SECTION IV
EVACUATION OF PATIENTS TO THE UNITED STATES;
DISCONTINUANCE OF HOSPITALS
CHAPTER XXVI
EVACUATION OF PATIENTS TO THE UNITED STATES
Administrative matters concerning the selection of disabled membersof the American Expeditionary Forces for return therefrom to the UnitedStates, and the transfer of such men from hospitals in the Services ofSupply to base ports and thence to suitable transports, were made a responsibilityof the hospitalization division of the chief surgeon's officer, A. E. F.As stated in Chapter XIV, Section I, a particular section of this division,namely, the transportation and evacuation section, was devoted to suchmatters.1
Early Medical Department plans for the return of the disabled to theUnited States comprised extensive hospitalization at Savenay, in base section No. 1, in order that selected cases mightbe collected there and evacuated thence through the port of St. Nazaire;and at Beau Desert, near Bordeaux, for evacuation through the latter place.Owing to the fact that Brest was not considered at the time in the schemeof the return movement, hospital facilities were not provided on a relativelylarge scale at that place until the latter months of the war.1
During the first eight or nine months of the existence of the AmericanExpeditionary Forces, cases believed to be suitable for transfer to the United States were relatively few in number, and comprisedmuch the same type of cases as would, in peace time, be considered unfit for further military service.2Such cases were selected initially in the various base hospitals of the American Expeditionary Forces and, usually, transported by hospitaltrain to the base hospitals of the above-mentioned ports. Here the patientswere surveyed by a physical disability board; and if found suitable fortransfer to the United States, were prepared for the journey there.2
The conditions of actual warfare and the difficulties incident to transportingpersonnel to France prompted general headquarters, A. E. F., in March,1918, to depart from our peace-time custom of determining degrees of physicaldisability.3 In the conduct of the war it was essential thatall personnel be utilized to the utmost. Thus, many cases of presumed disability,instead of being returned to the United States, were retained thereafterin the American Expeditionary Forces. The comprehensive order which generalheadquarters issued on the subject, though it deals with the determinationof the physically fit as well as the unfit, is given here practically infull, so far as the present subject is concerned:
The action of a disability board does not require reviewor approval by higher authority except upon application to the conveningauthority by the commander of an organization of
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which the officer or soldier examined is a member. Inthis latter case the action of the board will be passed upon by the conveningauthority, whose action will be final. Reports will be rendered on cardform, in duplicate, copies of which will be distributed, one to the statisticalsection, adjutant general's office, general headquarters, A. E. F., andone to the organization to which the officer or soldier is transferred.
The success of the evacuation service depended in great degree uponthe skill of disability boards, which the above quoted order prescribed, in selecting those cases throughout the AmericanExpeditionary Forces which were unfit for further duty but were able tobear transportation both to the base ports and to the United States.2Selection by these boards of cases capable of performing the land journey,but unable to withstand the difficulties incident to the sea trip, ledto congestion of the facilities for nontransportable cases at hospitalsnear the base ports, reduced the elasticity of these hospitals, and limitedtheir
embarkation facilities.2
As previously stated, patients in the American Expeditionary Forcesin France were embarked at one of the three following ports: Brest, St. Nazaire, and Bordeaux; however, until after the armisticewas signed the major portion of them sailed from Brest, due to the fact that this port had the deepest harbor, and inconsequence it was to this harbor that our largest ships came with troopsfrom the United States. Since large ships could not dock at Brest, patientshad to be placed on improvised lighters and carried on them out to thevessels, frequently in very rough weather. During the period of hostilities,most patients that were embarked at Brest were prepared for transfer tothe United States at the hospital center at Savenay,1 sinceit was desirable that there be a reservoir of patients from which a suitablenumber of them could be embarked, without an appreciable loss of time,following notification from shipping authorities that certain ships wouldbe available.2
Promptly after the armistice began, the War Department notified GeneralPershing that every effort would be made to expedite the early return ofthe American Expeditionary Forces.4 No necessity now obtainedfor so rigidly adhering to the principles which prompted the promulgationof General Orders, No. 41, quoted above. Now, not only were all patientsclassed D to be returned to the United States as soon as their conditionwould permit, but also all officers and soldiers in hospital who in theopinion of attending surgeons could be safely transported and, in addition,required at least two months' additional treatment.5 Exemptionsto this general classification included men with contagious6and venereal diseases.7 Pertinent parts of the instructionscovering the return of the disabled are as follows:
AMERICAN EXPEDITIONARYFORCES,
HEADQUARTERS, SERVICESOF SUPPLY,
France, November 20, 1918.
EMBARKATIONINSTRUCTIONS NO.1
(Personnel to be returned to the United States)
In order to carry out the policy outlined by general headquarters,the following regulations concerning the return of hospital patients andB and C class officers and soldiers to the United States are published.
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I
1. All officers and soldiers now in hospitals who willrequire at least two months' treatment who, in the opinion of the attendingsurgeons, can safely be transported, and all officers and soldiers whowould be evacuated as of class D will, as rapidly as facilities permit,be returned to the United States for continued treatment. The transportationof this class of personnel on hospital trains to designated ports and fromthence to hospital ships will be in accordance with regulations to be prescribedby the chief surgeon.
2. All officers and soldiers in hospitals who are evacuatedas of class C and all those who are evacuated as of class B, who will requireat least two months for restoration to class A, will be returned to theUnited States in accordance with regulations hereinafter prescribed.
* * * * * * *II
Officers and soldiers to be returned to the United Statesunder this order, excluding hospital patients referred to in paragraph1, section I, shall be sent to depots and rest camps at ports of embarkation,as follows: In the advance and intermediate sections to be sent directto the 1st Depot Division, St. Aignan-Noyers, for organization and equipmentand from thence to the rest camp, St. Nazaire, for transportation to theUnited States. In the Paris district to be sent direct to base depot, Blois,for organization and equipment, and from thence to rest camp, Brest, fortransportation to the United States. In base sections Nos. 4 and 5 to besent direct to rest camp, Brest, where they will be organized and equippedand returned to the United States. In base section No. 1 to be sent directto rest camp, St. Nazaire, for organization, equipment, and shipment. Inbase sections 2, 6, and 7 to be sent to rest camp, Bordeaux, for organization,equipment, and shipment.
