1 Medical Officer 2 Orderlies 16 Stretcher Bearers

Regimental Aid Post

The first medical station a casualty reached on leaving the frontline was the Regimental Aid Post (RAP). This was close to or within the frontline positions. Here a soldier would be patched up and returned to the frontline or, like Frank Moore, be sent on to the Dressing Station for further treatment. The treatment at the RAP included basic first aid such as cleaning and dressing wounds and providing pain relief, and a few comforts such as brandy, cocoa and biscuits.

First World War casualty rates for British and Commonwealth servicemen:

Killed 956,700Wounded 2,273,000Sickness 1,002,800

Of the wounded:Returned to frontline service 64%Returned for service in rear areas 18%Invalided out 8%Died of Wounds 7%

Wounded soldiers who were able to walk marched in pairs or small groups. Those who could not were carried. Teams of stretcher bearers carried or wheeled the wounded in relays of up to 4 miles across ground impassable by motor or horse transport.

Evacuating men from the frontline was a complicated process. It varied according to the intensity of the battle, the ground they were fought over and the number of wounded. This diagram illustrates the chain of evacuation which funnelled casualties from the Regimental Aid Post at the Front to the hospital ships transporting soldiers back to the UK. This process is shown in a simplified version across the following panels.

Frank Arnold Moore joined the Royal Fusiliers in May 1916 and saw active service on the Western Front between 1916 and 1918. Moore was wounded and returned to ‘Blighty’ three times. He recorded his experiences in more than 500 letters to friends and family.

1. & 2. The Fusilier Museum London permanent collection | 3. L0009419: Wellcome Library, London | 4. L0068379: Wellcome Library, London | 5. M0019188: Wellcome Library, London

"When we arrived there we had a mug of hot tea and some bread and butter. I think I enjoyed that tea more than any before…I had my wound dressed and was inoculated"2nd August 1917, Moore to his parents.

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Monday 30th July 1917, Moore notes his evacuation route from the battlefield in his notebook.

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Medical Advances:Medicine advanced rapidly during the FirstWorld War, with a huge impact on survivalrates. A fractured femur (thigh bone), if poorly treated, could lead to severe infection and amputation. In 1914 a broken leg was splinted with anything from a rifle, to a piece of wood or the soldiers other leg. By 1916 the Thomas splint, named after pioneering Welsh surgeon Hugh Owen Thomas was in use. At the beginning of the war 80% of all soldiers with a broken femur died. By 1916, 80% of soldiers with this injury survived.

The application of Thomas's splint, for fractures of the femur and leg bones.

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2nd August 1917, Moore writes to his parents of a shrapnel wound to the thigh.

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EVACUATION

Frontline

"There were several of our fellows hit at the same time and we waited in a big shell hole until things were a little quieter and then walked back to the dressing station" August 1917, Moore to his parents.

World War I: the Royal Army Medical Corps (RAMC) on active service. By, Haydn Reynolds Mackey.

36 Stretcher Bearers

On arrival at the Dressing station Moore would have been assessed by a Medical Officer (MO). The MO would have split his patients into minor wounds, severe but survivable wounds, and terminally wounded.

Those with minor wounds were patched up and sent back to their battalions or sent on to the Casualty Clearing Station (CCS), as happened to Moore on each occasion he was evacuated. More severely wounded patients would have been given emergency surgery before being moved, while those deemed hopeless cases were made comfortable but were given no further treatment.

“We were dealing with a mass, not individuals, and if selection had to be made, it must be made in favour of those who had a chance of being made fit again to return to the Front”John A. Hayward, doctor C B Purdom, Everyman at War: Sixty Personal Narratives of the War (London: JM Dent, 1930).

On arrival at the CCS soldiers found themselves billeted in more permanent structures. Marquees and wooden huts served as medical wards, operating theatres, as the dispensary and mortuary as well as sanitation, medical stores, kitchen and staff facilities.

Again soldiers were assessed and treated depending on the severity of their wounds. Minor wounds were treated and sent back to the Front. Those who were severely wounded but who were able to travel were sent immediately by rail or barge to base hospitals. Whilst those with life threatening wounds were treated immediately and sent to the larger base hospitals for further treatment when they were fit enough to travel.

A typical CCS could treat up to 300 patients at one time and hold around 1000 casualties prior to transfer.

“About six days ago I had a temperature of 101.4 and I got "excused duty". The following two days I did the same and then I was sent to No.5. Field Ambulance [Dressing station]”25th January 1917, Moore to his parents.

“Your son asks me to write you a line to let you know that he was wounded yesterday in the thigh. The wound was severe and I think he lost a lot of blood. He was operated on & had blood transfused from a comrade, & he has much improved”Extract from Chaplain’s letter above.

