The immense casualties of World War I shocked a generation that first believed in 1914 that the war would end in a few weeks. But, with the help of modern weapons and reckless leadership, the butchery continued unabated day after day, month after month, for more than four years.

Almost ten million soldiers were killed in combat and 21 million were wounded during the war from 1914 to 1918. One million British soldiers were killed in the war, and more than two million were wounded. On the first day of the Battle of the Somme, July 1, 1916, the British suffered almost sixty thousand casualties, of which 19,240 men were killed -- the bloodiest day in the history of the British Army.

At the outset of the war, the gruesome carnage and the massive casualties produced by the enormous battles of this first industrialized war stunned and overwhelmed the British medical personnel sent to treat wounded and dying soldiers on the Western Front.

Machine guns, powerful new bullets, and shrapnel from heavy artillery tore apart soldiers who fought from fetid, wet trenches, breeding grounds for infection and sepsis. The medical skills of medical personnel were tested further by other innovative weapons, such as poison gas, strafing from airplanes, and flamethrowers.

Despite early setbacks and chaos, many lives were saved as the British military medical system improvised in the face of the wholesale slaughter and came to grips with the multitudes of wounded and the complicated character of the new wounds by pushing medicine closer to the frontline, nearer the mayhem.

British medical historian Dr. Emily Mayhew tells the largely forgotten story of the wounded and those who treated them in her groundbreaking new book Wounded: A New History of the Western Front in World War I (Oxford University Press). She drew on dozens of previously unpublished letters, diaries, and other primary documents to tell recount this painful aspect of the war.

Dr. Mayhew describes the suffering of the wounded and the sacrifices of those who treated them, from courageous stretcher bearers who at great risk removed the wounded from the field, often while under fire, to the surgeons, nurses, orderlies, chaplains and others who decided to serve on the Western Front at great personal sacrifice and, at times, at the cost of their lives.

Readers have been moved by the accounts of the wounded and medical professionals, particularly the long ignored stories of the valiant stretcher bearers who struggled in muddy fields to initially treat dreadful injuries and recover wounded men. Andrew Czyzewski wrote of a presentation by Dr. Mayhew that focused on the stretcher bearers:

Emily presented her research for the first time at an event held at the Royal Society of Medicine. At the end of the talk she was approached by an elderly retired GP [general practitioner] who was in tears. He explained that his great uncle was a stretcher bearer and often tried to talk to him about his medical career, only to be dismissed by the young medic as “just a porter.” “Now I understand,” said the GP.

Wounded has been praised for its rigorous research, remarkable work of “historical rediscovery,” compelling narrative writing, and moving personal accounts of the human face of war from forgotten participants. Both the Library Journal and Publisher’s Weekly honored Dr. Mayhew’s book with starred reviews. Renowned author Jacqueline Winspear commented: “...what elevates Emily Mayhew’s book above the many others on the war is the compassion, the well of emotional resonance underpinned by scholarship as easily accessible to the layperson as it is to the academic. It brings the reader closer to a visceral experience of the twentieth century’s first and arguably most terrible world war and its lingering human cost.”

Dr. Mayhew is a Research Associate at the Imperial College School of Medicine and a consultant and lecturer at various institutions including the Wellcome Collection, the Imperial College, and the Royal College of Surgeons. She also wrote The Reconstruction of Warriors: Archibald McIndoe, the Royal Air Force and the Guinea Pig Club, and consulted on an acclaimed documentary based on that book. She also has advised on television projects, including Foyle’s War.

Dr. Emily Mayhew talked by telephone from London after a day of speaking to 450 schoolchildren about history as part of an outreach program at the Imperial War Museum.

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Robin Lindley: You just spoke to hundreds of schoolchildren as part of the Imperial War Museum’s outreach program. Don’t children have a special response to stories of war and the ways people are hurt and die?

Dr. Emily Mayhew: They certainly do. Sometimes they want the gory detail, but they ask questions that adults will not ask, and they can be very rewarding. And it keeps my lecture skills sharp because, if you can keep them awake, then you’re doing okay.

How did you come to write about the wounded British soldiers of World War I?

My first book was an academic book about the aircrews of the Second World War that were burned during RAF service. They were named the Guinea Pig Club and they [suffered] some of the worst burns that we’d known in medical history -- not just military history. They were treated at one particular unit in England by one particular surgeon.

I was interested in that because my grandmother was a nurse at the unit. It’s one of those things we know about as one of the heroic stories of the war, but I found a lot of the official material that related to it and I wrote that up in a history book called The Reconstruction of Warriors about this hospital and a particular kind of military medicine.

