CHAPTER XVIII
THE DIVISION OF HOSPITALIZATION (Continued)
THE PROFESSIONAL SERVICES
ORGANIZATION
The organization of the professional services in the American ExpeditionaryForces, conformably to a plan which had been developed in the Surgeon General's office, was undertaken by the chiefsurgeon in the autumn of 1917. In Circular No. 2, November 9, 1917, chief surgeon's office, the organization of theseservices was prescribed and the scope of their activities defined. This circular provided for eight services each under a director,and for the future assignment of assistant directors, consultants for corps, administrative sections of the line of communications,larger hospital centers, and other commands. The services prescribed weregeneral medicine; general surgery; orthopedic surgery; surgery of head;urology, skin, and genitourinary diseases; laboratories; psychiatry; Roentgenology. Itemphasized the fact that professional authority did not include administrative control; directors were to be immediately responsibleto the chief surgeon, and the professional services of hospitals were to be so organized that they conformed tothe eight divisions prescribed above.
At about this time, a plan for the organization of the professionalservices in hospitals was formulated in the Surgeon General's Office,1but no copy of this was received by the chief surgeon until several monthslater, and after a statement of organization of the professional servicesin the American Expeditionary Forces had been cabled to the War Department.2
On March 9, 1918, the Surgeon General wrote the chief surgeon as followsconcerning the organization of the professional services in base hospitals:3
1. The attention of the hospital division has just beencalled, for the first time, to your letter of November 9, Circular No.2, paragraph 5, in which it is noted that the commanding officer of eachbase hospital is directed to organize his hospital by the assignment ofsuitable officers to duty in charge of each of the eight sections, andthat each chief of section will report direct to the commanding officer,to whom he will be responsible for the operation of his particular section.
2. Attention is invited to the fact that this is not quitein accord with the plan of organization adopted by the Surgeon Generalof the Army in his memorandum of November 11, which should have been sentto you at that time.
3. It will be noted that instead of having eight independentsections there are three main clinical services-surgical, medical, andlaboratory-with a chief of each, and that each service is divided intosections representing the different special branches, eight in all. Thiswas the result of many conferences and was finally adopted as a betterplan of organization than to have the eight independent sections.
4. It is not contemplated that this arrangement will inany way interfere with the work of the different sections, but that thechief of each service will be the responsible coordinating officer forall of the different sections of that service and that he will be responsibledirectly to the commanding officer for the work of all the sections underhis control.
5. It is not considered that this plan of organizationof base hospitals would in any way interfere with your plan of organization,as provided for in paragraphs 1 and 2 of your Circular
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No. 2. All base hospitals now organized and in processof organization in this country for service overseas are being organizedin accordance with the Surgeon General's memorandum of November 11.
In another letter to the chief surgeon, dated March 16, 1918, the SurgeonGeneral stated that the plan under which his office was then working provided for nine sections, instead of eight, amongthe professional services.4 One section concerned with food and nutrition had been added.
While the Surgeon General and the chief surgeon, A. E. F., were thusdeveloping a continuity of policy in the provision and the orientation of the professional services, the services themselveswere undergoing rapid development.
DEVELOPMENT
By General Orders, No. 58, general headquarters, A. E. F., November10, 1917, "directors," as the chiefs of the several specialties were first designated, were appointed, respectively, forthe laboratory service, general surgery, orthopedic surgery, and venereal, skin, and genitourinary diseases. In the followingmonth a director of psychiatry was designated and directors of Roentgenology and general medicine in March of the followingyear.
On December 21, 1917, the following letter of instructions, which wastypical of that issued to other directors, was forwarded to the director of general surgery:5
You are hereby announced as director of the division ofgeneral surgery for the American Expeditionary Forces.
You will proceed to such places in the training areasas may be necessary from time to time for consultation with medical officersserving with the American Expeditionary Forces, in matters pertaining togeneral surgery.
In this connection, your attention is invited to GeneralOrders, No. 58, dated November 10, 1917, an advance copy of which is herewithfurnished you.
At the end of each month you will submit, for confirmationby these headquarters, a list of the journeys performed by you under theseinstructions.
Commanding officers of the places visited by you are herebydirected to afford you proper facilities for carrying out this work; thisletter to you is to be considered their authority for such action.
Chiefs of all services were announced and their new official designationprescribed by General Orders, No. 88, general headquarters, A. E. F., June 6, 1918, which is discussed below.
As shown by the histories of the individual services, there was greatdevelopment of their activities prior to the publication of the general order last mentioned. The directors of all except the laboratoryservice were congregated at Neufchateau, where they were technically under the control of the hospitalization divisionof the chief surgeon's office, which was located from September 1, 1917, to March 18, 1918, at Chaumont, some 45 miles distant.6Means of communication between the two offices were at first very limited, for transportation was scant, andmail and telephone facilities inadequate. The group continued to receive its orders from the chief surgeon's office evenafter this had been moved to Tours.6
Until April, 1918, the group of directors did not function as an organizedbody, therefore their activities were uncoordinated, each director seeking to solve in his own way his very different anddifficult problems.6 No specific
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instructions had been issued governing their status. The only officeprovided until April, 1918, which had the power to coordinate the efforts of this group was that of the chief surgeon,A. E. F., which, meanwhile, was being concerned with many other urgent responsibilities.
It is necessary to visualize the situation of the directors in the fallof 1917, and during the earlier succeeding months, in order to appreciate the difficulties of their task. Headquarters, A. E. F.,including the chief surgeon's office, were undergoing rapid expansion and incessantly meeting new emergencies. The new professionaldirectors, lacking military experience, were further handicapped thoughnot having special regulations detailing their duties, and by lack of anagency for their effective organization and control.7 Each director believed that hisappointment granted him authority to organize and direct separately his special department. Each was an enthusiast in his own specialtyand the misnomer "director" seemed to imply administrative control which in fact was not conferred.6Yet the direction and supervision of the professional services in all sanitary formations, the provision for continuity of treatment fromfront to rear, the modification, as need be, of accepted methods of treatment and the inauguration of new ones, were some ofthe duties with which they were charged.8 In the absence both of military experience and of specific instructions someconfusion was inevitable, and for these reasons the zeal of the directors was at first to an appreciable degree misdirectedas well as uncoordinated.6
Great embarrassments also developed in supplying members of the groupwith transportation, for each director was authorized to utilize an automobile for an unlimited time, though themultiplicity of their organizations and the shortage of motor vehicles rendered their supply very difficult.6
During this period many of the most able operators had been detailedas consultants in divisions and other formations, and thus removed from that service which they were peculiarly able to perform.9Theprofessional services were thus deprived of many of their best clinicians, for these officers were placed in positionswhere they, under existing conditions, could neither exercise their professional attainments nor handle properly the newsituations that arose.
When junior members of the special professional services began to arriveand were assigned to combat divisions, the complications pertaining to the general operation of the professionalservices considerably increased.7 These officers were not recognizedin the Tables of Organization, and the details of arranging for billets,mess facilities and transportation already greatly overtaxed were therefore difficult. For this reason the divisionalspecialists were assigned for billet and mess to field hospitals or to those facilities at division headquarters which accommodatedtransients and officers of junior rank.6 Assignment to divisional hospitals separated them from the divisionsurgeon, for these units were not located at headquarters and this precluded the best performance of the specialists' dutieswhich were divisional in scope. These complications now seem trifling, but they led to disturbed feelings which impaired theusefulness of the junior consultants.7
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Usually division surgeons were officers of the Regular Army, and weretrained along line of military administrative control. The specialist presented a new problem concerning which the divisionsurgeon had not been sufficiently informed.7 The division surgeon had the choice of taking the specialist into his ownovercrowded office, forcing him into a mess, where, usually, he was not wanted because of inadequate facilities and becausehe did not hold one of the positions which entitled him to membership, urging a harassed billeting officer to make roomfor him in an overcrowded headquarters town, or sending him to a hospital where also he was at once regarded as a personapart.7 The specialist, because of his new and unique status, was brought out in sharp contrast to the other medicalofficers serving with divisions.7 If he was not tactful, and he was not always so, his position was difficult. The division surgeonfound it hard to make suitable arrangements for specialists even in billeting areas, and when battle conditions ensuedthe situation was almost impossible.7
By the spring of 1918, several divisions were in the firing line andadditional divisions were arriving rapidly.10 As corps and armies were formed, the complexity of the situation for the consultantsincreased enormously.7 Medical officers in administrative positions, as well as the specialists, knew that a defectiveplan was in operation. All professional branches still lacked coordination and there was much confusion of activity; therewere too many orders, too many reports, too many inspection trips; uncoordinated ideas were surging up from below, anduntil April, 1918, there was lack of effective administration from above.6As the functions of the specialists were not well defined, the problemsof the special branches were being handled by many different methods.
Some of the difficulties experienced by the consultants with divisionsdid not as a rule exist in the hospital centers.11 There theconsultants usually were chiefs of services of base hospitals, who wereassigned as consultants in addition to their other duties. Their living facilities were thus already provided and thegeographical scope of their activities was limited. Though often harassed by demands from the directors for reports, the dutiesof their positions were generally well understood and systematically performed. There were some differences in the methodsfollowed by the several services, but there were many basic similarities.
Though considerable attention is given above to the early lack of coordination,to the initial misconception of their duties on the part of directors, and to the difficult position which the specialistsoccupied with divisions, the fact should be stressed that despite these handicaps the initial work accomplished was of very greatimportance.7 After the group of chiefs of service at Neufchateau was reorganized in April, 1918, its efforts coordinated,and the duties of its members more clearly defined (in Circular No. 25, chief surgeon's office, A. E. F.), the value of theconsultants' services was greatly increased.7
On April 18, a director of professional services was appointed withstation at Chaumont,6 his office, for purposes of coordination, being in juxtaposition to that of the representativeof the chief surgeon, A. E. F., with the general staff.12 Inthe letter notifying him of this assignment the chief surgeon wrote asfollows:13
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By virtue of this appointment, you are empowered to representthe chief surgeon, A. E. F., in all matters pertaining to the administration,direction, and coordination of the professional services. You are responsiblefor such professional matters relating to hospitalization, evacuation,laboratories, sanitation, and other activities as may pertain to the propersorting, distribution, and evacuation of sick and wounded through the channelsthat will best insure efficient treatment from the front to the rear.
All requests for the movement of personnel and suppliesoriginating in the professional services will be forwarded by or throughyou to the chief surgeon, A. E. F., or to some one designated by him.
The consultants in the professional divisions will berecommended by you for detail as teachers at the Army Sanitary School insuch numbers and at such intervals as may be requested by the commandantof the school. In order that recent methods of treatment may be standardized,it is desired to make the instruction course at this school as thoroughand intensive as circumstances will permit, and no effort will be sparedin securing all instruction hours possible on the schedule of the school.
There is transmitted a tentative scheme of organizationfor the divisions under your control, and, after it has been given a fairtrial, should any changes, in your opinion, seem warranted, you will submitappropriate recommendations to this office for recommendation.
The tentative scheme of organization to which allusion was made in thisletter was published, as finally developed, in Circular No. 25, chief surgeon's office.
This circular charged the director with the supervision and coordinationof the professional activities of the American Expeditionary Forces. The chief consultant in surgery was charged withthe supervision of the professional surgical subdivisions, their organization and coordinations; with timely recommendationsconcerning changes in personnel, the formation of surgical teams and reports of their activities; with recommendationsconcerning inspections of his specialty. The chief consultant of the medical services was similarly charged withsupervision of the medical subdivisions in the American Expeditionary Forces, and with such recommendations as were necessaryto insure a high professional standard and complete harmony among his assistants in all formations. Senior consultantswere to coordinate under their respective chiefs, professional activities pertaining to their respective specialties,and to make appropriate recommendations for instruction of consultants and specialists in divisional or other formations.
