To deal with the scale and complexity of the injuries incurred on the Western Front, the RAMC needed a system that it could manage strictly. Sir Alfred Keogh was an excellent administrator and Haldane described him to Kitchener as ‘one of the best organisers I ever knew’.12 From his senior position in the War Office and with his wide experience of setting up the Territorial Force hospitals, he was able to construct a system that adapted to the needs of the war and was capable of dealing with the terrible scale of the wounds inflicted over the next few years.
Every soldier in the British Army was now to carry in a pocket in his uniform jacket a basic field dressing consisting of two gauze dressings, cotton wool and a bandage, packed inside a waterproof parcel. The idea was that if he was hit by a rifle or machine gun bullet, a soldier nearby would pull out the dressing and wrap it around the entry and exit points of the wound. But the dressings were often not large enough to cover shrapnel wounds, so a man wounded by a shell fragment would usually have to wait until a stretcher-bearer appeared. There were sixteen stretcher-bearers to every battalion, every one of whom was trained in basic first aid and carried in his haversack a medium first aid kit containing larger gauze dressings to cover shrapnel wounds. The intention was to keep a wound as clean as possible until the injured man could receive proper medical attention; in reality, however, men often lay wounded, sometimes for hours, in the fetid conditions of no man’s land, with mud, water and filth everywhere, and even if wounds had not already been infected by the bacteria carried on the shell fragment they were likely soon to become infected.
By the end of 1914, the war in the west had ossified into the static war along the trench lines of the Western Front. This enabled armies on both sides to develop a system of medical care that relied upon a method of getting wounded men back from the front line to an established hierarchy of medical aid positions. In the British Army, stretcher-bearers would first take a wounded man to the Regimental Aid Post or Advanced Dressing Station. Each battalion had its own medical officer, a qualified doctor who would work with a small group of orderlies. The medical officer was a familiar figure, living with the men in the trenches, and in addition to dealing with daily issues relating to the soldiers’ health, like regular colds, aches and pains, he was the first port of call for the wounded. His duty was to run the Regimental Aid Post, which was usually only two or three hundred yards behind the front line, situated where possible in an old farm building or in dugouts. Being so close to the front, the posts were frequently exposed to enemy fire and were only marginally safer than the front line itself; as a consequence more than a thousand medical officers were killed during the war.13
Often, during a major advance, the situation in the posts became chaotic as large numbers of wounded were brought in. There were often only minimal supplies of clean water and rarely enough space. But the intention was to examine and clean up every wound if possible, sometimes by coating a wound with iodine or setting a fracture in a splint. There would not be time for much in the way of medical intervention, but as soon as possible a field ambulance would remove the wounded man further from the front. The Field Ambulance units themselves included dressing stations, but their principal purpose was to convey wounded men to the next tier of care, known as the Casualty Clearing Station (CCS).
The CCS was effectively a small hospital a few miles behind the front, out of range of the enemy’s artillery. By 1916 the British Army had set up about fifty of them in France and Belgium, and each could accommodate between 500 and 1200 wounded men. There would be about ten medical officers in a CCS, supported by many orderlies and even a few female nurses. This was as far forward as the army allowed women during the war. Despite the opposition of some doctors, who thought that having women this near to the front brought unnecessary risks and burdens, the presence of female nursing staff was usually a great encouragement to the men and good for morale. The CCSs included wards for different types of patient, modern operating theatres, a laboratory, X-ray machines and a full medical supply depot. Under pressure from Sir Anthony Bowlby, as the war progressed the CCSs would increasingly come to specialise in particular treatments, such as abdominal wounds or head injuries. They were usually located at central points near road junctions or railway sidings. Some were made up of large buildings requisitioned for the purpose; others consisted of rows of marquees and temporary Nissen huts laid out across green fields.
As soon as a wounded man arrived at a CCS he was classified in one of three categories that determined the type of treatment he received. This was not a new system in the Great War, the principles went back as far as the treatment of the wounded in Napoleon’s army. Soldiers with slight injuries were treated quickly and returned to the battle zone as fast as possible to clear space for others. The second group, those needing more serious attention, were treated to the highest level available at the CCS. This might entail the amputation of infected limbs or the cutting out of wounded flesh to prevent infections from spreading or getting hold. The third group, those regarded as being beyond hope, were left on one side. There was a cruel arithmetic to military medicine. It was thought that if a man was too far gone there was no point trying to treat him when the time could be spent on saving perhaps three or four others. Every CCS was therefore surrounded by slowly dying men, often in terrible agony, calling out for help, for water, for attention. And each CCS would have attached to it a cemetery that during the course of the war grew inexorably in size. It was horrible, but this was the reality of war.