III. ORGANIZATION AND EQUIPMENT
1. All soldiers, upon arrival at the 1st Depot Division,at the base depot, Blois, or at a rest camp at a base port, if sent directlythere, shall be organized into casual companies consisting of 2 officersand 150 enlisted men per company, the necessary medical attendants (classB or C, if available), and medical supplies to accompany each company orgroup of companies. White and colored troops to be organized separately.Such companies to be serially numbered, with the added designation of thedepot or rest camp at which the company is organized. To avoid duplicationof numbers assignment is made in blocks, as follows: "Bordeaux Casual CompaniesNos. 1 to 100"; "St. Nazaire Casual Companies Nos. 101 to 200"; "BrestCasual Companies Nos. 201 to 300"; "Blois Casual Companies Nos. 301 to400"; "St. Aignan Casual Companies Nos. 401 to 500." When a block is exhaustedat any camp a new series will be started by adding 500 to the initial numberof the previous series; for example, Bordeaux's second series of numberswill be 501 to 600.
2. Each company will be physically examined for contagiousdiseases and deloused at the depot or rest camp at which it is organized,and the commanding officer of the organization will be furnished with acertificate showing its serial number and other designation and the factthat each member has been thoroughly deloused and is free from contagiousdisease. The proper sanitary inspection will also be made at base portsprior to embarkation.
3. When a company is organized each soldier will be providedwith a neat and well-fitting uniform and serviceable equipment * * *.
IV. DISPOSITION OF RECORDS
1. It is of the utmost importance that each soldier returnedto the United States under this order shall be accompanied by his qualificationcard, service record, all war-risk papers pay card individual pay recordbook, and individual equipment record; and also that each officer takeswith him his original qualification card securely wrapped and sealed, hisidentity card, and, if a captain or of lower rank, his officer's recordbook.
2. Commanding officers of hospitals will, upon the evacuationof B or C class personnel under this order, send immediate telegraphicnotice, as far in advance of evacuation as possible; in the case of officers,to the statistical division, adjutant general's office, general head-
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quarters, and in the case of soldiers, to the centralrecords office, Bourges, stating the name, rank, serial number, formerorganization, together with the depot or rest camp to which the recordsare to be sent.
3. In the case of class B or C personnel on duty in theAmerican Expeditionary Forces affected by this order, the commanding officerforwarding such personnel will be held responsible that the proper recordsaccompany them to the depot or rest camp to which sent.
4. Courier service will be established between the centralrecords office and the two depots and the three rest camps at which casualsand organizations are prepared for embarkation, for the purpose of theprompt procurement of records. In the event that the central records officeis unable to furnish the required records, all data available, includingthe statement that the records can not be obtained, will be forwarded withthe organization with which the soldier sails. The commanding officer ofthe rest camp shall furnish the central records office with a list of enlistedmen departing for the United States without their individual records, showingthe organization to which they belonged. The central records office willforward such records as soon as obtained to The Adjutant General, Washington,D. C.
5. In the case of officers and soldiers sent direct tothe United States as hospital cases, as provided in paragraph 1, sectionI, of this order, telegraphic notice shall be sent as above, stating theport at which the patients are to be embarked and directing that the recordsbe sent there, addressed to the commanding officer of the base hospitalat the port of embarkation, and plainly marked, "Records of hospital cases."The embarkation of hospital patients shall not be delayed by reason ofthe failure to obtain the individual records. Every effort shall be made,however, to obtain them in every case, as required by existing orders.The evacuating hospital at port of embarkation will furnish the centralrecords office with lists of men returned to the United States withouttheir records, by courier, accompanied by any records received too lateto go with the patient.
V. REPORTS
The commanding generals of base depot, Blois, and the1st Depot Division will send telegraphic notification to the rest campwhich they feed, immediately upon the departure of an organization, givingthe following information:
(a) Designation of organization.
(b) Date and hour of departure.
(c) Number of officers.
(d) Number of soldiers.
A duplicate of this telegram will be sent to the commandinggeneral, Services of Supply (G-1).
VI. GENERAL INSTRUCTIONS
1. Class B and C personnel of the Marine Corps will beorganized into provisional companies composed entirely of Marine Corpsofficers and soldiers. No attempt will be made to segregate marines withreference to the geographical area from which they were recruited in theUnited States.
2. Whenever casuals in sufficient numbers come from thesame sections of the United States, they will be formed into companiesaccording to localities, in order that they may be sent to the cantonmentor camp nearest the place from which they entered the service. This willnot apply to hospital evacuations.
3. The commanding general, base section No. 3, will makenecessary arrangements for the return to the United States of hospitalpatients and class B and C personnel through English ports and rest camps,in accordance with special instructions issued from these headquarters.
4. The provisions of this bulletin do not apply to basesection No. 8, concerning which special arrangements will be made.
By command of Major General Harbord:
W. D. CONNOR, Chief of Staff.
Official:
L. H. BASH,AdjutantGeneral.
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Embarkation Instructions No. 4, headquarters, Services of Supply, November25, 1918, required that commanding officers of casual companies organizedfor embarkation would be held responsible that the records of both officersand enlisted men were completed. If a service record was not at hand orwas not procurable at the central records office, a supplementary recordwas to be prepared from the best available data, usually consisting ofinformation from the soldier.
The effect of Embarkation Instructions No. 4 was to delay the evacuationof patients, even more so from England than from France, since those of our men who had been serving with the British,as in the American Second Corps, and were evacuated through British hospitalsafter injury, often had their records lost or delayed in transit. Afterthe order above mentioned was published, the commanding general of ourtroops in England estimated that only 4 per cent of the records pertainingto our sick and wounded there were obtainable, that many of these patientswere selected and ready for embarkation, and that ships were at the docks,with adequate space for the patients.2
It was now necessary to decide whether the best interests of the patientswould be served by prompt embarkation or their retention until service records became available.2 If lookedat solely from the standpoint of evacuation, it mattered relatively littlewhether or not the incapacitated were accompanied by service records; however,the difficulties of properly disposing of patients in the United Statesafter their arrival there precluded the possibility of disregarding thenecessity for service records accompanying the patients. Therefore, subsequentpromulgations dealing with the evacuation of sick and wounded from Francetook into consideration not only the necessity for facilitating the embarkationof patients, but also the great need for having service records accompanypatients so embarked.
