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Ann Thorac Surg 1997;63:264-268
© 1997 The Society of Thoracic Surgeons
Indian Wells, California
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When you go homeTell them of us, and say:
For your tomorrow,
We gave our today
Memorial to British soldiers killed in India [1]
Belgium's strategic location, hospitable terrain and accessible waterways have made the country an inescapable battleground for invading armies ever since the Romans conquered Gaul in 57 BC. Eloquently memorialized in Belgian military history are the battles of Waterloo, Ypres, Passchendaele, and Bastogne.
Eruption of the First World War on August 4, 1914, with the surprise German invasion of neutral Belgium was a bold attempt to overpower France by an outflanking "race to the sea." Germany's sweep across Belgium was stopped by British, French, and Belgian forces on the perimeter of the town of Ypres (Ieper) in Flanders.
The crucial role that Ypres and the surrounding area played in the Great War resulted in its total destruction from continuous heavy bombardment (Fig 1
). The town is overlooked by hills on three sides, and this higher ground was controlled by the Germans, enabling them to shell the town almost continuously for the entire 4 years of war. Ypres is sometimes referred to as "the Hiroshima of the Great War." Ypres, dominated by the Cloth Hall-one of the largest Gothic civil buildings in Europe-was a flourishing medieval textile marketplace from which the word "diaper" is derived (from the French d'ypres and Middle English diapre). The destruction was so complete that rebuilding the razed city in its original style took more than 40 years.
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By 1914, Western Front armies had come to depend on weaponry rather than individual soldiers, forcing the troops to desperately dig holes in the ground to escape the deadly firepower they suddenly realized had been created. These soldiers understood they no longer could depend on personal courage or strength for survival, as modern weapons with mutilation, dismemberment, and agonal asphyxiation by poison gas added new meaning to the terrors of death [4].
In the battle of Neuve Chapelle on March 10, 1915, when the British stormed the German trenches, more shells were fired in the opening 35-minute artillery barrage than were used during the entire Boer War, demonstrating the "terrifying transformation of the nature of war" in a 15-year period [3]. The ferocity of the battles, reflected in new and improved weaponry such as the high-powered rifle, machine gun, and heavy artillery, led to massive casualties and deaths previously unknown in warfare.
To further illustrate the incredible destructiveness of war wounds, Sir Philip Gibbs described this scene from a visit to a casualty clearing station: "Men with chunks of steel in their lungs and bowels vomiting great gobs of blood, men with legs and arms torn from their trunks, men without noses, and their brains throbbing though open scalps, men without faces" [5].
Despite the idealism of the "Age of Innocence," the soldiers arriving in the war zone were faced with the brutal realities of "a frozen hell," with "land ...cratered like the moon" from shell pocks of deadlocked trench warfare [6]. There was only "Flesh versus iron, concrete, flame and wire," in the words of Gilbert Frankau, German soldier and poet [7].
The firing trenches, a 760-km zig-zag "ribbon of death," 2 to 2
m deep and 1 or 1 m wide, extended from the Belgian coast to the Swiss border (Fig 2). The manure-contaminated swamp soil of Belgium created appalling, inhuman conditions in the trenches. In addition to the putrid mud and water, the trenches often were rat-infested. This led to "trench foot" and horrific wound infections, including gas gangrene.
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The First World War sparked more literary creativity-predominantly poetic-than any other previous conflict [8]. Always poignant, sometimes embittered, the heroic poem is, according to poet John Dryden, "undoubtedly the greatest work which the soul of man is capable to perform."
The list of "War or Trench Poets" is long and includes some who became major literary figures: Wilfred Owen, Sigfried Sassoon, Isaac Rosenberg, Robert Graves, Edmund Thomas, Edmund Blunden, Charles Sorley, Julian Grenfell, Alan Seeger, and John McCrae. Rupert Brooke, already an established poet, created his greatest work during this period before his death at age 28 of septicemia. Seeger, who wrote "I Have a Rendezvous with Death," the most renowned American poem, was killed on July 4, 1916; Owen, considered one of the outstanding modern English writers, was killed a week before the Armistice; Thomas was killed by a shell blast in 1917 at age 19; Sorley was shot in the head by a sniper at age 19; and Rosenberg was killed during a German offensive in April 1918.
However, the most popular poem of the Great War was the haunting "In Flanders Fields," written by Lieutenant Colonel John McCrae (Fig 3), a distinguished Canadian doctor:
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In Flanders fields the poppies blowBetween the crosses, row on row,
That mark our place; and in the sky
The larks, still bravely singing, fly
Scarce heard amid the guns below.
This inspirational poem was born of "fire and blood" on May 3, 1915, during the hottest phase of the Second Battle of Ypres. "In Flanders Fields," the only great poem McCrae wrote, was published anonymously in the December 8, 1915, issue of Punch. It was written at his Essex Farm dugout dressing station (Fig 4) beside the Yser Canal in the early morning after his close friend, Lieutenant Alexis Helmer, was annihilated by an artillery shell.