In most cases, the wounded never got further than the CCS. If they were not returned to their units immediately after treatment, they would be sent back after being given a short time to recuperate or recover. The seriously wounded were, however, evacuated from the CCS and sent back ‘down the line’, usually in a specially equipped ambulance train or barge. Early in the war, trains were like almost everything else in desperately short supply. But through voluntary contributions and sponsorship from the private railway companies in Britain, their numbers grew considerably. By 1916, there were more than thirty such trains, fitted out to transport badly wounded men. Some carriages contained wards with beds, others had seating, and each train had a complement of at least three doctors and forty orderlies.
The next tier in the medical hierarchy to which the trains and barges took the wounded men was the base camp General Hospital. There were three main general hospitals located along the French coast: one at the port of Boulogne, another just north of Etaples along the coastal dunes and the third a few miles south of Rouen. These were huge establishments with up to 14,000 beds and full facilities to treat the victims of gas attacks and wound infections, and to carry out surgery. Most of their nursing work was carried out by women. The presence of women continued to cause controversy, although in the main they were far more popular among the wounded than the male orderlies. Having a sympathetic young female figure to talk to was usually very important to the men when they felt at their weakest and most vulnerable. Many of the nurses, as volunteers, were from the middle classes, and so in the main they regarded themselves as on a par with officers, but in their caring role they were able to gain the respect and admiration of many of the ‘other ranks’, normally from the working classes. There were occasional stories of liaisons between nurses and wounded officers, although such relationships seem to have been extremely rare and were certainly frowned upon by the authorities.
Most of the young women had been thrown into situations completely outside their previous experience, and for many this was as significant in their lives as fighting in the trenches proved to be for their brothers. Having felt that student life at Oxford was ‘like Nero fiddling while Rome was burning’, Vera Brittain left her studies at Somerville College, Oxford after only a year to work as a volunteer nurse. She explained her reasons for taking up nursing as ‘not being a man and able to go to the front, I wanted to do the next best thing.’ And the experience of nursing horribly wounded men in military hospitals had
an immense impact on her; she wrote in a letter that ‘after seeing some of the dreadful things I have to see here, I feel I shall never be the same person again.’14
Army policy was to return even the more seriously wounded to their units as soon as possible. But for men who needed further treatment or convalescence, the next stop on the journey was back to ‘Blighty’. Six hospital ships, each with the capacity to carry 2500 men, constantly ferried the wounded back across the Channel. From the Channel ports they were taken by train, often to Charing Cross station in London where huge crowds regularly gathered to cheer them as they were carried across the station to waiting ambulances. In December 1914, there had been 40,000 beds set aside in hospitals in Britain for war wounded. By the end of the war this number had grown to more than 360,000.
Back in Britain, non-commissioned soldiers and ‘other ranks’ were still kept under strict military discipline, doing useful tasks where possible and ordered to carry out drill when fit enough. Officers, on the other hand, were allowed to plan their own sick leave and convalescence, presumably on the basis that as a matter of honour they would return to their regiments as soon as possible. But as the shortage of men became acute, so in 1917 this loose system was tightened and all sick and wounded up to the rank of colonel had their convalescence scheduled for them. However, officers were still put in different wards and sent to separate hospitals from the men they commanded.
As the war progressed the system continued to provide more specialist medical care at each tier. But at every stage, the evacuation of the wounded brought its own transport problems. The stretcher-bearers were usually terribly overworked at times of offensive action. The mass of mud in the Flanders salient meant that it might take eight men rather than four to carry a stretcher and by the time they arrived at an aid post the stretcher-bearers were often utterly exhausted. There were never enough stretcher-bearers to cope at times of heavy action. Nor were there enough field ambulances to carry men to the CCSs, while those available were often without suspension, so that despite being motorised they provided a bumpy and horribly uncomfortable ride. At the next stage of evacuation, the ambulance trains had to run largely on single-track French railways where priority was given to munitions trains carrying supplies up to the front and troop trains bringing up reinforcements, so journeys could take many hours longer than expected as trains with the wounded waited in sidings. But however rudimentary, the lives of hundreds of thousands of men were saved by a system that in the main worked, and which improved as the war progressed.
Many aspects of the medical care of the wounded during the war were debated intensely at the time. The professional army surgeons did not always see eye to eye with their civilian advisers, while the civilians regularly argued among themselves as to the best way to solve the new problems thrown up by the war. One prominent member of the Medical Research Committee, Sir Almroth Wright from St Mary’s Hospital, Paddington, argued that the army was taking the wrong approach to the treatment of the wounded. He set out to investigate the problem of wound infections at the Base Hospital in Boulogne, establishing a small laboratory and taking with him to study the use of antiseptics many of his researchers from St Mary’s, among them the young Alexander Fleming, who fifteen years later would discover penicillin. Wright argued that the rapid evacuation of the wounded increased the likelihood of war wounds becoming infected. By 1916 most military surgeons in France were trying to prevent infection by cutting out damaged tissue and irrigating the wound with a new antiseptic solution pioneered by the American Dr Alexander Carrell in France and the Scottish chemist Henry Dakin. The use of the Carrell-Dakin solution to sterilise wounds rapidly became widespread. But Wright believed this was ineffective and suggested the use of a form of hypertonic saline solution, which entailed packing septic wounds with tablets of salt.