In the early part of January, 1919, revised instructions concerningthe evacuation of sick and wounded from the American Expeditionary Forces were issued by headquarters, Services of Supply.8These instructions contained not only much that former embarkation instructions included, but also details that wouldfurther insure the ready and accurate identification of each patient soevacuated. That part which has present pertinence is as follows:
II. (1) All officers and soldiers in hospitals who willrequire at least two months' treatment and who, in the opinion of the attendantsurgeons, can safely be transported, and all officers and soldiers whowould be evacuated as of class D, will, as rapidly as facilities permit,be returned to the United States for continued treatment. The transportationof this class of personnel on hospital trains to designated ports and fromthence to hospital ships will be in accordance with regulations to be prescribedby the chief surgeon.
(2) In accordance with detailed instructions to be issuedby the chief surgeon, convalescent or ambulant patients who require nospecial accommodations evacuated on any transport will be organized intoone or more detachments, each not exceeding 150 men, and under commandof an officer, to be selected wherever practicable from casual medicalofficers, convalescents, or B or C class personnel. These detachments willbe numbered serially, beginning with No. 1 at each port of embarkation,as follows: (Convalescent Detachment No. -, Bordeaux). The destinationof the detachments to which these men are assigned will be entered on thepassenger lists, hospital records, and on the service record that is forwardedwith the soldier. The officer in command of each detachment is chargedwith the duties outlined in Section I, paragraph 7.
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On each transport carrying sick and wounded not organizedinto casual detachments, as above indicated, a medical officer will beput in charge of the sick and wounded, and such officer will be chargedwith the duties outlined in Section I, paragraph 7. On naval transportsthe duties of this officer will be discharged after consultation and infull accord with the naval authorities.
To insure accurate identification, in addition to propernotations on the passenger lists and hospital records, the sailing numberof the transport will be entered, in each case, on the service recordsof all sick and wounded not organized into casual detachments.
(3) Commanding officers of hospitals will, upon evacuationof officers, send immediate telegraphic notice, as far in advance of evacuationas possible, to the statistical division, adjutant general's office, atgeneral headquarters, stating their name, rank, and organization, togetherwith the hospital, depot, or embarkation camp to which their records areto be sent.
(4) Daily courier service will be maintained by the postalexpress service between the central records office and the evacuation hospitalsat base sections Nos. 1, 2, and 5, for the purpose of the prompt procurementof records of enlisted men received at these hospitals without them. Requestssubmitted by this courier system (and those submitted as outlined in SectionIII, par. 4) will be given preference by the central records office. Inthe event that the central records office is unable to furnish the requiredrecords, all data available, including statement from the central recordsoffice that the records can not be furnished by that office, will be forwardedwith the organization with which the soldier sails. When records can notbe obtained, steps should be taken to provide supplementary records andpayments as outlined in Section I, paragraph 10. The commanding officersof such hospitals are charged with arranging for the payment of all patientsprior to evacuation. The evacuation hospitals at ports of embarkation willfurnish the central records office, by courier, with a list of names ofmen returned to the United States without their records, showing the organizationsto which the men belong. (Notation in red ink under man's name on passengerlist furnished central records office may be used in lieu of list.) Thecentral records office will forward such records, as soon as obtained,to The Adjutant General, Washington, D. C. Records received too late toaccompany hospital patients will be forwarded by base port personnel adjutantto The Adjutant General's office, Washington, D. C., with a letter of transmittal,giving the organization to which the men belong and the name of the boaton which they sailed; a copy of this letter will be sent by courier tothe central records office.
On January 5, 1919, general orders were promulgated by general headquarters,A. E. F., prescribing that all soldiers in hospitals, classified for return to the United States under the provisionsoutlined above, with the exception of class D patients, were to be transferredto specified overseas casual camps.9 Patients classed D wereto be transferred to hospitals at Savenay, Bordeaux, or Brest, and carriedon casual rolls. Prior to embarkation all soldiers were to be transferredfrom casual camp or hospital to a properly numbered casual company, convalescentdetachment, or sailing convoy for transportation to the United States.9Soldiers selected for transfer to the United States were to be droppedfrom the rolls of their organizations, and the service records of thesesoldiers were required, when obtainable, to be completed by the hospitalcommander, and to accompany the men upon transfer.
On February 2, 1919, further instructions were issued by general headquarters,A. E. F.,10 to the effect that officers and soldiers admitted to hospital would not be dropped from the rolls oftheir organizations, except when the hospital to which the officers orsoldiers were admitted was not in the vicinity of the organization, thusprecluding the organization from carrying the patients concerned as presentsick. In the event it was necessary to drop patients in hospital from therolls of their organizations (for example, when the hospital
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was not in the vicinity of the organization or when patients carriedpresent sick by organizations were selected for transfer to some other hospital), commanding officers of organizations, upon propernotification, furnished commanding officers of hospitals with the service records of the men concerned. Commandingofficers of hospitals were directed to make proper notations on the service records of men evacuated. Service recordswere to accompany men when evacuated.
EVACUATION OF SICK AND WOUNDED FROM THE PORT OF ST. NAZAIRE, BASE
SECTION NO. 1
DURING THE PERIOD OF HOSTILITIES
In the evacuation of sick and wounded from the port of St. Nazaire thefactors always to be considered were comfort to the patients, and at the same time as much speed as possible.11The element of speed was made necessary by the fact that the arrival of vessels invariably was kept secret until the last few hoursbefore arrival. Then, as a rule, only tentative arrangements could be made, for a great deal depended on the size and the numberof the transports.
At this port there were adequate docking facilities, so that each shipusually found a berth alongside a dock.11 Thus little troublewas experienced in loading of the disabled.