One senior medical and one surgical consultant, were to be assignedto each tactical organization equivalent to an army corps, and consultants were to be appointed in such numbers as mightbe necessary to assist divisional consultants. Senior division consultants were to be responsible for the duties theretoforedischarged by division consultants, were to make frequent and complete surveys of professional practices in the division,supervise the activities of consultants, operating teams and other professional personnel attached to the division; organizeand distribute such teams, including those which would serve newly arrived troops, and promote their efficiency; renderappropriate reports, returns, and recommendations to the chief surgical consultant.
You will direct the compilation of a classified rosterby each chief consultant, of all professional personnel, such as specialists,consultants, or surgical teams among the various army units of our ownand allied formations, so as to facilitate their proper distribution andutilization in emergencies as well as in routine. When the organizationof the professional service is completed, you will direct its workings,either from general headquarters or such other places as best serves theinterests of the service.
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With the three original divisions, medicine, surgery andlaboratories as a basis, you will so coordinate the activities of the subdivisionthereof that scientific research and clinical proficiency may be effectuallypromoted.
Circular No. 2 and Circular No. 11, this office, willbe revoked or modified, as will all other orders, letters and instructionsheretofore issued which conflict with the instructions contained in thiscommunication.
A circular is now being prepared in this office alongthese lines.
The senior divisional medical consultant was to secure medical casesthe best and most advanced treatment possible and make appropriate reports and recommendations to the chief medical consultant.
The divisional surgical consultant was to exercise immediate supervisionover the work of operating teams in the division, but in time of mobile or semimobile warfare and when evacuation hospitalswere lacking, this supervision was to be exercised by the senior divisional consultant or his assistant, over teams workingin hospital for nontransportable wounded. Direction and supervision of the purely operative work in divisional formationswas a duty of the senior divisional surgical consultant or his assistants. Divisional medical consultants were to supervise theimmediate medical activities in the division to which they were assigned. The division surgeon was to furnish the necessary hospitalfacilities, supplies, and personnel other than those forming teams.
Such consultants for base hospital groups as were thought necessaryby the chief surgical and medical consultants were to be appointed from time to time. Base and other hospitals so far as possiblewere to be organized in three services-surgical, medical, and laboratory-each under a chief of service. Underthe chief of the surgical service were grouped general, orthopedic, and head surgery, including that of the brain,nervous system, eye, ear, nose, throat, face, and mouth; urology; roentgenology; and dentistry. Under the chief of the medicalservice were general medicine, neurology, and psychiatry, and under the chief of the laboratory service, pathology,bacteriology, and serology.
The first copies of Circular No. 25 were received simultaneously withthe notice that the corps would not function while our divisions were reenforcing the French, and it was modified to permitthe appointment of consultants to the tactical equivalent of an army corps.6 One week after Circular No. 25 was issuedother changes were again instituted which permitted the consultants for corps to function.6
In effecting the reorganization of the professional services, the directorof these services found himself considerably embarrassed by the fact that individual organizations had been builtup around each director; the harmonizing of these, their coordination and summetrical development, therefore, were very difficult.6
An effort was made to procure a copy of the card index, prepared inthe office of the Surgeon General, showing the professional qualifications of all officers in the American ExpeditionaryForces, but this was unsuccessful and the director was obliged, in makingassignments, to rely upon his very inadequate personal6 knowledgeof the ability of each officer concerned.6
The publication on June 6, 1918, of General Orders, No. 88, generalheadquarters, A. E. F., gave the directors, whose titles were now changed to consultants, a status in the forces generally whichpromoted a broader appreciation of
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their responsibilities.6 This order directed that there beappointed for the coordination and supervision of the professional careof the sick and wounded of the American Expeditionary Forces a directorof those services, and a chief consultant in medicine and in surgery, respectively; also, that there be appointedfor each army chief consultants, senior consultants, and consultants in special subdivisions of surgery and medicine. It alsoassigned selected officers as director of professional services, as chief consultants in the surgical and medical services,and as senior consultants in the following branches: General medicine; roentgenology; surgical research; neurological surgery; orthopedicsurgery; ear, nose, and throat surgery; general surgery; neuropsychiatry; venereal, skin, and genitourinary surgery;maxillofacial surgery; ophthalmology. The order further directed that other senior consultants and consultants for hospitalcenters and other formations be designated from time to time as the need for them arose and that specialists in neuropsychiatry,urology, and orthopedic surgery be appointed from the divisional sanitary personnel.
It will be observed that Circular No. 25, unlike Circular No. 2, chiefsurgeon's office, A. E. F., did not include the laboratory division among the professional services, except in so far as the organizationof base and general hospitals was concerned. Nor was that division included among them by General Orders, No. 88.Nevertheless, Circular No. 25, recognized the close relationship of this specialty and that of dentistry with the otherservices by including them with the special services in the hospital organization which it prescribed.
By General Orders, No. 88, and by Circular No. 25 the professional serviceswere centralized and their efficiency greatly enhanced.
On August 7, 1918, the chief surgeon, A. E. F., wrote to the directorof professional services stating that it was desired to have consultants in various specialties stationed at each hospitalcenter; he was requested to nominate the officers who would be ordered to these centers for duty.14 These consultantswere to include a specialist in diseases of the heart and one specialist in orthopedics who it was planned would be attached to eachconvalescent camp which formed part of a hospital center.
Each of these consultants was notified of his appointment and informedthat he was expected not only to act as consultant for the hospitals in his center, but also that at regular intervals hewould visit others, which his letter of assignment designated.15 With respect to the hospitals visited, these visits were to be madeof service in establishing standardized methods of treatment and to assistin selection of cases for evacuation to the United States or to other hospitals.
On August 13, 1918, the chief surgeon asked the director of professionalservices to designate certain hospital centers to which specialists arriving in France might be sent, both in order toexpedite their clearance from depot divisions and to determine their capabilities.16 At that time Roentgenologistswere being sent automatically to the hospital center at Bazoilles, and it was desired that officers skilled in other specialties be similarlydistributed to other selected places. The distribution was not to be made to apply to surgeons and internists who had notpracticed specialties. It was, therefore, recommended that psychiatrists and neurologists who arrived as casuals be sentto Base Hospital No. 117
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at La Fauche; specialists in eye, ear, nose, and throat surgery andophthalmology to Base Hospital No. 115, at Vichy; specialists in tuberculosis to Base Hospital No. 8, at Savenay; urologistsand dermatologists to Base Hospital No. 66, at Neufchateau; orthopedic surgeons to Base Hospital No. 9, at Chateauroux,and specialists in neurosurgery to Base Hospital No. 46, at Bazoilles.7
On August 27, 1918, certain orthopedic surgeons were appointed consultantsin their specialty for designated districts.17 Hospitals and other formations in those districts which needed theirservices were authorized to apply to the nearest consultant at the address given in Circular Letter No. 7a. This circulargave the names of these consultants, their respective addresses, and the hospitals, hospital centers, and depot divisionswhich each of these consultants was expected to serve.
On September 2, 1918, the chief consultant of the medical and surgicalservices informed the chief surgeon that in order to meet the needs for qualified medical officers, it was essential thatthe chief consultants be authorized to reserve such officers as might be necessary to carry out the work in their several departments.18They requested that the chief surgeon authorize such reservation of medical officers, and that their representativesbe instructed to confer with representatives of the chief surgeon in order to prepare and put in operation a method for dealingwith questions relating to the personnel of the professional services. The chief surgeon considered this plan practicablewithin certain limitations and arranged for a conference whereby a thoroughunderstanding might be reached of the points involved.
On the same date the chief surgeon notified the director of professionalservices that certain officers had been designated professional consultants and heart specialists at five of the moreimportant hospital centers; also, that they had been informed that this designation did not necessarily relieve them from their otherduties.19 It was requested that, if possible, in making future recommendations to fill other vacancies among consultants inhospital centers, some officer belonging to a unit in the center be selected.19
On September 8, at the instance of the director of the professionalservices the following general letter was addressed by the chief surgeon to all division surgeons concerning the service of psychiatrists,urologists, and orthopedic surgeons assigned thereto:20
There is apparently some misunderstanding among divisionsurgeons relative to the duties and status of specialists assigned to divisionalformations for duty.
During the recent activities one division surgeon assignedthe psychiatrist to dressing the slightly wounded. While he was engagedat this work, several hundred cases of slight war neurosis were evacuatedthat would never have left their division if they had been examined bya trained psychiatrist.
The above instance is cited to show the importance ofproperly utilizing the services of these trained specialists with a viewin this instance of avoiding a repetition of the experiences during therecent activities, when a total of nearly four thousand cases of slightwar neurosis were evacuated to base hospitals that should never have lefttheir divisions.
I. GENERAL STATUSANDDUTIES
Orthopedists, urologists and psychiatrists are attachedto tactical divisions solely to aid in dealing with the medical and surgicalproblems of the divisions.
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Their activities have two objects: (a) To keepthe fighting strength of the division at the highest possible point and(b) to bring about the prompt elimination from the division of thosewho become unfit for duty.
These three branches of medicine and surgery are representedbecause they are concerned with those diseases and injuries which experienceshows contribute most to noneffectiveness of individual soldiers and troopsin general.
The function of these specialists is to help the divisionsurgeon in the clinical work of the division in much the same way thatthe sanitary inspector does in sanitation and the assistant to the divisionsurgeon in administration. They should be attached to the office of thedivision surgeon as additional assistants. In no other way can they renderefficient service. Their permanent assignment to any subordinate sanitaryformation of the division inevitably curtails their usefulness. In periodsof stress, however, they should be stationed by division surgeons in thepost in which they can work to the best advantage (e. g. orthopedists andpsychiatrists in triages, the urologist in the surgical hospital duringcombat).
They should not be regarded as consultants representingan organization outside divisional control, but as integral parts of thedivision sanitary personnel, wholly concerned with the medical work ofthe division to which they are attached and directly under the supervisionof the division surgeon.
II. SPECIFIC DUTIES
ORTHOPEDISTS
Division in training or rest.-(l) Instruction inapplication of splints and dressings to entire sanitary personnel.
(2) Instruction in proper care of the wounded during transportation.
(3) Instruction in prevention and treatment of shock andhemorrhage.
(4) Examination and reclassification of those unfit forcombat due to faulty posture and foot disabilities.
(5) The inspection of shoes and instruction in propershoeing and care of the feet.
Division in combat.-(l) Supervision of supply anddistribution of splints and dressings.
(2) Continuance of instruction in application of splintdressing, treatment of shock and hemorrhage, and care of wounded duringtransportation.
(3) Supervision of surgical treatment of wounded fromfront line to hospital.
(4) Prophylaxis of foot conditions arising in trench warfare.
UROLOGISTS
Venereal diseases.-Prophylaxis of venereal diseases:(1) Lectures to medical officers and personnel of prophylactic stations.
(2) Inspection of prophylactic stations as to proper location,equipment, personnel, technique, results, and failures.
(3) Cooperation with the A. P. M. in investigation oflocal conditions concerning prostitution, regulated and clandestine, andalcoholism.
Treatment: (1) Supervision of physical inspections, earlyrecognition of venereal cases and evacuation to medical labor camp.
(2) Supervision of genito-urinary treatment and operationsin divisions.
Skin diseases.-Prophylaxis: (1) Cooperation withother departments and officers concerned in the bathing and disinfectingof troops and equipment.
(2) Instruction of personnel assigned to bathing establishmentsin the prompt recognition of skin diseases, and the importance of removingthem at once from their commands.
(3) Supervision of inspections for skin diseases madesimultaneously with venereal inspections.
Treatment.-Supervision of treatment of skin diseasesin field hospital or other medical unit assigned for the purpose.
Cooperation with the senior consultant in venereal, skin,and genito-urinary diseases through the division surgeon in accumulationof data concerning venereal, skin, and genito-urinary surgery, by monthlyreports.
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PSYCHIATRISTS
Division in training or rest.-(l) Elimination ofinsane, feeble-minded and epileptic (especially among replacements).
(2) Mental examination of general prisoners in accordancewith section 11, General Orders, No. 56, current series.
(3) Instruction of medical officers regarding diagnosis,early management, and prevention of war neurosis (shell shock).
