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Aeromedical
Evacuation
Management of Acute
and Stabilized Patients
William W. Hurd
William Beninati
Editors
Second Edition

123
Aeromedical Evacuation
William W. Hurd • William Beninati
Editors

Aeromedical Evacuation
Management of Acute
and Stabilized Patients

Second Edition
Editors
William W. Hurd, MD, MPH, FACOG, William Beninati, MD, FCCM
FACS Col, USAF, MC, CFS (ret.)
Col, USAF, MC, SFS (ret.) Senior Medical Director
Chief Medical Officer lntermountain Life Flight and Virtual
American Society for Reproductive Hospital
Medicine University of Utah School of Medicine
Professor Emeritus Salt Lake City, UT
Department of Obstetrics USA
and Gynecology
Duke University Medical Center Clinical Associate Professor (Affiliated)
Durham, NC Stanford University School of Medicine
USA Stanford, CA
USA

ISBN 978-3-030-15902-3 ISBN 978-3-030-15903-0 (eBook)

https://doi.org/10.1007/978-3-030-15903-0

© Springer Nature Switzerland AG 2019

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Foreword

Killed in action (KIA), died of wounds (DOW), and case fatality (CF) rates
among US service members are at their lowest points in the history of war-
fare. Directly attributable to this striking rise in survivability are numerous
factors, which include highly effective body armor, widespread use of Tactical
Combat Casualty Care at the point of injury (POI), rapid casualty evacuation/
tactical critical care evacuation from POI to higher levels of medical care,
forward resuscitative surgery, a standardized trauma network that is inte-
grated across all theaters of operation, and aeromedical evacuation (AE) bol-
stered by Critical Care Air Transport Teams (CCATT). Clearly, all of the
aforementioned capabilities have saved thousands of lives and mitigated
incalculable suffering. The en route care system (a series of clinical and
mobility processes bridged by a command and control system, along with a
network of organizations composed of highly trained, multidisciplinary per-
sonnel; machines, technology, and information systems) has been the key-
stone for the dramatic reduction in the footprint of medical personnel and
infrastructure within the theater of operations. As a result, logistics support is
freed up for other purposes while further advancing the quality of care for our
injured and/or ailing service members. Moreover, whether supporting combat
or humanitarian/disaster relief operations, the en route care system represents
a national capability essential to the security of the United States.
Undoubtedly, America’s national security is based on the appropriate
application of the instruments of national power (diplomacy, information,
military, and economic). However, without the patriotic, courageous, dedi-
cated, and self-sacrificing men and women serving in our nation’s armed
forces, the instruments of national power would be fatally weakened. It is,
therefore, critical for America’s political and military leaders to heed the
advice of Major (Dr.) Jonathan Letterman, Medical Director, Army of the
Potomac, whose innovations still form the backbone of the US military’s
standardized battlefield trauma system, as well as its en route care casualty
evacuation system: “It is the interest of the Government, aside from all the
motives of humanity, to bestow the greatest possible care upon its wounded
and sick, and to use every means to preserve the health of those who are well,
since the greater the labor given to the preservation of health, the greater will
be the number for duty, and the more attention bestowed upon the sick and
wounded, the more speedily will they perform the duties for which they were
employed.” In other words, regardless of the cost, it is incumbent upon the
US Government to provide all the resources required to optimize care for its

v
vi Foreword

armed service members, and it is incumbent upon the leadership of the

Military Health System to ensure all military medical personnel are resourced,
trained, experienced, and always ready to deliver increasingly sophisticated
healthcare. This must encompass the total spectrum of care required to sup-
port the nation’s defenders of freedom, whether it be at home garrison, the
battlefield, and all points in-between. It is to this end this essential textbook
lies. Its contents have been updated by a distinguished panel of experts in
disciplines who collectively and synergistically compose the US military’s
unrivaled en route care system.

Bart O. Iddins, MD, DVM, SM

Maj Gen, USAF, MC, CFS (ret.)
Medical Director, Oak Ridge National Laboratory
Oak Ridge, TN, USA
Preface

Aeromedical evacuation (AE), the long-distance air transportation of patients,

has advanced dramatically since the first edition of this book was published
almost two decades ago. At that time, forward-deployed medical units have
become lighter and more rapidly deployable, and thus have little patient-
holding capacity. This evolution has made AE an essential element of contin-
gency medical care throughout the world. The reach of AE is global, and it
spans contingencies from humanitarian operations and disaster relief to sup-
port for combat operations and the response to terrorism. The second edition
of this book is an update that summarizes much of what has been learned
about important issues that should be considered in planning and executing
long-distance AE.
We asked our expert authors to concentrate on two primary objectives as
they rewrote their chapters. The first objective is to describe the problems
and limitations of medical care in-flight. Ground-based medical teams man-
age patients before AE and determine the timing of when to request
AE. Their clinical and operational decisions can have a major impact on
how their patients will tolerate the stresses and limitations of the AE envi-
ronment. The goal is to increase non-flying clinicians’ appreciation of the
medical flight environment so that they can better select and prepare their
patients for AE.
The second objective is to examine the unique challenges that AE pres-
ents for patients with specific medical conditions. This applies to both
elective and urgent AE. It is especially important for urgent AE, since
recently stabilized patients have less physiologic reserve, and are often
more sensitive to the stresses of flight. To minimize patient risks during
flight, we have asked experts in their fields to provide criteria that patients
with specific conditions should fulfill prior to AE. These experts have also
outlined patient preparation and equipment required for safe air transpor-
tation and management of the most likely complications that can occur
during flight.
Years of AE experience transporting stabilized patients who are critically
ill or injured has greatly improved our understanding of the stresses of flight
and the risks to specific patients during long-distance AE. We hope that the

vii
viii Preface

updated information in this edition will help guide medical planners and
serve as a useful reference for the military and civilian clinicians who prepare
patients for AE, and especially the medical flight crews who take care of them
in the air.

William W. Hurd, MD, MPH, FACOG, FACS

Col, USAF, MC, SFS (ret.)
Durham, NC, USA

William Beninati, MD, FCCM

Col, USAF, MC, CFS (ret.)
Salt Lake City, UT, USA
Disclaimer

The views expressed herein are those of the authors and do not necessarily
reflect the official policies or positions of any agency of the US Government,
including the US Air Force, the US Army, the US Navy, the Department of
Defense, the Department of Veterans Affairs, and the Federal Aviation
Administration.

ix
Contents

Part I The Need

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
William W. Hurd and William Beninati
2 Aeromedical Evacuation: A Historical Perspective . . . . . . . . . . . 5
Kathleen M. Flarity, Tamara A. Averett-Brauer,
and Jennifer J. Hatzfeld
3 Military Casualty Evacuation: MEDEVAC . . . . . . . . . . . . . . . . . 21
Cord W. Cunningham, Donald E. Keen, Steven G. Schauer,
Chetan U. Kharod, and Robert A. De Lorenzo
4 Civilian Air Medical Transport . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
William Beninati, J. D. Polk, and William F. Fallon Jr.

Part II The Means

5 Aircraft Considerations for Aeromedical Evacuation . . . . . . . . . 61

John G. Jernigan
6 Preparation for Long-Distance Aeromedical Evacuation . . . . . . 77
Warren C. Dorlac, Phillip E. Mason, and Gina R. Dorlac
7 Aeromedical Patient Staging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Lisa Diane DeDecker and William W. Hurd
8 Military Aeromedical Evacuation Nursing . . . . . . . . . . . . . . . . . . 107
Elizabeth Bridges and Melissa A. Buzbee-Stiles
9 Critical Care Air Transport: Patient Flight Physiology
and Organizational Considerations. . . . . . . . . . . . . . . . . . . . . . . . 127
William Beninati and Thomas E. Grissom

Part III The Patients

10 Aeromedical Evacuation of Patients with Abdominal,

Genitourinary, and Soft Tissue Injuries . . . . . . . . . . . . . . . . . . . . 147
Christopher J. Pickard-Gabriel, Raymond Fang, and Jeremy
W. Cannon

xi
xii Contents

11 Orthopedic Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

Russell K. Stewart, Steven L. Oreck, Lucas Teske,
and Brian R. Waterman
12 Aeromedical Evacuation of the Neurosurgical Patient . . . . . . . . 175
Daniel J. Donovan, Matthew A. Borgman,
Rose M. Leary-Wojcik, and Mick J. Perez-Cruet
13 Otorhinolaryngology Head and Neck Surgery Patients . . . . . . . 199
Skyler W. Nielsen, David G. Schall, Joseph A. Brennan,
and John R. Bennett
14 Care of Ophthalmic Casualties . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Nathan Aschel Jordan, Robert A. Mazzoli, Bryan Propes,
and Jo Ann Egan
15 Peripheral Vascular Casualties . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Ryan E. Earnest, Anthony J. Hayes, and Amy T. Makley
16 Aeromedical Evacuation of Cardiothoracic Casualties . . . . . . . . 249
Michael J. Eppinger and Kenton E. Stephens Jr.
17 Burn Casualties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
David J. Barillo, Julie A. Rizzo, and Kristine P. Broger
18 Patients Requiring Mechanical Ventilation . . . . . . . . . . . . . . . . . 289
Dario Rodriquez Jr. and Richard D. Branson
19 Medical Casualties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
J. Christopher Farmer, Thomas J. McLaughlin,
and Robert A. Klocke
20 Aeromedical Evacuation of Patients with
Contagious Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
Brian T. Garibaldi, Nicholas G. Conger, Mark R. Withers,
Steven J. Hatfill, Jose J. Gutierrez-Nunez,
and George W. Christopher
21 Aeromedical Evacuation of Obstetric and
Gynecological Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
William W. Hurd, Jeffrey M. Rothenberg,
and Robert E. Rogers
22 Overview of Pediatric and Neonatal Transport . . . . . . . . . . . . . . 363
T. Jacob Lee, Angela M. Fagiana, Robert J. Wells,
Howard S. Heiman, William W. Hurd,
and Matthew A. Borgman
23 Aeromedical Evacuation of Psychiatric Casualties . . . . . . . . . . . 391
Alan L. Peterson, Dhiya V. Shah, Jose M. Lara-Ruiz,
and Elspeth Cameron Ritchie
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403
Contributors

