Medical aspects of the First World War
Article based on the extended content of Before My Helpless Sight - Suffering, Dying and Military Medicine on the Western Front 1914 - 1918 by Leo van Bergen

Content of the article  Medical aspects of the First World War

  'To my knowledge 'Before my Helpless Sight' is the best book on the wounds of war.'
          Jay Winter. Yale University and Historial de la Grande Guerre, Peronne

I: The photo book Krieg dem Kriege! - II: Heroism alone - III: War and the individual - IV: Who is the enemy?
V: The soldier as ‘Hero’ - VI: Victims and perpetrators - VII: The dead of the Eastern Front and the civilian victims
VIII: Animal suffering
- IX: Atrocity propaganda - X: The war at sea and in the air -
XI: The misery was universal

Chapter 1 Battle
Introduction I: Changes on the eve of war - II: The dominant military ideology - III: The war  - IV: Shared affliction
                        V: The Great War was too great
1914 I: The overture  - II: The invasion of Belgium - III: Germans against the French -
          IV: The British and their ‘great retreat’ - V: Towards the stalemate - VI: The First Battle of Ypres
1915 I: The spring offensives - II: Battle of Loos
1916 I: Battle of Verdun - II: The colonial troops - III: Battle of the Somme
1917 I: Battle of the Chemin des Dames - II: Battle of Messines - III: Battle of Passchendaele (Third Ypres)
1918 I: The German advance - II: The Allied advance - III: The armistice on 11 November 1918
1914-18: the casualties Counting the victims of war

Chapter 2 Body
Conditions in the trenches I: Clothing - II: The soldier’s burden - III: Hunger and thirst - IV: Rain and mud and cold
                                                   V: Vermin - VI: Noise and stench - VII: The trenches
Disease I: Introduction - II: Sickness in the trenches - III: Heart problems, venereal disease and Spanish 'flu'
Wounds I: Introduction - II: Bullets and shells - III: The chemical horror - IV: The lucky wound

Chapter 3 Mind
Introduction A complete psychological breakdown
From health to neurosis I: Morale - II: Numbness - III: Inhumanity - IV: Fear - V: Self-mutilation and suicide
Neurosis I: Introduction - II: Definition of war neurosis - III: Numbers of war neurosis - IV: Causes of war neurosis
                  V: Symptoms of war neurosis -
VI: The alleged hallmark: cowardice

Chapter 4 Aid
Introduction:  The pain represented by figures - From wounding to aid post - From first aid to hospital -
The field hospital - The base hospital - Too many wounded, too little help - Complication - Is survival a blessing? -
Medical experiments - Medical aid and military necessity 
Military psychiatry - I: War and madness - II: Kaufmann and colleagues - II: The Allies -
IV: Discipline versus analysis
In summary: the character of military medicine

Chapter 5 Death on the Western Front
Killing and being killed
Death outside of battle

I: ‘Ordinary’ losses - II: Accidents and snipers - III: Prisoners of war  - IV: Friendly fire - V: Death by execution
Death in battle I: Bayonet and barbed wire - II: The trench raid - III: Artillery, the great destroyer - IV: The offensive
Meetings with Death I: Individuals
 - II: The battlefield
Burial in wartime I: Bodies in hospital - II: Burial parties
 - III: No peace, no rest - IV: Too many dead 

Afterword  ‘There is in our lives a wound which will never heal. Nor should it.’

Information About the author - Reviews Before My Helpless Sight

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I: The photo book Krieg dem Kriege!
On Ernst Friedrich, his Krieg dem Kriege / War against War and the (false) idea that showing gruesome war pictures, the ‘truth of war’, would make an end to war. “The photographs portray the dead and wounded of a disastrous conflict that remains even now the archetype of modern, total war. People responded by saying the photographs were repulsive, but that only proved they were good photographs; Friedrich had chosen them precisely because they were repulsive, and in any case the entire 1914-18 war had been repulsive. Many people, including the historian Jay Winter, have argued that since the photographs in Friedrich’s book were ‘almost unbearable to look at’ they inevitably missed their target to some degree. They were unlikely to convince anyone of the horrors of war; at best they might reinforce the views of those who no longer needed any convincing. There is undoubtedly some truth in this, but Krieg dem Kriege! prompts us to contemplate how terrible the reality must have been if even its portrayal was unbearable.”

II: Heroism alone
On the (as false) idea that war is about camaraderie, heroism, altruism, and the attractiveness of war, even on those who protest against it. “War fascinates. The children of veterans of Passchendaele dreamed of heroic roles in a battle their fathers told them had made any kind of heroism impossible. Take Philip Toynbee, a former peace activist who fought in the Second World War. In Friends Apart, published in 1954, he wrote: ‘Even in our Anti-War campaigns of the early thirties we were half in love with the horrors which we cried out against, and, as a boy, I can remember murmuring the name ‘Passchendaele’ in an ecstasy of excitement and regret.’”

III: War and the individual
On the desastrous effect of modern warfare on the individual; on individuality. “In his novel The Middle Parts of Fortune (reissued only many years later but quickly published in a bowdlerized form as Her Privates We), British soldier Frederic Manning observed that soldiers no longer possessed anything, ‘not even their own bodies, which had become mere implements of warfare’.”

IV: Who is the enemy?
On the anything but easy task to define exactly who in the eyes of the 1914-1918 soldier in fact the enemy was. “As time went on the average soldier began to wonder who his real enemies were. The men facing him from beyond no man’s land? The well-fed generals in their spacious accommodation miles from the front? The politicians who allowed the war to continue? The industrialists, lining their pockets with the profits of war? Or civilians, who seemed incapable of understanding what war actually meant?”

V: The soldier as ‘Hero’
On the ritual that soldiers – especially dead soldiers – are celebrated Heroes (with a capital H) even if they died by a bomb shot ten miles from him. “With their sceptical attitudes towards courage and honour, Brants, Winter and Baggett are in fact following a line taken at the time by an ordinary German soldier, Herbert Weißer, who in March 1915, two months before his death, wrote that the impression given in history lessons, in stories told by parents and in books was thoroughly misleading. Every soldier was given the honorary title ‘Hero’; soldiers stopped being ordinary people, they were Heroes who performed Heroic deeds, spilled Heroic blood, died Heroic deaths and were buried in Heroes’ graves. … But, asks Weißer, were heroic deeds really the hallmark of warfare, were they truly its most prominent and characteristic feature? ‘How much of a contribution is made to these heroic deeds by momentary, instinctive excitement, perhaps lust for blood and unjustified hatred? ... There are also very quiet, unrecognised acts of heroism. (Really so much more rare in times of peace??). And there are alcoholism, aesthetic and ethical brutalization, spiritual and physical laziness. When do people ever write about those in their war reporting?’”

VI: Victims and perpetrators
On the unjustified idea that soldiers fighting in modern wars are victims. They are at least perpetrators as well. “The twentieth century was the first in which soldiers could see themselves as victims rather than as agents or perpetrators. This was a consequence of the total helplessness of the individual in modern warfare. In that sense they were indeed victims. But innocent, unwitting victims or not, the soldiers were also, indeed primarily, the active party. The shot precedes the wound. Although men caught in gunfire and shelling are central to this book, not dying but killing, sanctioned killing, is the main feature of war.”

VII: The dead of the Eastern Front and the civilian victims
On the non-Western front victims. “Although in the war as a whole there were more deaths in the West than in the East – leaving aside other theatres of conflict – the Eastern Front was the most lethal in percentage terms, certainly in the first year of fighting. Disease in particular took a heavy toll in the East. Epidemics, including malaria and typhoid (blamed, incidentally, on working-class Polish Jews) wreaked far more havoc than in the West. They were the main reason why deaths in the Serbian army reached forty per cent and in the Romanian army around thirty per cent. Prisoners of war were not immune: 70,000 Austrian soldiers died in camps that lacked sanitation of any kind.”

VIII: Animal suffering in the First World War
On the impact of seeing and hearing animal suffering on the soldiers’ psyche. “The pain caused to animals is not the subject of this book, but it undoubtedly contributed to the mental sufferings of soldiers. The sight of a wounded horse, and perhaps even worse the sound of a wounded horse, was harrowing in the extreme. Alan Hanbury-Sparrow described the order received during the retreat from Mons to give wounded horses the coup de grâce as ‘perhaps the most senselessly savage order ever issued by the staff’. Graves grew used to the sight of human corpses, but he was shocked every time he saw a dead horse or donkey.”

IX: Atrocity propaganda
On the impact of atrocity propaganda on the harshness of warfare. “It is important to add that there was not in fact any ‘propaganda’ in the strict sense of the word. No fabricated stories were distributed by the military and political authorities with the aim of fuelling hatred for the enemy and thereby strengthening the will to fight. Propaganda consisted of stories that arose among the ranks of soldiers and civilians, and were sincerely believed by them. Perhaps such tales had a greater and more subtle impact for this very reason, but although neither distributed from above nor deliberately invented, their effect was nevertheless to deepen the gulf between the two sides, increasing the hatred and making the fighting even more horrific. In other words, the victims featured in propaganda were mythical, but the victims of propaganda were all too real.”

X: The war at sea and in the air
On the atypical forms of 1914-1918 warfare. “In the post-war years the cult of the hero underwent a transition. It no longer applied to every soldier, the anonymous soldier, the unknown soldier, but to a few famous characters whose names were known to all, like Canada’s Billy Bishop and Germany’s Manfred von Richthofen, the Red Baron. These were names that made hearts beat faster and after the war men longed to emulate them. The anachronistic nature of the desert war and the futuristic nature of the air war, in which the enemy was known by name and honoured in death by friend and foe alike, meant that even after 1918 warfare was still bathed in an aura of romanticism.”

XI: The misery was universal
On the impartiality of suffering. “In this book I describe a small part of the total, horrific experience of soldiers who served on the front line between 1 August 1914 and 11 November 1918, voluntarily or not. I see their sufferings as illustrative of the horrors confronted by all those exposed to war. To paraphrase Owen: my subject is war, and the horrors of war. All a historian can do is describe.”

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Chapter 1 Battle


I: Changes on the eve of war
On societal changes, military ideology and arms race. “
By 1914 a company of 300 men could deploy firepower equivalent to that of the entire 60,000 strong army commanded by the Duke of Wellington at the Battle of Waterloo. Wilhelm Lamszus, author of Menschenschlachthaus. Visionen des Krieges (The Human Slaughterhouse: Scenes from the War That Is Sure to Come), published in 1912, realized after watching a military exercise that a future war would bear no resemblance to 1870-71. ‘It is as if death,’ he wrote, ‘had thrown his scythe onto the scrap-metal heap and become a machine operator.’”

II: The dominant military ideology
On the offensive mind-set of the military. “What the enemy did was immaterial, the thinking went; it was his location that mattered. The army must not cede an inch of ground. The bayonet was of greater importance than the machine-gun. Heavy artillery would only get in the way. The last remnants of caution in the British Field Service Regulations of 1905 were omitted from the 1909 edition. A battle could be decided only by a ruthless and uncompromising attack. Any officer who recognized the disadvantages of this strategy and expressed his misgivings had little chance of promotion.”

III: The war
On the paradox that the defence had the advantage but the war could only be decided by the offence. “The war of 1914-18 was neither the brief, bloody battle the cavalry had anticipated nor the lengthy but literally bloodless stalemate some had feared. It was the worst of both worlds, an extremely bloody trench war that lasted more than four years, drawing upon all the achievements of preceding decades in social, technical and medical fields, not for the benefit of humanity but in pursuit of destruction.”

IV: Shared affliction
On the impartiality of suffering. “Many officers regarded urban populations as largely composed of leftwing radicals or, even worse, enfeebled drunkards. For the army staffs this presented one advantage: the blame for any offensive that ended in bloody failure could be placed on the men. There had been nothing wrong with their plans for a great breakthrough, but those responsible for executing them were not up to the task.”

