Books and Documents

UNITED STATES ARMY IN THE WORLD WAR 1917-1919

Reports of the Commander-in-Chief, Staff Sections and Services

Volume 15

Washington, D.C.: Center of Military History, United States Army, 1991

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C-in-C Report File: Fldr. 319: Report

Activities of Chief Surgeon`s Office

February 28, 1919

INTRODUCTION:

[Extract]

Although the date when General Pershing organized his Headquarters in PARIS in June 1917, marks the official beginning of the Chief Surgeon`s Office of the A. F. F., the history of the Medical Department of the A. E. F. began prior to that date. In April 1917, after the British Mission had indicated the need of medical assistance from the U. S., the War Department called upon the American Red Cross to furnish six base hospitals for immediate shipment to France to serve with the B. E. F. These were to be taken from among those authorized by the War Department in Jan. of 19 16 to be organized by the Red Cross. Between May 8 and 25, the following six base hospitals sailed from the United States in the order indicated:

No. 4, organized by George W. Crile, in CLEVELAND, Ohio.

No. 5, organized by Harvey Cushing, in BOSTON, Mass., and known as the Harvard unit.

No. 2, organized by George R. Brewer, at the Presbyterian Hospital, NEW YORK CITY.

No. 10, organized by R. H. Harte, at the University of Pennsylvania, PHILADELPHIA.

No. 21, organized by Fred Murphy, at Washington University, St. LOUIS, MO.

No. 12, organized by F. A. Besley, at Northwestern University, CHICAGO, Ill.

The first members of the A. E. F. to lose their lives by enemy action were among the personnel of Base Hospitals Nos. 5 and 12. This occurred in an air raid on DANNES-CAMIERS, Sept. 4, 1917, one officer and 3 soldiers being killed.

Accompanying General Pershing when he left NEW YORK on May 28, 1917, were four Medical Officers, Colonel (now Major General) M. W. Ireland: Lt. Col. (now Col.) George P. Peed: Major (now Colonel) J. R. Mount, and Major (now Lt.Col.1 Henry Beeuwkes, four civilian clerks and two enlisted men of the Medical Corps. Shortly after their arrival in England on June 8, 1917, they were joined by Colonel (afterwards Brigadier General) A. E. Bradley, M. C., under appointment as Chief Surgeon, who had been in England since May, 1916, as a military observer. On arrival in Paris on June 13, 1917, the Medical Staff was further augmented by two other officers, Lt. Col. (now Colonel) James R. Church, M. C., and Lt. Col. (now Colonel) Sanford H. Wadhams, M. C. The above mentioned officers constituted the personnel of the Chief Surgeon`s Office when General Pershing organized his Headquarters in Paris in June, 1917.

On July 28, the Chief Surgeon`s Office was organized into six divisions, as follows:

1. HOSPITALIZATION: In charge of location, construction, repair and administration of all hospitals. Collection and evacuation of the sick and wounded, including the management of hospital trains.

2. SANITATION AND STATISTICS: In charge of sanitation of camps and quarters, laundries, disinfection and delousing, health of command. Reports of sick and wounded. Statistics and sanitary reports.

3. PERSONNEL: Including Medical Corps, Medical Reserve Corps, Dental Corps,

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civilian employees, and schools of instruction.

4. SUPPLIES: Hospital equipment, medical, veterinary, and dental supplies. Settlement of accounts: ambulances and all medical motor transportation.

5. RECORDS AND CORRESPONDENCE:

6. GAS SERVICE: (Subsequently organized into a separate service.)

On July 18, Colonel (now Brigadier General) F. A. Winter, arrived from the United States with a small detachment of clerks, and in compliance with instructions of the Surgeon General, was appointed Chief Surgeon, Base Group and Line of Communications. From this date until March 21, 1918, the Chief Surgeon, L. of C., had immediate charge of base hospitals, supplies and medical personnel on the Lines of Communication. With the reorganization which took place with the promulgation of General Order No. 31, 1918, and when the Chief Surgeon`s Office was moved from Chaumont to Tours, the Chief Surgeon`s Office, L. of C., was merged with the Chief Surgeon`s Office.

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The reorganization brought about by General Orders No. 31, was advantageous in bringing about a more efficient administration of the medical activities of the A. E. F., insofar as it brought the Chief Surgeon in close touch with the Line of Communication or Services of Supply, and in bringing about a closer relation with the General Staff by representation on various sections of the General Staff. In a letter to the C-in-C under date of April 30, 1918, the Chief Surgeon stated that the transfer to the Chief Surgeon`s Office to the Services of Supply has been tested in actual operation, and has in many ways facilitated the transaction of business, especially in matters concerning supplies, the distribution and training of personnel, and the construction of hospital accommodations. Attention was called, however, to the fact that the separation of the Chief Surgeon from G. H. Q. had a tendency to place the Chief Surgeon out of touch with the medical service at the front, although this has in part been remedied by the detail of medical officers on the various sections of the General Staff at G. H. Q., and by more frequent visits of the Chief Surgeon in person to General Headquarters and to the divisions in the front line. In this connection, the Chief Surgeon has repeatedly pointed out the fact that the Medical Department does not function as an S. O. S. service merely: its activities reach clear up to the battle front, and in times of heavy fighting, when thousands of wounded men have to be cleared from the battle field, the most perfect coordination between the services of the front and rear is imperative.

At the time that the Chief Surgeon`s Office was installed in the French Barracks No. 66 at Tours, in compliance with General Order No. 31 above mentioned, there was added to the organization the Finance and Accounting Division. The personnel composing this division was selected from a detachment consisting of 7 officers and 135 men which had been organized in the U. S. under the direction of the Surgeon General, to audit the money and property accounts of the Medical Department in France, after Congress had passed the Act of September 26, 1917, authorizing the Comptroller of the Treasury and the Auditor of the War Dept. to perform the duties of their offices and audit the accounts of the military establishment at any place other than the seat of the Government.

At a later date (Aug. 28, 19181, the Veterinary Division was added. * * *

THE HEATH AND SANITATION OF THE TROOPS OF THE AMERICAN EXPEDITIONARY FORCES

The health of the officers and men in the A. E. F. has in the main been good and the noneffective rate from disease, that is, the number of men in proportion to the

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strength of troops incapacitated from duty from other causes than battle casualties and injuries from accidents, etc., has been low. As has been the case with our Allies the number of beds occupied in our hospitals by men incapacitated by battle casualties has not at any time equalled the number occupied by the sick and injured. From August 1 until the last of November, 1918, when the battle casualties and the accidental injuries requiring hospital care were at highest, the percentage of hospital beds occupied by these cases varied between 41% and 47% of the total hospital beds occupied. For the period to the sharing of American troops in active military operations accidental injuries and all the various external causes which incapacitated men for active duty represented from 6% to 10% of all hospitalized patients. In other words, disease caused from 60% to 90% of the noneffectiveness in the A. E. F. according to the participation of our troops in offensive operations and the presence of the various epidemics of disease.

Only two diseases developed in a sufficiently generalized way to affect the entire A. E. F. and cause serious difficulties and temporarily excessive sick rates, epidemic diarrhea and influenza and only the latter as the result of the secondary pneumonia developed a serious rise in the death rate.

Against neither disease is there any known specific protection. Both diseases were prevalent in the armies of our Allied and of the enemy at the same time as well as in the civilian population.

It is doubtful if there are any sanitary measures which could have been applied under the existing conditions which would have prevented either of these two extensive epidemics among our troops although the coincident crisis in the military situation throughout this period (July 15-November 1) demanded such priority in service, transportation and material that many precautions, practicable under ordinary field conditions, were inevitably neglected.

Epidemic diarrhea with a considerable amount of dysentery and probably some unrecognized typhoid and paratyphoid fevers developed in various parts of France late in June, appearing first in the more southern areas occupied by our troops, and wherever insanitary disposal of human wastes, fly breeding and insufficient precautions in the preparation and serving of food prevailed. Immediately after the Chateau-Thierry offensive as many as 70% of the troops engaged were in the course of two or three weeks more or less incapacitated by diarrhea. Polluted water sources, the utter disregard of even elementary principles of sanitation and the plague of flies which bred and fed upon human excreta everywhere exposed, and upon dead bodies of men and draft animals upon the battlefield, combined to develop the epidemic rapidly and over a wide area. Most of the cases never reached a hospital or obtained medical treatment. Spontaneous recovery in a few days was the rule. The enthusiasm of the victorious forward movement of the troops carried many men out of reach of hospitalization, and the true measure of noneffectiveness from that epidemic can only be guessed. A small number of serious and persistent infections found their way through the evacuation hospitals to the base hospitals, and the great majority of those examined early in the course of their disease were found to be suffering from true dysentery caused by well recognized strains of bacilli. Fortunately the type of the infection was mild and very few deaths resulted from the entire epidemic. The disease prevailed during the war weather while the fly breeding season continued. In a few favored places, where alert medical care was combined with adequate physical equipment to avoid fecal exposure and pollution of food and water only an occasional case of diarrhea developed and entire organizations escaped infection, but in the main the disease prevailed throughout the A. E. F. from July 1 to the middle of September.