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Although John McCrae is chiefly remembered for his one poem, few realize that this remarkable man was a highly respected Professor of Medicine and teacher who achieved recognition as one of the leaders in Canadian medicine before the outbreak of the Great War [10].
John McCrae was born in Guelph, Ontario, Canada, on November 30, 1872, of devout Scottish Presbyterian parents, the second son of Lieutenant David and Janet McCrae. Thomas, his elder brother, became a distinguished physician and Professor of Medicine and also joined the Canadian Expeditionary Force at the onset of the war.
McCrae was educated in the local schools, and at an early age he learned spiritual values and love of country. At 12 he entered the Guelph Collegiate Institute or high school, a preparatory school for those planning to enter a profession. He joined the Highland Cadets at 14 and won a gold medal for the best drilled cadet in Ontario. Upon graduation, McCrae was the Institute's first scholarship winner to the University of Toronto.
From his father he developed a passion for the military; he became a gunner in "K" company of the Queen's Own Rifles for his father's Field Artillery Brigade while studying science at the University of Toronto. He remained active in the militia and rose to the rank of company lieutenant.
John shared his mother's love of literature and the arts, and as a high school student began writing verse and stories. As an undergraduate at the University of Toronto, McCrae had written 16 poems that were published in various magazines and newspapers. Sir Andrew Macphail published 29 of McCrae's poems posthumously in 1919, including the well-known "The Unconquered Dead," regarded as a prelude to "In Flanders Fields."
In 1888 McCrae entered the University of Toronto, but after 3 years dropped out because of recurrent asthmatic attacks from which he had suffered since a teenager. During this year off in 1892, he taught English and mathematics at the Ontario Agricultural College in Guelph. While there, he fell in love with an 18-year-old woman who died soon after they met. His subsequent writing resonated a preoccupation with death, which became a recurrent theme in his poetry. McCrae never married.
He resumed his studies at the University of Toronto in 1893 and graduated with a Bachelor of Arts degree the following year, earning a gold medal for academic achievement in physiology and pathology. McCrae then entered medical school and received his Bachelor of Medicine degree and a gold medal for academic excellence in 1898 at age 26. He was appointed resident house officer for a year at the Toronto General Hospital. In 1899 he interned at Johns Hopkins Hospital, an appointment accorded only to the best medical graduates of the University of Toronto. His brother, Thomas, was an assistant resident at this same hospital; both brothers became associates of the great Professor of Medicine, Dr William Osler, assisting him in writing and editing. Tom later married Osler's niece, Amy Gwyn.
Osler emphasized that a successful career in medicine required a thorough knowledge of pathology. Thus John McCrae applied for and was awarded a scholarship as a Governor's Fellow in Pathology at McGill University, working under the noted Professor John George Adami. Shortly after he arrived at McGill, the Boer War broke out. McCrae volunteered as a Lieutenant in the Canadian Field Artillery-not as a medical officer but as a combat officer-after he was permitted to postpone his fellowship for a year. Upon his return to Canada after the war, he rejoined Professor Adami for the next 4 years, studying pathology, conducting laboratory research, and performing autopsies at Montreal General Hospital. He published articles on various subjects including medical history, unusual case studies, anemia, and tropical medicine. In 1902 he was appointed Resident Pathologist at Montreal General Hospital, later Assistant Pathologist at Royal Victoria Hospital, and eventually Physician at the Royal Alexandra Hospital for Infectious Diseases.
McCrae, widely respected for his integrity, extensive knowledge, writing skills, and teaching ability, was appointed to the editorial board of the American Journal of Medical Sciences. In 1903 he became Special Professor to the University of Vermont Medical School, a position he held for a decade and where he was a popular lecturer.
McCrae traveled to London in 1904 where, after studying for several months, he passed the Licentiate examination for the Royal College of Physicians. The following year he started a successful part-time private practice in Montreal, and became well known as an excellent lecturer in pathology and medicine also at McGill University.
John McCrae was a tireless worker involved in teaching, lectures, clinics, autopsies, meetings, editing, and publishing papers. In addition, he became a member of the Montreal Shakespeare Club and the Pen and Pencil Club, where he met and became a close friend of the famous humorist and economist Stephen Leacock. McCrae also contributed several chapters to Modern Medicine, a ten-volume work edited by Professor Osler and his brother, Tom. In 1911 he assisted Professor Adami in writing a textbook entitled Principles of Pathology. The following year they published a student version: A Textbook of Pathology for Students of Medicine. McCrae was elected to the Society of American Physicians in 1913, an honor shared with few Canadians, which distinguished him as one of Canada's leading doctors.
In July 1914, McCrae was in Atlantic City, New Jersey, revising his book Principles of Pathology for Students when war clouds were gathering over Europe. McCrae planned a holiday to France to meet Professor Adami at LeHavre. War broke out while his ship was on the Atlantic, and McCrae was rerouted to Portland on the south coast of England. "All is excitement; the ships run without lights," McCrae wrote. "Surely the German Kaiser has his head in the noose at last; it will be a terrible war, and the finish of one or the other."