V: The Great War was too great
On the simple fact that the costs in men and material from the Great War was too much for any country participating in it. “The huge death toll can be blamed in part on the fact that none of the countries involved was prepared for war on such a scale, nor could have been.”


I: The overture
On the weeks predating the war and the motives and expectations of those who were about to engage in battle. “
Many historians believe people welcomed the war with all the enthusiasm described by the politicians, soldiers and journalists of the day. The evidence suggests that the story is more myth than reality. The monotony and boredom said to characterize the lives of ordinary citizens, from which the war promised escape, were to a large extent figments of the imaginations of a small intellectual elite.”

II: The invasion of Belgium
On the opening days of the war in the West and on the Belgian army. “Medical services were poorly organized. Before the war it had been assumed that the intensity of firepower would prevent any movement of the wounded during a battle, so hardly any stretcher-bearers had been trained. For the same reason no motorized vehicles were provided as ambulances, only horses and carts – after all, once a battle was over it would no longer be necessary to move casualties particularly quickly. There were thirty-three SSA trains (Service de Santé de l’Armée), whose 300 carriages had room for 3,840 prostrate wounded and seats for another 3,600, but there were insufficient Red Cross staff to man them. Nevertheless the wounded were moved back behind the lines train-loads at a time. They had to be transported from railway stations to hospitals on open stretchers. There were not enough army doctors to treat those who made it that far.”

III: The Germans against the French
On the first struggles between the German and the French. “French reservists and volunteers, in their traditional and highly visible red trousers, fell to German gunfire in their tens of thousands, in the Vosges Mountains and in Champagne, at Reims, St Quentin and Chateau-Thierry, on the Aisne and the Marne. They advanced in formation, without cover of any kind. Within two weeks their losses had reached 300,000 and five thousand officers were dead. At Roselies near Charleroi on 22 August, the 74th Infantry Brigade lost 1,100 men. On that one day alone, 27,000 Frenchmen died on various battlefields, making it the bloodiest day in French history.”

IV: The British and their ‘great retreat’
On the first battles, Mons, Elogues, Le Cateau, between the Germans and the British Expeditionary Force and the overwhelming fatigue during the retreat after Mons. “Britain declared war on Germany as soon as the German army crossed the Belgian border. Many British men spontaneously reported for service with the British Expeditionary Force (BEF). Their enthusiasm only increased when the BEF suffered defeat at Mons. The battle was costly for the Germans and in accordance with an old British custom the defeat was celebrated as a moral victory.”

V: Towards the stalemate
On the exhaustion of the Germans and the battle at the Marne, leading to trench warfare. “Stephan Westman, a doctor who was serving as a young conscript with the 113th Infantry Regiment wrote: ‘We slogged on, living, as it were, in a coma, often sleeping whilst we marched, and when the column came to a sudden halt we ran with our noses against the billycans of the men in front of us.’”

VI: The First Battle of Ypres
On the First Battle of Ypres fall 1914 and other battles in the surroundings, making ‘Belgium’ a horror filled word, and it would only get worse. “Corporal George Matheson wrote from First Ypres, ‘We were complaining about the Aisne being bad, but it was a king to the fighting we have done since we came to Belgium. This is pure murder, not war.’”


I: The spring offensives
On the first battles of 1915, Neuve Chapelle, Fromelles, Champagne, Notre Dame de Lorette, St Mihiel, Aubers Ridge, Argonne, and the Hartmannswillerkopf in the Vosgues Mountains, the blood and rain and mud and cold that typified them, and on the Second Battle of Ypres giving birth to poison-gas. “Towards the end of the afternoon of 22 April, on the northern side of the front near Langemarck, immediately after a short but heavy barrage, the valves of thousands of cylinders were unscrewed and 168 tons of yellow-green chlorine gas drifted from German positions towards the French in the northern sector, in clouds that gradually turned into a bluish-white haze. French troops without any protective equipment, many of them from the colonies, panicked and left a gap in the front almost eight kilometres wide.”

II: Battle of Loos
In the battle of Loos where the British heavily suffered in spite of using gas themselves for the first time. “
Thousands of recruits to the new British volunteer army had their first experience of battle here, and in many cases their last. Within two hours, on the British side alone, more soldiers died than were lost on all sides on D-Day, 6 June 1944.”


I: Battle of Verdun
On the battle of Verdun, the ‘greatest’ (and longest, and bloodiest) battle in history. “Paul Valéry had every reason to describe the Battle of Verdun as a war within a war. Henri Barbusse had every reason to write, with Verdun in mind, that ‘two armies engaged in battle are one great army committing suicide’. Jünger had every reason to conclude that Verdun was not a battle but a massacre, a bloody massacre on a few square kilometres that brought no visible benefit or advantage to either side. Many would argue it brought no invisible gains either.”

II: The colonial troops
On the special problems of the colonial troops, wandered of in the war that wasn’t theirs, fought in a way they did not understand and rejected, although mostly they were seen as the repulsive ones using inhuman ways of warfare. “One Indian soldier wrote home that he found himself not in the midst of a war but at the ending of the world. Nor could they understand why a wound did not exempt them from any further fighting. A Sikh wrote to his father in amazement that they were like baked grain flung into the oven a second time, ‘and life does not come out of it’.”

III: Battle of the Somme
On the five months long British offensive at the river Somme, most famous for its opening day, 1 July 1916, leaving 20.000 British men dead on the ‘field of honour’, the biggest toll ever of a single army in one day on such a limited area. “The army of volunteers, Kitchener’s men, was born during the hard labours of Loos and buried less than a year later. Siegfried Sassoon, whose platoon was not among the first to advance, took a quick look at the battlefield after he had finished shaving – a fleeting glance, since merely looking put him in deadly danger. It was as if he had seen ‘a sunlit picture of hell’.”


I: Battle of the Chemin des Dames
On the only attack in 1914-18, perhaps even in history, unanimously condemned by military historians. “The Germans were lying low in their extensive chalk tunnels inside a hill, the Caverne du Dragon. After a preparatory barrage they emerged from several tunnel exits to inflict a bloodbath on the French troops clambering up towards them. In heavy rain and sleet, the French and Senegalese soldiers had to work their way up through a hail of hand grenades and machine-gun bullets.”

 II: Battle of Messines
On the intended explosion of several tunnels near Ypres, 7 June 1917, the biggest explosion in history apart from Hiroshima and Nagasaki. “One of the few Germans who lived to tell the tale wrote: ‘The ground trembled as in a natural earthquake, heavy concrete shelters rocked, a hurricane of hot air from the explosion swept back for many kilometres, dropping fragments of wood, iron and earth, and gigantic black clouds of smoke and dust spread over the country. … The trenches were now the graves of our infantry.’”

III: Battle of Passchendaele (Third Ypres)
On the battle that made ‘Passchendaele’ a metaphor for the senselessness, the insanity of warfare. “Canadian doctor Frederick W. Noyes experienced only the final two weeks of the battle, but looking back he wrote: ‘One long, weird, and terrible nightmare of water-filled-trenches, zigzagging duck-walks, foul slime-filled shell-holes, half-buried bodies and dead men, horses and mules, cement pillboxes, twisted wire, shrieking shells, flying humming metal, crashing aerial bombs, stinking mud, water-logged and blood-soaked trenches – a slough of Despond even Bunyan couldn’t conceive of.’”


I: The German advance
On the last, desperate attempt of the German army to win the war, before the America troops would be fully deployed. ‘The price paid was huge. In four months the German army lost around a million men, twice as many as the British and French combined. After two months of fighting, Zuckmayer wrote from Flanders to his friend Kurt Grell: “What have I experienced (since our last letter)? Offensives. ‘Kaiserschlacht’. Blood. Cambrai. Blood. Gas shells. Kemmelberg. Blood. Horror. A brief time in Lille. Schnapps. Whores. Booze. Armentières: Blood. Killing. Blood. Three steps from insanity.’”

II: The Allied advance
On the final turning of the tide, summer and fall 1918, fro instance resulting in the ‘Black day’ for the German army 8 August.  “Douglas MacArthur, who would command American forces in the Southwest Pacific more than twenty years later, walked across the battlefield amid the moans and screams of wounded men abandoned there. He estimated he had seen 2,000 German corpses. A machine-gun post was scattered with bodies, ‘the lieutenant with shrapnel through his heart, the sergeant with his belly blown into his back, the corporal with his spine where his head should have been’. Yet we should not be misled by sights and body-counts like these. Roles had been reversed, but not completely. Now it was the French, British, Australians, New Zealanders, Canadians and Americans who were advancing, and therefore it was the French, British, Australians, New Zealanders, Canadians and Americans who died. The Battle of the Marne, for example, cost the Germans 25,000 men, the French around 100,000.”

III: The armistice on 11 November 1918
On 11 November 1918, a day too good to be true and too sad to be enjoyed. “The war that was supposed to be over by Christmas 1914, and which many soldiers believed would never stop, had finally ended. Many were not convinced. The war over? They refused to believe it. Most celebrations took place back home, among those who knew that friends and family still out in France or Belgium were safe and unhurt. In the trenches the most noticeable effect was silence. No more roaring of guns, no more whistling of bullets, little revelry either, virtually no jubilation. The soldiers had been beaten numb. Relief? Yes. Festivities? Although joy was certainly one element of the numerous different moods that overcame soldiers when they heard of the armistice, many were incapable of responding with enthusiasm. Some had no reason to feel joyful. The end had come too late and they would either die or face life without arms or legs. Graves later quoted a poem by Sassoon about the armistice, including the words ‘everybody suddenly burst out singing’, only to remark: ‘But “everybody” did not include me.’”

1914-18: the casualties

Counting the victims of war
On the difficulty of counting the victims of war, for instance because of the uncertainly who is to be considered a victim, but nevertheless agreeing on the conclusion that either number will be vast. “Take the Battle of Verdun. Some sources speak of 100,000 dead and 500,000 wounded on either side. Historian Luc de Vos gives figures of 160,000 dead and missing Frenchmen, and 220,000 French wounded, while Kurt Tucholsky, for example, speaks of 400,000 dead on the French side alone. One French officer had no hesitation in announcing that there had been 1.5 million French casualties. It is perhaps characteristic that Martin Gilbert writes at one point in his The First World War of more than a million French dead in the war as a whole and elsewhere of almost 1.4 million. Of course this is not a discrepancy, but it is telling that almost 400,000 dead seem simply to have been rounded down.”

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Chapter 2 Body

Conditions in the trenches

I: Clothing
On the suffering coming from the inadequacy of clothing, both in quantity as in quality. “In his book Krieg (War), Arnold Vieth von Golssena, writing as Ludwig Renn, described his one and only pair of underpants as a rag. Only the legs were still in one piece; they had no seat left, nor any buttons. In desperation he sewed laces to the sides and tied them round his waist. In Mud and Khaki, H.S. Clapham describes how he walked around for six months with a large hole in the seat of his trousers and was once unable to change his underwear for a month.”

II: The soldier’s burden
On the weight of the packs, making marched even more exhausting and almost unbearable. “Henri Barbusse described it as ‘monumental, crushing’, what with flares, periscopes, wire-cutters, spare clothes (if he had any), shaving kit, food, drinking water, tea, cigarettes, matches, a Bible and perhaps other books, family photographs and so on. A Swiss, Ulrich Braker, serving in that famous German regiment whose name, the Itzenplitz, conjures up images of Schweijk rather than serious combat, opened his shirt after a march to feel some fresh air on his chest and ‘steam rose up as if from a boiling kettle’. One British soldier, a former choirmaster, sighed that it was no fun having to carry your house on your back.”