Then it was suggested that I might like to do a prequel. I looked for a similar story in the First World War, and there’s not that much in terms of the specific records. But when I began to look at the way that the military medical organization was reconstructed during the First World War -- how badly it failed and how quickly and efficiently it was remade -- that was where I knew I needed to go in the history. I knew I had to look at how doctors were given the freedom to rebuild the medical system, and it was done not with just physicians and surgeons, but they did it with stretcher bearers and nurses, so that there was this whole population at the Western Front that was completely committed to a new military medical system.

At the same time, I was working with a variety of organizations and my college on contemporary military medicine and military medical research. I realized that the system that we use in the British Army today is the system that they developed back in the Great War. There was this incredible resonance and synthesis, and I knew I had to follow that story.

What originally sparked your interest in the subject of military medicine?

Initially I did a Masters at Imperial College in the history of science, technology and medicine. Because I have always been a bit of a fighter plane buff, I was looking at the development of engines for fighter aircraft and then I noticed a correlation between the location of engines and fuel tanks in front of the pilot (in the Spitfire) and the new patterns of serious burns injury. This was of course known at the time but a decision was taken not to move the fuel tanks even though they were a significant cause of pilot attrition because the location ensured the speed and maneuverability of the aircraft. 

So my PhD was essentially about the intersection between strategy, tactics, technology, injury and recovery in modern warfare.

The RAF knew their pilots would be badly burned but there was a strategic necessity for the air war so they made sure they had the best possible care from the leading medical teams of the day. The really interesting part was when the RAF decided that these pilots who had been so badly burned were a symbol of the fighting effort in the air and made them publicly very famous, becoming a feature on the home front and a way in which the civilian population could identify and support war casualties. 

This was completely different from the First World War, where badly injured men were hidden away after they came home. My interest in the subjects of Wounded came originally from the facial casualties of the First World War also caused by technological innovation and strategic choices (high speed rifles and mechanized artillery) but broadened to include the entire structure of reorganized medical care on the Western Front.

Do you also have a medical background?

I don’t have a medical background. I am simply a historian. But I do most of my teaching in our medical school. I’m exposed to medical education on a daily basis so I probably have a little bit more understanding of medicine and medical education than most historians of medicine would have.

You describe your first book as academic, but Wounded is very accessible and is based on many personal recollections.

I thought I could write it for academics on the story of the medical organization, but it was difficult to do that without the official records. But because [Wounded] is constructed from personal archives, I knew that it would be tough to find an academic audience. I decided that I didn’t care if it just got to an academic audience. I wanted everyone, as many people as possible, for those who saw War Horse or read Birdsong, to know this extraordinary story and this extraordinary achievement. That’s why I chose to write it [and] I wanted to take people there as quickly as I possibly could, and that’s why I went to the narrative style.

You call the book “recovered history,” as opposed to a conventional history. And you note that many of the official records had been destroyed.

Absolutely. They were destroyed in the late 1920s because nobody in government thought that they would need them. It was going to be “The War to End All Wars,” so why would you need [records] of military medicine if you’re not having another big war? That was the plan, and obviously it wasn’t a great plan.

I got an idea about the way medics operated and did their work on the Western Front. In a way is was a classic scientific approach. I had a hypothesis. I couldn’t prove my hypothesis from official records, but I found that if I looked at enough personal records -- diaries, letters, archives, photograph albums, anything produced by someone who was actually there -- there was enough material for me to prove my hypothesis with this recovered history, history from below as it were. It’s not unofficial history, it’s personal history.

I was very lucky that there were some high quality witnesses. A doctor like Charles McKerrow, one of the regimental medical officers, understood instinctively the importance of the new role of the stretcher bearer corps. He gave a lot of detail in his memoir about working with the stretcher bearer corps and how they had the training to become the expert corps that they were on the Western Front, and how important the role of the medical officer was in continuing that training and how important they become to each other. He can’t do his job forward in the field without an expert team of stretcher bearers. That’s something he focused on in his testimony. That gave me a really good idea of how that system worked. Then I could look in other medical officer records and get supporting testimony from them.

So I didn’t have official records but I had these really good expert witnesses. I could build this up gradually. It could be a simple line in a letter. It could be a doctor writing home and saying, “My stretcher bearers were extraordinary.” Then I knew the relationship wasn’t an exception, but it was a relationship that was repeated all over the front to incredible effect.

In a way, I was making a leap. I had this hypothesis, and that was all it was. I hadn’t much of clue and I looked for things that supported it. Then I had to test my hypothesis in case it didn’t work, but I found that it did work.