Division in combat.-(l) Examination and sortingof officers and men returned to advanced sanitary posts for exhaustion,concussion by shell explosion, and war neurosis in order to control theirevacuation.
(2) Treatment of light cases of exhaustion, concussion,and war neuroses in divisional sanitary formations so as to preserve thegreatest number possible for duty.
(3) Mental examination of general prisoners and men suspectedof having self-inflicted injuries.
Concerning the withdrawal of consultants from the army corps, the chiefsurgeon of the First Army Corps, on November 4,
1918, forwarded the following record of his analysis of the situation:21
The chief surgeon, First Army Corps, desires to call attentionto certain features connected with the organization of the Medical Departmentof a corps.
There appears to be a tendency to withdraw corps consultants.The undersigned believes this would be a vital mistake.
The corps surgeon should have on his staff the following:(a) Internist; (b) psychiatrist; (c) urologist workduring active operations is concerned largely with bathing, delousing,and skin diseases; (d) orthopedist; (e) medical gas officer;(f) sanitary inspector.
Evacuation of sick and wounded should be supervised bythe commanding officer, corps sanitary train.
All the above men should be carefully selected in orderthat each fits perfectly into his place. Each must have the undivided supportof the corps surgeon.
Concentration of these specialists in an army and attemptingto control the work of divisions without working through the corps willresult in inefficiency. The army is too far removed from the front line.Personal contact with conditions in the front line is absolutely essentialin order to properly appreciate the difficulties connected with divisionalwork and to formulate means for their correction.
The only consultant whose services can be dispensed within a corps under present conditions is the surgical consultant. The chiefsurgeon, First Army Corps, however, feels that mobile hospitals shouldbe under the control of the corps surgeon, and in that event a corps consultantin surgery would be indispensable. Mobile hospitals should work so farforward that only the corps surgeon is sufficiently familiar with conditionsto determine promptly when and where they should be moved. The presentsystem has not been satisfactory.
Divisions need constant supervision in all phases of theirmedical, surgical, sanitary and evacuation work. Obviously, the corps surgeonwould be helpless in attempting such supervision alone. His staff of consultantsfurnishes him with an invaluable means for keeping in touch with everyphase of the work in the various divisions, and if properly selected, supervisedand supported, they are absolutely indispensable in enabling the corpssurgeon promptly to detect defects and to correct them.
This can not be done from an army largely because of thelack of personal contact.
In this plan, each division consultant would be underthe direct supervision of the corresponding corps consultant; each corpsconsultant under the supervision of the corresponding army consultant;each army consultant under the supervision of the corresponding chief consultant,G. H. Q., A. E. F. The chief consultant, general headquarters, A. E. F.,would formulate policies-the army, corps, and division consultants wouldbe responsible that these policies are enforced. Without supervision, theywill not be carried out; with proper organization and supervision, theywill be carried out.
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The above plan gives a logical, balanced organizationthat will bring results. If corps supervision is not included, there willbe a missing link that will mean inefficiency.
Transportation is of course vital. Without it, consultantsin either army, corps or division are helpless.
It may be possible at some latter date that divisionsmay become so experienced and well trained that this supervision may notbe necessary. This is certainly not true at present and we do not believeit will be true during the continuance of this war.
The chief surgeon, First Army Corps, feels so stronglyin this matter that, in case the corps consultants are not included asthe general policy, he requests that the First Army Corps be permittedto retain the staff as outlined above.
In commenting upon the above-outlined plan the chief surgeon, FirstArmy, stated:22
It was thought at first the duties could be performedby assigning consultants to the army with assistants to work with the corps,but this plan has not proven effective due to the great distance the combatanttroops are from the army headquarters, rendering it impossible to keepin touch with them with the paucity of transportation.
The paucity of truck transportation has precluded thefurther use of complementary groups with divisions, and it has been necessaryto move the mobile hospitals far to the front to act as nontransportablehospitals, using the corps field hospitals for reservoirs.
The attitude of the chief consultant in surgery, concerning the planof the chief surgeon, First Army Corps, was expressed by him as follows:23
The plan as outlined by Colonel Grissinger with referenceto corps consultants is most heartily approved.
His suggestion with regard to the disposition of mobilehospitals and their control by the corps surgeon has been fully justifiedby recent experiences in the Argonne and is also concurred in.
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On November 16, 1918, the chief surgeon instructed the director of professionalservices to confer with the chief consultants in medicine and surgery at the earliest possible date, with a viewof compiling a report on the activities of the different subdivisions of medicine and surgery.24 He felt that byutilizing the services of the officers in the professional services during the then inactive period, every phase of the subject, from front torear, could be covered without difficulty.
Unfortunately the early dissolution of the consultants' staff and thereturn of many of them to the United States prevented a full realization of the chief surgeon's project.
ACTIVITIES OF THE SURGICAL SERVICES
GENERAL SURGERYa
The section of general surgery, the parent stem from which the subsectionof the surgical services, A. E. F., were subsequent offshoots, came into existence upon the appointment of a director ofgeneral surgery, November 10, 1917. On December 22, 1917, two assistants to the director were appointed, and on January28, 1918, a joint office for administrative purposes was opened in Neufchateau, with the directors of the "divisions" oforthopedic surgery, psychiatry, and genitourinary surgery.
aThe statements of fact appearing herein are based on "Report of the activities of the division of general surgery, A. E. F.," by Brig. Gen. J. M. T. Finney, M. C., chief consultant, surgical services, A. E. F. The report is on file in the Historical Division, Surgeon General's Office, Washington, D. C.-Ed.
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The section of general surgery, being independent at the time in question,as was true of the other professional services, reported directly to the chief surgeon, A. E. F. Pursuant to GeneralOrders, No. 88, general headquarters, A. E. F., June 8, 1918, the various professional services were coordinated under a directorof professional services, and the director of the surgical services now became the chief consultant thereof, with thefollowing subdivisions, each in charge of a senior consultant, directly under him: roentgenology; surgical research; neurologicalsurgery; orthopedic surgery; ear, nose, and throat surgery; general surgery; venereal and skin diseases and genitourinarysurgery; maxillofacial surgery; ophthalmology.
SURGICAL CONSULTANTSWITH TACTICALUNITS
The first step taken was the recommendation that a surgical consultantbe appointed by the director of surgical services, following his appointment in November, 1917, for each of the tacticaldivisions then in France. After their appointment, these officers met the medical officers of the divisions and advised withand instructed them. When the tactical divisions went into the front line the services of the divisional surgical consultantsproved to be more valuable in the hospitals, and thereafter their time was chiefly spent in the evacuation hospitals. Consultants toour divisions operating in French armies occupied their time chiefly in observing the methods and treatment in French hospitals.
There was in the beginning (in each division) a decided tendency todo surgery in the field hospitals. The chief consultant in surgery received an order from the chief surgeon, A. E. F., forbiddingoperations in a field hospital when an evacuation hospital was available. This made it possible to place consultantswith mobile and evacuation hospitals only.
As the surgery was now all done in hospitals, other than divisional,save in unusual circumstances, it soon became apparent that consultants were not needed with divisions; therefore a consultantand assistant were then designated for each corps. This new arrangement was satisfactory until the First Army was formed,when the same objections obtained as to consultants with corps as proved true of divisions. A consultant for each armywas then appointed, with a sufficient number of assistants, to supervise the surgical work in all the evacuation and mobile hospitals.This policy was put in operation in both the First and Second Armies andproved fairly satisfactory. Corps surgeons were almost unanimous in theopinion that no consultants were needed with divisions or corps.
SURGICAL TEAMS
Another important step, after securing the assignment of consultants to tactical units, was the organization of surgical teams from the personnel of all base hospitals. This was initiated on January 7, 1918. Each team consisted of 1 operator and assistant anesthetist, 2 nurses, and 2 orderlies. A dozen teams were quickly organized, and others as more hospital units arrived, so that by the end of October some three hundred teams had been organized and two hundred were operating with the First and Second Armies.
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THE PREOPERATIVE TRAIN
Another improvement instituted by the chief consultant, surgical services,was the "preoperative train"-a train filled with certain (unoperated) cases, which would not suffer from transportationand a delay of 29 to 36 hours. During the St. Mihiel operation the chief surgeon, First Army, was furnished a listof the type of cases suitable and the plan was put in practice, thus relieving the forward hospitals of many cases. No badresults followed except in a few instances where trains were sent to more distant hospitals.
SURGICAL CONSULTANTS,HOSPITAL CENTERS
The necessity for surgical consultants in the large hospital centerswas apparent to the chief consultant for a long time; however, through lack of personnel, they could not be supplied untiltoward the end of active hostilities. At the end of 1918, 16 hospital centers had surgical consultants.
EXPERIMENTAL WORK
Early in January, 1918, a committee was appointed by the chief consultantin surgery to study the best methods of blood transfusion for use in the forward area. An excellent report was preparedand distributed to the medical officers. Instruction in the treatment ofshock was given at the central laboratory, Dijon. Experimental work inconnection with the problems of wounds of the thorax also was done. The chief consultant suggestedan interchange of personnel between base and mobile hospitals and this plan was partly carried out.
LECTURES
In addition to the activities directly connected with the treatmentof the wounded, the senior consultants of the subsections and the consultants with troops and hospital centers gave lecturesat the Army sanitary school, Langres, on surgical subjects connected with their various departments.
NEUROLOGICAL SURGERYb
A senior consultant in neurological surgery was appointed on June 7,1918, and directed to organize a subsection. His problem was unique since no precedent existed in any army. A roughestimate by him made it seem probable that 25 per cent of all casualties would present neurological problems; unofficialfigures from British and French sources gave the following percentage of nerve injuries: Wounds of the head, 16 percent of all wounds; wounds of the spine, 2 per cent of all wounds; wounds of major peripheral nerves, 20 per cent of all seriouswounds of the extremities.
The problem presented two aspects: The immediate care, in forward hospitals,of the more serious cranial and spinal cases; later care at base hospitals of residual paralysis of peripheral nerves.The results at that time in both cases were not encouraging; over 50 per cent of penetrating skull wounds
bThe statements of fact appearing herein are based on "Report to the chief surgeon, A. E. F., from the senior consultant in neurological surgery, dated Neufchateau, Dec. 2, 1918, on summary of the activities of the department." Copy on file, Historical Division, S. G. O.-Ed.
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and 80 per cent of the spine were fatal. The wounds of peripheral nerveswere simply accumulating and awaiting treatment later.
The plan of organization provided for teams for hospitals in the zoneof the advance; representatives in the base hospitals; neurological centers.
For each team, one surgeon from each evacuation hospital was selected,given special instructions and assigned to this work in his hospital; also proper equipment was supplied. A difficulty wasthat in "centers" devoted exclusively to diseases and injuries of the nervous system, as in the French Service, on emergencythese surgeons were often impressed for general work. Another difficulty, in a rush period, was the slowness of headoperations. Often the tedious head cases were passed on to base hospitals that more cases might be handled. Through June,1918, there were teams only at Mobile Hospitals Nos. 1 and 2; by July most of the evacuation and mobile hospitals had suchteams. Following this, more specialists arrived from the United Statesand more instruments were available; so that, before the St. Mihiel operationin September, each hospital in the forward area had an experienced team.Although this operation was relatively short, it was seen that one teamin eachhospital was not sufficient to screen out the cases; in some hospitalsthe teams were off duty or doing general surgery, and the results werenot satisfactory. Fifty per cent of head cases died, exclusive of thosedying later in base hospitals.
In preparation for the Meuse-Argonne operation, the senior consultant,neurological surgery, urged the chief surgeon to supply two teams to each hospital on the main line of evacuation-Fleury,Souilly, and Villers-Dancourt; and to direct that field hospitals route suitable cases to one of these points. Instead,the British plan was followed; one hospital at Deuxnouds, was selected, and several teams concentrated there. Some813 cases were secondarily routed to this hospital, whose location and general arrangements were poor. Because of theseconditions and the changing personnel results were not entirely satisfactory, resulting in the adoption of the formerplan, that is having special hospitals, farther forward, as named above. From 50 to 100 beds were set aside for these cases ateach of the three hospitals.
