by John Nichol
Stockton was on an immediate evacuation flight back to England and, a matter of hours after the RPG crashed through his arm beside a canal in Afghanistan, he was lying back in the calm atmosphere of Selly Oak Hospital in Birmingham. An anxious Emma arrived with his mother to see him.
He was in a side room and, at first, we walked past him. Then I saw him in the corner of my eye, in lovely salmon-coloured pyjamas! There were two St John Ambulance women with him – he was charming the ladies, as usual! I rushed into the room, but I didn’t know what to do. Do I give him a hug? Would he be able to hug? Would it hurt him if we did? I’d expected him to be lying in bed, but he was standing up, and I was very conscious of looking at his arm, and then worried that I was staring at it. ‘What do we do? What do we say to each other?’ I thought. Then he asked: ‘Are you coming outside for a cigarette?’ and I knew he was still the same Andy. We managed a hug. The partner who’d left me to go to war was back, just minus an arm.
*
War is a brutal business with terrible physical consequences, and Andy Stockton had been at its cruel cutting edge. His departure from Camp Bastion coincided with the arrival of a British government minister on one of those heavily orchestrated whirlwind tours to rally the troops. They met briefly, and one observer noted laconically that the visitor from Westminster ‘at least had the good grace to look embarrassed as he shook the sergeant major’s good hand’. Blushes apart, it is right for those who make the decisions that put other men in the firing line to see at close quarters the results of what they ordain, to confront the butcher’s bill. That bill is the stock in trade of medics. It falls to them to witness the terrifying consequences of combat, to deal with inhumanity in its starkest form.
Young doctors joining the Royal Army Medical Corps in 1941, perhaps the bleakest period of the Second World War for Britain, when catastrophic defeats in Africa and the Far East left little to be optimistic about, were offered this prospectus for what lay ahead for them: ‘In battle you will live dangerously and you will feel the grip of fear. You will be unarmed amid violent, indiscriminate lethality. To you, the hurt and the frightened will turn for easement and comfort. The work that you do – under conditions that will range from the merely inconvenient to the utterly impossible – will be of the very greatest importance.’9
Sixty-five years later, Gary Lawrence, Damien van Carrapiett, Paul Parker and all those working with them were doing exactly that in Afghanistan. Their courage and dedication were the saving of Sergeant Major Stockton.
2. Inhumanity
Medics are not to be taken for granted, as if they had always existed, their presence on the battlefield assured. On the contrary, historically, men going to war have seldom been able to rely on medical intervention to save their lives. Indeed, if the history of humanity were measured by the way it treats those who fight its battles, then it is only in the last hundred years that we have come out of the Dark Ages. Since time immemorial, ordinary soldiers, professionals and conscripts alike, have been treated as cannon-fodder – and, before artillery was invented, as bow-fodder, sword-fodder, club-fodder, fist-fodder. Even into the twentieth century, their welfare has been of little importance to their commanders or to those people whose interests they fight to defend. It was Rudyard Kipling who, in his poem ‘Tommy’, captured the hypocrisy of a society that delighted in the glory of war but turned its nose up at the warriors, until they were needed to do the dirty work.
O it’s Tommy this, an’ Tommy that, an “Tommy, go away”;
But it’s “Thank you, Mister Atkins”, when the band begins to play
Yes it’s Tommy this, an’ Tommy that, an’ “Chuck him out, the brute!”
But it’s “Saviour of ’is country” when the guns begin to shoot.1
If ordinary soldiers were snubbed when able-bodied, then their position was hopeless when wounded. The accounts of wars and great battles give short shrift to the maimed. They often have to slink home to a society whose gratitude and forbearance all too quickly dry up. The world moves on, yet they are left with their scars, physical and, increasingly these days, mental. Men blinded by chlorine gas in the First World War sold matches in the street. After the Second, there were few jobs for the one-legged victims of anti-personnel mines, one of its most pernicious (and, sadly, most enduring) innovations. In the United States, wounded veterans of Vietnam returned to a nation that was embarrassed by their existence. And so it has gone on into the twenty-first century. Iraq and Afghanistan are whirlwinds of human tragedy, the full consequences of which we are yet to reap. If the dismissive reaction of some people to troops returning from those conflicts is any indication, then the future may not be much better.