The other thing it enabled me to do was to take my reader there by, for example, having a letter or a diary that had been written two miles behind the lines at the Somme. They took me there.

The more testimony that I was able to recover, then the more detail I was able to visualize. By the time I worked out my method, I could say now I’m standing in a casualty station that is receiving casualties from the Somme. Who can I see in the resuscitation ward? Who is there? What are they doing? What can they see? What are they feeling? What can they smell? What had they done the day before at the Somme? What will they do the day after? So I could put myself there and try to be as empathic as possible, and try to convey what I saw there to my readers.

It was a sort of double approach. It was using personal sources and being highly empathic with the material that they gave me.

That seems more a novelist’s approach than a historian.

I tried to be disciplined and I wasn’t making it up. It was definitely an empathic, novelistic approach, but the richness of the sources and the testimony allowed me to do that, whether a sound off by a stretcher bearer or a highly educated surgeon used to writing diaries and letters. And nobody else had looked at that. We don’t have official records on the stretcher bearers, they’ve almost disappeared from history, and so it’s a recovery and a restoration as well.

Aren’t these stretcher bearers the precursors of modern military medics?

Absolutely. We call them combat medical technicians. They are pretty much stretcher bearers, and they are the military version of paramedics. They are skilled in emergency care and they are strong. In Afghanistan, they travel by helicopters to situations where they will be under fire. They are skilled in physically recovering a human being from a site under fire into a helicopter and treating them on the move and then triaging clearly to surgeons when they get back to the base hospital. With the exception of the helicopter, that’s exactly what they did on the Western Front. They had to be strong and expert.

If there’s one thing I want people to take away from Wounded it’s the achievement of the creation and the operation of the specialist stretcher bearer corps, because it’s so important. They were required to carry someone for hours under fire, but they were also required to very carefully stop a bleed or splint a leg. It’s an amazing range of skills.

And of course they weren’t as educated as the doctors, so they didn’t tend to keep diaries, but the Imperial War Museum had great foresight. In the 1970s they went out and interviewed a lot of stretcher bearers and put the material in the archives. We do have their actual voices, so even though they weren’t able to keep diaries or write many letters home, we do have a wonderful set of testimonies.

That must be moving to hear.

Really moving. Sometimes almost too moving. When I looked at the records at the archive and found out that no one else had ever listened to them, I felt a real sense of responsibility to them, to tell their stories and to make sure that people understand the nature of their achievement. And I really hope that’s something that people are going to do for today’s wars. They’re interviewing casualties and surgeons, but they need to also talk to the medical auxiliary because it’s a complex journey to get someone to surgery and, without the auxiliary, the people won’t survive.

I sometimes wonder how historians like you read these very moving and often horrific accounts and keep their wits.

There were times that were difficult. Going back to Charles McKerrow, his diary was one in a huge pile of boxes that I had that were diaries of medical officers. I didn’t think it would be a particularly special archive, and I started reading it, and I turned the page where he’s writing that “I’m coming home next week.” And then he was killed. I literally gasped in the archive and people shushed me. That happened to me a lot when I thought I’m not sure I can go on reading this, and then I thought, but somebody was there and they had to go on working, so the least you can do is pay careful attention.

After I realized where the gaps were and how I had to fill in those, I really felt a sense of responsibility to the people that I was writing about to get their stories right.

I read that you also wrote a play based on the experience of the stretcher bearers.

I didn’t write it, but worked closely to the playwright. She was referred to me because she was writing a play to commemorate the centenary of the military medical facility where our soldiers still go in Birmingham. She was originally going to write about a surgeon of the Great War, but I said may I suggest that you look at another group of people who have never really been commemorated. the stretcher bearers. I worked closely with her. She was able to take all the bits I was able to find and build a play out of that. It played in schools, and the schoolchildren really understood it. They understood a play about this person who was a different kind of specialist. It was wonderful to see that was working.

That happened before Wounded was published so it was tremendously confidence boosting to see that people got behind the story of stretcher bearers.

In the play, a stretcher bearer and someone from the twenty-first century meet at night in a hospital ward as if they were both ghosts. The idea of the echoes in today’s wars and back in the wars of the early twentieth century is very strong. And it’s very depressing and disheartening that we’re still asking people to go to that level of sacrifice.

It seems it would also make a compelling film. Your descriptions in the book and excerpts from the writings are vivid and cinematic, and the book brings home the human cost of war.