Tamara A. Averett-Brauer, MN, BSN Col, USAF, NC. CFN, En Route

Care and Expeditionary Medicine, Human Performance Wing, Aeromedical
Research Department, USAF School of Aerospace Medicine, Wright
Patterson AFB, Dayton, OH, USA
David J. Barillo, MD, FACS, FCCM COL, MC, USA (ret.), Former,
Clinical Division/Director US Army Burn Center, Former, US Army Burn
Flight Team, U.S. Army Institute of Surgical Research, Joint Base San
Antonio-Fort Sam Houston, San Antonio, TX, USA
Disaster Response/Critical Care Consultants, LLC, Mount Pleasant, SC,
USA
William Beninati, MD, FCCM Col, USAF, MC, CFS (ret.), Senior Medical
Director, Intermountain Life Flight and Virtual Hospital, University of Utah
School of Medicine, Salt Lake City, UT, USA
Clinical Associate Professor (Affiliated), Stanford University School of
Medicine, Stanford, CA, USA
John R. Bennett, MD, FAAO-HNS, FAAFPRS Ear Nose & Throat Center
of Utah, Salt Lake City, UT, USA
Matthew A. Borgman, MD, FCCM, CHSE LTC, MC, USA, Pediatric
Critical Care Services, Brook Army Medical Center Simulation Center, Joint
Base San Antonio - Fort Sam Houston, San Antonio, TX, USA
Department of Pediatrics, F. Edward Hebert School of Medicine - Uniformed
Services University, Bethesda, MD, USA
Richard D. Branson, MS, RRT, FAARC, FCCM Department of Surgery,
Division of Trauma/Critical Care, University of Cincinnati, Cincinnati,
OH, USA
School of Aerospace Medicine, Wright Patterson Air Force Base, Dayton,
OH, USA
Joseph A. Brennan, MD, FACS Col, USAF, MC (ret.), Clinical Operations,
Department of Surgery, Uniformed Services University of the Health
Sciences, Annapolis, MD, USA
Elizabeth Bridges, PhD, RN, CCNS Col, USAF, NC (ret.), Biobehavioral
Nursing and Health Informatics, University of Washington School of Nursing,
University of Washington Medical Center, Seattle, WA, USA

xiii
xiv Contributors

Kristine P. Broger, DNP, RN, MHA, CCRN, NE-BC LTC, NC, USA, US
Army Burn Flight Team, Nursing, US Army Medical Department, Guthrie
MEDDAC, Fort Drum, NY, USA
Melissa A. Buzbee-Stiles, MSN, RN, CEN Maj, USAF, NC, En Route
Medical Care Division, Office of the Command Surgeon, Headquarters Air
Mobility Command, Scott Air Force Base, IL, USA
Jeremy W. Cannon, MD, MS, FACS Col, USAFR, MC, Department of
Surgery, Penn Presbyterian Medical Center, Perelman School of Medicine at
the University of Pennsylvania, Philadelphia, PA, USA
Uniformed Services University of the Health Sciences, Bethesda, MD, USA
George W. Christopher, MD Col, USAF, MC (ret.), Medical
Countermeasure Systems, Joint Program Executive Office for Chemical and
Biological Defense, Fort Belvoir, VA, USA
Nicholas G. Conger, MD Col, USAF, MC, Wright Patterson Air Force
Base, Dayton, OH, USA
Division of Infectious Disease, Department of Internal Medicine, Wright
State University School of Medicine, Dayton, OH, USA
Cord W. Cunningham, MD, MPH, FACEP, FAEMS LTC (P), MC, FS,
DMO, USA, Critical Care Flight Paramedic Program, Center for Prehospital
Medicine, Army Medical Department Center and School Health Readiness
Center of Excellence, Joint Trauma System Committee on En Route Combat
Casualty Care, DoD EMS & Disaster Medicine Fellowship SAUSHEC, Joint
Base San Antonio-Fort Sam Houston, San Antonio, TX, USA
Robert A. De Lorenzo, MD, MSM, MSCI, FACEP LTC, MC, FS, USA
(ret.), Faculty Development, Department of Emergency Medicine, University
of Texas Health Science Center at San Antonio, San Antonio, TX, USA
Lisa Diane DeDecker, MS, RN Lt Col, USAF, NC, CFN (ret.), En Route
Critical Care Program, Division of En Route Medical Care, Headquarters Air
Mobility Command, Command Surgeon’s Office, Scott Air Force Base, IL,
USA
Daniel J. Donovan, MD, MBA, MHCM COL, MC, USAR, 1252nd
Medical Detachment, Tripler Army Medical Center, Department of Surgery,
University of Hawaii John A. Burns School of Medicine, Honolulu, HI, USA
Gina R. Dorlac, MD Col, USAF, MC (ret.), Critical Care Medicine and
Pulmonary Disease, University of Colorado Health, Fort Collins, CO, USA
Warren C. Dorlac, MD, FACS Col, USAF, MC, FS (ret.), Trauma and
Acute Care Surgery, Department of Surgery, Medical Center of the Rockies
and the University of Colorado School of Medicine, University of Colorado
Health, Trauma Services, Loveland, CO, USA
Ryan E. Earnest, MD, FACS LtCol, USAF, MC, Surgical Critical Care,
Department of Trauma and General Surgery, University of Cincinnati Medical
Center, Cincinnati, OH, USA
Contributors xv

Jo Ann Egan, BSN, MS Department of Ophthalmology, Madigan Army

Medical Center, Tacoma, WA, USA
DoD-VA Vision Center of Excellence, Bethesda, MD, USA
Michael J. Eppinger, MD Col, USAF (ret.), Cardiothoracic Surgery,
Department of Surgery, South Texas Veterans Health Care System, San
Antonio, TX, USA
Angela M. Fagiana, MD, FAAP Maj, USAF, MC, Neonatal Transport,
Department of Neonatology, Brooke Army Medical Center, Fort Sam
Houston, TX, USA
Department of Pediatrics, F. Edward Hebert School of Medicine – Uniformed
Services University, Bethesda, MD, USA
William F. Fallon Jr, MD, MBA LTC, MC, USA (ret.), Trauma Surgery &
Surgical Critical Care, Summa Health System, Akron, OH, USA
Department of Surgery, Case West Reserve University School of Medicine,
Cleveland, OH, USA
Raymond Fang, MD, FACS Col, USAF, MC (ret.), Department of Surgery,
Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
J. Christopher Farmer, MD, FACP, FCCP, FCCM Col, USAF, MC, FS
(ret.), Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix,
AZ, USA
Kathleen M. Flarity, DNP, PhD, CEN, CFRN, FAEN Col, USAF, NC,
CFN, Air Mobility Command, Scott Air Force Base, IL, USA
Emergency Medicine, University of Colorado School of Medicine, UC
Health, Aurora, CO, USA
Brian T. Garibaldi, MD Department of Medicine and Physiology, Division
of Pulmonary and Critical Care Medicine, Johns Hopkins Biocontainment
Unit, Johns Hopkins University School of Medicine, Baltimore, MD, USA
Thomas E. Grissom, MD, MSIS, FCCM Col, USAF, MC (ret.), Department
of Anesthesiology, R Adams Cowley Shock Trauma Center, University of
Maryland School of Medicine, Catonsville, MD, USA
Jose J. Gutierrez-Nunez, MD Col, USAF, MC (ret.), University of Puerto
Rico School of Medicine, Department of Medicine, San Juan Veterans
Administration Medical Center, San Juan, PR, USA
Steven J. Hatfill, MD, MSc, MSc, M.Med Department of Clinical Research
and Leadership, Department of Microbiology, Immunology, and Tropical
Medicine, George Washington University Medical School, Washington,
DC, USA
Jennifer J. Hatzfeld, PhD, RN, APHN-BC Lt Col, USAF, NC, TriService
Nursing Research Program, Uniformed Services University of Health
Sciences, Bethesda, MD, USA
Anthony J. Hayes, BS, MD LT, MC, USN, Department of General Surgery,
Navy Medical Center Camp Lejeune, Camp Lejeune, NC, USA
xvi Contributors

Howard S. Heiman, MD, FAAP COL, MC, USA (ret.), Neonatal Transport,
Department of Pediatrics, Neonatal-Perinatal Division, Cohen Children’s
Medical Center of Greater New York, Northwell Health, New Hyde Park,
NY, USA
William W. Hurd, MD, MPH, FACOG, FACS Col, USAF, MC, SFS (ret.),
Chief Medical Officer, American Society for Reproductive Medicine,
Professor Emeritus Department of Obstetrics and Gynecology, Duke
University Medical Center, Durham, NC, USA
Formerly, CCATT physician and Commander, 445th ASTS, Wright-Patterson
Air Force Base, Dayton, OH, USA
Bart O. Iddins, MD, DVM, SM Maj Gen, USAF, MC, CFS (ret.), Formerly,
Command Surgeon, Air Mobility Command & Air Force Special Operations
Command, Director, Health Services Division, Oak Ridge National
Laboratory, Oak Ridge, TN, USA
T. Jacob Lee Jr, MD, FAAP Maj, USAF, MC, Pediatric Critical Care,
Critical Care Air Transport, Department of Pediatrics, Brooke Army Medical
Center, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX, USA
John G. Jernigan, MPH, MD Brig Gen, USAF, CFS (ret.), Formerly
Commander, Human Systems Center, Brooks Air Force Base, Texas, San
Antonio, TX, USA
Nathan A. Jordan, MD MAJ, MC, USA, Department of Surgery, Tripler
Army Medical Center, Uniformed Services University of the Health Sciences,
Honolulu, HI, USA
Donald E. Keen, MD, MPH, EMTP MAJ, MC, FS, USA, Army Critical
Care Flight Paramedic Program, Center for Pre-Hospital Medicine, U.S
Army Medical Department Center and School, Joint Base San Antonio-Fort
Sam Houston, San Antonio, TX, USA
Chetan U. Kharod, MD, MPH Col, USAF, MC, SFS (ret.), SAUSHEC
Military EMS & Disaster Medicine Fellowship, Emergency Medicine,
Uniformed Services University, Bethesda, MD, USA
Department of Emergency Medicine, San Antonio Military Medical Center,
Joint Base San Antonio-Fort Sam Houston, San Antonio, TX, USA
Robert A. Klocke, MD, FACP Department of Medicine, Jacobs School of
Medicine and Biomedical Education, State University of New York at
Buffalo, Buffalo, NY, USA
Jose M. Lara-Ruiz, MA Department of Psychiatry, University of Texas
Health Science Center, San Antonio, TX, USA
Rose M. Leary-Wojcik, DMD, MD Col, USAF, MC (ret.), Oral &
Maxillofacial Surgery, Good Samaritan Clinic, DeLand, FL, USA
Amy T. Makley, MD Department of Surgery, University of Cincinnati,
Cincinnati, OH, USA
Phillip E. Mason, MD, FACEP Lt Col, USAF, MC, Department of Surgery,
San Antonio Military Medical Center, Fort Sam Houston, TX, USA
Contributors xvii