As soon as the base surgeon's office received news of the expected arrivalof a convoy the hospital center at Savenay, the main center of evacuationof class D patients, was notified, and the names of the ships were givenif known.11 In this way tentative plans could be made, for byreferring to a list provided by the Navy Medical Department the numberof patients of each type capable of being loaded aboard each of the shipscould be calculated. It now remained to find out from the Transport Servicethe most convenient time for loading the transports and the docks to whichthey were to be moored.
The passenger lists were made out at Base Hospital No. 8 under the followingheadings:11
Litter | Walking | Surgical | Medical | Mental | Total | |||
Litter | Walking | T. B. | Others | Restraint | Others | |||
--- | --- | --- | --- | --- | --- | --- | --- | --- |
--- | --- | --- | --- | --- | --- | --- | --- | --- |
--- | --- | --- | --- | --- | --- | --- | --- | --- |
--- | --- | --- | --- | --- | --- | --- | --- | --- |
A medium-sized transport could carry 50 bed cases, 500 walking cases,and 30 to 40 officers of either type.11 If mental cases wereto be sent, the number was usually about 35, 1 attendant being requiredfor every 8 mental cases. In order to further facilitate matters, a navalrepresentative proceeded to Base Hospital No. 8 for the purpose of taggingeach patient, designating the compartment of the ship, if possible, andshowing a serial number corresponding to that on the passenger list.
Choosing patients fit to travel and whose records were complete wasa duty of the base hospital.11 The passenger lists were
made out there also,
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and, based on the total number of patients, blankets (three per man)and mess kits were drawn and placed aboard the hospital train. If the patientswere destined to return home on a hospital ship, no mess gear or blanketswere required, the ship being amply supplied with these essentials.
The loading of the hospital train was in charge of the evacuation officer.11In addition to seeing that the proper patients were placed aboard, it was his duty to see that each man was tagged, hadhis medical envelope attached to his clothing, and had his blankets andmess kit, and that the lists of patients and the records were deliveredto the commanding officer of the train. On occasions it became necessaryfor the evacuation officer to accompany the patients to the base port.In this event he in person turned over to the detraining officer the recordsof the patients and the passenger lists. If the evacuation officer didnot board the train, the above-mentioned records and equipment were turnedover to the commanding officer of the train.
When the loading of the train was well under way, the evacuating officernotified the railway transport officer, who arranged a schedule for thetrain over the French railroad.11 On this particular divisiona schedule was usually possible every 20 minutes. Thus the time of thedeparture of the train could be anticipated almost to the minute. The trainhaving left the sidetrack running up to the hospital, the commanding officerof the hospital or his adjutant notified the base surgeon, whose officewas in the city (St. Nazaire) in which the detraining and embarkation occurred.
From the base surgeon's office the various auxiliary departments werecalled on the telephone.11 The naval liaison officer was notified;also, the officer in charge of the ambulance battalion was notified ofthe probable time of arrival of the train, and was instructed as to whatkind and how much equipment to bring with him. The detraining officer wasnotified. In this way all was in readiness when the train backed into therailroad yards, the ambulances were lined up beside the track, the detrainingofficer was on hand, and the necessary arrangements were made aboard theship to be loaded. It may be well to state here that it was customary toload but one boat at a time.11 This avoided confusion and misplacingpatients and records.
The detraining officer boarded the staff car, procured the passengerlists and records, and signed receipt for mess kits and blankets.11 He then ascertained the position in the trainsof the cars containing the various types of patients. As a rule, the walking cases were kept in cars by themselves, the bedridden in othercars, and the officers and nurses, if any, in still another section. Having obtained this information, he planned the method ofunloading accordingly and gave instructions to the commanding officer of the ambulance convoy. These instructions variedwith each evacuation, for there were several factors to be considered.Among these factors were: (a) The type of train (if American, thebunks and beddings were fixtures on the train; if French, the men werelying on litters in racks of three tiers, covered with blankets, the propertyof the train); (b) the relative proportion of the litter and walkingcases; (c) the position in the train of patients of each group;(d) the time of day and the weather.
In the case of an American hospital train it proved best to have onhand a large extra supply of blankets and litters, for none of the train'sequipment
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could very readily be used.11 The extra supplies, carriedin small motor trucks, kept up with the ambulances as they unloaded firstone car and then another. By keeping the two types of machines abreast,patients with extension apparatus too long or too awkward for the smallFord machine could be placed in a G. M. C. Furthermore, when things wererunning smoothly the detail easily could load two ambulances at once ateach of the several train doors. Seldom more than two cars could be workedat one and the same time, for to do this 13 men were required at each car,4 to handle the litters in the car, 8 outside, and a noncommissioned officerto direct in case of the temporary absence of one of the officers. Then,too, too much speed at the train congested loading at the ship, since thechecking required some time, and the litter bearers could progress withonly moderate rapidity in the narrow passageways and up the steep stairways.They might further be detained by having to wait some time for the patientsto be transferred from litter to bunk. In order not to lose property, itwas the rule for each pair of men to return with the litter on which theycarried their patient aboard. In order not to lose time, sitting or walkingpatients were transferred in G. M. C.'s Fords, and even in motor lorries,during the time the litter cases were being handled. Therefore there wereno idle vehicles. The detraining officer proceeded by first ambulance tothe transports, carrying records and passenger lists, so that checkingmight begin the moment the first patient arrived.
PROCEDURE DURING THE ARMISTICE
The signature of the armistice, on the 11th of November, marked theturning point with respect to the policy of evacuation of the sick and wounded of the American Expeditionary Forces. The secrecysurrounding arrivals and departures of ships and the haste required inloading them no longer obtained. Every effort was made to keep the properauthorities advised of the expected arrival of transports, and once they arrived, due considerationcould be paid to the comfort of the patients-speed was not the importantfactor that it had been.11
On November 25, 1918, the work of the evacuation of patients to theUnited States from base section No. 1 was officially placed under the base commander by the following letter from the commandinggeneral, Services of Supply:
AMERICAN EXPEDITIONARYFORCES,
HEADQUARTERS SERVICESOF SUPPLY,
FIRST SECTION,GENERAL STAFF,
November 25, 1918.
From: Commanding general.
