The following extract is taken from the book Military Organization and Administration by Major G R N Collins, Instructor at the Canadian Military School, 1918, Hugh, Rees, Ltd, London

Major Collins was incapacitated from gneral service in the field, he had served in the 4th Battalion, Canadian Army and subsequently lectured in the Canadian Army Military School. He gave a course of a series of lectures in Military Organisation and Administration to the officers of the Canadian Army and these lectures were published in 1918.

Reference should also be made here to the war drawings of Muirhead Bone that illustrate the evacuation by barge and hospital ship. Click here for Muirhead Bone's WWI Sketches

Dr. M G Miller, Editor

EVACUATION OF THE SICK AND WOUNDED

Organization of Medical Units---System of Evacuation-Treatment-Invaliding-

Red Cross Protection-Voluntary Organization.

The principle upon which the Medical Service is built up is that the troops must be kept fit for service, but when they become unfit they must be evacuated from the field of operations as rapidly as possible. The presence of a number of sick and wounded proves an encumbrance to a Commander, and since his mobility will be handicapped by being compelled to carry a number of unfit men, every effort is made to remove them to the lines of communication with all despatch. As the supplies required to maintain the unfit must be carried overseas, which makes additional work for the Administrative Services, only those, who are unfit to continue their journey to the Home bases are kept on the lines of communication. Where the theatre of operations is situated some distance from England, there may be several areas close to the theatre of operations which will be used for the care of sick and wounded, and they would be removed to those areas to recuperate, the permanently unfit being returned to England.

As the removal of the sick and wounded starts from the firing line, we shall follow them down the lines of communication, and will start our studies at the firing line itself.

Every soldier in the field carries a first field dressing, which is sewn in the small pocket on the inner side of the tunic at the left corner of the skirt of the coat. The first field dressing consists of two roller bandages which are each attached to a pad of absorbent material. In packing them, the inner surface of the pad is folded so that the surface is protected from contact with the fingers when opening the package. A safety-pin is lightly stitched to each bandage, and is folded in wax paper to protect it. These two pads ,and bandages are rendered surgically clean when being cut and folded, and after being sterilized are enclosed in a waterproof outer covering which is scaled hermetically by means of a gummed edge. A small ampoule of iodine is enclosed in a cardboard tube, and is placed between the two sealed packages, the whole being enclosed in a khaki cloth covering, on which instructions for use are printed. Upon a soldier being wounded, he will use the first field dressing to cover the wound, binding it on by means of the roller bandage attached, or where he cannot manipulate the bandage himself, a comrade will do it for him. This is the first treatment that the soldier gets.    

 
Every regiment in the field maintains a proportion of personnel who are trained and are proficient in first aid to the injured. In a unit as large as an Infantry battalion there is a party of stretcher-bearers, who provide the local transport, by means of stretchers, for the collection of the wounded of the unit. These men are trained in first aid, and after rendering what aid can be given in the field, they concentrate the wounded at a Regimental Dressing Station. Every unit has a Regimental Medical Officer, who is assisted by orderlies. The Medical Officer is provided with a cart to carry his equipment, which consists of a medical and a surgical pannier containing sundry articles by which sufficient treatment can be given to any soldier to allow him to be transported to the nearest medical unit. The Medical Officer of the unit will establish a Regimental Dressing Station, the position of which is published in the operation orders, and, assisted by his orderlies, prepares for the reception of casualties. As the wounded are brought in by the stretcher-bearers, or, where there are no stretcher-bearers, by their comrades, they are given the necessary treatment. Where there is much pain the soldier may be given a sedative to ease the pain, and if necessary his wounds are re-dressed. Broken limbs are adequately protected, and the troops made comfortable until the transport arrives to remove them.

The sick are paraded daily at fixed hours, being collected by the Orderly Corporal of the unit and taken to the M.0. for treatment. A sick report is made out, upon which the M.O. records the disposition of the soldier and the nature of his ailment. This report is returned to the Orderly Room of the unit for record.

Every sick or wounded soldier is provided with a tally card, which is affixed to the button of the soldier's coat. On this tally card the number, rank, and name of the soldier, which is copied from the identity disc of an unconscious patient, is recorded, and also the nature of the injury or sickness, any opiate which has been given, and any special precautions as to treatment or carriage which may be necessary. This tally card accompanies the man until he reaches his final destination, being marked by each successive Medical Officer through whose hands the patient passes, so that a. complete history of the case is kept, this precaution insuring proper treatment throughout the journey.