Following this period a few cases of typhoid and paratyphoid fever developed each week, often in commends which had participated or were still in the areas of recent active operations. In December, 1918, and January, 1919, the greatest number of cases

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occurred, the incidence declining sharply in February and March. During the entire period after November 11, 1918 the infection in a great majority of the cases reported were found on careful study to be attributable to the use of polluted and unauthorized water supplies or to carriers in the organizations in which the cases developed. In many instances the carriers were found among the cooks and kitchen police on duty. There is good reason to believe that the carriers and early undetected cases of these diseases had acquired their infection during the period of extensive incidence of intestinal disease in the summer months.

The other epidemic and one which was much more serious as a cause of noneffectiveness, and as the cause of the greatest mortality in the A. E. F. was that of influenza, which was and continues to be part of a pandemic of the disease which has within the past year affected all parts of the world. The disease in a mild form prevailed from the middle of April until the middle of July without interfering materially with the activities of the A. E. F. There was much increase in noneffectiveness for a week or so while the disease swept through a command, but the recoveries were prompt, complications rarely occurred and there were very few deaths from the primary infection or from complications,

In September, the disease returned at the time when large shipments of troops were arriving from U. S., when every resource of men and material was being strained to prepare for or take part in the Meuse-Argonne Offensive. The weather was unfavorable, the type of disease was more severe, the means of evacuation and the hospitals were strained to their capacity in caring for the wounded. Troops movements were extensive and urgent, military necessity demanded every sacrifice for offensive operations. These conditions combined to make adequate preventive measures and early and sufficient

hospital care well night impossible.

Heavily infected, and exhausted by the strain of the voyage, troops arrived with a loss in some instances of as many as 2% of their entire strength within three weeks after embarking in the U. S. Long delays and insufficient provision for rest, food and medical supervision during train transport to training areas or replacement divisions added to the spread of the disease. Crowding in billets and barracks beyond the limits of safety, unfamiliarity of officers and men with the precautions needed in this climate, ignorance of the part which warmth, dry clothing, sufficient rest and hot food play in raising bodily resistance to infection, delayed diagnosis and removal of infected men, and insufficient precautions in hospitals of all kinds to prevent communication of the disease in the wards, all contributed to a heavy incidence of pneumonia and high mortality from this common complication.

By the middle or third week of October, the epidemic again began to subside and by December 1, the incidence of influenza was well below the usual rate for the month of the year. In the latter part of January there was a third wave of disease in a mild form, and, coming at a time when every precaution could be taken, and when other factors were favorable, it did not cause a serious loss of life.

Venereal diseases have been subject to control by policies medical, educational and disciplinary, so different from those applied in any army heretofore that only detailed report of these diseases can adequately present the subject. It is not too much to say that the official attitude of the Government as expressed in orders from the War Department and from the C-in-C supported by a logical medical service for the prevention and treatment of venereal diseases have resulted in a smaller loss of man

power to the army, a lower incidence rate of the disease, and a smaller number of permanently disabled and invalided men from these diseases than has been recorded among the troops in the U. S.

These diseases when treated according to the information available through medical sciences can be controlled, and to a greater degree than ever before have been controlled by applying the principles of preventive medicine, namely, diminution of contact

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with human sources of infection, prophylactic treatment promptly after exposure, and segregation with intensive treatment for those in the communicable stages of the diseases.

Supplementary to the application of these fundamental medical principles have been the forces of education, recreation, discipline and appeal to patriotism and morality.

Of the less important communicable diseases mumps holds first place and indeed leads all diseases as a cause of noneffectiveness in the first year of the A.E.F. No measures applicable under existing conditions appeared to have any definite effect in controlling this disease. It is to be presumed that exposure was almost universal and that those, not already insusceptible because of a previous attack developed the disease when exposed.

Measles similarly prevailed among immature and susceptible troops, but where the principles of daily examination and segregation of all men who showed the least catarrhal symptom or rise of temperature, spacing out and separation of men into small units, and separating old or mature troops from contact with replacement or new detachments could be and were carried out intelligently this disease was quickly stamped out. Measles was always prevalent at the base ports among recently arrived troops and appeared to a less and less degree as the troops were passed through replacement depots and training camps on their way to the front.

Diphtheria while occurring to a degree not previously experienced in our army occurred only in epidemic form in few divisions and hospital formations and then only for a brief period until well known methods of control could be made effective. The successful treatment of diphtheria epidemics demands laboratory facilities of a very efficient kind for the detection of carriers and diagnosis of mild cases. In this war, these facilities have for the first time in our army has been furnished to bodies of troops in the field by means of mobile laboratories, which were sent out instantly on call from the Central Laboratory at Dijon, and constituted an extension of that institution. Scarlet fever, except on one occasion in a regiment, delayed in its passage across France in December, 1917, never developed into an epidemic of any proportions, although the A. E. F. was never wholly free from it.

The incidence of the other communicable or preventable diseases was not sufficient to justify mention in a general survey such as this.

Modern, firm, humane methods applied to the prevention and treatment of mental disease spared many men for service, or from a life time of invalidism which could have followed the persistence in methods only too prevalent in our civil police and institutional administration at home.

The stationing of trained physicians skilled in the detection of war neuroses at the sorting stations did much to save the A. E. F. from the high noneffective rate from these diseases which occurred at times in the armies of our Allies.

Of the diseases which caused serious loss of manpower to our Allies at one time or another during the war and more particularly before the participation of the A. E. F. in active operations, several deserve special comment if, for no other reason than that they played an insignificant role among the causes of sickness in our troops.

Because of the nature of the military operations in which our troops took part, and as a result of the seasons of the year during which most of our front line activities were undertaken, our troops almost wholly escaped trench nephritis and trench foot, afflictions due in large measure to exposure to wet and cold for long periods under trench conditions such as prevailed in the mud of Flanders.

The conditions moreover under which trench fever become prevalent especially in the British forces never developed among our troops, chiefly because of military conditions and not on account of any more favorable state of sanitation or cleanliness among our troops.

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The certainty that trench fever could have been effectively controlled or prevented if it had appeared among our troops at all generally was assured by the results of the work of the trench fever committee. This committee, acting under authority of the Commander-in-Chief of December 22, 1917, carried out early in 1918, accurately controlled experiments upon the means of transmission and the period of infectivity of the disease which determined without question that the body louse was the intermediate host and the means of transmission of the disease from the sick to the well.

This piece of scientific research added materially to the security of the troops by its contribution to the knowledge of preventive medicine.

The so-called trench mouth, a condition of sluggish infection and ulceration of the gums and mucous membrane of the mouth, developed in large numbers of our men where neglect of oral hygiene was coupled with a poor condition of general health, but relatively simple general and local measures sufficed to prevent this annoying conditions from becoming a noticeable source of noneffectiveness.

From tetanus, we were almost entirely spared, partly because of the character of terrain over which our men fought and partly because of the universal and adequate use of prophylactic doses of tetanus antitoxin.

Gas gangrene as a complication of battle casualties was often serious and always a threatening cause of much loss of life, but in actual numbers this infection developed in but a small fraction of the wounded. A month before the signing of the Armistice preventive inoculations were undertaken which promised to give still further protection against this much feared complication of surgical cases.

Effort syndrome, the irritable heart of soldiers, well known to the army surgeons of our Civil War occurred as a primary cause of disability requiring prolonged care in convalescent camps, or as a complication following gassing or infectious fevers. Owing chiefly to the short period of our participation in the war and to the vigor and freshness of our troops, this typically war disability did not develop into the proportions observed in the English and French armies.

In the matter of lousiness and scabies, from which our troops suffered generally throughout France the avoidance and elimination of these infestations was a matter at all times dependent chiefly upon the resourcefulness and conviction of officers that their men should keep themselves and their clothing clean. All troops became lousy in the trenches. Lack of bathing facilities, and of fuel and appliances to accomplish disinfestation was almost universal. At times 75% of many commands were heavily infested. The attention given by officers and men to correct this condition soon after the Armistice accomplished more in two months than had resulted from the efforts made in the previous year. The A. E. F. never had any such experience with the chronic infestions of the skin, the pyodermias or inflammations of the cutaneous tissues as the armies of our Allies suffered from in the earlier years of the war.