Absolutely. It’s very difficult for me to do anything other than for whatever is happening, for whatever reason, the cost is too high. The death of one doctor or one stretcher bearer is such a terrible waste, and the war went on for so long, and it was such a waste. It’s difficult for me to think about war beyond the terrible facts that I deal with every day. It is the most appalling cost for human beings to pay and I think it’s too high.

It seems that you and your colleagues would become pacifists.

Yes. We have a Centre for Blast Injury Studies at the Imperial War Museum where we have a dedicated, multidisciplinary department that deals with everything from trying to design the bases for vehicles to repels the force of the blast from an IED [improvised explosive device], to the materials for prosthetic limbs for those who required amputation when injured by an IED.

I think we don’t allow ourselves to think beyond the medical problems that war poses. If you do, you’d go mad. We don’t talk about it. In Wounded, I try to make it so that, even if you don’t know what the First World War was, you’d still see it as a dreadful war. I don’t give the details of the battles that were fought. I just give the details of casualties. I limit my focus to that because otherwise, on that way, lies madness or aggressive pacifism.

For me, the it’s a powerful antiwar book.

I hope people will look at it and say here are some basic reasons why this should be the very final and last resort. You must have a very good reason to do this because you’re taking that decision on behalf of these people. It’s difficult at the moment to see that these decisions were sometimes not taken in the seriousness that they should have been.

There was a change in the character of war with World War I, the first industrialized war with use of terrifying new weapons: machine guns, airplanes, gas, heavy artillery, tanks, and more. Did the character of this modern war change the nature of wounds that soldiers suffered?

Absolutely. And the place where I began to realize that it was significantly different was when I looked at testimony from doctors saying, “We were not prepared for this.” Yet, it seemed on paper, that they were very well prepared for this. Lots of them had been members of the Royal Army Medical Corps and then had been fighting in Britain’s colonial wars, such as the Boer War, and many of them had really solid experience of military medicine. Yet, when they got to the Western Front in particular, everything had been absolutely transformed and they had to re-learn everything from zero.

And it wasn’t just a technologic revolution. There was also a revolution in public health care. People weren’t getting the same diseases. They weren’t getting dysentery or typhus or cholera, which would have brought down seven out of ten of the casualties in the South African wars and was a huge problem in the American Civil War -- the infection and disease.

Instead of seeing seven out ten people with disease, they were seeing nine or ten out of ten people with the most dreadful wounds. When I worked with the our blast injury study center, I also became aware of blast in First World War injuries. It isn’t just the impact of the new pointed bullet -- high speed, highly accurate bullets -- and also large pieces of shrapnel. They do damage initially, but because they’re so much more powerful, you’re also seeing blast in the First World War, so you see the piece of the bullet or shell going into the person but continuing to transmit force around the human body with destruction of the soft tissue and far larger wounds. It may not look it on the outside; it might be a little nick. But when the surgeon goes in, there’s real destruction of the soft tissue for inches around the actual damage by the [bullet or shrapnel].

Of course, that’s very similar today. People are hit by IEDs and it’s not just the damage from the fragment, it’s the actual physics of the blast that’s giving them conditions like blast lung and far worse injuries from an invisible force that comes from high-powered weaponry.

Then what we call traumatic brain injury now must have been prevalent almost a century ago in the First World War so that suffering was caused by brain injury that wouldn’t be revealed on physical examination.

Exactly. It’s the invisible injury. You get injured twice. You get the punch and recoil of the punch almost. Head injuries were very difficult for them then. It was something they were never able to get a grip on in the Great War in the way we can today.

But abdominal injuries are very similar. You can look at a series of them from the twenty-first century and twentieth century wars, and they look very similar. They have the same problem in that you have the initial shock and the soft tissue of the abdomen destroyed by the shock wave.

There was also the problem that shock waves appeared to damage the structure of the bones themselves. This was discovered by an extraordinary American scientist, Augusta Dejerine-Klumpke. She studied medicine in France and married a French neuroscientist. In 1917, she was working in an American medical facility in Paris, and she realized that, with people who had limb amputation as the result of a blast injury, the amputation site was difficult to treat over the long term -- even years after the original amputation and the fitting of the prosthetic. This was something that happened only with a blast injury. With cancer or congenital deformity, there weren’t the same problems at the stump site. She hypothesized that it was the effect of blast at the molecular level of the bone. We are only just starting to come to grips with this today. Again, this began in the First World War with these industrial, high-powered weapons with the double capacity to injure and to kill from their own materiality and the physics of the blast.

