Contents

CHAPTER XVI

THE DIVISION OF HOSPITALIZATION (Continued)

HOSPITALIZATION OF SICK AND WOUNDED

Though the hospitalization division of the chief surgeon's office, A.E. F., was charged with the supervision of all hospitals of the AmericanExpeditionary Forces, this volume gives but brief consideration to themobile hospitals which served armies, corps, or divisions in battle orin training areas. These mobile hospitals are discussed in Volume VIIIof this history, which considers field operations of the Medical Department.Though they were a part of the entire hospital provision of the AmericanExpeditionary Forces, their procurement did not form a part of the hospitalizationprogram as that term was technically understood. The hospitalization programreferred essentially to the provision of fixed formations-i. e., base andcamp hospitals and convalescent camps-and only when qualified by some explanatoryphrase was the term "hospital program" made to include the field hospitalizationof the American Expeditionary Forces. One reason for this was the factthat most of these field units were authorized by Tables of Organizationin certain numbers for each body of troops and were supposed to accompanythem automatically except as this provision was modified by priority ofthe shipping schedule. Certain units-e. g., mobile hospitals and mobilesurgical units-were not originally prescribed by organization tables butwere authorized by general orders and were provided according to tacticalneeds and resources. Thus, mobile hospitals were authorized¹but not supplied² in the proportion of one per division. Butthe prime reason why the field units were not included in the hospitalizationprogram proper was the fact that they were expected to give only very temporaryaccommodation to casualties. They had to clear as rapidly as possible inorder to receive new arrivals from the front and to be prepared to clearand move on very short notice in order to accompany the troops they served.Therefore their bed capacity could not be considered a part of the totalthat should be available at a given moment. Nor did this program technicallyinclude infirmaries established by the American Red Cross along the lineof communications, nor the infirmaries with capacities of from 10 to 50beds which the military forces established and staffed with local personnelfor care of the slightly sick and injured belonging to regiments in camps,small groups serving in towns, or other detached commands. These latterinfirmaries were established where neither the number nor the severityof the cases required the establishment of a camp hospital and were underthe administrative control of the local commander. All of these servicesthough not included in the hospitalization program proper were neverthelessunder the general supervision of the hospitalization division of the chiefsurgeon's office.

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Therefore, though the term "hospitalization," as technically understoodand as utilized in the following text, was applied to only fixed formations,and among these essentially to base and camp hospitals, including militarizedAmerican Red Cross hospitals and naval base hospitals receiving Army casualties,and to convalescent camps, it was used also in another and more generalsense, being applied to the entire hospital system of the American ExpeditionaryForces from the battle areas to the sea. This general system is here brieflydescribed, before a discussion of hospitalization in its more technicalsenseis undertaken, in order that there may be given a coherent view of thesubject in its entirety, and that the position therein of the fixed hospitalizationmay be defined.
 

HOSPITAL FACILITIES AT THE FRONT

The following units, which are discussed at some length in Volume VIII,comprised, during the World War, the sanitary train of divisions, corps,and armies:³ 3 field hospitals, motorized; 1 field hospital,animal-drawn; 3 ambulance companies, motorized; 1 ambulance company, animal-drawn;8 camp infirmaries; 1 medical supply unit; 1 mobile laboratory (added later).The normal capacity of the field hospital was 216 patients.⁴

When we entered the World War field hospitals were equipped similarlythroughout and in accordance with existent tables of organization, butthe unlooked for conditions it was necessary for them to meet in Francenecessitated additions to this equipment.⁵ Thus to one of thefour divisional field hospitals additional surgical equipment was issuedin order that it might function on a larger scale as a surgical hospital.To one of the other hospitals was added the equipment for the treatmentof gassed patients.

Field hospitals were utilized according to current needs, their serviceand disposition differing considerably in the several divisions under changingcircumstances. Often two hospitals were combined and here patients weresorted, distributed if need be to the other field hospitals with the division,or sent to the rear.

Usually one of the divisional field hospitals was used to sort patientsand to care for the wounded, one received sick, and another gassed, whilethe fourth hospital was held in reserve or was used to supplement one ofthe others.⁵ Sometimes one of these hospitals was used for thenontransportable surgical cases only. When facilities permitted, this last-mentionedunit was reenforced by a mobile surgical unit, extra bedding and equipmentand, rarely, by surgical teams. The hospitals carried their own tentage,but when opportunity offered occupied buildings in suitable locations.

As stated above, mobile hospitals were authorized in the proportionof one per division in action¹ but were not provided in thatnumber.² Only 12 were actually utilized.² These unitswere devised to care for the serious surgical cases and therefore wereprovided with appropriate equipment and with 120 beds for nontransportablewounded. The equipment to a large degree was surgical, and included X-rayapparatus, sterilizing apparatus, operating room supplies, electric lightingplant and mobile laundry. They cared for the seriously wounded who couldnot be transported to the rear without grave

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danger. They were distributed by the army surgeon to augment the serviceof field or evacuation hospitals. One was used for a time for the treatment,in the army zone, of cranial cases only.⁶ These units, thoughsmall, were complete, required but a few hours for their establishmentor packing, were readily transportable.

Mobile surgical units were smaller organizations transportable on threetrucks each provided with an operating room, sterilizing, X-ray and electriclight equipment. They also were assigned by the army surgeon to supplementthe hospitals of division, corps, or army.²

The sanitary train of a corps consisted of four field hospitals, fourambulance companies (all motorized) withdrawn from the replacement divisions.⁷These units cared for and evacuated patients from the divisional hospitalsin front of them to the army units in their rear and cared for the disabledwhile en route.

The sanitary train prescribed for an army was the same as that of anInfantry division.⁸ It was supplemented by the mobile hospitalsand mobile surgical units above mentioned, and by evacuation hospitalswhich were authorized in the proportion of the two per division.⁹However, that number of evacuation hospitals was never reached, thoughequipment for 16 of them was sent overseas early in the war.²Each evacuation hospital originally provided for 432 patients but in thesummer of 1918 their capacity was increased to 1,000 beds and the equipmentof these units already in France expanded accordingly.² In emergenciestheir capacity was further increased. These units under control of thearmy surgeon were located at railheads, where they received from the frontall patients that were to be sent to base hospitals on the line of communications.They were supplemented by other army hospitals which cared for gassed patientsby three neuropsychiatric hospitals and by certain militarized units furnishedby the American Red Cross.²
 

HOSPITAL FACILITIES IN THE SERVICES OF SUPPLY

The hospital facilities provided in the interior, in France, Englandand Italy, but by far to the greatest degree in France, were base hospitals(including one pertaining to the Navy), hospital centers, convalescentcamps, camp hospitals, American Red Cross military hospitals, AmericanRed Cross hospitals, and American Red Cross convalescent homes.²

BASE HOSPITALS

Prior to the World War, base hospitals were the Medical Department unitsof the line of communications designed to receive patients from field andevacuation hospitals, as well as cases originating on the line of communications,and to give them definitive treatment.¹⁰ It was intended thatbase hospitals would be well equipped for such treatment and that therewould be sent to the home territory only patients requiring special treatmentor whose condition might be such as to warrant the opinion that they wereeither disabled permanently or not likely to recover within a reasonablelength of time.

Base hospitals had been organized originally with a staff of 20 officers,46 nurses, and 153 enlisted men.¹⁰ This staff was increasedin the latter part

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of 1917, then consisting of 35 officers, 100 nurses, 200 enlisted menand a valuable but limited number of civilian employees, viz, dietitians,technicians, and stenographers.¹¹

Base hospital units were allowed in the shipping schedule in the proportionof four to a division, but were displaced to a considerable degree by combattroops, with the result that from the time our forces began to conductoperations on a large scale, in the summer of 1918, their number was inadequateand remained so until after the armistice was signed.² In manyinstances their equipment was not received for many months after havingarriving overseas.

HOSPITAL CENTERS

In the American Expeditionary Forces the controlling factor in the preparationof plans for base hospitals was economy in personnel and material. Butthere was every necessity for further economy in personnel, administration,and supply; consequently, these hospitals were grouped, in so far as localconditions permitted, into "centers of hospitalization,"¹² orhospital centers, as they came to be called.
 

CONVALESCENT CAMPS

Before headquarters, A. E. F., authorized the establishment of convalescentcamps, on June 1, 1918,¹³ there were in nearly all our militaryhospitals in France many patients whose medical or surgical treatment hadbeen completed, but whose physical condition was such that their attendingsurgeons could not return them to their commands for full duty.¹⁴Since there was every necessity for keeping as many base hospital bedsas possible ready for the reception of patients from the front, the substandardmen referred to above frequently had to be evacuated long distances toother hospitals where the demand for beds was not so insistent. Particularlywas this necessity for a clearance true of the base hospitals located nearerto the front. To relieve this condition and, at the same time, to increasehospital facilities generally, the chief surgeon, A. E. F., recommendedon May 17, 1918,¹⁵ that convalescent camps be authorized andconstructed, one in the vicinity of each hospital group. Its size in pointof bed capacity was to be rated at one-fifth that of the hospital groupit was to serve.

The cases to be sent to a convalescent camp were those for whom medicaland surgical treatment, beyond dispensary care was no longer necessary,but who needed a more or less brief period of graded physical trainingand rehabilitation suited to their condition. This physical rehabilitationwas to be under an experienced medical officer; but line officers assistedby noncommissioned officers, temporarily or permanently disabled for furtherduty, were to be used for commanding and drilling provisional companies.Thus over-hospitalization and loss of discipline would tend to be obviated.