The next link in the chain of Medical Services is the Cavalry Field Ambulance for Cavalry forces, and the Field Ambulance for Infantry forces. To thoroughly understand the working of the Field Medical Service it is necessary to master the organization of these units.

The Cavalry Field Ambulances are organized into two sections. Each section accommodates 25 helpless cases. Cavalry Field Ambulances are allotted in the proportion of four to each Cavalry division.

Field Ambulances are organized into three sections, each of which accommodates 50 patients, making a total of 150 for each Field Ambulance. They are allotted in the proportion of three Field Ambulances to each Infantry division.

Both Cavalry Field Ambulances and Field Ambulances are organized into sections which are complete in themselves, as far as transport, personnel, and equipment are concerned. Each of the sections is organized into two distinct parts, the Transport and the Tent Subdivisions.     

The Transport Subdivision is responsible for the collection of the sick and wounded, bringing them into the Tent Subdivisions, which give them required attention and treatment. The transport allotted to these Transport Subdivisions is Cavalry Field Ambulances, 4 six-horse (2 per section) and 6 two-horse (3 per section) ambulances, carrying 4 lying-down cases or 12 sitting-up cases, or 2 lying and 4 sitting cases, for the six-horse vehicles, and 2 lying-down or 8 sitting-up cases in the two-horse vehicles; and also 1 G.S. wagon for medical stores.

Field Ambulances have 10 two-horse ambulances, each capable of carrying 4 lying-down cases, 12 sitting-up cases, or 2 lying. and 4 sitting cases. They are distributed as follows: Section A, 4; B and C Sections, 3 each. Motor ambulances may be substituted in the same proportion, and having the same accommodation. Two G.S. wagons are allotted to each section for medical stores.

The Tent Subdivisions are the hospitals proper, and carry the surgical and medical equipment and the necessary personnel for their use. The equipment carried is sufficient for a Field Hospital, each section having its own complete sets. The staff of each, section consists of doctors, orderlies, dispensers, storemen, drivers, etc.

A Motor Ambulance Workshop is attached to one of the Field Ambulances in an Infantry division to attend to the Vehicles. The peculiar organization of the Field Ambulances lends itself to the collection of wounded in the field of operations without endangering the efficiency of the Medical Services.

During an advance, the number of cases will be very small at first, but, as the advance gets closer to the enemy, the number will increase. In the early stages, it will be sufficient to detach a section to attend to the cases, whilst the others push on toward the troops. Eventually the line will develop a battle of considerable length of time, which both sides will be fighting for superiority of fire. At this time the troops will be deployed and occupying an extended front. The distribution of the ambulances will then be governed by the roads available, nature of the country, protection available, etc., but usually the section will be detached, to form several dressing stations in convenient spots behind the Regimental stations.

During the initial stages of the advance the Regimental medical officers will concentrate their wounded at suitable places, where they render temporary aid. The units to which they belong will be advancing, so that unless the M.O. is relieved, the unit will be left without medical service. The Field Ambulance will detach a section which will he sent forward to take over the wounded from the medical officer, and as soon as possible the cases are evacuated back to the railhead. The Regimental officer will establish a chain of successive stations according to the distance covered, and this system of relieving will be continued until the final position of battle is reached. In order to insure effective co-operation between the Regimental dressing stations, and the Field Ambulances, it is necessary that each should keep in touch with the other. After the final position is reached, the Regimental stations will become permanent, and the Field Hospitals established by the Ambulances will be so situated that they can collect the wounded from the various Regimental dressing stations over which they operate, sending them back for evacuation.

In the Cavalry division, the Field Ambulance will look after groups consisting of a Cavalry Brigade, a Troop of Engineers and Signal Service, whilst a proportion of the Horse Artillery will probably be on their front. There is no definite distribution of their units, but this will be the normal position in battle, and consequently the distribution of the ambulances will result in their being responsible for groups of that composition.

In the Infantry division, the groups allotted to the Field Ambulance may consist of an Infantry Brigade, Field Artillery Brigade, Field Company of Engineers, and sundry Divisional Troops.

