Medical War Pt. 4



Hello everyone and welcome to History of the Great War Premium episode number 29. This is our fourth and last episode in our series about the Medical war. In this episode we will be discussing the logistics of what happened after a soldier was wounded on the battlefield. It would be a long journey, both in terms of geographical distance and time between the battlefields and the permanent base hospitals were the most severely injured would recover. All armies created a system of checkpoints along the way where the soldiers would get the care that they needed, and then be prepared for transport further to the rear if that is what they needed. The exact duties and structure of these checkpoints would differ from army to army, and would change over time, as the requirements and needs of the armies also changes and evolved.

Just like with every other process during the war the armies of Europe all had slightly different ways of evacuating and caring for the wounded along the way. However, the German, British, and French medical units and facilities were generally organized in a reasonably similar way. When the Americans arrived they brought with them their own organizational structure with medical units broken into three distinct groups. Those in the Zone of activity which incorporated field hospitals and ambulances, those in the Evacuation zone which incorporated base hospitals in Europe, then finally the distribution zone which were hospitals back in the United States. During normal operations, however the specific army had their evacuation situation setup, it worked pretty well. A soldier would be injured, evacuated from the battlefield, and then they would slowly move further and further from the front depending on their treatment needs. The problem, as all problems did, came during offensives, and the biggest problem was simply one of volume. Doctors would work day and night but there would always be a constant deluge of new soldiers in need of care. Many of the horror stories of medical care during the war came from these moments, when there were simply too many wounded soldiers for each to receive the level of care that they probably needed. All along the way all that doctors and nurses could do was work as hard as they could and help as many as possible.

The entire process did not start with doctors and nurses though, and instead began with stretcher bearers. It was on the battlefield that the bearers were responsible for getting the wounded men off the battlefield and transporting them to somebody who could help. In theory you only need two men to carry a stretcher, but there would be many situations where they would not be enough. The wounded had to be evacuated from a battlefield, and this environment was far from a soccer pitch, it was often destroyed by artillery fire, making the ground irregular and difficult, anything but an easy carry. Here is Sergeant W.J. Collins of the Royal Army Medical Corps to explain “A stretcher squad consists of four men and you lift the stretcher up on on to your shoulder, and each corner had a man. Now that’s the only way you can carry a man properly. But, my God it was hard work, really hard. When conditions got really appalling it required 12 men to a stretcher, but they couldn’t get on the stretcher all at the same time.” There are many accounts of it taking 8 men, or even more, to move stretchers in the mud of Flanders, especially after everything got weighed down with mud. When the war first started the British continued the old tradition of using members of the regimental band as stretcher bearers, but this would not be a sufficient source of volunteers and soon there would be 16 men assigned as stretcher bearers to every regimental medical unit, during battles this would often not be close to enough.

The bearers would transport the wounded to the Regimental aid post, which would be under the command of the Regimental medical officers. His job was to create an aid post close to the front that provided at least some shelter for the wounded. Early in the war this could mean a simple dugout, or even just a tent behind the lines, but the facilities would be expanded as the war continued. By 1917 many aid posts were in dugouts big enough for multiple men to walk side by side, with passages on the sides where wounded could be laid down and tended to. While they grew in size, regimental aid posts were still far from luxurious, often either cold or hot depending on the season with poor lighting and poor ventilation. Dutch Doctor J.A. Verdoorn would describe the ordeal of the Regimental Medical Officers like this “In this environment of death and suffering, of blood and sweat, the front-line medical officer in charge, physically and mentally exhausted after working day and night, had to ensure the reliable functioning of this part of the chain of medical aid and at the same time more or less decide the fate of each of the countless wounded who passe through the aid post.” When a casualty arrived the Medical Officer had two jobs, stabilize and prepare for transport. This meant examining the wound, carrying out any emergency procedures that were necessary to ensure survival, like say amputation, and then trying to make sure that the wounded did not go into shock. In the best case scenario the wounded man would be quickly prepared to transport and sent down the line, but sometimes this could not happen in a very timely manner.

If you remember from previous episodes it was the Regimental medical officers that were targeted as a positions where perhaps an actual doctor was not required. It was believed by many that instead of a fully qualified and trained doctor somebody else could just be quickly trained to do most of what the RMO was called upon to do. This idea was considered but then rejected by the army because it was felt that the RMO played a critical role in diagnosing illnesses and reacting to unforeseen injuries. It was also important for a medical professional to be close to the front, and to the men in the front lines, for morale reasons.