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1. L0009404: Wellcome Library, London | 2. Reproduced with permission of the Council of the National Army Museum, NAM. 1986-06-77-62 3. © IWM (Art.IWM ART 3809) | 4. The Fusilier Museum London permanent collection | 5. L0024143: The RAMC Muniment Collection in the care of the Wellcome Library

There were six mobile x-ray units serving in the British Expeditionary Force in France and Belgium. Stationary x-ray units were attached to divisional casualty clearing stations.

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Medical Advances:

The British Army began the routine use of blood transfusion during WWI. In the beginning blood was transferred directly from one person to another. Captain Oswald Robertson, a US Army doctor, realisedthe need to stockpile blood before casualties arrived. He established the first blood bank on the Western Front in 1917. Blood was kept on ice for up to 26 days and then transported to casualty clearing stations for use in life-saving surgery.

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The Officers' Ward at the 41st Casualty Clearing Station.

Also serving with the Royal Fusiliers was Frank York. On the 25th March 1918 York was working as a runner in no mans land when he was hit by a sniper. He received a gun shot wound to the right thigh. Severely wounded he was evacuated from the battlefield but unlike Frank Moore, York would not return to the Front.

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25th March 1918, the Chaplain’s letter to York’s parents.

EVACUATION

10 Medical Officers

Dressing Station

180 Royal Army Medical Corps (RAMC) Orderlies

40 Support Staff

Casualty Clearing Station

7 Medical Officers

70 RAMC Orderlies

80 Support Staff

7 Nurses

1 Dentist

1 Pathologist 36 Stretcher Bearers

Ambulance trains and hospital barges were used to transport soldiers from the CCS to the base hospitals. A train could carry an average load of 400-500 patients and a barge around 30 patients. Barges were towed in pairs by a steam tug and although slow, moved smoothly, which was particularly suited to patients with more serious injuries.

Base hospitals were the final overseas hospitals to receive casualties. They were located near the army’s principal bases at Boulogne, Le Havre, Rouen, Le Touquet, and Etaples. More than half the sick and wounded were evacuated from a base hospital for further treatment or convalescence in the UK.

“On Thursday at about 11am a lot of patients from No 9 C.C.S. were put on a hospital train…At about 3am the next morning we arrived at the station…where we were put on motor ambulances and soon found ourselves here. The ward is a wooden hut fitted up with electric light etc. It is a very nice place”"C" Coy, 24th Royal Fusiliers. Ward 19, No 5 Gen Hospital. B.E.F. 3rd February 1917, Moore to his parents.

“I left No. 5 General Hospital at 7.30 this morning and after a ride in the motor ambulance I boarded the good ship St. Patrick and set out on a voyage of discovery at 9 a.m…About 10 p.m. the ship stopped - somewhere outside Southampton I suppose - and we have to wait till tomorrow before we land. The Sergt. Major (R.A.M.C.) came round during the afternoon and asked us where our homes were and then told us which train we were to get into. Mine is No. 1”28th February 1917, Moore to his parents.

“about 10.0 a.m. we landed. No. 1 train was full up when I was carried off the boat so I had to go on No. 3… My new address is L/Cpl F. A. Moore, 24th Royal Fusiliers, Ward A2, 1st Southern General Hospital, MaryhillSection, Birmingham. The hospital was a school I should imagine and it is very nice. Our ward contains 12 beds so it is quite a nice little party. At Rouen we had 42 in the ward”1st March 1917, Moore to his parents.

Not every soldier returning to the UK was wounded, many soldiers returned due to illness. Trenches were waterlogged, cold, and lacked sanitation, while mental stress, lack of sleep and poor diet weakened their immune systems. Diagnosis was difficult, and many illnesses were simply categorised ‘Pyrexia [fever] of unknown origin’. Frank Moore was invalided back to the UK after suffering from a sudden high temperature, impetigo (a severe skin infection), joint pain, and neurasthenia (loss of nerve sensation). He took five months to recover – his longest period of recuperation.

Like Frank Moore, those who were sent back to the UK travelled on hospital ships. These were mostly converted passenger liners and were staffed by members of the Queen Alexandra’s Imperial Military Nursing Service.

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Red Cross train loading up at Casualty Clearing Station.

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Interior of a Hospital Barge.

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Nurses of the Queen Alexandra's Imperial Military Nursing Service Reserve and convalescent soldiers in a ward in the Casino Lechin, one of the six sections of No. 2 General Hospital at Le Havre.