As to wounds of peripheral nerves little more could be done in the advancehospitals than to prevent the destruction of nerves by extensive débridement,and to have some divided nerves sutured. This latter procedure was necessarilyrare. These cases were generally handled in the base hospitals, where provisionwas made as far as possible, for a specialist at each.
As a rule each hospital group, a center, had one selected hospital towhich proper cases were to be sent, either on arrival or later.
It was the intention to have a group of well-trained neurologists andneurosurgeons for each of the large centers and this planwas put in operation at some centers, as, Bazoilles, and Contrexeville.Military Hospital No. 1 served for the Paris group.Owing to lack of suitable personnel and to the difficulties of secondaryrouting, the project of a district neurological centerhad to be abandoned; though Base Hospital No. 115, at Vichy, made avery successful start in that direction.
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ORTHOPEDIC SURGERYc
The orthopedic service began with the dispatch to England of an orthopedic surgeon and 20 assistants in May, 1917. These officers were assigned to duty at different orthopedic centers there pending the organization of the American Expeditionary Forces.
The subject of splinting was taken up in July, 1917, and a committeewas appointed by the chief surgeon, A. E. F., for the purpose of formulating regulations for the standardization of splints.This committee recommended a set of splints, which were adopted, and described in the Manual of Splints and Appliancesfor the Medical Department of the United States Army, 1917.
More orthopedic personnel was now arranged for, and in October, 1917,45 orthopedic surgeons, with 3 Sanitary Corps officers trained for splint shop work and 12 special nurses, sailedfrom the United States for England. All this personnel was assigned (temporarily) to the British Service, partly for instructionand partly to assist the British Medical Service.
In November, 1917, a director of orthopedic surgery and two assistantswere appointed. The director and one assistant were stationed at Neufchateau, the other assistant was stationed inLondon as liaison officer with the British Medical Service.
Shortly after this time, our troops occupying training areas, the orthopedicproblems were chiefly static defects, such as flat feet, weak back and knees, among line troops. To correct these staticdefects, a special training battalion was established in the 26th Division, then at Harechamp, where the men were trained tocorrect faulty habits of posture while on a duty status. This battalion was successful and was later transferred to the FirstDepot Division at St. Aignan-Noyers. By July, 1918, the need for class C men-that is, men unfit for front line duty-was sogreat and the number of the men mentioned so great and instead of attempting to make them fit for class A theywere given short periods of training and assigned directly to class C duty. In this manner, at one time, 1,200 men were assignedto the Hospital Corps, 1,000 at another time, 1,000for prison guard duty, 100 for military police, and others in smallergroups.
In November, 1918, a number of our orthopedic surgeons were withdrawnfrom service in England and assigned to combat divisions in the American Expeditionary Forces for the purpose of trainingMedical Department officers and men in the proper application of splints. At first three such orthopedists wereassigned to each division for this purpose. In addition they made a survey of the entire personnel, and as far as possible, correcteddefects of this. Later, when the divisions entered combat, training in the application of splints became a principal featureof the orthopedic section. Divisional arrangements for the transportation, storage, and handling of splints were also in thehands of the orthopedic surgeon.
Supervision of bone and joint cases was given to the orthopedic section.To accomplish this, one of the assistants to the chief consultant was assigned to
cThe statements of fact appearing herein are based on "Report of the senior consultant, orthopedic surgery, on the activities of the department of orthopedic surgery, made to the chief surgeon, A. E. F." On file, Historical Division, S. G. O.-Ed.
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the zone of the advance and another to the hospitals in the rear; supervisionof the work in the combat divisions was given to a third. In addition to these, special consultants were assigned tovarious groups, to centers, and hospitals.
In order to care properly for the bone and joint cases, standardizedmethods were announced and taught: First, splinting; second, transportation; third, posture of limb injured. This standardizationdid away with the unnecessary changing of splints and the possible harmful changes of methods of treatment. "Splint teams"were organized, each consisting of one orthopedic surgeon and two enlisted men. These teams took charge of the woundedman as soon as his operation was completed, applied the necessary splints, and cared for him (if retained in hospitalat the front) or supervised his transport to the rear.
Groups of reconstruction aids were also employed for giving physicaltherapy to the men in base hospitals; curative workshops were established.
The work of the orthopedic service demonstrated, first, that a largenumber of physically unfit men can be restored to duty by proper training,and that many such conditions as flat-foot and weak back should not becarried on the sick report as sickness, but should be considered simply as weakness, to be correctedby training; second, the use of standard methods of splinting, transportation, and after treatment, reduced the mortalityrate among combat casualties and greatly reduced the amount of their later impaired functions.
ROENTGENOLOGYd
The personnel of this department consisted of medical officers expertin X-ray work; officers of the Sanitary Corps, called technicians; enlisted men of the Medical Department. They arrived inFrance as members of hospital units or as casuals. Though some of the officers proved to have had little or no actualexperience in this line of work, a large percentage of them had received an intensive course of training in the United States,and so arrived in France with a general knowledge of the physics underlying X-ray work and with the construction and operationof the various types of X-ray machines being used. Additional instruction was given in France, at first, at the X-rayrepair shop in Paris, and later at a school established at the hospital center, Bazoilles. Several groups were instructed at Toursby a medical officer of the French Army.
The installation and repair of apparatus was done by 12 officers ofthe Sanitary Corps. The care and routine work was done by enlisted men, known as manipulators. As a rule, these enlisted menwere trained in the United States, though some were trained in France.
The X-ray apparatus used in the hospitals in the American ExpeditionaryForces was similar to that used in military hospitals of the United States. The large interrupterless type of machine wasnot suited to French conditions on account of the current supplied; only bedside units and modified bedside transformers werefound suitable. At some places no current was available, requiring the use of a gas engine. One bedside unit wasfound to be needed for each 500 beds. This apparatus could be operated on practically any type
dThe statements of fact appearing herein are based on "Report of the activities of the Roentgenological service. A. E. F., by the senior consultant, roentgenology." On file, Historical Division, S. G. O.-Ed.
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of current and used so little current that it could be attached to anelectric light plug. The Army portable outfit was found very satisfactory for base hospital use.
Mobile hospitals were supplied with an X-ray motor truck of French manufacture,which had a number of faults and disadvantages. A camion devised in America was much superior, but didnot arrive in the American Expeditionary Forces until toward the end of hostilities.
X-ray work was done in all the army zones and sections. At the frontpractically all battle casualties were examined in evacuation, mobile, and fixed field hospitals; fractures were brieflydescribed, foreign bodies located, and evidence in chest wounds was recorded. X-ray work during an operation was but seldomnecessary. The combat divisions did not need X-ray apparatus. The proportionof patients X-rayed was 80 per cent in the field hospitals for nontransferablecases and 90 to 95 per cent in evacuation and mobile hospitals. To keepup with the work in times of emergency it was necessary to employ two shiftsand work continuously.
The base hospitals also employed the X ray extensively, especially incare of wounded coming directly from the front.
MAXILLOFACIAL SURGERYe
On April 18, there arrived at Brest a party consisting of 19 medicalofficers, expert in oral and plastic surgery, and 15 special dental surgeons. Pending active operations by the American troops,these officers were scheduled for assignment, some to a French hospital at Lyons and the remainder to British hospitals atCroydon and Sidcup, England. The officers intended for Lyons, however, were delayed and were assigned to a British hospitalinstead. Other officers were assigned to Evacuation Hospital No. 1, Base Hospital No. 15, and American Red Cross HospitalNo. 1. Those who had been sent to allied hospitals were gradually withdrawn for general surgical and dentalwork, to be reassigned to their own specialty when needed.
In authorizing the establishment of the maxillofacial service the chiefsurgeon, A. E. F., directed that it be conducted as a part of the general surgical service, but in such a manner as to receivethe cooperation of the dental service in the most efficient manner. The chief consultant, surgical service, the chief dental surgeon,and the senior consultant of the maxillofacial service were in accord as to the advisability of this plan. The general planoutlined specified that the maxillary and facial cases should be in charge of a surgeon working in cooperation with a dental surgeon.It was believed that if these cases could receive proper treatment in the advanced hospitals, and this treatment continuedin the base hospitals, they could be saved (except in a few cases with great loss of time) from the reconstruction classand made fit for duty within the time cases were allowed retained in the American Expeditionary Forces. Further, that with propercare reconstruction would be simpler and moresuccessful. Experience proved this view to be correct.
eThe statements of fact appearing herein are based on "Report of the senior consultant, maxillofacial surgery, on the activities of the maxillofacial service, A. E. F., made to the chief surgeon, A. E. F." On file, Historical Division, S. G. O.-Ed.
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As planned in the office of the Surgeon General, each evacuation hospitalwas to have one surgeon and one dental surgeon for this special work. No provision was made for mobile and AmericanRed Cross hospitals.
It was soon learned that it was best not to designate these specialistsfor the various hospitals by specific orders, but rather by individual understanding with the various commanding officers, whowere requested to assign the most desirable officers of their personnel. The lack of special surgeons was later compensatedfor by the appointment of local consultants.
In each base and evacuation hospital a specially qualified dental surgeonwas assigned to care for prosthetic and splint work. Unfortunately, not all the mobile hospitals were so equipped, evenat the signing of the armistice, and, in a number of cases these dental surgeons were handicapped by having other duties assignedthem, such as those of evacuation officers and mess officers.
On June 11, 1918, the senior consultant, maxillofacial surgery, maderecommendation as to a definite plan of early treatment. This plan was authorized by the chief surgeon, A. E. F., in a memorandumissued in October. Instructions were also issued by him covering the evacuation and transportation of maxillofacialcases. It was directed that such cases, evacuated to the Paris district, be treated in American Red Cross Hospital No. 1; othercases that could be were to be transferred to any hospital having this special service, or to Base Hospital No. 115.Base Hospital No. 115 had been designated as a special hospital for surgery of the head. While there was much general surgerydone there, there were more special facilities for maxillofacial surgery, such as expert modelers in wax reproductions,expert surgeons and dentists, and special supplies. With all the above facilities, however, the contemplated plan of makingthe repair of the soft parts in extensive injuries before return to the States was practicable in but few instances.
In September, a number of local consultants were appointed. One wasassigned as local consultant, advance section, and also as assistant to the senior consultant. Local consultants wereassigned as follows: Base sections Nos. 1 and 5, station at Savenay; base section No. 2, station at Beau Desert hospital center;area 3 (Toul, Bazoilles, Vittel, Chaumont, Rimaucourt, and Langres), station at Toul; area 4 (Dijon, Allerey, Beaune, Mars,and Mesves), station at Beaune; area 5 (Vichy group), station at Vichy; area 6 (Tours and Orleans), station at Tours; Parisarea.
Though the senior consultant remained in America until the special equipmentneeded was ready for shipment, with the exception of one intratracheal vaporizor, a few sets of oral and plasticinstruments, and 500 emergency jaw splints, none of this equipment had been received when the armistice was signed. Thisshortage was partly compensated for by the collection and having made of special jaw splinting material and by ingenuityin extemporizing material.
To sum up, the work done by the service included: (1) The training ofa number of surgeons and dental surgeons in the work to be done, both in special schools and in French and British hospitals;(2) the organization of the work in the American Expeditionary Forces. This included the general organization, the appointmentof local consultants, and the development of centers.
In so far as the American Expeditionary Forces are concerned the resultsobtained in maxillofacial surgery were not as great in quantity as had been
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anticipated, owing to the lack of both personnel and equipment, theutilization of some of the personnel for other work, and the relative brevity of the period of active hostilities.
VENEREAL AND SKIN DISEASES AND GENITOURINARY SURGERYf
Four members of the Medical Corps reported to the British Army in Englandon June 8, 1917, for the purpose of studying the British methods of treatingvenereal diseases. A month was devoted to this study in England and inthe British Expeditionary Forces, France. Numerous hospitals in Englandand in France were visited, and the routing of venereal cases from organizationto hospital was studied. A second month was then spent in the study ofmethods employed in French military hospitals, two of the medical officersreferred to making, in addition, an extended tour, accompanied by a seniorFrench medical officer, of several French armies with the view of observingthe sanitary organizations.