Wright also believed that treatment should be standardised in line with the latest scientific research. Suggesting that the Medical Research Committee should coordinate this treatment by studying the nature of injuries across the entire Western Front, he wrote in 1915 that every doctor should work ‘not as he individually thinks best but as part and parcel of a great machine’.15 This was one aspect of the rationalisation of care that the Medical Research Committee strongly believed in. At the end of 1916 Wright publicly criticised the army, offering a direct challenge to Keogh and the members of the army medical corps. Seeing his insistence on standardisation as nothing more than a way of introducing his own ideas on treating wounds, they united in opposition to Wright’s attack. Sloggett insisted that one of Wright’s pamphlets should be banned on the grounds that the ideas it put forward were dangerous, and after meeting with Wright, the army’s chief consulting surgeon, Sir Anthony Bowlby, wrote in his diary, ‘Wright, who knows nothing whatever about wounds at all, and also nothing about Carrell’s treatment, talked the usual rot about his pet salt treatment which everyone else has given up.’16
The controversy went as far as the Secretary of State for War at the time, Lord Derby. When he was persuaded not to take Wright’s criticisms seriously, the matter was dropped, at least at the official level, but it was a sign that in the rapidly expanding world of medical research, there were usually at least two answers to most questions. And it showed that the relationship between the Royal Army Medical Corps and the civilians of the new Medical Research Committee was not always an easy one.
The Battle of Loos in September 1915 proved a turning point in the establishment of the military evacuation system. British losses exceeded 50,000 and the pressure on the medical units was severe. General Haig, commander of the assault, paid particular attention to the treatment of the wounded and was shocked when he visited a CCS and found that doctors had been working continuously without rest for seventy-two hours. Haig respected both Sloggett and Bowlby and under the influence of the surgeons agreed that more surgery should be carried out in the CCSs, shifting the emphasis to treating wounded men nearer to the front. When Haig became commander-in-chief towards the end of the year, he maintained close links with the medical care services, and his confidence in them might have encouraged him in sustaining the war of attrition on the Western Front.17
Before the launch of Haig’s Somme offensive in the summer of 1916, the army made meticulous preparations for medical care of the anticipated casualties. With estimates that there might be up to 10,000 wounded men each day to treat and evacuate, fourteen CCSs were prepared behind the lines where the assault would take place. For each one an ambulance train was equipped and readied and six ambulance convoys were on standby. Three days before the assault all the CCSs were cleared of non-emergency work, and dental and optical care was postponed. On 1 July, the bloodiest day in the history of the British Army, all these preparations were overwhelmed. The actual number of wounded that day amounted to nearly 40,000, half of whom had suffered serious injuries. But only 22,436 were treated during the day by field ambulances or in CCSs, all of which struggled desperately to keep up.18 The remainder never got beyond the Regimental Aid Posts or, more probably, were still out in no man’s land waiting to be brought in and fed into the system. At many places up and down the front, truces agreed with the Germans on the night of 1 July allowed stretcher-bearers to go out from both sides and bring in the wounded.19 Nevertheless, many wounded men had to wait for hours, some for days. One, Private Matthews of the 56th (London) Division, lay in no man’s land stuck fast in mud for fourteen days. Miraculously his wounds did not turn septic and he survived.
Howard Somervell was twenty-six and had only qualified as a doctor at University College Hospital, London, in 1915. He volunteered on qualifying and went straight into the RAMC. On 1 July he was a surgeon at a CCS at Vecquemont, a large tented hospital that had prepared for 1000 patients. Like the other CCSs along the Somme front, Vecquemont was overwhelmed by the numbers of wounded, as a line of ambulances one mile long waited patiently to unload their human cargoes. Somervell wrote that ‘the whole area of the camp, a field of five or
six acres, was completely covered with stretchers placed side to side, each with its suffering or dying man upon it.’ Working in one of the four operating theatres, he had the chance occasionally to make ‘a brief look around to select from the thousands of patients those few fortunate ones whose life or limbs we had time to save. It was a terrible business.’ He learned quickly the principles of military surgery: ‘we rapidly surveyed them to see who was most worthwhile saving. Abdominal cases and others requiring long operations simply had to be left to die. Saving life by amputation, which can be done in a few minutes, or saving of limbs by the wide opening of wounds, had to be thought of first.’ Writing nearly twenty years later, Somervell recalled,
Even now I am haunted by the touching look of the young, bright, anxious eyes, as we passed along the rows of sufferers. Hardly ever did any of them say a word, except to ask for water or relief from pain. I don’t remember any single man in all those thousands who even suggested that we should save him and not the fellow next to him... There, all around us, lying maimed and battered and dying, was the flower of Britain’s youth – a terrible sight if ever there was one, yet full of courage and unselfishness and beauty.20
Secret Warriors Page 24