The condition of the trenches was dreadful. You discuss the constant damp, the rats and fleas, the filth. You also note that the new projectiles carried all this material from the trench and the soiled clothes of soldiers into their wounds to make treatment especially complicated with infection, gangrene and numerous amputations.

Yes, indeed. And they go in so deep and take in this soil where manure has been in for thousands of years. Or, later in the war, when there are still dead unburied soldiers from 1914.

The problem with the bullets, which is different from the Civil War and Britain’s colonial wars, is that the bullets previously didn’t go deep and could still cause dreadful damage. But these [newer bullets] took infection deep inside the body so that it’s unmanageable. So people might have their lives saved, but the gangrene will get them within a week or two.

And one of the things people don’t realize is that soldiers in the trenches led a dreadful life, but they were in and out fairly quickly. You were pulled back to the rear or to your billet. But often, doctors and stretcher bearers were there for weeks at a time with little relief. They were expected to remain there in medical dugouts and the soldiers circulate around them. I found wonderful testimony of people who literally lived in the trenches week after week with very little relief. People don’t often realize how long the medics were there and how intense their exposure to the war was.

You also refer to the plight of the wounded who often awaited treatment for days at a time, sometimes in ambulances or trains. As you describe, the wounded soldiers on upper berths or stretchers would secrete blood or other fluids onto the wounded resting below.

Yes. I recently did an event at a services charity where I talked about the kind of wounds soldiers got in 1917. Then a serviceman who had been wounded in 2007 talked about his experience. He talked about being in an ambulance where he had seen a friend die and he could hear people around him. I was fascinated to know that essentially that experience hasn’t changed at all.

When you’re loaded into an ambulance, whether in 1917 or 2013, doesn’t make any difference. You’re being moved, and around you people are suffering and dying, and you are conscious enough to hear that. That’s an experience that all wounded soldiers must share: the moment when they stop being a soldier and become a casualty, and there are people dying around them who they cannot help. And they cannot get anyone to help them because of that dreadful delay in treatment.

Another new Great War weapon that must have required special medical treatment was poison gas.

Although gas attacks were terrifying for those who endured them, particularly in 1915 when no one really knew what they were, they caused relatively little impact on the casualty figures; less than five percent it is calculated.  Most of the effects were temporary - blindness, coughing, and loss of taste and smell -- and were corrected after a couple of weeks treatment.  Field hospitals used canisters of oxygen to relieve the respiratory symptoms and washed the skin of the casualty thoroughly.  Eyes were treated with drops and eventually vision returned in the majority of cases. 

There were of course some deaths and some permanent respiratory damage suffered, but generally gas was not very efficient and everyone relied on artillery.  But large numbers of gas casualties, even with only temporary injuries, caused dreadful congestion in the field hospitals, so gas posed a double threat to medical facilities on the Western Front.  This is still the case today - gas is only really effectively used on captive civilian populations - as the recent attacks in Syria have horrifyingly demonstrated. 

Another group of medical workers you focus on were women, and particularly nurses. It seems that the First World War was the first time nurses were used in a large-scale way and closer to the frontlines than ever before.

Absolutely. This was the first time women worked in a sustained way within the sound of the guns in the thousands. The system could not have run without them. As any surgeon would tell you, you need a team of pre- and post-operative nurses to work with, otherwise there’s not point in doing the surgery. Thousands of women put themselves in physical danger. Doctors and nurses were killed occasionally when artillery targeted the field hospital. Never mind that nurses were re-defining military medical care by taking on these responsibilities and were quite happy to do so. And there was very little guidance for the nurses and they were improvising. They developed incredible expertise in everything from resuscitation to running the moribund wards -- what we would call the terminal wards today. They did it on their own and shared the information with each other. Their achievement is absolutely extraordinary.

It seems that much of modern medicine and nursing comes out of what was learned in the First World War.

Yes, that’s probably true.

The first thing it did was prove that nurses could be relied upon in very extreme circumstances, and that nurses were not just there for cleaning and flower arranging and for taking orders from doctors. They could be given a high level of responsibility, and particularly nursing could embrace resuscitation and treatment of very serious wounds such as facial wounds. The nurse would clean a wound and dress and redress it on an hourly basis. And it’s the nurse who feed the patient to make him strong enough to undergo surgery for facial repair. She used tubes for feeding the patient because he had no mouth.

So it broadened the area in which nurses became directly involved in medical care. It also created the use of pre- and post-operative. It broadened the idea of what nursing expertise should be. And it proved they could do it.

There were fewer specific medical innovations but it’s about process change and a change in identity and in expertise. There’s no question that the thousands of women who proved themselves on the Western Front went on to fundamentally change how nursing was used by the rest of the medical profession.