Sanitation, or the control of environment for the sake of prevention of disease was limited narrowly in the A. E. F. by the restriction of transportation, the insufficiency of structural material and of labor to build shelter and by the difficulty of getting enough fuel to heat living places and to dry clothing, and enough water of a pure quality to provide sufficient facilities for body cleanliness and the washing of

clothes.

Wherever owing to fortunate local conditions, adequate floor space per capita was made available for living purposes, or where the ingenuity, resourcefulness and determination of the medical and commanding officers to obtain adequate space and facilities was brought into play, the sick rate was always low. In the A. E. F. as elsewhere attention to the comfort, cleanliness, food, sleep, exercise and rest of the men was always accompanied by a low sick rate.

Adjustment to environment by green troops under young officers with the advice of

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medical officers wholly unfamiliar with any aspect of medicine except those of the family or hospital practitioner was accompanied by many of the disabilities and losses from sickness which seasoned troops, with each man a trained practical hygienist and sanitarian, with line officers capable and willing to take infinite pains to guard the health of their men and surgeons who have learned the preventive side of medicine, escape. With every month, the improvement in sanitary discipline and experience became more marked and at the time of the Armistice some organizations and areas in the armies and in the S. O. S. had reached a good standard of field sanitation.

HAVEN EMERSON,

Colonel, M. C.

MEDICAL DEPARTMENT TRANSPORTATION

Transportation of the Medical Department comprises trains, ambulances, and canal barges. The trains consist of those obtained from the French and those from the British. There were two French trains made up of cars converted to hospital train purposes from either passenger or baggage car type and 50 trains, some of which were ordinary box cars, fitted with litter racks, others passenger coaches for sitting cases, The first idea of the American army was to adapt ordinary box cars for hospital train purpose by introducing fittings for supporting tiers of litters: these fittings were metal posts capable of being screwed into the floors of the cars so that they would take up little space and could be cleared away readily when not wanted, permitting them to serve the double purpose of evacuating wounded from the front and, when empty of wounded, carrying back supplies to the armies. Both the British and French armies adopted this procedure but found it impracticable.

The American Government, profiting by the experience of those armies, promptly placed orders with the British Government for a sufficient number of the latest and best type of hospital train. Owing to the great distance from the United States and the shortage of cargo space, no coaches were imported from home.

The trams were, for the most part, supplied through the Agency of the British Railway Executive Committee appointed a special committee to make all arrangements relative to design, equipment, transportation, etc., in conjunction with a military advisory committee in France. These trains were designed primarily for the evacuation of the sick and wounded and were not intended strictly as hospital trains in the sense of treatment, operative or otherwise for patients, and were in accordance with what experience had proved the best. Great importance was attended to standardization and simplicity was combined with usefulness.

Nineteen of these trains, obtained from Great Britain, were delivered prior to the signing of the Armistice. The cars, completely equipped, were transferred from England by special ferries to a port in France, in order that the trains might be ready for service as soon as they arrive in France.

Each train consists of

1 Infectious case car, 18 beds,

1 Staff car, 8 beds,

1 Sitting sick officers` car, 3 beds and 20 seats,

8 Ordinary lying ward cars, 288 beds,

1 Infectious case sitting car, 56 seats, 14 upper berths,

1 Kitchen and Mess car, 3 beds (for cooks),

1 Personnel car, 30 beds,

1 Train crew and store car,

Total number of beds available for patients, lying, 360.

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Long coaches 54 to 56 feet in length were used instead of the short continental coach type, to insure a comfortable journey for the patients. These trains are so attractive in appearance and arouse such interest in the public that they have been frequently placed on exhibition in England before shipment to the continent so that the public may see what excellent care is being taken of the soldiers by the Medical Department, U. S. army.

The first of these trains was delivered in France, February 11, 1918, and the last at about the time hostilities ceased.

The beds of the ward cars, 36 in number, especially designed, are removable, and in case of necessity can be used as stretchers. They are capable of being folded against the sides of the coach, and lowered to the floor, become converted into a couch for the patients able to sit up, whilst the top bed is still available for lying down cases. By this arrangement the less seriously wounded are made comfortable and can either sit up or lie down. A so-called sitting case cannot sit up for a prolonged period, and it is necessary to provide a bed which a sitting case might use some time during a long journey. This conversion of beds into seats, with litters placed in front of the doors, enabled these trains to evacuate as many as 720 sitting cases.

The two French hospital trains and the 19 trains made in Great Britain were used principally for secondary evacuations. These evacuations totalled on November 11, 1918:

The 50 trains borrowed from the French were used principally for the so-called primary evacuations. These totalled on November 11, 1918:

Insofar as the personnel, materiel, supply and maintenance of the equipment, the hospital trains were administered under the direction of the Chief Surgeon, A. E. F. As railway units, however, they were operated under the direction of the officers to whom they were assigned, and were repaired by the Transportation Service. Assignments of hospital trains, operated in the Zone of the Army, were made by G-4, G. H. Q., to regulating officers, and in the S. O. S., they were under the jurisdiction of the Chief Surgeon, A. E. F.

An officer of the Medical Department was assigned to each regulating station as part of the Staff of the Regulating Officer, and as a representative of the Chief Surgeon.

The Chief Surgeon, A. E. F., allotted a requisite number of beds daily to each regulating officer, advising him by telegraph as to their number and location. These beds were reserved for the exclusive use of the regulating officer to whom allotted and daily notice of any changes in these credits were furnished him. The G-4 of the army

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furnished the regulating officer daily all data bearing upon evacuations in order that the latter could judge the sufficiency of trains and beds at his disposal and take necessary steps to correct a shortage. Upon receipt of advice for the necessity of evacuating patients from a given hospital, the representative of the Chief Surgeon at the regulating station, cognizant of available beds in different hospitals indicated destination of train. The commanding officer of the evaluation hospital was charged with seeing that the necessary steps were taken in order that the train might be loaded promptly in the time allotted. The regulating officer notified the commanding officer notified the commanding officer of the receiving hospital of the contents of each train, showing the number of officers, soldiers, and enemy prisoners, number of sitting and lying patients, number of contagious diseases, together with any other information which would facilitate the unloading of the train.

The cost of each train purchased was approximately $200,000. The French trains were rented at a cost of 150 francs a day.

HOSPITAL BARGES

In August, 19 18, the Chief Surgeon proposed that barges be used for severely wounded and gassed soldiers; the type of cases to be those with compound fractures, chest and abdominal wounds, many of which would have been nontransportable by hospital train.

At the time of the signing of the Armistice, there were about 60 barges being converted to hospital purposes.

During the Chateau-Thierry, many patients were evacuated by this means of transportation from the Chateau-Thierry sector to Paris, Barges were operated in flotillas of 6, motive power being furnished by tug boat.

AMBULANCES

The Medical Department was charged with the responsibility of procuring ambulances for the American Expeditionary Forces. In the early days of the war, the G. M. C. type of ambulance was adopted, because of its capacity. The ambulances were shipped to France, unassembled, the constitutent parts of the bodies being placed in crates and a series of envelopes were made up containing the number of screws, bolts and nuts necessary for assembling the ambulances. Each operation was numbered and the corresponding number was placed on the envelope containing the hardware used. This ambulance body was not what is regularly known as a knocked-down body and it was appreciated that considerable difficulty would be encountered in its assembly, unless trained men fully familiar with body construction were available in France. The Surgeon General`s Office accordingly organized a unit known as the Motor Ambulance Assembly Detachment, comprised of 3 officers of the Sanitary Corps and 60 body builders and motor experts. Probably no organizations ever arrived in France better equipped than this Ambulance Assembly Unit. It began operations on January 2, 1918, at St-Nazaire. Within two weeks, the necessary shelters had been constructed, power lines had been run and the ambulance assembly commenced. A number of chassis and bodies had accumulated on the beach at St-Nazaire and there was an urgent call from various organizations and divisions then in France for ambulances. The shop soon took on the appearance of a modern American factory and ambulances were turned out at the rate of 4 a day. This number was gradually increased until a daily output of 15 was reached.

