The RAMC Chain of Evacuation
The Great War 1914 - 1918
A man's chances of survival depended on how quickly his wound was treated; modern warfare was now producing vast numbers of casualties requiring treatment at the same time.
Regimental Aid Post. [RAP]
Medical treated was to start as soon as feasible, and as near to the front line as possible, for this reason Regimental Aid Posts were set up. The Battalion Medical Officer, his orderlies and stretcher-bearers, attended these.
When not in action this is a Camp Reception Station [CRS] or Medical Inspection Room [MI Room] for infantry battalions (or other arm) and contained 2 - 6 beds for short term holding. The Regimental Medical Officer [RMO] is RAMC and has a RAMC Sergeant or Corporal attached to him and perhaps 1 or 2 RAMC other ranks.
In action, the RAP was situated a few metres behind the front line, this could have been in a dugout, in a communication trench, a ruined house, or a deep shell hole. The RMO had the same staff but this became augmented by Regimental Stretcher-Bearers, usually the regimental bandsmen or others. When under pressure, he could be further augmented with bearer teams from a Field Ambulance.
The facilities were only sufficient to carry out first aid. The RMO's equipment was supplied by the Advance Dressing Station and normally consisted of Anti-Tetanus Serum, Assorted Bandages, Plain Gauze., Shell Dressings., 1st Field Dressings., Sulphur Ointment., Boric Ointment., Cotton Wool., Blankets., and Stretchers. There were also a Primus Stove., a Beatrice Stove., Short trench stretchers., an Acetylene Lamp., a Vermoral Sprayer., Reserve boxes of all of the above, and a hamper containing medical comforts such as Brandy., Cocoa., Bovril., Oxo., Biscuits etc.
The Regimental Aid Post had no holding capacity. Wounded men were to either make their own way or be carried, usually by a member of his own Unit. The object of the exercise was to patch them up and either return them to their duties in the line or pass them back, via hand carriage, wheeled stretchers, or walk if he was able to, to an Advance Dressing station. Those who were in need of further treatment were collected by RAMC Stretcher Bearers from the Advanced Dressing Station and taken to the ADS.
In battle a casualty is to be transported direct to the ADS, however, in the Great War situations necessitated Collecting Posts [CPs] and Relay Posts [RPs] to avoid congestion. This meant there were teams of RAMC stretcher bearers, strung out over miles of ground unpassable by motor or horsed transport, that shuttled between the posts and passing the wounded on to the next team. A "carry" could be anything up to 4 miles over muddy or shell-pocked ground, either in trenches or above ground. The equipment for these posts was the same as for the RAP.
Walking Wounded also had a route between Walking Wounded Collecting Posts [WWCPs]. Where possible in the terrain there were car posts where casualties could be transported by ambulance.
Field Ambulance. [Fd Amb or FA]
There was at least one (In the case of a Cavalry and some Infantry Field Ambulances), but normally two, Advanced Dressing Stations set up by the Field Ambulances. In a textbook situation, the Advance Dressing Station would be sited about 400 yards behind the RAPs, in tents where necessary, but preferable in large houses or schools, and the Main Dressing Stations sited roughly one-mile further back. In the Great War though this seldom was the norm.
The Field ambulance was the most forward of the RAMC units and the first line of documentation. There were three Field Ambulances attached to the 75 Infantry Divisions and others such as the 4 Mounted Divisions and Guards etc, and four attached to the 5 Cavalry Divisions, that was one Field Ambulance attached to every Brigade. In action two of these were forward and the other was held in the rear. When the Division was out of the line the Fd Ambs were allocated special tasks such as a scabies centre or for other ailments, a Divisional Rest Centre [DRS], or as a bath unit. If the latter it was usually sited in a Brewery where up to 50 men could be bathed at a time in the large Vats and local women were used for laundering and the repair of clothing and uniforms.
The team, which made up a Cavalry Field Ambulance, consisted of 6 Officers and 70 O/Rs RAMC working alongside 42 O/Rís from the Army Service Corps. Within an Infantry Field Ambulance, the team was 10 Officers and 182 O/Rs RAMC working alongside 49 O/Rs ASC etc. A Field Ambulance composed of a Headquarters Company [A coy] which formed the MDS, and two companies [B & C Coys] which deployed forward to form the two ADS's. Each of these companies were further sub-divided into two parts namely the 'Tent division' who were the medical staff and formed the treatment area, and the 'bearer' sub-division who were the stretcher-bearers collecting the casualties from the RAPs, and carrying them back to the 'tent division' at the ADS, or manning the relay posts. Each Company had horse-drawn ambulances and, perhaps, one or two motor ambulances.
