Before "Geneva" Law : a British Surgeon in the Crimean War
28-02-1995 Article, International Review of the Red Cross, No. 304, by Hilaire McCoubrey
Hilaire McCoubrey is a Senior Lecturer in Law and Director of the Centre for International Defence Law Studies at the University of Nottingham. He is also a member of the Council of the British Red Cross Society and Chair of its Principles and Law Panel. His published books include, International Humanitarian Law (Dartmouth 1990), International Law and Armed Conflict , with N. D. White (Dartmouth 1992) and International Organizations and Civil Wars , with N. D. White (Dartmouth, 1995) as well as a number of articles in the field of international humanitarian law.
* This article is based upon documents held in the Wrench Collection in the University of Nottingham Library Department of Manuscripts. The assistance of the staff of the Department is gratefully acknowledged.
It is well known that modern " Geneva " international humanitarian law has its origins in the impartial rescue and relief work undertaken by Henry Dunant in June 1859 for the wounded soldiers abandoned on the battlefield at Solferino and the proposals made thereafter in his book A Memory of Solferino. Henry Dunant's initiative led to the establishment of the International Red Cross Movement and the conclusion of the initial Geneva Convention for the Amelioration of the Condition of the Wounded and Sick in Armies in the Field, signed in 1864. These humanitarian developments were, b y 1859, sorely needed. The first half of the nineteenth century had seen an increase in the scale of warfare and with it a combination of incapacity and unconcern in relation to the wounded and war victims in general. Hence the scenes which so horrified Dunant as he crossed the battlefield at Solferino. The world for which Henry Dunant addressed his important work was becoming aware of the shortcomings in the treatment of the wounded and sick in armed conflict, and the shocking revelations of the Crimean War some four years earlier had played a significant part in prompting this new concern.
The official medical services in the Crimean War were not only inadequate in extent but also enmeshed in bureaucratic inefficiency and inertia, with appalling human consequences. Such efforts as were made for improvement were undertaken mainly by private persons and charitable bodies, often in the face of official hostility and obstruction. The work of Florence Nightingale at the British hospital in Scutari, in particular, is seen as a major step in the development of modern nursing. Other important work included that undertaken with the French forces by the Order of St. Vincent de Paul and with the Russian army in Sevastopol by the nursing Sisters of the Order of the Exaltation of the Holy Cross.
The papers of a British military surgeon, Edward Mason Wrench, offer a valuable insight into the conditions in which the military medical services worked on the battlefields of the Crimea. These documents reveal a somewhat more complex picture than that suggested by a straightforward comparison drawn between callous official indifference and private humanitarian endeavour. The image which emerges from the Wrench papers is rather that of a conscientious surgeon well aware of the shortcomings of his service but frustrated by bureaucratic incompetence and obscurantism. These were the obstacles, which in the mid-19th century so urgently needed to be addressed, which r epresented a challenge for people such as Florence Nightingale and which ultimately prompted the saving initiative of Henry Dunant.
Edward Mason Wrench, FRCS (1833-1912)
Edward Mason Wrench was born in Nottingham on 1 July 1833, the son of a clergyman. He received an education normal for his time and situation and underwent medical training at St. Thomas's Hospital in London. In November 1853, at the age of 20, he joined the Army Medical Service and was posted to the Crimea. Upon arrival he was put in charge of a section of the British Military Hospital located in the buildings of the Russian Military Academy in Balaclava, which was receiving wounded from the battle of Inkerman. From Wrench's account this building was far from ideal for hospital use and had anyway been severely damaged by a hurricane which had blown out all the windows shortly before his arrival. Subsequently, in December 1854, he was appointed Assistant Surgeon to the 34th Regiment of foot and served with them in the trenches before Redan until the fall of Sevastopol in September 1855. Subsequently Wrench served with the 12th Lancers during the Indian Mutiny. He retired into civilian medical practice in 1862 but became a member of the volunteer reserve forces, attaining the rank of Surgeon Lieutenant Colonel with the Sherwood Foresters. He was elected President of the Midlands Branch of the British Medical Association in 1899 and died in 1912.