Saving lives rather than destroying them has rarely been a priority of the battlefield. Surgeons travelled with Julius Caesar’s legions and, a millennium later, with William the Conqueror when the Normans invaded Britain. In the countless wars in the intervening centuries, there was no such help, and wounded men were left to die where they fell, saved only if camp-following wives came to their rescue. In medieval times, the Knights of St John of Jerusalem provided hospitals for the Crusaders – though their medical skills were rudimentary compared with those of Saladin’s doctors. But what medical support existed was for the high-born. One of the duties of a knight’s squire was to carry dressings and ointments such as arnica to treat his lord in battle. But the common soldiers could rot.
Not that rank was a guarantee of survival. Richard I died of his wounds after the clumsy extraction of an arrow from his shoulder. Another king, however, Edward I, was saved by a surgeon who cut away the morbid flesh around a deep wound (not that very different from the way in which Sergeant Major Andy Stockton’s arm was debrided and cleansed in Afghanistan in 2006). Henry V had twenty physicians in the army he took to France in 1415. They were overwhelmed, as medics so often are in warfare. Dysentery swept away soldiers in their thousands, but surgeons did manage to save the Duke of Gloucester, successfully binding up a potentially fatal stab wound in his abdomen and sending him back to England. Again, the common soldiery were not so privileged. The hopelessly wounded were put out of their misery, their throats cut, while those with survivable injuries were paid off and abandoned to find their own way home.
Slowly, the importance of trying to save lives was realized, out of practicality as much as philosophy. Fighting men were a commodity not to be wasted – patch up the wounded and send them back into the fray. But the methods employed were gruesome in the extreme and often hastened death rather than preventing it. Wounds – particularly from gunshots, the consequence of increasing use of gunpowder – were treated with boiling oil to stem the bloodflow. The patient screamed in agony until he passed out, sometimes never to wake again. Shattered limbs, liable to become gangrenous, were hacked off with knives and saws, and a red-hot iron was used to seal the blood vessels. The better sort of surgeon sewed up the arteries and even put on a tourniquet first, a French innovation of 1674 which proved an enduring (if controversial) life-saver over the succeeding centuries. A French treatment that did not last was sucking wounds to cleanse them and then packing them with chewed pieces of paper.
The courage of soldiers undergoing any of these procedures without anaesthetic can still catch the breath, all the more so because such drastic remedies were happening far more recently than, in our ignorance, we might imagine. Take this spine-chilling account from Henry Durant in 1859, just 150 years ago, after the Battle of Solferino.
With one knee on the ground and a terrible knife in his hand, the surgeon threw his arm around the soldier’s thigh and with a single movement cut the skin around the mangled leg. A piercing cry rang through the hospital. The young doctor, looking into the suffering man’s face, could see the frightful agony he was undergoing. ‘Be brave,’ he said under his breath. ‘Two more minutes and you will be all right.’ The surgeon began to separate the skin from the muscles under it. Then he cut away the flesh from the skin and raised the skin about
an inch, like a sort of cuff. Then, with a vigorous movement, he cut through the muscles with his knife as far as the bone. A torrent of blood burst from the opened muscles, covering the surgeon and dripping on to the floor. The patient, in an ecstasy of pain, muttered weakly, ‘Oh let me die,’ and cold sweat ran down his face. But there was still another minute to go through, a minute that seemed like eternity. ‘An assistant counted the seconds, looking from the operator to the patient’s face and back again, trying to sustain his courage and seeing him shaking with terror. It was now time for the saw and I could hear the grating of the steel as it entered the living bone and separated the half-rotten limb from the body…2
The young soldier somehow survived, but his ordeal and that of the other thirty thousand dead and wounded on that single day – and as many again succumbing in the following two months from disease, infection and exhaustion – so shocked Dunant that he devoted himself to founding the International Red Cross organization.
