George Thompson, M.A., M.F.A.
Adjunct Associate Professor
Historian
History and Philosophy of Medicine
The University of Kansas Medical Center

Wounded soldiers passed through several medical units beginning with stabilizing emergency care from aid posts, dressing stations and field hospitals that prepared them for treatment at an Evacuation Hospital.

Corps-army Diagram

This hospital was planned to support the division's field hospitals by receiving their patients when they moved to a new location. However, this was not to be their role in France. What caused it to change was the experience acquired in 1917 that forced doctrine and unit missions to adapt in order to provide what was necessary in wartime.

It was envisioned in 1916 that the Field Hospital would be the "emergency hospital for the battlefield". However, experience proved its size, location and requirement to be mobile transformed it into a "magnified and improved dressing station rather than a hospital." In response the army re-defined the function of the Evacuation Hospital to be similar to that of the British Casualty Clearing Station. The implication of this was if the Field Hospital was not to provide life saving surgery then it fell to the Evacuation Hospital to perform it.

Surgery in progress in an operating theatre suite at No 3 Casualty Clearing Station, July 1916

The hospital's 432 patients were to be cared for by 16 medical officers and 179 men. Two were to be allocated to an infantry division. Although, available supplies could equip 22 they had no personnel. This problem was eventually solved by increasing the patient number to 1,000, finding and enlarging the staff to 34 officers and 237 men, and by allocating their limited number and increasing personnel on an as needed basis.

Although, their size varied their function, general layout and location remained consistent. Their purpose to provide "with great rapidity" the best possible surgical care was constrained by the number of casualties received per day. In order to prevent confusion, congestion and over-loading, the army chief surgeon wrote a medical plan for each offensive. In it he clustered hospitals in order to support each other and sited them to allow easy reception and evacuation of their patients to base hospitals. This meant in practice they were relay stations that treated but did not retain patients any longer than necessary.

Evacuation hospitals were mobile which meant they were housed in tents. To move one required ninety 3-ton trucks or 30 rail cars. However, if possible they were placed in villages which provided buildings and access to fuel and water. They were located 9 to 15 miles from the front on roads to forward medical units and by rail lines to base hospitals.

Tents used by Evacuation Hospital No. 1

The hospital's layout was designed to quickly treat a large number of admissions. The plan for Evacuation Hospitals 6 and 7 at Souilly illustrates this by the placement of its rooms and wards. Their Receiving Room and Evacuation Wards were adjacent to a road and rail lines which facilitated patient arrival and evacuation. In the center were the Operating Rooms, X-Ray rooms, and adjacent to them the hospital wards.

Evac Hospital 6 & 7 Layout

These hospitals were organized into two parts which were Administrative and Medical. The former dealt with records, supply, personnel and administrative matters while the Medical provided patient care as directed by the Chief of Surgical Service and Chief of Medical Service.

The Chief of Surgical Service supervised the:

• Receiving Room
• Dressing Room
• X-Ray Room
• Pre-Operative Ward
• Shock Ward
• Operating Room
• Post-Operative Ward
• Evacuation Ward

The Chief of Medical Service supervised the Medical and Gas Wards and assisted the Chief of Surgical Service in the Receiving Ward.

Receiving Room of an Evacuation Hospital

The process of sorting patients began with their examination on arrival at the Receiving Room which determined where each patient would be routed. At this point an important decision would be: Should he receive an operation or could it be delayed until at a Base Hospital?

For example, a small perforated wound, gutter wound, flesh wound or small bone fracture made one eligible for re-dressing in the Dressing Room and on to the Evacuation Ward to await a Hospital Train. This decision was likely if 1,000 casualties were received in a day. These injuries were not deemed as serious as head, chest, abdomen wounds or a fractured femur or multiple injuries.

Five wards and three rooms performed the surgical work which was the Pre-operative Ward, X-Ray Room, Shock Ward, Operating Room and Post-Operative Ward. All were aligned to reduce the distance a patient was carried and to efficiently use staff and resources.

The Pre-operative Ward prepared patients for surgery through another examination, undressing, bathing, morphine, shock prevention and sorting them into head, chest, abdominal, shock and fracture cases. If a patient was in shock or on the verge of it he was moved to the Shock Ward for resuscitation and if an X-ray was ordered he was transported to that room.

X-ray showing fractured clavicle and lodged missile in the outer end of the clavicle

The Operating Room was staffed by four teams using eight tables. Each team consisted of two surgeons, one anesthetist and two nurses, which if experienced performed 35 to 40 operations per shift. By mid-1918 it was common for teams to be augmented by ones from quiet evacuation and base hospitals which could be up to fourteen teams.

Operating room, Evacuation Hospital No. 2, Baccarat

The surgeries addressed the types and severity of injuries. A laparotomy was performed for abdominal wounds. Wounds caused by bullets and shell fragments required the devitalized tissue and foreign bodies be removed through debridement. This method was used to arrest or prevent infection, especially gas gangrene caused by anaerobic bacteria. The wound, if there was a possibility of infection, was packed or wrapped with gauze in anticipation of using the Carrel-Dakin system to prevent or control infection.

Debridement: Excision of the external wound, of the aponeurotic layer, of injured muscles

Fractures were set as well as repairs to the knee or elbow. If a limb was too damaged it was amputated. Head wounds were a challenge. They required neurosurgical skills and if an operation was performed it prevented an immediate evacuation. Therefore, the Chief of Surgical Service might recommend a delay and evacuate the patient to a base hospital.

Post-operative ward of an Evacuation Hospital

Upon completion the surgeon recorded his findings, the procedure and whether the patient should be 'detained' or 'evacuated'. Both categories were moved to the Post-operative Ward for recovery. If a patient was detained he was then moved to an appropriate ward of similar injuries. All cases, however, were not retained any longer than necessary which on average was 10 to 14 days.

Fracture ward of an Evacuation Hospital

If a patient was identified for evacuation upon recovery he was moved to the Evacuation Ward to join those from the Receiving Ward or Dressing Room. Here he was prepared for evacuation by being classified as a sitting or stretcher patient and whether he was a surgical, medical, infectious disease, or psychiatric case.

It was at this point the soldier passed to the next level, which was the rear area of base hospitals, via a Hospital Train. The coordination of this transfer was essential for the success of the entire patient management system designed by the Medical Department. It was entrusted to the Chief of Surgical Service who arranged with the army's Regulating Officer a Hospital Train for the evacuation of patients to their final destination.

Sources

Jaffin, Colonel Jonathan H. Medical support for the American Expeditionary Forces in France during the First World War (Fort Leavenworth 1990)

Surgery in progress in an operating theatre suite at No 3 Casualty Clearing Station, July 1916, CO 157, The Imperial War Museum, London

Volume VIII, Field Operations, The Medical Department of the United States Army in the World War (Washington, 1925)