It was expected that all motor transportation would be delivered at the Port of St-Nazaire. This, however, proved to be impracticable, and before long, ambulances were being received at Le Havre, Brest, Bordeaus, Marseilles and La Pallice. Certain numbers of the original Motor Ambulance Assembly Detachment were sent to the parks at

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these ports and soon built up assembly organizations composed of Medical Department personnel and Motor Transport corps personnel and the same efficiency was obtained as at St-Nazaire. In General Orders, G. H. Q., A. E. F., at Headquarters, S. O. S., ambulances were classed as special vehicles. While orders covering assignments have been prepared by the Motor Transport Corps, all requisitions have been submitted to the Chief Surgeon`s Office, and that office has submitted requests to the Motor Transport Corps to assign ambulances to the points where they were most needed. Many organizations to whom ambulances were assigned in the United States delivered them to the ports of embarkation and they were shipped to France whenever practicable. However, no notice of prior assignment was taken in France and all motor transportation received was pooled.

Many assembled ambulances arrived at base ports in France but in most cases they were in such bad condition that a request was cabled to the United States, asking that they discontinue the practice, as nearly every motor was damaged to such an extent that repairs were necessitated: nearly all the accessories were missing and in many cases it was not worthwhile to attempt these repairs on account of the shortage of spare parts.

About one month before the Armistice was signed, a new type of knocked-down body was shipped to France. Inasmuch as it was assembled and painted in the factory and then taken down in sections and shipped in crates, considerable time was saved in the final assembly at base ports in France and very much less personnel was required to operate the body shops. Four men could assemble two bodies in a day.

One of the greatest difficulties which has been encountered has been the question of spare parts. It is believed that, in the future, if it is necessary to send ambulances outside of the limits of the United States, some arrangement should be made to supply spare parts with every chassis that is shipped and that these parts should be inclosed in the crate with the chassis. Another perplexity was caused by the arrival of the shipment of the chassis at one base port and bodies at another. This made it necessary to assemble the chassis and drive overland to the Motor Reception Parks where the bodies were being assembled, thus causing a divergence of much personnel and expenditure of considerable gasoline. Bodies and chassis should be shipped on the same boat.

There were shipped to France (and Italy) 3,070 G. M. C. Ambulances and 3,805 Fords. Patients evacuated from France have been embarked principally from St-Nazaire and Brest, and latterly from Bordeaux.

Hospitalization on a large scale was planned at Savenay in order that cases selected as suitable for transfer to the United States might be collected and evacuated from there through St-Nazaire; and at Beau Desert, near Bordeaux, for evacuation through the latter place. Owing to the fact that Brest was not contemplated as a port of embarkation hospitalization on a large scale was not provided at that place until the latter months of the war. As the large boats could some only to that port, however, direct evacuations were made through Brest from the hospital center, Savenay. The hospital center at Kerhuon, on the outskirts of Brest. was constructed and a capacity of 4,000 beds reached at the time of the signing of the Armistice. Owing to lack of good roads leading to this place, it could not be extensively used.

The secondary evacuations of cases chosen for transfer to the United States were made from base hospitals in the Advance and Intermediate Sections to the hospitals at base ports, where they were both given final hospitalization and preparation for embarkation. This preparation consisted in the completion of medical records insofar as it was possible, the arrangement of passenger lists, the forming of a number of patients into convoys, divided into various types of cases which enabled naval authorities in charge of transports to properly and rapidly place them aboard ships. As the transports usually arrived in large convoys, proportionately large groups of patients

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could be evacuated at a given time.

Patients that were selected for return to the United States were those permanently unfitted physically for any military duty and those who would require at least six months further hospital treatment before becoming class A. Boards of officers passed upon these cases at base ports and determined the class into which they fell as well as the fact that they were capable of standing transportation over seas. Supplemental records were prepared for those whose service records were not received at the time of evacuation, Each enlisted man evacuated was issued sufficient clothing to enable him to travel in comfort and, in addition, a toilet kit bag containing a shaving outfit, soap, tooth brush and paste, and a hand towel. The following tabulation shows the number of evacuations August 1, 1917, to about Nov. 11, 1918:

F.W.W.

SUPPLY DIVISION

On the declaration of war by the United States, the Medical Department immediately took steps to prepare for our active participation, Committees were appointed to standardize equipment, and a survey of the resources of the whole country was made to determine what steps should be taken to best meet the emergency and supply the enormous quantities of medicines, surgical dressings and instruments which would be required. The Red Cross commenced, during the winter of 1916/17, to collect the equipment for forty base hospitals, and it was due to the aid rendered by this far-sighted policy that the Medical Department was able to meet the problems presented. This aid was especially valuable because no appropriation was available for actual purchase until about the middle of June, and our own reserves had been completely exhausted by the mobilization of the National Guard on the Border in 1916.

In anticipation of the departure of the first increment of the American Expeditionary Forces from the States, plans were naturally made by the Office of the Surgeon General for the shipment to France of medical supplies, and, in the same convoy which brought to France these troops, there was, of course, included among the supplies shipped over a quantity of medical supplies which arrived in June, 1917, at St-Nazaire. Upon arrival in France, effort was at once made by representatives of the Supply Department, who had accompanied General Pershing`s original expeditionary force, to obtain in France a suitable location and buildings for the establishment of the first medical supply depot. These efforts resulted in the establishment at Cosne-sur-Loire, in the early part of July, 1917, of a medical supply depot containing storage space approximating 50,000 square feet, in buildings which had theretofore been used by the

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French as an aerial bomb depot. From that time on, this depot, which later acquired the designation of Intermediate Medical Supply Depot No. 3, was operated practically as the principal medical supply depot of the American Expeditionary Forces, until January, 1919, when, at the request of the French, it was abandoned and the buildings returned to the French for their use. It was at this depot that practically all medical supply officers trained in France were developed, and its function in training these officers might almost be rated as of equal importance with its functions as a supply depot, for, from the beginning, the inability of the Supply Department to obtain officers trained in handling medical supplies was one of the most difficult problems with which it had to cope.

With the establishment of headquarters of the American Expeditionary Forces in France, a subdivision of the office of the Chief Surgeon was created to handle medical supplies. There was also a supply division in the Office of the Chief Surgeon, Line of Communications. Attention was immediately given by these divisions to the institution of an automatic supply of medical supplies from the States, which was early accomplished. In compiling the basis of the automatic supply, the estimated quantity of medical supplies needed per month for each 25,000 in France, effort was consistently made to conserve tonnage by eliminating from the supply tables of the Manual for the Medical Department all items which were not absolutely essential, and particularly those items which were of a bulky nature. From time to time, the basis of this automatic supply was revised in the light of the experience which we were acquiring by virtue of our troops being under the actual conditions of modern-day warfare; and this source of supply was augmented by requisitions made upon the States, by purchases made here in Europe, and by calls upon the Red Cross for materials needed and not in stock in Medical Supply Depots of the American E. F., but in stock in the warehouses of the Red Cross. It should be stated that all requests made by the Supply Division of the Medical Department upon the Red Cross were always, so far as possible, complied with by that organization.

In August, 1917, there was established in Paris a Medical Purchasing Agent, and, in order to conserve tonnage, effort was made, so far as practicable, to purchase in Europe so much of the needed Medical supplies as could be obtained from this source. This office was subsequently consolidated with the General Purchasing Board, American E. F., upon its establishment as the Medical Division thereof. It has operated continuously and effectively, receiving at all times the hearty cooperation of the representatives of the French and British Governments in placing contracts for goods upon the respective markets of these two nations. Up until the signing of the Armistice, contracts had been placed by this agency in European markets for goods to the value of $37,500,000.00. The material received through this source helped very materially in meeting the demands made upon the Supply Division of the Medical Department.

From time to time, as the expeditionary force grew in size, additional medical supply depots were opened in France to care for the needs of the particular localities in which they were located and embraced: (a) Base Storage Stations: (b) Medical Supply Depots: and (c) Army, Corps and Division Medical Supply Dumps.

Upon the arrival at base ports, shipment of medical supplies was made by the Medical Property Officer stationed at the docks, in accordance with orders issued by this office which were changed from time to time as stocks on hand at the various depots necessitated. There were established at Base Sections 1, 2 and 6 base storage stations, whose function it was to take into stock for storage certain items in large amounts that were not immediately needed for consumption by our troops. These depots were not issue depots, but storage stations for the warehousing of stores which were held subject to the exclusive orders of the Supply Division. However, at Base Sections Nos. 1 and 2, there were established, in addition to the storage stations, medical supply issue depots, for the purpose of supplying the demands of the hospitals and

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organizations within each of their respective sections. Intermediate Medical Supply Depot No. 2 was established at Gievres on October 10, 1917, as a part of the General Intermediate Storage Depot at that location. Advance Medical Supply Depot No. 1 was established at Is-sur-Tille on November 18, 1917, in connection with the depots of the other staff departments at that location. In general, medical supply depots were established throughout France where necessity for their presence existed. In the Zone of the Armies, Army, Corps and Division Medical Supply Dumps were established for the purpose of taking care of the medical supply needs of their respective organizations. Replenishment of the stocks of these dumps being made by shipments from the various depots, and, when practicable, by direct shipment from base ports. Effort was made at all times to conserve the available shipping facilities in the movement of medical supplies.