The nurses were very strong and courageous, as your book shows, and they put their lives on the line.

They really did. I think a lot of them found great satisfaction in that job. Had they been nurses at home in Britain, it was very hierarchical and nursing wasn’t a matter of being medically expert. You were doing a lot of cleaning and bed changing and laundry. But they had an opportunity where the hierarchy was swept away, and all they could do was deal with wounded men. They had a responsibility that they never could have anticipated back at home in civilian life. I think many of them relished it. Even though the war was appalling and horrific, they felt personally satisfied that they did the best possible job they could and someone relied on them to do it.

And many of the original medical original officers were unhappy that they had nurses to supervise. They expected all male teams. They got these nurses and thought they’ll be a lot of silly women with pink handkerchiefs who couldn’t handle this. As they realized that this war would be unlike anything they had ever known, these medical officers realized they were very fortunate that they had teams of women who could cope and that they couldn’t do their job without them, so they have to reassess their idea of women very quickly.

Many [nurses] when they came back to England returned to conventional nursing jobs or get married and have families and much of that experience is lost. But the overall experience was embedded into the professional memory and was very significant.

This seems an important part of women’s history in the context of the suffragettes before the war, the outcry for expanded rights, and then more women at home working traditionally male jobs because so many men are at war.

Absolutely. The suffragette campaign in Britain was suspended once the First World War came. It was a policy decision of suffragette organizations. But women would prove themselves at the war, and it would be suffragism by other means as they proved themselves worthy of citizenship, so that when they came back after the war, there was no option but to give them the vote.

There was testimony from soldiers who got to know their nurses when they were in hospitals, and they saw that a lot of nurses wore the green and purple badge of the suffragette movement on their uniforms, but it was hidden away, tucked under a collar, but it was there. It’s a secret that the nurses kept among themselves and they revealed it only to soldiers that they think will be amenable to the idea. But there’s no question that this was a huge moment for women when they proved their worthiness of citizenship.

Although one of the things I wanted to emphasize in Wounded was that it wasn’t just that [the women] stepped up to the plate and were present and did the work, but it’s also how expert they became in the job they took on: how expert they were in resuscitation techniques and in nursing men who were dying. In today’s hospital, that would be two completely different kinds of nursing, but on the Western Front they have to be able to do everything and they took that on and became really expert, and I hope that I’ve conveyed these new levels of expertise.

I don’t know if many nurses went into the field like stretch bearers, but they seem to have the skills of present day paramedics.

Exactly. A lot of histories of nursing talk about this in general terms, so I wanted to be very specific about here were nurses, a group of women who generally through tactical experience worked out the formula for resuscitation and rehydration techniques. It isn’t just that they were there and very brave. They sat down, conferred with each other, and gained technical expertise.

And they were paramedics. They didn’t go into the field, except for a few. Although I write in the “Ambulance Train” chapter about some who went to the quiet part of the line and meet soldiers and have them show them around the trenches because they’ve heard about the trenches and the frontline, but they’ve never really seen it, although they’ve heard the guns. I realized that the presence of the sound of the guns was with them all the time.

And I appreciated the cameo appearance of Madame Curie in your book. I didn’t realize she was at the front and helping with x-rays and then she was doing mechanical work and making machine repairs.

Everyone knows that Marie Curie was the first woman to win the Nobel Prize and that she had many scientific discoveries, but I had no idea that she was quite so practical. She realized that the medical system had failed in the early months of the war, and she watched it being rebuilt. Because she had a particular understanding of this industrial war, she knew about fragments and she knew how dangerous they could be if they weren’t extracted by surgeons.

She understood how important the role of x-rays would be in that process. She also knew that most of the x-ray units were too far back for the surgeons, who were forward, to use. So she came up with the idea of the mobile x-ray unit. She bought the vans from Renault with money from friends and she had a student adapt these vans into mobile x-ray units. She didn’t know how to drive, so she learned to drive. She learned how to change a tire and mend an engine. So she got in one of the vans and her colleagues got into others and they drove to whatever hospitals needed them.

In some cases, they would set up the unit and leave the technology for someone who was trained in x-ray. In the case of the hospital that I look at, the Number One Belgian Field, she ran it herself. She was there for several weeks. She would walk into the operating theater carrying the film and show the surgeons the fragments of shell that she had found and where they needed to look when the patient was on the operating table.