Military medical facilities in the Crimean War
Wrench's first posting to the base hospital at Balaclava seems to have been marked by the same horrors which so appalled Florence Nightingale at Scutari. Forty-four years later, in his address to the Midlands Branch of the British Medical Association, he wrote:
" I had charge of from 20 to 30 patients, wounded from Inkerman, mixed with cases of cholera, dysentery, and fever. There were no beds... or proper bedding. The patients lay in their clothes on the floor, which from rain blown in through the open (i.e. broken and unrepaired) windows, and the traffic to and from the open-air latrines, was as muddy as a country road. " [1 ]
In a letter written to his parents on 22 November 1854 Wrench had emphasized the difficulties involved in medical practice in such circumstances. He wrote:
" I saw Henry Ludlow today, he was disgusted with everything and wants to go back to Scutari, he has had the care of the Russian wounded... (T)hey had 130 last week, but they have all died but 60, our wounded are pretty well for out here but (much) ... worse than the worst sick in any hospital in England. We have got no opium (for pain relief), ... arrow root, tea and many other things. Which of course does not facilitate the treatment. " [2 ]
This reflects a situation which was appalling even by the standards of 1854 and strikingly reminiscent of that described by Henry Dunant in Castiglione after Solferino:
" Wounds were infected by the heat and dust, by shortage of water and lack of proper care, and grew more and more painful. Foul exhalations contaminated the air, in spite of the praiseworthy attempts of the authorities to keep hospital areas in a sanitary condition. " [3 ]
Wrench remarks that the'modern'concept of medical sanitation hardly existed at the time of the Crimean War, but even in its absence the conditions in which patients were kept can hardly have been considered conducive to their recovery.
If the physical surroundings were deplorable, the medical resources were hardly better. Wrench wrote:
" We were practically without medicine s, the supply landed at the commencement of the campaign was exhausted, and the reserve had gone to the bottom of the sea in the wreck of ... the Prince so that in November 1854 even the base hospital at Balaclava was devoid of opium, quinine, ammonia, and indeed of all important drugs " .[4 ]
The hospital which Wrench thus describes was, of course, primarily intended for the treatment of British casualties, notably, during his time there, from the battle of Inkerman. It may be assumed that Russian wounded would not have found any better conditions. It would certainly be unwise to apply the modern requirement contained in Article 1 of the First Geneva Convention of 1949, i.e.
" They (the protected wounded and sick) shall be treated humanely and cared for... They shall not be left without medical assistance and care, nor shall conditions exposing them to contagion or infection be created,
retroactively to the 1850s, but any modern military medical unit run along the lines of the one in Balaclava described by Edward Wrench would manifestly be in violation of this provision. In modern terms, a rather more complex question arises in comparison with Article 10, para. 2, of 1977 Additional Protocol I. This requires that in all circumstances the wounded and sick
" ...shall be treated humanely and shall receive to the fullest extent practicable and with the least possible delay, the medical care and attention required by their condition. "
The emphasis is added. The sinking of the medical supply ship Prince appears to have interrupted the intended supply of medicaments to the military medical facility and it might even now be possible to bring such a disaster within the limits of what is'practicable'. Indeed, it is accepted that in applying the modern Geneva pro vision account must be taken of the'material possibilities'of the time and place.[5 ] Although modern drug therapies are quite different from and much more effective than those available in 1854, the deficit at Balaclava was serious. They seem initially to have been the result of misfortune rather than neglect, but the efforts made to improve the situation appear to have been less than satisfactory. The material conditions in the hospital were, even by the generally poor contemporary hospital standards, medically indefensible, and would now be legally indefensible.
In field hospitals near the front line, conditions were even worse. On 13 June 1855 Wrench wrote to his family from the camp of the 34th Regiment before Sevastopol:
" Things are in an awful state up here now and the patients, poor fellows, suffer dreadfully. I have just been round my wards for the night and have two men which I don't expect to find alive in the morning, they are literally dying from exhaustion and we have nothing to give them. They are suffering from fever alike many more... and we have not got a drop of wine to give them although there is lots at Balaclava we have no means of getting it up. I managed to get some tea... and it was delightful to me how grateful the poor fellows were for it but I am sorry to say it is nearly all gone and I can get no more till I go down to Balaclava again, but which I hope to do on the first fine day. " [6 ]
This letter speaks eloquently for the state of supplies to the hospital, and to the front line generally, not least by showing the dependence upon the'charitable'initiative of an individual surgeon.
