I wrote a Steam review of this game, and I wanted to include looking at the historical context of the game as part of the review. Does what it shows reflect much of the reality of the BEF medical services during the war? How close or wide of that is it? What about its context within the First World War and the Battles therein?

Sadly I went 5,545 characters over the limit in doing so. So I thought I'd put some thoughts down about what I think it gets right, what may have been simplified for gameplay, and what it gets wrong.

Before you read any further, it must always be borne in mind that many good people put in the supreme effort to save lives and give injured men a chance at returning to their lives during and after the First World War. Many paid the price for it, and War Hospital's efforts to bring attention to that are greatly admirable.

If this guide is to be worthy of anything, it should be dedicated to the memory of those people such people too, and to help improve - even a little - people's understanding the world in which they worked better.

The Title Card shows a Voluntary Aid Detachment Nurse, Flossie Hamer Lewis, who sadly died of exhaustion in early 1917.
Image © Imperial War Museum: IWM WWC H2-70-1 - https://www.iwm.org.uk/collections/item/object/205380723

It's worth looking first at how medical services were deployed by the British Army in the First World War so that we can consider what War Hospital portrays.


Battalion Level
The idea of organic (i.e. owned by the fighting unit they support) combat medics is very much a post-First World War development, although we see the seeds of such soldiers sown here.

Prior to the First World War, medical aid at the point of actual combat was relatively basic: Each Battalion had a band, and the Bandsmen's war role was to provide the duty of Stretcher-Bearer (SB). They would collect injured and bring them to the Regimental Medical Officer, usually a medical officer attached to a Battalion, who would provide treatment and / or send them down the line for further treatment.

First Aid was taught only at a rudimentary level, and the SB's role was one of fetching and carrying casualties primarily. In some 300 pages of text in the Field Service Pocket Book, 1914 (FSPB 1914), fewer than seven pages are devoted to First Aid. It teaches how to deal with basic bleeds, provide artificial respiration and how to improvise a splint. Whilst the FSPB 1914 is just a basic aide-memoire for an officer, and isn't a replacement for supplementary training or the be-all and end-all of its subjects, it's very telling from it that medical treatment was considered the world of the specialists. For instance, its Horse First Aid section actually teaches how to deal with more conditions (like foreskin rot, what a treat!) than the human First Aid section. Again, this isn't because the Army doesn't value or know how to treat various injuries, but that the expectation is that the casualty will be brought to the specialists.
Field Service Pocket Book, 1914 (Amended 1916) p.199

So, the injured man is taken to a Regimental Aid Post (RAP), located within the lines. He could take himself there, or be brought by comrades or (Regimental) Stretcher Bearers. Here he would be given basic treatment and the first meaningful effort to stabilise his injuries would take place here.
© Imperial War Museum - IWM Q 6942 - https://www.iwm.org.uk/collections/item/object/205238813
Regimental Aid Post at Chipilly, 10th August 1918, during the Battle of Amiens. This is also a battlefield salvage point.


Divisional Level
The next layer of Medical Treatment is the Field Ambulance (a unit, not a vehicle). These large units of some 234 personnel established Advanced Dressing Stations and Dressing Stations, the main difference being their relative size and location. These were where Primary Care was given to casualties. Depending on their wound, they could be treated directly there before being sent back to their unit, or treated to reach a condition where they could be transported to a Casualty Clearing Station (CCS) (which are in effect what War Hospital primarily portrays). Surgery was primarily carried out at CCS. Dressing Stations were within the combat area, but located toward the rear.

The below map gives some idea of the layout of medical services in the battle area. Showing medical points for the 1st Canadian Division in Ypres, all the RAPs are close to but behind the line, with the Dressing Stations being located further back. For reference, the distance as the bird flies between Ypres and Poelcappelle is about 6 miles.
© The Long, Long Trail - The Evacuation Chain for Wounded and Sick Soldiers
https://www.longlongtrail.co.uk/soldiers/a-soldiers-life-1914-1918/the-evacuation-chain-for-wounded-and-sick-soldiers/

Soldiers would be brought to Dressing Stations from RAPs by men of the Field Ambulance units which ran the Dressing Stations. From here, they would likely be taken by ambulance (horse-drawn or motorised) to a Casualty Clearing Station.


