THE JOURNEY HOME

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Let us trace the course of a wounded or sick man from the very front of one of our armies, a course differing, as one may suppose, according to the varying conditions and circumstances of terrain and of fighting. The man was—we will say—on outpost duty and was hit by the bullet of a sniper. A regimental stretcher-bearer crawls from shell-hole to shell-hole till he reaches the patient, and because of his training in first aid, now assisted by ripe experience, rapidly examines the wound and applies a first field-dressing to it, more with a view to excluding dirt than to obtaining any particular surgical advantage.

 

Shells are raining about the place maybe. The devoted bearer cowers beside his patient, even shields him with his own body. Bearers have won their own particular reputation on our fighting fronts, so that no one will cavil at this description. For stretcher-bearers, though sometimes of indifferent physique, are made of heroic stuff, and have done much—very much—to gain the appreciation of other soldiers and to heighten the reputation of their own corps.

 

Perhaps there is a lull in the firing. The bearer hoists the man to his shoulders and staggers across broken ground to the shelter of the trench. Or perhaps it was there that the man received his wound. He is slung in a waterproof sheet and borne along a winding and narrow communication trench through inches of mud to a gaping doorway.

 

The letters " R.A.P." indicate that it is the Regimental Aid Post. In the early days of the war it was perhaps a wrecked cottage, an old barn, a shaking ruin. But shellfire soon drove it beneath ground till the regimental aid post was located in a deep dug-out. Whatever the position there the regimental surgeon bends over his patient, redresses the wound if need be, sums up the man's general condition, applies restoratives—perhaps detains him because of the danger to life of further movement, or because a burst of shelling makes delay imperative.

 

It may be that night falls before the opportunity arrives to evacuate the patient. Come the moment will, when, now on a stretcher, and if suffering from a fractured leg, with the injured limb immobilised by

a suitable splint, the man is borne along the trench to the point where it opens. There is a relay-post of bearers of a field ambulance are waiting.

 

The stretcher is placed on a light-wheeled carrier if a track exists, even upon a horsed ambulance under favourable conditions, and in rarer cases direct upon a motor ambulance.

 

Too often, though, bearers must struggle back, accompanied by reliefs, till firm ground is reached and the mud and the shell-holes of the forward area are left behind. The wounded man is now out of the hands of the regimental medical unit, and in that of a field ambulance. This latter unit is one of the hardest worked and most efficient units of the army, and seeing that it works with cavalry and infantry, it has been organised specially for each particular service. That is to say, there are cavalry field ambulances and field ambulances designed for service with infantry units. The former were, it was hoped, sufficiently mobile to cope with the most rapid movement. It was anticipated that the latter would quite easily maintain contact with infantry units. Yet, as facts revealed themselves, in

August 1914 both classes of field ambulance were hopelessly immobile when engaged with wounded.

 

That this statement is true in fact will be the more readily perceived as the narrative of events during the retreat from Mons is perused. It is a truth rendered even more glaring as the Marne was crossed and the

valley of the River Aisne reached ; for there, beneath the famous Chemin-des-Dames—the Ladies' Road— across which and for which bloody conflict raged during all the years of the fighting, there, on the banks of the river, the real cause of their fatal want of mobility was

remedied, and active and efficient steps were taken to make good the one item of equipment of these particular units which had hitherto marred their usefulness. Not until the really auspicious moment when this sadly needed requirement was supplied was the precise reason

of the hitherto want of mobility of field ambulances appreciated to its full extent. Dependence on horse transport for the movement of each individual unit and for the evacuation of its patients was obviously the

fault, but how much the fault—how fatally and exasperatingly it hampered these medical units, only became fully and widely recognised when motor ambulances, long asked for by the Director-General in times of peace, were rushed to the Aisne, at the insistent call of war, and at once relieved the situation.

 

The narrative of the great Retreat from Mons—an epic of British endurance—of our advance across the Marne and of the first week's fighting on the Aisne, produces its own clear evidence of the breakdown of horse transport and of the paralysing effect it had on the efficiency of our otherwise efficient field ambulances. With that evidence go obvious strictures. For here was the Expeditionary Force of the wealthiest nation

of the world supplied with a medical service on which thought and continuous and far-seeing effort had been expended, an organisation the forward units of which—the essential and vital units, one may say—were rendered semi-inactive because of the need of equipment which could have been supplied at relatively small expenditure.