If some allowance may be made for the drug supply deficit at Balaclava, the same is not true for some of the official directions with regard to treatment and especially to pain relief. Wrench remarked, also in his 1899 Presidential Address, that the Director General of the Armed Medical Services had all but banned the use of chloroform as an anaesthetic, then a recently discovered - and admittedly far from risk-free - technique. Nonetheless, in the context of'heroic'battlefield surgery, involving amputation of shattered limbs and so on, this can only be seen as practically, if not indeed intentionally, cruel obscurantism. This was clearly Edward Wrench's view of the matter. The tone of outrage is obvious in his citation of the official view in the Crimea that:
" the cries of the patient undergoing an operation were satisfactory to the surgeon, as an indication that there was no fear of syncope and that the pain was a stimulant that aided recovery. " [7 ]
This attitude was indeed significant, showing as it does the unconcern for the sufferings of the wounded which informed the views of a hidebound bureaucracy. That Wrench in the field thought differently is also significant. In a letter dated 5 June 1855 and written to his brother, who was then in the course of medical training, Edward Wrench himself gave a detailed account of one of the patients under his care. This shows both Wrench's genuine concern for those under his care and the very hard lot of the disabled soldier in the mid-19th century. He stated:
" I have got a splendid case under my care just now, a man was hit in the arm 3 or 4 weeks ago, about 2 inches of the ulna was carried away and the bullet went clean through his arm... he was apparently doing well, when frightful arterial haemorrhage set in one day when I was out of camp. Our surgeon plugged the wound... and put a tourniquet on - this stopped it and for another week he did admirably. Then on Thursday last it bled again, I asked my (senior) surgeon's advice and he again recommended (the procedure adopted)... this stopped it but the wound had such an unhealthy... appearance the next morning that tying the artery was then out of the question and amputation was the only alternative. I therefore amputated his arm just above the elbow and he is now doing admirably. No arm is much better for a soldier than an arm of little use as for the first he gets a shilling a day pension (for the loss of a limb) whereas for the latter he gets nothing, but is just turned out as unfit for service, so that the old story of where in doubt operate, is doubly applicable in the army. " [8 ]
The problems described here of postoperative infection in an era in which antisepsis was little known and of the limited provision made for many of the disabled are commonplace in writings of the Napoleonic Wars.[9 ] Little had changed in the forty years between 1815 and 1855.
A rather different question arises in relation to the exposure of military medical facilities to avoidable perils of conflict. A striking instance is found in Wrench's account in his 1856 Diary of an explosion in the British lines before Sevastopol in December 1855. It would seem that this was an explosion of powder in an ammunition dump rather than a result of enemy bombardment. It was nonetheless catastrophic in its effects. Wrench reported:
" I went to the scene of the explosion... the broken huts had suffered like my house[10 ] with the roofs being lifted and crushing down the walls (if they were not blown out) when they came down again. I saw a hospital roof resting on the beds.... " [11 ]
Accidental explosions of ammunition have not been unknown in much later conflicts than the Crimean War. The striking aspect of the incident described by Wrench is, however, the apparent location of a field hospital in the immediate vicinity of an ammunition dump. This location was on general grounds unwise in view of the possibility, and in the case in point the reality, of accident. The danger in the event of enemy attack is also obvious; this is what Article 19 of the First Geneva Convention of 1949 has in mind in stipulating:
" The responsible authorities shall ensure that... medical establishments and units are, as far as possible, situated in such a manner that attacks against military objectives cannot imperil their safety. "
In modern law, an ammunition dump is clearly in itself a military objective. The collapse of military medical services during the first half of the 19th century, roughly from the French Revolutionary and Napoleonic Wars to the Franco-Austrian War, is well illustrated by the horrors experienced by Edward Wrench in the base hospital at Balaclava. This, as underlined by Wrench's comment about anaesthesia, is all the more striking in the light of the very significant medical advances which took place during the same period. It is, however, evident that many people, certainly military surgeons such as Edward Wrench, were well ware of the defects of the system in which they worked. This point is one which Wrench himself emphasized. The notion of an organization which was both incompetent and uncaring is also suggested by the location of a hospital next to an ammunition dump. Many of these issues were to be addressed by the original Geneva Convention of 1864 and are certainly now exhaustively covered by the instruments of 1949 and 1977.