Though it was proposed to use barracks for convalescent camps, no objectionwas held to the use of tents, the stipulation being, however, that thereshould be an increase in floor space over that for ordinary barracks andthat there should be no double bunks.

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As mentioned above, this proposal of the chief surgeon was approvedby headquarters, A. E. F., June 1, 1918. The bed capacity of convalescentcamps was included in the normal capacity of the hospitals with which theywere connected.

CAMP HOSPITALS

It is neither necessary nor advisable to place all cases originatingon the lines of communications in base hospitals; all such cases do notrequire the more extensive or definitive treatment for which base hospitalsare intended; furthermore, it is axiomatic that sick and injured soldiersshould receive hospital care just as near their commands as is compatiblewith the condition of the patients and with the exigencies of the militarysituation. Therefore, in the American Expeditionary Forces for each divisionaltraining area and camp, a camp hospital was provided,¹⁶ whereall local cases could be admitted, only the severely sick and injured requiringa better quality of treatment being transferred to base hospitals.

As early as July, 1917, the chief surgeon, A. E. F., attempted to secureauthorization for personnel for these important units but his recommendationwas disapproved, on the ground that personnel from the divisional sanitarytrains would be available to fill this need.² Experience provedthat such a view is based on a misconception of the problem presented.To employ the sanitary train personnel in this way prevents the trainingin preparation for combat, which is just as essential for sanitary unitsas for those of the line. Moreover, divisions were constantly changingfrom one area to another and to have followed the plan proposed by thegeneral staff, A. E. F., would have resulted in abandoning these excellently-equippedsanitary formations until the next division chanced into the same area.²The necessity for providing and authorizing sanitary personnel for thecamp hospitals is one of the outstanding lessons of the experience gainedin this war.²

CAPACITY OF HOSPITALS

BASE HOSPITALS

The pre-war bed capacity of a base hospital was 500.¹⁰ Thiswas based upon the fact that in a war of motion it frequently would becomenecessary with the progression or recession of the battle front to changethe locations of base hospitals along lines of communications. Thus mobilitywas a factor which had to be borne in mind in connection with the equipmentof a base hospital. However, in France, there was every indication thatthe location of a given base hospital would be relatively fixed; consequently,in his study of hospitalization for the American Expeditionary Forces,the chief surgeon, A. E. F., on August 2, 1917, stated that the personnelof a base hospital, with proper material, could reasonably well care for1,000 patients, and that it was his intention to increase the equipmentof these units and to operate them with a capacity of 1,000 beds each.¹⁶This increased capacity was effected in General Pershing's project of therear which he sent by cable to the War Department during the followingmonth.

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Fig79. Outline map of France showing the location of thevarious fixed hospitals of the American Expeditionary Forces

In addition to the increase in capacity of base hospitals from 500 to1,000 beds, a crisis expansion of 1,000 beds was provided for by the useof tents.¹⁷ Thus there came to be two kinds of bed capacity:normal and crisis expansion. It was only upon the normal bed capacity,however, that the ratio of hospital beds to troops was based.¹³

HOSPITAL CENTERS

Since hospital centers comprised an aggregation of base hospitals, theirseparate bed capacities were not fixed. They possessed an elasticity, inso far as hospital beds were concerned, that was limited, on the one hand,by available ground where buildings constructed in situ were to be used,and, on the other hand, by available buildings where these were to be used,for example, at Vichy.

At a number of points several-i. e., from 2 to 11-base hospitals weregrouped physically in hospital centers, and accommodations for much largerformations were under construction when the armistice was signed.

The largest of these hospital centers were at Mesves, Mars, Savenay,Bordeaux, Bazoilles, Rimaucourt, Beaune, Allerey, Nantes, Brest, and Limoges,whereas in Paris the hospitals were grouped administratively as one center.The principal hospital centers in existing buildings were Vichy (hotels),Toul (casernes), Clermont-Ferrand, Vittel-Contrexeville, and Cannes.
 

CAMP HOSPITALS

Camp hospitals had an authorized capacity of 300 beds and crisis capacityin emergencies,¹⁶ but some were much larger; e. g., No. 26,which served the first replacement depot at St. Aignan, and had a capacityof 2,200 beds,¹⁹ and Camp Hospital No. 52 at Le Mans, whichhad a capacity of 2,300.²⁰
 

AMERICAN RED CROSS HOSPITALS

American Red Cross military hospitals and convalescent homes were avaluable asset to the American Expeditionary Forces, particularly in Paris,where up to the time of the Chateau-Thierry operation the Medical Departmentwas not allowed to establish hospitals.² Their bed capacitywas variable. After July 1 the Medical Department did establish many hospitalsin and around Paris and on November 11 arrangements were under way by whichwe would have had 20,000 beds in that city.²¹ Other notableRed Cross hospitals were at Beauvais, Juilly, Jouy-sur-Marne, Toul, Froidos,and Glorieux, as well as convalescent homes for officers, nurses, and men.

RATIO OF BEDS

In the early summer of 1917 the hospitalization question concerningthe American Expeditionary Forces naturally divided itself into two distinctproblems: Hospital accommodations to meet the immediate needs of the sickof the American troops in France; the provision of hospitals for the careof the wounded to be expected when our troops became actively engaged inthe front line.

As it obviously was impossible for us to construct hospitals in timeto meet our immediate needs, the French were asked to relinquish to usaccommodations of this character wherever they were needed.²To these requests they willingly acceded.

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After the French had met the initial needs of our service in the transferof hospital facilities, they urged that we prepare a hospitalization programin which we would outline what we considered necessary to meet both presentand future needs.²² They did not seek to influence the termsof the program, but sought chiefly to learn the number of beds that theAmerican Army would require as well as their geographical distributionin order that they might promote our projects and coordinate a similarplan of their own with ours. Accordingly, on July 8, 1917, representativesof the chief surgeon's office, A. E. F., and of the French Medical Serviceheld a conference whose purpose was the study of a project to provide 50,000beds, which it was the intention of headquarters, A. E. F., to locate inFrance during 1917.²³
 

^{FIG. 80.-American Red Cross Military HospitalNo. 21, Paignton, Devon, England}

This number of beds was considered by the chief surgeon as being toosmall to use in connection with a project, in view of the inevitable delayin securing sites and completing necessary construction work; thereforeon August 2 he recommended in its stead that not less than 100,000 bedsbe provided, using 500,000 troops as a basis for his estimates.²⁴At this time the general staff was willing to agree to the chief surgeon'sestimate in part only;²⁵ that is to say, no fault was foundwith the proportion of the number of beds to be supplied, but, since itwas believed that there had been an inadequate time for mutual researchand study, there was a possibility of error which would be minimized

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in a basic number smaller than 500,000 troops. Therefore, the applicationof the chief surgeon's percentages was made to a force of 300,000 men,thus providing for 73,000 beds.

Since there must be a correlation of the provision of beds and personnelwith which to operate them, and further, since the bringing of personnelto France had been placed on a phase basis, it is not surprising that headquarters,A. E. F., should adopt a similar basis for hospitals. This was done inmid-October, 1917.² Hospital beds were now allowed on the basisof 10 per cent of our total forces in Europe for a given phase, with anadditional 10 per cent for troops in combat. It was anticipated by thegeneral staff that not more than four of the five corps concerned wouldbe engaged simultaneously, consequently the above allowance would approximate15 per cent hospital beds for ordinary needs and 25 per cent for maximumneeds, in addition to the beds of the divisional field hospitals.²²

FIG. 81.-American Red Cross Convalescent HospitalNo. 101, Lingfield, Surrey, England. (For officers)

The provision of base hospitals according to the successive incrementof forces was tabulated as follows:

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American Expeditionary Forces hospitalization program-estimatedbeds required

In forwarding this program to the chief surgeon, the adjutant general,A. E. F., stated that since the whole question of the strength of the AmericanExpeditionary Forces was dependent upon the amount of tonnage that mightbe placed by our Government in the trans-Atlantic transport service, andthat accurate information on this particular subject would not be availablefor some time, the commander in chief, A. E. F., was not prepared to takeany definite action beyond such authorization for providing hospitals ashad already been given.²⁶ The study was believed to be completeenough to warrant consideration by the chief surgeon with a view of makingsuch recommendations as he desired.

In his analysis of this program, the chief surgeon pointed out thatthere were two factors which must be taken into consideration as havinga possible modifying influence on the result arrived at:²⁷ First,the basic principle on which the program was founded was that the personnelof each base hospital unit could care for 1,000 patients; second that abase hospital unit in an emergency, could increase its capacity from 1,000beds to 2,000 beds by the use of tentage. As to the first, the base hospitalunit obviously could not care for 1,000 patients if it became necessaryto divide the units into small detachments in order to fit them into smallexisting buildings which might be taken over from the French. As to thesecond factor, the emergency expansion could not be considered as beingpossible were existing buildings such as schools and hotels to be takenover and used as hospitals, in view of the fact that in connection withmost of these buildings there was inadequate ground space for expansion.Even if there were the necessary ground space, the lack of usual hospitalfacilities, by additionally burdening the personnel, would almost makeexpansion out of the question.