III: Hunger and thirst
On the two greatest torments that can afflict a man and which afflicted troops throughout their time in the trenches: hunger and thirst. “If thirst was a torment in dry periods, in times of particularly bad flooding it was hell indeed. Soldiers suffered unquenchable thirst, caused partly by their dry biscuits, while water polluted by corpses lay everywhere they looked. Estimates suggest that by early 1915, in the inundated area around the Yser alone, tens of thousands of bodies floated on the floodwaters or under the murky surface. Men crawled out of their trenches and risked their lives to fill their bottles with water from beneath the greenish-brown slime that coated ponds and flooded shell-holes, despite knowing they were certain to have been polluted by gas or by the decomposing flesh of men and horses. They knew the risks and accepted them.”

IV: Rain and mud and cold
On the torment of  bad weather when forced to stay outside or even attacking in them, although on the whole the weather was not particularly better or worse than in other years; the impact increased enormously. In other words: rain did not cause the Somme and Ypres mud, the war did. “In January 1915, five days before his death, German soldier Karl Aldag wrote from his Flanders dugout: ‘Mud and water fill the trench, water from below and rain from above. Day and night we lie low, moving earth, shovelling water and pumping it. And all the time that sense of futility, knowing it’s all completely pointless! The water remains.’ Eugen Röcker wrote home that in his shelter it was impossible for him to sleep in his bunk, since it was floating around in deep water.”

V: Vermin
On lice and mice, and rats and flies. “The only enemy the rats encountered was an unnatural one: gas. A gas attack would result in a huge death toll among rats, but the positive effect was short-lived. As soon as the gas had dissipated, more rats would start arriving from neighbouring trenches. Alistair Horne writes that rats seemed to be the only creatures who really profited from the war, although, he adds cynically, there were few other respects in which the life of a rat differed from that of a soldier.”

VI: Noise and stench
On the wall of sound of guns and flies and moaning wounded (and the singing of birds) and the stomach turning stench of gas and decaying corpses. “During a bombardment the noise was loud enough to split the eardrums and it quite commonly caused permanent hearing loss, especially among gunners. The sound of one shell bursting nearby is deafening, let alone thousands. Many men said you did not so much hear the noise as feel it. A Canadian soldier even wrote that it had assumed a tangible form; for him the barrage had become a solid, immovable ceiling of sound.”

VII: The trenches
On ‘life’ in the trenches. “It will be clear from all this that life in and around the trenches was filthy, foul, sickening, deafening, dispiriting and extremely unhealthy. It was safer than in no man’s land, but that was about all. Anyone who peered over the breastwork out of curiosity, even for a second, stood a fair chance of being shot by a sniper. A man might be buried, alive or dead, in the foxhole where he was hiding. In a trench there was a good chance of being ripped apart by a bursting shell, indeed death in the trenches was rarely quick or clean. Unless they were caught by a sniper’s bullet, few of the men killed while still in their trenches were hit in the head or heart by a single shot. Shrapnel and shell splinters made for a long, painful death.”


I: Introduction
On the huge amount of ‘non effective mandays’ caused by disease and the definition it had. “Disease was not just a serious problem on a human level, it was a substantial military threat. Even though the mortality rate among soldiers who contracted diseases was far lower (at around one per cent) than that of the wounded (some thirty per cent), sickness was and remained the main cause of loss of manpower. It should be noted here that the word ‘disease’ had a different meaning in the trenches than in normal life. A large proportion of men who took part in offensives may have had heavy colds or 'flu' but they were not regarded as sick. This made it possible to claim that given the circumstances the health of the troops was surprisingly good. If the definition of the word ‘ill’ had been the same in 1914-18 as it is today, there would have been practically no healthy soldiers left to fight battles.”

II: Sickness in the trenches
On illnesses tied up to the specific kind of warfare of 1914-1918 such as skin infections,  myalgia, rheumatism, trench fever, pyrexia, trench feet, frostbite, trench mouth, pneumonia, diarrhoea, tuberculosis, bronchitis, enteritis, typhus, typhoid, Weil’s disease, diphtheria,  dysentery, meningitis, tetanus and on the measures, such as declaring some of them a military offence, taken against them. “From 1916 onwards soldiers were simply forbidden to develop trench foot. The duty officer was obliged to ensure men took the prescribed precautions, and if there were too many cases of trench foot in a battalion, the officer in charge would be dismissed. Anyone who contracted trench foot, at least if he were an ordinary soldier or junior officer, would be court-martialled.       This was not as unreasonable as it sounds. Like trench fever and trench mouth, trench foot was one way out of a terrible mess, court martial or no court martial. A very painful way, certainly.”

III: Heart problems, venereal disease and Spanish ’flu
On illnesses not particularly tied up to war and trenches, such as heart problems, Spanish influenza and venereal diseases. “Twice as many suffered from venereal disease as from any other complaint. Given that the chances of infection in a single sexual act have been estimated at no more than about three per cent, it is clear that many soldiers in the vicinity of the trenches and on short-term leave must have shared their beds with prostitutes or local women. Leave in Paris was particularly feared by army doctors. This does not alter the fact that, generally speaking, precious little sex is mentioned in war memoirs. The same applies to personal experiences of killing. Individual contributions to the beginning or ending of a life are perhaps part of one and the same taboo. Many men saw others go off to visit prostitutes, and many saw others in the act of killing, but few admitted to taking part in such activities themselves.”


I: Introduction
On the estimations before the war of the numbers of soldiers wounded, on the completely conflicting actual numbers and on the nature and survival chances of the wounds. “Wounds to the abdomen proved even more deadly than wounds to the head. Of one British sample of a thousand soldiers with stomach wounds, 510 died on the battlefield, 460 on their way to hospital and twenty-two following surgery. Only eight survived, or 0.8 per cent. In this particular case the circumstances may have been extreme – other studies conclude that the survival rate was eight per cent – but clearly the survival chances for men with abdominal wounds were small, even compared to chest wounds which, despite proximity to the heart, were survived by seventy-two per cent.”

II: Bullets and shells
On the wounds caused by ‘conventional’ weaponry and the essence of war. “The essence of warfare, as the First World War makes graphically clear, can be described as the handing over of one’s body to the state, giving the government free rein to dispose of it as it sees fit, even if that means it will be grotesquely mutilated by bullets and shells, most but not all fired by the enemy. Nevertheless, in theory bullet wounds were relatively clean. If the bullet entered the body undamaged, there was usually little bleeding, only a bluish hole with smears of blood around it. Rotation of the bullet could cause contusions, but even then heavy bleeding was rare, since shock reduced blood pressure and severed blood vessels sealed themselves off. […] However, if the bullet did not go straight to its target but ricocheted, as was very often the case, then the consequences could be ghastly. The twisting bullet did not enter the flesh point first but made a huge hole and could easily smash a bone. Even in the first month of the war, the British Medical Journal recorded bullet holes measuring five by three inches as a result of ricochets.”

III: The chemical horror
On the flamethrower and poison gas. “In the days after the first mustard gas attack, the Casualty Clearing Station at Mendringhem alone received more than a thousand gas casualties. Many were actually victims of the very first attack. They had crawled into shell-holes with yellow cross lying in the bottom where it had failed to evaporate and did not notice as it soaked into their clothes. After several days they emerged from their hiding places. Their uniforms had burned through in patches and their skin was covered in blisters.”

IV: The lucky wound
On the Blighty, the bonne blessure, the Heimatschuss. “The lightly wounded stood a good chance of being sent back up to the line before very long. Those with serious wounds risked dying or being disabled for life. But there was an intermediate category: the Blighty, the Heimatschuss, the bonne blessure. Such a wound was the best of all ways to get out of the war. Being wounded meant there was no need to feel any guilt. A Blighty was serious enough to keep a man out for the duration, but not so serious that he would go through life horribly maimed. Soldiers had little respect for modern medicine, as we shall see, but its ability to heal wounds that would once have been fatal so that a man could set off home and say goodbye to the front for ever was generally welcomed.”

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Chapter 3 Mind


A complete psychological breakdown
On the inevitable psychological trauma, mild, severe or somewhere in between, in individuals fighting a highly mechanized industrial war. “In his evidence before the War Office Committee of Enquiry into Shell Shock, J.F.C. Fuller said he had seen many men who were in a perfectly healthy frame of mind when they embarked for the continent whose first experience of being under fire caused physical fear, which quickly abated to be replaced by indifference. This mental state might then develop along a path that led to extreme nervousness and finally complete psychological breakdown. In other words, healthy fear degenerated first into indifference and later into obsessive fear, and the chances of this happening were greater than in previous wars because of new military technologies that increasingly depersonalized war.”

From health to neurosis

I: Morale
On the decline of morale, starting already before but accelerating after the soldiers had dug in. “The constant awareness of death and destruction, the apparent hopelessness of the fighting and the complete lack of information all clearly impacted on morale. Depression, lethargy and drunkenness steadily increased and the number of cases of desertion and neurosis rose.”

II: Numbness
On the change of individual personality as a consequence of wartime conditions. “Vera Brittain’s fiancé, Roland Leighton, expressed it by saying: ‘I feel like a barbarian, a wild man of the woods, stiff, narrowed, practical, an incipient martinet perhaps.’ Feelings that were normal in civilian life, like empathy and grief, soon vanished. The men’s joie de vivre and erotic fantasies faded and sank ‘into the mire that covered everything’, as Sophie de Schaepdrijver put it, writing of the Belgian soldiers at the Yser front for whom the impossibility of leave was a further demoralizing factor.”

III: Inhumanity
On the danger of developing a delight in killing and a complete lack of respect for humans, the living as well as the dead, in spite of the numerous tales of quite the opposite. “In wartime people are ordered to do things that are otherwise strictly forbidden. Everything that is valued in peacetime, including human life, is stripped of its value in times of war. Soldiers become alienated from the civil society that produced them, indeed it actively alienates them, until they become strangers to their own world and even to themselves. The fear, lack of sleep, appalling experiences, ubiquitous violence and group pressures of wartime are a lethal combination. They lead to what one historian of the holocaust, Christopher Browning, has called ‘battlefield frenzy’. […]. ‘Sometimes Tommy is not a pleasant animal’, wrote Corporal W.H.L. Watson, an Oxford undergraduate, after watching British infantrymen fighting to wrench as many belongings as possible out of the clothes of their German opponents in the early weeks of the war. ‘One dead German had his pockets full of chocolate. They scrambled over him, pulling him about, until it was all divided.’”

IV: Fear
On the source of all psychological and emotional problems, fear: fear of bombardment, of gas, of mutilation, fear of death, fear of fear itself, or of showing fear, and fear of the war in general. “On 1 July 1916, Private Surfleet watched men stumble back from the front line. They were pale as death, with bloodstained hands and uniforms and makeshift bandages. Each one had a look of indescribable fear in his eyes. ‘I know, now, I hate this warring business,’ he wrote.”

V: Self-mutilation and suicide
On the soldiers who not succeeded in suppressing their fear, staving of le cafard, leading to the physical way out of misery, self-mutilation, in spite of the probability of court martial, or even suicide, and the connection between this and military failure or success. “
There is probably a connection between the number of suicides and self-inflicted wounds and the degree of military success the men were experiencing at the time. This certainly seems a reasonable conclusion to draw from reports in the early months of the war about British soldiers who had killed themselves, or attempted to, and from German suicide figures. While the suicide rate back in Germany fell steadily, the rate among soldiers increased in the final phase of the conflict. In August 1918 there were officially 3,500 cases; three months later there were more than 5,100. Few would doubt that the true figure was higher.”