 

The fault lies not with the medical service, for it had foreseen this want of motor ambulances. Its Director-General had realised that mobility was the essence of success in modern warfare, and what more mobile than

the motor ? Yet a Director-General is by no means all-powerful. He can recommend, and to be precise did recommend, the supply of motor ambulances. He can reiterate his demands with some degree of force.

But he does not decide the issue. In point of fact this was a question which was, in the main, determined by the General Staff and by the

Finance Department, and while it is not possible to go deeply into the question, one may state that fear of congested roads behind our divisions made the General Staff chary of sanctioning convoys of motor ambulances.

 

The Finance Department had its annual estimates to consider, and no doubt it hesitated to approve of a scheme hardly yet accepted even in principle by the General Staff—a scheme which must of necessity be

experimental, seeing that motor ambulances had never yet been employed in warfare—and moreover, a scheme which would cost money. Search the record of the great retreat for the inevitable

result of this unfortunate decision. Seek the evidence of wounded officers and men who passed through purgatory on horsed ambulances and motor lorries.

 

Question those unfortunate men of Mons, prisoners since 1914,  wounded in the first hours of the war—abandoned for lack of transport. The dead yield no word of these doings. Yet men died for this self-same

reason. To continue the course of the wounded man, now in the hands of the field ambulance, he is borne as rapidly as possible back to the advanced dressing station, which may be above or below ground, and as likely as not is within easy distance of the front line and certainly under range of enemy guns. Farther behind there is a main dressing station, perhaps in a church, a mansion, or a farmhouse. Latterly, as the war progressed and the British Expeditionary Force assumed vast proportions and its operations became increasingly extensive, these

advanced dressing stations and main dressing stations, organised by individual field ambulances, became frequently welded together. There was a tendency to amalgamate units, to join forces so as the more readily to deal with more strenuous conditions. In this manner one or more dressing stations were organised for each corps, not for each division or each brigade as formerly.

 

But whether grouped or otherwise, the routine as regards the wounded man differed hardly at all. Arrived at the advanced dressing station his wound was closely examined, perhaps redressed, a cup of hot tea provided, and bread and jam or other food. Then the man went on by motor ambulance to the main dressing station. That is, he went on provided his condition did not forbid further movement. Shock and the strain of subsequent movement undoubtedly cost lives in the earlier days of the war when wounded in large numbers overwhelmed

the field ambulances, and evacuation was essential. Even though men in obviously extreme condition were detained, there was little to be done beyond providing restoratives and rest. Tranquillity was out of the

question. But other methods supervened. The value of warmth as a restorative became increasingly recognised, and "rechauffement wards ' had their place at all dressing stations, be they merely in some rickety barn or a mere dug-out. Blankets kept out draughts, stoves provided warmth, and special arrangements were organised to heat up the patient's body and revitalise his forces.

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Speaking generally, field ambulances do not undertake surgical operations other than the most trivial, though in the first two months of the war operations were an important part of their mission. But the British Expeditionary Force was then engaged essentially in mobile warfare, and the tax upon French railroads and means of transport generally did not allow of the early arrival of the clearing hospital—the casualty clearing station as it is now known. During the retreat towards

Paris and the advance over the Marne casualty clearing stations gave but a tenth part of the assistance they gave in later months. Thus, surgical operations fell to the field ambulances, which became mobile hospitals. Following the hypothetical case, we have been tracing, our wounded man passes from advanced dressing station to the main dressing station of some field ambulance, is more precisely dressed, receives an injection of anti-tetanic serum, is fed, and all his particulars are duly entered in the Admission and Discharge book of the unit. Also, they are attached to his own person in the shape of a label—now known as a field medical card —which has changed in appearance and in the scope of the information inscribed upon it more than once since 1914. Briefly explained, this card provides information for the next medical officer as to the condition of the patient when he left the previous unit.