Robert A. Mazzoli, MD, FACS COL, MC, USA (ret.), Department of

Ophthalmology, Ophthalmic Plastic, Reconstructive, and Orbital Surgery,
Madigan Army Medical Center, Tacoma, WA, USA
Uniformed Services University of the Health Sciences, Bethesda, MD, USA
Former Consultant to the US Army Surgeon General, DoD-VA Vision Center
of Excellence, Bethesda, MD, USA
Thomas J. McLaughlin, DO, FACEP Colonel, USAF, MC, SFS (ret.),
Department of Emergency Medicine, Texas A&M University College of
Medicine, Bryan, TX, USA
Department of Emergency Medicine, CHRISTUS Health/Texas A&M Spahn
Emergency Medicine Residency, Corpus Christi, TX, USA
Skyler W. Nielsen, BS, DO Capt, USAF USARMY MEDCOM BAMC,
Department of Otolaryngology, San Antonio Military Medical Center, Fort
Sam Houston, TX, USA
Steven L. Oreck, SB, MA, MD CAPT, MC, USN (FMF) (ret.), Department
of History, University of Wisconsin-Madison, Madison, WI, USA
Mick J. Perez-Cruet, MD, MS Department of Neurosurgery, Oakland
University William Beaumont School of Medicine, Royal Oak, MI, USA
Alan L. Peterson, PhD, ABPP Col, USAF (ret.), Department of Psychiatry,
Division of Behavioral Medicine, The Military Health Institute, University of
Texas Health Science Center, San Antonio, TX, USA
Christopher J. Pickard-Gabriel, MD Maj, USAF, MC, Anesthesia Critical
Care, Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA, USA
J. D. Polk, DO, MS, MMM, FACOEP, FAsMA LtCol, USAF, MC, CFS
(ret.), National Aeronautics and Space Administration, Washington, DC, USA
Department of Policy, George Mason University, Fairfax County, VA, USA
Edward Via College of Osteopathic Medicine, Blacksburg, VA, USA
Bryan Propes, MD CDR, MC, USN, Department of Ophthalmology, Naval
Medical Center San Diego, San Diego, CA, USA
Elspeth Cameron Ritchie, MD, MPH COL, MC, USA (ret.), Department
of Psychiatry, Washington Hospital Center, Washington, DC, USA
Julie A. Rizzo, MD, FACS MAJ, MC, USA, Burn Unit, United States Army
Institute of Surgical Research, Fort Sam Houston, TX, USA
Dario Rodriquez Jr, MSc, RRT, FAARC CMS, USAF (ret.), Research
Health Science, CSTARS, Cincinnati, OH, USA
Department of Aeromedical Research, En Route Care Research Division,
USAF School of Aerospace Medicine, University of Cincinnati, Cincinnati,
OH, USA
Robert E. Rogers, MD, FACOG COL, MC, USA (ret.), Department of
Obstetrics and Gynecology, Indiana University School of Medicine,
Indianapolis, IN, USA
xviii Contributors

Jeffrey M. Rothenberg, MD, FACOG Obstetrics-Gynecology, St. Vincent

Hospitals, Indianapolis, IN, USA
David G. Schall, MD, MPH, FACS Col, USAF, MC, CFS (ret.), Formerly
Otolaryngology Head & Neck Surgery Consultant to the USAF Surgeon
General, Regional Flight Surgery/Aerospace Neurology, Office of Aerospace
Medicine, Federal Aviation Administration, Des Plaines, IL, USA
Steven G. Schauer, DO, MS MAJ, MC, USA, US Army Institute of Surgical
Research, San Antonio Military Medical Center, Joint Base San Antonio-Fort
Sam Houston, San Antonio, TX, USA
Dhiya V. Shah, PsyD Department of Psychiatry and Primary Care Center,
Division of Behavioral Medicine, University of Texas Health Science Center,
San Antonio, TX, USA
Kenton E. Stephens Jr, MD Cardiothoracic Surgery, Denali Cardiac &
Thoracic Surgical Group, Anchorage, AK, USA
Russell K. Stewart, BA Wake Forest School of Medicine, Winston-Salem,
NC, USA
Lucas Teske, MD Department of Orthopedic Surgery, Wake Forest Baptist
Health, Winston Salem, NC, USA
Brian R. Waterman, MD Department of Orthopaedic Surgery, Wake Forest
Baptist Health, Winston Salem, NC, USA
Robert J. Wells, MD Col, USAF, MC, CFS (ret.), Formerly, Department of
Pediatrics, University Of Texas MD Anderson Cancer Center, Houston, TX,
USA
Formerly Commander, 445th ASTS, Wright-Patterson AFB, Dayton,
OH, USA
Mark R. Withers, MD COL, MC, USA (ret.), Office of Medical Support &
Oversight, U.S. Army Research Institute of Environmental Medicine, Natick,
MA, USA
Abbreviations

AFB Air Force Base

APHN-BC Advanced Public Health Nurse, Board Certified
Brig Gen Brigadier General
BS Bachelor of Science
BSN Bachelor of Science in Nursing
CAPT Captain (USN)
Capt Captain (USAF)
CEN Certified Emergency Nurse
CFN Chief Flight Nurse
CFRN Certified Flight Registered Nurse
CFS Chief Flight Surgeon
CHSE Certified Healthcare Simulation Educator
CNA Certified Nursing Administrator
CNS Clinical Nurse Specialist
COL Colonel (USA)
Col Colonel (USAF)
CPE Certified Physician Executive
CPT Captain (USA)
DC District of Columbia
DNP Doctor of Nursing Practice
DO Doctor of Osteopathic Medicine
FAAFPRS Fellow of the American Academy of Facial Plastic and
Reconstructive Surgery
FAAO-HNS Fellow of the American Academy of Otolaryngology-Head
and Neck Surgery
FAAP Fellow, American Academy of Pediatrics
FAARC Fellow, American Association for Respiratory Care
FACOEP Fellow, American College of Osteopathic Emergency
Physicians
FACOG Fellow, American College of Obstetricians and Gynecologists
FACP Fellow, American College of Physicians
FAsMA Fellow, Aerospace Medical Association
FACEP Fellow, American College of Emergency Physicians
FACS Fellow, American College of Surgeons
FACEM Fellow, Australasian College for Emergency Medicine
FAEN Fellow, Academy of Emergency Nursing
FCCP Fellow, American College of Chest Physicians