I: Introduction
On the subconscious way out of misery: neuroses such as hysteria or neurasthenia, or, as they conveniently but medically inadequate were called in general: shell-shock. “The term ‘shell shock’ became synonymous with war neurosis in general, despite the well-founded medical criticism of it, in the context of the 1914-18 war. Terminology like NYD(N), DAH, hysteria and neurasthenia were meaningless to soldiers and civilians alike. Shell shock on the other hand, like Granatshock, Granatfieber and so on, contained references not only to war but to artillery and trench warfare in particular. The term says something about the 1914-18 war, just as for example ‘combat exhaustion’ says something about the Second World War and ‘combat stress’ about the war in Vietnam. Moreover, to a soldier the term was attractive in that it placed the blame for a mental disorder outside the man himself and even sounded a heroic note. It did not of itself impose the stigma of being labelled either a coward or mentally inferior, whether for reasons of heredity or not.”

II: Definition of war neurosis
On the difficulty of an exact definition of war neurosis, amongst others depending from cause or from a psychological or neurological point of view. “Charles Myers [who had introduced the term shell shock into the medical world], like his old companion W.H.R. Rivers, had been part of a small group of pre-war British psychiatrists and psychologists who were more interested in possible psychological causes of insanity than in its presumed organic origins. Perhaps it was because of this that Myers quickly realized neurosis was by no means always caused by a bursting shell. Even an event that seemed insignificant compared to the things soldiers had to deal with every day could prove the final straw.”

III: Numbers of war neurosis
On the impossibility to know how many men suffered from war neurosis and therefore on the enormous relativity of all exact looking numbers mentioned. “In the absence of reliable evidence, the compilers of Britain’s Medical History of the War settled upon the figure of around 80,000 cases, or two per cent of British men mobilized, a percentage that gave little cause for alarm. In fact it was a misleading extrapolation, greatly underestimating the scale of the problem. We may nevertheless wonder, like John Ellis, at a situation in which around 20,000 men per year on the British side alone were officially driven temporarily or permanently insane.”

IV: Causes of war neurosis
On the at the same time enormous simplicity and difficulty of agreeing on the causes. “It does not take long to sum up the causes. Apart from a handful of cases of men who ought to have been declared unfit for duty from the outset on psychiatric grounds, the main cause was simply the war. Even if we examine the matter more closely, the conclusion is briefly stated. There were almost as many origins of shell shock as there were patients. […] Otto Binswanger, a German professor of psychiatry, wrote in an article published in 1922 that he found it difficult to say anything meaningful about war neurosis, not because few hard facts were available but because he had too many facts and they were too diverse.”

V: Symptoms of war neurosis
On the symptoms of war neurosis, as divers as the causes, having as well a close as very distant relation to each other. “Babington writes of a man who screamed incessantly: ‘He’s gone! He’s gone!’ After a while it became clear that his brother had been killed as he stood next to him in a trench. One of Rivers’ patients at his war hospital for mental cases at Craiglockhart had broken down after he bent to pick up what he thought was a ball lying in the bottom of a trench. It was indeed a ball. An eyeball. Insanity had robbed him of his sight. […] None of this alters the fact that, as already suggested, many men presented symptoms that seemed to have little to do with the immediate causes of their psychological wounds. Rifleman Arthur Russell, a stretcher-bearer, had gone with a group of men who had orders to dig a communication trench, in case any of them should be wounded. It was a bitterly cold night. Russell did not have to dig, so he suffered even more from the cold than the others. At some point he took the pick from one of his companions to allow him to rest for a short time. As he worked he gradually became a bit warmer. Then the point of the pick hit ‘something hard and unyielding as a block of concrete’ and suddenly pins and needles shot through his body like an electric shock. He lost consciousness. There was not a scratch on his body, but he was struck dumb and paralysed, able to move only his eyes.”

VI: The alleged hallmark: cowardice
On the often stated, but highly improbable – and insulting – cause of neurosis: cowardice. “Although a subconscious flight into insanity was far from usual, there is no reason to conclude that neurosis was caused by cowardice. Rarely were symptoms found to be less than genuine, and faking was no simple matter. Nevertheless, as Gibbs pointed out, in the early years of the war especially, the neurotic was commonly considered a deserter or a coward. After all, if he was suffering from mental exhaustion as a result of the conditions of war, then why was one soldier affected more than another? Any man who was treated as mentally ill or psychologically wounded rather than as a deserter had his luck to thank more than anything else. […] Lieutenant-Colonel Frank Maxwell of the 12th Middlesex Regiment wrote in a letter to his wife dated 26 July 1916: ‘“Shell shock” is a complaint which, to my mind, is too prevalent everywhere; and I have told my people that my name for it is fright, or something worse, and I am not going to have it. Of course, the average nerve system of this class is much lower than ours, and sights and sounds affect them much more. It means … that they haven’t got our power of self-control, that’s all.’”

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Chapter 4 Aid

Introduction: The pain represented by figures
On the improvement of medical care for soldiers since the midst of the nineteenth century, not least because of the introduction of conscription in many countries, based on nationalist sentiments, which obliged the state to pay more attention to military medicine, and on the organization of medical care during the war But neither improvement not organization could live up to the demands of 1914-1918. “[During the war] around nine million British sick and wounded were treated and 1,088 million doses of drugs administered. Doctors and orderlies applied 1.5 million splints and 108 million bandages, used 7,250 tons of cotton wool and fitted over 20,000 artificial eyes. The German military medical service gave no less than 200 million inoculations, an average of fifteen per soldier. Whenever an epidemic threatened, whole regiments would line up to be immunized or to receive booster injections. The German army had 3,355 hospitals at its disposal, amounting to almost 200,000 beds. A collection for medical aid to soldiers raised 534 million marks, plus donated material worth another 200 million. The American army had 443 medical officers in 1916 and another 146 in reserve. By the end of the war their number had risen to almost 31,000 and the Army Nurse Corps had grown from 400 to 21,500. In addition there were more than 200,000 support staff, both men and women. When the American Expeditionary Force left for France, it estimated that 73,000 beds would be sufficient. This assessment was quickly adjusted to 600,000 and by the end of the war a total of 380,000 were available, 260,000 in France and 120,000 back in the US. Denis Winter comments: ‘If the pain represented by these figures could be similarly quantified, then it would be beyond any man to comprehend such grief.’”

From wounding to aid post
On the first step to salvation, getting from No Man’s Land to the nearest aid post, a trip, although sometimes no more than  a mile, could take hours or even days, even with the help of sometimes up to aught stretcher bearers for each wounded, but often would not be made at all, also because it was often forbidden for other soldiers to help them and bring them back. “In late 1914 Louis Barthas saw the following scene: ‘In the squad in front of us a bullet had gone right through a man’s shoulder and he bled profusely, eventually dying for lack of first aid; but goodness knows where the stretcher-bearers had got to and anyhow we couldn’t delay our march, having been ordered not to stop to look after anyone, not even to save our own brothers. We passed in front, or rather stepped over, this first wounded man, as he breathed his last.’”

From first aid to hospital
On the initial care in the aid post, almost always little more than a table and a supply of dressings in one of the dugouts - dimly-lit places, sometimes even pitch dark, damp, often with no fresh air and poorly heated in cold weather giving room to swarms of flies, and never out of the way of danger, explaining for a great deal the bad name military medicine often had -, and the laborious tour of getting from there to better equipped hospitals further on (in the hope one would not get send back, because they were also crowded. “Battalion doctor Maurice Duwez (Max Deauville) described his job: ‘Our aid post is located in a small café, in a street perpendicular to the firing line. Straw has been hastily laid on the blue tiles. The dressings, the brown bottles with red labels, the nickel instruments from our opened bags are piled high on the bar. Two men, wounded by falling bricks, sit on the ground dazed, leaning back on the wall, their bleeding heads bandaged with field dressings. Ambulances come all the way to our post. Stretcher-bearers are available to us. As I am talking with two of them, one is suddenly hit in the leg by a projectile. A snapping sound reverberates, as if someone has broken a thin plank of wood, and the man falls to the ground howling.’”

The field hospital
On the overcrowded and sometimes almost empty field hospitals, giving under equipped doctors either too much work to handle, or days or even weeks of utter boredom and on the contact with nurses – the first women the soldiers saw on their march home or back to the front. “The hospital added one more complication to the life of a soldier, already under enormous strain in such constant close proximity to death. To the tension between soldier and civilian, sick and healthy, front-line service and safety, low and high rank, was added the tension between the wounded and their nurses, or between men and women, which was not made any easier by the image of a nurse as someone who handed out pills and asked: ‘How are we feeling today?’ Unrealistic though this may have been – nurses rarely had time for such personal attention – it was a pervasive image, and the ‘hero’ saw himself as a sick child. […]

The Feldpuffordnung (field brothel regulations) drawn up by German soldiers themselves, which Hans Magnus Hirschfeld describes as the most grassroots expression of front-line eroticism, stated that there was no need to set up brothels in the vicinity of hospitals where Red Cross nurses worked.
[…] It was a reputation that could make a nurse like Jane De Launoy extremely agitated, but which cannot be dismissed as pure slander and delusion. Her own diary illustrates this on several occasions. Nurses had of course been drawn to the front by a desire to help the sick and wounded, although they were rarely employed at aid posts in the direct vicinity of the front line.

The Frontschwester, the front-line nurse, celebrated in books like Frontschwestern – Ein Deutsches Ehrenbuch (Front-Line Nurses – A German Tribute), published in 1936, is largely a mythical figure. Riemann’s Schwester der Vierten Armee, for instance, can be read as an account of her sustained but ultimately futile efforts to be allowed to work close to Ypres and the Yser. Wanting to help the sick and wounded did not preclude other, more human and down-to-earth motives, such as a desire to take part in the war in the only truly feminine way permitted, a longing to serve one’s country and prove oneself a worthy citizen, an urge for adventure, or a yearning for male company in women whose menfolk had left for the war.

Suddenly they were seeing men in ways they had seldom if ever seen them before. Abruptly coming into contact with large numbers of naked men undoubtedly aroused sexual excitement in completely unprepared nurses, something that Enid Bagnold’s A Diary Without Dates, for example, makes unambiguously clear. Mary Borden’s denial that this applied in her case only serves to confirm the general picture. She wrote that the men she nursed could hardly be called men any longer, ‘so why should I be a woman?’ As a nurse she was interested in the wounded as patients, not as men, but the fact that she mentions sexual tension so explicitly suggests she was an exception in this respect. […]

It was Vera Brittain who described this aspect of nursing work most frankly. She had not seen a boy without his clothes since she was three or four and had never laid eyes on a naked man. Neither she nor her patients felt the nervousness and shame that would normally have been expected, and, apart from actually having shred a bed with one of the wounded, in her four years as a war nurse she had no choice but to carry out practically every intimate act imaginable. There were not many things for which she was grateful to the war, but she was glad that it had liberated her from much of the sexual reticence instilled by her Victorian upbringing.”

The base hospital
On the ambulance trains and ships taking the severely wounded to base hospitals deep in the Fatherland, and on the ghastly site all these wounded must have been (so the ‘heroes’ were brought from the stations to the hospitals by night to not upset the public and make them doubt the war effort). “A British nurse described the tumult that always surrounded a train about to depart. She watched as thousands of wounded men ‘swarmed about a long ambulance train standing in a field. They crowded the carriages, leaned out of the windows with their bandaged heads and arms, shouting at friends they saw in the other crowds. … There were other wounded men from whom no laughter came, nor any sound. They were carried on to the train on stretchers, laid down awhile on the wooden platforms, covered with blankets up to their chins. … I saw one young Londoner so smashed about the face that only his eyes were uncovered between layers of bandages, and they were glazed with the first film of death. Another had his jaw clean blown away, so the doctor told me. … Outside a square brick building … the ‘bad’ cases were unloaded: men with chunks of steel in their lungs and bowels were vomiting great gobs of blood, men with arms and legs torn from their trunks, men without noses, and their brains throbbing through opened scalps, men without faces.’ […] Magnus Hirschfeld, who was to become a celebrated sexologist between the wars, described a German base hospital in his Sittengeschichte des Weltkrieges (The Sexual History of the World War), one of the first books to be thrown onto the Nazi pyres by German youth in 1933, although the adolescents are said to have taken a quick look at the photographs and drawings of unclothed women first. He hit the nail on the head. ‘The entire hospital ... with all its fabled romanticism and its all too real distress was overshadowed by death. The way out led in most cases, either directly or via a detour to the trenches, to the heroes’ cemetery. The great war factory known as a hospital normally gave people back to life only after they had left parts of their limbs or what little health they had behind its walls.’”