As regards the British Army, it was found that, during the year 1916,112,249 cases of venereal disease were treated in hospital. Of these cases, 52,495 were treated in 14 hospitals in Englandand 59,754 in 5 British Expeditionary Force hospitals in France. The capacity of the hospitals in England variedfrom 100 to 1,500 beds, and of the British Expeditionary Force hospitals from 500 to 3,500. The largest hospital-that is, 3,500-bedcapacity-had treated 55,634 patients with venereal disease, including 12,000 syphilitics. Duringthe years 1915-16 the hospital referred to had treated 22,596 cases of gonorrhea, representing 1,082,621 days lostin hospital, or an average of 48 days each. Sixty per cent of the gonorrhea cases had complications, usually prostatitisor epididymitis; 17 per cent were readmissions for relapses of the disease after supposedly having been cured. In addition to thedays lost in hospital, the patients lost from one to two weeks in traveling to and from hospital.
In respect to the French Army no statistics were obtainable by the medicalofficers studying the venereal situation therein, as to the prevalence of venereal disease, partly owing to the fact thatuncomplicated gonorrhea had been treated habitually by the French in regimental organizations. It had been estimated by theFrench, however, that up to the end of the year 1916 there had been 200,000 cases of syphilis in the French Army. Thesesyphilitics were treated in approximately 20 hospitals, the bed capacity of which varied from 100 to 800, each patient remainingin hospital from 4 to 7 weeks. The French practice was to establish throughout the country centers for the treatment ofskin and venereal diseases, where both civil and military patients received dispensary and bed treatment, as the case might callfor.
As a result of this investigation, the officer who was subsequentlyto become the senior consultant in skin and venereal diseases, as well as in genitourinary surgery, concluded that the establishedsystem of transferring venereal patients from their organizations to hospitals situated from 50 to 100 miles removed wasnot the best method, and that such venereal diseases as might arise inthe American Expeditionary Forces could be treated fully as efficientlyin the
fThe statements of fact appearing herein are based on "Report of the division of urology, A. E. F.," by Col. Hugh H. Young, M. C., senior consultant in venereal and skin diseases and genitourinary surgery, Dec. 20, 1918. On file, Historical Division, S. G. O.-Ed.
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organizations to which the patients concerned belonged. This lattermethod had the following advantages: (a) Saving of time lost in the transfer of patient to and from hospital. (b) Moreefficient treatment. Treatment of venereal patients in their organizations permitted better control and continuity, especially asregards syphilis. (c) Saving in personnel and material by eliminating large base hospitals for the treatment of venereal diseases.
The treatment of venereal diseases in the organizations to which theybelonged, then, became the established procedure in the American ExpeditionaryForces. To facilitate this, a regimental infirmary urological set was adoptedand a supply of them was ordered for the American Expeditionary Forces, delivery being madeto the forces in January, 1918, and subsequently. Also, a proper stock of drugs for the treatment of venereal diseaseswas ordered; the injection treatment of syphilis was standardized; a condensed, one-page syphilitic register was devisedand placed in use; special ampoule syringes containing gray oil, and ampoules of novarsenobenzol, of sterilized distilledwater, and of cyanide of mercury were designed and supplied for the treatment of syphilis. Diagnostic facilities in theexamination of blood smears, for the Wassermann reaction, the examination of urethral smears, were established through collaborationwith the director of laboratories, A. E. F. Owing to the lack of suitable equipment in the field, the Fontana and Hollandestains were adopted for the detection of spirocheta in the field, the dark field illumination being reserved for employmentin laboratories established at central points and at base hospitals. Individual prophylactic tubes for the prevention of venerealdisease were devised and supplied for the use of those who did not have ready access to prophylactic stations, such as smalldetachments at remote stations.
A beginning was made, at the instance of the senior consultant in urology,to minimize the venereal infectiousness of the civil population of France. A hospital was established by the American RedCross at Neufchateau, with a subsidiary hospital at Doulaincourt. From these places teams, each consisting of a medicalofficer and a nurse, would make daily visits to surrounding towns to establish clinics for the treatment of venerealdiseases among the civil population. Six routes were established covering 50 clinics in an area radiating fully 50 milesin all directions from Neufchateau. The hospital, constructed for the purpose at Neufchateau, was completed on March 15, 1918. Itcontained 50 beds and had operating room and laboratory facilities.
To insure the systematic treatment of venereal diseases in the AmericanExpeditionary Forces, urologists at base hospitals were instructed as to the methods to be employed, and specially qualifiedurologists were, after a preliminary course of training, appointed as urologists in each tactical division and ineach base port.
In so far as the tactical divisions were concerned, the establishedsystem of treating all venereal cases in their organizations operated satisfactorily until these divisions began to take their placesin the front line. Because many commands then became so broken up with working parties as to make it practically impossiblefor regimental medical officers to keep constantly in touch with venereal cases, who, in many instances were at work at distancesvarying from 5 to 10 miles from the nearest medical officer, it was necessary
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to modify the organization for treatment. Accordingly, working campsnow were established in connection with divisions at the front, wherein were collected all venereal disease cases in thedivision concerned. It proved that approximately three-fourths of such venereal disease cases thus could be kept ona duty status and supplied for working parties, under the direction of the divisional quartermaster or engineer officer.
As to the location of the working camps for venereal cases, a tryoutof several schemes proved that such a camp could functionate best if established in one of the divisional field hospitals.Therefore, the accepted practice was to establish such a camp in conjunction with a divisional field hospital given over tothe treatment of venereal and skin diseases.
Venereal camps were established not only in connection with tacticaldivisions but also at depot divisions, and on the same principles as obtained in the combat divisions. In the depot divisionsthe venereal camps were used for venereal cases sifted out from the replacement troops, thus preventing them from becominga burden to the tactical organizations at the front.
One of the final uses to which venereal camps were put was in connectionwith home-going troops following the signing of the armistice. In thisconnection, it was required that all members of the American ExpeditionaryForces returning to the United States were to be examined for venerealdisease prior to embarkation, and that those found venereally infectiouswere to be detained and placed in segregation camps.
A manual of military urology was prepared under the direction of thesenior consultant in urology and was distributed to medical officers of the American Expeditionary Forces. This manualcomprised sections on venereal diseases, dermatology, and surgery of urinary and male genitalia. Also, it contained appendicesgiving in full all promulgations concerning the subject of venereal diseases and alcoholism both in the United States and inthe American Expeditionary Forces, and the French regulations on prostitution and alcoholism.
Concerning the problems connected with dermatology in the American ExpeditionaryForces, after an extensive study of the conditions in reference to scabies and lousiness in both the AmericanExpeditionary Forces and those of our Allies, the plan of action decided upon was as follows: (a) Instructions wereprepared which appeared from time to time either as general orders, headquarters, A. E. F., or as circulars from the chief surgeon'soffice, A. E. F. (b) Divisional and other urologists were especiallyinstructed in the measures for the prevention, diagnosis, and treatmentof these diseases. (c) Specially qualified dermatologists were constantlyin the field inspecting pertinent conditions and in giving instructionson these topics. (d) Scabies hospitals were established in connectionwith the divisional venereal camps. (e) Regional disinfestation,rather than divisional. (f) Observance of the principles of theprevention and treatment of skin diseases as outlined in the Manual ofMilitary Urology.
Though it was planned having special hospitals wherein cases requiringgenitourinary surgery could be given special treatment, this was found to be impracticable in view of the fact that such injuriesor conditions were so relatively scattered and few in number.
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SURGICAL RESEARCHg
The section of surgical research of the surgical services, A. E. F.,comprised a senior consultant and three consultants, with the necessary assistants. The work of the senior consultant was doneat Base Hospital No. 4, which operated with the British Expeditionary Force at Rouen, and in collaboration with several officersin his laboratories in Cleveland; one of the consultants carried on his investigations at Base Hospital No. 10,also operating with the British Expeditionary Force at Treport; the remaining two consultants established a surgical researchlaboratory in connection with the central Medical Department laboratory, Dijon.
It was under the broad interpretation of research as including anythingthat would offer promise of yielding useful information that the work, much of which was done in the British service beforeour forces became actively engaged at the front, was made possible.
A program of work was planned by the senior consultant and in hand onNovember 11, 1917, which was contemplated for the following winter months of anticipated light military activity.It was during this relatively inactive surgical period that the researches included not only general surgical subjects but also subjectsof interest to both the combatant and the medical arms. The latter researches were made in collaboration with the BritishRoyal Engineers' training school, Rouen; however, during periods of active warfare these studies were dropped and subjectsof immediate surgical bearing were taken up. The following list will indicate the wide range of subjects thus investigated:(1) Phosgene poisoning, clinical and experimental; (2) biologic test of safe and danger points in gas defense works; (3) researchinto carbon monoxide poisoning; (4) research into psychic effect of minor explosives; (5) further research into the effectsof high explosives; (6) research into the effects of various infusions; (7) the inceptive stage of shock; (8) research intothe effects of hypertonic salines.
The following researches into practical surgical problems were made:(1) Organization of resuscitation teams with the British Expeditionary Force, France; (2) slightly wounded; (3) delayed infectedwounds; (4) on blood transfusion; (5) shock and hemorrhage; (6) treatment of infections; (7) chemical antiseptics;(8) delayed closure of wounds; (9) surgery of the chest; (10) study of types of wound that bear transportation.
Apparatus was secured from the United States, and the central MedicalDepartment laboratory cooperated in every way; the American Red Cross gave grants of money freely for supplies and sundryexpenses. The Research Society of the American Red Cross provided excellent opportunity for cooperation with similarservices in the British, French, and Italian Armies.
The plan for the laboratory which was necessary for the various researchesprojected was perfected in January, 1918, and in April the laboratory was established at Dijon. Here investigationswere begun in May. The principal work of this laboratory was along two lines: First, treatment of wounds of the chest, and,second, shock and hemorrhage. The results accomplished appear in Vol-
gThe statements of fact appearing herein are based on "Report of the activities of the division of surgical research, A. E. F.," made Dec. 18, 1918, by Col. G. W. Crile, M. C., senior consultant in surgical research, A. E. F. On file, Historical Division, S. G. O.-Ed.
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ume XI, Part I. At this time it is only necessary to say that the treatmentof chest wounds was largely standardized, and by the organization of transfusion and shock teams undoubtedly many liveswere saved. The use of Bayliss' solution of gum acacia as a substitute for transfusion was an important demonstration;another was that of a measure of the degree of anemia requiring transfusion.
OTOLARYNGOLOGYh
When the senior consultant of otolaryngology was designated in June,1918, there were 17 base hospitals actively functionating, with one otolaryngologist on duty in each. There werealready 50 camp hospitals established, 50 per cent of which were not functionating. Of those which were active less thanone-third had an otolaryngologist assigned to them. The total roster of otolaryngologists at that time was 32.
One-third of the base hospitals operating at the time were lacking inotolaryngological instruments and equipment to care adequately for the patients they were receiving. The senior consultantvisited each hospital, inspected the instruments and equipment, and assisted in compiling a list for requisition from themedical supply depot. Plans for an examination and treatment room for ambulatory patients were formed in those hospitalswhere no provision had been made previously for them and suitable construction was at once begun. Special wards wereobtained for this department and where possible specially trained nurses assigned to duty in these wards.
Of the camp hospitals operating only two had sufficient instrumentsand equipment properly to care for otolaryngological cases.
In only one was an otolaryngologist on duty, with practically no instrumentsor equipment with which to work. Otolaryngologists subsequently were assigned to all camp hospitalsin the order of their needs. Instruments and equipment were obtained and examination and treatment rooms constructed.
None of the mobile hospitals established early had an ear, nose, andthroat surgeon connection with them. Officers were assigned to these hospitals as needed and assistance was given to procureinstruments and equipment sufficient for the needs of the department.