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On December 15, 1917, the chief surgeon reported to the commander inchief, A. E. F., that in so far as the Medical Department was concerned,the project of 73,000 hospital beds along the line of communications hadbeen accomplished.²⁸ In this accomplishment, he had found thatadherence to a fixed numerical fractional program had caused much confusionand delay in the acquisition of sites and labor and in the placing of material.It was thus obvious that hospital construction on a definitely prescribedpercentage basis could not keep pace with the arrival of troops. In theabsence of authorization to perfect plans for a progressive hospitalizationprogram looking far into the future, it was impossible to provide in timethe necessary hospital facilities eventually required. For this reasonthe chief surgeon recommended that hospital construction be authorizedon the basis of the strength of an army rather than in proportion to incrementsof troops. Such authorization, he pointed out, would permit the developmentof a much more comprehensive plan of hospitalization than the phase orprogressive fractional plan. This program was to contemplate the ultimateprovision of a total of 200,000 hospital beds, ordinary capacity.

Pursuing this question further, a medical representative of the chiefsurgeon, G-4, G. H. Q., A. E. F., made an analytical study of the resourcesand limitations of hospitalization. The result of this study was submittedto the general staff on March 31, 1918, together with a recommendationthat there be authorized an automatic bed allowance which would recognizethat six months would be necessary to complete a project.²⁹It was also recommended that the Medical Department be authorized to arrangefor new hospital accommodations on the basis of 12,000 beds a month, whichwould be acquired either through acquisition of existing buildings or bynew construction. These recommendations were not approved at the time,and until a new policy was announced it was necessary for the Medical Departmentto take up direct with the general staff any new project for which newconstruction was necessary.

At this time 45,300 beds were allowed on the strength of the troopspresent, 1 corps-i. e., 300,000 men-but of these beds there were actuallyavailable in the hospitals of the American Expeditionary Forces only 21,340,leaving a shortage of 23,960.² Projects then under way to meetthe needs of present and prospective strength would provide for a totalof 118,930 beds when completed.²

On June 1, 1918, headquarters, A. E. F., authorized the Medical Departmentto maintain an actual current bed status aggregating 15 per cent of thetotal strength of the American Expeditionary Forces.¹³ In effect,this was approximately the same percentage that previously had obtained-thatis, 10 per cent for total forces and 10 per cent additional for combatforces-however, in reality, the establishment of the flat rate tended toavoid future conflict of opinion as to the ratio of combat and other troops.This latest numerical allowance was to include the accommodations in allfixed hospitals, irrespective of type, as well as in convalescent camps,and the computation was to be made on the basis of ordinary capacity.

Since it now was well recognized that projects involving new constructioncould not ordinarily be available for occupancy before the lapse of atleast six months, and that the provision of adequate hospital accommodationsmust

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keep pace with the arrival of troops, headquarters authorized the MedicalDepartment an additional credit of 90,000 beds over the 15 per cent referredto, in order that it could make timely anticipation of its future needs.In utilizing this credit the Medical Department was to write off approximatelyone-sixth of it monthly.¹³
 

LOCATION OF HOSPITALS; PROGRESS IN HOSPITALIZATION

The first program for the location of hospitals of the American ExpeditionaryForces, formulated by the chief surgeon, A. E. F., in the summer of 1917,was, of necessity, tentative for the reason that before it could be adoptedcertain factors must definitely be decided upon, especially the sectorof the front which the American forces would occupy, and the main railwaylines and ports which would afford means of communication.²Up to the fall of 1917, the chief surgeon had not received any definiteinformation concerning the sector our troops eventually would occupy atthe front;² however, as delay could not be countenanced, heproceeded on the assumption that our principal bases must be St. Nazaireand Bordeaux, and that our sector would be in Lorraine, in the vicinityof the training areas (Gondrecourt, Neufchateau, Mirecourt, and Le Valdahon)in which they were placing our troops.² This assumption indicated,in turn, what probably would be our lines of communications, and eventsproved that these early conjectures generally were correct. The Americansector eventually occupied extended from west of Verdun to east of Belfort,³⁰and the base ports most utilized were Bordeaux, La Rochelle, St. Nazaire,and Brest.³¹

While estimates of the number of troops that would be used in the AmericanExpeditionary Forces were being formulated by general headquarters, A.E. F., the hospital program was being furthered, inspections for possiblehospitals were continued and arrangements made for obtaining buildingswhich were suitable for hospital purposes, and, so far as could be estimated,properly located near St. Nazaire, Bordeaux, the training areas mentionedabove and along the railway lines between them and the ports.²In carrying out this project studies were made of prospective hospitalsites in or near the following places: Nantes, Angers, Tours, Romorantin,Bourges, Gievres, Nevers, Beaune, Dijon, Langres, Chaumont, Martigny, Neufchateau,Vittel, Contrexeville, Bordeaux, Perigueux, Limoges, Chateauroux, St. Nazaire,Savenay, La Rochelle, Cercy-la-Tour, Le Valdahon, Besançon, Rigny-les-Salles,Cosne, Ourches, Epinal, and Sens.²⁸ The Engineer and the MedicalDepartments concurred in the belief that Bordeaux and St. Nazaire werethe most desirable ports, since in both places there were good facilitiesfor docks, large base hospitals, camps, and water supply.

As stated above, the first allowance for hospital beds made by generalheadquarters, A. E. F., was 73,000.²⁵ As to the location ofthese, headquarters directed that a joint study be made by the chief quartermaster,the chief surgeon, and the chief of engineers, A. E. F., which resultedin the geographical distribution of hospital beds as follows: 14,000 bedsin the advance section, 21,000 beds between Tours and the French zone ofthe armies, 38,000 beds from Tours westward.

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The chief surgeon, A. E. F., now proposed that such construction forhospitals be located as follows, the several establishments in each sectionbeing entered on this list, in order of their preferability:²
 

On October 6, the commander in chief, A. E. F., wrote the French militarymission in part as follows:³²

The attached letter shows in detail the program that isnow being carried out by the Medical Corps, American Expeditionary Forces.It shows the immediate necessity of providing hospital facilities for 73,000beds in the zone of the line of communications. It shows also the generalareas in which it is desired to locate the various hospitals with the desiredbed capacity of each.

It is believed, however, that during the preliminary phasesof our operations here we will be forced to use existing buildings, hotels,etc., as hospitals pending the construction of new hospitals, notwithstandingtheir disadvantages. This is on account of the shortage of constructionmaterial.

The most practical plan for us to follow, it is believed,is to make use temporarily of the existing facilities and at the same timepush new construction as fast as possible. The sites for construction ofhospitals must be at points where the available ground will permit of largeexpansion and where the railroad evacuations will be best met.

It is therefore requested that we be given the benefitof the opinion of the French authorities on this entire question at asearly a date as practicable. Please include lists of available buildingsin the zone of the line of communications of these forces, not includingthose listed in the attached letter, suitable and available for hospitalization.At the same time, please give your recommendations as to location of definitesites for construction of hospital centers.

From the attached letter the difficulties that the MedicalCorps, American Expeditionary Forces, have had in their endeavor to procurehospital accommodations and sites are clearly presented. It is requestedthat this matter be immediately taken up and that these headquarters beinformed as to what steps it should take with reference to placing theproper representatives of the Medical Corps in relation to representativesof the French Government, to the end that any further delay in providinghospitals for these forces be prevented.

On October 8, 1917, the chief surgeon informed the chief of staff, A.E. F., that the commander in chief of the French Armies had stated thatit would be necessary to hold a conference to establish a program of hospitalization.³³He added that a working basis concerning this subject in the French zoneof the interior had been reached between his office and that of the FrenchMedical Service, but that until a similar arrangement could be made forhospitalization in the zone of the armies, but little progress could bemade in

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providing the absolutely necessary hospital facilities in that jurisdiction.He therefore recommended that the proposed conference between representativesof the French and American services for the consideration of hospitalizationbe held at the earliest practical moment.

On October 11, the commander in chief wrote to the chief of the Frenchmilitary mission calling attention to the need of hospitalization in theAmerican Expeditionary Forces and to the necessity for immediate stepsto provide adequate hospital facilities. He recommended that a conferencebe called at the earliest possible moment.³⁴ Accordingly a conferencewas held at Chaumont, October 17, between representatives of the Americanand French Armies, when the following conclusions were reached:³⁵

Seventy-three thousand beds should be provided for a forceof 300,000 men. In order to shorten the journey for wounded and to effecteconomies in transportation, equipment, personnel, the general distributionof beds proposed by the general staff (13,000 in the advance zone, 21,000in the intermediate, and 39,000 in the bases) should be modified, so that40,000 beds would be located in the intermediate zone and 20,000 in thezone of the bases. The intermediate zone would be included (roughly) inthe area bounded by Sens (exclusive), Orleans, Tours, Dijon, Lyon. Sanitaryinstallations would not be restricted to the lines of communication only,but might also be developed on subsidiary branches of these lines. Thisarrangement would secure treatment of slight cases in the zone of the advance,of more serious cases in the intermediate zone and of the very seriouscases, including those returnable to the United States, in the zone ofthe bases. Inspections with a view of locating suitable hospital siteswould be undertaken jointly, by the Americans and French without delayand installations would be sought not only on the direct lines of communicationbut in subsidiary lines as well. In the zone of the armies, formationsthen held by the French would be turned over with their equipment to theAmerican service as soon as its troops entered the sectors these formationsserved, while regional installations would be, in principle, retained underthe general jurisdication of the territory they served, the transfer beingdecided according to circumstances in each case.

