The evacuation chain

This page describes the main medical functions in a complex chain that processed the casualty from the front line back to hospitals at home. It is in a simplified format. Many men missed stages altogether, and of course many wounded soldiers were in no condition to know which of these units was caring for them.

One man's experience

The initial shock of being wounded is illustrated here by one man's experience. He was Private Tom Bluette, a former journalist for the Grimsby Daily Telegraph and a member of A Company, 1/5th Lincolns in 138th Brigade, 46th (North Midland) Division. On the evening of the 10 May 1915 the battalion had already assembled for the relief at One Tree Farm (in the Messines Ridge sector near to Spanbroekmolen). They could hear the noise and could see the star shells rising into the air. Tom Bluette was among those waiting at One Tree Farm. His experience of that night was relayed to those at home in a published letter later that month.

We went up to relieve the 4th Leicesters, and, as we were lying down near the supports just prior to moving up, a particularly heavy rifle fire commenced. Instantly we were aware that something untoward was happening and quickly came under order to take off everything except the bare fighting order. We were served out with additional respirator in almost as few moments as it takes to mention the fact….The rifle and artillery fire was incessant and every man was prepared for business as everything pointed to hot work. I never noticed the slightest sign of the “white feather” and I do honestly believe that our lads were keen and anxious to get to close quarters. Then we learnt the news! It appears that a party of German bomb throwers had crept up to the advance breastwork and hurling in the bombs had made a mess of nearly every man in the trench. Although we stood to arms all that night, nothing else happened.

On the last day of the trench tour, 14 May, Tom became the 21st member of the battalion to be wounded since the beginning of the month, two of which lost their lives. His injury was rather unfortunate. The men had become understandably rather jittery since the bombing incident. Private George Wilberforce, a comrade in Bluette’s platoon had been taking pot-shots over the parapet. Wilberforce’s rifle had a round still in the breach and somehow it managed to fire as he was lifting it, the bullet passing through Bluette’s hand and thigh. Colonel Sandall asked for an investigation into the incident and a report from the Medical Officer. The conclusion was that the incident was an accident and no punishment was dealt out. The M.O. concluded that the wounded man would soon recover and would be able to resume his duties in due course. Bluette described in a letter the evacuation process which would become familiar to so many of the men in the months ahead:

I realised I had been accidentally shot. Aid was soon forthcoming. My cloths were cut away and bandages applied, while later my comrade, who was quite upset offered his explanation and apologies. I was obliged to remain in the trench from 9 a.m. until nightfall before I could be removed to the dressing station at the end of the communication trenches. Just before tea the Germans sent over a few shells that knocked over our parapet. This was, I must confess a very very trying time for me, as I felt the position very keenly.

Regimental Aid Post

The 'dressing station' that Tom referred to was probably a Regimental Aid Post. The picture above is a RAP in open ground near Monchy le Preux in 1917. Front-line units, such as infantry battalions, were able to provide only the most superficial medical care. Located near the front line, often in a support or reserve trench, was their Regimental Aid Post, attended by the Battalion Medical Officer and his orderlies and stretcher bearers. A wounded man would either make his own way there if possible, or be carried there. The facilities were crude and often just sufficed to carry out light first aid, give the casualty a drink, or just pass him down the chain to the Advanced Dressing Station. The RAPs were manned by troops of the infantry or other unit. Casualties moving on to the ADS were moved by hand carriage, wheeled stretchers, trolley lines, etc as conditions permitted. Those wounded men who could walk, did so. From 1916, relay posts for stretcher bearers were established every 1000 yards or so. To avoid congestion, certain communication trenches were allocated for the removal of casualties.

One man's experience, continued

Just as it became dark Bluette was carried away by two stretcher bearers. Even though the communication trenches had been improved considerably it was still a difficult journey which took three hours to complete, eventually reaching the Advanced Dressing Station after several stops:

'Here I was tallied with a label stating name, regiment, particulars of wounds, and as my wounds had already been dressed, they despatched me to a field hospital near to our billets. I was detained here for one night and my wounds were again dressed and an injection against septic poisoning given….(The next morning) I was moved once more to a hospital about five miles further back, the chaplain visited each patient and offered assistance in informing relatives of their injuries. The next hospital was an extensive building where men were deposited from miles around. I was only kept here for the evening as only the serious cases are detained'