In none of the field hospitals functionating was there an otolaryngologistor any instruments or equipment for use in this department. Officers were assigned as needed and instruments and equipmentprocured.
There were eight otolaryngologists on duty with various combat divisions.Later the number was increased as requests were made, but at no time during active military operations were there sufficientofficers from this department to meet the demands made upon it.
At hospital centers a set of buildings was assigned to this departmentso that all the work in the center could be accomplished at the one place.Special wards and operating rooms were arranged and large examination andtreatment rooms for ambulatory patients fitted up, and a staff composedof officers from the base hospital units of the center was formed. Thisobviated redupli-
hThe statements of fact appearing herein are based on "Report of the activities of the ear, nose, and throat service, A. E. F.," made by Col. James T. McKernon, M. C., senior consultant, ear, nose, and throat surgery, A. E. F. On file, Historical Division, S. G. O.-Ed.
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cation of instruments and equipment and resulted in a better care forthe patients, besides allowing the excess officers in the department to be made available for duty elsewhere.
At all the large hospital centers a consultant in otolaryngology wasappointed whose duty was to supervise generally the work in the centerand to act as consultant when called upon by the center otolaryngologistor the individual units. This arrangement proved most satisfactory, resultingin a better care for the patients as well as maintaining a more rigid disciplinefor the staffs of the center.
The senior consultant visited all the hospitals, many times seeing casesin consultation, operating when necessary, and consulted as to the needs of the service with both the local otolaryngologistand the commanding officer of the hospital. Many visits were made to evacuation,mobile, and field hospitals in consultation during which advice was givenas to the care and routing of the otolaryngological cases; and later followingup such cases as had been routed to base hospitals in the rear, consulting as to the nature and amount of reparative work to be doneon them.
In December, 1918, there were 238 officers on active duty in this department,and 12 others being held in reserve for future duty with the Third Army, when needed.
OPHTHALMOLOGYi
The senior consultant in ophthalmology was appointed in June, 1918.As the service developed, an assistant was added to the office, Neufchateau, and in September, 1918, another.
Each base hospital unit arriving in France had one or more expert ophthalmologists.To visit, advise with, and supervise these officers was one of the principal functions of the chief consultant.Some of the clinics were well equipped (for example, that of Base HospitalNo. 36 of the Vittel-Contrexeville hospital center); others were not. BaseHospital No. 36 served as a special ophthalmological hospital for the Vittel-Contrexevillecenter. Camp hospitals, as a rule, sent all important cases to the nearestbase hospital.
Gradually local consultants were supplied to the principal hospitalcenters and base areas.
One of the striking features of the subsection was the base opticalunit, which arrived in France May 4, 1918. This unit had a strength of 1 officer and 69 men. The equipment, stock, and machinery(amounting to nearly 19 tons in weight) was delayed, but part of it reached Paris in July. Shortly after the arrival ofthe unit, eight auxiliary units were organized and assigned to various base hospitals; later, seven other units were made up and likewiseassigned.
The shop was located first at Neuilly, but later it was removed to PortSt. Cloud. It began operating July 27, 1918, and was in full operation by October 1. The equipment was sufficient for theproduction of 100 pairs of glasses per day. From July 27 to December 1, 1918, theproduction was as follows: 21,828 prescriptionjobs; 3,091 smoked spectacles; 1,620 repair jobs.
iThe statements of fact appearing herein are based on "Report of the activities of the ophthalmological services, A. E. F.," by Lieut. Col. Allen Greenwood, M. C., senior consultant, ophthalmology, A. E. F. On file, Historical Division, S. G. O.-Ed.
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On account of the unusual amount of work to be done, a full day andnight force was in operation in the shop. A special attachment was devised to supply the demand for prescription lensesin gas masks. The unit had men and machinery sufficient to handle all work received, but could never get sufficientsupplies or material.
Artificial eyes were also supplied as needed; 1,000 were taken to Francewith the unit and 700 were received later. Large stocks were kept at a few places and at the base ports.
The totally blind were given preliminary training at Paris, Savenay,and Vichy, before being returned to the United States.
An important feature of ophthalmic surgery was the giant magnet. A supplyof magnets, shipped to France early in 1918, was lost for a long time.When finally found, magnets were placed in two of the forward evacuationhospitals and in base hospitals at Chaumont, Bazoilles, and Vittel. AmericanRed Cross Hospital No. 1, at Paris, was also supplied. As no more magnetsarrived, work was begun on the building of giant magnets at the MedicalDepartment repair shop in Paris, and five were turned out. Somewhat latersome medium-sized and small magnets arrived from the United States, andwith them it was possible to equip all hospitals necessary.
A trachoma survey was made of the labor organizations, A. E. F.; 12,461laborers were examined and 261 cases found. Means were suggested for handling this problem.
Circulars of instruction were issued on such subjects as gassed eyes,injuries, refraction, pterygia, strabismus, wounds of the eyelids and orbits, artificial eyes, trachoma, and plastic work.
MEDICAL SERVICESj
The chief consultant, medical services, A. E. F., entered upon his dutiesNovember 9, 1917. The fact that, at the time, the chief consultant was designated "director," has been explained above,and need not be gone into further here.
With the sudden and great expansion of the Army in 1917-18, the greaterpart of the Regular Medical Corps was required for administrative work, leaving the professional practiceof medicine and surgery almost entirely to temporary medical officers. Of this great body of new officers, generally unknownto their commanders, lay the responsibility of the actual care of the sick and wounded in the American Expeditionary Forces.On the proper selection and supervision of this ever-increasing class of officers depended very largely the cure andrestoration to duty of the many thousands of sick and wounded of the Army. The efficiency of the professional services dependedto a marked degree on this factor.
The chief consultant, medical services, understood that he had beenselected, in part at least, on account of his general acquaintance with the character and qualifications of the medical professionof the United States, and that his duty was not only to supervise the practice of medicine in the American
jThe statements of fact appearing herein are based on "Report of the activities of the office of the chief consultant, medical services," made December, 1918, by Brig. Gen. W. S. Thayer, M. C., chief consultant, medical services, A. E. F. On file, Historical Division, S. G. O.-Ed.
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Expeditionary Forces, but also to furnish the chief surgeon, A. E. F.,with such information as to the special qualifications of various new medical officers as might facilitate proper selection andassignments.
On March 12, 1918, a principal assistant to the chief consultant wasdesignated.
A study of medical conditions revealed considerable variations in professionalpersonnel and practices in the various base hospitals, tactical divisions, and formations at the bases along thelines of communication. The need for supervision was clearly seen; but with the multiplicity of organization, widespreadterritory, and difficulties of transportation, this supervision could not be exercised by one or two officers. Special consultant officerswere necessary for special localities, but few were available in France; internists who were suitable could not be sparedfrom their stations. Accordingly, officers were sought in the United States. During April, May, and June, 1918, efforts weremade to obtain from America a number of clinicians of recognized ability, who could be utilized as consultants, chiefs ofservice, or for special research.
The great and increasing need for officers especially qualified in internalmedicine led to a cabled request on June 10, 1918, for 50 such officers of the grade of lieutenant or captain; and again,on September 26, for a request for an additional 150.
In April, a consultant, general medicine, was assigned to the advancesection and zone of the army; consultants in tuberculosis and in cardiovasculardiseases were designated. In June, a consultant in gas poisoning was designated.In July, senior consultants, Air Service, and general medicine were assigned.In the following month, consultants, general medicine, were assigned tobase sections Nos. 1, 2, and 115, and to the hospital centers at Bazoillesand Vittel-Contrexeville.
The greater part of the medical officers requested in May did not arrivein France until October, and despite the pressing need for consultants no more designations could be made until theirarrival. Beginning with October the following assignments of medical consultants were made: To the hospitals at Rimaucourt andChaumont; Dijon, Beaune, and Allerey; Mesves; Vichy and Clermont-Ferrand; Paris section; Mars; Orleans and Tours;Justice group, Toul; and to base section No. 5; parts of the intermediate section; base section No. 2.
At the end of October, a consultant for base section No. 3 was designated.After the armistice was signed the consultant, gas poisoning, became consultantto the camp hospitals in the advance section.
With the formation of army corps, consultants were assigned to each.Likewise, when armies were organized consultants were assigned to each.
One of the earliest organizational procedures of the chief consultant,medical services, was the institution of certain medical teams. The need for the preparation of medical officers in the careof surgical shock and in the treatment of men suffering from poisoning by suffocative gases was early apparent, and, in viewof the lack of such special training among the medical officers of organizations at the front, special gas and shock teamswere organized. The officers of each shock team were habitually required to take the course in treat-
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ment of surgical shock given weekly at the central Medical Departmentlaboratory, Dijon. With the onset of open warfare the shock teams, subsequently called emergency medical teams, werein great demand for the treatment of surgical shock.
The emergency medical teams did effective service; however, the employmentof them at the front resulted in great hardship in base hospitals at times because of the shortage of medical officersthere, and inability to obtain replacements during the absence of these teams.
TUBERCULOSISk
The efforts of the senior consultant in tuberculosis were directed towardthe education of the medical personnel of the various hospitals, more particularlybase hospitals, of the American Expeditionary Forces, in the early recognitionof pulmonary tuberculosis, the investigation of the pervalence of tuberculosisin the American Expeditionary Forces, and methods for its control.
Following the careful examination of the troops of the Army in the UnitedStates and the exclusion of the manifest cases of pulmonary tuberculosis there, the incidence of such cases in the AmericanExpeditionary Forces was expected to be low. However, despite this care in elimination, approximately 2,000 casesdiagnosed pulmonary tuberculosis were transferred from the American Expeditionary Forces to the United States prior toDecember 31, 1918. Of these over 80 per cent had sputum positive for tubercle bacilli. For the same period-that is,up to the end of 1918-there were 250 deaths from pulmonary tuberculosisamong our troops in France. Unofficial reports from the French Army, subsequentlyproving erroneous, had led to a fear in our Medical Department, A.E. F., that there would be a greater development of tuberculosis among the American Expeditionary Forces. The causes whichunderlay the mistakes in the French Army also were found to obtain in the American Expeditionary Forces; that is,delayed convalescence from pneumonia, bronchopneumonia, the bronchitides-especiallythose combined with nasal sinus conditions.
In January and February, 1918, it was noted in the Surgeon General'sOffice that of the men being returned to the United States from France over 50 per cent failed to show positive evidenceof the tuberculosis for which they had been sent home. This situation was very easily and effectively remedied by the seniorconsultant for tuberculosis as follows: (a) A change in nomenclature; that is to say, only cases showing tubercle bacilli inthe sputum were now to be diagnosed frankly as pulmonary tuberculosis; all others were to be diagnosed "tuberculosis,observative," (b) The establishment of three centers where these cases could be more expertly studied, namely, Base HospitalNo. 8, Savenay; Base Hospital No. 20, Chatel Guyon; Base Hospital No. 3, Vauclaire. (c) Visiting frequentlythe base hospitals to standardize the diagnosis of the disease from theclinical, roentgenological, and laboratory viewpoints. (d) Promulgatingdata, concerning these matters, to chiefs of medical services and to medicalofficers who were registered as preferring tuberculosis work.
kThe statements of fact appearing herein are based on "Report of the activities of the senior consultant for tuberculosis," made Dec. 18, 1918, by Lieut. Col. Gerald B. Webb, M. C., senior consultant for tuberculosis, A. E. F. On file, Historical Division, S. G. O.-Ed.
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As regards treatment, all patients suspected of having, or actuallyhaving, tuberculosis and sent to any of the three hospitals mentioned above received excellent care. Those with fever were keptat rest, the temperature and pulse being carefully studied. Sputa were examined frequently, from 10 to 15 times beforea given case would be declared negative; when time permitted, concentration methods were practiced in laboratories.
Patients found to be tuberculous were returned to the United States,their physical conditions permitting; others were given graded exercises, first in hospital and later in a convalescent camp,and restored to duty.