Unlike many other medical positions in the armies, the RMOs were in real danger due to their proximity to combat. By 1917 the casualty rate for British RMOs was around 40 per 1,000 every month. With the supply of doctors being such an issue there were some very stern discussions with RMOs about making sure that they were not risking their lives needlessly. Many of these medical officers were young doctors, and they were just as patriotic as the men who had volunteered into the infantry. Because of this there were time when, in their enthusiasm, they were a bit reckless. There was also a tendency of the doctors to want to prove that they were just as brave as those around them that were going into combat. This resulted in some very strongly worded messages being sent to the RMOs that they should not take unnecessary risks. They would then be ‘severely warned’ in 1917 not to risk their health. They were then also reminded that at times there were advantages to leaving the safety of the aid post. Visiting the front lines was good for troop morale and informative for the doctors but it was also important that the doctors not try to be heroes which could result in injury. Another factor that played into these actions was how boring the work of an RMO could be for the majority of their line at the front. Sure, there were bouts of excitement and action during attacks, but for the vast majority of the time they were just treating the same small problems day after day, week after week, and month after month.

While the Regimental Aid Posts were good at stabilizing the wounded, for the more severe wounds it was critical to get them out of the trenches and to more permanent forms of medical care. For the British this was a function performed by the Field Ambulances. The idea, at least before the war, was that each infantry division would have three Field Ambulance units and their entire goal was to move men from the Regimental Aid Posts to the hospitals, while also treating them along the way. In Doctors in the Great War Ian R. Whitehead would have this to say about how each Field Ambulance was organized. “Each FA usually served around three or four battalions at once; and in order to fulfil its duties properly, it was divisible into three sections (A, B and C) capable of independent action. These sections were of similar composition, except that Section A (the headquarters section) had four motor ambulance cars (or horsedrawn wagons), whilst B and C had only three. Each of these sections, A, B, and C, was, in turn, subdivided into a stretcher-bearer section (for collecting the wounded) and a tent section (for treatment of the wounded).” While this was the general idea before the war, it very rapidly became clear that changes would have to be made.

There were two primary problems with the Field Ambulance units. The first was simple the number of available ambulances. During the early British campaigns it became very clear that there were simple not enough ambulances, and that horse drawn ambulances were just too slow. When this information reached the homefront it caused a large fundraising campaign to buy motor ambulances for the medical services. While this helped there were still just too many wounded for all of the Ambulances to mve. This meant that most of the surgical work in 1914 would fall to the Medical Officers in the Field Ambulances because there was simply no place that the ambulances could move them to. This was not ideal, especially since much of the surgical work therefore happened near the fighting. But this was more of a problem with the number and availability of where the Ambulances were trying to move wounded men to, the Casualty Clearning Stations. It should be noted that for most of the war the Field Ambulances seemed somewhat unimportant, with static lines the transportation routes between the front and the CCSs were quite small, but when mobile warfare visited the western front, both in 1914 and 1918 they served their purpose well as more stationary medical facilities struggled to adapt to constant movement.

As I mentioned the next step in the chain was the Casualty Clearing Station, or Clearing Hospital, or CCS which is how I will refer to them. These facilities had 3 functions, the first being to simply receive wounded troops from the Field Ambulances. Once they were received they would, much like the Aid Posts, be evaluated and any life threatening problems would be dealt with. The second duty of the CCS was to prepare as many casualties as possible for transport to base hospitals, which would clear beds and space for further casualties to be received. The final purpose was to retain soldiers with any hope of returning to the line quickly. The exact definition of “quickly” depended on the situation. In quieter times soldiers could stay in the CCS longer, while in more active moments there may be no spare beds at all. With these three duties the CCSs were mostly designed as simple sorting centers, to make sure the soldiers stayed alive long enough to be moved on. Since the British were planning on a war of movement, these CCSs would also have to move along with the troops which had some influence in dictating their capabilities. However, this changed just like everything else when trenches came into play and the front settled down. Eventually the CCSs would be at the end of railheads and basically stationary hospitals that never moved, that was not their initial purpose.