xix
xx Abbreviations

FCCM Fellow, American College of Critical Care Medicine

FS Flight Surgeon
LT Lieutenant (USN)
LTC Lieutenant Colonel (USA)
LtCol Lieutenant Colonel (USAF)
LTC(P) Lieutenant Colonel, Promotable (USA)
MAJ Major (USA)
Maj Major (USAF)
Maj Gen Major General (USAF)
MBA Master of Business Administration
MC Medical Corps
MD Doctor of Medicine
MHA Master of Health Administration
MMM Master of Medical Management
MPH Master of Public Health
MS Master of Science
MSCI Master of Science in Clinical Investigation
MSIS Master of Science in Information Systems
MSM Master of Science in Management
MSN Master of Science in Nursing
NASA National Aeronautics and Space Administration
NC Nurse Corps
PhD Doctor of Philosophy
RN Registered Nurse
ret. Retired
RRT Registered Respiratory Therapist
SFS Senior Flight Surgeon
USA United States Army
USAR United States Army Reserve
USAF United States Air Force
USAFR United States Air Force Reserve
USN United States Navy
USNR United States Navy Reserve
 Part I
The Need
 Introduction
William W. Hurd and William Beninati
Aeromedical evacuation (AE), the long-distance
air transportation of patients, has seen dramatic
advancements over the last two decades. As a
result, AE has become an essential linchpin of
contingency medical care throughout the world.
Transportation of casualties from the site of injury
to the highest levels of care has undergone two
key technological revolutions in the last 60 years.
During the Korean and Vietnam conflicts, battle-
field and tactical medical evacuation (MEDEVAC)
was greatly improved by the use of helicopters to
augment ground transportation. The ability to
transport seriously wounded soldiers quickly
from the injury site to field hospitals for definitive
surgical care dramatically reduced battlefield
mortality. More recently, during the wars in Iraq
W. W. Hurd ( )
Col, USAF, MC, SFS (ret.), Chief Medical Officer,
American Society for Reproductive Medicine,
Professor Emeritus Department of Obstetrics and
Gynecology, Duke University Medical Center,
Durham, NC, USA
Formerly, CCATT physician and Commander, 445th
ASTS, Wright-Patterson Air Force Base, Dayton,
OH, USA
e-mail: whurd@asrm.org
W. Beninati
Col, USAF, MC, CFS (ret.), Senior Medical Director,
Intermountain Life Flight and Virtual Hospital, University
of Utah School of Medicine, Salt Lake City, UT, USA
Clinical Associate Professor (Affiliated), Stanford
University School of Medicine, Stanford, CA, USA
© Springer Nature Switzerland AG 2019
W. W. Hurd, W. Beninati (eds.), Aeromedical Evacuation,
https://doi.org/10.1007/978-3-030-15903-0_1
1
and Afghanistan, the military medical system has
been transformed by the earlier use of AE for the
transport of both stable and stabilized patients as
soon as possible after definitive therapy. Years of
practical experience has dramatically improved
our ability to maximize in-flight care and mini-
mized the risk of adverse sequelae that can be
associated with transporting these patients.
The majority of military AE remains elective,
where air transportation is reserved for stable or
convalescing patients who will be only minimally
affected by the stresses of air transportation.
Highly trained flight nurses and medical techni-
cians monitor patients in-flight to minimize the
chance that they will experience difficulty during
AE. Elective AE continues to be performed using
a variety of military and civilian aircraft with an
assorted level of medical equipment and personnel
required to deal with the uncommon medical
emergencies that occur in-flight.
The last decade has seen the rapid development
of a robust Urgent AE system as a result of increased
training for AE flight crews and the total integration
of specially trained and equipped Critical Care Air
Transport Teams (CCATT). These highly trained
Operational Support teams are comprised of physi-
cians, critical care nurses, and cardiorespiratory
therapists and their specialized equipment and
remain on standby alert to transport stabilized
patients to higher echelons of care whenever the
need arises. This integrated system for transporting
patients requiring ongoing intensive care greatly
3
4 W. W. Hurd and W. Beninati
enhances the US Air Force (USAF) capability to
provide AE to stabilized critically ill or injured per-
sonnel anywhere in the world.
The original impetus for enhancing medical
care capability of AE was to minimize the in-
theater medical footprint, since quality postopera-
tive care and large patient-holding facilities are
difficult to maintain in a contingency environment.
This contemporary AE paradigm has resulted in
continued improvements in the survival of criti-
cally ill and severely injured patients throughout
the world—particularly during armed conflicts,
natural disasters, or other catastrophic events.
A great deal has been learned over the last
decade about the optimal preparation for AE of
patients with a broad spectrum of medical and
surgical conditions, both in terms of patient prep-
aration and AE crew preparation. However, not
all of this new information has been well docu-
mented, primarily because the clinicians who
have become experts in this type of Operational
Support medicine are not always in environments
conducive to such reporting.
The second edition of this book is an update
that summarizes much of what has been learned
over the last two decades about important issues
that should be considered prior to and during
long-distance AE. Since AE is a complex process
with many steps, we have two primary objec-
tives. The first is to describe the problems and
limitations of medical care in-flight. The goal is
to increase nonflying clinicians’ appreciation of
the medical flight environment when considering
AE for their patients.
Our second objective is to examine the unique
AE problems and risks for patients with specific
conditions when considering either Elective or
Urgent AE. This is especially important for
Urgent AE, since it is well appreciated that
recently treated patients are often more sensitive
to the stresses of flight and at higher risk for
decompensation. To minimize patient risks dur-
ing flight, we have asked experts in their fields to
provide criteria that patients with specific condi-
tions should fulfill prior to AE. These experts
have also outlined patient preparation and equip-
ment required for safe air transportation and the
most likely complications that can occur during
flight.
Years of AE experience transporting critically
ill patients has greatly improved our understand-
ing of the stresses of flight and the risks to spe-
cific patients during long-distance AE. We hope
that this updated information will serve as a use-
ful reference source for both the military and
civilian clinicians who prepare patients for AE
and the medical flight crews who take care of
them in the air.
 Aeromedical Evacuation:
A Historical Perspective
Kathleen M. Flarity, Tamara A. Averett-Brauer,
and Jennifer J. Hatzfeld
Introduction
The origin of aeromedical evacuation (AE), the
transport of the sick and wounded by aircraft, has
a proud heritage that spans more than 100 years.
The current AE system has been instrumental in
saving thousands of lives in peace, war, contingen-
cies, conflicts other than war, and during humani-
tarian missions. The resolute progress of AE,
which parallels the advances in human flight, has
been the result of humankind’s desire to avoid the
ultimate sacrifice of death while bravely defending
their country’s vital interests. Although early
development of AE progressed slowly, its many
champions steadfastly believed that air transport
of the wounded could significantly decrease the
K. M. Flarity ( )
Col, USAF, NC, CFN, Air Mobility Command,
Scott Air Force Base, IL, USA
Emergency Medicine, University of Colorado School
of Medicine, UC Health, Aurora, CO, USA
e-mail: Kathleen.flarity@uchealth.org
T. A. Averett-Brauer
Col, USAF, NC. CFN, En Route Care and
Expeditionary Medicine, Human Performance Wing,
Aeromedical Research Department, USAF School
of Aerospace Medicine, Wright Patterson AFB,
Dayton, OH, USA
J. J. Hatzfeld
Lt Col, USAF, NC, TriService Nursing Research
Program, Uniformed Services University of Health
Sciences, Bethesda, MD, USA
© Springer Nature Switzerland AG 2019
W. W. Hurd, W. Beninati (eds.), Aeromedical Evacuation,
https://doi.org/10.1007/978-3-030-15903-0_2
2
morbidity and mortality of those injured in battle.
The history of AE began in the early part of the
twentieth century as an important part of military
medicine. In the modern era, AE has risen to new
heights with the implementation of technological
advances in both flight and medicine [1–3].
Before World War I
The concept of moving the wounded by air began
almost simultaneously with the concept of fixed-
wing aircraft flight. Shortly after the Wright
brothers successfully flew their first airplane, two
US Army medical officers, Captain George H. R.
Gosman and Lieutenant A. L. Rhodes, designed
an airplane built to transport patients [1–3]. Using
their own money, they built and flew the world’s
first air ambulance at Fort Barrancas, FL, in 1910.
Unfortunately, on its first test flight, it only flew
500 yards at an altitude of 100 feet before crash-
ing. This flight, followed by Captain Gosman’s
unsuccessful attempt to obtain official backing
for the project, proved to be only the beginning of
many challenges for this new concept [2, 3].
World War I Era
World War I will not be remembered for the
extent that AE was used, but as a time when air
ambulance design made significant progress by
5
6 K. M. Flarity et al.
trial and error. A French medical officer, Eugene
Chassaing, first adapted French military planes
for use as air ambulances [1, 2]. Two patients
were inserted side-by-side into the fuselage
behind the pilot’s cockpit. Modified Dorand II
aircraft were used on the battlefield in April
1918 in what was the first actual AE of the
wounded in airplanes specifically equipped for
patient movement [1, 2].
The United States also used airplanes for
evacuating the injured from the battlefield in
World War I, but found it difficult to use planes
not suited for patient airlift [1]. Specifically, the
fuselages were too small to accommodate stretch-
ers and the open cockpit exposed patients to the
elements. The US Army Medical Corps used air-
planes primarily to transport flight surgeons to
the site of airplane accidents to assist in the
ground transportation of casualties [1–3].
By the end of the War, the US Army recog-
nized the emerging requirement to transport the
wounded by air. In 1918, Major Nelson E. Driver
and Captain William C. Ocker converted a Curtiss
JN-4 Jenny biplane into an airplane ambulance
by modifying the rear cockpit to accommodate a
standard Army stretcher (Fig. 2.1). This allowed
Fig. 2.1 The Curtiss
JN-4 Jenny was
converted to an air
ambulance by removing
the rear cockpit seat.
(USAF photo, 311th
Human Systems Wing
Archives, Brooks
AFB, TX)
the US Army to transport patients by airplane for
the first time [1, 2].
Between the World Wars
The success of the Curtis JN-4 Jenny air ambu-
lances during World War I paved the way for the
further development of AE [1]. In 1920, the De
Havilland DH-4 aircraft was modified to carry a
medical attendant in addition to two side-by-side
patients in the fuselage. Shortly thereafter, the
Cox-Klemmin aircraft became the first aircraft
built specifically as an air ambulance. This air-
plane carried two patients and a medical atten-
dant enclosed within the aircraft. In 1921, the
Curtis Eagle aircraft was built to transport four
patients on litters and six ambulatory patients.
Unfortunately, in its first year in service, a Curtis
Eagle crashed during an electrical storm, killing
seven people. Despite this apparent setback,
aeromedical transportation continued to prog-
ress. In 1922, the US Army converted the largest
single-engine airplane built at the time, the
Fokker F-IV, into an air ambulance designated as
the A-2. In the same year, a US Army physician,
2 Aeromedical Evacuation: A Historical Perspective
Colonel Albert E. Truby, enumerated the poten-
tial uses of the airplane ambulances [3]:
• Transportation of medical officers to the site
of aircraft crashes and evacuation of casualties
from the crash back to hospitals
• Transportation of patients from isolated sta-
tions to larger hospitals where they could
receive more definitive care
• In time of war, transportation of seriously
wounded from the front to rear hospitals.
• Transportation of medical supplies in
emergencies
Transportation of patients by air began to take
on operational importance as well. In 1922, in the
Riffian War in Morocco, the French Army trans-
ported more than 1200 patients by air with a fleet
of 6 airplanes [3]. In 1928, a Ford Trimotor was
converted to an air ambulance capable of carry-
ing six litter patients, a crew of two pilots, a flight
surgeon, and a medical technician [1]. Also in
1928, the US Marines in Nicaragua established
that aircraft used to transport supplies into the
jungle would then be used to evacuate sick and
wounded patients to the rear on the return flight.
This concept proved to be an essential part of
modern AE doctrine.
In the 1930s, a registered nurse and visionary,
Lauretta M. Schimmoler, believed that 1 day
there would be a need to evacuate the wounded
by air, and for 15 years was a proponent for
establishing the Aerial Nurse Corps of America.
However, not everyone supported this premise.
Mary Beard, RN, the Director of the Red Cross
Nursing Service in 1930, stated, “No one of our
nursing organizations, no leading school of nurs-
ing, nor any other professional group, has taken
up this subject seriously and definitely tried to
promote the organization of a group of nurses
who understand conditions surrounding patients
when they are traveling by air” [2, 3]. In 1940,
the Acting Superintendent of the Army Nurse
Corps stated, “The present mobilization plan
does not contemplate the extensive use of air-
plane ambulances. For this reason, it is believed
that a special corps of nurses with qualifications
for such assignment will not be required” [3].
7
The Surgeon General at the time, Major
General C. R. Reynolds, added, “If commercial
aviation companies require special nurses in any
way, which at present I can’t visualize, this is a
matter which has nothing to do with the Medical
Department of the Army” [3]. AE and flight nurs-
ing were yet to prove themselves in the quest to
save lives through air transport.
World War II
At the beginning of World War II, it was com-
monly believed that air evacuation of the sick and
wounded was dangerous, medically unsound, and
militarily impossible [3]. The Army Medical
Department did not believe that the airplane was a
substitute for field ambulances, even when it was
necessary to evacuate casualties over long dis-
tances. The Surgeon for the Army Air Force
Combat Command, Major I. B. March, was con-
cerned that field ambulances would not be suffi-
cient to cover the aerial paths of the Air Forces. In
response, the Surgeon of the Third Air Force,
Lieutenant Colonel Malcolm C. Grow, stated that
the “chief stumbling block in the way of air ambu-
lances has been the lack of interest on the part of
the Army Surgeon General. ...Until he accepts the
airplane as a vehicle for casualty transportation, I
doubt if very much can be done about it” [3].
The war soon demonstrated the necessity of
AE. Large numbers of casualties needed to be
transported back from distant theaters of war.
Because designated AE aircraft did not exist, the
Army Air Force made it their policy to use
transport planes for AE flights as their second-
ary mission (Fig. 2.2). Regular transport aircraft
were reconfigured for AE using removable litter
supports (Fig. 2.3) [3]. In this way, aircraft that
had transported troops and supplies to the the-
aters of operation could be utilized as AE air-
craft for the return trip. By January 1942, Army
Air Force C-47 aircraft had transported more
than 10,000 casualties back from Burma, New
Guinea, and Guadalcanal. In 1941, the first Air
Surgeon of the Army Air Force, Colonel David
N. Grant, advocated AE with airborne compe-
tent medical care as a way to increase the speed
8 K. M. Flarity et al.