PSYCHIATRYl
Psychiatry was established as a professional division in the AmericanExpeditionary Forces in November, 1917, with a director. Subsequently, however, it was subordinated to the medicalportion of the professional services, the director then becoming senior consultant. On his nomination, a specially qualifiedbody of officers was assigned as division, army, hospital group, and section psychiatrists. These officers, under the guidanceof the senior consultant, did valuable work in detecting early and treating wisely the psychoses common to armies in the field.
A neurological hospital, Base Hospital No. 117, was established at LaFauche, where patients with war neuroses were sent from army neurological hospitals and all base hospitals in the AmericanExpeditionary Forces. The psychiatric department of Base Hospital No. 116, Bazoilles, was made to serve as a collectingstation for mental cases from the tactical divisions and from hospitals in the advance section. Neuropsychiatric departmentswere established in base hospitals at both the Mars and Allerey hospital centers, at the base ports, and in Paris section.
The problems arising in the front areas in relation to the provisionsfor the care and disposition of patients suffering from disorders of the mind and nervous system can best be considered undertwo general heads: Conditions which occurred during periods of relative military quiet, and those occurring duringactive military operations.
Cases originating in front areas during times of relative quiet comprisedmen who could be classified in groups exhibiting defective mental development, constitutional psychopathic states, psychoneuroses-independentof combat experiences-war neuroses, and, finally, psychoses. These cases werecared for adequately in the divisional hospitals by the divisional neuropsychiatrists in the following manner: All exceptthose with war neuroses were kept under observation sufficiently long to permit making proper diagnoses, whereupon theywere transferred to base hospitals especially provided to care for thetypes of cases under consideration. Patients with war neuroses, which haddeveloped in quiet areas, and when the number of such patients was comparativelysmall, were successfully treated for the most part in the divisional fieldhospitals; few required transfer to Base Hospital No. 117, at La Fauche,
lThe statements of fact appearing herein are based on, (1) "Report of the activities of the section of neuropsychiatry," made by Col. Thomas W. Salmon, M. C., senior consultant, neuropsychiatry; (2) "History of advance neurological formations," made by Lieut. Col. John H. W. Rhein, M. C., consultant in neuropsychiatry, First Army. On file, Historical Division, S. G. O.-Ed.
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which, as stated above, was the special hospital for such cases. Thosethat were transferred to Base Hospital No. 117 were readily transported in motor ambulances, since this hospital was situatedsufficiently near to make this possible.
Because war neuroses developed in much larger numbers during periodsof active military operations, their management at the front became much more complicated. Our first relatively largeexperience with such cases occurred during the Aisne defensive. At this time, the plan proposed by the senior consultant,neuropsychiatry, was to have the cases of war neuroses which developed during combat retained in divisional hospitals underthe care of divisional neuropsychiatrists for as long a period as possible (not to exceed 10 days or 2 weeks), especially suchcases promising that degree of improvement during the period in question as to make it seem possible they could be returnedto their organizations on a duty status. On the other hand, cases holding out no such promise were to be evacuated to BaseHospital No. 117, at La Fauche.
In so far as it was possible to do so, division surgeons were consultedwith by the consultants in neuropsychiatry who outlined the above plan for dealing with cases of war neuroses incidentto combat experiences. Unfortunately, facilities for caring for such cases in divisional hospitalsat the time were inadequate; consequently, the results were on the whole disappointing. Many cases were not retained at allin the divisional hospitals but were evacuated immediately through evacuation hospitals to base hospitals with thegeneral run of sick and wounded. This evacuation naturally tended toward Paris where cases of war neuroses were receivedin base and camp hospitals in relatively large numbers. Hence they had to be distributed to hospitals farther rearwardor to Base Hospital No. 117. Needless to say, the capacity of Base Hospital No. 117 was taxed.
Though the plans went awry, the ultimate results in these cases weresatisfactory, for under the care of the neuropsychiatrists attached to the base hospitals and after a short period of rest, patients,in a satisfactorily large percentage, were discharged from hospital to duty.
Of the approximately 200,000 men engaged in the military operationsreferred to above, the incidence of war neuroses was about 2 per cent of the number engaged and 10 per cent of all casualties.Not only was this number believed to be unnecessarily large but it was also thought by the senior consultantin neuropsychiatry that at least 65 per cent of the men admitted to divisional hospitals for war neuroses could have been returnedto duty therefrom within a period of 10 days had suitable equipment for their local care been on hand.
Based upon the above experiences, the senior consultant in neurospychiatryinitiated the establishment of neurological hospitals in the front areas a short distance to the rear of fieldhospitals. The purpose of these hospitals was to care for men with war neuroses who in all probabilities would be fit for duty withintwo or three weeks.
For the St. Mihiel operation the plan was as follows: In addition tothe divisional neuropsychiatrist, each division was supplied with an assistantneuropsychiatrist. Thus one of these officers could sort cases coming through
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the divisional sorting station; the other could treat them in the fieldhospital. For the cases of war neuroses, which appeared ton require moretime then the specified time they should be kept in divisional hospitals,neurological hospitals were established, one at Benoit Vaux and anotherat Toul. These units functioned in an entirely satisfactory manner, thusretaining at the front, after a few days' treatment, many men who otherwisewould have been evacuated to the rear.
During the Meuse-Argonne operation, a third such neurological hospitalwas established at Neubicourt. Over 60 per cent admitted to the neurological hospital at Benoit Vaux were returnedto duty within a period averaging 10 to 14 days; approximately 73 per cent of the patients admitted to the neurologicalhospital at Neubicourt were returned to duty in an average of 10.4 days.
Neuropsychiatrists proved so necessary for expert examination of defectivesand of men about to be brought to trail by court-martial, as witnesses during trial, and as experts in the examinationof men with alleged self-inflicted wounds, that they were retained throughout the war in the combat divisions. So far asthe combat divisions were concerned, this was true of only two other specialties, urology and orthopedicsurgery.
COMMUNICABLE DISEASESm
Since the section dealing with the communicable diseases was in operationonly for three months prior to the end of 1918, many of the plans that were contemplated could not be brought to completionand much of the work of the section necessarily remained fragmentary and unfinished.
A large part of the time was devoted to the hospitalization and professionalcare of the cases of communicable disease. A considerable number of visits were made, either by special requestor by order, to various parts of the American Expeditionary Forces to consult upon diagnosis or the disposition ofpatients with epidemic diseases or upon individual patients suffering with unusual infections.
Since the hospitalization of the communicable disease cases seemed ofimmediate and prime importance, visits were paid to many base hospitals and to hospital centers to determine what conditionsactually existed and to consult with the commanding officers upon plansfor the future hospitalization of these cases. During these visits it seemedobvious, when some sort of segregation of these patients had not been made,that such a method for their care would have to be adopted, and as a ruleone of the following methods of segregation was put into operation: (1)The establishment of infectious disease hospitals; (2) the segregationof different classes of cases in different hospitals or in different wardsof a single hospital.
For hospital groups the former method seemed preferable for severalreasons: It would minimize the danger of spreading infection through the hospital group; it would allow of the properadmission through observation wards of the undiagnosed infections and therefore reduce cross infections;
mThe statements of fact appearing herein are based on "Report of the activities of the section of communicable diseases," made Dec. 21, 1918, by Col. Warfield T. Longcope, M. C., senior consultant in infections diseases. On file, Historical Division, S. G. O.-Ed.
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it would allow of a concentration of the personnel especially qualifiedto care for these particular diseases and therefore would assure better professional treatment; hospital epidemics, suchas occurred in the late fall of 1918 in a minor degree with diphtheria, could thereby be immediately recognized; it wouldsimplify administration and save hospital space and beds.
At one hospital center the first plan mentioned above was immediatelyput into operation. One hospital of the center was selected to care for all the communicable diseases, including influenzaand pneumonia. According to the center commander, this method as he developed it proved to be the most efficient onefor the center from the administrative standpoint; and from visits made by the senior consultant, infectious diseases, it was evidentto him that the patients were most excellently cared for from a professionalpoint of view. From practical application, therefore, the plan proved notonly feasible but also highly successful, even though it was not possible to develop it in an idealmanner. In a few other centers similar organizations, though not quite so complete, were instituted.
In several other centers where the second plan was put into effect itproved not quite as satisfactory from a professional standpoint. As the plan was worked out practically it was as follows:Cases of pneumonia and influenza were sent to one hospital, mumps and measles to another, meningitis, typhoid fever,and dysentery to a third, and so on. The objections that arose to this plan in the hospitals where it was adopted were thatthe establishment of observation wards was not practicable and that occasionally cross infections occurred, probably from admittingto a ward suspicious cases of measles or scarlet fever. It also resulted in a rather uneven grade of professional careof the infectious diseases, for though some wards were most admirably cared for, others were not so well conducted. Aftera trial of this method in several centers, it was theconsensus of opinion that the first method would be far preferable.
During the epidemic of influenza and pneumonia in the fall of 1918,considerable time was spent both at the front and in base hospitals in consultation with army and corps surgeons, and with commandingofficers upon the proper hospitalization and care of these cases. Hospitals were established at Revigny and at Brizeauxin the First Army area for the exclusive care of these patients, while the many patients that could not beaccommodatedin these hospitals were adequately treated in other evacuation hospitals. When it was possible to hold all these casesin hospital and not evacuate them the disease ceased to overwhelm the forward hospital centers.
At this time a circular was prepared on the hospitalization and treatmentof influenza and pneumonia which was published as Circular No. 51, chief surgeon's office, A. E. F.
During visits to hospitals the senior consultant gave advice regardingthe handling of infectious diseases and the proper forms of cubicling and masking and when these methods were not in use theywere insisted upon, or where they were improperly devised the methods were corrected. During these visits professionalconsultations were frequently held with chiefs of medical services uponmany patients.
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An attempt to furnish personnel for these infectious-disease hospitalsand wards was impossible. Plans had previously been made to do so, and a group of clinicians had been trained in the UnitedStates for this purpose, but the exigencies of the situation rendered it impossible to obtain the services of these officers.
GAS POISONINGn
The activities of the gas poisoning section of general medicine maybe classified as follows: (a) Instruction; (b) hospitalization and treatment; (c) actual supervision of the care of the gassed.
INSTRUCTION
Instruction was carried out either by means of circulars of informationor by lectures. Circular No. 34, chief surgeon's office, which had to do with the treatment of gassed patients, was preparedin this section. Other circulars in regard to the treatment of gas poisoning were prepared from time to time in this section. Eitherthe consultant in general medicine in charge of gas poisoning, or other representatives of his office, gave lectures onthe subject of the care and hospitalization of the gassed. These lectures were given to medical officers either in tactical divisionsor at the Army sanitary school, Langres.
HOSPITALIZATION AND TREATMENT
The question of the hospitalization and treatment of gassed patients,especially in division and army areas, was given much study. An endeavor was made, by advice and conference with those inauthority, to emphasize the important but simple principles involved, and to achieve their acceptance throughout theAmerican Expeditionary Forces. After comparatively little study it became obvious that the question of the care of the gassedwas largely an administrative one. From the clinical point of view the question was simple. The question of the hospitalizationof the gassed was a more complicated one. Like the wounded soldier, the gassed soldier needed early examination and treatmentand it soon became obvious that each tactical division in active warfare must have a mobile gas hospital as a partof its sanitary train. This need was met by utilizing one field hospitalper division which was supplied with the necessary extra equipment to carefor the gassed. Much correspondence and conference with those in authorityfinally led to a simple and standard equipment which could be used in divisionalgas hospitals. The matter of the secondary hospitalization of gassed caseswas complicated by the promulgation of the principle that gassed caseswere not to be cared for in evacuation hospitals, although it was recognizedthat the gassed needed special care in a hospital at the level of the evacuationhospital, quite to the same extent as did the wounded.