EVACUATIONLocated in existing hospitals or re-purposed buildings, base hospitals were situated near railway lines and ports in order to send treated soldiers back to their battalion or across the Channel to the UK. They were fully equipped with X-Ray departments, pathology, mobile hygiene and bacteriological laboratories.

“I have been X rayed to find whether there is any shrapnel in my thigh.Have just heard result of X ray examination – ‘no foreign body and no bone broken’ ”No 4 Stationary Hospital, Winnereux, BoulogneThursday 2nd August 1917, Moore to his parents.

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“The doctor wrote on my ticket before I left Rouen.

Diagnosis – P. U. O.Impetigo of face

Pains in legs, joints & shinsPyrexia 14 days”

28th February 1917, Moore to his parents.

Base Hospital

Up to 32 Medical Officers

206 RAMC Orderlies

plus Support Staff

70 Nurses

3 Chaplains

On arrival in the UK, hospital trains carried wounded soldiers to hospitals across the country. Existing military hospitals were expanded whilst many civilian hospitals, private houses and public buildings were requisitioned for military use. By the end of the War specialist hospitals had been set up to provide on going care and recuperation for the most serious casualties.

An estimated 41,000 men suffered partial or total limb amputations during WWI.

Amputation was common, particularly at the beginning of the War when the use of splints was very basic.

Frank York was one of the large number of casualties to undergo amputation, “to save his life it was found necessary to amputate his the leg below the knee” (28th March 1918, Chaplain to York’s father).

By the 9th April 1918 York was back in England at the 1st Western General hospital, Liverpool. Here he was subject to plenty of bed rest and the occasional outing in a wheelchair around the grounds. At first his wound healed well but by June the progress had slowed and he was frustrated to find himself in the same hospital bed three months on. He wrote to his parents asking them to send him drawing materials so that he could keep himself busy. In July he was moved to the nearby Camp Hill Auxiliary hospital, which he liked very much. The hospital was smaller, there were watercolours on the walls and a great view of the Mersey Valley. On the 19th of July he was finally moved to Whipps Cross Hospital in London and closer to his family. During 1919 he spent time recuperating and his sketches from this period show people, landscapes and trips to music halls and the seaside.

Once a patient had been fitted with a new prosthetic limb they received physical therapy and retraining to help them return to civilian life and post-war employment.

Items made by patients at the workshops at Queen Mary’s included the Thomas splint. This simple but effective frame was used on the battlefield by Medical Officers and Stretcher Bearers to support the leg of a soldier with a compound fracture of the femur.

1. & 2. The Fusilier Museum London permanent collection | 3. © IWM (Q 33684) | 4. L0057722: Science Museum, London, Wellcome Images5. L0057927: Science Museum, London, Wellcome Images 6. © IWM (Q 33687) | 7. © IWM (Q 108160)8. L0025839: Army Medical Services Museum, Keogh Barracks, Wellcome Images

Prosthetic limbs were fitted after amputation. Queen Mary’s Hospital in Roehampton became one of the world’s leading limb fitting and amputee rehabilitation centres.

Early prosthetics were wooden and heavy. Patients often abandoned them in favour of crutches or ‘peg legs’. It was not until the early 1920s that lighter metal versions were designed.

Despite new innovations the Anglesey limb remained popular well into the 20th century. It was relatively lightweight and capable of a natural-looking walking movement.

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Examples of artificial legs made for a patient who had their leg amputated above the knee.

Above - made from fibre, wood and with leather padding to secure the limb around the waistLeft – the Anglesey limb made from willow and leather

Plaster cast being taken in preparation of Artificial Limb.

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Making an artificial leg for a wounded serviceman at Roehampton Hospital in Surrey.

SHELL SHOCKNot all wounds were visible. Some soldiers suffered from paralysis, anxiety, dizziness, muteness, deafness, nightmares, vomiting, extreme fatigue, chest pains, or tremors.

In the early stages of the war it was thought that these symptoms were physical reactions to the explosions of nearby shells, hence the condition’s name. Initially the condition was viewed with suspicion, many believing it to be a form of cowardice or a sign of mental weakness. However as cases increased it became recognised as a genuine psychological condition.

Treatment varied according to rank. Officers received talking therapies, hypnosis or massage at specialist institutions to restore their ability to lead under pressure. Soldiers below officer rank received less specialised treatment, such as drugs to aid sleep and a regime of exercise, fresh air, and improved diet. The focus on physical symptoms meant that some soldiers returned to service in a matter of weeks. More serious cases were treated with electric shock therapy or were sectioned under martial law.

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A soldier learning to use his artificial arm at Roehampton Hospital near London, 1917.

‘Study of Stumps’ sketched by Pte Frank York whilst convalescing at Whipps Cross Hospital 1918.