Too many wounded, too little help
On the first reason why, the soldiers had little to expect from medical world in spite of all its efforts: there were simply too many sick and wounded to heal and to look after. “Many died who would have lived had it been possible to treat them in time. Gangrene and other complications arose not only because of the filthy soil that entered wounds but as a result of inadequate medical aid, in many cases no aid at all. There were too few doctors, nurses, hospitals, operating theatres, drugs and instruments, and too many sick and wounded. At certain times and places medical treatment was practically impossible, no matter how much planning went into the provision of medical services as time went on and however well prepared the armies became for large numbers of wounded. As we have seen, it was impossible to treat every casualty after a major battle, despite the willingness of doctors and nurses to work without a break.”

On complications, the unavoidable consequence of medical care in utterly filthy surroundings, carried out with equipment not sterile and unsatisfactory, by doctors and nurses often to tired to focus. “In his novella Die Pfeiferstube (The Whistlers’ Room), Paul Alverdes tells the story of Pointner, a farmer’s son from Bavaria whose jaw and larynx had been crushed by a shell fragment. The wound was serious, but he would have lived had blood poisoning not set in. He was one of three Frontschweine and one Tommy who were known as Pfeifers, whistlers, because their wounds caused an audible whistling in their throats as they breathed. ‘Slowly, almost imperceptibly, the poison irrevocably affected his blood. Often he could not get out of bed, was choosy about the little he ate and had a fever. ... One early morning when everyone was still lying in bed, the whistlers heard him become restless. He shook his bedside table fiercely; a glass fell to the floor and smashed with a tinkling sound. They turned on the light and saw Pointner sitting bolt upright in bed. ... Harry leapt over to him in his nightshirt, barefoot, to give him some support, but Pointner had already fallen slowly backwards and was looking up at the ceiling and no longer moving.’”

Is survival a blessing?
On wounds so ghastly that one wonders if the patient would not have been better of dead. “Bagnold wrote of having to nurse a man called Ryan at the hospital where she worked in England. He lay on five or six pillows, tied down with bandages that ran under his arms and were secured to the bars of the bed. ‘He lay with his profile to me – only he has no profile, as we know a man’s. Like an ape, he has only his bumpy forehead and his protruding lips – the nose, the left eye, gone.’ Then there was a man without nostrils, struggling to breathe through two rubber tubes. ‘It gave him a more horrible look to his face than I have ever seen.’ Bagnold believed the medical orderly was convinced he would not survive and she asked herself whether the soldier in question might actually prefer that to the prospect of living.”

Medical experiments
On the fact that war gives a lot of experimental materiel for doctors to make a career in medical science, without things like ethics bothering them. “In a chapter entitled ‘A Surgical Triumph’, La Motte tells the story of a barber’s son who was gravely wounded. After several operations he was able to return to his father, who fortunately was not short of money. He was alive, but not fit and well – as his father Antoine, crippled by polio as a child and therefore not eligible for military service, had already begun to suspect in the long period between hearing his son ‘had been wounded and his return home. “He learned that his son was wounded, and then followed many long weeks while the boy lay in hospital, during which time many kind-hearted Red Cross ladies wrote to Antoine, telling him to be of brave heart and of good courage.

And Antoine … took quite large sums of money out of the bank from time to time, and sent them to the Red Cross ladies, to buy for his son whatever might be necessary for his recovery. He heard … that artificial legs were costly. Thus he steeled himself to the fact that his son would be more hideously lame than he himself. There was some further consultation about artificial arms, rather vague, but Antoine was troubled.

Then he learned that a marvellous operation had been performed upon the boy, known as plastic surgery, that is to say, the rebuilding, out of other parts of the body, of certain features of the face that are missing. All this while he heard nothing directly from the lad himself, and in every letter from the Red Cross ladies, dictated to them, the boy begged that neither his father nor his mother would make any attempt to visit him … till he was ready.

Finally, the lad was ‘ready’. He had been four or five months in hospital, and the best surgeons of the country had done for him the best they knew. They had not only saved his life, but, thanks to his father’s money, he had been fitted out with certain artificial aids to the human body which would go far towards making life supportable. In fact, they expressed themselves as extremely gratified with what they had been able to do for the poor young man, nay, they were even proud of him. He was a surgical triumph, and as such they were returning him to Paris. … In a little room back of the hairdressing shop, Antoine looked down upon the surgical triumph. This triumph was his son. The two were pretty well mixed up. A passion of love and a passion of furious resentment filled the breast of the little hairdresser. Two very expensive, very good artificial legs lay on the sofa beside the boy. …

From the same firm it would also be possible to obtain two very nice artificial arms, light, easily adjustable, well hinged. A hideous flabby heap, called a nose, fashioned by unique skill out of the flesh of his breast, replaced the little snub nose that Antoine remembered. The mouth they had done little with. All the front teeth were gone, but these could doubtless be replaced, in time, by others. Across the lad’s forehead was a black silk bandage, which could be removed later, and in his pocket there was an address from which artificial eyes might be purchased. … Antoine looked down upon this wreck of his son that lay before him, and the wreck, not appreciating that he was a surgical triumph, kept sobbing, kept weeping out of his sightless eyes, kept jerking his four stumps in supplication, kept begging in agony: ‘Kill me Papa!’ However, Antoine couldn’t do this, for he was civilized.’”

Medical aid and military necessity
On the next reason that soldiers were not always helped as one thinks they should have been: aid was first of all given out of military necessity and not out of medical, humanitarian necessity. “The enthusiasm with which many doctors […] greeted the war brings us to the relationship between military and medical aims. Even more than by the desire of the sick and wounded to get well, even more than by the urge to experiment, medical treatment was driven by military necessity.

The medical services were an integral part of their countries’ armed forces and like all other army units they had to respond to the demands of warfare. Georges Duhamel in particular, with his book Civilisation and especially the chapter ‘Discipline’, emphasized the point that the primary task of medicine was to maintain fighting strength rather than to care for individual casualties. Hippocrates was not impartial: he served Mars. […] 

It was this attitude that made Oskar Maria Graf explode with rage when a doctor assured him he was only a man, just like him, and that he wanted nothing other than to cure him. No, Graf exclaimed, the doctor was not a man like him. ‘You’re the greatest criminal! You only heal so that there’s someone left to kill! ... The generals, the emperor, all those commanders-in-chief act just as they’ve been taught to act, but you – you’ve learned something different but you let yourself be used for the most shameful ignominy. You bring soldiers worn to death back to life so they can be killed again, torn to pieces again! You’re a pimp, you’re a whore!’ […]

It was because the medical services had supported the war and thereby prolonged it that one American nurse sent back her Croix de Guerre ten years after the armistice. It was for this reason too that in 1926 German medical officer Karl Kassowitz said war was a sickness all doctors had a duty to try to prevent. Dutch nurse Jeanne van Lanschot Hubrecht, and twenty years after the armistice British doctor John A. Ryle, a Cambridge professor, asked themselves whether it would not be a good idea to refuse to give any medical assistance during a war or the preparations for war. Would that not ultimately be more in accord with the Hippocratic oath and medical ethics than a willingness to provide medical aid?”

Military psychiatry

I: War and madness
On the problem of defining madness in war when the war itself is declared mad and on the task of military psychiatrists if this means that men gone mad from madness have to be made capable to face madness again. “S
aying that the war was mad rather than the patients […] was a notion particularly prevalent in the Dada movement but it can be found elsewhere too, in Louis Ferdinand Céline’s novel Voyage au Bout de la Nuit for example. Ernst Friedrich’s Anti-War Museum in Berlin grew out of the conviction that in 1914 the whole world had shown itself to be a madhouse. Friedrich decided to document this ubiquitous mental illness in the hope that his efforts might contribute to its reduction or even disappearance.

Wilhelm Lamszus called the second volume of one of his books, written before the war but published only after it, Menschen­schlachthaus. Visionen vom Krieg: Das Irren­haus (The Human Slaughterhouse. Scenes from the war that is sure to come: the madhouse), and the pacifist and future Nobel Peace Prize winner Carl von Ossietzky wrote in the foreword that ‘we have meanwhile experienced the madhouse ourselves’.

Stefan Zweig spoke of enthusiasm for the war as evidence of mass psychosis, insanity and hate-hysteria, and Theodor Lessing remarked: ‘It is certainly valid and legitimate to speak of the great world war and the self-laceration of the white race in the occident as a symptom of the madness of humanity.’ This same insight would lead to the publication in 1932 of a book by Emil Flusser, with an introduction by Albert Einstein, entitled Krieg als Krankheit (War as Illness), which concluded that doctors, especially psychiatrists and psychologists, had a role to play in combating the mental illness known as war.”

II: Kaufmann and colleagues
On the German military psychiatrists and their ideas and methods, especially Fritz Kaufmann and his electric disciplinary method. “Kaufmann’s main concern was to spare the state as many pension payments as possible, which meant that patients must be made to recover by whatever means it took. The end result Kaufmann had in mind was therefore not necessarily the restoration of a man’s fitness for war service. If anything that was a higher level of recovery. He was certainly in favour of initial attempts to ‘cure’ men as close as possible to the front – which was still regarded as having a curative effect – and of keeping them as far away as possible from their homeland, where they would be embraced by their wives and families and have their perception of themselves as ill reinforced. A return to front-line service was therefore the primary aim, but once a soldier had been taken further back behind the lines to the point where Kaufmann would treat him, efforts would have to be concentrated on making him fit to re-enter society. He must recover sufficiently to be able to support the war effort as a factory worker. It was of course unfortunate that most patients preferred this solution to a return to the front, but nothing could be done about that.”

III: The Allies
On the Allied psychiatrists such as W.H.R. Rivers, Lewis Yealland or Joseph Babinski, often using means anything but more humane than those of the Central power psychiatrists, and those who did, such as Rivers, knew as well that the outcome should be: back to the front. “Discussion among French psychiatrists and neurologists primarily concerned measures that might prevent malingering. The policy was threefold: isolation, surveillance and therapy. The psychosomatic sequence of ‘shock, emotion, suggestion, exaggeration, simulation and progression’ had to be cut short. Céline wrote in Voyage au Bout de la Nuit: ‘
Professor Bestombes, our medical major with the beautiful eyes, had installed a complicated assortment of gleaming electrical contraptions which periodically pumped us full of shocks. He claimed they had a tonic effect. ... “That, Bardamu, is how I mean to treat my patients, electricity for the body, and for the mind massive doses of patriotic ethics, injections as it were of invigorating morality!”’”

IV: Discipline versus analysis
On the already mentioned difference in method, but not in outcome strived for, between the harsh disciplinary methods and the more humane – officers’only – analytic methods used by Rivers and others like him, and on the measures taken against those who did not comply. “It is certainly the case that psychiatrists, neurologists and psychologists who showed ‘too much’ compassion for the individual soldier were not making life any easier for themselves. Lieutenant Kirkwood examined the 11th Border Regiment 97th Infantry Battalion one week after the start of the Battle of the Somme and concluded that a large proportion of the men were not fit for duty because they were suffering from shell shock of one form or another. He was relieved of his position. H.W. Hills acquired a reputation for being too kind-hearted and received an order from higher up not to send so many patients to the base hospitals. He had to be reminded that, given the shortage of manpower, it was not his task to heal his patients but to get them back to the battlefield as quickly as possible.”