To: C. O., base section No. 1; C. G., base section No.2; C. G., base section No. 5.
Subject: Evacuation service.
* * * * * * *
2. The responsibility for the evacuation of personnelto transports is vested in base section commanders, and the details willnormally be executed through their staffs. Naval medical liaison officershave been detailed to duty at ports of embarkation, and the utilizationof the services of these officers along the lines indicated in this correspondenceshould materially assist these staff officers in handling this importantwork.
By order of the C. G.
J. B. CAVANAUGH,
Assistant Chief of Staff, G-1.
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On December 2, 1918, additional instructions were given by the chiefsurgeon, A. E. F., in the following letter, and three hospital trains were assigned permanently to the section for the transportationof sick and wounded between hospitals of the section and from hospitals to transports:
AMERICAN EXPEDITIONARYFORCES,
OFFICE OF THE CHIEFSURGEON, A. P. O. No. 717,
December 2, 1918.
From: Chief surgeon.
To: Surgeon base section No. 1
Subject: Evacuation of patients to the United States.
1. The chief surgeon desires that you assume charge ofthe evacuation of all patients selected for transfer to the United Statesfrom the hospital centers, Angers, Nantes, Savenay, and St. Nazaire. Whensuch patients are selected at these hospitals, use the hospital trains50 and 51, now assigned to you, to collect them at Savenay for final scrutiny,assembly of records and equipment, with clothing, blankets, mess kit, andtoilet articles.
2. It is very essential that improper cases for transferto the United States be not all assembled at Savenay, resulting in congestionof nontransportable cases there, so that you are advised to have the caseswhich are moved from Angers and Nantes selected from those able to bearthe journey to the United States. Also, take advantage of the fact thatmen discharged from hospitals of classes B and C who are able to join casualcompanies may be sent to the casual concentration camp at St. Nazaire.
3. Keep this office informed of your needs in the wayof personnel, transportation, supplies, and equipment, in order that thedeficiencies may be promptly met. A copy of this letter has been sent tothe commanding officer, hospital centers, Angers, Nantes, Savenay, andBase Hospital No. 101, St. Nazaire.
By direction:
R. M. CULLER, Colonel, MedicalCorps.
When this port was designated as one of the three principal ports ofembarkation, plans immediately were made to cope with the situation, andin the medical, as well as in all the other departments, an evacuationbranch was inaugurated. "The general system used previously was not materiallychanged. However, instead of relying upon casual organizations at the restcamp to furnish details of litter bearers and ambulance drivers, an ambulancecompany was assigned to the duty. Soon it was found that in addition anevacuation ambulance company and a field hospital unit could be used, thethree organizations working as a battalion."
Furthermore, the regulating branch in the office of the base surgeontook on added responsibilities, and in order to systematize and standardizethe reports required by the different departments several mimeographedforms were promulgated.
The following circular letter was sent to all base hospitals and camphospitals, hospital centers and convalescent camps in Base Section No.1:
SERVICES OF SUPPLY,
OFFICE OF THE SURGEON,BASE SECTIONNO.1,
France, November 21, 1918.
Circular Letter A-16.
From: The surgeon.
To: The commanding officer.
Subject: Report of patients to be evacuated to the UnitedStates.
1. In order to facilitate the evacuation of patients tothe United States, it is requested that you submit daily telegraphic ortelephonic report to this office giving the following information by numbersof patients in your hospital ready to be evacuated to the United States:
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(1) Stretcher cases in sick bay.
(2) Requiring dressings, in standees.
(3) Requiring no dressings:
(a) Requiring help.
(b) Not requiring help.
(4) Tuberculosis.
(5) Mental.
2. The report should reach this office by 10 a.m., daily.
3. Report should be made as given in the form below:
BASE SURGEON,St.Nazaire:
Base Hospital twenty seven November twenty second re circularletter A sixteen one 133 two 145 three A231 B 452 four 99 five 63.
SMITH.
CHAS. L. FOSTER,
Colonel, Medical Corps, United States Army.
This report enabled the base surgeon to keep constantly on hand suchdata as the total number of class D patients in the base section, the totalnumber of litter patients, tuberculosis, mental, and other groups.11As soon as these data were received they were tabulated, so that at theend of each day it was possible to tell in a moment how many class D patientswere in the section, how many at a particular hospital, which hospitalwas overcrowded, and which one needed first consideration when an opportunityto evacuate presented.
A "Capacity and adaptability report" was made up as follows:11
Name of transport | Litter cases | Ambulatory surgical requiring dressings | Medical and surgical in standees | Attendants | Officers in rooms | Tuberculous patients | Medical or surgical not requiring attention | Mental patients | Total number of patients | Number of bunks to be reserved | |||||
Patients | Attendants | Bed | Walking | Restraint | Others | Attendants | Officers | Enlisted men | |||||||
--- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
--- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
--- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
--- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
This report was a great help also in that it covered all the essentialpoints with respect to a transport's fitness to receive patients.11 It was designed with the concurrence of thenaval medical representative, and was used by him, and by the Army medical officer assigned to the duty of passing judgment upon arrivingtransports. Upon receipt of this form the data were transcribed to permanent records in the office of the surgeon, wherethey were available for ready reference when the ship returned to this port. A copy of the report was sent to the hospitalcenter at Savenay, where it was used in preparing the passenger lists. In order not to delay matters, however, the data usuallywere read over the telephone to the commanding officer of the hospital center, and the report sent as confirmation.
A "space" report was used in connection with all transports, and wassent by courier to the evacuation officer at the evacuation camp, basesection No. 1, and to the superintendent, Army Transport Service.11Thus, if for any reason any part of a ship could not be utilized by theMedical Department, it could be utilized in returning to the United Statessuch casual and class B and C officers and men as might be awaiting transportation.
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The following "Evacuation report" was rendered to the chief surgeon,A. E. F., for each ship loaded with patients for transportation to the United States:11
1. The following is list of patients evacuated from thisport, above date, aboard
-----------------------------------------------
(Name of transport.)