But it was a struggle to get military commanders to think in humanitarian terms. Wellington was, at best, lukewarm about his men’s suffering and the need for doctors, at worst, contemptuous. His chief of medical services, James McGrigor, dared to disagree with the Iron Duke’s indifference. ‘In the proper execution of their duties,’ he wrote, ‘medical officers are frequently under fire. Some were killed and many lost limbs in sieges and battles. Yet it has been ignorantly advanced by some military men that the medical men have no business in exposed situations and they would deny the medical officer a pension for the loss of a limb. Yet the cases are numerous wherein the lives of officers and soldiers have been saved by the zealous medical officers of their regiments being on hand to repress haemorrhage.’
Napoleon put Wellington to shame. His armies were the first to develop ways of getting quantities of wounded men off the battlefield, while also bringing the best of medical care to them as soon as possible. The Emperor’s medics went to war, a dozen at a time, in specially designed carriages drawn by six horses. Chests held dressings for more than a thousand injuries. All this was at the behest of his surgeon-in-chief, Baron Percy, who was ‘distressed at seeing the deaths of so great a number of soldiers whose lives might have been preserved and limbs saved. One cannot too often repeat that the chief consolation and the assistance of first importance to a wounded man is for him to be carried promptly and properly from the scene of conflict.’ This was a big advance on leaving men to die where they fell, the practice of millennia past.
All the crucial steps in battlefield medicine at this time were French. The innovators, Percy, and his colleague, Baron Larrey, were never far from the front line. Larrey saw action in all of Napoleon’s campaigns – at sixty battles and four hundred skirmishes. On the retreat from Moscow, he performed two hip-joint amputations (the most difficult and dangerous of this type of operation) and put himself in such danger as he arranged passage for the sick that the soldiers in his party had to restrain him. In one battle he commandeered 150 wheelbarrows to trundle the wounded to safety.
The British Army closed its eyes and shut its ears to such advances, as was cruelly and disastrously exposed in the Crimean War. The scandal, every bit as significant as the diabolical hospital conditions that Florence Nightingale alighted on at Scutari, was that British generals had mounted an expedition to Russia with little thought for the treatment of casualties or any equipment for dealing with them on the battlefield. Medical wagons along the lines of the French model were available and indeed were landed from supply ships. But the horses to pull them were not. Officers, their eyes on military glory, were blind to such needs, giving cavalry mounts precedence. The commanding officer of one regiment took one look at the panniers of medical supplies and dismissed them as ‘useless encumbrances’. He left them on the quayside, where they stayed, while the soldiers whose lives they could have saved died of cholera, and all the doctor could offer them was a sip of brandy mixed with cayenne pepper.
The Crimea was a disgrace for the British Army. There were no stretcher-bearers, no hospital ships, no sense of the value of saving life. Nonetheless, the doctors did what they could, and magnificently. Three won Victoria Crosses for treating the wounded under fire. Afterwards, there was supposedly a change in attitude to medical care of troops, but how much the generals really cared was still debatable. When Kitchener took an army of nearly ten thousand to the Sudan in 1896, he could only be bothered to include five medical officers. In the Boer War a few years later he drastically cut back medical supplies when it suited him.
And yet the ability to inflict injury was increasing exponentially. The second half of the nineteenth century was remarkable for a boom in weapons technology, each device that little bit more lethal than the one before as slaughter moved on to an industrial scale. The American Civil War of 1860–64 was crucial, the breeding ground for an array of new killing machines and their accessories – repeating rifles, land mines, booby traps, revolving gun turrets, flame throwers, trench periscopes and the first machine gun. Medicine struggled to keep up. At Gettysburg there were fifty-five thousand casualties, and the makeshift operating tables, often just a barn door or plank of wood, ran red with blood. Severed limbs were tossed aside until the pile was level with the tables. But at least there was now ether or chloroform to dull the pain, for some. There was not enough to go round, and the lightly wounded had to grit their teeth, bite on a piece of wood or simply scream and sob.