 Each of the units in these formations will establish their own dressing stations, so that the Field Ambulance may have to collect from ten or more different stations. For this reason the location of the Field Ambulances must be regulated by the frontage to be covered, and the distribution of the Regimental dressing stations. In an advance, a section or more of a Field Ambulance may be detached to accompany the Advanced Guard.

The organization of the Field Ambulances is very elastic, and, as has been seen, permits the distribution of the various sections according to the demand, or where only a few casualties are in need of attention, they can be accommodated by a part of the unit, leaving the other part free to follow the troops until required. A section detached will evacuate its wounded, and rejoin the balance of the Field Ambulance at a place previously agreed upon.

In order to secure the co-operation of the Regimental and the Field Ambulance medical services, the senior medical officer of the Division will consult with the " G " branch of the Staff in regard to the possible developments, and will obtain the necessary information to permit the ambulances being detailed to those parts of the field where their services are most likely to be needed, and also to allow time for the :officer in charge of each ambulance to locate suitable positions. The A branch will be consulted in regard to the evacuation of the wounded, and the co-ordination of the Corps medical transport; or where a division is operating alone, the lines of communication transport, so that the wounded are evacuated from the field of operations. If necessary the "A" branch will arrange with the "Q" branch for the use of supply vehicles for the removal of the wounded. The situation of the Field Ambulances will be included in operation orders in order that the Regimental Officers will know where to communicate their needs as regards the evacuation of their wounded. The success of the operations of both the regimental and medical units depends upon the maintenance of intercommunication, in order that the transport may be used to the best advantage and distributed where the greatest need arises. At the same time, it is important that the positions of the hospitals should be. clearly identified, in order that cases capable of walking back to the hospital may be directed properly.

Upon the wounded being received at the Field Hospital, they are given further treatment. Whilst operations can be performed by a Field Ambulance, only very urgent cases should be handled, the operation then being a matter of necessity to enable the patient to be evacuated.

The wounded and sick are evacuated from the Field Ambulances by means of Motor Ambulance Convoys, which are controlled by the Corps Headquarters when the divisions form part of a corps, or by the I.G.C. when the division is acting independently. The use of the supply vehicles for evacuating wounded may be sanctioned by the Commander-in-Chief, the arrangements being completed by the Q" branch of the Staff, but ammunition wagons will never be used, since there will be danger of interfering with the fighting efficiency of the troops.

Arrangements for the reception of the wounded from the Field Hospitals are made by the Corps Staff for divisions within a corps, or by the I.G.C. (Inspector General of Communications) when acting alone. The wounded are brought down to the next unit in the chain namely the Casualty Clearing Hospital. This unit is not a mobile unit, but is capable of being moved as required by the use of special transport allotted by the I.G.C. The unit has accommodation for 200 cases, and is intended to receive cases from the field units, distributing them on the lines of communication in accordance with the accommodation available. It forms a regulating station whereby the flow of patients is controlled, relieving the field units of their cases, and only retaining them within its own hands until vacancies for their reception are found on the lines of communication. The allotment of Clearing Hospitals is made in the proportion of one to each division in the field.

The Medical Service in the field operates in three zones. The first zone, known as the "Collecting Zone," is represented by the Regimental Dressing Stations and the Field Ambulances, with the connecting transport between those units and the Clearing Hospitals. If we take the letter X" as an illustration, we get a rather clear idea of its working. The broad top of the letter represents the firing-line with its chain of Regimental Dressing Stations spread across the front. Farther back we get the Field Ambulances, which establish their hospitals on a lesser front, and which collect from the numerous regimental stations. The wounded are thereby concentrated into the four Cavalry Field Ambulances in a Cavalry division, or into the three Field Ambulances of the Infantry division, rendering their handling a much easier matter. From the Field Ambulances the cases are either directed to walk or are transported, according to their condition, back to the Casualty Clearing, Hospital, which represents the pivot of the letter X . The cases are then concentrated in one hospital. This hospital represents a separate zone, known as the "Evacuating Zone," and there may be included in this zone the methods of transportation by which the wounded are distributed on the lines of communication. The Clearing Hospital is situated near the railhead, and is in touch with the lines of communication, to which it transfers all cases. The lines of communication represent the third zone, known as the Distributing Zone," wherein the hospitals of a more permanent character are situated; and since they will be scattered according to the accommodation available and will, cover a broad area, the lower part of the letter "X" plainly illustrates the exact situation.

