (1914-18) and casualty evacuation from Afghanistan.  I’ve already put in a lot of work on the first of these, which will appear on these pages in the weeks and months ahead, but it was time to find out more about the second.

800px-Medical_Emergency_Response_Team_Recovers_a_Casualty_in_Afghanistan_MOD_45151884

En route I belatedly discovered the truly brilliant work of David Cotterrell who is, among many other things, an installation artist and Professor of Fine Art at Sheffield Hallam University.  He became interested in documenting the British military casualty evacuation chain from Afghanistan, and in 2007 secured access to the Joint Medical Forces’ operations at Camp Bastion in Helmand.  He underwent basic training, a course in even more basic battlefield first-aid, and then found himself on an RAF transport plane to Bastion.  The Role 3 Hospital was, as he notes, a staging-ground. ‘Field hospitals are islands between contrasting environments,’ he wrote in his diary, ‘between the danger and dirt of the Forward Operating Bases and the order and convention of civilian healthcare.’  You can read a long, illustrated extract from the diary (3 – 26 November 2007) here, follow the photo-essay as a slideshow here, and explore David’s many other projects on his own website here.

THEY-WERE-SOLDIERS_by-Ann-Jones_72The diary is immensely interesting and informative in its own right, not least about the exceptional personal and professional difficulties involved in documenting the evacuation process.  Here there’s a helpful comparison to be made with journalist Ann Jones‘s no less brilliant They were soldiers: how the wounded return from America’s wars (more on this in a later post), which starts at the US military’s own Level III Trauma Center, the Craig Joint Theater Hospital at Bagram, and moves via Landstuhl Regional Medical Center in Germany, the largest US hospital outside the United States, to the Walter Reed Army Medical Center in Washington DC.

David’s visual record is even more compelling, as you would expect from a visual artist, not only in its documentary dimension but also in the installations that have been derived from it.  In Serial Loop, for example, we are confronted with a looped film showing the endless arrival of casualties at Bastion: ‘The sound of a continuously arriving and departing Chinook helicopter accompanies images of a bleak and wasted landscape; the banality of the film’s fixed perspective masks the dramas that unfold within the ambulances as they travel to triage.’

9-liner explores what David calls ‘the abstraction of experience within conflict’:

9-Liner explores the dislocation between the parallel experiences of casualties within theatre. It is a quiet study of a dramatic event: the attempt to bring an injured soldier to the tented entrance of the desert field hospital. The screens show apparently unrelated information. JCHAT – a silent scrolling codified message – runs on a central screen. Our interpretation of it is enabled through its relationship between one of two radically different but equally accurate views of the same event. To the left we see the Watchkeeper – a soldier manning phones and reading computer screens in a crowded office. On the right we view the MERT flight – the journey of the Medical Emergency Response Team in a Chinook helicopter.

SHU’s REF submission includes this summary of David’s work (one of the very few useful things to come out of that otherwise absurdist exercise):

The research made clear that soldiers recovering from life-changing injuries had limited means of reconstructing the narrative of their transformative experiences. From the time of wounding through to secondary operations in the UK, many soldiers remained sedated or unconscious for a period of up to five days. The radical physical transformation that had occurred during this period was not adequately reconciled through medical notes, and the embargo on photographic documentation of incident and subsequent medical procedures served further to obscure this period of lost memory.

A culture of secrecy meant that medical professionals were unable to access documentation of the expanded care pathway with which they, and their colleagues, were engaged. This fragmentation of experience and understanding within the process of evacuation, treatment and rehabilitation meant that the assessment of the contradictions and disorientation experienced by casualties and medical practitioners was denied to front-line staff.

Family members, colleagues and members of the public outside the immediate environment of the military were unable to visualise or understand the transformative effects of conflict on directly affected civilians and soldiers. Partly as a result, the scope for public debate to engage meaningfully with the longer term societal cost of contemporary conflict was limited.

The submission goes on to list an impressive series of debriefings, presentations to military and medical professionals, major exhibitions, and follow-through research in Birmingham.

5-soldiers_header

And it’s one of those follow-throughs that prompted me to think some more about corpographies.  I’d noted the connection between corpography and choreography in my original post, but David’s extraordinary collaboration with choreographer Rosie Kay and her dance company gives that a much sharper edge.  Again, there’s a comparison to be drawn – this time with Owen Sheers‘s impressively researched and executed body of work, not only the astonishing Pink Mist but also The Two Worlds of Charlie F (2012)which was a stage play based on the experiences of wounded soldiers who also made up the majority of the cast (see my discussion of these two projects here).

5 Soldiers started life as a stage presentation in 2010 (watch some extracts here):

A dance theatre work with 5 dancers, it looks at how the human body is essential to, and used in, warfare. 5 SOLDIERS explores the physical training that prepares you for war, as well as the possible effects on the body, and the injury caused by warfare.

Featuring Kay’s trademark intense physicality and athleticism, 5 SOLDIERS weaves a journey of physical transformation, helping us understand how soldiers are made and how war affects them.

5 SOLDIERS is a unique collaboration between award-winning choreographer Rosie Kay, visual artist David Cotterrell and theatre director Walter Meierjohann. It follows an intense period of research, where Rosie learnt battle training with The 4th Battalion The Rifles and David spent time in Helmand Province with the Joint Forces Medical Group.

Rosie explained her commitment to the project (and her training with The Rifles) like this:

“I wanted to look at how the physicality of a soldier’s job defines them –like a dancer, the soldier is drilled, trained, their responses becoming automatic, but can anything prepare you for the realities of war? It is young soldiers and their bodies that are the ultimate weapon in war – their strength and weaknesses may win or lose a battle, their ability to harm or injure others is key to victory. While war is surrounded with weaponry, uniforms, history and ceremony, the real business is human, dirty, messy, painful and happening right now.”

(She is, not coincidentally, an affiliate of the School of Anthropology at Oxford).

5 Soldiers installation PNG

And now there’s a film version that works as a multi-screen installation (screen shot above).

Instead of just creating a short film, the team wanted the web user to get a truly interactive way to watch dance, and actually feel that they can go inside the minds and the body of the work. The 80-minute work was cut to just 10 minutes long, and the company spent one week filming in a huge aircraft hangar at Coventry Airport…

Using a variety of cutting edge filming techniques, the collaborative team have created a 13 angle edit that takes you into the heart of the work, follows each of the dancers, and zooms out so that the performers appear to be like ants in a huge empty landscape.

You can see the interactive, multi-perspectival version here.  This relied on helmetcams, and there’s a fine, more general commentary on this in Kevin McSorley‘s ‘Helmetcams, militarized sensation and “somatic war”‘ here.  But here’s the short, ‘director’s cut’ version:

And look at the tag-line: ‘The body is the frontline’.  It’s not only drones that make it so.