The report of the conference further reads as follows:

Hospitals in the zone of the armies: In regard to the10 division camp hospitals which the American staff proposed to establishas hospitals of 300 beds apiece with extension possibilities to 1,000 beds,the French staff thinks that it would be advisable, in order to obtainimmediately and at the lowest cost the necessary buildings for the hospitalizationof the sick, to provide each zone with places for cantonment infirmariesin each of the existing cantonments, and to use, for supplementary needs,the French hospitals which would be handed over to the Americans in thezones in question and to which evacuations could be made by motor ambulances.In this connection a list of hospitals containing from 7,000 to 8,000 bedswas handed the representative of the chief surgeon. These hospitals willbe handed over progressively to the American Medical Service concurrentlywith the arrival of 300,000 men.

It is also considered expedient to utilize as far as possibleat the present time all available structures, such as chateaux and largebuildings. In regard to the hospitals which are to be built, sites areto be searched for on the lines, Bricon-Chatillon, Chatillon-Troyes, Chalindrey,Boulogne-Rimaucourt.

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4. Hospitals in the zone of the interior.-Afterthe examination made of the projects entertained by the American staffin regard to the French hospitals which are to be taken over and hospitalsto be built, the conclusion is reached that in dealing with numbers ofbeds as detailed in page 1 it is advisable only to use, in selecting importanthospital centers, such plants or places that can be cleared by railroadservice. In this respect sites for large hospitals will be suggested andsearched for (subject to the approval of the commander in chief, A. E.F.).

(1) In the intermediate zone, sites will be located inthe district of Cercy-la-Tour, of Clamecy, of Autun, of Avallon, etc.

(2) In the zone of the bases, sites will be located inthe district of Redon and Auray in the northern area and in the districtof Bordeaux and Arcachon in the southern area. The sites to be utilizedand the hospitals in the interior which are to be taken over will be madethe subject of studies and agreements, to be concluded, in each case, betweenthe undersecretary of state of the service de santé and the generalstaff of the Army (fourth bureau, on the one hand, and the American staff,on the other).

5. It is agreed that this study is based on the requirementsof 300,000 men and that a new conference will be held in due course fora discussion of the needs of larger numbers of effectives.

With this report was included a statement of the hospitals which hadbeen and which would be turned over to the American Expeditionary Forcesand the bed capacity of each. These were as follows:

The report of this conference was accepted by the administrative section,general staff.² Concerning this program the chief surgeon wroteas follows on October 19, 1917.³⁶

  OCTOBER 19, 1917.

Memorandum for the C. of S.

Subject: Hospitalization.

1. The conference of October 17, 1917, referred to inattached memorandum brings up three points for consideration:

(a) The acceptance of certain French hospitalslocated to the north and east of Neufchateau.

(b) Changing the figures accepted by the generalstaff, from 38,000 beds in the base section and 21,000 beds in the intermediatesection, to read 21,000 beds in the base section and 38,000 beds in theintermediate section.

(c) The enlargement of the intermediate sectionto take in the territory shown on the attached map.

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2. All of these propositions meet with my approval. Theacceptance of the hospitals offered by the French appears at this timeto be a matter of necessity. The enlargement of the intermediate zone opensa considerable field where existing French hospitals suitable for our purposesmay be found.

3. The accompanying map shows very clearly the lack ofexisting French hospitals in the southwestern part of the divisional trainingareas, consequently as stated in the attached memorandum hospital facilitiescan be provided only by construction.

4. In paragraph 1-A of the attached memorandum the statementis made that 7,000 beds now existing in the French hospitals are availableto the American Expeditionary Forces. Attention is invited to the factthat while the French hospitals shown on the map attached total, accordingto the figures, 7,233 beds, 1,510 beds have already been turned over tothe American Expeditionary Forces and are not to be counted. This leaves5,700 beds which it is stated are available. From information now at handit appears that one of these proffered hospitals belongs to the civil communityand can not be disposed of by the G. Q. G.

5. This number will be further reduced through the factthat it appears probable from information now at hand that some of thesesmaller hospitals can not be used by the American Expeditionary Forces.In addition, the capacity of the hotels at Contrexeville, Martigny, andVittel is listed differently by the French for summer and winter; i. e.,certain of the hotels were built for summer use only and it has been possibleto occupy only a part of the buildings in winter time. The figures givenabove are the summer capacity.

6. It is recognized that in the present emergency anythingthat offers shelter for patients must be used. However, in concurring inthis memorandum it is with the reservation that the use of such buildingsas the French have offered can be considered only as an emergency measureand in no wise meets, from our point of view, the demands for adequatehospital facilities. The very serious obstacles to the use of buildingsnow employed by the French as emergency hospitals was indicated in detailin my letter of September 27, 1917, on the general subject of hospitalization.

A. E. BRADLEY,
Brigadier General, Chief Surgeon.

On October 23 the following hospitals were under the control of the chief surgeon, A. E. F.:³⁷

American Red Cross Military Hospital No. 1, Neuilly.
Base Hospital No. 6, A. E. F., Bordeaux.
Base Hospital No. 8, A. E. F., Savenay.
Base Hospital No. 9, A. E. F., Chateauroux.
Base Hospital No. 15, A. E. F., Chaumont.
Base Hospital No. 17, A. E. F., Dijon.
Base Hospital No. 18, A. E. F., Bazoilles.
Base Hospital No. 101, A. E. F., St. Nazaire.
Base Hospital No. 27, A. E. F., Angers.
Base Hospital No. 39, A. E. F., Limoges.
Base Hospital No. 2, care of General Hospital No. 1, British Expeditionary Force, Etretat.
Base Hospital No. 4, care of General Hospital No. 9, British Expeditionary Force, Rouen.
Base Hospital No. 5, care of General Hospital No. 13, British Expeditionary Force, Camiers.
Base Hospital No. 10, care of General Hospital No. 16, British Expeditionary Force, Treport.
Base Hospital No. 12, care of General Hospital No. 18, British Expeditionary Force, Camiers.
Base Hospital No. 21, care of General Hospital No. 12, British Expeditionary Force, Rouen.

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CAMP HOSPITALS ESTABLISHED OR TO BE ESTABLISHED

First divisional training area, Camp Hospital No. 1, A. E. F.
Second divisional training area, Camp Hospital No. 2, A. E. F.
Third divisional training area, Camp Hospital No. 3, A. E. F.
Fourth divisional training area, Camp Hospital No. 4, A. E. F.
Fifth divisional training area, Camp Hospital No. 5, A. E. F.
Sixth divisional training area, Camp Hospital No. 6, A. E. F.
Seventh divisional training area, Camp Hospital No. 7, A. E. F.
Eighth divisional training area, Camp Hospital No. 8, A. E. F.
Ninth divisional training area, Camp Hospital No. 9, A. E. F.
Tenth divisional training area, Camp Hospital No 10, A. E. F.
Camp hospital established at St. Nazaire, Camp Hospital No. 11, A. E. F.
Camp hospital established at Le Valdahon, Camp Hospital No. 12, A. E. F.
Camp hospital to be established at Mailly, Camp Hospital No. 13, A. E. F.
Camp hospital to be established at Issoudun, Camp Hospital No. 14, A. E. F.

Not until October 31 did the chief surgeon receive the approval of the chief of staff of the conclusion reached at the conference of October 17.³⁸ In the meantime very little could be accomplished in the prosecution of the hospitalization program because of the fact that it was necessary to have the approval of the commander in chief, A. E. F., before hospitals offered by the French could be accepted. These hospitals were particularly those in the region of Vittel, Contrexeville, and Martigny. Previously the general staff, A. E. F., had notified the chief surgeon that hospitalization projects should keep to the west of the general area in which these places were located.²⁵

On October 31, 1917, the chief of staff telegraphed the approval ofthe commander in chief concerning the hospitalization project of October17.³⁹ The chief of staff drew especial attention to that portionof his approval which pertained to the utilization of existing buildings.The next day the commander in chief approved this project in the followingterms:⁴⁰

A. S., G. S., November 1, 1917.

From: Commander in Chief

To: Chief, French Military Mission

Subject: Hospitalization

1. I have the honor to inform you that the hospitalizationproject contemplated in the conference held at the French mission October17, 1917, meets with the approval of the commander and chief as follows:

(a) Acceptance of existing hospitals offered inthe zone of the armies, to be taken over as required.

(b) Acceptance of the area Sens (exclusive)-Orleans-Tours-Dijon-Lyonfor hospitalization in the intermediate area, subject to remarks givenbelow.

(c) Acceptance of the altered distribution of the73,000 beds in the first program so as to give about 40,000 in the intermediatesection and about 20,000 in the base sections.

(d) Acceptance of the plan to seek sites for constructionof hospital centers in the general areas indicated in the conference; i.e., for the advance section in the vicinity of Is-sur-Tille, Champlitte,Andilly, Boulogne, Chatillon, etc., for the intermediate section in thevicinity of Cercy-la-Tour, Autun, Avallon, and Clamecy, and for the basesections in the vicinity of Bordeaux, Redon, and Auray.

2. With reference to (c) above, and in view ofthe necessity of utilizing existing buildings to the maximum, it is consideredadvisable that the areas in which such buildings may be ocated includealso the vicinity of the American line of communications from Tours toSt. Nazaire and Chateauroux to Bordeaux.

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3. The commander in chief in giving his approval of theproject for hospitalization lays special emphasis on the fact that, onaccount of the scarcity of shipping and difficulty of obtaining material,every effort should be made to obtain existing buildings and that whereconstruction is necessary it must be of the simplest character possibleconsistent with necessities. It is, therefore, requested that the facilitiesin existing hospitals or buildings which can be offered be made the maximumpossible.

4. It is the understanding that, as soon as possible,the French authorities will furnish preliminary studies of the questionof existing hospitals and other buildings in the interior and of sitesfor hospital construction in the three sections, as indicated under (d)above, which can be utilized by the American Army.