MEDICAL
Tuberculosis --------------------------------------------------------------------------------------------------------
Mental:
Restraint ----------------------------------------------------------------------------------------------------------------------------------
Others -----------------------------------------------------------------------------------------------------------------------------------
All other sick ------------------------------------------------------------------------------------------------------------------------------------
Total sick -------------------------------------------------------------------------------------------------------------------------------------
Sitting cases ------------------------------------------------------------------------------------------------------------------------------------
Litter cases ------------------------------------------------------------------------------------------------------------------------------------
SURGICAL
General surgical --------------------------------------------------------------------------------------------------------------
Fractures, upper extremities -----------------------------------------------------------------------------------------------------------------------------------
Fractures, femurs ------------------------------------------------------------------------------------------------------------------------------------------------
Other fractures ----------------------------------------------------------------------------------------------------------------------------------------------------
Total fractures ----------------------------------------------------------------------------------------------------------------------------------------------------
Sitting --------------------------------------------------------------------------------------------------------------------------------------------------------------
Litter ----------------------------------------------------------------------------------------------------------------------------------------------------------------
_____
Grand total-------------------------------------------------------------------------------------------------------------------------------------------------
This report was made instead of the lengthy one required by paragraph4-F, Circular No. 38, chief surgeon's office, July 1, 1918, and was rendered in the case of all sailings subsequentto December 1, 1918, to comply with letter, chief surgeon's office, dated November 22, 1918, quoted above.11One copy of this report was sent to the commanding officer, base sectionNo. 1, and one copy was held for file, the essential data being tabulatedupon a permanent form in the office of the base surgeon, for ready reference.11
Other reports, occasionally required, were readily compiled from thedata obtained in the manner outlined above.11 Thus a memorandum to the chief surgeon's office was sent from the office ofthe base surgeon each week end, of the total number of class D patientsremaining in the section.11 At the end of the month, a lettercovering the total number of patients of each class evacuated to the UnitedStates was forwarded to the chief surgeon, A. E. F., and copies were sentto the commanding officer, base section No. 1, and to the naval liaisonofficer.11
The following extract from the Annual Report of Surgeon General, UnitedStates Navy, 1919, concerns the part played by the Navy in the return ofsick and wounded from the American Expeditionary Forces:
At a very early stage of the war arose the problem ofhow to return the sick and wounded to America. The ideal solution wouldhave been for the Army to return its casualties in ambulance ships owned,manned, and equipped by its Medical Department and convoyed by the Navy.This was impossible, and the next measure considered was the use of theNavy hospital ship Solace, with its capacity for returning 200 casualtiesa month, and the use later of two other hospital ships in process of equipmentable to bring back 300 sick apiece per month. The Army's estimate of aminimum of 5,000 returnable casualties per month showed
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these resources to be utterly inadequate even had thesethree vessels not been required for their original and legitimate purposeof caring for the Navy sick. Out of this situation developed the arrangementby which all Navy transports would, on the westward passage, serve to thelimit of capacity for the return of Army sick and wounded, and a scheduleof each ship's carrying capacity was forthwith gotten up and generallypromulgated for the guidance of all concerned. This proved the best arrangementpossible under the circumstances and was entirely satisfactory wheneverthe limit of a given ship's capacity was not exceeded. Unfortunately itwas not always sufficiently clear that the complement of a troop ship boundeast by no means corresponded to its capacity for adequate care of returningsick and wounded. The pressure at evacuation centers in France was, ofcourse, enormous and it extended to ports of embarkation, but the Navytook the position from the start that what was good enough for healthymen being rushed to the front was by no means sufficient for the maimedand sick who had done their bit and were entitled to the best possiblecare and professional attention the moment their retrograde movement began.To subject the sick to the overcrowding of troop compartments for a 10-dayvoyage was to jeopardize their chances of recovery. The troop quarters,with their three and four tiers of standee bunks, on iron decks remotefrom mess room, toilet, and open-air recreation were absolutely out ofthe question for the lame and disabled, the bedridden, the surgical casesrequiring one or many daily dressings and, of course, during the periodof the submarine menace common humanity demanded that the number of totallydisabled and helpless passengers be not out of proportion to the facilitiesfor carrying them to and caring for them in rafts and lifeboats should"abandon ship" be necessary. The captain of the ship and the senior navalmedical officer were judged by the Navy Department to have sufficient appreciationof the need for rapid evacuation, combined with a practical knowledge ofconditions at sea, to determine not the maximum carrying power but themaximum of facilities approximating the required hospital service for sickand wounded on each ship. The much talked of "hommes 40, chevaux 8" carwas not esteemed an appropriate means of transfer rearward for the disabledashore, and it was not proposed to give them an analogous service on a1-day voyage on the water.
Had it been only a question of attendant personnel, thewhole matter would have been much simplified, but the humane treatmentof the returning casualties included a variety of other considerations.There was a limit to the number of attendants that could work in confinedship spaces without falling over each other, especially when the ship wasdarkened in the submarine zone. The proper handling of contagious cases,the tuberculous, the insane, involved nice adaptation of numbers and specialrequirements to available space and facilities.
Conferences of the bureaus concerned, beginning November,1917, led to the drawing up of a formal agreement by which the Navy undertookto handle all sick and wounded for which it could provide adequate space,the prime basis of adequate treatment, on troopships manned by the Navy,and to furnish the services of its three hospital ships in excess of itsown needs only.
In their joint report of February 7, 1918, to you, theSurgeon Generals of the two services agreed that the Navy hospital shipswere entirely unavailable for Army purposes as sick transports, their capacitybeing small and their services completely utilized with mobile units ofthe fleet. The Navy transports were agreed upon as the best available meansof returning Army sick and wounded, the number to be carried being limitedto available space after the Navy sick and the sick of the troops in transithad been provided for. There was also a joint recommendation for the purveyof six ambulance ships, of 500 or more capacity, for Army use.
Your letter of January 22, 1918, to the honorable Secretaryof War definitely assigned to Army use the facilities for handling Armysick and wounded returning to the United States available on Navy transportsthen in service and of others that might be subsequently obtained, andthe two Navy hospital ships Comfort and Mercy were also offeredwhen the services of these vessels could be spared from naval use. It wasstated that no increase in facilities for this purpose were contemplatedby the Navy, but that, should the Army find these repatriation provisionsinsufficient, naval personnel would be provided to man and operate suchvessels as the Army might procure. The substance of this letter was reiteratedin your letter of January 29. Again, in your letter of February 15 to thehonorable Secretary of War, it was clearly pointed out that the Navy wouldman and operate any number of hospital ships provided by the Army, saidships to be ready in all respects for occupation.