Instead CCSs would eventually become the primary point of care for most British soldiers, so it is important to dig into how they were organized. In general they were setup to be able to handle large numbers of wounded troops, and they were designed for easy and quick expansion when an attack was planned. There would first be a general admissions tent, where each patient would move through to be examined and sorted. There would then be a tent for handling men who could walk themselves and who were lightly wounded. Then another tent would be setup for patients who had to lie down, but did not require surgery. Finally there would be a series of tents setup for those who did require surgery. There would be a tent for pre-operation, a surgery tent, and then a resusciation tent for after. Then there was another tent for casualties who were stating at the CCS but would recover soon and then a final tent for casualties who would soon be evacuated. The exact number of these tents, and how many of each fell into each category, based on what was expected. While these facilities started as tents there would often be more permanent buildings on many areas of the front, with tents used for expansions as necessary. Another practice that started later in the war, due almost entirely to how long and large battles were, was the introduction of special surgical teams. These teams, of which there would be several, would move in before the attack and prepare for the influx of new casualties. The CCSs would also be setup in such a way where there would be a pair of them working together. First one would take all of the new wounded soldiers, processing them, preparing them for surgery, or sending them on. Then when it filled up the other would begin taking all new patients while the first worked its way through its inevitable surgery, treatment, and transportation backlog. This generally simplified the transportation process since the ambulances and trains only had to go to one CCS for a period of time instead of two all the time. These types of arrangements were required because men could arrive at the CCSs hundreds at a time.

Before any attack there would be very detailed plans for how many and where the CCSs would be located. Before the Battle of the Somme for example there were 14 CCSs arragned behind the front, and they were closed for new cases for three days before the attack began to make sure they were ready. Methods of evacuation like ambulances and hospital trains were then arranged so that they were in optimal positions to evacuate the sounded as soon as possible. A huge amount of planning and preparation went into all of this and on the Somme they were ready to handle up to 10,000 casualties a day. There was just one problem the Somme would kick off with 60,000 casualties on the first day, swamping even the most prepared CCSs. After the first day they would catch back up, and in general the medical services on the Somme did a reasonably good job, especially considering that they had to deal with 420,000 casualties. During the last two years of the war the British would greatly expand the number and size of their CCSs. This resulted in a huge increase in the number of cases that could be taken through at any given time. During 1915 there were some instances where only 5% of the cases had been able to get through a CCS, but by 1917 and the Third Battle of Ypres that number had risen to 30%. Considering the fact that the earlier that surgery was performed the greater the chance of survival was, this was a very important step to increasing the number of survivors. I don’t want to paint too rosey of a picture here though, so here is an account of a French doctor, Doctor Duhamel, who would visit a CCS near the front shortly after a large attack “The brutality of circumstances, the relief of units, the enormous sum of work, all combined to create one of those situation which dislocate and overwhelm the most willing service. We opened a door, and the men who were lying within began to scream at the top of their voices. Some, lying on their stretchers on the floor, seized us by the legs as we passed, imploring us to attend to them. A few bewildered orderlies hurried hither and thither, powerless to meet the needs of the mass of suffering. Every moment I felt my coat seized and heard a voice saying “I have been here 4 days. Dress my wounds, for God’s sake” and when I answered that I would come back again immediately, the poor fellow began to cry “They all say they will come back, but they never do.””

One of the other changes that occurred in CCSs as the war progressed was the introduction of female nurses into their staffs. This would only occur after the CCSs became more permanent and larger structures. Bringing in female nurses was an important step from a care perspective just from the fact that it opened up a larger, and experienced, labor pool to pull from. This represented the closest that the British allowed female nurses to the get to the front, and at times there was real danger involved. Later in the war there was often a danger of bombing raids, but during the retreats of 1918 there was also the danger of just being overrun by German troops. Even early in the war the British Nurses would feature heavily in the CCSs behind attacks, here is Nurse L. Mitchell describing her experiences after the Battle of Neuve Chapelle “Our division had the heaviest casualties of any of the divisions who took part in the attack (neuve chapelle) and it was an appalling affair. For three days we never stopped dressing the wounded men as they were brought in, and at the end of those three days we still have something like 60 or 70 stretcher cases outside. We just didn’t know what to do with them. The Major I was with dropped on the floor exhausted and I had to give an anesthetic for the removal of an arm and I have never given an anesthetic in my life.”