5. With regard to areas for construction of hospitals,it will be necessary to consider carefully the location of such hospitalcenters in order to avoid interference with storage depots, training areas,etc., and in order to permit this study to be made it is desirable to havethe suggestions of the French authorities as early as practicable. As soonas the French authorities are ready I shall take pleasure in having theAmerican representatives confer with their representatives to fix definitelocations for these hospitals.

By direction:

W. D. CONNOR, Acting Chief of Staff.

As of December 15 the following reports were submitted to the general staff concerning hospital status:²⁹

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Hospitals authorized in approved project now establishedand receiving or ready to receive patients

^aThese hospitals are operated in conjunction with American Red Cross at their expense.

302

Hospitals authorized in approved project, but not yetready for occupancy 

303

Additional hospitalization projects at the following-named places werealso tentatively proposed at this time in order to meet further prospectiveneeds.²⁸
 

It was believed now that a proper regional distribution of hospitalfacilities would be approximately as follows:²⁸ Advance section,15 per cent; intermediate section, 60 per cent; base sections, 25 per cent.

The chief surgeon's office also reported that, as had been planned,hospitals were located in general in the training areas centered aroundNeufchateau, along the lines of communications, and at Bordeaux, St. Nazaire,and Brest.²⁸ Considerable hospitalization was necessary at baseports for the permanently disabled. In selecting sites, consideration hadto be given also to such questions as availability of railroad sidings,situation at points where these formations would not interfere with themovement of troops, or those in training areas, and accessibility fromcamps and depots as well as from the front. Future experience, it was added,might show that some readjustments of these percentages might be necessary,but in any event these would serve as a basis for present plans and couldbe changed if the necessity arose.

On February 23 the chief surgeon forwarded to the Surgeon General the following data concerning the hospitalization facilities of the American Expeditionary Forces:⁴¹
 

ALPHABETICAL INDEX OF LOCATIONS, FIXED MEDICAL DEPARTMENT UNITS

Allerey: 10 type A, A. E. F. base hospital units underconstruction. Total ordinary capacity of this center to be 10,000 beds.Work in hands of French contractors and will soon be under way.

Angers: Base Hospital No. 27, with a capacity of 334 beds,in operation in old French hospital. Construction under way to increasecapacity to 2,000 beds, thus providing for a special clinic for the treatmentof "Diseases of the heart."

Bazoilles: Base Hospital No. 18, with a capacity of 740beds in operation in barrack hospital acquired from the French. Six typeA, A. E. F. base hospital units under construction by the Engineer Corps.Total ordinary capacity of this center to be 6,740 beds.

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Beaune: 10 type A, A. E. F. base hospital units underconstruction. Total ordinary capacity of this center to be 10,000 beds.Work in hands of French contractors and will soon be under way.

Blois: Camp Hospitals Nos. 25 and 26, with a total bedcapacity of 430, in operation in old French hospitals.

Bordeaux: Base Hospital No. 6, with a capacity of 900beds, in operation. Five type A, A. E. F. base hospital units under constructionon Beau Desert site. This site will be the eventual center for the constructionof a total of 20 type A, A. E. F. base hospitals with an ordinary capacityof 20,000 beds. Receiving and forwarding medical supply base No. 2. Basemedical laboratory, base section No. 2, temporarily housed in Base HospitalNo. 6.

Bourbonne-les-Bains: Camp Hospital No. 21, with a bedcapacity of 200, in operation in hotel leased for hospital purposes.

Bourmont: Camp Hospital No. 3, with a bed capacity of300 beds, in operation.

Brest: Naval Base Hospital No. 1, with a capacity of 407beds, in operation in old French hospital. Camp Hospital No. 33, with acapacity of 500 beds, capable of expansion to 1,000 beds, in operationat Pontanezen Barracks. Receiving and forwarding medical supply base No.5. Base medical laboratory, base section No. 5.

Burey-en-Vaux: Camp Hospital No. 17, with a capacity of125 beds. Vacated because of evacuation of training area.

Chateauroux: Base Hospital No. 9, with a capacity of 817beds, in operation in old French hospital. Base medical laboratory, basesection No. 3 (intermediate section) temporarily housed in Base HospitalNo. 9.

Chateau Villain: Base Hospital No. 9, with a capacityof 300 beds, under construction by Engineer Corps.

Chalaines: Camp Hospital No. 16, with a bed capacity of220, vacated because of evacuation of training area.

Chaumont: Base Hospital No. 15, with a capacity of 1,414beds, in operation in old French hospital.

Coetquidan: Camp Hospital No. 15, with a bed capacityof 525, in operation in an old French hospital.

Colombey: Camp Hospital No. 6, with a capacity of 150beds, vacated because of evacuation of training area.

Contrexeville: Base Hospitals Nos. 31 and 32, with a capacityof 1,250 beds each, in operation in hotels, leased for hospital purposes.

Cosne: Intermediate medical supply depot No. 3.

Dijon: Base Hospital No. 17, with a capacity of 833 beds,in operation in an old French hospital. Central medical laboratory, onUniversity of Dijon property.

Gievres: Intermediate medical supply depot No. 2.

Gondrecourt: Camp hospital No. 1, with a capacity of 300beds, in operation in barrack hospital acquired from the French.

Humes: Camp Hospital No. 7, with a capacity of 300 beds,under construction by Engineer Corps.

Issoudun: Camp Hospital No. 14, with a capacity of 300beds, in operation.

Is-sur-Tille: Advanced medical supply depot No. 1.

La Courcelles: Camp Hospital No. 38, with a capacity of240 beds, ready for occupancy.

La Courtine: Camp Hospital No. 19, with a capacity of300 beds, in operation in old French hospital.

La Fauche: Camp Hospital No. 4, with a capacity of 300beds, ready for occupancy.

Langres: Five type A, A. E. F. base hospital units approvedfor this place. Acquisition of site still under consideration by the French.Camp Hospitals Nos. 22, 23, and 24, with a total capacity of 520 beds,in operation in old French buildings.

Le Courneau: Camp Hospital No. 29, with a capacity of1,000 beds, in operation in old French hospital.

Le Valdahon: Camp Hospital No. 12, with a capacity of300 beds, in operation in an old French hospital.

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Limoges: Base Hospital No. 38, with a bed capacity of242, in operation in old French hospital; two modified type A, A. E. F.base hospital units, with a capacity of 1,500 beds each, under constructionby Engineer Corps. New Grand Séminaire, with alterations and additionsunder way to provide a capacity of 1,000 beds, will soon be occupied bya unit.

Liffol-le-Grand: Camp Hospital No. 18, with a capacityof 300 beds temporarily vacated.

Mailly: Camp Hospital No. 13, with a capacity of 250 beds,in operation in old French hospital.

Mars: Ten type A, A. E. F. base hospital units under construction.Total ordinary capacity of this center to be 10,000 beds. Work in handsof French contractors and will soon be under way.

Mesves: Ten type A, A. E. F. base hospital units underconstruction. Total ordinary capacity of this center to be 10,000 beds.Work in hands of French contractors and will soon be under way.

Meucon: Camp Hospital No. 31, with a capacity of 500 beds,under construction by French engineers

Montigny: Camp Hospital No. 8, with a capacity of 300beds, under construction by Engineer Corps.

Nantes: Base Hospital No. 34, occupying Grand Seminary;alterations and additions under way to increase capacity to 1,000 beds.Three type A, A. E. F. base hospital units under construction on the GrandBlottereay site. Work in the hands of French contractors.

Neufchateau: Base Hospital No. 66, with a capacity of735 beds, in operation in Rebeval Barracks. Army medical laboratory No.1.

Nevers: Camp Hospital No. 28, with a capacity of 130 beds,in operation in old French hospital.

Paris: American Red Cross Military Hospitals, No. 1, witha capacity of 600 beds; No. 2, with a capacity of 186 beds, and No. 3,with a capacity of 50 beds.

Perigueux: Five type A, A. E. F. base hospital units underconstruction. Total ordinary capacity of this center to be 5,000 beds.Work in hands of French contractors and will soon be under way.

Prauthoy: Camp Hospital No. 10, with a capacity of 300beds, now under construction by Engineer Corps.

Rimaucourt: Five type A, A. E. F. base hospital unitsapproved for this place. Work is to begin immediately upon two of theseunits by the Engineer Corps.

Savenay: Base Hospital No. 8, with a capacity of 800 beds,which construction, now under way, will increase to 1,300 beds; will eventuallybe center for 5,000 beds, the work to be carried on by Engineer Corps.To become center for psychiatric clinic of 100 beds.

Souge: Camp Hospital No. 20, with a present capacity of120 beds, which construction by Engineer Corps, now under way, will bringto 500 beds.

St. Maixent: Camp Hospital No. 30, with a capacity of117 beds, which construction by Engineer Corps, under way, will increaseto 300 beds.

St. Nazaire: Base Hospital No. 101, with a capacity of890 beds, in operation. Camp Hospital No. 11, with a capacity of 350 beds,under construction by Engineer Corps. Receiving and forwarding medicalsupply base No. 1. Base medical laboratory, base section No. 1.

Toul: Five hundred beds in wing of French H. O. E. Justice(Field Hospital No. 12 to operate here); 400 beds in Sebastopol Barracks(Evacuation Hospital No. 1 to operate here); 400 beds at Menil-la-Tour,evacuation ambulance company to operate at railway station.

Tours: Camp Hospital No. 27, with a capacity of 300 beds,in operation in old French hospital.