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The following was the agreement approved by yourself andthe honorable Secretary of War, March 28, 1918:
(a) That the sick and wounded being brought fromFrance or England to the United States will be brought in naval hospitalships or transports, whichever may be most suitable and available, exceptin special cases where transportation by commercial liners may be authorized.
(b) The Army will be in charge of the embarkationand disembarkation of all Army patients.
(c) The Navy will be charged with the care of thesepatients while on board ships of the Navy acting as transports or otherwise.
(d) At the request of the Navy, the Army will rendersuch assistance in personnel and matériel as may be necessary.
The following schedule shows the classified sick-carryingcapacity of the great majority of the transports in service on December1, 1918. The figures fluctuated more or less with alterations in internalstructural details made for better ventilation or other sanitary considerations.On some transports increased passenger service went hand in hand with improveddisposition of living spaces; in others, it was reduced. In every case,the numbers of different types that could be treated with gratifying resultsdepended absolutely on the type and general structure of the ship, which,in the main, was fixed and not susceptible of modification.
Revised table for rated capacity for troops invalidedhome September 5, 1918, on principal naval transports?
Total bedridden in sickbay bunks | Able to walk, requiring surgical dressings; in troop standees | Mental cases | Tuberculosis, in isolation or on open decks | Able to walk, requiring no attention; in rooms for officers | Convalescent, requiring | |
Aeolus | 24 | 100 | 10 | 30 | 145 | 2,580 |
Agamemmon | 38 | 130 | 20 | 60 | 230 | 3,000 |
America | 59 | 140 | 12 | 25 | 215 | 3,600 |
Antigone | 40 | 110 | 5 | 25 | 100 | 1,660 |
Calamares | 42 | 100 | 5 | 20 | 80 | 1,100 |
DeKalb | 12 | 150 | --- | 20 | 50 | 1,000 |
Finland | 40 | 200 | 6 | 30 | 150 | 3,350 |
George Washington | 60 | 500 | 8 | 50 | 500 | 4,600 |
Great Northern | 40 | 400 | 45 | 38 | 116 | 2,200 |
Hancock | 20 | 550 | 3 | --- | 40 | a750 |
Harrisburg | 38 | 200 | 5 | 25 | 100 | 2,200 |
Henderson | 50 | 350 | 8 | 16 | 64 | 1,164 |
Huron | 38 | 110 | 5 | 25 | 140 | 2,250 |
Konigen der Nederlanden | 24 | 300 | 2 | 30 | 80 | 1,500 |
Kroonland | 40 | 200 | 16 | 20 | 150 | 2,600 |
Leviathan | 100 | 1,000 | 360 | 55 | 400 | 1,000 |
Lenape | 20 | 100 | --- | 10 | 44 | 1,000 |
Louisville | 45 | 300 | 5 | 30 | 100 | 1,800 |
Madawaska | 40 | 100 | 5 | 25 | 105 | 1,750 |
Mallory | 20 | 100 | --- | 10 | 40 | 1,200 |
Manchuria | 38 | 300 | 22 | 40 | 175 | 2,850 |
Martha Washington | 50 | 150 | 25 | 30 | 100 | 2,250 |
Matsonia | 16 | 100 | 5 | 10 | 90 | 2,000 |
Maui | 30 | 100 | 5 | 10 | 100 | 2,000 |
Mercury | 44 | 110 | 20 | 25 | 120 | 2,300 |
Mongolia | 33 | 300 | 5 | 25 | 170 | 2,850 |
Mount Vernon | 40 | 130 | 25 | 25 | 140 | 1,800 |
Northern Pacific | 44 | 510 | 45 | 90 | 120 | 1,700 |
Orizaba | 40 | 500 | --- | 25 | 90 | 2,000 |
Pastores | 25 | 100 | --- | 15 | 50 | 1,000 |
Plattsburg | 38 | 200 | 10 | 45 | 100 | 2,000 |
Pocahontas | 39 | 120 | 5 | 25 | 130 | 2,180 |
Powhatan | 40 | 300 | 10 | 25-150 | 57 | 1,400 |
President Grant | 55 | 110 | 5 | 25 | 200 | 4,400 |
Princess Matoika | 35 | 150 | 5 | 16 | 150 | 3,000 |
Rijndam | 50 | 1,000 | 10 | 40 | 155 | 1,800 |
Siboney | 50 | 500 | --- | 25 | 90 | 2,000 |
Sierra | 30 | 200 | 5 | 25 | 100 | 1,300 |
Susquehanna | 45 | 130 | 5 | 25 | 105 | 1,850 |
Tenadores | 40 | 100 | 3 | 20 | 42 | 1,150 |
Von Steuben | --- | b200 | --- | 60 | 103 | a650 |
Wilhelmina | 20 | 100 | 5 | 10 | 100 | 1,500 |
Zeelandia | 27 | 500 | 5 | 30 | 76 | 1,100 |
aHammock. bCot.??????????????????????
805
DETAILS OF EVACUATION
In July and August the demand for return of sick and woundedto the United States at the hands of embarkation officials in France increased,and pressure was constantly exerted on commanding officers to exceed theirallotted complement of sick, notably in the case of the Kroonland,Finland,and Calamares. But whenever sympathy for the congested embarkationareas and for the sufferers in them got the better of the judgment of ships'officers and induced them to exceed the allotted complements the resultingovercrowding led later to complaint about overcrowding in transit. Thesuggestion was received from various quarters that a ship be modified instructure so as to bring back in same only in large numbers. These suggestionshad in view only the evacuation from France of this unfortunate class.They did not extend to a practical consideration of how they would be caredfor en masse amid the discomforts and inconveniences of life at sea andthe extremely small chance they would have of surviving in the event ofattack or disaster to such a ship. Neither was it appreciated by thoseunfamiliar with the sea that in moments of danger from enemy or stressof weather the presence on board of hundreds of insane would jeopardizethe safety of a ship and its complement.