Corps / Army Level
Beyond that we have Casualty Clearing Stations. These were very large, complicated sites with multiple buildings and tents, with wards for surgery, recovery, walking cases and general medical and so on. These were the point where casualties could expect serious injuries to be treated, and not just stabilised. Thus at these sites, surgery would be performed, and it is here that efforts were made to 'fix' the conditions men were brought in with, rather than just preserving them and then sending them on. Men would from here either be returned to their unit if sufficiently convalesced or, more likely, sent on to recovery depots, or Base Hospitals in Britain or France. Once the critical phase of post-treatment recovery was completed, aftercare and long-term recovery was carried out elsewhere.
3 Casualty Clearing Station - 31st May 1917 - 3CCS War Diary. Crown Copyright. Shared at The Long, Long Trail - The Evacuation Chain for Wounded and Sick Soldiers
https://www.longlongtrail.co.uk/soldiers/a-soldiers-life-1914-1918/the-evacuation-chain-for-wounded-and-sick-soldiers/

Most CCSs were sited near railheads and the majority of their cases were taken away by train. Indeed in 1916, 734,000 men were evacuated from CCSs by rail. The BEF at this point was the largest it would ever be, with around 5,000,000 men under arms at this point, but nevertheless the rate of men passing through is staggering. CCSs were quite static due to their nature, and were not attached to specific Divisions, but sat higher up the chain.

What War Hospital portrays, primarily is this sort of unit, albeit heavily condensed down. A CCS could easily occupy the entire of the village footprint portrayed, and would be further back behind the lines. It is very notable that many large War Cemeteries came to being because CCSs were located in the vicinity and it is at these points that the majority of men who were injured but did not die on the battlefield would die. Many cases brought were beyond saving and the most that could be done to them was to try to minimise their suffering until they died.

This section is under development - check back!

The original text of the review for this section is below, but will be expanded:

Regarding the state of Medical Services in the War, it's fair to say that all the structures and different levels get collapsed into each other. The Regimental Aide Post, which would have been the point of medical support contained organically within a Battalion (staffed by a Regimental Medical Officer and his team), is here omitted, with the Advanced Dressing Station fulfilling this role. Dressing Stations existed in reality in a similar position to what is portrayed, but were staffed and controlled by a Division asset, a Field Ambulance. This was a body of some 234 troops, according to the 1916 version of the British Army Field Service Pocket Book. The treatment of casualties and decision on what to do with them happened here. Very lightly wounded might be treated and sent back, with the rest being stabilised here and then passed further back to a Casualty Clearing Station, which in reality was the whole of the area we cover in game, and not a set building.

The Casualty Clearing Station then treated cases and performed surgery. Looking at surviving plans of CCSs, these were absolutely enormous and could easily have occupied all of the footprint of the village we see in game. I'm not complaining that for gameplay's sake they made it much smaller - it works - but it is interesting to note. Depending on the severity of wound, the casualties may convalesce here or be sent down the line by ambulance train to a Field Hospital in France or Britain. I would have liked to have seen this option, between passing troops to HQ or medically discharging them. I do at least see why it was all condensed.

Other sections to be written will cover:

The Context of War Hospital: Operation Michael, the Battle of Amiens and the Coming of the Armistice

The Battlefield of War Hospital and the 36th Division

Some Commentary of Some of the Characters of War Hospital

Medical Developments in the First World War & War Hospital's Portrayal

Reconstructive Surgery

This list is not exhaustive.

The Intention of this guide was always to give a bit of insight into the world of medical services of the First World War, and to maybe spark a bit of understanding or interest. Much cleverer people have written at length and done great research on the subject and I highly recommend reading / listening to what they have to say.


Authoritative site on the history of the BEF in the First World War. Has an excellent section with informative period diagrams of medical structures.
https://www.longlongtrail.co.uk/soldiers/a-soldiers-life-1914-1918/the-evacuation-chain-for-wounded-and-sick-soldiers/

Invaluable for its sources of photographs and archives.
https://www.iwm.org.uk/

Western Front Association on YouTube
https://www.youtube.com/watch?v=SeOA5v1tWhA

The Western Front Association on YouTube
https://www.youtube.com/watch?v=azyPKEIA2JQ

London, 1920
https://archive.org/details/plasticsurgeryof00gilluoft/page/ii/mode/2up

London, 2013

Otago (New Zealand), 2013

Exeter, 2017

London, 1916

London, 2013

In short, for me the game is worth your time, but the price was a little too steep given the lack of polish and and the relative shortness of the game and lack of replayability. There were localisation issues, plenty of bugs, and a lot of minor QoL issues (no autosave, clunky UI, inability to allocate staff by clicking directly on the Surgical area) that I don't think are excusable even if this is an indy game.

Not sure why Steam has clocked only two hours when I've completed the game, but there you go.