Vauclaire: Base Hospital No. 25, with a capacity of 1,000beds, to be located in French buildings leased for that purpose.

Vaucouleurs: Camp Hospital No. 5, with a capacity of 300beds, vacated because of evacuation of training area.

Vichy: Base Hospital center for 3,500 beds, to be acquiredby leasing French hotels.

Vittel: Base Hospitals 23 and 36, with a capacity of 1,750beds each, in operation in hotels, leased for hospital purposes.

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Cross reference

BASE HOSPITALS

[Receiving, or ready to receive, patients] 

CAMP HOSPITALS

[Receiving, or ready to receive, patients]

307

Cross reference-Continued

CONSTRUCTION PROGRAM 

^aAdditional contemplated.
^bAs contemplated by future addition.

MISCELLANEOUS MEDICAL DEPARTMENT ACTIVITIES
  

NOTE.-The following mobile sanitary units are automaticallyattached to each division of troops in the field: Four ambulance companies(3 motor and 1 horse-drawn); 4 field hospital companies (3 motor and 1horse-drawn); 1 evacuation ambulance company (motor).

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The following memorandum for the chief surgeon, A. E. F., from his deputyat general headquarters, A. E. F., gives a good perspective of the locationof our hospitals necessitated by the acquisition of the fact that our principalsector of the front was to be from St. Mihiel eastward:

GENERAL HEADQUARTERS,AMERICAN EXPEDITIONARYFORCES,

France, August 9, 1918

Memorandum for the chief surgeon (attention of hospitalization section):

1. Recent developments up here show that our principalsector is to be from St. Mihiel eastward. How far to the east we will godepends upon the number of troops available for holding the line.

2. The assistant chief of staff, G-4, has given instructionsthat all projects originally outlined for the development of railways,regulating stations, hospitals, etc., for the Toul sector are again inforce. I asked the assistant chief of staff, G-4, particularly about Chatillon-sur-Seine.He approves of it as a hospital site; and if the chief surgeon's officedesires, hospital construction can be gone ahead with at that place. Astudy of the railroad map will show how very well located this place isfor our purpose. Moreover, this is the finest hospital site I have seenin France. If more hospital facilities are desired in the advance section,this is undoubtedly the place.

3. We have another approved site at Mirebeau, near Dijon,which as a site is not as desirable as Chatillon.

4. The assistant chief of staff, G-4, is very anxiousthat we should have hospital facilities along the different lines northand south controlled by the different regulating stations. This in orderto prevent the cutting across in the rear of different armies with ourhospital trains. This is the case at the present time when the regulatingofficer at Le Bourget sends a train down into the advance section. It canbe done, as has been shown, but if railroad traffic is heavy it becomespractically impossible to cut across from west to east, or vice versa.The assistant chief of staff, G-4, thinks that we should plan our hospitalizationin the future to permit of evacuation practically from any part of theentire line along the north and south lines. I was surprised to find thathe included in this the English front. In this connection, I would liketo suggest Evreux as a site for hospital development. I am inclosing arailroad map which my assistant has prepared from one furnished him bythe French G. Q. G. This shows the lines of evacuation from each one ofthe French regulating stations, beginning on the west with Sotteville,then to Nantes, Creil, Le Bourget, Connantre, St. Dizier, Is-sur-Tille,and Gray. These regulating stations are also the stations which our troopswill use. As far as we have gone, we have followed the regulating systemfrom Is-sur-Tille as far as it was possible to do so and reach our ports.Everything that has been done in the way of locating hospitals will fitin there nicely with future developments along the lines indicated.

On August 17 the chief surgeon notified the chief of the French missionthat the offer of the French for accommodation for 3,300 beds in variouslocalities was accepted.⁴² In the Paris district, in additionto what was already organized, it was desired that facilities for 15,000beds be provided, and that extensive hospitalization be provided at Vichybecause of its accessibility by rail from the front, and the suitabilityof the buildings there.⁴²

On August 24, 1918, the chief surgeon reported as follows:[Memorandum]

AUGUST24, 1918.

From: Chief surgeon

To: Assistant chief of staff, G-4, Services of Supply.

Subject: Hospitalization.

1. There are 75,000 beds at present in base hospitals;50,000 are occupied. There are 1,400,000 troops in France, and 15 per centof hospitalization would give 210,000 beds that should be available, makinga shortage of 135,000 beds.

309

2. It is not believed that any construction should beeliminated from this program. The projects under construction as follows:

Each to include its proportionate convalescent camp andcrisis expansion.

3. It is believed that the following should be given priorityfor construction: Brest, Rimaucourt, Allerey, Mars, and Savenay.

By the end of August, 102,144 beds (including emergency beds) were provided,of which total 54,485 were occupied.²

The selection of sites, procurement of existing buildings, and constructionof new ones progressed steadily, though scarcely keeping pace with thenow rapidly increasing demand for beds, for large numbers of American troopswere now engaged and battle casualties reached the hospitals in considerablenumbers.²¹ One evacuation hospital (No. 7) received 27,000 patientsbetween June 15 and August 11. Also a considerable amount of sickness haddeveloped, including scattered outbreaks of influenza and quite generalepidemics of diarrhea and dysentery. Further preparation of hospitals wasnecessary for the impending offensive, but no one could foresee that contemporaneouslywith this conflict there would occur a great influenza epidemic that wouldcall for almost as many hospital beds as would the destructive effortsof the enemy.

During September 10, 150 beds were provided at Cannes, Nice, Menton,and other points on the Mediterranean and a lesser number at Biarritz,near the Pyrenees.²¹

The French submitted another long list of hotel buildings which mightbe used as hospitals, and a list of barracks and school buildings whichwere made available by their Government.⁴⁴ Of their last mentionedstructures certain were accepted, to a total capacity of 11,550 beds. Thedirector of construction and forestry, A. E. F., was notified of that fact,given the names and addresses of medical officers who would be concernedin the operations of the hospitals located in these public buildings, andrequested that the Engineer Department consult with them in each case concerningthe location of the building, repairs required, and any information desiredin connection with their operation.

By the end of September, 1918, the total fixed hospital capacity, includingemergency beds, was 148,596 beds. Of these, 79,580 were occupied. A hospitalcenter providing 10,240 beds was being established in 25 hotels on theRiviera. A center had also been established at Clermont-Ferrand.

During October the French furnished a long list of buildings which couldbe turned over to the Americans for use as hospitals, the total providingaccommodations for more than 30,000 beds.²¹ Most of these buildingswere schools, barracks, hotels, chateaux or residences.

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The demands for beds was increased to an unexpected degree at this timebecause of the epidemic of influenza which assumed grave proportions simultaneouslywith the prosecution of the Meuse-Argonne operation. American battle casualtiesduring that action included 72,584 wounded and 23,934 gassed.²

This cumulative combination of circumstances subjected the hospitalizationfacilities to a severe test-not so much because of the number of beds necessary,as because of demands for equipment and especially for personnel.²The inadequacy of Medical Department personnel to meet the demands nowmade upon it, is discussed in another chapter of this volume.

In the procurement of existing buildings for hospital purposes fullcooperation had been received from the French with the result that spacefor thousands of beds had been secured.²⁷ Though far from idealfor hospital purposes, these buildings at least afforded shelter. In spiteof all that could be done, however, with the heavy fighting at the frontand a serious influenza epidemic during the months of September and October,the margin of safety, consisting of unoccupied beds, steadily decreased.On October 10 there were more beds occupied than were shown by the normalbed capacity, and by October 17 the 166,200 beds occupied included 30,798for emergency use.²⁷ The authorized program at this time providedfor approximately 100,000 beds in addition to those already available.Careful consideration was directed toward the provision of 600,000 bedsbefore July 1, 1919, and all needed aid in the carrying out of the programwas promised.²⁷ On October 19, the commander in chief wroteto the commanding general, Services of Supply, as follows:

G. H. Q., A. E. F., 4TH SEC., G. S., October 19, 1918.

From: C. in C.

To: C. G., S. O. S.

Subject: Hospitalization program.

1. The situation of the American Expeditionary Forces,from the point of view of hospitalization, has become alarming. The smallmargin of safety which has existed heretofore has disappeared. The commanderin chief is deeply interested in this matter, and has expressed his concernover the outlook. He directs that immediate steps be taken to remedy thecritical situation with which we are now confronted, and that a hospitalizationprogram, more comprehensive in scope and sufficient to provide for ourfuture needs, be inaugurated with the least practicable delay.

2. In this connection, attention is invited to the indorsementfrom this office of June 1, 1918, a copy of which is herewith attached,which authorizes American Expeditionary Forces hospitalization requirementson the basis of 15 per cent of hospital beds for all American ExpeditionaryForces troops in Europe. In this indorsement it was specifically statedthat so-called "emergency expansion" was not to be included in computationof beds available. Based on the estimates as outlined in the indorsementreferred to, an analysis of this date shows a deficit of approximately100,000 beds therein prescribed, with apparently insufficient provisionfor the future. It would appear that a most unsatisfactory situation hasbeen permitted to develop. It must be rectified at the earliest possiblemoment.

3. In a recent communication, the War Department commentedupon the insufficiency of the American Expeditionary Forces hospitalizationprogram. It is recognized that the War Department has been somewhat remissin that it has failed to ship the necessary and authorized personnel andequipment for hospitals which are now available for occupancy. However,as a result of repeated cables and statements of the extreme seriousnessof the existing situation, it is believed that the personnel and equipmentphase of our present difficulties will soon be relieved. In any event,this is not a factor which should be taken into consideration at this timein providing hospitals on the scale which is necessary, if the needs ofthe future are to be met.