The medical officers and hospital corpsmen of the NavyTransport Service deserve the greatest credit for their faithfulness andskill in the repeated ocean crossings with their sanitary work on the outward,their hospital work on the homeward bound voyage-and the cleaning up, alterations,improvements, constantly going on during brief stays in home ports. Thiscredit has been accorded them by the vast majority of the men to whom theyministered, and the only criticism of the medical aspect of the Navy transportservice has arisen when more patients were assigned them than regulationswarranted or when men were put aboard unfit or unprepared for the voyageor with misleading diagnoses.
As late as September, 1918, it was necessary to specify,and in December to repeat the request, that at least three hours beforesick for return to the United States were sent alongside the transport,its officers should be furnished with quadruplicate lists separate fromthat of passengers, showing sources of patients, their rank, company, regiment,organization, and diagnosis. Our internal arrangements had long been soperfected that when once this advance information was regularly supplied,the walking patients would be assigned to compartments, the sick to wards,the bedridden carried to beds without a moment's delay, and by the timethe ship was well out of the harbor litters were beside each bedriddencase, with men detailed as bearers, and provision had been made or instructionsgiven for any exigency that might arise requiring "abandon ship."
Gradually as system and order in the evacuation of thesick and wounded developed all along the line, some of the overwhelmingburdens were lightened and at the same time a better service was given.Before the armistice was signed liaison between the two branches of theservice was so perfected that some of the early and radical mistakes ofevacuation from shore to ship have since been avoided, and it was no longerpossible to find one transport returning overloaded while a vastly largerone sailed practically empty from a near-by port. Much of the dissatisfactionwith the carrying (adequate caring) capacity of our transports was feltashore and grew out of methods of coastward routing and distribution ofinvalid cases in France. This waned as an orderly distribution was evolvedbased on proper advance information of ships' arrival and the accommodationsthey afforded.
In transporting the insane our medical officers had tofollow the rule of holding to the diagnosis furnished by the medical attendantswho had had the cases under observation and study in camps and hospitalsashore prior to embarkation. Every medical man knows the plausible speechand the docile behavior which the most dangerous maniac may assume foreven long periods, only to break out in his true light when suspicion hasbeen allayed. The overworked transport surgeon was not in a position toundertake the cure of the insane on an ocean voyage, nor had he the time,even if he pretended to the special skill required, to go into the nicetiesof differential diagnosis. When patients were no longer sent aboard indiscriminatelyan hour before sailing, without papers, descriptive lists, or diagnosis,but carefully tagged and sorted as surgical, medical, ambulant, or bedridden,contagious, nervous, and insane, etc., it was his duty to see that theinsane were humanely treated, and humanity here
806
consisted in preventing their jumping overboard or fallingdown the engine-room hatch, running amuck about the ship, incommoding otherpatients-in a word, in restraining them and delivering them alive in America.The bulk of the transports were provided with areas inclosed by metal screens,having access to air and light on deck, with a sentry to keep away thethoughtless or inquisitive, and attendants on watch day and night, everysanitary detail being observed in regard to these unfortunates. Passengerswho saw unkindness in this restraint or declined to accept the diagnosismade by the Army surgeons conversant with the cases before embarkationwere not prepared to accept the responsibility for a different procedurenor could they relieve the ship's surgeon of his. In some cases groupsof insane were put aboard our transports under the care of medical officersand attendants detailed for the voyage from the service to which they belonged,and under these circumstances those officers and attendants quartered andhandled their charges as they saw fit without the advice or interferenceof the ship's authorities.
During the most active period of our military campaignthe heaviest work of our medical officers on transports flowed from therequirement of surgical cases, many of whom required three or four changesof dressing daily. The most trying work was that of ministering to mensent home to die, a certain proportion of whom, of course, expired withina day or two of sailing.
* * * * * * *
As our battleships and cruisers are normally providedwith facilities for caring for the sick of their crews, estimated at notover 3 per cent for a force of from 600 to 1,000 men on each of these vessels,they were manifestly not adapted in any way nor used for the repatriationof sick and wounded.
Upon the signing of the armistice and with the initialmovement for the return of our troops from abroad, steps were taken toutilize certain German ships which had been unable to go to sea owing tothe preponderance of allied naval power and were still in German harbors.One of the best of this class was the Imperator, which was rapidlyconverted for transport purposes and, like the rest, was manned by a Navycrew composed in the main of officers and men already abroad and no longerrequired for campaigning. Other vessels of this category were the GrafWaldersee, Cap Finisterre, Kaiserine Augusta Victoria, Mobile, Patricia,Philippines, Pretoria, Prince Frederick Wilhelm, Zeppelin.
REFERENCES
(1) Report of the chief surgeon, A. E. F., to the SurgeonGeneral on the activities of the chief surgeon's office, A. E. F., to May1, 1919. On file, Historical Division, S. G. O.
(2) Report on the evacuation of sick and wounded, A. E.F., to the United States, undated, made to the Surgeon General by Col.R. M. Culler, M. C. On file, Historical Division, S. G. O.
(3) G. O. No. 41, G. H. Q., A. E. F., March 14, 1918.
(4) G. O. No. 206, G. H. Q., A. E. F., November 15, 1918.
(5) Embarkation Instruction No. 1, Hq. S. O. S., A. E.F., November 20, 1918.
(6) Embarkation Instruction No. 6, Hq. S. O. S., A. E.F., November 26, 1918.
(7) G. O. No. 215, G. H. Q., A. E. F., November 25, 1918.
(8) Embarkation Instruction No. 13, Hq. S. O. S., A. E.F., January 4, 1919.
(9) G. O. No. 5, G. H. Q., A. E. F., January 5, 1919.
(10) G. O. No. 23, G. H. Q., A. E. F., February 2, 1919.
(11) Report on the evacuation of sick and wounded fromthe port of St. Nazaire, undated, made to the surgeon, base section No.1, by First Lieut. Edward P. Heller, M. C. On file, Historical Division,S. G. O.