 

Further notes are added, and so on as he progresses to the base and to England. There is the effect of some special operation can be appraised, and, seeing that by experience and trial can man alone advance his knowledge, that report returned from some hospital in England to a medical unit in France upon a post card enclosed with the field medical card for the special purpose, gives early information to some particular army surgeon or physician as to the success or otherwise of his methods. It keeps him in touch with his case, encourages and greatly assists him. The wounded man leaves the main dressing station, cigarette in mouth, tucked up in blankets, lying on a comfortable stretcher, in a motor ambulance which defies criticism. In 1914 he was shaken and rocked in a horsed ambulance wagon, or he was racked in every joint in a swaying, rattling motor lorry. To the lightly wounded such a journey was no hardship. To the man of 1914 whose thigh was fractured such transport was a progression through purgatory, enduring the tortures of the damned.

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With the wounded man's departure from the field ambulance that unit can be dismissed for the moment with but brief additional description. It is a combined unit, bearer, and hospital, and so that it may function accordingly, it is divisible into a bearer and a tent division, each such division being as readily split into three sections. Thus, a single field ambulance could send out three sections of bearers and could open three dressing stations, each independent of the other. In August 1914 it could—on paper and under accommodating circumstances and over fair roads—transport some 120 cases in its ambulance wagons, how slowly only those who tramped the roads from Mons can fully appreciate. Then men of the R.A.M.C. harnessed themselves to ambulance wagons in the place of foundered horses, and medical officers turned their heads away and became blasphemous as they marched on, leaving wounded whom they could not carry.

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The motor ambulance revolutionised the evacuation of wounded. In August 19 14 our wounded man would have reached the nearest casualty clearing station on a horsed ambulance wagon belonging to the field ambulance through which he had passed, for there was then no other means of evacuating. In 191 5 and thereafter he would be aboard a motor ambulance, part of a motor ambulance convoy, one of which worked with each division, while all field ambulances had motor ambulances, reserving a solitary horsed ambulance wagon for use in forward areas where extensive shelling of roads and want of repair had made transport by motor ambulance out of the question. The motor ambulance convoy has been literally the sheet-anchor of directors of the medical service. It has saved impossible situations. The hopeless congestion of wounded near the front is a condition which every officer of the medical service dreads and seeks to avoid, a situation oft-times threatened when masses of wounded, and weather conditions, have made evacuation an almost impossible problem. But the motor ambulance convoy has done marvels in such circumstances. No degree of shelling has curtailed the effort and determination of its drivers. They and the drivers of motor lorries, upon which thousands of the lightly  wounded have been sent down the line, have been a veritable godsend to the army.

 

The doors of a casualty clearing station are thrown open to our wounded man, and he is borne within them. Whether under canvas or in some building the routine is the same, though in 19 14 far less elaborate and therefore less productive of results than in the later years of the conflict. Full details of the man are secured as he is set down in the receiving ward. A medical officer bends over him, scrutinises the matter on his field medical card, and gives a swift decision. Our man has borne the journey well. There is no need to send him to the rechauffement ward of the casualty clearing station. He has a severe gunshot wound of the thigh, and the femur is fractured. The limb is already "put up' in a Thomas' splint and is wonderfully comfortable. "Pre-op. ward," the medical officer pronounces, and at once the patient is borne into an adjacent apartment. Nursing sisters are there. They chat with him. He is undressed and cleansed by nursing orderlies with a tenderness and care which vie with that of woman herself."

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I cannot speak too highly of our nursing sisters," a brother officer says.

 

" The nation will never be capable of sufficiently expressing its thanks for their devotion, nor will our Tommie’s ever forget those women. But those trained nursing orderlies of the R.A.M.C.—the good ones—and there are many of them—are tenderness itself to our poor fellows. I never see them at work with some serious case but I gulp—it's almost pathetic." Bearing wounded from the front calls for initiative and courage, often for life's sacrifice itself. Transporting them to a casualty clearing station has its own particular trials. But to nurse a man well, so that woman nurses envy your skill and cannot surpass your devotion —that is a phase of the R.A.M.C. work surely unsuspected by the public. To proceed. Washed and clean and comfortable the wounded man is borne into the operating theatre. There are at least four tables, screened from one another, and four surgeons, all extremely busy. Another glance at the field medical card, the man meanwhile is anaesthetised, in the latter days of the war by a woman. He " comes to" in one of the surgical wards. He sleeps

and eats and chats. Then the motor ambulance convoy carries him to an ambulance train, and thence he passes to a base hospital, where, being a fracture case, he goes to a fracture ward, and remains for some weeks in France. If otherwise, he may leave for England in a day or so, aboard an ambulance transport.