Review
I did enjoy this game, but I was hoping for a game with the depth of Frostpunk or something and it's not. I don't think it's worth the price point. It has a lot of bugs and a lot of its Quality of Life elements are missing. The localisation for English is also fairly poor, which is surprising because the voice actors are fluent in English and even they say things which are grammatically incorrect which is surprisingly jarring.

Where it excels was in showing the overwhelming difficulty faced by medical services in the war. Having to manage exhausted staff, decide who to try and save and who to not treat was difficult and put you under pressure. This was similar to how Frostpunk made you take difficult decisions and prioritise certain elements over others. The medical side was great, the managing base supplies was less so.

The scouting elements didn't work, I can see - again - inspiration was taken by the way Scouts work for Frostpunk, but the implementation isn't so good, and the stories are jarring and make no sense. A lot of them centre around Germans being behind the lines, up to and including artillery units. How? At the end of 1917, the Germans withdrew to the Hindenburg Line. Britain had some 3 - 4 million men under arms, dominating the fighting area. They could locate something like 90% of all German batteries behind the German lines, so how these large formations are existing defies logic. The history for me doesn't work, but more than that the mechanics of it were unrewarding, clunky and got in the way of the main body of the game which should remain running a field hospital.

Now let's talk about the interesting bit - the historical world in which Field Hospital is based.

Someone commented in another review that they found some of the side-stories francophobic. I didn't find that particularly, but the game leaned into a lot of stereotypes which were completely tiresome and show a lack of understanding of history. The ANZAC Corps are sometimes portrayed as scruffy and unconventional - so of course the Scout character is an Australian. Never mind that Chapter 2 follows the battle of Amiens (whose pronunciation, coincidentally, was butchered by a voice actor - ouch!), which consisted of one of the greatest successes of the Australian Corps of the war, where they delivered a devastating but conventional combined-arms blow to the Germans that Erich Ludendorff described as "The Black Day of the German Army". This offensive precipitated the Hundred Days - a period of near continual offensive action and advances by the (predominantly British & Commonwealth) Western Allies against the Germans. Otherwise the game throws the same tiresome tropes: generals are stereotypically uncaring, corrupt and inept. It rains constantly, and there are never enough supplies. There is more nuance to this war than Blackadder, whilst still allowing for portraying the human catastrophe that it was.

The main thing for me that disappoints is the history or lack thereof. There is confusion about ranks and the roles they hold and how to address them. The Scottish Lieutenant Colonel of the 36th Division, who is key to the story is an anachronism and the worst offender for not understanding how the BEF worked, which is a bit of a shame given the theme of this game. Whilst he may hold Lt Col as his rank, he would be addressed primarily as "Sir" or "Colonel" to his face, with the Lieutenant part only really being referred to when written down formally. Having various characters respond to him with "Yes, Lieutenant Colonel" is irritating because it's a very basic thing that is got wrong. One would have hoped the IWM could have corrected it.

Many things like this suggest that if the Devs researched this thoroughly, they disregarded it entirely or didn't understand what they were reading. It would be unthinkable for a Lt Col to command a Division, or for units to be left holding the line indefinitely which is the case in this game. You would expect a Lt Col to command a Battalion, of roughly 1,000 men when at full strength, whilst a full-strength Division in 1918 (and good luck finding one of those) consisted of about 15,000 men. The British had a fairly rigidly implemented system of rotation for units whereby they only held the line for about a third of their time before rotating to "rest" and then to reserve, and these were periods of generally 4 days (but this varied according to circumstances). According to this game, this Scottish Lt Col was left to it for months, from the German offensives of March 1918 through to the Armistice in November 1918. There are so many points of command in the chain of command between a Bn commander and a Div commander that it's just not going to happen for a Lt Col to make the jump to take charge, but if due to some very localised catastrophe that they actually did, the Army would find someone from somewhere to take command fairly quickly. To put it into perspective, the actual British 36th (Ulster) Division had three commanders only over the duration of the war. Each was a Major General.

Is said Lt Colonel Scotsman anachronistic? Absolutely, it's clear they were inspired by characters like Cpt Price from Call of Duty (they've acknowledged being inspired by characters from Battlefield 1 too), but that horrendous turtleneck jumper he wears, and the facial hair, is totally off for the First World War. His and his "Division"'s role is weirdly ahistoric, and on the subject of ahistoric events, the chapters broadly follow the Spring 1918 offensive, the Battle of Amiens, and the last days of the war to the Armistice. However, these are merely titles as the reality of the story on the ground has absolutely no bearing to what might have been experienced.