Fig. 2.2 World War II

photo titled
“MEDICAL – Air
Evacuation” with
multiple aircraft and
vehicles used to
transport patients in
1944. (AFMS History
Office)

Fig. 2.3 A US Army

Air Force flight nurse
attends a wounded
soldier being evacuated
by air in 1944.
(Department of the
Army photo)

and caliber of casualty transportation and
pointed out that AE would be available when
other means of transportation were not [4]. The
first Medical Air Ambulance Squadron was
established in 1942 [1–3].
As AE evolved, it became clear that specially
trained personnel were needed to optimize casu-
alty care during air transport. Because there were
not enough physicians to put on every AE flight,
Grant proposed the establishment of a flight nurse
2 Aeromedical Evacuation: A Historical Perspective
corps [3]. Despite opposition from the Army
Surgeon General, the designation of “Flight
Nurse” was created for specially trained members
of the Army Nurse Corps assigned to the Army
Air Forces Evacuation Service. In February 1943,
the first class of flight nurses graduated from
Bowman Field, KY, after a 4-week course that
included aeromedical physiology, aircraft loading
procedures, and survival skills.
Soon regular AE routes were established and
hospitals were built along airstrips to care for the
wounded who needed to remain overnight along
the route [5]. In early 1943, AE aircraft began
transatlantic flights from Prestwick, Scotland, to
the United States. By the end of the same year,
the transpacific AE flights transported patients
back to the continental United States via Hawaii.
In 1944, a southern Atlantic route to the United
States was added, originating in North Africa
with stopovers in the Azores and Bermuda.
Aircraft used for AE during the war included the
C-54 Skymaster, C-46 Commando, C-47
Skytrain, C-64 Norseman, and C-87 Liberator
Express. Bombers and tankers were sometimes
used for tactical AE to move patients from for-
ward battle zones [2, 3].
The number of patients transported reflects
the importance of AE during World War II, with
the number increasing by 500% from 1943 to
1945 [2, 5]. At its peak, the Army Air Force evac-
uated the sick and wounded at a rate of almost
100,000 per month. In 1945, a 1-day AE record
was set at 4707 patients [5]. The risk of AE to the
patient had been a concern since the beginning of
the war. As the aeromedical crews gained experi-
ence, the risk of death during AE had dropped in
1943 to 6 of every 100,000 patients [1, 3]. By the
end of the war, the risk of death during AE was
only 1.5 of every 100,000 patients [3]. In fact, AE
was listed along with antibiotics and blood prod-
ucts as among the most important medical
advances in decreasing the mortality rate associ-
ated with warfare during World War II. In 1945,
General Dwight D. Eisenhower stated, “We evac-
uated almost everyone from our forward hospi-
tals by air, and it has unquestionably saved
hundreds of lives, thousands of lives” [1, 3].
9
Postwar Period and a New Service
The postwar drawdown changed the face of the
US military AE system. By 1946, the system con-
sisted of 12 aircraft at the School of Aviation
Medicine and one C-47 at each of 12 regional US
hospitals. In 1947, the US Air Force (USAF) was
established, and the Secretary of Defense, Louis
E. Johnson, established a policy directing that the
transportation of patients of the armed services
would be accomplished by aircraft when air
transportation was available, conditions were
suitable for air evacuation, and there was no med-
ical contradiction to air transport [2, 6]. In 1949,
the USAF was given the official role of providing
AE for the entire US military [5].
The Korean War
The unexpected start of the Korean War in 1950
caught the AE system as unprepared as the rest of
the US military. There was no AE system set up
in Korea, and there were few medical facilities
located near airstrips anywhere in the Far East.
Because of a lack of organizational infrastructure
and available AE aircraft, the Army was required
to develop a system of tactical AE in the Korean
theater. Due to a critical shortage of combat-
ready troops, the wounded were kept as far for-
ward as possible so that they could be returned to
combat as soon as they were physically able. In
the early months of the conflict, most patients
were evacuated by ship from Korea to Japan,
even though empty cargo planes were available
[1]. With the establishment of the Far East Air
Force, the logistics of establishing an operational
AE system was made a top priority [1]. Without
adequate dedicated AE aircraft, the concept of
retrograde aeromedical airlift again presented the
best solution. After offloading personnel and
cargo near the forward battle area in central
Korea, Air Force rescue aircraft (C-54/C-
46/C-47) were used to transport casualties fur-
ther south in Korea or to Japan. In the first
6 months of the war, more than 30,000 casualties
were evacuated by air. As the fighting became
10
more intense, more than 10,450 combat casualties
were airlifted between January 1 and 24, 1951 [1].
By fall 1952, the C-124 Globemaster became
the primary air cargo aircraft, almost completely
replacing the C-54. When configured for AE, the
much larger C-124 accommodated 127 litters or
200 ambulatory patients. It also had the advan-
tage of a shorter enplaning and deplaning time
and required a smaller medical aircrew than the
C-54. Unfortunately, because of its size, the
C-124 could not land in Pusan, South Korea to
evacuate patients from this area. Instead, the
smaller C-46 aircraft, which carried a maximum
load of 26 patients, was used for intratheater AE
in Korea and Japan [1]. By the conclusion of the
Korean War in 1955, the USAF AE system was
again capable of safely moving a large number of
casualties within the theater and back to the
United States (Fig. 2.4). This system was also
attributed to the decrease in the death rate of the
wounded during the Korean War, which was 50%
less than that seen during World War II [1, 6].
Pre-Vietnam War
In the years immediately after the Korean War,
the peacetime AE system continued to serve the
US Department of Defense by transporting mili-
Fig. 2.4 The Douglas
C-54 Skymaster was
used for aeromedical
evacuation during the
Korean War. (US Air
Force photo)
K. M. Flarity et al.
tary and civilian patients from the overseas the-
aters back to the United States [1]. A new aircraft,
the Convair C-131A Samaritan, became the first
airplane designed specifically for AE (Fig. 2.5).
This first fully pressurized twin-engine transport
was designed as a “flying hospital ward,” com-
plete with air conditioning and oxygen for
patients, and had the capability to carry bulky
medical equipment, such as the iron lung, chest
respirator, and incubator [7]. The Samaritan
accommodated 40 ambulatory or 27 litter patients
or a combination of both [2].
Vietnam War
In 1964, the United States entered the Vietnam con-
flict. Again, the peacetime AE system had to be
built up to meet the wartime needs of the US mili-
tary. Initially, C-118 and C-130 cargo aircraft were
used to evacuate patients within Vietnam and to
offshore islands. When the C-141 Starlifter jet-
powered cargo aircraft became available in 1965, it
was given the AE mission in addition to its primary
cargo mission. By 1967, the Pacific Air Forces
aeromedical evacuation system had 17 operating
locations throughout the Pacific. The C-118
became the workhorse for in-theater AE, allowing
the C-130 to concentrate on the cargo mission [1].
2 Aeromedical Evacuation: A Historical Perspective 11

Fig. 2.5 The Convair

C-131A Samaritan was
used by the US Military
Airlift Command
aeromedical evacuation
during the Vietnam War.
(AFMS History Office)

Fig. 2.6 Early biplane

to sophisticated jet:
C-9A Nightingale with
Curtiss JN-4 Jenny.
(USAF photo, 311th
Human Systems Wing
Archives, Brooks AFB,
TX)

In 1968, the C-9A Nightingale made its
debut as a state-of-the art medium-range, twin-
jet aircraft used almost exclusively for the AE
mission [1]. The Nightingale was a modified
version of the McDonnell Douglas Aircraft
Corporation’s DC-9 and could carry 40 ambula-
tory patients, 40 litter patients, or a combina-
tion of both (Fig. 2.6).
However, the character of the combat in
Vietnam made tactical AE especially important.
Small transport aircraft, such as the C-123, would
arrive at small airstrips carrying cargo. Within
Another random document with
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 CHAPTER XI
DOSTOIEVSKY’S ANNIVERSARY

St. Petersburg, February 24th.