There was established in Liverpool, England, on August 7, 1918, an issue medical supply depot which, continuously since its establishment, has cared for the supply of troops located in England, and of that part of the American Expeditionary Forces in Russia. Stocks of medical supplies at this depot were replenished by automatic supply shipped direct from the States.

A medical supply depot was established at Cristo, Italy, on July 29, 1918, for the purpose of caring for organizations of the American E. F. stationed in Italy. This depot was stocked and replenished by train load shipments made from medical supply depots of the American E. F. in France.

For the purpose of storing and preparing for reissue field medical supplies, Field Medical Supply Salvage Depot was established at Montierchaume on December 13, 1918. At Treves, Germany, there was established on December 27, 1918, a medical supply depot (S. O. S.) capable of caring for the needs of the Army of Occupation.

With the return of troops to the States, there was established at the American Embarkation Center, Le Mans, and at headquarters, Base Section No. 5, medical supply depot capable of caring for the needs of the troops stationed, temporarily or otherwise, in these respective localities.

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C.C.W.

FINANCE AND ACCOUNTING

After authority was given by Congress to close money and property accounts in France, a unit was authorized by the Surgeon General to perform in France under the Chief Surgeon all departmental auditing functions, and there was organized a staff of seven officers and 137 men, who were secured by transfer, induction or enlistment. The soldier personnel were all carefully selected men who had had experience in banking or mercantile establishments, It was thought that this personnel would take care of the accounting needs of a Medical Department organization based on an army of 2,000,000 men.

This unit was outfitted, drilled and instructed, and journeyed to France as a separate Medical Detachment, maintaining this status until the enlisted personnel was merged with the detachment of the Chief Surgeon`s Office on May 1, 1919. Previous to this date, however, the personnel of the unit had been reduced, by transfer to other medical organizations, to six officers and 47 men, which was considered sufficient to take care of the accounting needs of the Medical Department at that time.

At the time of its organization, the division had three main functions, money

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accounting, disbursing and property accounting. At a later date the administration of the hospital fund was taken over and after the signing of the Armistice the problem of clearance for officers became an added function of great importance.

The accounts of all Medical Department disbursing officers in the American Expeditionary Forces are examined and audited. Errors and inaccuracies are taken up with the disbursing officers with a view to their correction, before submission to the Assistant Auditor for the War Department for final audit. The vouchers are examined as to their legality and whether or not they are correct Medical Department charges. Officers contracting bills are checked up as to authorization for purchases and a careful lookout is kept for duplications of payments. A record is made of all vouchers, showing such data as material, price, date of payment, by whom paid, etc., and in the case of bills for civilian employment, name of employee, when and where employed, authority for payment and increase in pay, when paid and by whom. Bills to Allied Governments have been prepared and forwarded. Up to February 15, 1919, over $160,000.00 had been billed to Allied Governments for hospitalization, and nearly $5.500.00 for supplies. Financial reports are submitted from time to time to competent authorities.

Experience has already demonstrated the value of this careful auditing of money vouchers and the recording of financial data. Accounts are in such condition when finally submitted to the Assistant Auditor for the War Department that they can be and actually have been accepted with practically no difficulty for the disbursing officer. By the running down of duplications of payment and the cancellation of vouchers, over $12,000.00 has been actually saved to the Government. The records maintained will be of great value in the prevention of fraudulent claims against the Government by reason of alleged nonpayment for services or supplies. A careful record of time elapsing between dates of purchase and payment, with a view to subsequent more prompt payment has resulted in the creating of good will between the American army and the French vendors. Arrangements were made early by which quartermaster disbursing officers at base hospitals and hospital centers might pay the accounts for services to civilians employed in the hospitals, a reimbursement from Medical Department appropriations to be made by treasury transfer. At a later date a quicker method of payment of civilian employees was authorized, namely: From the hospital funds, with later reimbursement through the Medical Department disbursing officer. When it is considered that there were 3,782 civilian employees of the Medical Department on November 30, 1918, most of whom are needy people, dependent upon their meager pay for a living, the importance of these provisions for prompt payment is readily apparent.

During the latter part of August, the auditing of hospital fund statements which comprise the record of financial operations of hospital mess officers was taken over. The importance of this work will be seen when it is known that reports are being received from nearly 700 medical organizations and that over 30,000,000 francs monthly is represented in the financial operations involved. The Central Hospital Fund has grown from 18,800 francs, when this work was taken over, to over 1,300,000 francs on March 4, 1919.

Overpayments and under-payments of local bills are corrected, warnings are issued to prevent deficits, and in some cases authority has been secured to request the liquidation of deficits from private funds, Efforts are put forward to see that French civilian bills are paid promptly.

One of the interesting activities of this section is the collection of officer`s hospital accounts. Many officers leave the hospital, forgetting to pay the small charge of $1.00 a day. Thousands of dollars have been saved the Government by a careful following up of these accounts, and their ultimate collection directly, or through the A. G. O. and the stoppage circular of the Chief Quartermaster. Several matters connected with food supply and mess management have been taken up with the Chief Quartermaster and settlements made. These include the securing to the Medical

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Department mess of the proceeds from sale of garbage, an apparently insignificant consideration, which in reality involves in the aggregate, hundreds of thousands of francs, also securing the proceeds from the sale of food stocks left when the hospital disbands, and the transfer of food stocks between organizations.

Traveling auditors are kept constantly in the field assisting officers responsible for hospital funds, and in the systematic and proper handling of their accounts. These men, having a broad knowledge of both finance and property accounting are thus able to give instructions to Medical Department clerks in the preparation of disbursement vouchers, property vouchers and returns, and in the closing of money and property accounts.

The disbursing officer of the division pays all commercial bills incurred by the Medical Department in France, all laundry accounts, and the pay rolls of civilian employees, together with doubtful vouchers referred by other Medical Department disbursing officers when these are found to be legal. In the audit before payment, duplications are checked up. A liaison was established with the Hospitalization Division and the Chief Quartermaster, by which an up-to-date list of quartermaster laundries is kept, and many hospitals near these laundries instructed to make use of them, thereby saving many thousands of dollars in laundry bills.

The property accounting section of the division and its the accounts of all property officers of the Medical Department, checking and comparing invoices, receipts and returns of all Medical Department property. This work has been seriously handicapped by the uncertain status of property accountability in the A. E. F. occasioned by confusing orders capable of a varied interpretation. Indeed, up to the signing of the Armistice these questions were in a very uncertain state. An attempt has been made however, to require a strict accountability, due regard being taken to those considerations affecting accountability incident to active warfare.

At its organization, there was established in the division what is known as a Reference Library, Here all General Orders, Bulletins and Circulars, both of the War Department and the A. E. F. are indexed and ready references compiled. Questions are referred here much as opinions are asked of lawyers in civil life. Many officers outside of the Accounting Division and in other services have benefited by the services of the Reference Library.

HOSPITALIZATION

The first requirement in hospitalization was the securing of buildings suitable for hospital purposes, properly located and with capacity to provide sufficient beds for the troops of the A. E. F. The two possible sources from which these might be obtained were to take over (1) existing buildings from the French, such as, schools, hotels, casernes, chateaus and French hospitals, and (2) by construction.

A conference was held on July 8, 1917, between representatives of the Chief Surgeon`s Surgeon`s Office, A. E. F., and the French Service de Sante with a view of projecting a study for the organization of 50,000 beds which it was the tentative intention of the American General Staff to locate in French territory during the remainder of 1917.

It was agreed that these representatives should make studies:

(a) In the region of the naval bases of St-Nazaire. La Rochelle and Bordeaux.

(b) In the vicinity of the camps at Gondrecourt and Le Valdahon.

(c) Along the lines of communication.

In carrying out this project, studies were made of prospective hospital sites in the neighborhood of the following cities: Angers, St-Nazaire, Savenay, Nantes, La Rochelle, Bordeaux, Perigueux, Limoges, Chateauroux. Tours, Cosne, Nevers,

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Cercy-la-Tour, Beaune, Dijon, Le Valdahon, Besancon, Langres. Chaumont, Neufchateau, Vittel, Martigny. Contrexeville, Rigny-la-Salles, Ourches, Epinal and Sens.