Clearing Hospitals may be established as Rest Stations for the care of cases which are likely to recover in a short while, when they are drawn off to one side from the main communications, receiving their quota of wounded and sick through the Field Ambulances, who may evacuate the severe cases by rail or motor directly to the distributing zone.

From the Clearing Hospitals performing their normal duty in the field, the cases are transferred by either Motor Ambulance Convoy, hospital trains, or barges. The Senior Medical Officer at railhead will be advised as to vacancies on the lines of communication and will distribute cases accordingly.

Hospital trains may be specially constructed, when they are manned and equipped with 396 cots; or they may, be improvised from ordinary trains, by means of portable t structures, or even by the use of improvised materials, slinging stretchers from the roof and securing them against movement.

Hospital flotillas consist of six barges, accommodating thirty patients each; and since their movement is smooth, and the construction of barges such as to provide roomy wards they are particularly suitable for the evacuation of sick and wounded.

Arrangements for transportation are made through the I.G.C., the orders for the allotment of transport being conveyed through his local representative to the transport services concerned, the actual medical attention being provided, of course, by the Medical Services who are responsible for acquainting the I.G.C. of their requirements.

The wounded are taken down the lines of communication and distributed in the hospitals having sufficient room for their reception, these hospitals notifying the I.G.C., through their local Administrative Commandant, as to their available accommodation.

Stationary Hospitals, which are allocated in the proportion of one for each Division in the field, are capable of accommodating 400 cases. They are equipped to perform any operation, but are intended to handle cases who are likely to recover and return to duty in a short time. They may be situated at the Advanced Bases, and occasionally, for special purposes, at the Main Base. Hospitals for particular diseases or for the treatment of any special diseases are usually Stationary Hospitals.

General Hospitals are allotted in the proportion of one for each division in the field, and have accommodation for 1,040 cases. They. are fully equipped, and closely resemble the military hospitals maintained in time of peace. They can deal with any type of case and retain the patient until recovery, unless it is decided to evacuate him from the theatre of operations, when he may be sent to special areas allotted for the care of the sick and wounded or to the Home country.

The situation of the Stationary and General Hospitals is usually governed, by accommodation available. They require suitable buildings, or camping areas where tents are used, and must have water, healthy locations, etc.

The patients are brought down from the Clearing Hospitals and retained at these hospitals until they are fit for return to duty, transfer to a convalescent depot, or are evacuated from the theatre of operations.

Convalescent depots are organized to handle 1,000 cases, and return the soldier to duty, or, if authorized, send him on sick leave, after which he reports to his unit. They may be situated within the theatre of operations or outside the war zone, and deal with cases transferred to them from the local hospitals.

When a soldier is evacuated from the theatre of operations, he is either sent home on a Hospital Ship which is devoted entirely to the transport of the sick and wounded, and which is protected by the Geneva Convention, or he may travel by a returning transport. Only walking cases would be sent by the latter method. Hospital Ships are equipped to hold 220 lying-down cases, carrying a staff sufficient for that number. Hired vessels of large tonnage may be equipped to carry larger numbers.

On arrival overseas the cases are taken to whatever accommodation may be available, which may be in stationary, general, or private hospitals operated by Voluntary Aid or other charitable organizations. Here the soldier receives further treatment, and eventually recovers and returns to his depot, after being sent to a convalescent depot and granted a sick leave, when he again becomes available for draft, or he may be discharged, if no longer fit for service. Under the heading of "Records" we shall discuss the system of keeping record of the wounded, since the chain of record will be rendered more complete by that method.

There are a few rules regarding the carrying of the kit of. the men, and subsequent renewals of lost or damaged kit, which it may be well to cover.

Ammunition is taken away from the wounded before they leave the firing-line, and is disposed of according to instructions; usually these contain orders to hand same over to the nearest ammunition reserve. The arms, accoutrements, and personal kits of the men accompany them to hospital, and are turned over to Ordnance stores periodically.

As men arrive at the stationary hospitals or general hospitals, as the case may be, their clothing is taken away from them, an inventory made, and the articles deposited in the stores attached to the hospital. The clothing is subjected to disinfectants in order to kill vermin or possible infection, being returned to stores when satisfactory. Clothing, equipment, etc., required to replace damaged or lost articles are drawn from the Ordnance depots, and issued to the troops as required. Every soldier returning to the firing-line must be fully armed, accoutred, and equipped.