They are celebrating the 25th anniversary of the death of

Dostoievski, and this fact has brought back to my mind, with great
vividness, a conversation I had with the officers of the battery at Jen-
tzen-tung last September, and which I have already noted in my
diary.
We were sitting in the ante-room of the small Chinese house which
formed our quarters. This ante-room, which had paper windows and
no doors, a floor of mud, and a table composed of boards laid upon
two small tressels, formed our dining-room. We had just finished
dinner, and were drinking tea out of pewter cups. Across the
courtyard from the part of the dwelling where the Chinese herded
together, we could hear the monotonous song of a Chinaman or a
Mongol singing over and over to himself the same strophe, which
rose by the intervals of a scale more subtle than ours and sank again
to die away in the vibrations of one prolonged note, to the
accompaniment of a single-stringed instrument.
The conversation had languished. Somebody was absorbed in a
patience, we were talking of books and novels in a vague, desultory
fashion, when suddenly Hliebnikov, a young Cossack officer, said:
“Who is the greatest writer in the world?” Vague answers were made
as to the comparative merits of Homer, Dante, Shakespeare, and
Molière, but Hliebnikov impatiently waived all this talk aside. Then
turning to me he said: “He knows; there is one writer greater than all
of them, and that is Dostoievski.”
“Dostoievski!” said the doctor. “Dostoievski’s work is like a clinical
laboratory or a dissecting-room. There is no sore spot in the human
soul into which he does not poke his dirty finger. His characters are
either mad or abnormal. His books are those of a madman, and can
only be appreciated by people who are half mad themselves.”
The young Cossack officer did not bother to discuss the question.
He went out into the night in disgust. We continued the argument for
a short time. “There is not a single character,” said the doctor, “in all
Dostoievski’s books who is normal.” The doctor was a cultivated
man, and seeing that we differed we agreed to differ, and we talked
of other things, but I was left wondering why Hliebnikov was so
convinced that Dostoievski was the greatest of all writers, and why he
knew I should agree with him. I have been thinking this over ever
since, and in a sense I do agree with Hliebnikov. I think that
Dostoievski is the greatest writer that has ever lived, if by a great
writer is meant a man whose work, message, or whatever you like to
call it, can do the greatest good, can afford the greatest consolation to
poor humanity. If we mean by the greatest writer the greatest artist,
the most powerful magician, who can bid us soar like Shelley or
Schubert into the seventh heaven of melody, or submerge us like
Wagner beneath heavy seas until we drown with pleasure, or touch
and set all the fibres of our associations and our æsthetic
appreciation vibrating with incommunicable rapture by the magic of
wonderful phrases like Virgil or Keats, or strike into our very heart
with a divine sword like Sappho, Catullus, Heine, or Burns, or ravish
us by the blend of pathos and nobility of purpose with faultless
diction like Leopardi, Gray, and Racine, or bid us understand and
feel the whole burden of mankind in a thin thread of notes like
Beethoven or in a few simple words like Goethe, or evoke for us the
whole pageant of life like Shakespeare to the sound of Renaissance
flutes, or all Heaven and Hell like Dante, by “thoughts that breathe
and words that burn”?
If we are thinking of all these miraculous achievements when we
say a great writer or the greatest writer, then we must not name
Dostoievski. Dostoievski is not of these; in his own province, that of
the novelist, he is as a mere workman, a mere craftsman, one of the
worst, inferior to any French or English ephemeral writer of the day
you like to mention; but, on the other hand, if we mean by a great
writer a man who has given to mankind an inestimable boon, a
priceless gift, a consolation, a help to life, which nothing can equal or
replace, then Dostoievski is a great writer, and perhaps the greatest
writer that has ever lived. I mean that if the Holy Scriptures were
destroyed and no trace were left of them in the world, the books
where mankind, bereft of its Divine and inestimable treasure, would
find the nearest approach to the supreme message of comfort would
be the books of Dostoievski.
Dostoievski is not an artist; his stories and his books are put
together and shaped anyhow. The surroundings and the
circumstances in which he places his characters are fantastic and
impossible to the verge of absurdity. The characters themselves are
also often impossible and fantastic to the verge of absurdity; yet they
are vivid in a way no other characters are vivid, and alive, not only so
that we perceive and recognise their outward appearance, but so that
we know the innermost corners of their souls. His characters, it is
said, are abnormal. One of his principal figures is a murderer who
kills an old woman from ambition to be like Napoleon, and put
himself above the law; another is a victim to epileptic fits. But the
fact should be borne in mind that absolutely normal people, like
absolutely happy nations, have no history; that since the whole of
humanity is suffering and groaning beneath the same burden of life,
the people who in literature are the most important to mankind are
not the most normal, but those who are made of the most complex
machinery and of the most receptive wax, and who are thus able to
receive and to record the deepest and most varied impressions. And
in the same way as Job and David are more important to humanity
than George I. or Louis-Philippe, so are Hamlet and Falstaff more
important than Tom Jones and Mr. Bultitude. And the reason of this
is not because Hamlet and Falstaff are abnormal—although
compared with Tom Jones they are abnormal—but because they are
human: more profoundly human, and more widely human. Hamlet
has been read, played, and understood by succeeding generations in
various countries and tongues, in innumerable different and
contradictory fashions; but in each country, at each period, and in
each tongue, he has been understood by his readers or his audience,
according to their lights, because in him they have seen a reflection
of themselves, because in themselves they have found an echo of
Hamlet. The fact that audiences, actors, readers, and commentators
have all interpreted Hamlet in utterly contradictory ways testifies not
merely to the profound humanity of the character but to its
multiplicity and manysidedness. Every human being recognises in
himself something of Hamlet and something of Falstaff; but every
human being does not necessarily recognise in himself something of
Tom Jones or Mr. Bultitude. At least what in these characters
resembles him is so like himself that he cannot notice the likeness; it
consists in the broad elementary facts of being a human being; but
when he hears Hamlet or Falstaff philosophising or making jokes on
the riddle of life he is suddenly made conscious that he has gone
through the same process himself in the same way.
So it is with Dostoievski. Dostoievski’s characters are mostly
abnormal, but it is in their very abnormality that we recognise their
profound and poignant humanity and a thousand human traits that
we ourselves share. And in showing us humanity at its acutest, at its
intensest pitch of suffering, at the soul’s lowest depth of degradation,
or highest summit of aspiration, he makes us feel his comprehension,
pity, and love for everything that is in us, so that we feel that there is
nothing which we could think or experience; no sensation, no hope,
no ambition, no despair, no disappointment, no regret, no greatness,
no meanness that he would not understand; no wound, no sore for
which he would not have just the very balm and medicine which we
need. Pity and love are the chief elements of the work of Dostoievski
—pity such as King Lear felt on the heath; and just as the terrible
circumstances in which King Lear raves and wanders make his pity
all the greater and the more poignant in its pathos, so do the
fantastic, nightmarish circumstances in which Dostoievski’s
characters live make their humanness more poignant, their love
more lovable, their pity more piteous.
A great writer should see “life steadily and see life whole.”
Dostoievski does not see the whole of life steadily, like Tolstoi, for
instance, but he sees the soul of man whole, and perhaps he sees
more deeply into it than any other writer has done. He shrinks from
nothing. He sees the “soul of goodness in things evil”: not exclusively
the evil, like Zola; nor does he evade the evil like many of our writers.
He sees and pities it. And this is why his work is great. He writes
about the saddest things that can happen; the most melancholy, the
most hopeless, the most terrible things in the world; but his books do
not leave us with a feeling of despair; on the contrary, his own “sweet
reasonableness,” the pity and love with which they are filled are like
balm. We are left with a belief in some great inscrutable goodness,
and his books act upon us as once his conversation did on a fellow
prisoner whom he met on the way to Siberia. The man was on the
verge of suicide; but after Dostoievski had talked to him for an hour
—we may be sure there was no sermonising in that talk—he felt able
to go on, to live even with perpetual penal servitude before him. To
some people, Dostoievski’s books act in just this way, and it is,
therefore, not odd that they think him the greatest of all writers.
 CHAPTER XII
THE POLITICAL PARTIES

Moscow, March 11th.

The political parties which are now crystallising themselves are the
result of the Liberal movement which began in the twenties, and
proceeded steadily until the beginning of the war in 1904, when the
Liberal leaders resolved, for patriotic reasons, to mark time and wait.
This cessation of hostilities did not last long, and the disasters caused
by the war produced so universal a feeling of discontent that the
liberation movement was automatically set in motion once more.
On the 19th of June, 1905, a deputation of the United Zemstva, at
the head of which was Prince S. N. Troubetzkoi, was received by the
Emperor. Prince Troubetzkoi, in a historic speech, expressed with
the utmost frankness and directness the imperative need of sweeping
reform and of the introduction of national representation. The
coalition of the Zemstva formed the first political Russian party, but
it was not until after the great strike, and the granting of the
Manifesto in October, that parties of different shades came into
existence and took definite shape. During the month which followed
the Manifesto the process of crystallisation of parties began, and is
still continuing, and they can now roughly be divided into three
categories—Right, Centre, and Left, the Right being the extreme
Conservatives, the Centre the Constitutional Monarchists, and the
Left consisting of two wings, the Constitutional Democrats on the
right and the Social Democrats and Social Revolutionaries on the
left. Of these the most important is the party of the Constitutional
Democrats, nicknamed the “Cadets.” “Cadets” means “K.D.,” the
word “Constitutional” being spelt with a “K” in Russian, and as the
letter “K” in the Russian alphabet has the same sound as it has in
French, the result is a word which sounds exactly like the French
word “Cadet.” Similarly, Social Revolutionaries are nicknamed
“S.R.’s” and the Social Democrats “S.D.’s.”
In order to understand the origin of the Constitutional Democrats
one must understand the part played by the Zemstva. In 1876 a
group of County Councillors, or Zemstvoists, under the leadership of
M. Petrunkevitch devoted themselves to the task of introducing
reforms in the economical condition of Russia. In 1894 their
representatives, headed by M. Rodichev, were summarily sent about
their business, after putting forward a few moderate demands. In
1902 these men formed with others a “League of Liberation.” M.
Schipov tried to unite these various “Zemstva” in a common
organisation, and some of the members of the Liberation League,
while co-operating with them, started a separate organisation called
the Zemstvo Constitutionalists. Among the members of this group
were names which are well known in Russia, such as Prince
Dolgoroukov, MM. Stachovitch, Kokoshkin, and Lvov. But these
“Zemstvoists” formed only a small group; what they needed, in order
to represent thinking Russia, was to be united with the professional
classes. In November, 1904, the various professions began to group
themselves together in political bodies. Various political unions were
formed, such as those of the engineers, doctors, lawyers, and
schoolmasters. Then Professor Milioukov, one of the leading
pioneers of the Liberal movement, whose name is well known in
Europe and America, united all professional unions into a great
“Union of Unions,” which represented the great mass of educated
Russia. Before the great strike in October, 1905, he created, together
with the best of his colleagues, a new political party, which united the
mass of professional opinion with the small group of Zemstvo
leaders. He had recognised the fact that the Zemstvoists were the
only men who had any political experience, and that they could do
nothing without enrolling the professional class. Therefore it is
owing to Professor Milioukov that the experienced Zemstvo leaders
in October had the whole rank and file of the middle class behind
them, and the Constitutional Democrats, as they are at present,
represent practically the whole “Intelligenzia,” or professional class,
of Russia. This party is the only one which is seriously and practically
organised. This being so, it is the most important of the political
parties.
 Those of the Right have not enough followers to give them
importance, and those of the Left have announced their intention of
boycotting the elections. These various parties are now preparing for
the elections.
We are experiencing now the suspense of an entr’acte before the
curtain rises once more on the next act of the revolutionary drama.
This will probably occur when the Duma meets in April. People of all
parties seem to be agreed as to one thing, that the present state of
things cannot last. There is at present a reaction against reaction.
After the disorders here in December many people were driven to the
Right; now the reactionary conduct of the Government has driven
them back to the Left.
So many people have been arrested lately that there is no longer
room for them in prison. An influential political leader said to me
yesterday that a proof of the incompetence of the police was that they
had not foreseen the armed rising in December, whereas every one
else had foreseen it. “And now,” he said, “they have been, so to speak,
let loose on the paths of repression; old papers and old cases,
sometimes of forty years ago, are raked up, and people are arrested
for no reason except that the old machine, which is broken and
thoroughly out of order, has been set working with renewed energy.”
The following conversation is related to me—if it is not true (and I
am convinced that it is not true) it is typical—as having taken place
between a Minister and his subordinate:—
The Subordinate: There are so many people in prison that there is
no possibility of getting in another man. The prisons are packed, yet
arrests are still being made. What are we to do? Where are these
people to be put?
The Minister: We must let some of the prisoners out.
The Subordinate: How many?
The Minister: Say five thousand.
The Subordinate: Why five thousand?
The Minister: A nice even number.
The Subordinate: But how? Which? How shall we choose them?
The Minister: Let out any five thousand. What does it matter to
them? Any five thousand will be as pleased as any other to be let out.
 It is interesting to note that last November the Minister of the
Interior was reported to have said that if he could be given a free
hand to arrest twenty thousand “intellectuals,” he would stop the
revolution. The twenty thousand have been arrested, but the
revolution has not been stopped.
So far, in spite of the many manifestoes, no guarantee of a
Constitution has been granted. The Emperor has, it is true, declared
that he will fulfil the promises made in his declaration of the 17th of
October, and it is true that if these promises were fulfilled, the result
would be Constitutional Government. But at the same time he
declared that his absolute power remained intact. At first sight this
appears to be a contradiction in terms; but, as the Power which
granted the Manifesto of October 17th was autocratic and unlimited,
and as it made no mention of the future limiting of itself, it is now, as
a matter of fact, not proceeding contrarily to any of its promises. The
liberties which were promised may only have been meant to be
temporary. They could be withdrawn at any moment, since the
Emperor’s autocratic power remained. The Manifesto might only
have been a sign of goodwill of the Emperor towards his people. It
promised certain things, but gave no guarantee as to the fulfilment of
these promises. The whole of Russia, it is true, understood it
otherwise. The whole of Russia understood when this Manifesto was
published that a Constitution had been promised, and that autocracy
was in future to be limited. What Count Witte understood by it, it is
difficult to say. Whether he foresaw or not that this Manifesto by its
vagueness would one day mean much less than it did then, or
whether he only realised this at the same time that he realised that
the Conservative element was much stronger than it was thought to
be, it is impossible to determine. The fact remains that the Emperor
has not withdrawn anything; he has merely not done what he never
said he would do, namely, voluntarily abdicate his autocratic power.
The Conservatives are opposed to any such proceeding; not in the
same way as the extreme reactionaries, some of whom relegated the
portrait of the Emperor to the scullery on the day of the Manifesto
from sheer Conservative principle, but because they say that if the
autocratic power is destroyed the peasant population will be
convulsed, and the danger will be immense. To this Liberals—all
liberal-minded men, not revolutionaries—reply that this supposed
danger is a delusion of the Conservatives, who have unconsciously
invented the fact to support their theory and have not based their
theory on the fact; that many peasants clearly understand and
recognise that there is to be a constitutional régime in Russia; that if
this danger does exist, the risk incurred by it must be taken; that in
any case it is the lesser of two evils, less dangerous than the
maintenance of the autocracy.
Count Witte’s opponents on the Liberal side say that the course of
events up to this moment has been deliberately brought about by
Count Witte; that he disbelieved and disbelieves in Constitutional
Government for Russia; that he provoked disorder in order to crush
the revolutionary element; that the Moderate parties played into his
hands by not meeting him with a united front; that, Duma or no
Duma, he intends everything to remain as before and the power to be
in his hands. What his supporters say I do not know, because I have
never seen one in the flesh, but I have seen many people who say that
what has happened so far has been brought about with infinite skill
and knowledge of the elements with which he had to deal. Further,
they add that Count Witte has no principles and no convictions; that
he has always accommodated himself to the situation of the moment,
and worked in harmony with the men of the moment, whatever they
were; that he has no belief in the force or the stability of any
movement in Russia; that he trusts the Russian character to simmer
down after it has violently fizzed; that he intends to outstay the
fizzing period; that he has a great advantage in the attitude of the
Moderate parties, who, although they do not trust him, play into his
hands by disagreeing on small points and not meeting him with clear
and definite opposition. They add, however, that he has
miscalculated and wrongly gauged the situation this time, because
the simmering down period will only be temporary and the fizzing
will be renewed again with increasing violence, until either the cork
flies into space or the bottle is burst. The cork is autocracy, the bottle
Russia, and the mineral water the revolution. The corkscrew was the
promise of a Constitution with which the cork was partially loosened,
only to be screwed down again by Count Witte’s powerful hand.
Among all the parties the most logical seem to be the Extreme
Conservatives and the Extreme Radicals. The Extreme Conservatives
have said all along that the talk of a Constitution was nonsensical,
and the Manifesto of October 17th a great betrayal; that the only
result of it has been disorder, riot, and bloodshed. They are firmly
based on a principle. The Extreme Radicals are equally firmly based
on a principle, namely, that the autocratic régime must be done away
with at all costs, and that until it is swept away and a Constitution
based on universal suffrage takes its place there is no hope for
Russia. Therefore the danger that the Moderate parties may
eventually be submerged and the two extremes be left face to face,
still exists. As a great quantity of the Radicals are in prison they are
for the time being less perceptible; but this era of repression cannot
last, and it has already created a reaction against itself. But then the
question arises, what will happen when it stops? What will happen
when the valve on which the police have been sitting is released?
The influential political leader with whom I dined last night, and
who is one of the leading members of the party of October 17th, said
that there was not a man in Russia who believed in Witte, that Witte
was a man who had no convictions. I asked why he himself and other
Zemstvo leaders had refused to take part in the administration
directly after the Manifesto had been issued, when posts in the
Cabinet were offered to them. He said their terms had been that the
Cabinet should be exclusively formed of Liberal leaders; but they did
not choose to serve in company with a man like Durnovo, with whom
he would refuse to shake hands.
He added that it would not have bettered their position in the
country with regard to the coming Duma, which he was convinced
would be Liberal. Talking of the Constitutional Democrats he said
they were really republicans but did not dare own it.
 CHAPTER XIII
IN THE COUNTRY