From the CCSs most cases were loaded on ambulance trains for transport, there were also motor ambulances or in some cases ambulance barges, but trains were the workhorses for this part of the journey, with each train carrying around 400 cases. Here is Ian R. Whitehead once again to describe how a train was organized “Working backwards from the engine, a typical train came to be organized with ‘[a] carriage used as an isolation ward; a coach with its compartments arranged as sleeping quarters for the medical and nursing staff; a kitchen coach; four or five ward carriages; an administrative carriage, providing an office, a room for the performance of operations, and a dispensary; four or five coaches for sitting-up patients; a carriage for general cooking purposes; a coach to serve as sleeping quarters for the subordinate personnel; a van for stores; and a guard’s van’.” That all seems pretty neat and tidy, and on paper they were, but there was a less glamorous side especially as wounded started pouring in. Here is Dutch Doctor J.A. Verdoorn again to describe his experiences on hospital trains “Good wagons were coupled to passenger carriages and nowhere was there a single empty seat. Hundreds of wounded sat or lay piled up against one another. It was a terrible sight, especially since not a sound, not a sob, not a howl came from that hulk. All you could see was bandaged misery, and the train was overflowing with it”

Regardless of how the men were transported, or how nicely they travelled, their next stop was the hospital. Hospitals had to be able to deal with every kind of wound or sickness that they were likely to see. They were essentially the end of the line and so they had to be able to handle just about everything. They were generally divided into a medical division and a surgical division to allow for some specialization. When wounded soldiers arrived there was some variance on admission procedures based on the time period and location but there were, in general, three steps. The first was to examine the patient and determine the injury or illness. The second was to remove their clothing and bathe them, if possible. The most important reason for this step was to remove possible contaminants and lice from the equation. To remove lice from the clothing it was boiled in iron containers for at least an hour. The third step in the process was to either move them straight to treatment or to the proper areas to wait. Generally the first step of treatment was to make sure that the wound was clean and to just sort of follow up on anything done earlier in the patients journey. While hospitals were the end of the line for the battlefield wounded, they were also home to many men suffering from other illnesses and some would be stuck there for a long time. There were some areas that were worse than others in these hospitals as Sgt. Arthur H. Lynch describes “There’s only one ward in any hospital which is a meaner place to work in than the place filled with patients suffering from dysentery. And here this big, healthy men are diligently carefully and patiently making it easier for the men who have become so weak that they cannot control the action of their organs. From early in morning till late at night the same faces may be seen moving about the ward washing men, changing foul bedding, emptying refuse cans, taking temperatures and pulses. Nothing seems to be too much trouble for them, and I’ve never heard one of them growl at the rankest, rottenest job a man can picture. They are men to their backbones, but are seldom lauded.” While the environment in the hospital was not always pleasant, if a soldier made it to the hospital they had a pretty good chance of survival. This was both a function of the skill and resources available for treatment at the hospital as well as the most severely wounded not even making it that far. While most British patients stopped at hospitals in France, some would make their way back to Britain for longer recuperation or discharge from the army. From a percentage perspective the number of men taken back home decreased as the war progressed and the British medical facilities on the continent expanded, even if the raw numbers increased greatly. Over the course of the war the number of beds and patients in Britain increased from 40,000 in 1914 to over 350,000 in 1918.

During and after the war there was much debate in Britain about the efficacy of the medical services during the conflict. Critics of the system were led by Sir Almroth Wright who began his crusade against the medical services in 1917. Wright’s primary concern was the emphasis placed on evacuating the wounded troops, instead of treating them as close to the front as possible. In general, few would necessarily disagree that evacuation was not the best process for treatment, but it was also required due to the military situation. Not focusing on evacuation would have meant creating a much larger number of front-line hospitals, all of which would have to be constructed, supplied, and manned, straining the already stretched medical services. Then there was also other problem of moving those hospitals if the front did begin to shift. These reasons would cause Sir Wilmot Herringham to say that evacuation was a necessarily evil for the British, along with every other army. Overall, recent scholarship on the British medical services has been quite kind to them. They were not perfect, especially early in the war, but they were more than acceptable by the end.

Overall, due to the advantage of the static front, the British were able to use all available infrastructure and personnel adequate medical care to the patients they were given. This allowed them to return 29%, or 585,000 wounded soldiers back to duty while 68% or 2.4 million sick patients were also returned to due. In total almost two thirds of the British soldiers who were taken off the front line due to illness or injury would eventually return to the front, which seems like a pretty good percentage to me, all things considered.