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311

4. Accordingly, the commander in chief directs that thismatter be given careful consideration, and that a hospitalization programaiming at the provision of 600,000 beds for the American ExpeditionaryForces by July 1, 1919, be immediately inaugurated. As the possibilitiesof acquiring existing buildings or hospitals from the French have beenpractically exhausted, the greater part of this program will, of necessity,be possible of fulfillment only through the means of new construction,chiefly of the hut or portable barrack type.

5. In accomplishing this project, the skilled servicesof civilian contractors should be utilized to the maximum extent possible,and provision be made to furnish them as much additional labor and otherassistance as may be necessary to expedite construction undertaken by thismeans. If necessary, every effort will be made to assign or procure foryou such additional labor or construction troops as will be required tocarry out this program.

6. The chief surgeon should make an immediate generalsurvey and submit to you his recommendations as to where the hospitalizationherein prescribed can most advantageously be established. As the changingmilitary situation will probably frequently require the presence of ourtroops as far north as the channel ports, the need for new hospitalizationnorth and west of Paris should be given careful consideration. The evacuationlines from the regulating station at Creil should be given careful consideration.As a beginning, the French have already consented to the establishmentof an American Expeditionary Force hospital at Evereux, authority for whichhas already been transmitted to you.

7. If this headquarters can assist in any way toward furtheringthe accomplishment of this hospitalization program, your recommendationsthereon are desired, and will be carefully considered.

8. A brief report by letter as to the progress made, particularlywith reference to new construction undertaken to meet future needs, willbe forwarded to these headquarters at the end of each month.

By order of the commander in chief.

GEO. VAN HORN MOSELEY,
Brigadier General, G. S., Assistant Chief of Staff, G-4.

In his reply the commanding general, Services of Supply, stated that the hospitalization program of the American Expeditionary Forces had always been under the most careful observation and that every effort possible had been put forth to carry it out successfully.²³ The reasons why this had not been actually accomplished were pointed out substantially as outlined above; i. e., difficulties incident to procurement of suitable sites and to effecting new construction. Following this correspondence, a telegram was issued by the chief of staff American Expeditionary Forces, to the commanding general, Services of Supply, as follows:

G. H. Q., A. E. F., 4th SEC. G. S., October 20, 1918.

COMMANDING GENERAL,

Services of Supply, American Expeditionary Forces:

Because of the critical situation produced by the heavydemands on hospitals, the commander in chief directs as follows: First,the completion of all buildings under construction for hospital purposesand the necessary alteration in buildings taken over by the Medical Departmentfrom the French must be expedited in every possible manner. Second, commandingofficers of base hospitals and hospital centers are authorized to retainclass B privates capable of assisting hospital personnel for temporaryduty. The number of these men will be determined by the commanders mentionedabove, but will be kept at the minimum necessary to permit hospitals tofunction under emergency conditions now prevailing. Commanding officerswill be held responsible for not exceeding the number hereby authorized.Third, every effort must be made to move Medical Department personnel,units, and hospital equipment coming into ports, other equipment beingshipped from depots to hospitals with least possible delay. When hospitalunits arrive at ports with equipment, trains should be made up and equipmentshipped at once with unit.

MCANDREW.

???????????????

Official:

ROBT. C. DAVIS,AdjutantGeneral.

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On October 28 the bed status of the American Expeditionary Forces wasas follows:

AMERICAN EXPEDITIONARY FORCES,
OFFICE OF THE CHIEF SURGEON,
  October 28, 1918.

Memorandum for the A. C. of S., G-4, Hdqrs. S. O. S., A. E. F.:

1. In reply to your memorandum of October 26, 1918, fileNo. 010186, submit the following information:

(a) Number of beds installed in hospitals ready to receive patients:

	Beds
Camp hospitals:
Occupied	17,751
Vacant	7,481
Total	25,232
Base hospitals (includes normal and crisis expansion beds):
Occupied	142,675
Vacant (the vacant beds in base hospitals are all emergency)	50,289
Total	192,964
Convalescent camps:
Occupied	15,995
Vacant	4,927
Total	20,721
Total beds in camp hospitals, base hospitals, and convalescent camps	238,917
Total occupied beds in camp hospitals, base hospitals, and convalescent camps	176,421
Total vacant beds in camp hospitals, base hospitals, and convalescent camps	62,496

(b) Number of beds complete now in depots and shippedbut not installed and not taken up on daily bed report, 47,500.

(c) Personnel in Europe not operating hospitals,one base hospital. This personnel can operate 1,500 beds.

(d) Number of beds complete expected from the UnitedStates, to include February, 1919, as shown on priority schedule, 250,000.

(e) Personnel expected from the United States toinclude January 31, 1919, as shown on the priority schedule, officers,9,324; nurses, 16,717; enlisted men, 100,748.

February shipment schedule not yet made up. Beds whichthis personnel can operate:

Normal beds in base hospitals	124,000
Normal beds in camp hospitals	13,500
Normal beds in convalescent camps	24,800
Total normal beds	162,300
Total normal beds	162,300
Crisis expansion beds	62,000
Total normal and crisis expansion beds	224,300

  For the chief surgeon:

J. D. GLENNAN,
Brigadier General, Medical Corps.

On October 31, of 221,421 beds in camp and base hospitals 163,767were occupied.⁴⁵ A number of casualties were passing throughfield, mobile, and evacuation hospitals, and there were yet others-relativelyvery few-in allied and Red Cross hospitals.² In camp and basehospitals 35,045 normal beds were vacant, for a number of patients wereoccupying emergency beds.⁴⁵ But for

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that fact 98.3 per cent of the 166,534 normal beds then provided wouldhave been occupied by 163,767 patients then in these institutions. In additionto the 221,421 normal and emergency beds in camp and base hospitals, asnoted above, there were in operation convalescent camps which provided25,070 beds. Of these, 19,047 were occupied. The grand total of all vacantbeds, normal and emergency and in hospitals and convalescent camps, was88,807. On November 1 the total number on sick report amounted to 9.08per cent of the American Expeditionary Forces, i. e., in round numbers,180,000 patients.²¹

The number of vacant beds, normal and emergency, during August and Septemberhad been well above double the number of patients, but during October,when the number of patients nearly doubled, the factor of safety fell from100 to 33 per cent.²³

Shortly before the armistice was signed 115,000 additional beds wereauthorized either in existing institutions or in new formations, and buildingsfor accommodations to shelter 103,000 of this number of beds were underconstruction.²³ Also French buildings were secured and structuresauthorized in connection therewith for a total of 73,000 other additionalbeds. Buildings for 31,000 of the latter number were under preparation.New convalescent camps were also being constructed and others enlarged,increasing their total capacity by 15,000 beds. The total of new beds thuscontemplated was:²³

	Authorized	Under construction
New construction	115,000	103,000
In French buildings	73,000	31,000
Convalescent camps	15,000	15,000
Totals	203,000	149,000

Completion of these projects in addition to the 281,598 beds alreadyprovided would have given a bed capacity of 484,598. This would have beensufficient for 15 per cent sick and wounded of a force of 3,210,000 men.There were nearly 2,000,000 men in France at this time, and it was expectedthat this number would rapidly be increased so that the entire bed allowanceauthorized would be required by the spring of 1919.²³

This project was soon increased so that when the armistice was signedon November 11 the hospitalization program included construction projectsand leased buildings which together with those already established wouldbe capable of providing ultimately for 423,722 normal beds and for emergencybeds in addition to these to a grand total of approximately 541,000. Thesewere to be distributed as follows:²³

	Beds normal	Beds emergency (including normal)
Base hospitals	322,376	437,744
Camp hospitals	38,686	40,835
Convalescent camps	62,660	62,660
Totals	423,722	541,239

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Among the large projects planned at this time were the following:²¹In Paris, 20,000 beds; Lyons, 15,000 beds; the Riviera, 15,000; Pau andvicinity, 10,000; Clermont and vicinity, 10,000; Vichy, expansion to 30,000;Orleans, 5,000; Blois, 3,000. Smaller projects were to be provided at Poitiers,Bordeaux, Angouleme, Rouen, Moulins, Roanne, Caen, and Parthenay. Theseplans, however, were changed after the armistice so as to provide hospitalizationfor an army of 80 divisions, or about 400,000 men.²¹

On November 1 the number of patients on sick report numbered approximately182,000-i. e., 9.08 per cent of the entire force-but a number of thesewere under treatment in field formations. The number of patients in fixedformations reported on November 7 totaled 31,813. They were then distributedas follows:⁴⁶

Recapitulation
 

	Bed situation								Per cent of beds occupied				Percentage on sections
	Occupied		Vacant		Normal		Emergency		Normal		Emergency
	Base	Camp	Base	Camp	Base	Camp	Base	Camp	Base	Camp	Base	Camp	Normal	emergency
Advance section	22,521	3,425	20,463	2,622	42,472	5,616	58,050	6,411	53.0	61.0	38.7	53.4	54.0	40.3
Intermediate section	69,802	6,226	5,198	2,360	52,624	7,527	98,993	7,709	132.6	82.7	70.6	70.6	126.4	71.2
District of Paris	11,683	---	677	---	8,306	---	12,498	---	140.6	---	81.2	---	140.6	81.2
Base section No. 1	17,992	1,591	2,169	998	16,717	2,589	22,677	2,629	107.6	61.7	79.3	60.5	101.4	77.4
Base section No. 2	22,663	1,747	415	1,420	16,283	3,167	26,641	3,126	139.2	55.2	84.7	55.9	125.5	82.0
Base section No. 3	6,906	1,200	197	220	6,350	1,420	7,137	1,420	108.7	84.5	96.7	84.5	104.3	94.7
Base section No. 4	7	---	473	---	480	---	480	---	1.4	---	1.4	---	1.4	1.4
Base section No. 5	2,202	1,780	942	3	3,144	1,450	3,280	1,450	70.0	122.7	67.1	122.7	88.7	84.2
Base section No. 6	---	187	1,000	113	1,000	300	1,000	300	---	62.3	---	62.3	14.4	14.4
Base section No. 7	---	373	---	64	---	413	---	463	---	90.3	---	80.6	90.3	80.6
Subtotal	153,776	16,529	31,534	7,800	157,379	22,482	230,756	23,508	97.7	73.5	66.5	70.3	94.7	66.9