As a result of recommendations from the Chief Surgeon, based upon the above noted studies, the Commander-in-Chief on August 13, 1917, authorized the Chief Quartermaster and the Chief Engineer, in cooperation with the Chief Surgeon, to take steps immediately to provide hospitalization on the Lines of Communication for 300,000 men, having in view the increase required for two million men as follows:

By September 20, 1917, French hospitals with a total capacity of 6,250 beds have been turned over to the American Medical Department by the French Service de Sante and the following sites selected for the construction of barrack hospitals:

Confidential Memorandum No. 76, Hq. A. E. F., dated August 30, 1917, had previously directed that, where suitable buildings could not be found for the purpose, 300-bed camp hospitals would be constructed in each divisional training area.

On November 1, 1917, the C-in-C approved an altered distribution of the 73,000 beds in the first program so as to give about 40,000 in the Intermediate Section and about 20,000 in the Base Sections, upon the recommendation of a joint board of American and French officers, previously appointed to make a further study of American hospitalization.

Prior to June 1, 1918, all matters of hospitalization involving new projects and new construction required the approval of the C-m-C. The more rapid arrival of troops in France than had been expected, the many difficulties that were encountered in securing and leasing suitable hospital sites, which rendered projects involving new construction not available for six months, and the recognition of the fact that the provision

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of adequate hospital accommodations should keep pace with the arrival of troops made it necessary to adopt a more comprehensive, definite and settled policy on hospitalization, one which would provide for an automatic supply of beds computed on the total A. E. F. strength of troops in Europe. On that date, acting upon recommendation from the C. S., A. E. F., the C-in-C authorized the Medical Department to maintain an actual current bed status aggregating 15% of the total A. E. F. troops in Europe. This numerical bed allowance was to include the accommodations provided in all fixed hospitals, irrespective of type, as well as convalescent camps, computation to be made on the basis of ordinary bed capacity and was not to include temporary increases in capacity by the use of tentage in fixed formations or the temporary hospitalization provided in mobile sanitary formations.

In order that the Medical Department could make timely provision in anticipation of future needs it was authorized to utilize an additional credit of 90,000 beds over the 15% flat rate, to be made up in monthly allotments of 15,000 beds each. This authorization permitted the expansion of existing hospitals, hospital centers, and the construction of camp hospitals without reference to G. H. Q., but required all matters of hospitalization involving new projects to be referred for consideration. This authorization provided a satisfactory working basis upon which the Chief Surgeon could plan hospitalization upon a priority schedule, based upon the expected arrival of troops in Europe and made it possible to avoid any conflict of opinion as to the ratio between combat and other troops.

LOCATION

The location of American hospitals offered very considerable difficulty. It was desirable to have them near the troops, they were to serve and near the Lines of Communication. It was some time after America`s entry into the war before it was decided in what sector the Americans would operate and where the Line of Communication would be, as a result of which the Medical Department was hampered in making definite plans as to the location of hospitals.

In locating the hospitals, consideration had to be given to the transportation situation and to the problem as to whether or not the treatment of the greatest possible number of cases would be required towards the bases or towards the front. Attention had to be given to the matter of sidings for the purpose of unloading supplies and patients at the hospitals. It was necessary to locate the hospitals in such places as would not interfere with the training of troops, the location of camps and the establishing of depots.

The training Areas for the Americans had been centered around Neufchateau and the Lines of Communication extended back through Dijon, Nevers. Bourges, Tours, Angers, Nantes, St-Nazaire; and from Bourges, through Chateauroux. Limoges and Perigueux to Bordeaux: and the logical location for the greater number of A. E. F. hospitals was in these areas and along these Lines of Communication. The base ports of Bordeaux, St-Nazaire and Brest required considerable hospitalization as debarkation ports for the permanently disabled and for the prospective care of sick from troops returning to the U. S. from the A. E. F.

BUILDINGS

1. Existing French hospitals.

2. Suitable buildings by lease.

3. Construction,

EXISTING FRENCH BUILDINGS: By 1917 the French and English had almost exhausted the

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supply of available buildings in France for hospitalization and the large influx of French and Belgian refugees from the devastated areas had made heavy demands upon any remaining reserve. The buildings which could be turned over to the Americans by the French at this time were not well suited to American hospital organization and methods. In many cases, the offerings were inaccessible, in a condition of bad repair, without modern sanitary plumping, and too small and scattered to be operated to advantage under the American system of hospitalization. School buildings, hotels, casernes and French hospitals, while not well suited to hospital purposes, were secured later in large numbers, however, and were with difficulty operated as military hospitals with more or less success. French hospitals generally were small institutions of from 25 to 300 beds, widely scattered, personnel led largely by voluntary workers who lived at home. If taken over by the A. E. F., it would have been necessary to quarter the personnel in the hospitals, thereby lessening the bed capacity. The administration of small hospitals required the distribution of the sanitary personnel in small groups, which results in a very considerable increase of the total personnel required. The allowance of sanitary personnel in the American army had been fixed at a figure so low in proportion to combatant troops that their work could be effectively accomplished only in large groups. The hospital unit had been increased to a thousand beds capacity, capable of being expanded in emergency by providing crisis expansion in tents. From the beginning it was apparent that French hospitals could not be utilized to advantage by the Americans except to meet the needs of small camps or to form a nucleus around which barrack hospitals could be constructed.

HOTELS: Hotels as hospitals had not only the objections of being hard to administer, extravagant in the requirement of personnel, but were otherwise not generally suited for hospital purposes because of the numerous halls, small rooms and many stairs. Those available were very largely summer hotels without heating facilities, with insufficient water and very limited plumbing, were expensive to operate in that the rental was high, many alterations had to be made, damages were sustained to the furniture in being removed, and, when returned to the owners, complete restoration was required to be made under the French law.

Inasmuch as construction was unavoidably delayed, it was necessary to lease hotels in large numbers and operate them as hospitals in order that the sick and wounded of the fast arriving troops could be cared for, notwithstanding the many objections to their use.

CONSTRUCTION: Two standard types of hospitals were adopted for construction, Types A and B. plans for which were furnished the Engineer Department by the Chief Surgeon. These differed only in that the wards of the type B hospital were smaller. The type B usually had a capacity of about 300 beds and were utilized as camp hospitals: the type A had a normal capacity of 1,000 beds and were used for base hospital purposes. Vacant ground was left adjoining the wards for the erection of crisis expansion sufficient to double their capacity. The crisis expansion consisted of tents with floors, with water and light installations, and, when equipped, served a most useful purpose in caring for the sick and wounded in emergency.

HOSPITAL CENTERS

The necessity for economy in Medical Department personnel, the recognition of the difficulties to be encountered in the transport of medical supplies, and, particularly, the transportation of the sick and wounded from the battle line, the necessity for sidings for American hospital trains and unloading stations, the necessity for economy in building materials, led the Medical Department soon after the arrival of American troops in France to the consideration of plans for the concentration of hospitals in groups. After considerable study by the Chief Surgeon, of French, and English

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hospitalization, of the American Lines of Communication, of French ports available for the use of the American army, of transportation and personnel difficulties, of available and suitable sites for hospitals, recommendations were approved by the C-in-C for the erection of hospitals in groups which were officially designated as hospital centers.

The scheme of the organization of these centers was to have from two to twenty independent base hospitals and a convalescent camp, operate under one administrative head. It was contemplated that the larger centers, with crisis expansion and convalescent camp, provide for from thirty thousand to thirty-six thousand patients. Each center was provided with its own auxiliary activities such as Quartermaster and Medical Department Depots, laundry, bakery, motor transport park, electric light plant, detachments of Quartermaster, Engineer and Medical Department troops, with Military Police and Headquarters detachments.

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The immensity of some of these centers will be recognized when it is noted that from November 11 to December 5, 1918 Mesves Hospital Center reported daily a capacity of 25,000 emergency beds. This center, on November 16, 1918, had a total of 20,186 patients. On November 21, 1918, the number of permanent personnel on duty in that center was 8,642, On November 16, 1918, the total strength of the command in that center, including personnel on duty and patients in hospitals, was 28,828, the strength of a division of infantry.

In these centers, the hospitals were grouped to the best advantage and the system permitted the development of special hospitals to a high degree of perfection. Special hospitals were a feature of all the centers, there being, as for instance at the Savenay Center, a tuberculosis, an orthopedic and a psychopathic hospital in addition to those used for general surgery and medicine.