The ADS did not normally have a holding capacity, but if it moved whilst handling casualties it could take itís casualties with it. The object of the exercise was to collect the sick or wounded from the RAPs and provide sufficient treatment so again, the men could be returned to their units in the line where possible. Although these were better equipped they could still only provide limited medical treatment. If the casualty was not fit enough to be returned to his unit he was collected by horsed or motor transport by the bearer sub-division of the MDS.
The MDS did not at first have a surgical capacity, but did carry a surgeonís roll of instruments and sterilisers for life saving operations only. It had a holding capacity of up to 1 week for the patient to be fit enough to return to their unit or be able to be transported back to the Casualty Clearing Station [CCS]. Later in the war fully equipped surgical teams were attached to the Field Ambulances, and urgent surgical interference could be performed to sustain life.
If the Line of Communication [LOC] from the front to the CCS's was a long journey, other Fd Amb's were placed along the way, and these served only to check dressings, taking a casualty off the ambulance for treatment only if necessary. There were also Field Ambulances on the lines of Communication between the CCS's and the General Hospitals if there was no rail link.
Casualty Clearing Station. [CCS].
The Casualty Clearing Stations were to facilitate movement of casualties from the battlefield on to the hospitals. The general rule was one CCS per Division but they were under Army Corps rather than under Divisional control. Todate, 72 have been traced.
A Casualty Clearing Station was a very large unit, and could hold a minimum of 50 beds and 150 stretchers in order to treat a minimum of two hundred sick and wounded at any one time. In normal circumstances the team would be seven Medical Officers, one Quartermaster and seventy-seven other ranks, there would also be a Dentist, a Pathologist, seven QAIMNS and other non-medical personnel attached. In times of stress this number could be increased and a specialised ĎSurgical Teamí could be brought forward. Because they were so large they needed up to about half a mile square of real estate. Each CCS would carry its own marquees and wooden huts so as to create medical and surgical wards, kitchens, Sanitation, Dispensary, Operating Theatres, Medical stores, Surgical stores, Incineration plant, Ablutions and Mortuary, as well as sleeping accommodation for the Nurses, Officers and Soldiers of the unit. Sanitation was dug, and a water supply assured.
They were usually situated about 20 kilometres behind the front lines; roughly mid-way between the front line and the Base Area, and about 500 yards from a main railway line or waterway system. Transportation to a CCS could have been via horse-drawn or motor ambulances. This was the first line of surgery and the furthest forward of nursing staff but treatment could still only be limited.
Casualty Clearing stations were usually grouped in twos or threes and would have worked in relay, that is, one would be closed and treating casualties for evacuation by train or ambulance to the Base Area, whilst the other would be empty and ready to receive new casualties. When this became full it would close, but the first would by now be empty and ready to receive new casualties again. A third would only be treating the sick, but would evacuate to receive battle casualties in an emergency. The CCS's collected the casualties from the MDS's by sending forward the Motor Ambulance Convoys [MAC's] that were attached to them. The ambulances of the MAC's were Army Service Corps vehicles [ASC] and each had an ASC driver and an RAMC attendant. In exceptional circumstances a Field Ambulance would be attached to assist.
There were six mobile X-Ray units serving in the British Expeditionary Force during the Great War and these were sent to assist the CCS's during the great battles.
The Rontgen Tube had been in use during the South African War of 1898-1902 and complete trailer X-Ray equipment was attached to every CCS from very early in the Great War.
The holding capacity was about four weeks in order for men to be returned to their units or be transferred by Ambulance Trains or Inland Water Transport to a hospital. The seriousness of many wounds challenged the facilities of the Casualty Clearing Stations and as a result their positions are marked today by large military cemeteries.
Stationary Hospital / General Hospital / Base Area.
The title ĎStationary Hospitalí was a bit of a misnomer as these units could move easier than the CCS's. There were two Stationary Hospitals to every Division and each one was designed to hold up to 400 casualties. There was however, a tendency to use these as specialist hospitals, i.e.: sick; VD; gas victims, neurasthenia cases, epidemics, etc. So far, 55 Stationary Hospitals have been traced, they were normally found occupying a civilian hospital in large cities or towns, but were equipped for fieldwork if necessary.
A General Hospital was located on or near railway lines to facilitate movement of casualties from the Casualty Clearing Stations on to the Ports. The Great Hotels and other large building such as casinos were requisitioned but other hospitals were hutted and constructed on open ground. Many of the general hospitals were Voluntarily Hospitals supplied by the British Red Cross and St. John Combined Organisation and by the titled ladies of Great Britain, and some became Convalescent Depots
In the Base Areas such as Etaples., Boulogne., Rouen., Havre., Paris, Plage, General Hospitals operated as normal civilian hospitals do, having all the departments and paraphernalia. Bacteriological and X-ray units would be attached, and pathological research on the field conditions found was undertaken.