Sosnofka, Government of Tambov,

March 25th.

When one has seen a thing which had hitherto been vaguely familiar
suddenly illuminated by a flood of light, making it real, living, and
vivid, it is difficult to recall one’s old state of mind before the inrush
of the illuminating flood; and still more difficult to discuss that thing
with people who have not had the opportunity of illumination. The
experience is similar to that which a child feels when, after having
worshipped a certain writer of novels or tales, and wondered why he
was not acknowledged by the whole world to be the greatest author
that has ever been, he grows up, and by reading other books, sees the
old favourite in a new light, the light of fresh horizons opened by
great masterpieces; in this new light the old favourite seems to be a
sorry enough impostor, his golden glamour has faded to tinsel. The
grown-up child will now with difficulty try to discover what was the
cause and secret of his old infatuation, and every now and then he
will receive a shock on hearing some fellow grown-up person talk of
the former idol in the same terms as he would have talked of him
when a child, the reason being that this second person has never got
farther; has never reached the illuminating light of new horizons. So
it is with many things; and so it is in my case with Russia. I find it
extremely difficult to recall exactly what I thought Russia was before
I had been there; and I find Russia difficult to describe to those who
have never been there. There is so much when one has been there
that becomes so soon a matter of course that it no longer strikes one,
but which to the newcomer is probably striking.
 The first time I came to Russia I travelled straight to the small
village where I am now staying. What did I imagine Russia to be like?
All I can think of now is that there was a big blank in my mind. I had
read translations of Russian books, but they had left no definite
picture or landscape in my mind; I had read some books about
Russia and got from them very definite pictures of a fantastic
country, which proved to be curiously unlike Russia in every respect.
A country where feudal castles, Pevenseys and Hurstmonceuxs,
loomed in a kind of Rhine-land covered with snow, inhabited by
mute, inglorious Bismarcks, and Princesses who carried about
dynamite in their cigarette-cases and wore bombs in their tiaras;
Princesses who owed much of their being to Ouida, and some of it to
Sardou.
Then everything in these books was so gloriously managed;
everybody was so efficient, so powerful; the Bismarcks so
Machiavellian and so mighty; the Princesses so splendide mendaces.
The background was also gorgeous, barbaric, crowded with Tartars
and Circassians, blazing with scimitars, pennons, armour, and
sequins, like a scene in a Drury Lane pantomime; and every now and
then a fugitive household would gallop in the snow through a
primæval forest, throwing their children to the wolves, so as to
escape being devoured themselves. This, I think, was the impression
of Russia which I derived before I went there from reading French
and English fiction about Russia, from Jules Verne’s “Michel
Strogoff,” and from memories of many melodramas. Then came the
impressions received from reading Russian books, which were again
totally different from this melodramatic atmosphere.
From Russian novels I derived a clear idea of certain types of men
who drank tea out of a samovar and drove forty versts in a vehicle
called a Tarantass. I made the acquaintance of all kinds of people,
who were as real to me as living acquaintances; of Natascha and
Levine, and Pierre and Anna Karenine, and Basaroff, and Dolly, and
many others. But I never saw their setting clearly, I never realised
their background, and I used to see them move before a French or
German background. Then I saw the real thing, and it was utterly
and totally different from my imaginations and my expectations. But
now when I try to give the slightest sketch of what the country is
really like the old difficulty presents itself; the difficulty which arises
from talking of a thing of which one has a clear idea to people who
have a vague and probably false idea of the reality. The first thing one
can safely say is this: eliminate all notions of castles, Rhine country,
feudal keeps, and stone houses in general. Think of an endless plain,
a sheet of dazzling snow in winter, an ocean of golden corn in
summer, a tract of brown earth in autumn, and now in the earliest
days of spring an expanse of white melting snow, with great patches
of brown earth and sometimes green grass appearing at intervals,
and further patches of half-melted snow of a steely-grey colour,
sometimes blue as they catch the reflection of the dazzling sky in the
sunlight. In the distance on one side the plain stretches to infinity, on
the other you may see the delicate shapes of a brown, leafless wood,
the outlines soft in the haze. If I had to describe Russia in three
words I should say a plain, a windmill, and a church. The church is
made of wood, and is built in Byzantine style, with a small cupola
and a minaret. It is painted red and white, or white and pale-green.
Sometimes the cupola is gilt.
The plain is dotted with villages, and one village is very like
another. They consist generally of two rows of houses, forming what
does duty for a street, but the word street would be as misleading as
possible in this case. It would be more exact to say an exceedingly
broad expanse of earth: dusty in summer, and in spring and autumn
a swamp of deep soaking black mud. The houses, at irregular
intervals, sometimes huddled close together, sometimes with wide
gaps between them, succeed each other (the gaps probably caused by
the fact that the houses which were there have been burnt). They are
made of logs, thatched with straw; sometimes (but rarely) they are
made of bricks and roofed with iron. As a rule they look as if they had
been built by Robinson Crusoe. The road is strewn with straw and
rich in abundance of every kind of mess. Every now and then there is
a well of the primitive kind which we see on the banks of the Nile,
and which one imagines to be of the same pattern as those from
which the people in the Old Testament drew their water. The roads
are generally peopled with peasants driving at a leisurely walk in
winter in big wooden sledges and in summer in big wooden carts.
Often the cart is going on by itself with somebody in the extreme
distance every now and then grunting at the horse. A plain, a village,
a church, every now and then a wood of birch-trees, every now and
then a stream, a weir, and a broken-down lock. A great deal of dirt, a
great deal of moisture. An overwhelming feeling of space and
leisureliness, a sense that nothing you could say or do could possibly
hurry anybody or anything, or make the lazy, creaking wheels of life
go faster—that is, I think, the picture which arises first in my mind
when I think of the Russian country.
Then as to the people. With regard to these, there is one fact of
capital importance which must be borne in mind. The people if you
know the language and if you don’t are two separate things. The first
time I went to Russia I did not know a word of the language, and,
though certain facts were obvious with regard to the people, I found
it a vastly different thing when I could talk to them myself. So
different that I am persuaded that those who wish to study this
country and do not know the language are wasting their time, and
might with greater profit study the suburbs of London or the Isle of
Man. And here again a fresh difficulty arises. All the amusing things
one hears said in this country, all that is characteristic and smells of
the Russian land, all that is peculiarly Russian, is like everything
which is peculiarly anything, peculiarly English, Irish, Italian, or
Turkish, untranslatable, and loses all its savour and point in
translation. This is especially true with regard to the Russian
language, which is rich in peculiar phrases and locutions,
diminutives, and terms which range over a whole scale of delicate
shades of endearment and familiarity, such as “little pigeon,” “little
father,” &c., and these phrases translated into any other language
lose all their meaning. However, the main impression I received
when I first came to Russia, and the impression which I received
from the Russian soldiers with whom I mingled in Manchuria in the
war, the impression which is now the strongest with regard to them
is that of humaneness. Those who read in the newspapers of acts of
brutality and ferocity, of houses set on fire and pillaged, of huge
massacres of Jews, of ruthless executions and arbitrary
imprisonments, will rub their eyes perhaps and think that I must be
insane. It is true, nevertheless. A country which is in a state of
revolution is no more in its normal condition than a man when he is
intoxicated. If a man is soaked in alcohol and then murders his wife
and children and sets his house on fire, it does not necessarily prove
that he is not a humane member of society. He may be as gentle as a
dormouse and as timid as a hare by nature. His excitement and
demented behaviour are merely artificial. It seems to me now that
the whole of Russia at this moment is like an intoxicated man; a man
inebriated after starvation, and passing from fits of frenzy to sullen
stupor. The truth of this has been illustrated by things which have
lately occurred in the country. Peasants who have looted the spirit
stores and destroyed every house within reach have repented with
tears on the next day.
The peasants have an infinite capacity for pity and remorse, and
therefore the more violent their outbreaks of fury the more bitter is
their remorse. A peasant has been known to worry himself almost to
death, as if he had committed a terrible crime, because he had
smoked a cigarette before receiving the Blessed Sacrament. If they
can feel acute remorse for such things, much more acute will it be if
they set houses on fire or commit similar outrages. If you talk to a
peasant for two minutes you will notice that he has a fervent belief in
a great, good, and inscrutable Providence. He never accuses man of
the calamities to which flesh is heir. When the railway strike was at
its height, and we were held up at a small side station, the train
attendant repeated all day long that God had sent us a severe trial,
which He had. Yesterday I had a talk with a man who had returned
from the war; he had been a soldier and a surgeon’s assistant, and
had received the Cross of St. George for rescuing a wounded officer
under fire. I asked him if he had been wounded. He said, “No, my
clothes were not even touched; men all around me were wounded.
This was the ordinance of God. God had pity on the orphan’s tears. It
was all prearranged thus that I was to come home. So it was to be.” I
also had tea with a stonemason yesterday who said to me, “I and my
whole family have prayed for you in your absence because these are
times of trouble, and we did not know what bitter cup you might not
have to drink.” Then he gave me three new-laid eggs with which to
eat his very good health.