Certain technical laboratories are maintained on the lines of communication for research work. Mobile laboratories (Hygiene, Bacteriological) are provided for research work in regard to technical matters. The positions of these units are fixed by the Commander-in-Chief, who issues his orders through the Director of Medical Services. They are usually situated at the base or at advanced depots.

Medical Stores depots are located at the base, and Advanced Medical Stores at the advanced bases, through which all supplies required by the field medical units are supplied. The transport required to carry the supplies forward is provided by the I.G.C., and by arrangement between the "A" and "Q" branches of the field Staffs.

Voluntary Red Cross Organizations. - By arrangement with the British authorities, voluntary assistance to the Medical Services is given by three Societies:

1. British Red Cross Society.

2. The Ambulance Department of the Order of the Hospital of St. John of Jerusalem, in England.

3. The St. Andrews Ambulance Association.

The first organization is intended for war service, whilst the latter two maintain special departments for use in war. All applications for war services must be forwarded through the first organization, who submit them to the Army Council. During the present war the three organizations have combined for the good. of the country's cause, and operate as one organization.

Voluntary organizations are classified under two headings, namely:

1. Those willing to provide suitable gifts for the use of the troops, wounded, sick, etc., and

2. Those willing to provide complete medical units, such as hospitals, rest and refreshment stations, units for road and water transport of the sick and wounded, hospital ships and ambulance trains.

Those of the first class forward all their stores, etc., through the British Red Cross Society, the latter organization stating from whom same were received. These gifts are acknowledged, and are then forwarded to those requiring them.

Persons who are willing to receive patients, whether Officers or soldiers, on their arrival in the Home country, or those who desire to present complete hospitals for the use. of the Military Authorities, forward their application for. acceptance through the' British Red Cross Society, for transmission to the Army Council. The Army Council reserve the right to refuse any offer in regard to the supply of personnel or hospital units. Under no circumstances will those who are not British subjects be accepted as a part of the personnel of field units.

All voluntary workers must he subject to the Military Regulations, and will be placed under the orders of the Commander-in-Chief. As a rule they will be allotted to lines of communication units, and no voluntary aid may be utilized for field service without the consent of' the Commander-in-Chief.

The British Red Cross Society maintains a force of Voluntary Aid Detachments for use in time of war, but each person so enlisting for overseas service must be examined and passed for service as for the Regular forces.

The St. John Ambulance Brigade maintains a force of qualified men and women who are specially trained, who are organized for special war services. These forces consist of The Military Home Hospitals Reserve, which provides male orderlies to relieve the regular hospital orderli6s of the Royal Army Medical Corps in the Home hospitals; St. John Voluntary Aid Detachments, who are trained to establish rest stations, temporary hospitals, etc.; and Royal Navy Auxiliary Sick Berth Reserve, which supplies the Royal Navy with trained sick-berth orderlies.

These units are trained under the supervision of the Army Council, and are recognized as a part of the Medical Reserve.

Use of the Geneva Cross.-The Geneva Cross is reserved exclusively for the use of persons engaged in the collection, transport, and treatment of sick and wounded, and in the administration of the Medical Services. The badge is worn by personnel on a white armlet, which is worn on the left arm. Every person authorized to wear the red cross brassard must be registered, and the badge issued to them will be stamped with the official stamp of the Medical Services,. An identification certificate is issued at the same time. bearing the date and number borne on the brassard, this number corresponding with that shown on the official register of issues.

Red Cross materials, strictly confined to those used for the benefit of the sick and wounded, are marked with the red cross in order to give them protection.

It may be necessary to allot special troops to the use of the Medical Services occasionally, but these are not permitted to use the red cross. Where the number of stretcher-bearers is insufficient for complete collection of the wounded, or when wounded are being loaded into train's or ships, the services of extra troops may be necessary, when they will be allotted by the local command. They are not protected whilst carrying out their duties.

Regimental stretcher-bearers are provided with a special badge marked "SB", worn on the left arm. This does not give them protection under the Geneva Convention. Water Details are not provided with brassards. Sanitary Police wear an armlet "S.P", which does not come within the provisions of this Convention.

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