Field Ambulance

The Field Ambulance attached to the infantry brigade provided one or more Advanced Dressing Stations in reasonable proximity of the front lines. The ADS was better equipped than the RAP but could still only provide limited medical treatment. Mens wounds could be dressed and some emergency operations carried out. In times of heavy fighting, the ADS would be overwhelmed by the volume of casualties arriving. Often, wounded men had to lie in the open on stretchers for a considerable time. The wounded man would be passed on down the line to a CCS, often by the wagon transport of the Divisional Supply Column. Buses, charabancs, light and broad gauge railways were also used as conditions allowed. In addition to the ADS, the Field Ambulance was also responsible for the stretcher bearer relay posts, walking wounded collecting stations, sick collecting stations and rest stations. A larger version of the ADS, the Main Dressing Station, was often provided for the Division. The next stop for most casualties was the CCS.

Casualty Clearing Stations

The CCS was the first large, well-equipped medical facility that the wounded man would visit. Its role was to retain all serious cases that were unfit for further travel, treat and return slight cases, and evacuate all others. It was usually a tented camp, although in the static trench areas the accommodation would sometimes be huts. CCS's were often grouped into clusters of two or three in a small area, usually a few miles behind the lines and on a railway line. A typical CCS could hold 1,000 casualties at any time, and each would admit 15-300 cases, in rotation. At peak times of battle, even the CCS's were overflowing. Serious operations, such as limb amputations, were carried out here. Some CCSs' were specialist units, for nervous disorders, skin diseases, infectious diseases, certain types of wounds, etc. CCS's did not move location very often, and the transport infrastructure of railways usually dictated their location. Most casualties came away by rail, although motor ambulances and canal barges also carried casualties to Base Hospitals, or directly to a port of embarkation if the man had been identified as a "Blighty" case. (In 1916, 734,000 wounded men were evacuated from CCS's by train; another 17,000 by barge, on the Western Front alone. There were 4 ambulance trains in 1914, and 28 by July 1916). The serious nature of many wounds defied the medical facilities and skills of a CCS, and many CCS positions are today marked by large military cemeteries. CCS's also catered for sick men. Generally, considering the conditions, the troops were kept in good health. Great care was taken in reporting sickness and infection, and early preventive measures were taken. The largest percentage of sick men were venereal disease cases at 18.1 per 1000 casualties; trench foot was next with 12.7. Until mid 1915, the CCS was known as a Clearing Hospital. Generally there was one provided for each Division. From the CCS, the casualty would be evacuated to a Base Hospital.

Base Hospitals

Once admitted to a Base Hospital, the Tommy stood a reasonable chance of survival. More than half were evacuated to the UK from a General or Stationary Hospital for further treatment or convalescence. The Stationary Hospitals, two per Division, could hold 400 casualties. The General Hospital could hold 1040 patients. They were located near the Army's principal bases at Boulogne, Le Havre, Rouen, Le Touquet and Etaples. The establishment of a General Hospital included 32 Medical Officers of the RAMC, 3 Chaplains, 73 female Nurses and 206 RAMC troops acting as orderlies, etc. The hospitals were enlarged in 1917, to as many as 2,500 beds.

A casualty's chances of survival in France and Flanders

Admissions of wounded men to Hospital, Western Front 1916 (Source: Official History)
	Number of men	% of total admitted
Died in hospital	36,879	7.3%
Returned to duty after treatment	169,842	33.6%
Evacuated to UK for further treatment	290,461	57.5%

Expansion of medical facilities and capacity

The medical support for the Army was developed rapidly as the size of the army grew, and as the nature of the wounds, sickness and other ailments faced in this war became clear. The lessons learned in the early phases of the war included those concerning the need for speedy treatment of wounds. A casualty's chances of survival were much greater if he could be attended to quickly. Hospitals had to be built - and mant doctors and nurses recruited and trained.

Numbers of medical troops (Source: Official History)
	August 1914	July 1916	November 1918
Officers	200	10,669
Other Ranks	9,000	114,939
Nurses	516		6,394

Treatment in Blighty

Casualties whose wounds permitted them to travel would often be moved back to the United Kingdom for treatment. This chance of seeing home and family was more attractive to many men than remaining unwounded in the trenches. Men would hope for a 'Blighty one'. A huge network of hospitals of all specialities and convalscent units were developed. One of the final destinations for a recovered wounded soldier was a Command Depot: last stop before the return to hell.