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In 1914 onward to 1917 it was a luxurious hospital ship, bearing the Red Cross, brilliantly lighted at night. But the German has been no ordinary mortal, nor even just a mere exponent of violence. He has been the apostle of ruthless and cold-blooded murder. To many an infamy he has added the torpedoing of hospital ships, so that the Red Cross, respected by all other nationalities, having no particular significance to him, has not served to protect hospital ships. It was painted out, and from 1917 onward our wounded man reached England upon a ship, luxurious  enough, but bearing no particular mark showing her calling. At home the "case" proceeds by ambulance train to one of the twenty-four great Territorial Force hospitals organised by local Territorial Force centres, or to some war hospital, or perhaps to a civil hospital with beds made available for soldiers, or to a well-equipped and often privately maintained auxiliary hospital. Wherever it be, it is home. Rest, first-class treatment, and nursing follow, and, later, convalescence and furlough. Then back to the Front perhaps, a little reluctantly, proud of the wound stripe, or to a special hospital for more treatment, to a hospital for the limbless, to an orthopaedic, a nerve, an eye, or some other unit. Perhaps to the place where a Medical Board is sitting. "Unfit for further service." The man is pensioned. He appears in mufti with a silver badge and his wound stripe. The shell-hole and the bearer who stood by him over there at the Front become a fading memory. But the limp reminds him. At night, when his wound aches and he is restless, he sometimes traces his own progression from the Front, remembers the subdued light in the casualty clearing station, the moving figures, the flitting nurses, recollects that nursing orderly who helped the nursing sister. Is he grateful and appreciative of the R.A.M.C.—the medical service ? Ask him.

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The rapid progress of a wounded man from Front to Base and thence to England has been one of the features of the war, as rapid almost as the above description. Therein, his admission to and evacuation from the various units has, no doubt, given some indication of their functions,  more particularly of those of the regimental unit, the field ambulance, and the motor ambulance convoy. Some further description, however, is needed of others of the units, though necessarily it must be brief, while mention should be made of organisations not yet indicated. The casualty clearing station has proved of vital service and has done immense and important work. It has been a vital link in the scheme of medical arrangements and has again and again justified its existence. During the South African War, no such unit was in being, and the medical service  has to thank General Macpherson amongst others for their wise forethought in establishing such an organisation. As first designed, it was intended, as in the case of the field ambulance, to be distinctly and essentially mobile, so that it might follow closely behind an army and keep in touch with field ambulances. It was to relieve those units—and has so relieved them—of all cases and having treated them suitably was to evacuate them to hospitals on the lines of communication. Rapid evacuation was to be a sine qua non^ otherwise hopeless congestion would result.

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First as to mobility. The casualty clearing station was designed to accommodate two hundred patients, for whom it carried paillasse cases and adequate marquees and equipment. Its transport was to be supplied by the railway and by the supply and transport department. The conditions of warfare in France brought about drastic changes and called for many additions to the equipment of such units. In the first months of the conflict tents were practically discarded, seeing that permanent buildings were obtainable. Then trench warfare and an immobilised army permitted the supply of huts, though canvas was employed to supplement accommodation. The most prominent metamorphosis of this class of unit was in the direction of size and interior equipment. Designed to accommodate two hundred, its beds have in numerous cases approached 2000 in number. Its paillasses have given place to real beds, and its equipment, supplemented because of its expansion, has been consistently and generously augmented by the British Red Cross Society and the Order of St. John, who have supplied an infinity of articles—mats, pillows, pictures, what not—till casualty clearing stations have borne all the appearance and have vied with the comfort of permanent base or general hospitals. In point of actual fact, from January 1915 onward to July 1916, the casualty clearing station was, in effect, a forward semi-permanent hospital. Then