The general hospitals in the Base Areas had complete X-Ray departments and operated as separate sections within the hospitalís complex. Also working to support the hospitals Mobile Hygiene and Bacteriological Laboratories. There was one Hygiene and two Bacteriological Laboratories allocated to each Army.
The holding capacity was such that a patient could remain until fit to be returned to his unit or sent across the Channel via Hospital Ships to the UK for very specialist work, or discharge from the forces. Once admitted there was a good chance of survival, the Official History states that whilst 36,879 men died on hospital, 169,842 returned to duty after treatment. Some of the General Hospitals were still handling the treatment of held patients until well into 1919, and others went forward into Germany to care for the British Forces holding the Rhine.
Military and War Hospitals at Home
Once home, casualties were distributed to Military and War hospitals, which were divided into 9 Command areas. These were the: -
Other RAMC Related topics
Early Blood Transfusions, as we know them, had begun well before the turn of the century but the systems in experimental use were enhanced in the American Base Hospital No.5, from the Harvard University, which took over the Casino at Boulogne from No.13 General Hospital in November 1917. A modification of the paraffined glass 'Kimpton' Tube, called "the No.17 Tube" was first used in No.17 CCS for Blood Transfusions of whole blood. As well replacing blood loss; the transfusions given considerably reduced the amount of shock suffered by the casualties.
Some of the problems of this war handled by the RAMC:
This odious type of warfare was first used at 3 'o' clock in the afternoon of 22nd April 1915 when chlorine gas was released by the Germans in the Ypres sector. There was no defence for this and 402 officers and 11,778 other ranks of the 27th Division alone had been admitted to the field ambulances by 30th of that month. The immediate remedy was to urinate onto a handkerchief and hold it over the nose and mouth. Paris was scoured for ladies face-veiling and the medical services of the 1st and 2nd Armies, assisted by the women of the locality in which they were billeted, made up emergency masks using the veiling to wrap pads of horsehair and cotton waste soaked in Hyposulphate of soda, and 98 thousand of these were sent into the front line. A solution of 10lbs of water, 10lbs of Hyposulphate, 2.5lbs of soda and 1lb of glycerine was placed in buckets in the trenches to renew the effectiveness of the pads. This, then, was the first British military respirator.
The gas first used was Chlorine, which led to a slow death by asphyxiation. Mustard gas, first used in 1917, delayed any effect for up to 12 hours, and then began to rot the body from both within and without and a very painful death took from four to five weeks. Lachrimatory gasses caused blindness. Gas hung around in sunken roads for weeks, and it was possible to be overcome merely by removing a patientís clothing, so it was not only during an attack that one could become gassed.
Boots and Putees were intended to keep small stones, etc., from causing problems whilst walking, but when standing for hours on end in a trench that is over ones ankles in water, the skin takes on the effect that one sees when keeping the hands emerged in the washing up bowl. This eventually causes the skin to break down and fall away thus exposing the muscles underneath.
This was caused by any one of four bacillus that entered either directly into wounds, or was implanted by fragments of shell that burst after burying themselves into the ground. Flanders was a very wet country due to the water table being so near the surface; consequently prior to the war the farmers had plenty of water drainage ditches. These, however, were destroyed by the constant shelling, and the result was water everywhere and the ground was infiltrated with bacillus that entered the wounds of the casualties, or into the skin of trench foot. Difficult to treat, it even re-entered a wound after amputation.
The effect of "no heart for the fight" was recorded as far back as 480 BC and was, indeed, known to the Pharaohs. In Napoleonic times it was called "The Wind of the Ball" and did not really manifest itself into the British Army until the Great War. It was extremely difficult to separate the shirkers and malingerers from those with genuine neurosis and, despite the efforts of medical officers on the spot, the higher eschelon castigated it as cowardice which, processed through the system, produced dire results. It is interesting to note that the officers were allowed to be diagnosed with neuresthenia whilst the other ranks received rough justice. There were, however, specialist hospitals put aside to treat the ever-increasing condition, followed by long periods of convalescence. The French recognised the condition from the outset, but their treatment was often worse than the cause of the effect in the first place.
These creatures carried trench fever, relapsing fever, and typhus. They laid their eggs in the seams of clothing, and in the tails of the menís shirts, in fact where it was warm and where the clothing was not frequently changed. The men normally cleansed their clothing by passing the seams over a candle flame, but they forgot that they also hatched out in the body hair, thus the clothing was re-infected. Serious cases of fever were treated in the specialist Stationary Hospitals, and the men usually returned to their units. The infestations were however continuous and created a virtual war on their own.
Information researched and compiled by Barbara Janman (Courtesy of Reginald Leonard Barrett-Cross)
'Organisation, Strategy and Tactics of The Army Medical Services in War by Lieut-Colonel T B Nicholls, M.B., Ch.B.' and various Unit histories.