The sciences of medicine and war have advanced, one behind the other, ever since. The Franco-Prussian War dealt out death as never before. The latest machine guns had 25 revolving barrels spitting out 125 rounds a minute. But, then, the victims of their salvos had a better chance of surviving because chemists Lister and Pasteur had done the research that led to the development of antiseptics. Disease had always killed more men than bullets or blades. Now there was a chance of tackling gangrene and other deadly wound infections. As for those machine guns, what came out of their multiple barrels were thin, coned bullets, which passed through human flesh and made cleaner wounds than the exploding musket balls they replaced.
The First World War was not the revolutionary event it is often deemed to be. In the techniques of inflicting human suffering, it was the culmination of all that had gone before but magnified to obscene levels. The casualty rate, in fact, was no different from wars before and since, but with armies counted in millions and offensives that lasted for weeks, the numbers of dead and injured were simply astronomical. To those taking part, it felt like the end of civilization. In many ways it was – living in trenches, bombed, gassed, advancing through minefields and into machine guns, dying in foxholes, drowning in mud.
The medical services had – like the rest of the military – gone into the war with a plan. Getting the casualties out was what mattered. There was a well-defined chain of evacuation, from regimental aid post to dressing stations, casualty clearing stations and field hospitals well behind the front line, the latter staffed by members of the Royal Army Medical Corps, which had been set up as a separate, specialist military unit twenty years earlier. The idea was that there would be little surgery on the front line, just a patching and dispatching. The theory didn’t survive the reality for a minute. In the offensives, when men with fixed bayonets marched in lines against machine guns, the regimental first-aid posts became butcher’s shops where the already dying were cast aside and the maimed but just viable operated on in extremis to give them the barest chance of reaching hospital alive.
Often, writes historian John Laffin, that first-aid post ‘was no more than two orderlies crouching in a shell-hole or behind a pile of sandbags with a stretcher beside them. At best, it was a low-ceilinged shelter in a dug-out with just enough room for a doctor, his assistant and a table. In the heat of an action, their clothing would be saturated with blood. There would be men holding their intestines in both hands, broken bones tearing flesh, arteries spurting blood, bared brains, maimed hands, empty eye sockets, pierced chests, skin hang
ing down in tatters from a burned face, missing lower jaws. The only light was from acetylene lamps, flashlights or candles. Sometimes it was necessary to work in the dark, with doctors groping to wind or unwind a bandage.’
Further along the evacuation chain, conditions were marginally less frantic but every bit as harrowing. Chloroform was a boon and so was morphine, but ‘there was so much to be done and so many soldiers for whom surgery could do so little – the abdominal cases, who died quickly; the brain cases, who took a long time to die.’ And of all the dreadful wounds in war, the lacerating brain wound was the hardest to treat. ‘Restless, noisy, delirious, the victim struggled with the orderlies, babbling incoherently, crying for water and yet spitting it out when brought.’3
For First World War medics, the tidy idea of surgeons operating in some safe, calm, sanitized spot away from the sights, sounds and smells of war was a Dr Finlay-type fantasy. To save lives most effectively, doctors had to get as close as they could to where those lives were in danger. Ninety years on, the same discussion takes place. Should medical services be concentrated on the front line or behind it? Military doctors in Iraq and Afghanistan can’t decide whether the priority should be faster evacuation – with, say, a dedicated helicopter fleet for the wounded – or sending the very best of surgeons right into the heart of the fighting and risking them being killed and their critical life-saving medical skills lost. The difficulty in this debate is that, in today’s wars against terrorists and insurgents, there is no front line nor any safe haven behind it. But, in reality, it was always thus. More often than not, medics of all degrees have had no choice in the matter of where they did their duty. The front line not only came to them but sometimes totally overwhelmed them – as it did most memorably on the beaches of Dunkirk in 1940.