 

Summary
 

	Bed situation				Per cent of beds occupied
	Occupied	Vacant	Normal	Emergency	Normal	Emergency
Base hospitals	153,776	31,534	157,379	230,756	97.7	66.5
Camp hospitals	16,529	7,800	22,482	23,508	73.5	70.3
Grand total	170,305	39,334	179,861	254,264	94.7	66.9
Total beds including convalescent camps ----------------------------------------------------------------------------------------------------------------------- 281,598
Total patients including convalescent camps ------------------------------------------------------------------------------------------------------------------- 193,813
Vacant beds ---------------------------------------------------------------------------------------------------------------------------------------------------------------  87,785

REFERENCES

(1) G. O. No. 70, G. H. Q., A. E. F., May 6, 1918.

(2) Report of the activities of G-4-B, medical group,fourth section, general staff, G. H. Q., A. E. F., by Col. S. H. Wadhams,M. C., chief of section, December 31, 1918. On file, Historical Division,S. G. O.

(3) Tables of Organization, No. 28, W. D., 1918.

(4) Manual for the Medical Department, U. S. Army, 1916,Art. XIII.

(5) Evacuation system of a field army, by Col. C. R. Reynolds,M. C., undated. On file, Historical Division, S. G. O.

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(6) Report of the activities of the neurological service,A. E. F., by Col. Harvey Cushing, M. C., December 2, 1918. On file, HistoricalDivision, S. G. O.

(7) Tables of Organization, No. 101, W. D., 1918.

(8) Tables of Organization, No. 201, W. D., 1918.

(9) Manual for the Medical Department, U. S. Army, 1918,par. 793.

(10) Manual for the Medical Department, U. S. Army, 1916,Art. XIV.

(11) Tables of Organization (Medical Department). On file,Record Room, S. G. O., 320.3-1 (Tables Organ.).

(12) Memorandum for the chief engineer, L. O. C., A. E.F., from the chief surgeon, A. E. F., September 20, 1917. Copy on file,Historical Division, S. G. O.

(13) 1st indorsement from the commander in chief, assistantchief of staff, G-4, general staff, G. H. Q., A. E. F., June 1, 1918, tothe commanding general, S. O. S. Copy on file, Historical Division, S.G. O.

(14) Memorandum for the assistant chief of staff, G-4,G. H. Q., A. E. F., from Maj. A. D. Tuttle, M. C., March 31, 1918. Subject:Hospitalization data. Copy on file, Historical Division, S. G. O.

(15) Memorandum on convalescent camps for the assistantchief of staff, G-4, G. H. Q., A. E. F., May 17, 1918. Copy on file, HistoricalDivision, S. G. O.

(16) Letter from the commander in chief, A. E. F., tothe chief French military mission, September 27, 1917. Subject: Programfor hospitalization, A. E. F. Copy on file, Historical Division, S. G.O.

(17) Letter from the commander in chief, A. E. F., toMaj. Gen. Omar Bundy, September 18, 1918. Subject: Camp infirmaries (hospitals)in division areas. On file, A. G. O., World War Division, chief surgeon'sfiles, 322.32911.

(18) Manual for the Medical Department, U. S. Army, 1916,par. 757.

(19) Report of the activities Camp Hospital No. 26, St.Aignan-Noyers, as of January 1, 1919, by Lieut. Col. Wm. C. Riddell, M.C. On file, Historical Division, S. G. O.

(20) Report of activities of Camp Hospital No. 52, LeMans, as of January 1, 1919, by Maj. Wm. J. Buck, M. C. On file, HistoricalDivision, 
S. G. O.

(21) War Diary, chief surgeon's office, A. E. F., 1917-18.On file, Historical Division, S. G. O.

(22) Wadhams, S. H., Col., M. C. and Tuttle, A. D., Col.,M. C.: Some of the early problems of the Medical Department, A. E. F. TheMilitary Surgeon, Washington, xlv, No. 6, 636.

(23) Report of the activities of the chief surgeon's office,A. E. F., from the arrival of the American Expeditionary Forces in Europeto the armistice, by the chief surgeon, A. E. F., March 20, 1919. On file,Historical Division, S. G. O.

(24) Letter from the chief surgeon, A. E. F., to the commanderin chief, A. E. F., August 2, 1917. Subject: Study of hospitalization.Copy on file, Historical Division, S. G. O.

(25) Memorandum for the chief of staff from the chiefof operations section, general staff, G. H. Q., A. E. F., August 11, 1917.Subject: Hospitalization. On file, A. G. O., World War Division, 632.

(26) Confidential memorandum for the chief surgeon, A.E. F., from the adjutant general, A. E. F., November 17, 1917. Subject:Hospitalization program. On file, A. G. O., World War Division, chief surgeon'sfiles, 322.32911.

(27) 1st indorsement, chief surgeon's office, A. E. F.,November 21, 1917, to the chief of staff, G. H. Q., A. E. F. On file, A.G. O., World War Division, chief surgeon's files, 322.32911.

(28) Report from the chief surgeon, A. E. F., to the commanderin chief, A. E. F., December 15, 1917. Subject: Hospital construction,personnel, and equipment, as of December 15, 1917. On file, A. G. O., WorldWar Division, chief surgeon's files, 329.1.

(29) Memorandum on hospitalization for the assistant chiefof staff, fourth section, general staff, prepared by Maj. A. D. Tuttle,M. C. Copy on file, Historical Division, S. G. O.

(30) Final report of General John J. Pershing, September1, 1919.

(31) Monograph No. 7, prepared in the Historical Branch,War Plans Division, General Staff, June, 1921.

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(32) Letter from the commander in chief, A. E. F., tothe chief, French Military Mission, October 6, 1917. Subject: Program forhospitalization, A. E. F. Copy on file, A. G. O., World War Division, chiefsurgeon's files, 322.32911.

(33) Memorandum from the chief surgeon, A. E. F., to thechief of staff, G. H. Q., A. E. F., October 8, 1917. Subject: Conferencefor hospitalization program. On file, A. G. O., World War Division, chiefsurgeon's files, 322.32911.

(34) Letter from the commander in chief, A. E. F., tothe chief, French military mission, October 11, 1917. Subject: Hospitalization,A. E. F. Copy on file, A. G. O., World War Division, chief surgeon's files,322.32911.

(35) Report of conference held October 17, 1917, at Chaumont,on the study of the hospitalization program, A. E. F. Translated copy onfile, A. G. O., World War Division, chief surgeon's files, 322.32911.

(36) Memorandum for the chief of staff, from the chiefsurgeon, A. E. F., October 19, 1917. Subject: Hospitalization. Copy onfile, A. G. O., World War Division, chief surgeon's files, 322.32911.

(37) Report of hospitals under control of the chief surgeon,A. E. F., October 23, 1917. Copy on file, A. G. O., World War Division,chief surgeon's files, 322.329 (Misc.).

(38) Memorandum for file, by Col. S. H. Wadhams, M. C.,October 30, 1917. Subject: Information concerning hospitalization. On file,A. G. O., World War Division, chief surgeon's files, 322.32911.

(39) Memorandum for the chief surgeon, A. E. F., fromthe acting chief of staff, October 31, 1917. Subject: Hospitalization.On file, A. G. O., World War Division, chief surgeon's files, 322.32911.

(40) Letter from the commander in chief, A. E. F., tothe chief, French military mission, November 1, 1917. Subject: Hospitalization.Copy on file, A. G. O., World War Division, chief surgeon's files, 322.32911.

(41) Letter from the chief surgeon, A. E. F., to the SurgeonGeneral, February 23, 1918. Subject: Hospitalization data. On file, RecordRoom, S. G. O., 322.3 (Med. Dept. Units, France).

(42) Letter from the chief surgeon, A. E. F., to the chief,French military mission, August 17, 1918. Subject: Hospitalization. Copyon file, A. G. O., World War Division, chief surgeon's files, 322.32911.

(43) Memorandum for assistant chief of staff, G-4, S.O. S., from the chief surgeon, A. E. F., August 24, 1918. Subject: Hospitalization.Copy on file, A. G. O., World War Division, chief surgeon's files, 322.32911.

(44) Memorandum for the director, construction and forestry,A. E. F., from the chief surgeon, A. E. F., September 28, 1918. Subject:Hospitalization. Copy on file, A. G. O., World War Division, chief surgeon'sfiles, 329.32911.

(45) Weekly bed reports, October 31, 1918, proposed inthe office of the chief surgeon, A. E. F. Copy on file, Historical Division,S. G. O.

(46) Weekly bed report, November 7, 1918, prepared inthe office of the chief surgeon, A. E. F. Copy on file, Historical Division,S. G. O.

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