The Germans shattered the already battered British Fifth Army at the start of the March 1918 Offensive and made a breakthrough, capturing some 1,200 square miles of France. The "Field Hospital" (which is really analogous to a BEF Casualty Clearing Station -- see below) would have either been overrun or at least forced to completely relocate. Instead it sits static, feeding men right back into the 36th Division. The battles are represented as small and I have to say disappointingly Men of War-esque FMVs, and give you casualty spikes, after which things go static. I understand it's a gameplay thing, but they might have chosen any number of other periods and fronts of the war to set the game in. The Second Chapter focuses on detonating mines, which borrows its history from various mining efforts throughout the war, but it really jarrs that we, a Casualty Clearing Station, are stumping up engineers. These efforts are usually Corps-level and would be the concern of the Corps and Divisional Commanders down. The idea that some random Bn Commander and Medical Officer would conspire to set up their own is again very ahistoric.

The Third chapter follows the days leading up to the Armistice, where you face relentless attacks from the Germans, including a breakthrough that places you in a salient, all the while HQ asks for more platoons of troops. By this point,the German Army was comprehensively defeated, it had been being forced into retreat near continually since Amiens began. The British Army was operating around 60 miles from its railheads (that is to say, the point supplies come in and are dropped off by train). The 1914 Field Service Pocket Book reckons that soldiers should be operating within a radius of about 7 miles. The Armistice was needed for the Western Allies as much as the Germans because they had completely run out of supply - the Australians were out of ammunition and (!) pants by November 11th. The idea that this weird little battalion-come-division was only barely holding its salient against incessant German attacks is just not a thing. This was a trap that the Netflix All Quiet On The Western Front made too.

Regarding the state of Medical Services in the War, it's fair to say that all the structures and different levels get collapsed into each other. The Regimental Aide Post, which would have been the point of medical support contained organically within a Battalion (staffed by a Regimental Medical Officer and his team), is here omitted, with the Advanced Dressing Station fulfilling this role. Dressing Stations existed in reality in a similar position to what is portrayed, but were staffed and controlled by a Division asset, a Field Ambulance. This was a body of some 234 troops, according to the 1916 version of the British Army Field Service Pocket Book. The treatment of casualties and decision on what to do with them happened here. Very lightly wounded might be treated and sent back, with the rest being stabilised here and then passed further back to a Casualty Clearing Station, which in reality was the whole of the area we cover in game, and not a set building.

The Casualty Clearing Station then treated cases and performed surgery. Looking at surviving plans of CCSs, these were absolutely enormous and could easily have occupied all of the footprint of the village we see in game. I'm not complaining that for gameplay's sake they made it much smaller - it works - but it is interesting to note. Depending on the severity of wound, the casualties may convalesce here or be sent down the line by ambulance train to a Field Hospital in France or Britain. I would have liked to have seen this option, between passing troops to HQ or medically discharging them. I do at least see why it was all condensed.

My other issue is the approach to the medical history, it feels like a missed opportunity to have educated people a bit better. The First World War really brought into reality the idea of stabilising first aide. At the start of the war, Stretcher Bearers were little more than that - they brought casualties to treatment. Battlefield First Aid was very rudimentary, with soldiers being issued a First Field Dressing (essentially a trauma bandage). The Field Service Pocket Book contains some very basic first aide advice, but essentially the way to treat casualties was to send them down the line so that a medically-trained person could assess and treat them. By necessity, stretcher bearers essentially became proto-paramedics. Emily Mayhew, in a lecture delivered to the Western Front Association, made the point that the Thomas Splint is awarded the distinction of greatly reducing death from serious thigh injuries, but it's more that the stretcher-bearers became able to provide the necessary stabilisation to get the casualties to surgery without dying. In game, this great advancement - a research option - is paraphrased as providing + 10% time before a casualty dies. Between the two of them, the Thomas Splint and upskilled SBs reduced deaths from femur fractures down from an 80% mortality rate to below 20%.

There is also absolutely no consideration to reconstructive surgery. The whole gamut of modern reconstructive (plastic) surgery owes its genesis to the pioneering work of doctors like Harold Gillies during the First World War. It's not entirely appropriate for the level of hospital portrayed in game here - casualties would be saved from death, allowed to heal, and then would come to the ministration of Gillies and his teams. But the lack of acknowledgement is disappointing to say the least.

This could have been such an amazing teaching tool which still remained a challenging and exciting game. Ultimately it barely scratches the surface of the history it is trying to tell and whilst it does a good job of showing the incredible work of army medical services, it doesn't push understanding as well as it could. Such a shame.