Highly skilled specialists were detailed as consultants on the staff of the commanding officers to supervise the proper care of the sick and wounded. These specialists were of the most skilled that America has produced, many of the leading and most prominent surgeons, neurologists, orthopedists, internists, bacteriologists and roentgenologists of our country having come to the aid of the Medical Department at the outset of the war.

Hospital Centers were of two types:

1. Those established in French buildings.

2. Constructed barrack hospitals.

Those established in French buildings consisted of groups of hotels or casernes where hospital units of personnel operated from two to seven base hospitals, with capacities varying from one thousand to sixteen thousand emergency beds. The two most prominent of these were the Toul and Vichy Centers, the hospitals of the former occupying casernes largely, and those of the latter being established in hotels at that famous watering resort.

The constructed centers as authorized were to consist of from two to twenty complete type A hospitals, with a crisis expansion sufficient to increase the capacity of each from 50% to 100% and a convalescent camp with a capacity of 20% of the normal beds of the center. The type A hospitals had a normal capacity of 1,000 beds. One base hospital personnel in emergency with crisis expansion could care for from 1.500 to 2,000 patients.

When the Armistice was signed there were five centers in operation in French buildings with a total capacity of 38,340 normal and 51,523 emergency beds, and fourteen centers operating in constructed barrack hospitals with a total capacity of 69,059 normal and 127,270 beds.

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BED CAPACITY, NOVEMBER 11, 1918

The total capacity of the 153 base hospitals, 66 camp hospitals and 12 convalescent camps operating on November 11, 1918, was 192.844 normal and 276,347 emergency beds, of which 184,421 were occupied.

INFIRMARIES

Infirmaries of from 10 to 50 beds capacity were authorized for organizations in camps, such as regiments, and for detachments, in towns where the number of troops present did not justify the establishing of camp hospitals. The function of these infirmaries was to care for the slightly sick that did not require hospital treatment. They were operated by Medical Department personnel attached to the organization served.

ADMINISTRATION

Hospital centers and independent base hospitals, for the purposes of administration, were operated under the direct supervision of the Commanding General, S. O. S.: but for purposes of supply and discipline they were under the jurisdiction of the commanding officer of the section in which they were located. The administration, supply and discipline of camp hospitals came under the jurisdiction of the section commanders. Camp infirmaries were administered and supplied under the supervision of

the commanding officer of the local troops served.

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T. H. J.

REPORT ON ORGANIZATION AND ACTIVITIES OF THE DIVISION OF

LABORATORIES AND INFECTIOUS DISEASES, OFFICE OF THE

CHIEF SURGEON

I. INTRODUCTION

When the United States entered the war, practically no information was at hand relative to the organization and activities of the laboratory services of the nations engaged. It was not possible therefore, at that time, to formulate any definite plan of organization based on their experience.

The organization, development and activities of this division may be divided, for purposes of discussion, into two periods: From June to November, 1917, and from November, 1917, to November, 1918.

II. PERIOD FROM JUNE TO NOVEMBER, 1917

A. SECTION OF LABORATORIES

1. General plan of Organization and Development: Soon after the first American troops sailed for France, five commissioned officers and six enlisted when under command of Maj. H. J. Nichols, M. C., and designated as Army Laboratory No. 1, sailed July 26, 1917, arriving at Liverpool, August 4, and in France, August 5. It was presumed that

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general laboratory supplies would be available in France and this unit brought with it only a few special items. It was ordered to Neufchateau for station. An emergency equipment was secured from the Pasteur Institute consisting of one French army model field laboratory packed in chests. The laboratory was of necessity housed in a building altogether unsuitable for the purpose: the necessary alterations were made under almost insurmountable difficulties and neither gas or electricity was available with sufficient constancy to permit their use. The following tentative plan of organization was agreed upon:

Each base hospital coming to France to bring with it trained commissioned and enlisted laboratory personnel and its initial laboratory equipment. To meet the requirements of combatant troops the following laboratories to be provided (C. S. to S. G., Aug. 12, 1917):

1 Field Mobile Laboratory for each division: 2 officers and 4 enlisted men.

1 Corps Laboratory for each corps: 4 officers and 8 enlisted men.

1 Army Laboratory: 8 officers and 16 enlisted men.

None of these units arrived prior to Nov. 1. 1917, though several Base Hospitals (Nos. 15, 18, 17, 8, 9, and others) arrived and their laboratories began operating.

2. Personnel: The personnel for the period consisted of that of Army Laboratory No. 1, and two commissioned officers and a varying number of enlisted technicians for each base hospital laboratory.

3. Equipment and Supplies: The equipment secured from the Pasteur Institute consisted of very limited material for clinical pathology and general bacteriology. With the greatest difficulty a very incomplete equipment for serologic and pathologic work was got together. A small requisition for supplies had been placed with the Supply Division before the unit left the United States, but much of this material never reached Neufchateau. A requisition was placed for the limited number of items of laboratory equipment on the supply tables of the M. M. D. [Manual of the Medical Department] and provision was made for supply of the standard cantonment laboratory equipment to corps laboratories and the army standard field laboratory equipment plus a poison-detection chest, etc., to field (mobile) laboratory units as they were ordered overseas. The Red Cross base hospitals in France had fairly complete laboratory equipment and supplies but much of it was useless, since neither sufficient gas or usable electric current was obtainable.

4. The Technical Laboratory Services: A considerable amount of routine clinical pathology was done and an autopsy service of practical value conducted. The bacteriologic work done during this period consisted mainly of a study of the organisms concerned in the prevalent infections of the respiratory tract. The Wassermann service was begun in September, 1917. The difficulties to be overcome were many. Little equipment was available, all reagents had to be prepared and standardized, only with the greatest difficulty could guinea-pigs be secured, only a low speed hand centrifuge was available and it was necessary to use a tin basin heated with an alcohol lamp as an inactivating bath. At that time it was planned that the Wassermann work for the entire A. E. F. would be done at Army Laboratory No. 1. This, however, was not possible because of delays in transmission of specimens and reports.

III. PERIOD FROM NOVEMBER, 19 17, TO NOVEMBER 1918

In the latter part of October, 1917, a division, charged with the supervision of the laboratory service for the American E. F., was created as part of the Office of the Chief Surgeon, American E. F., and Col. Joseph F. Siler, Medical Corps, was designated as director. He reported to the Chief Surgeon, November 11, 1917, and was directed to submit plans including a Section of Laboratories and a Section of Infec-

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tious Diseases. December 28, a final plan for the organization of the division was submitted and approved. January 1, division headquarters were established at Dijon, in which city the Central Medical Department Laboratory of the American E. F. was being established. In the development of this division it eventually became necessary to include two additional sections, the Section of Food and Nutrition and the Section of Water Supplies.

In the organization and development of all sections of this division it was borne in mind that the main activities of its sections, Laboratories, Infectious Diseases, Food and Nutrition, and Water Supplies, were primarily concerned with the prevention and control of epidemic diseases, the maintenance of the physical well-being of the troops, investigations furthering the prompt return to duty of sick and wounded, and the inspection at autopsy of a portion of the professional services rendered. Hence, it quite naturally became an integral part of the decision of Sanitation and Inspection of this office.

When the office of this division was established at Dijon the Office of the Chief Surgeon was located at Chaumont and no great difficulties of coordination were anticipated. Later, the Chief Surgeon`s Office was transferred to Tours and, not infrequently, there was considerable delay in the transfer of personnel as all orders for such transfers emanated either from General Headquarters, or from Headquarters, S. O. S. Such delays were occasioned by unavoidable congestion of telegraph and telephone lines, necessary censorship regulations and irregular mail facilities. The remedy was the delegation, to the Director of the Division, of authority to issue orders to meet emergencies and to fill existing vacancies from the reserve staff on duty at the Central Medical Department Laboratory. The necessary authority was granted and the efficiency of the service thereby greatly increased, particularly in the early investigation of epidemic diseases and in meeting combat emergencies.

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A. SECTION OF LABORATORIES

1. General Plan of Organization and Development: The Section of Laboratories was charged with the following general duties: (2) Representative of the Chief Surgeon in all matters relating to the laboratory service: (b) Organization and general supervision of all laboratories and the assignment of special personnel: (c) adviser to the Supply Division, Chief Surgeon`s Office, in the purchase and distribution of laboratory equipment and supplies: (d) publication of circulars relating to standardization of technical methods, collection of specimens and other matters of technical interest to the laboratory service: (e) collection and distribution of literature relating to practical and definite advances in laboratory methods: (f) collection and compilation of statistics on routine and special technical work done in laboratories; (g) instruction of Medical Department personnel in general and special laboratory technic; (h) distribution and replenishment of transportable laboratory equipment: (i) cooperation and coordination with the Chemical Warfare Service, American E. F.; (j) supervision of the collection of museum specimens and photographic records of Medical Department activities.