The application of this principle led to the establishment of specialhospitals for the gassed. During the actions which preceded the St. Mihiel and Meuse-Argonne operations there were nospecial hospitals for the care of the gassed. Gassed cases were passed through the evacuation hospitals rapidly and often
nThe statements of fact appearing herein are based on "Report of activities of section of gas poisoning," made Dec. 17, 1918, by Lieut. Col. Richard Dexter, M. C., consultant in general medicine for gas poisoning. This report is on file in the Historical Division, Surgeon General's Office, Washington, D. C.-Ed.
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received their first hospital treatment at the bases, a system whichwas unsatisfactory at best. In the St. Mihiel operation one gas hospital was established at the Justice hospital center, Toul,and one in the French gas hospital at Rambluzin. The personnel of these hospitals consisted of casuals or of officers andmen loaned from base or evacuation hospitals, ambulance companies, etc. In each hospital one officer thoroughly conversantwith the principles of the care of the gassed was stationed. The consultantin general medicine for gas poisoning had general supervision of the clinicalwork in both hospitals.
During the Meuse-Argonne operation, five hospitals were designated bythe chief surgeon, First Army, to receive gassed cases. These were: Rambluzin, capacity, 250 beds; La Morlette, capacity,550 beds; Julvecourt, capacity, 400 beds; Rarecourt, capacity, 250 beds; Villers Daucourt, capacity, 200 beds.These hospitals were enlarged by the addition of tentage and became the most important gas hospitals in the area.
The officers and personnel of these hospitals, as was the case in theSt. Mihiel operation, were largely casual officers and men from ambulance companies, evacuation hospitals, etc.
After the first rush was over the five gas hospitals mentioned abovecarried on the care and treatment of the gassed in an eminently satisfactory manner. It was unfortunate that, owing to ashortage of nurses, only two nurses were available for use in these gas hospitals during the period from September 26 to November11.
These hospitals received upward of 20,000 patients from September 26,1918, to November 11, 1918. The cases were about equally divided between those who had been actually exposed togas and those who, though they entered the hospital with a diagnosis of "gassed," had in all probability never been exposedto toxic warfare gases. The large number of cases that could not be classified as "gassed" were due principally to exhaustion,neuroses, light respiratory infections, or other unimportant conditions. The great proportion of these men could havebeen returned to duty without having left the army area had the propermachinery for this existed. In order that these light cases be returnedto duty, rest camps must exist. Only one of the three corps in the FirstArmy established a rest camp where men presumably fit for duty could bereturned from the gas hospital and be further observed and tested beforereturning to the replacement battalion and the line. One corps had a replacementbattalion and no rest camp, while the third had neither replacement battalionnor rest camp. With this imperfect machinery it was natural that largenumbers of men who could have been returned to duty perforce were evacuatedto the base.
The effect of the treatment received in the Army gas hospitals duringthis period on the condition of the men sent to the bases was apparent. There were found in the base fewer serious eye conditionsthan ever before, burns of the skin were in better condition, and cases of lung involvement were received in better generalcondition. Each case of definite pulmonary irritation was considered as a possible pneumonia and was held at the gas hospitalfor observation and treatment until it was deemed safe for the case to be evacuated.
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The lessons learned during this period lead to the following conclusions:
(a) At least 1,000 beds for gas cases should be provided foreach corps during active mobile warfare such as that of September and October, 1918.
(b) To facilitate evacuation and to economize personnel, notmore than one hospital to a corps area is considered advisable. Experience has shown that the principle of having gassed cases caredfor in special isolated hospitals is not a wise one. These hospitals wereusually far from a railhead and off the main traffic routes. This necessitatedmuch extra ambulance carriage, and increased the length of time that patientswere in the ambulances. As no provision for gas hospitals was found inthe Tables of Organization, these scattered units had to be operated asannexes to evacuation hospitals. This arrangement complicated the administration of these hospitals, and required duplicationof administrative personnel. Experience showed that the recommendation to the effect that gassed cases be cared forin evacuation hospitals with augmented equipment and
personnel, made in the letter of May 7, 1918, from the senior consultantin general medicine to the chief consultant, medical services, was sound, and should be accepted as a guiding principlein the matter.
(c) The personnel of gas hospitals should be proportionatelythe same as that of an evacuation hospital. The staff of medical officers need not be large; no surgeons are necessary. A chief of medicalservice expert in the problems of the diagnosis and treatment of the gassed and in the sorting of those presumably fitfor duty is essential. The rest of the officers may be young men of ordinary capacity. Nurses are absolutely necessary for the propercare of the gassed.
(d) In order that men may be returned to duty, rest camps, wherethe men may be observed for a time and tested by simple exercises to determine their fitness for duty, are necessary. Whetherthe rest camp shall be under the immediate management of the corps or of the army is open to discussion. It is noteworthy,however, that while divisions change rapidly and frequently from one corpsto another, they do not as frequently or as rapidly leave an army area.For this reason it would appear that the army would be able to return themen to their proper organizations better than could the corps.
SUPERVISION
In July, 1918, after conference between the medical director of theChemical Warfare Service, A. E. F., the chief consultant, medical services, A. E. F., and the consultant in generalmedicine for gas poisoning, it was recommended that each division have one officer whose special duty it would be to takecharge of the organization of the treatment, care, and evacuation of the gassed within the divisional areas. The officer wasto be known as the divisional medical gas officer. This recommendation was accepted and authorized by General Orders, No. 144,G. H. Q., A. E. F., August 29, 1918. Owing to the late date at which the divisional medical gas officers wereauthorized, many divisions never received the full benefit of the services of such an officer. In those divisions where an officerfunctioned as medical gas officer, the care of the gassed
immeasurably improved.
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PERSONNELo
(July 28, 1917, to July 15, 1919)
Col. William L. Keller, M. C., director of professionalservices.
SURGICAL SERVICES
Brig. Gen. John M. T. Finney, M. C., chief consultant.
Col. George W. Crile, M. C., senior consultant insurgical research.
Col. Arthur C. Christie, M. C., senior consultantin Roentgenology.
Col. Harvey Cushing, M. C., senior consultant inneurological surgery.
Col. Joel E. Goldthwait, M. C., senior consultantin orthopedic surgery.
Col. James F. McKernon, M. C., senior consultantin ear, nose, and throat surgery.
Col. Charles H. Peck, M. C., senior consultant ingeneral surgery.
Col. Hugh H. Young, M. C., senior consultant invenereal and skin diseases and genitourinary surgery.
Lieut. Col. Vilray P. Blair, M. C., senior consultantin maxillofacial surgery.
Lieut. Col. James T. Case, M. C., senior consultantin Roentgenology.
Lieut. Col. Allen Greenwood, M. C., senior consultantin ophthalmology.
MEDICAL SERVICES
Brig. Gen. William S. Thayer, M. C., chief consultant.
Col. Thomas R. Boggs, M. C., senior consultant ingeneral medicine.
Col. Warfield T. Longcope, M. C., senior consultantin infectious diseases.
Col. Thomas W. Salmon, M. C., senior consultantin neuropsychiatry.
Lieut. Col. Richard Dexter, M. C., senior consultantin general medicine for poisoning by deleterious gases.
Lieut. Col. Alfred E. Cohn, M. C., senior consultantin cardiovascular diseases.
Lieut. Col. Gerald B. Webb, M. C., senior consultantin tuberculosis.
Maj. Franklin C. McLean, M. C., senior consultantin general medicine.
REFERENCES
(1) Circular letter from the Surgeon General to commandingofficers of hospitals, November 11, 1917. Subject: Specialists. Copy onfile, Historical Division, S. G. O.
(2) Cable No. 427-S from General Pershing to The AdjutantGeneral, Washington, December 30, 1917. On file, A. G. O., World War Division,chief surgeon's files, 321.62.
(3) Letter from the Surgeon General to the chief surgeon,A. E. F., March 9, 1918. Subject: Professional services. On file, A. G.O., World War Division, chief surgeon's files, 321.62.
(4) Letter from the Surgeon General to the chief surgeon,A.E. F., March 16, 1918. Subject: Organization of general and base hospitals.On file, A. G. O., World War Division, chief surgeon's files, 321.62.
(5) Letter from the adjutant general, A. E. F., to Maj.J. M. T. Finney, M. C., December 21, 1917. Subject: General instructions.Copy on file, A. G. O., World War Division, chief surgeon's files, 201(Finney, J. M. T.).
oIn this list have been included the names of those who at one time or another were assigned to the division during the period, July 28, 1917, to July 15, 1919.
There are two primary groups-the heads of the divisionor the section and the assistants. In each group names have been arrangedalphabetically, by grades, irrespective of chronological sequence of service.-Ed.
386
(6) Report of the activities of the professional services,A. E. F., between April, 1918, and December, 1918, made December 31, 1918,by Col. W. L. Keller, M. C., director of professional services. On file,Historical Division, S. G. O.
(7) Bevans, M. L., Col., M. C.: The function of medicaland surgical consulting staffs determined by the late war. The MilitarySurgeon, xlvi, No. 5, Washington, 1920.
(8) Circular No. 2, H. A. E. F., office of the chief surgeon,November 9, 1917.
(9) Report on the activities of the chief surgeon's office,A. E. F., to May 1, 1919, made by the chief surgeon, A. E. F., to the SurgeonGeneral. Copy on file, Historical Division, S. G. O.
(10) Final report of Gen. John J. Pershing, September1, 1919.
(11) Based on reports of the activities of hospital centers,A. E. F. On file, Historical Division, S. G. O.
(12) Report of the activities of G-4-B, G. H. Q., A. E.F., to December 31, 1918, by Col. S. H. Wadhams, M. C. Copy on file, HistoricalDivision, S. G. O.
(13) Letter from the chief surgeon, A. E. F., to Lieut.Col. W. L. Keller, M. C., April 18, 1918. Subject: Detail as director ofprofessional division, A. E. F. Copy on file, A. G. O., World War Division,chief surgeon's files, 321.60.
(14) Letter from the chief surgeon, A. E. F., to the directorof professional services, A. E. F., August 7, 1918. Subject: Consultantsin the different specialties for hospital centers. On file, A. G. O., WorldWar Division, chief surgeon's files, 211.52.
(15) Letter from the chief surgeon, A. E. F., to Capt.De Forest F. Willard, M. R. C., August 23, 1918. Subject: General instructions.Copy on file, A. G. O., World War Division, chief surgeon's files, 321.62.
(16) Memorandum from the chief surgeon, A. E. F., to thedirector of professional services, A. E. F., August 13, 1918. Subject:Designation of hospital centers for specialists. Copy on file, A. G. O.,World War Division, chief surgeon's files, 321.62.
(17) Circular Letter No. 7-a, chief surgeon's office,A. E. F., August 27, 1918.
(18) Letter from the chiefs of medical and surgical services,A. E. F., to the chief surgeon, A. E. F., September 2, 1918. Subject: Personnelof professional services. On file, A. G. O., World War Division, chiefsurgeon's files, 321.62.
(19) Letter from the chief surgeon, A. E. F., to the directorof professional services, A. E. F., September 2, 1918. Subject: Designationof professional consultants and heart specialists at hospital centers.On file, A. G. O., World War Division, chief surgeon's files, 321.62.
(20) Letter from the chief surgeon, A. E. F., to all divisionsurgeons, September 8, 1918. Subject: Psychiatrists, urologists, and ophthalmologistsin tactical divisions. On file, A. G. O., World War Division, chief surgeon'sfiles, 321.62.
(21) Letter from the chief surgeon, First Army Corps,to the chief surgeon, A. E. F., November 4, 1918. Subject: Corps consultants.On file, A. G. O., World War Division, chief surgeon's files, 211.52.
(22) First indorsement from the chief surgeon, First Army,to the chief surgeon, A. E. F., November 5, 1918. On file, A. G. O., WorldWar Division, chief surgeon's files, 211.52.
(23) Third indorsement from the chief consultant, surgicalservices, A. E. F., to the chief surgeon, A. E. F., November 30, 1918.On file, A. G. O., World War Division, chief surgeon's files, 211.52.
(24) Memorandum from the chief surgeon, A. E. F., to thechief of staff, S. O. S., January 3, 1919. Copy on file, Historical Division,S. G. O.