In summary: the character of military medicine
On the system of military medicine being more important than the individual doctors and nurses. “We should ask how free doctors were to choose their own path. Once we question whether, under the circumstances, the doctors could have acted in fundamentally different ways than they did, we begin to see how little choice they had. Even had they wanted to, there was a limit to the degree to which they could have treated their patients sympathetically. During his service as a military doctor, the famous psychologist Alfred Adler was all too well aware of the consequences of declaring a soldier healthy, in fact he was haunted by nightmares about soldiers he had returned to the front. But he could not have acted any differently. His function as a doctor in wartime, in the service of the War Ministry, did not allow him to act in any other way. Belgian doctor Armand Colard came to the same conclusion. He regretted for the rest of his life every occasion on which he had handed over to the military court a soldier who was simulating illness, but there had been no other option open to him.”

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Chapter 5 Death on the Western Front


Killing and being killed
On war and what it is about above all: killing and being killed and on the way Death showed itself. “Death in the trenches and on the battlefield was rarely a matter of personal choice as to a certain degree it had been in earlier wars, and still was in that anachronism of the First World War, the desert battle. Technology had defeated human will and courage. A man was rarely killed because he faced a mentally and physically superior opponent. Death did not come from close by but from far away. A man did not look death in the eye; it was a great unknown far beyond the horizon. You could hardly ever choose death. It chose you. Death had become impersonal, and hideous.”

Death outside of battle

I: ‘Ordinary’ losses
On death in times when all was quiet on the Western Front. “Whole companies were virtually wiped out in periods when they were required merely to hold the line, with no significant fighting at all. At Ypres alone on such days the British might suffer 300 deaths. Augustin Cochin, a French officer, spent five days in the trenches at the Mort Homme in April 1916, of which ‘the last two days soaked in icy mud, under terrible bombardment, without any shelter other than the narrowness of the trench.’ He had arrived there with 175 men; he left with thirty-four, ‘several half mad … not replying any more when I spoke to them’.”

II: Accidents and snipers
On death when feeling save, caused by snipers or accidents. “The frequency of accidents was partly a result of the unrelieved stress of life in the trenches, stress rarely punctuated by the excitement of battle but exacerbated by long periods of inactivity and boredom. Men knew they had to be vigilant at all times, but no one could remain alert for days, weeks, months on end. The unremitting tension, along with the continual handling of explosives that made the hazards seem ordinary, led to carelessness in place of caution. Graves writes of a man who threw a percussion bomb but aimed too low. The bomb hit the edge of the breastwork instead of going over it, blasted back and killed him. A sergeant decided to demonstrate how dangerous a percussion grenade could be, a demonstration that could not have been more vivid. He rapped the edge of a table with it, killing himself and the man standing next to him instantly.
Twelve others were wounded, several seriously.”

III: Prisoners of war
On the deaths in prisoner of war camps and on the question if, in spoite of thweae deaths, POW’s are actually causalties of war. “Arthur Osburn, medical officer with the 4th Dragoon Guards and author of Unwilling Passenger gave the term ‘prisoner of war’ a different interpretation, as did Louis Barthas, Andreas Latzko and others: not those who had surrendered but those still on active service at the front line were prisoners, Osburn said. They were ‘prisoners of the war’. In a conversation with Stefan Zweig, Rainer Maria Rilke went even further. The war itself was a prison. It kept everyone within its walls, soldiers and civilians alike. Few will have given much thought to these alternative meanings of the term, but the fact remains that there were many, if always a minority, to whom the idea of safety in a prisoner of war camp seemed inviting. The notion of ‘voluntary capture’ is a myth, and one that made many prisoners of war furious, but it is a myth with some basis in truth. Soldiers preferred to be prisoners of war than to fight on in the face of almost certain death. Unless they were convinced they would be mistreated or executed on the spot, surrender represented an alternative to futile combat.”

IV: Friendly fire
On the deaths killed by fire from own troops, euphemistically called friendly fire. “Both Robert Graves and Edmund Blunden regularly mention incidents of friendly fire. Graves even describes one engagement in which more British soldiers were killed by the British army than by the Germans. The German 49th Field Artillery Regiment was commonly referred to as the 48.5th because other regiments said that the shells they fired more often than not fell short. Ernst Jünger and his comrades once found themselves under fire from German artillery whose range was set short. The gunners did not stop firing despite being quickly informed and before long the trench looked like a butcher’s shop, with bloodstains everywhere, and pieces of brain and flesh on which swarms of flies settled.

V: Death by execution
On the men shot at dawn, for the sake of example, a practice especially popular amongst the French and certainly relatively speaking even more the British troops and on the questionable role medical officers played. “Sidney Chaplin, who was a military policeman at the time, sitting on horseback on a nearby hill, gave an impression of how the British executed their soldiers. ‘I saw the man brought out to the post and the firing squad march into position, turn right and take up stand. I heard the report as they fired and saw the smoke from their rifles. Then they turned and marched off. The officer, with revolver in hand, inspected the body, then turned away. The dead man was then taken away in a blanket and buried in the small cemetery in the next field. It was over. I came down, but it did not seem real. The next one followed the same pattern, except the Assistant Provost Marshal said, “Cowardice” – and the man said, “Never!” They were shot by men from their own units, in front of comrades forced to attend, only a few hours after they had been told their sentences would not be commuted. Twelve men were chosen, by drawing lots, to form a firing squad. Each was given a rifle, some loaded only with blanks so that any one of the twelve could convince himself if he so wished that he had not been responsible for the death of his brother in arms.”

Death in battle

I: Bayonet and barbed wire
On the deaths inflicted by an antagonism and a feature of trench warfare. “We should bear in mind that the bayonet often claimed its victims indirectly. One of the reasons why bayoneting was such a prominent feature of training, despite the lack of opportunities to use the weapon as originally intended, was that it nourished the spirit of attack. With bayonets fixed, troops were more inclined to attack than to seek cover. Most soldiers seem to have been aware of this. They were keen to fix bayonets because doing so symbolized what they felt war ought to be: a personal encounter with an opponent, from which, after a fair fight, the stronger man emerged victorious. […]There are innumerable stories of soldiers caught in barbed-wire entanglements being shot to pieces by machine-gun fire. Ypres, the Somme, Verdun: everywhere men became ensnared in the many coils of wire, ripping their flesh to shreds in hopeless attempts to free themselves, efforts that often served only to entangle them further. Gaps a few metres deep blasted into the wire were no answer.
They were a fatal trap.”

II: The trench raid
On the trench raid, the ideal way for soldiers to commit suicide without ever being found out, since anyone who volunteered to take part had a good chance of not coming back. “Edmund Blunden states this repeatedly in his book. ‘The word ‘raid’ may be defined as the one in the whole vocabulary of the war which instantly caused a sinking feeling in the stomach of ordinary mortals. … I do not know what opinion prevailed among other battalions, but I can say that our greatest distress at this period was due to that short and dry word “raid”.’”

III: Artillery, the great destroyer
On the main feature of World War I-warfare, not the machine gun, not poison gas, but artillery, responsible for about 90 percent of all the deaths. “Estimates of the average number of shells and mortars the infantry needed to fire to kill one man – not including those aimed at earthworks and barbed wire rather than into the trenches or at strongpoints and advancing troops – range from several dozen to hundreds, even over a thousand. No matter which figure is the more accurate, the fact that the majority of the millions killed were victims of artillery fire is a reminder of the enormous quantity of explosives fired between August 1914 and November 1918. A single shell did not usually kill a large number of men, but collectively they did, mostly in a gruesome manner, occasionally very cleanly indeed. Frank Richards penetrated a machine-gun nest and found eighteen dead Germans, all without a scratch. A shell had burst directly above them and they had been killed by the blast.”

IV: The offensive
On the most costly part of warfare in World War I: the offensive, against an almost always  superior defense. “Men prayed, they pooled their money so it could be shared out among the survivors, they exchanged addresses so that relatives could if necessary be notified by one of their own instead of by an official letter. Rum rations were issued. Then came the order to prepare for the attack. One foot was placed up against the side of the trench, bayonets were fixed and rifles held at the ready. Men waited for the signal to clamber up over the parapet and run forward, or walk, or stumble. The tension rose. Many carried what might be their last letter home in their uniform pockets, so that it could be sent posthumously if need be. The barrage became even heavier. Everyone knew he would be exposing his entire body to machine-gun fire. Sweat broke out. Hands shook. It was almost impossible to keep one’s nerve. Men felt sick, but often they had nothing in their stomachs to bring up, partly because nerves had given them diarrhoea. Their heartbeats seemed to keep pace with the rattle of the machine-guns. They could feel their blood race. No one knew how far he would get before being hit.”

Meetings with Death

I: Individuals
On the way Death presented itself to and through individuals, making men senseless towards the dead, but occasionally taking care for a change of heart. “Death’s work could be seen everywhere, and in some sense he became visible himself; he sat next to you in the trench and walked beside you on the battlefield. He lay next to you in hospital. He was such an overwhelming presence that the boundary between death and life faded. Siegfried Sassoon saw the dead and living next to each other in the trenches and could no longer tell which was which, ‘for death was in all our hearts’. […]  One day Toller was standing in a trench, hacking at the earth with a pick. ‘The steel point sticks, I yank and pull it out with a jerk. Hanging from it is a slimy knot and whichever way I look at it, I see human entrails. A dead man is buried here. A – dead – man. What makes me pause? Why do these words force me to stand still, why do they press upon my brain like a vice, why do they close up my throat and freeze my heart? Three words like any other three. A dead man – ultimately I want to forget these three words. What is it about these words? Why do they overpower and overwhelm me? A – dead – man. And suddenly, like darkness splitting itself from light, the word splits from its meaning and I grasp the simple truth of Man, which I had forgotten, which was buried and covered over; the oneness, the unity, the uniting. A dead man. Not: a dead Frenchman. Not: a dead German. A dead man. All these dead are men, all these corpses have breathed as I do, all these dead had a father, a mother, wives whom they loved, a piece of land where they put down roots, faces that told of their joys and sufferings, eyes that saw the light and the sky.’”

II: The battlefield
On the field of battle after Death had used his scythe without distinction, mowing soldiers down in vast numbers leaving a landscape only Death himself could enjoy. “The aftermath of a battle was a desolate, deathly sight. Hoffman described it as the most pitiful place on earth. To Stanhope Walker, the landscape after a battle was an ‘absolute scene of destruction, miles and miles of country battered beyond all possible recognition’, demonstrating the enormity of contemporary warfare. Blunden spoke of the Schwaben Redoubt as a web of trenches in which ‘mud, and death, and life were much the same thing’. Seeing dead men strewn all about him, he concluded ‘the whole zone was a corpse’. Death had done his work and could take a rest; he had wreaked havoc on the field of honour and the field now belonged to him, or perhaps more accurately, as Blunden suggested, death and the battlefield had become one.”

Burial in wartime

I: Bodies in hospital
On burial of corpses died in a hospital. “Chaplain John Michael
Stanhope Walker had to bury 900 men in three months at his own CCS alone. Little wonder that he regarded the ‘moribund ward’ as the most depressing place he knew. ‘Two large tents laced together packed with dying officers and men, here they lie given up as hopeless, of course they do not know it.’ Georges Duhamel would have recognized the scene had he read Stanhope Walker’s account. He wrote in similar terms about the hospital outbuildings, often more than one, that were used as mortuaries. The dead lay there ‘side by side, their feet together, their hands crossed on their breasts, when indeed they still possessed hands and feet’. Sometimes, despite the heavy medical workload, there was time to give a man a fairly decent funeral, although the ceremony was never lengthy. ‘The burial-ground is near. About a dozen of us follow the lantern, slipping in the mud, and stumbling over the graves. Here we are at the wall, and here is the long ditch, always open, which every day is prolonged a little to the right, and filled in a little to the left.’”