March 29th.

To-day I went out riding through the leafless woods and I saw one
of the most beautiful sights I have ever seen, a sight peculiarly
characteristic of Russian landscape. We passed a small river that up
to now has been frozen, but the thaw has come and with it the floods
of spring. The whole valley as seen from the higher slopes of the
woods was a sheet of shining water. Beyond it in the distance was a
line of dark-brown woods. The water was grey, with gleaming layers
in it reflecting the white clouds and the blue sky; and on it the bare
trees seemed to float and rise like delicate ghosts, casting clearly
defined brown reflections. The whole place had a look of magic and
enchantment about it, as if out of the elements of the winter, out of
the snow and the ice and the leafless boughs, the spring had devised
and evoked a silvery pageant to celebrate its resurrection.

Moscow, April 6th.

I have spent twelve instructive days in the country; instructive,

because I was able to obtain some first-hand glimpses into the state
of the country, into the actual frame of mind of the peasants; and the
peasants are the obscure and hidden factor which will ultimately
decide the fate of Russian political life. It is difficult to get at the
peasants; it is exceedingly difficult to get them to speak their mind.
You can do so by travelling with them in a third-class carriage,
because then they seem to regard one as a fleeting shadow of no
significance which will soon vanish into space. However, I saw
peasants; I heard them discuss the land question and the manner in
which they proposed to buy their landlords’ property. I also had
some interesting talks with a man who had lived among the peasants
for years. From him and from others I gathered that their attitude at
present was chiefly one of expectation. They are waiting to see how
things turn out. They were continually asking my chief informant
whether anything would come of the “levelling” (Ravnienie); this is,
it appears, what they call the revolutionary movement. It is
extremely significant that they look upon this as a process of
equalisation. The land question in Russia is hopelessly complicated;
it is about ten times as complicated as the land question in Ireland,
and of the same nature. I had glimpses of this complexity. The village
where I was staying was divided into four “societies”; each of these
societies was willing to purchase so much land, but when the matter
was definitely settled with regard to one society two representatives
of two-thirds of that society appeared and stated that they were “Old
Souls” (i.e., they had since the abolition of serfage a separate
arrangement), and wished to purchase the lands separately in order
to avoid its partition; upon which the representatives of the whole
society said that this was impossible, and that they were the
majority. The “Old Souls” retorted finally that a general meeting
should be held, and then it would be seen that the majority was in
favour of them. They were in a minority; and in spite of the
speciousness of their arguments it was difficult to see how the
majority, whose interests were contrary to those of the “Old Souls,”
could be persuaded to support them. This is only one instance out of
many.
Another element of complication is that the peasants who can earn
their living by working on the landlords’ land are naturally greatly
averse from anything like a complete sale of it, and are alarmed by
the possibility of such an idea. Also there is a class of peasants who
work in factories, and therefore are only interested in the land
inasmuch as profit can be derived from it while it belongs to the
landlord. Again, there are others who are without land, who need
land, and who are too poor to buy it. If all the land were given to
them as a present to-morrow the result in the long run would be
deplorable, because the quality of the land—once you eliminate the
landlord and his more advanced methods—would gradually
deteriorate and poverty would merely be spread over a larger area.
One fact is obvious: that many of the peasants have not got enough
land, and to them land is now being sold by a great number of
landlords. To settle the matter further, a radical scheme of agrarian
reform is necessary; many such schemes are being elaborated at this
moment, but those which have seen the light up to the present have
so far proved a source of universal disagreement. The fact which lies
at the root of the matter is of course that if the land question is to be
solved the peasant must be educated to adopt fresher methods of
agriculture than those which were employed in the Garden of Eden;
methods which were doubtless excellent until the fall of man
rendered the cultivation of the soil a matter of painful duty, instead
of pleasant recreation.
I asked my friend who had lived among the peasants and studied
them for years what they thought of things in general. He said that in
this village they had never been inclined to loot (looting can always
arise from the gathering together of six drunken men), that they are
perfectly conscious of what is happening (my friend is one of the
most impartial and fair-minded men alive); they are distrustful and
they say little; but they know. As we were talking of these things I
mentioned the fact that a statement I had made in print about the
peasants in this village and in Russia generally reading Milton’s
“Paradise Lost” had been received with interest in England and in
some quarters with incredulity. It was in this very village and from
the same friend, who had been a teacher there for more than twenty
years, that I first heard of this. It was afterwards confirmed by my
own experience.
“Who denies it?” he asked. “Russians or Englishmen?”
“Englishmen,” I answered. “But why?” he said. “I have only read it
myself once long ago, but I should have thought that it was obvious
that such a work would be likely to make a strong impression.”
I explained that at first sight it appeared to Englishmen incredible
that Russian peasants, who were known to be so backward in many
things, should have taken a fancy to a work which was considered as
a touchstone of rare literary taste in England. I alluded to the
difficulties of the classicism of the style—the scholarly quality of the
verse.
“But is it written in verse?” he asked. And when I explained to him
that “Paradise Lost” was as literary a work as the Æneid he perfectly
understood the incredulity of the English public. As a matter of fact,
it is not at all difficult to understand and even to explain why the
Russian peasant likes “Paradise Lost.” It is popular in exactly the
same way as Bunyan’s “Pilgrim’s Progress” has always been popular
in England. Was it not Dr. Johnson who said that Bunyan’s work was
great because, while it appealed to the most refined critical palate, it
was understood and enjoyed by the simplest of men, by babes and
sucklings? This remark applies to the case of “Paradise Lost” and the
Russian peasant. The fact therefore is not surprising, as would be, for
instance, the admiration of Tommy Atkins for a translation of
Lucretius. It is no more and no less surprising than the popularity of
Bunyan or of any epic story or fairy tale. When people laugh and say
that these tastes are the inventions of essayists they forget that the
epics of the world were the supply resulting from the demand caused
by the deeply-rooted desire of human nature for stories—long stories
of heroic deeds in verse; the further you go back the more plainly this
demand and supply is manifest. Therefore in Russia among the
peasants, a great many of whom cannot read, the desire for epics is
strong at this moment. And those who can read prefer an epic tale to
a modern novel.
Besides this, “Paradise Lost” appeals to the peasants because it is
not only epic, full of fantasy and episode, but also because it is
religious, and, like children, they prefer a story to be true. In
countries where few people read or write, memory flourishes, and in
Russian villages there are regular tellers of fairy tales (skashi) who
hand down from generation to generation fairy tales of incredible
length in prose and in verse.
But to return to my friend the schoolmaster. I asked him if
“Paradise Lost” was still popular in the village. “Yes,” he answered,
“they come and ask me for it every year. Unfortunately,” he added, “I
may not have it in the school library as it is not on the list of books
which are allowed by the censor. It is not forbidden; but it is not on
the official list of books for school use.” Then he said that after all his
experience the taste of the peasants in literature baffled him. “They
will not read modern stories,” he said. “When I ask them why they
like ‘Paradise Lost’ they point to their heart and say, ‘It is near to the
heart; it speaks; you read and a sweetness comes to you.’ Gogol they
do not like. On the other hand they ask for a strange book of
adventures, about a Count or a Baron.” “Baron Munchausen?” I
suggested. “No,” he said, “a Count.” “Not Monte Cristo?” I asked.
“Yes,” he said, “that is it. And what baffles me more than all is that
they like Dostoievski’s ‘Letters from a Dead House.’” (Dostoievski’s
record of his life in prison in Siberia.) Their taste does not to me
personally seem to be so baffling. As for Dostoievski’s book, I am
certain they recognise its great truth, and they feel the sweetness and
simplicity of the writer’s character, and this “speaks” to them also. As
for “Monte Cristo,” is not the beginning of it epical? It was a mistake,
he said, to suppose the peasants were unimaginative. Sometimes this
was manifested in a curious manner. There was a peasant who was
well known as a great drunkard. In one of his fits of drink he
imagined that he had sold his wife to the “Tzar of Turkey,” and that
at midnight her head must be cut off. As the hour drew near he wept
bitterly, said goodbye to his wife, and fetching an axe said with much
lamentation that this terrible deed had to be done because he had
promised her life to the “Tzar of Turkey.” The neighbours eventually
interfered and stopped the execution.