Germany swept across neutral Belgium on August 4, 1914, and Britain declared war on Germany the next day. McCrae traveled to London and volunteered for service in the British Army. He was turned down because of his age-nearly 42. He then cabled Lieutenant Colonel Edward Morrison, his friend from the Boer War and Director of Artillery, Permanent Force, in Ottowa. McCrae offered to serve as either a combatant or medical officer. However, he was appointed as Brigade Surgeon with the rank of Major in the First Brigade Canadian Field Artillery, second in command under Morrison. The unit sailed from Canada on October 3, 1914, arriving at Plymouth for additional training on Salisbury Plain. The Canadian troops then were transported to France in the winter of 1915 and were attached to General Sir Douglas Haig's First Army. McCrae refused to wear the Red Cross noncombatant arm band, and directed the artillery unit when not treating casualties.
On his arrival in Flanders on April 17, 1915, McCrae was promoted to Lieutenant Colonel in the Canadian Army Medical Corps. On April 22 the Germans launched a devastating attack in the Ypres Salient in an attempt to end the stalemate and capture the town. At 4 PM, during this Second Battle of Ypres, the Germans used deadly asphyxiating chlorine gas for the first time in warfare. Shortly after this gas attack the First Brigade Canadian Field Artillery was ordered to a position by the Yser Canal, where they held out under almost continuous heavy artillery bombardment for 17 days-"seventeen days of Hades," in McCrae's words. Many French Colonial troops were blinded, gasping for breath and asphyxiated, with pulmonary edema; others were terrorized and fled, leaving the Canadian left flank uncovered. The Canadians rallied with great courage under fire, took the offensive and inflicted a bloody defeat on the Germans. Unable to capture Ypres, the Germans then methodically leveled the city, including the historic Cloth Hall.
McCrae's Essex Farm dressing station consisted of a dugout in the Yser Canal embankment, just north of the town. McCrae's diary records that he treated a "never-ending stream which lasted day and night for seven days without cessation: in all some five thousand two hundred cases passed through our hands ...wounds everywhere. Legs, feet, hands missing; bleeding stumps controlled by rough field tourniquets; large portions of the abdominal walls shot away; faces horribly mutilated; bones shattered to pieces; holes that you could put your clenched fist into, filled with dirt, mud, bits of equipment and clothing, until it all became like a hideous nightmare, as if we were living in the seventh hell of the damned." On May 9, the First Brigade Canadian First Artillery was taken off line, relieving Major John McCrae and his troops. He was, however, a changed man, emotionally drained, visibly aged, lacking his usual buoyancy and outgoing personality. It is of interest that Sir William Osler's son, Lieutenant Revere Osler, who lost his life in the Ypres Salient sector in 1917, was triaged at this dressing station [11].
In recognition of meritorious service, McCrae was promoted to Officer in Charge of Medicine at a new Canadian military hospital staffed by McGill University faculty. This facility, located near Boulogne, France, was named No. 3 Canadian General Hospital. Alexander Fleming, who years later discovered penicillin, was in a nearby field bacteriologic laboratory studying the terrible infected war wounds, and helped to define a new disease entity: gas gangrene.
In October 1916 McCrae became ill with respiratory disease and pleurisy and was transferred to No. 14 British General Hospital for Officers at nearby Wimereux. When his condition improved, he was sent to the South of France for a brief convalescence.
McCrae's outstanding military record and total dedication to the war effort, remaining even after his tour of duty had ended, led to his appointment on January 24, 1918, as Consulting Physician to the First British Army, with the rank of Colonel. He was the first Canadian doctor so honored. When he learned of this appointment, McCrae was ill in bed with what he diagnosed as "pneumonia." He was transferred to the British General Hospital for Officers under the care of Sir Bertrand Dawson, who was King George's physician. Although he appeared to improve, McCrae was anxious and declared that he "knew it was the end." Cerebral meningitis was diagnosed 2 days later. He became progressively weaker and comatose and died at 1:30 AM on January 28, 1918, a courageous physician with a profound sense of right and wrong-a hero to his generation through his poem "In Flanders Fields."
Lieutenant Colonel John McCrae's funeral-with full military honors and the largest ever at the Boulogne Base-was held on January 30 at Wimereux Municipal Cemetery. Doctor Harvey Cushing of the Harvard University Unit, a friend of McCrae, eulogized, "Was there ever a man more loved and respected than he?"
The Strathcona Medical and Dental Building at McGill University contains a beautiful stained glass window dedicated to the memory of John McCrae: "Pathologist, Poet, Soldier, Physician, a man among men."
Near Flanders a voice from the grave speaks:
We are the Dead. Short days agoWe lived, felt dawn, saw sunset glow,
Loved, and were loved, and now we lie
In Flanders fields.
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Acknowledgments |
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