And not everybody liked her, according to her daughter’s memoirs. Even though she was Marie Curie, some surgeons weren’t happy to be told what to do by a woman. They weren’t interested in that. She should let an orderly or a male x-ray orderly or a male x-ray specialist do that. At the hospital I looked at, the surgeon was a keen amateur physicist, and he was overwhelmed and delighted to have her working with him. It comes through very strongly in her memoirs how honored he was to have Marie Curie with him.

They also realized how practical she was. She repaired machinery and she installed phone lines and repaired them the hospital so that senior officers in the ward could talk with officers in the rear. I had no idea about this.

She was prepared to get her hands dirty. She worked for the whole course of the war with her little band training others. And there’s an excellent photograph of her, which you can find online, working with American medics to set up mobile x-ray units for them. When the Americans came over in 1917, they realized it was a very good system, so she worked again. She gave up all of her theoretical physics and she just served the medical needs of the war. That was something extraordinary to find out.

Wounding must have been a great leveler, but didn’t social class have some influence on treatment? A history professor friend of mine mentioned that some upper class families arranged for private ambulances to deliver their wounded brothers and sons from field hospitals near the front and back to England.

He's quite right about the funerals although this only happened in the early years of the war.  From the beginning of 1916, there were simply too many people dead from any class to bring home and have a funeral for.  Also the government was very worried about the effect of so many funerals on civilian morale - it would have been constant black corteges on every high street so that was kept in France or at cemeteries in theatre. 

At the same time, elaborate mourning costumes were discouraged because everyone would have been wearing black for their lost family and friends.  Instead, both women and men wore a black armband or dark purple dress but it was only a detail.  This was in very sharp contrast to the American Civil War where mourning (particularly in the South) was the full Victorian elaborate melodrama and visitors noticed that it was like going to a religious order in some communities where everyone was in black.  In Great War Britain this was specifically avoided. 

Class affected the wounded in a particular way.  The field hospitals in France were operated on a non-rank basis but, once the casualties got back to Britain, there were wards for the enlisted men and separate wards (and separate hospitals) for officers, although the same people did their medical care. But badly wounded soldiers left with long term disabilities were also put in long term care homes and were not necessarily cared for at home, even if their families had the means to do so, and those care homes were also segregated by rank and class.

The complexity of treating facial wounds comes up again and again in Wounded. After the war, a group of French veterans with severe facial wounds marched together in veteran’s parades to expose the reality of the war. I think they were called something like the Union of the Facially Disfigured.

They were called Gueules Cassees, “The Broken Faces.”

Did a group of British veterans with similar wounds band together?

No. As I wrote in my previous book, the wounded from the RAF air crews in the Second World War founded the Guinea Pig Club and most of them had their faces burnt off. They became extremely famous in the Second World War.

But Britain wasn’t ready for it in 1918 and they hid them away. Most of the people who suffered a severe facial wound went home to their families and never came out again. There were very few that were publically visible. Some of them went into homes run by military charities and were again hidden away.

The French did a very good film called The Officer’s Ward. It’s about a surgeon in one hospital where they focus on repairing faces. In France, the Gueules Cassees developed a strong spirit and marched in military parades.

We had a surgeon, Harold Gillies, who was very committed to treating these injuries. They [the facially injured] pretty much disappear and, in fact, it’s considered that the public must be sheltered from these casualties. The hospital was in the suburbs and the municipal authority in that area painted the park benches blue for the people in the hospital so they could sit there in the park, but the public would know that the people using the bench were facial casualties, so they could look away and not be terrified by them. They also had blue uniforms so you could tell from a distance that someone was injured and you might need to be protected from the horrible sight, especially if you were a woman or a child. And the hospital ran its bells when the patients would be walking around the town.

There was generally an expectation by the government that the public could not handle that kind of injury. It was proved they could in the Second World War, but in the First World War, [the facially wounded] were pretty much invisible. A great tragedy.

Although there were great achievements in the forward military medical division, some of the achievements at home were not so significant.

And the physician/artist Henry Tonks made vivid color drawings of facial wounds.

Exactly. He worked closely with Gillies and, all those people knew that [the injured] were very well hidden away. That’s a fascinating set of pictures. And Henry Tonks knew the Elephant Man. When I look at the Tonks pictures, I see how much he was able to look at those people and represent them so accurately, and in a strangely beautiful way. I think they’re the equivalent of the war poets -- about this terrible horror but beautifully expressed. But Tonks trained in the same hospital as John Merrick, the Elephant Man. He knew how bad a human face could look. I have no evidence for this, but I think that informs the fact that he can look at them so coolly and represent them so accurately after seeing this terrible [disfigurement] early in the century.