Rescue and enemy wounded: the "Solferino" problems
The state of medical facilities and the type of treatment given, vital as these considerations are, matter little if the wounded are never brought in. This is an important consideration for all the wounded and sick but is an especially sensitive issue in relation to endeavours to rescue and treat enemy wounded. It is clear from Henry Dunant's account of the aftermath of Solferino in 1859 that the essential problem was less one of callous aband onment, even of enemy wounded than one of incapacity and of pitifully limited resources being overwhelmed by vast numbers. Dunant wrote:
" On the Saturday the number of convoys of wounded increased to such proportions that the local authorities, the townspeople, and the troops left in Castiglione, were absolutely incapable of dealing with all the suffering. " [12 ]
It was to alleviate this appalling suffering that Henry Dunant organized his corps of volunteers to engage in both treatment and rescue. A similar crisis to that which Dunant described after Solferino existed also in the Crimea. The inadequacy of the official hospital services has already been described, but rescue work was also beset by difficulties. In his 1899 Presidential Address to the Midlands Branch of the British Medical Association, Edward Wrench gave a harrowing account of the transport of the wounded by mule train over rough tracks down to Balaclava harbour to await conveyance by ship to Scutari.
" The wretched patients (were) jolted and tossed about by the mules on the mountain paths, the short road to Balaclava... being then considered unsafe. Several mules fell, and one poor soldier recovering from a bullet through his chest was thrown out and crimsoned the snow from his re-opened wound. " [13 ]
Wrench added that all the men in this convoy reached Balaclava alive but were still left to lie for many hours on the wharf at Balaclava because there were no ships to transport them. It would seem that no local truces with a view to retrieval of the wounded, such as are now urged by the First Geneva Convention, Article 15, were considered, although for other purposes brief truces were arranged. Wrench notes in his summary of events for 1855 that a brief truce was arranged between the Sevastopol garrison and the besieging forces and indeed that friendly fraternization between British and Russian offi cers took place on this occasion. The comparison with the Christmas Day cease-fire on the western front in 1914 during the First World War is compelling. So far as collection of the wounded was concerned, it would seem that in general organizational inadequacy again defeated good intentions.
Wrench also reveals in his papers that at least some effort was made to care for enemy wounded. Reference has been made above to the provision made for the enemy wounded at Balaclava. In his Diary for 1855 Wrench refers to an incident on 22 March during the siege of Sevastopol.
" The Russians made a sortie .... In the following morning a wounded Russian ... was brought into our hospital and we amputated his leg, he did well and was eventually discharged.... " [14 ]
Again during the siege he wrote to his family on 7 July 1855 describing an encounter with a dying Russian soldier.
" (During a night action) I was sitting on a stone when I heard a groan near me, and upon looking I found a poor Russian boy wounded in the side, I lit a candle and looked at him but found I could do nothing to (i.e. for) him so I gave him some water... and laid his head on a flat stone, but upon looking at him again I found him dead. " [15 ]
It is difficult to say how much effort was put into rescuing enemy wounded, but clearly some attempt was made. The situation had, however, manifestly improved since the siege of Messina in 1848, only five years before the outbreak of the Crimean War, when Dr. Palasciano had been imprisoned, and only just escaped execution, for treating wounded enemy soldiers.[16 ] Elsewhere in the Wrench papers an indication is given of the effects of inadequate provision for collection of the wounded, together with the absence of effective humanitarian, and sanitary, provision for the dead. It is clear that little or no allowance was made for the co llection and burial of the dead. In a letter written on 10 February 1855 from the camp before Sevastopol, Wrench said:
" The dead Russians have been lying in the part I went to today till quite lately as the Russians fired on us if we went in any numbers to bury them. " [17 ]
Long after the Crimean War, in an undated 1905 cutting from the Daily Mail newspaper, correspondence received by the paper from Wrench is cited in relation to the discovery of the body of a Miss Hickson and its state of preservation. The newspaper reported:
" Mr. E.M. Wrench FRCS, referring to the preservation of the hands while the neck was gnawed, states that he saw dead Russians on the field of Inkerman with the crocuses blooming between their mummified fingers after the fleshy parts of the body had been devoured by birds and beasts. "
Such a condition would not have been reached immediately and one is left to wonder both whether they had suffered instant death on the battlefield and what the condition of the battlefield had been in the intervening period.
What was wrong with medical services in the Crimean War?