the operations on the Somme called for a move to the east and the employment of canvas and easily portable huts, buildings having crumbled under shellfire. This condition may be said to have existed up to and beyond the cessation of hostilities. Ambulance trains deserve further description. In the first weeks of the war we were dependent on our Ally for the provision of rolling stock, and the result was no less unfortunate than in the case of field ambulance transport. Ambulance trains consisted of a length of goods trucks—-fourgeons de marchandise—indescribably uncomfortable even when specially fitted, providing no means of inter-communication, and therefore fatally curtailing the efforts of those placed on them to attend the wounded. The employment of nursing sisters was out of the question, and that alone was sufficient to condemn the arrangement. Short springs and a constricted wheel base resulted in extremely uncomfortable travel, so that from every and any point of view the arrangement was unsatisfactory. The provision of hot water, hot meals, tea, cocoa, etc., was out of the question, while the absence of inter-communication, previously referred to, and the natural keenness of commanding officers nearly resulted in the very first week of the war in the death or serious injury of at least two of them who essayed the hazardous task of clambering from truck to truck while the train was in motion. Happily, for our wounded, specially fitted ambulance trains were in our possession within a month of the first days' fighting, and these have provided splendid accommodation. The fourgeon was discarded at once, much to the relief of the R.A.M.C. and, doubtless, of their patients. Base hospitals need no particular description at this stage. The functions of advanced and base depots of medical stores are sufficiently indicated by their designation. Convalescent depots will be referred to in detail in future volumes, and it needs only to mention that just as they absorbed convalescents, passing them under investigation, and rendering a high percentage of returns to duty, so did a new unit, the outcome of the war, to wit, the divisional rest station, deal with the semi-ill in forward areas.

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Territorial Force hospitals in England, war hospitals, the efforts of civil hospitals and of a very numerous band of voluntary workers who opened and staffed auxiliary hospitals have been mentioned already. They, and the voluntary workers who crossed to France soon after the commencement of hostilities, and who worked indefatigably throughout the duration of the war, giving service of incalculable value, will demand attention at a later period, seeing that their effort dates from October 1914. Yet mention now, though brief in the extreme, is necessary,  seeing that the men of Mons, of the Marne, and of the Aisne—those " gallant Contemptibles "—found a haven in the units organised by this numerous and enthusiastic band of volunteers.

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Lastly, before we pursue the fortunes of the Army Medical Service further, it were well to emphasise a point apt at times to be ill-conceived by the public. The R.A.M.C. is not the Red Cross, though it has the honour to work under that symbol. The Red Cross in this war stands for the British Red Cross Society and the Order of St. John, a joint body separate from and entirely independent of the Army Medical Service, yet working loyally and most helpfully with it. Under the control of its Chairman, Sir Arthur Stanley, it has accomplished a gigantic work, and after the British soldier—and many an allied soldier too—the Army Medical Service is the first to acknowledge its thanks and its indebtedness. It is the conjoint society which in this war has given so generously to the Army Medical Service those comforts and luxuries which have assisted toward the cure of the sick and wounded, and which they have so appreciated. It will be found that it was this energetic body which came to the assistance of the R.A.M.C. in the early weeks of the war, and by the provision of motor ambulances helped not a little to save a more or less desperate situation. The British Red Cross Society did in fact, then and later, during the whole course of the war render  most valuable services to our sick and wounded.

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It is, on the other hand, the Army Medical Service, the R.A.M.C, whose duty it has been to succour those sick and wounded, to carry them out of danger, to treat their injuries, and either at the Front or at home to nurse them back to health and strength. At the head of that R.A.M.C. in August 1914, as Director-General was Sir Arthur Sloggett. With him was an able and experienced administrator in the person of General Macpherson. Sir Alfred Keogh, the late Director-General, was Chief Commissioner of the British Red Cross. But this gigantic war has demanded the services of the nation. The Army Medical Service required the assistance of every one of its trained heads and provided work for all. It called for the return of Sir Alfred Keogh to direct the expansion of a service which he had largely created, and it sent Sir Arthur Sloggett, and with him General Macpherson, to France, there to control the greatest medical service that has ever been concentrated on any front, and to compete with difficulties which have often been of an extremely urgent nature.

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