Didn’t they make masks, tin noses and other prosthetics for facial wounds?

Yes, they did, and they spent such a long time making and painting them and using photographs from the patient’s families. But, in fact, they were very uncomfortable to use and they got very hot under the mask and often they would sweat into their injuries, and that wasn’t medically efficient.

The masks were very durable, and we have a lot of the masks in very good condition, but in fact they were an anomaly because they weren’t very functional and they were rarely used so they were set aside and carefully wrapped up. Museum curators put them front and center in their museums, although they don’t represent the reality of facial casualties.

John Glubb, one of the wounded soldiers you profile, said, “The real horrors of war were to be seen in the hospitals, not on the battlefield.” Do you have a thought on his observation?

Absolutely. In fact, he was a facial casualty and a patient of Harold Gillies in the hospital in Sidcup. He was in the special unit for facial casualties which was at the cutting edge of facial reconstruction surgery. But people were in there for a very long time, and wherever you’d look in the bed, you’d see someone with a dreadful hole in the face. It was often a painful treatment, and you’d hear men cry out in the night. I think that’s what he’s talking about.

He’s talking about how he came away from the horror of the trenches thinking surely it must be better when you get into the hospital, but in fact he was seeing equivalent horror with very long periods of people being treated for very painful injuries with painful treatment for them. And their lives were falling apart around them. Quite often they were rejected by their families. At the hospital, they were encouraged not to go out and scare the population.

It’s a very sad comment. It was a different horror in the trenches, but a horror just the same. They were stuck in a place they couldn’t come out of.

Also, anesthetics were horrible then. It was an ordeal to go under anesthetics, so they dreaded that. But they also dreaded what would happen to them when they left the hospital. They were between a rock and a very hard place.

What was the problem with anesthetics then?

There were two problems. First, the anesthetic was very basic at the time and anesthesiology wasn’t recognized as a medical specialty. It was very strong ether and it made everybody sick. People would weep when they went in [for surgery] because once they had one anesthetic, they knew what would happen. It was extremely difficult to keep people down.

If you had a facial injury, it was very difficult because they didn’t use endotracheal intubation or a direct pipe down the throat. They had a large, heavy rubber mask that covered the whole face, and it had to be taken down so the surgeon could take them off and operate. It was very a basic and a very degrading, painful process for the men undergoing it and for the surgeons and anesthetists who had to operate with it. The default, if you couldn’t give anesthetic on their face, was with a anesthetic solution rectally. I want people to know how grueling it was.

It seems Wounded has universal resonance, but you’ve mentioned a concern about the reception in the United States.

One of the things it has been really interesting to explore in the last six months is the meaning of the Great War in the United States.  As I have worked, I realize that the American Civil War occupies much of the same place in the national memory as the Great War does in Europe.  It is the same kind of impact on the population (although in percentage terms much worse in the Civil War), the same impact on the home front, a similar legacy in terms of the returning injured to the home front, even poetry and songs that have extraordinary symbolic value in the national consciousness, in the same way that our war poets and soldiers songs are still an important part of British culture. 

Although obviously medical techniques and military technology had changed radically between 1860 and 1914, the moment of wounding and the effort of dealing with so many casualties has very strong resonances between both wars.  It was something I had at the back of my mind when writing Wounded; that someone should be able to read it whose primary interest was in another war, perhaps the Civil War or the wars in the 21st century, rather than the Great War. and still be able to understand the commitment of medical expertise and the universal suffering of soldiers in such terrible places. 

If I contrast the reception of Wounded in Europe with its reception (so far) in the United States, it is that in Europe it provokes very personal responses from readers: many have written to me to say that a specific member of their family was a medic and they had not realized the extent of his or her dedication in the war.  In the US, the response is more general, about the horrors of war and the overall dedication of the medical staff who serve in any war in modern times.  It's an ideal situation for a historian really!

Is there anything you’d like to add about Wounded?

Only how common the experience of the wounded soldier is -- that moment when the soldiers stop being soldiers and become casualties and then patients. That’s something common to all wars. Focusing very closely on that moment of transition tells you everything you really need to know about a war. The strategy and tactics fall away and it’s really about that wounded man and who can get to him and who can save his life.

From the point of wounding to the point of coming home, it isn’t just about one doctor or one nurse; it’s about this journey along a team of experts who are absolutely dedicated to saving lives.

I wanted to be the first person to do that story from the stretcher bearer to the surgeon back in Britain. And I’m dedicated to the story of these extraordinary people and the achievement that has fallen away from the history and I want to put it back front and center because it’s so important in telling the history of the wars today.