The papers of Edward Mason Wrench indicate, as was suggested at the outset, a rather more complex situation in mid-19th century military medical services before the pioneering work of Henry Dunant than is sometimes assumed. The state of official medical services and, most particularly, of the medical supply system stands unequivocally condemned in Wrench's writings. At the same time it is clear that he and other medical staff working at or near the front line were well aware of the defects and eager for improvement. A particularly interesting light is cast upon this by the attitude taken by Wrench, as a milita ry surgeon, to the work of Florence Nightingale. In a letter written on 14 May 1855 from the camp before Sevastopol, Wrench wrote to his family:
" Poor Miss Nightingale was landed today at 4 o'clock and carried up to the convalescent hospital at Balaclava on a stretcher, she has got fever. I hope she will get better, she has been the saving of many lives herself - I am disgusted with anyone speaking ill of her... they little know what she has gone through. The big surgeons may call her interfering, but the adjutants stick up for her and as they were the men who did all the work at Scutari they ought to know best. " [18 ]
The implicit contrast shown by this letter between bureaucratic obscurantism and the view of those in the front line is highly significant. The ultimate conclusion reached by Edward Wrench upon the failures of the official military medical services in the Crimean War put the essential point clearly. In 1899, looking back upon the lessons of the war, he wrote,
" (I)t was the system and not the men that failed. The medical department was, like every other in the army of that date, quite unprepared for a great and prolonged war, hampered by red tape and denied all independence of action... The Crimean campaign taught a lesson I trust will never be forgotten... that unless the medical department of the army is made efficient and supplied with its proper complement of officers and ambulances during peace, it cannot be expected to do its duty efficiently during war. " [19 ]
These needs were in part matters for post-Crimean reforms of military organization, but were also in large part those that Henry Dunant was to address with such effect after his experience at Solferino.
In the context of the background to modern development of international humanitarian law, the papers of Edward Mason Wrench have considerable sign ificance. They confirm the image of an age which had reached a nadir in, amongst other matters, humanitarian provision for the wounded and sick in armed conflict, but also one which at some levels was aware of and concerned about that fact. The profoundly important proposals made by Henry Dunant in " A Memory of Solferino " found a receptive audience, and the developing climate of opinion which Dunant encouraged and led in order to prompt positive action can be seen very clearly in the writings of the young English military surgeon in the Crimea. Edward Mason Wrench cannot be called a " precursor " in the development of international humanitarian law, but the attitudes which he represented were an important part of the background to the emergence of that law and practice.
1. E. M. Wrench, " The lessons of the Crimean War " , offprint from the British Medical Journal , 22 July 1899, p.1.
2. Original letters preserved in the Wrench Collection at the Department of Manuscripts and special Collections, University of Nottingham Library.
3. Henry Dunant, " A Memory of Solferino " , 1962, published in English translation by the American National Red Cross, 1959, p. 31.
4. Ibid, p. 2.
5. Y Sandoz, C Swinarski, B Zimmermann (eds), Commentary on the Additional Protocols of 8 June 1977 to the Geneva Conventions of 12 August 1949 , ICRC, Martinus Nijhoff, Geneva, 1987, referring to Arti cle 10 of 1977 Additional Protocol I.
6. Original letter preserved in the Wrench Collection at the Department of Manuscripts and Special Collections, University of Nottingham Library.
7. E.M. Wrench, op.cit. , p. 8.
8. Wrench Collection, University o Nottingham Library.
9. The account of a Russian field hospital in 1812, during the Napoleonic wars, given by Leon Tolstoy in his novel War and Peace, Book X, Ch. xxxvii, emphasizes the unavoidable horror of battlefield surgery in that era.
10. This seems to have been a large hut built by Wrench himself. The Diary includes a drawing of this structure as a substantial one- or two-room dwelling.
11. Undated entry in Wrench's summary of events at the beginning of his Diary for 1856.
12. Henry Dunant, op.cit. , (note 3), p. 30.
13. E.M. Wrench, op.cit. , (note 3), p. 6.
14. E.M. Wrench, Diary for 1855 , summary of events referring to 22 March 1855.
15. Wrench Collection, University of Nottingham Library.
16. Jean Pictet, Development and principles of international humanitarian law , Martinus Nijhoff, 1985, p. 25.
17. Wrench Collection, University of Nottingham Library.
19. E.M. Wrench, op. cit. , (note 1), p. 8.