II: Burial parties
On perhaps the most gruesome of all jobs: burying the dead who had lain in No Man’s Land for days or even weeks. “After the war Ferdinand Bringolf committed his memories of burial parties to paper under the title Das Grauen (The Horror). Bringolf and several other young German soldiers had to clear the market square at Wytschaete near Ypres at midnight after the battle fought there in November 1914. In despair he dug pit after pit while his comrades dragged corpse after corpse towards him. Always two of them, one dead and one living, and Bringolf did not know ‘who felt colder. And always the first spadeful of earth fell onto the disfigured, once human face, always the second onto the clenched hands, until gradually what had once been a human being disappeared under lumps of earth – it was November after all. They brought a young, handsome captain with soft feminine hands as if made of wax, and with a Henry IV beard on his interesting pale face – what a shame that he’d lost the top half of his skull somewhere!’”

III: No peace, no rest
On the fact that also the dead once buried where not allocated a final resting place, but washed free by the pouring rains or dug up again by exploding shell. “Lance-Corporal Ken Lovell lay in hospital troubled by his promise to tell a man’s parents exactly how he had died. He particularly dreaded them asking him where their son was buried. ‘We’d buried him all right, a few yards behind our position in the wood, with a rifle plunged into the earth to mark the grave and his tin hat on top of it. But by the next morning it had entirely disappeared.’ German NCO Carl Heller remembered a neatly maintained German cemetery. When he visited it again at the end of the war ‘it was recognizable only by a few splintered crosses and bleached bones sticking half out of the ground here and there’.”

IV: Too many dead
On the simple but awful truth that a decent burial, however important out of a military as well as a humanitarian point of view, was simply impossible because of the enormous amount of dead. “If we are to believe Captain De Lécluse, enemy dead were sometimes deliberately left on the battlefield as a warning to their comrades. If they were buried at all, then the bodies were thrown into hastily dug mass graves with crude wooden crosses on top. The survivors had their hands full bringing in the wounded and could not make time for even a rapid, provisional burial. The bodies that lay on the battlefield for days, weeks, even months, were yet another visible sign that the image of a romantic war so many soldiers had in mind at the start of the conflict bore no relation to the reality. Ernst Jünger admitted he had never imagined ‘that in this war the dead would be left month after month to the mercy of wind and weather, as once the bodies on the gallows were’.”


'There is in our lives a wound which will never heal. Nor should it.'
On the remembrance and commemoration of all the grieve the War had brought, including the most heart breaking piece of art it has given us, the statue of the Grieving Parents made by Käthe Kollwitz. “In one graveyard […] post-war suffering, civilian suffering, is starkly evident. In Germany after the war, a small group of leftwing intellectuals fiercely opposed the soldier cult, with its veneration of youth and glorification of death. Toller and others set out to ‘deheroicize’ death. They campaigned against the idea that death was something a man should long for on the grounds that the death of an individual meant the community would live, saying that sacrifice on the ‘altar of the fatherland’ was not heroic, it was senseless. Käthe Kollwitz, whose eighteen-year-old son Peter had been killed in the Battle of the Yser at the beginning of the war, was receptive to their protest. In those early months she had still been in thrall to the glorification of youth and was therefore quite unlike the anti-war militant she later became. Yet even before her son was killed she had begun to have doubts that verged on abhorrence. Her personal loss increased those doubts: ‘There is in our lives a wound which will never heal. Nor should it.’

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About the author Dr Leo van Bergen is a medical historian working at the Vrije Universiteit Medical Centre in Amsterdam, The Netherlands. His main focus is on the relationship between war and medicine. Dr van Bergen is a member of the editorial board of Medicine, Conflict and Survival. Prize: Awarded the 'Dr. J.A. Verdoorn-award' for excellent scientific work on the topic of medicine and war 2009.

Review: Before My Helpless Sight
by Mark Harrison - University of Oxford - in Medical History. 2010 July; 54(3): 411–412
Before my helpless sight is “a book about soldiers as victims” (p. 215) rather than a military or medical history in any conventional sense. It tells us very little about generals or other senior officers, and the work of the military medical services is tangential to the main story, which is about the soldier as patient and invalid. From an historiographical point of view, this book has, therefore, much in common with a genre of literature on the First World War (primarily the Western Front) that focuses upon the experience of soldiers. This has encompassed studies of wartime literature and painting as well as the day-to-day trials of soldiers in the trenches or during battle, being typified by works such as Paul Fussell’s The Great War and modern memory (London, 1975), John Ellis’s Eye-deep in hell (London, 1976), and Stéphane Audoin-Rouzeau’s Men at war, 1914–1918 (Providence, 1992).

From a specifically medical point of view, its closest stable-mates are Joanna Bourke’s Dismembering the male (Chicago, 1996) and some of the work on “shell shock” which has dwelt on the soldier’s experience of the condition and its treatment: for example, Peter Barham’s Forgotten lunatics of the Great War (New Haven, 2004). It shares with these histories great tenderness and sympathy towards the plight of the men who fought the war and of their civilian victims. As far as possible, it attempts to see the horrors of the Western Front through their own eyes. Readers may not be surprised by much of what they read here but some of the material—especially the book’s unusually graphic depictions of the casualties of war—still has the capacity to shock.

The book is, however, quite distinctive in the stance which the author takes against war of any kind. The conflict on the Western Front—the mud, the seemingly pointless assaults, and the first use of weapons such as gas—often stands as the epitome of senseless slaughter. Millions died for a cause which most of us now fail to understand or have little sympathy with. In this sense, our memory of the war of 1914–18 is very different to our memory of the war of 1939–45, which, despite its many victims, is often remembered as a great patriotic war or at least a cause worth fighting for. Van Bergen’s uncompromising pacifist stance gives this book an edge which other books covering similar subject matter lack. His theme is not so much the horror of the Western Front but of war in general.

Before my helpless sight focuses exclusively upon the Western Front but it draws upon a wide range of literature in English, French, Dutch, Flemish and German. In this sense, it has few parallels among works which examine medicine and medically related topics, and is an extremely useful work of reference in consequence. Readers will gain an overview of how the “disposal” of casualties differed in the armies of the various combatant nations, even though it is not the author’s main intention to analyse this from a comparative perspective.

In view of the paucity of general accounts of medicine in the First World War, the advantages of the broad brush-stroke inevitably outweigh its disadvantages in this case. But the author tends to make generalizations on the basis of texts which are not necessarily representative. A certain amount of distortion and lack of nuance is the inevitable result, although van Bergen generally tries to be even handed. For instance, the author asserts (p. 286) that “the medical profession was powerless” to do much for the enormous number of casualties that passed through medical units on the Western Front and that “no amount of organization could resolve all the problems that inevitably arose” (p. 288). This was, of course, true and the treatment provided was often inadequate.

However, such statements ignore that fact that medical arrangements did not break down, as they did in previous conflicts such as the South African and Crimean Wars, and that specialized centres of treatment became increasingly adept at treating even complex injuries. Death rates in front-line medical units fell in the last two years of the war (despite the comment made to the contrary on p. 327) and an impressive percentage of men were returned to duty of some sort. Van Bergen does not pay sufficient attention to how medical arrangements evolved over the period of the campaign on the Western Front and how they coped, for example, with the resumption of more mobile warfare from the spring of 1918.

Another questionable assertion made in the book is that practising medicine under wartime conditions necessarily rendered doctors “numb” and “insensitive” (p. 291); the reality was often a good deal more complex and one would need to differentiate between doctors working with regiments (where they were “part of the family”, so to speak) and those at units some distance from the front. It is also problematic to write of the “motivation” of doctors (p. 361) for these and other reasons. Yet, these quibbles ought not to detract from what is, by any standards, a major achievement and a landmark in the medical historiography of the Great War.

Review: Before My Helpless Sight
Review by John E. Talbott, University of California, Santa Barbara.
H-France Review Vol. 11 (March 2011), No. 76
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Review: Before My Helpless Sight
Victor W. Sidel, MD - Distinguished University Professor of Social Medicine - Montefiore Medical Center and Albert Einstein College of Medicine - Bronx, New York
Leo van Bergens book, Before My Helpless Sight, is an extraordinary achievement on at least three levels. First, the book provides an invaluable trove of information on the history of war and on the history of medicine. Richly footnoted and indexed, with an extensive bibliography, it will be an important source of information for future historians and analysts of the role of the healing arts in relation to armed conflict.

Second, the book presents a moving description of the Great War, supported by 20 remarkable illustrations. Rarely has there appeared such a readable narrative on the heroic and tragic ways in which a war was fought and the dedicated yet at times inept ways in which medical workers attempted to tend the dying and treat the wounded.

Third, and most importantly, the book holds clear lessons for our own times. The policy mistakes in the planning and the execution of the war, the military mistakes in strategy and tactics, and the medical mistakes in triage and treatment during the Awar to end all wars must be remembered or they will undoubtedly be repeated in future wars. The descriptions of the dysfunctional and shameful ways in which combatants were sent into battle and of the suffering not only through physical wounds but also through what was then called shell shock and is now called post-traumatic stress syndrome, are directly relevant to the discussions of current wars in Iraq and Afghanistan.

This book is the most recent example of a long tradition of work in the Netherlands on medicine and its relationship to war, a field known as medical polemology. One of the leaders of this field of study and action was Dr. J.A. Verdoorn, whose pathbreaking book, Arts en Oorlog (Medicine and War) awakened many military and medical policy makers to the folly of modern warfare. The establishment of the Dutch Medical Association for Peace Research (NVMP), the affiliate of the International Physicians for the Prevention of Nuclear War in the Netherlands, has supported and strengthened this work.

English language readers, including members of Medact and readers of Medicine Conflict and Survival, will have access to this invaluable book because of the clear and evocative writing of the author and the excellent translation into English by Liz Waters. This book is an important contribution to an understanding of medical consequences of war and a much-needed contribution to the prevention of future wars.

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Review in the Journal of Military History, Vol 74, No 1, January 2010 (read more...)

Review: Before My Helpless Sight
by Carol Acton, St Jerome’s, University of Waterloo, Ontario, Canada
Wilfred Owen Association Journal 2009 Issue 2.)

eo Van Bergen in Before My Helpless Sight uses the concept of witness in Wilfred Owen’s famous line along with Owen’s desire to make public photographs of the dead and maimed, to ser the approach and tone of his book, first published in 1999 and now issued in translation with revisions. Focusing on the combatant experience in the context of more technical aspects of the war, Van Bergen brings together a large range of sources to examine the brutality of life for French, British and German soldiers on the Western Front.

The first chapter, ‘Battle’, sets the approach for the rest of the book, weaving together the technical aspects of the war and the individual experience of officers and men. Subsequent chapters treat salient aspects of the trench experience under the headings ‘Body’, ‘Mind’, ‘Aid’ and ‘Death’, with a long introduction outlining the war experience overall and the main critical-historical and primary s
ources Van Bergen draws on throughout the text.

His ironic point is made in the introduction where he brings together what he sees as the two representative technologies common to European culture that defined the conduct of the war: ‘The machine-gun and the scalpel exemplified the fact that all those developments that had been such a boon to humanity in the preceding century [...] could be used in pursuit of total destruction’(p. 33).

Van Bergen brings together a large range of sources to create a very readable and useful discussion of the war primarily from the perspective of the combatant. As he notes in his introduction, rather than setting out to do anything new, his work is ‘an attempt to bring together [...] all the diffuse knowledge available in primary and secondary literature on the subject of war’(p. 1). However, the strength of such an approach can also be seen as its weakness.
On the one hand, this tactic is particularly successful in showing how similar the individual experience of the French, German and British soldier was, and, in an afterword, how that experience was used in radically different ways by post war French, British and German governments in their remembrances of the war. It also gives the reader an enormously comprehensive and detailed sense of the combatant experience.