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AMPUTATION

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Gas was first used in 1915. With the introduction of the gas mask, death was usually avoided - of the 188,700 British victims of gas only 3% proved fatal. 70% were usually returned to active service within 6 months.

1. & 2. Photographs available at - © Museums at the Royal College of Surgeons | 3. © IWM (Q 30460) | 4. © IWM (Q 30456) | 5. © IWM (Q 30457) | 6. © IWM (Q 27526) | 7. & 8. The Fusilier Museum London permanent collection

DISFIGUREMENTWhilst some wounds were unseen others were very visible. Shards of shrapnel, bullets and burns caused severe facial disfigurement. A specialised hospital, the Queen’s Hospital, was opened in Sidcup, Kent to treat the most difficult cases. It became the pioneering centre for plastic surgery under the renowned surgeon, Harold Gillies.

Private Harold Burbidge, of the 20th Royal Fusiliers, suffered a gunshot wound to his chin on 24th October 1916 which caused a complex bone fracture. Burbidge underwent multiple operations to reconstruct his jaw and mouth. He was finally discharged in May 1918. His fracture healed but, unfit for active service, he was discharged from the Army.

Not all surgery successfully reversed a patient's disfigurement. Known as the ‘Tin Nose Shop’, or ‘Masks for Facial Disfigurement Department’, a special Clinic was set up at the 3rd London General Hospital in Wandsworth by the renowned sculptor Francis Derwent Wood.

A plaster cast was taken of the patients face which allowed the sculptor to mould a mask to conceal the disfigurement. These were made from thin copper plate which could easily be moulded, then painted to match skin tones and eye colouring, and held in place by the use of spectacles.

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Captain Francis Derwent Wood puts the finishing touches to a cosmetic plate made for a British soldier with a serious facial wound.

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Captain Francis Derwent Wood adds the finishing touches to a patient's new facial plate. He is trying to make the mask blend in with the patient's skin to make it look as life-like as possible.

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A selection of items used to conceal facial injuries during the early development of plastic surgery.

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Portrait of Private Harold Burbridge. By, Henry Tonks, 1918.This is part of a series of portraits made by Henry Tonks (1862-1937) showing patients treated by Harold Gillies and colleagues at Cambridge Military Hospital, Aldershot and Queen's Hospital, Sidcup, during and after the First World War.

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The 3 main types of gas were:

Chlorine: Appeared as a yellow cloud. It was used as a choking (pulmonary) agent. Contact with moist tissue such as the eyes, throat, and lungs caused an acid to be produced and an exposure of just two minutes could, in the worst cases, cause pulmonary lesions (spots on the lungs).

Phosgene: Could be colourless or appear as a white cloud. At low concentrations it smelt of newly mown hay. It was used as a choking (pulmonary) agent and was responsible for a large number of deaths. The gas acted as an irritant damaging the skin, eyes, nose, throat, and lungs. Exposure to the gas could have delayed effects with symptoms not becoming apparent for up to 48 hours.

Gas attack photographed from the air.

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GAS

“I saw the Doctor this morning with five others and he just looked at our chests and hands and said “fit”. He didn’t give us a chance to say anything” No 7 Coy. 6th Royal Fus. Langdon Prison, Dover.10th May 1917, Moore to his parents.

At the Command Depots, soldiers were introduced to physical exercises to retrain them for active service. Every 7-10 days they were assessed and graded by a Medical Officer according to their level of fitness and required length of retraining. The grades were shown by coloured armlets.

CONVALESCENCEOnce discharged from hospital those who were to be retrained and sent back to the Front were sent to Military Command Depots.

The men wore one-size-fits-all ‘Hospital Blues’. These uniforms were disliked by the men, who felt they appeared comical in ill fitting uniforms. The uniforms served a number of purposes from cleanliness, to a means of maintaining discipline amongst recovering soldiers. The outfit indicated that a man had served his country and was not shirking his responsibility.

Grade 4 – White – The worse cases.Grade 3 – Pink – Well enough for one to six months of retraining.Grade 2 – Light Blue – Required less than one month of retraining.Grade 1 – Dark Blue – Almost fit.

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Postcard of soldiers in their hospital blues from Frank York’s scrapbook.

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Gas Defence pamphlet belonging to Pte York.

Mustard Gas: Was not introduced until 1917. Generally a colourless gas it was recognised by its mustard or garlic odour. As well as effecting the lungs, it caused severe burns to exposed skin, eyes and respiratory tract, blindness, difficulty breathing and abdominal pain. Symptoms did not usually show until 12 to 24 hours later although exposure was not usually lethal.