However, drawing on already available sources means that there is no questioning of the way the war has been portrayed over the past 20 or so years prior to 1999 when the book was first published. Thus, for example, although the chapter on ‘Aid’ provides a strong and useful technical account of the treatment of casualties and does include some direct quotations by doctors and nurses, the lack of recourse to primary archival material limits the perspective, since with a very few exceptions, Van Bergen confines his quotations to those used in other accounts.

This allows for a certain negative slant towards medical personnel which underplays the dedication to their work and concern for the wounded combatant evident in multiple diaries, letters and memoirs both by medical personnel and the soldiers in their care, and overplays the sense of the system as inconsiderate of the needs of the soldier.

Problematically, relying on established sources can mean the repeat of the particular agenda of those sources, which is not always offset by the range of material Van Bergen draws on. In addition, there is some repetition in in chapters so that the topics of illness and psychological breakdown are discussed both in the chapters on ‘Body’ and ‘Mind’ and in the chapter on ‘Aid’.

In spite of the repetition and the problems inherent in relying almost entirety on previous work that is a consequence of this approach, the book is a very useful detailed and thorough examination of the combatants experience on the Western Front, particularly valuable as a starting point for anyone looking for a desriptive rather than analytical text.

The accumulation of detail, both in statistics and specifics of the soldiers’ lives allows for a moving portrayal of of the combatant lot. Thus, for example, with the recent 2009 commemorations of D-Day still in mind, Van Bergen’s comments on the Batlle of Loos in the chapter ‘Battle’ reminds us of the massive casualties of the First WorldWar: ‘[w]ithin the first two hours, on the British side alone, more soldiers died than there were lost on all sides on D-Day, 6 June 1944’ (p. 67). This book-offers the immediate narrative of those casualties and the millions of others like them.

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Review: Before My Helpless Sight
by Ian Whitehead University of Derby published in The Social History of Medicine 12-11-2009 pp. 620-622
Leo van Bergen examines the journey of First World War soldiers, from the moment of embarkation, through the experience of sickness, wounding and medical aid to the possibility of burial—whether alive or dead. The physical and mental traumas of the battlefield are the focus, conveying a profound sense of human suffering in warfare, which van Bergen sees as ‘illustrative of the horrors confronted by all those exposed to war’ (p. 29). He hopes to free the dead and wounded from the confines of cold casualty statistics, thus reminding us of their centrality to any understanding of the war. Chapter one, ‘Battle’, highlights the impact of technological change on the conduct of warfare. Science and industry conspired to produce unprecedented slaughter on the battlefields of the Western Front. For the troops, ‘two weapons and one instrument came to typify the Great War: the heavy guns deployed by the artillery, the machine-guns carried by the infantry, and the surgeons’ scalpel' (pp. 32–3). Medical science provided a repair service for the wounded, re-fitting them as cogs in the machinery of battle.

Chapter two, ‘Body’, describes the challenges of physical endurance posed by trench life. It details the burdens of a soldier's daily existence and the common diseases that afflicted the troops, examining attempts to contain epidemics through the implementation of preventive measures. It explores the impact of warfare on a soldier's sex drive, highlighting the moral, disciplinary and medical issues involved in controlling sexual conduct and minimising the incidence of venereal diseases. The harsh realities of life at the front placed an immense strain on the mind and nerves of the soldier, providing the subject of the third chapter, ‘Mind’. Shell-shock was a problematic term, both medically and militarily, but it gained an unstoppable currency as an umbrella term for describing the strains of warfare on the human mind. Aside from its potential to encourage misdiagnosis of war neuroses, much of the opposition to shell-shock arose from fears that it made mental collapse in battle a respectable war injury. Not only might this have negative consequences for the maintenance of discipline and morale, it threatened to cost large sums in terms of war pensions. The position was complicated by moral prejudices, in which many of the men presenting with hysterical conditions were looked upon as having failed the manly test of war. Psychological casualties were regarded with suspicion, received little sympathy and were subjected to painful treatments, which were thought likely to overcome the symptoms and revive the fighting spirit. Class distinctions were apparent in the treatment of mental illness. Officers were much more likely to be diagnosed as neurasthenics, thus sparing the upper classes the shame of moral failure and the brutalities of the treatment room.

The wider difficulties of treating the sick and wounded are set out in the fourth chapter, ‘Aid’, which looks at how the military medical services responded to the challenge of treating unexpected numbers of sick and wounded. Modern medical knowledge enabled men with grossly mutilated bodies to survive their injuries, whilst nascent plastic surgery sought to rebuild men's bodies. The recipients of these treatments were the dubious beneficiaries of medical experimentation, and, as van Bergen illustrates, many would rather have died than live out the painful life of disability and disfigurement, which was the legacy of medical intervention.

Occasionally, van Bergen seems a little harsh in his judgements of the medical profession, given the pressures it faced, whilst his focus on suffering inevitably distracts us from some of the positive achievements of medicine on the Western Front. However, he correctly highlights the extent to which medical treatment was driven by military imperatives. Whether and when a man received medical treatment depended on his potential to be returned to military fitness. The efficiency with which the medical services undertook their role made them a crucial factor in sustaining the long years of war, thus causing much debate about the implications for medical ethics.

In the final chapter, ‘Death’, van Bergen examines experiences of dying and killing. He highlights that not only were the chances of dying higher than in earlier conflicts, but the nature of modern warfare meant that death could occur anywhere at any time. The random nature of the killing ‘meant that the front was synonymous with death’ (p. 411), despite the fact that more men survived the battles than the number who were killed. Death itself did not necessarily deliver peace from the conflict; many of the men were buried in shallow graves, which became exposed, either due to the weather or the impact of explosions. Their decomposing bodies were part of the devastated scenery of the battlefield, witness to which created an inevitable gulf between those who only read about the war, and those who had experienced it at first hand. As van Bergen writes, ‘[t]he conditions of war are impossible for anyone who has not experienced them first hand to comprehend’ (p. 473).

In his opening sentence, Van Bergen states that the book ‘is not the result of weeks or months spent in dark bunkers and damp cellars, leafing through old documents page by mildewed page’. Instead, he intends to encapsulate, in one volume, knowledge of the casualties and their medical treatment, from British, Dutch, French and German publications. Certainly, by placing his prime focus on the suffering of the individual casualties, he provides a different approach to that found in many other books on the war. Across the boundaries of the belligerent nations, he shows the commonality of the soldiers' experiences of combat, sickness, wounding and death. The casualties emerge not as mere consequences of battle, but as the essential agents of warfare. On the other hand, van Bergen's approach does mean that readers familiar with the history of the First World War in general, or specifically of medicine and the war, will find little that is new to them in the many pages of his book. Moreover, given his aim of diffusing existing knowledge, he tends to draw upon a disappointingly narrow range of sources and opinions.

Nevertheless, the book serves as a powerful reminder of the terrible human suffering endured, both during and after the war, by those who bore the physical, mental and emotional scars of the conflict. Van Bergen leaves the reader with an overwhelming sense of the human tragedy inflicted by industrialised warfare and mass killing.

Review: Before My Helpless Sight
by Christopher Albon (hhtp://conflicthealth.com)
Leo van Bergen’s book, Before My Helpless Sight, is a history of suffering in World War I, a description the author readily admits: “At the roots of the book lies the question of what can happen to a soldier between the moment he steps onto a train or ship bound for the theatre of battle an the point at which he is evacuated wounded, or whether dead or alive, buried in the ground” (pg. 1). Needless to say, the book is not a light read. Read more.......

Review: Before My Helpless Sight
A.W. Purdue (www.timeshighereducation.co.uk)
The First World War gave war a bad name and, as the rather chilling title of this book forewarns, Leo van Bergen is keen to tell us why in grisly detail. No doubt a stroll around the battlefields of Agincourt or Flodden immediately after opposing armies clashed would have been grisly, but the total war on the Western Front was characterised by its industrial scale, the huge numbers involved and its perseverance with no breaks for the seasons or the harvests. The industrial image of the conflict is brought home not just by the machinery of war, the artillery, barbed wire, gas and the tank, but by van Bergen's concept of hospitals for the wounded as repair factories, putting men together again so that they could go back into action. Read more.......

WFA East Coast Chapter - Books on medical care
... I highly recommend this book to all who are students of that war and the wars of today because the real horrors of war are not on the battlefield but in the aide stations and hospitals then as now. Read more.......

Before my Helpless Sight - an excellent work
by Onne Eling (www.amazon.co.uk)
Drawing from sources in four different languages the Dutch medical and military historian Leo van Bergen has written an excellent work on the wounds and diseases ravaging the World War I soldier at both sides of the front, and the aid he did or did not receive. He paints a rather grim picture of medical care, more driven by military and political arguments than humanitarian and closes with a chapter on the encounters with Death and the (impossibility of) burying following such encounters. Before my Helpless Sight - a line from Owen's poem Dulce et Decorum but also referring to Kollwitz's statue of the Grieving Parents shown on the cover - is beautifully written, beautifully composed and - of course - horrible in content. It makes it a `must have' for all interested in topics of war and medicine especially of course World War I.

Are you interested? Would you like to order now? Click here: Leo van Bergen - Before My Helpless Sight

This book is definitely worth the reading
Reviewed by Jolie Velasquez - St. Mihiel Trip Wire.The online newsletter of the Great war Society, April 2011
More than one historian has voiced the opinion that fiction is the best way to express the true horrors of war. Perhaps they envy the resonance that anti-war classics like Johnny Got His Gun has had compared to the short attention that even the best historical studies get from the public. Dr. van Bergen's work could perhaps be the ultimate non-fiction war deterrent if enough people could overcome their queasiness upon reading the subtitle.

After a fairly crisp chronological summary of the war and the technical developments that led to new kinds of injuries, van Bergen (a medical historian) divides the content into sections on the physical consequences of combat, effects on the mental health of those involved, the techniques used to treat the afflicted, and then the problem of dealing with the ultimate sacrifice made by the dead. Using a massive amount of statistics and medical information, the author gives the reader the entire scope of medical needs and practices that took place at and behind the lines.

Remarkably, we learn that even though great strides in medicine had taken place by 1914, such as the initial survival rate for bullet wound casualties, the fight against infection was little better than in America's Civil War. Childhood illnesses, relatively minor injuries, and nutritional deprivation were all exacerbated by the environment of the trenches. (Not being able to change one's socks could lead to gangrene.) And the advances in artillery resulted in bodily injuries far surpassing the damage expected from more personal forms of combat and in numbers that outstripped any other kind of casualty. Doctors were often forced to experiment with unorthodox treatments to keep their patients alive.

Perhaps the best section is on the treatment of mental disorders, which they called shell shock. The general attitude of military doctors was often dismissive and skeptical of non-physical injuries. Affected soldiers were considered shirkers or worse, facing punishment as often as treatment. The influx of psychologists from civilian practice into the services changed the tenor, but the discipline was so new that effective methods were rare. The new doctors also fought again the practice of "fixing" the soldiers so they could be sent back into battle as soon as possible.

The exhaustive descriptions of even simple physical discomforts would be numbing or dry after time, but van Bergen intersperses his text with excerpts from the diaries, memoirs and letters, of people on both sides of No Man's Land. Soldiers, doctors, care-givers, and civilians offer their poignant memories and make the personal connection so necessary to complete the experience. Van Bergen's pacing allows one to move smoothly through almost 500 pages of text, some gruesome illustrations, and casualty tables that can leave one staggered. If one can take the subject, this book is definitely worth the reading.

Are you interested? Would you like to order now? Click here: Leo van Bergen - Before My Helpless Sight


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