The following officers were assigned to duty in this section to supervise its activities: Lt. Col. Geo. B. Foster, Jr., M. C., Lt. Col. Wm J. Elser, M. C., Lt. Col., M. C., Lt. Col. Louis B. Wilson, M. C., and Major W. J. MacNeal. M. C.

From time to time circulars of instruction and memoranda covering matters of information have been prepared in this section. The policy was adopted of having all circulars of general interest to the Medical Department at large issued from the Office

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of the Chief Surgeon. The director of the division was authorized to prepare and distribute directly special letters and circulars of instruction relating to the organization and activities of the division. The original plan of organization contemplated the following types of laboratories which, with the number operating in each month in 1918, are shown in the following table:

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(a) Central Medical Department Laboratory: This laboratory was established at Dijon, Jan. 1, 1918, by officers from Army Laboratory No. 1, Neufchateau. The building for the purpose was donated by the University of Dijon at a nominal rent of one franc per year. The entire plant occupied eighteen buildings, large and small. The average personnel on duty between June and November, 1918, was 24 officers, 93 enlisted men, and 23 civilian employees. The important activities of the laboratory, in contrast to other types, line in the following features: (1) The instruction of laboratory officers for service elsewhere in the American E. F.; (2) the standardization of bacteriologic methods; (3) the preparation of supplies for other laboratories; (4) the conduct of research looking toward the improvement of medical and surgical treatment of cases in the field; (5) the organization of trained teams of officers and equipment which could be sent on short notice to investigate and advise on the causes

* Includes laboratories functioning prior to January 1, 1918.

** In July, 1918, it became necessary to furnish laboratory personnel and equipment for American Red Cross Hospitals functioning as hospital units with the American E. F.

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and remedy for epidemics. Routine laboratory examinations were also conducted here but the great importance of the Central Laboratory rests in the development of the above noted phases.

The activities of this laboratory may be summarized as follows:

(1) During battle activities this division manufactured many thousands of liters of gum-salt solution for intravenous use in the resuscitation of the seriously wounded. The laboratory also prepared standard solutions and reagents for transportable laboratories and such other laboratories as were not equipped to prepare their own.

(2) In the Laboratory of Surgical Research experimental studies on animals were fruitful in their bearing on the prevention of wastage from battle casualties. The cause, prevention and treatment of surgical shock were approached experimentally here and the results applied practically at the front during the Chateau-Thierry and subsequent offensives.

(3) Perhaps the most important work of the laboratory from the practical point of view was that concerned with the laboratory and epidemiologic investigation and control of communicable diseases. Specially trained commissioned and enlisted personnel with mobile equipment were held in reserve at this laboratory for the prompt investigation of epidemics or threatened epidemics anywhere in the American E. F. By bacteriologic detection of early cases of communicable diseases, mild cases missed clinically, and carriers, this laboratory did much to prevent the spread of influenza, pneumonia, diphtheria, meningitis, and enteric infections, and thus decreased the wastage concomitant with outbreaks of these diseases when not detected early and effectually controlled.

(4) The supply division of this laboratory was charged with the assembling, equipping and issuing transportable laboratory equipment to mobile units: replenishing expendable items and replacing those that had become unserviceable; issuing to mobile units and camp hospitals various culture media and reagents required for bacteriologic work in the field: and issuing to all Medical Department units in the geographic region served by the Central Medical Department Laboratory the various biologic products used in the diagnosis, prevention and treatment of infectious diseases. During the period of active participation of our troops at the front, the greater portion of these supplies was delivered by courier service, necessitating the constant operation of numerous camionettes, trucks, and motor cycles.

(5) From its inception this laboratory conducted courses of instruction in professional subjects. One hundred and fifty-eight student officers were given two-week courses of instruction in the bacteriology of war wounds: while in the Laboratory of Surgical Research a six-day course, repeated weekly, was given to prospective members of shock teams which covered the experimental evidence that had been gathered as to the cause, prevention and treatment of surgical shock, and its practical application to the resuscitation of the seriously wounded. Selected student officers in lesser numbers were also given special courses in epidemiologic laboratory methods, in serologic work, and other laboratory procedures.

(b) Base Laboratories (Sections of the S. O. S.): In the original plan of organization provision was made for one base laboratory for each section or other subdivision of the S. O. S. It was contemplated that these laboratories would be located, when possible, at the headquarters of each section and under the direct control of the surgeon of the section, They were to be housed in permanent buildings and completely equipped for general laboratory work. It was intended that these units should afford general and special laboratory facilities for troops in their sections not cared for by local laboratories. Their activities were to consist of clinical examinations, general and special bacteriology, general and special serologic work, the distribution of culture media, laboratory examinations of water supplies, the investigation of outbreaks of epidemic diseases and such other activities as the section surgeon might deem advisable.

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(c) Base Laboratories for Hospital Centers, and (d) Hospital Laboratories for Hospital Units Serving in Centers: It was planned to organize in each hospital center, one base laboratory for the center and one small clinical laboratory for each base hospital unit. The base laboratory was to be a part of the headquarters organization and its commanding officer, the representative of the commanding officer of the center, in all matters relating to the laboratory service. Its personnel was to consist of selected officers and enlisted technicians drawn from the hospital units comprising the center and its equipment was to be drawn from the same source.

(e) Base Hospital Laboratories, for Base Hospitals Operating Independently: The establishment of these units presented no difficulty as, in the organization of the base hospitals, provision was made for laboratory personnel and equipment. The installation of these laboratories was a matter of local administration. The activities of these units have been in general all routine clinical and anatomic pathologic work, and all bacteriologic and serologic work for the hospital.

(f) Camp Hospital Laboratories: In the early stages of development of the American E. F., it was contemplated that camp hospitals would retain only patients suffering with slight ailments, all others to be evacuated promptly to base hospitals. It was presumed that most of these hospitals would require only a clinical laboratory service. As a matter of fact, the functions of the camp hospitals varied widely: some functioned as base hospitals, others were little more than evacuating infirmaries, and still others varied between these two extremes. An attempt was made to furnish these hospitals with laboratory service in accordance with their requirements. In November, 1918, there were fifty-eight camp hospitals operating with the American E. F. and of these there is record of laboratory service in fifty-one.

(g) Evacuation, and (h) Mobile Hospital Laboratories: The original conception of the organization and activities of the Laboratory service for these units was based very largely on the experience of the Allies after three years of trench, or stationary warfare. It was anticipated, however, that this type of warfare would change to one of movement and the laboratory equipment for these units was placed in chests capable of being packed or unpacked quickly and easily transportable. The equipment provided

permitted the performance of all types of clinical and general bacteriologic work.

(i) Army Laboratories: In the original plan of organization a laboratory unit for each army was considered but it was thought best to await further developments before making definite plans. Until July, 1918, all laboratory investigations of outbreaks of epidemic diseases in Advanced Section and Zone of the Advance were covered by personnel and motor laboratories from the Central Medical Department Laboratory or Army Laboratory No. 1.

During the Chateau-Thierry offensive, a motor laboratory car was attached to the I Corps for the investigation of epidemic diseases and it was understood by the Chief Surgeon, First Army, that this car was available for use anywhere in the First Army. The work done by this unit in the Chateau-Thierry sector proved to be of value, demonstrating that much of the diarrhea and dysentery occurring in that sector was bacillary dysentery, typhoid, and para-typhoid.

In August, 19 18, it became evident that there should be attached to each Army a laboratory unit equipped to do general bacteriology, serology, and examinations of water supplies. A transportable laboratory equipment for the First Army was assembled and shipped to Toul just prior to the St-Mihiel offensive. Special personnel was not immediately available and the equipment was installed at the Toul Hospital Center where the laboratory operated for the center and also met the emergency requirements of the First Army.

During the early phases of the Argonne offensive, a motor laboratory was attached to the I Corps of the First Army.

When the Second Army was formed, a motor laboratory car was attached to the Office

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of the Chief Surgeon, functioning under the Sanitary Inspector of the Army in the investigation of epidemic diseases.

(j) Divisional Laboratories: These units consisted of two officers and four enlisted technicians, one such unit being attached to each division. The unit constituted a part of the sanitary staff of the Division Surgeon to be used by the divisional sanitary inspector in the investigation and control of epidemic diseases and in inspection and supervision of sterilization of water supplies. The laboratory equipment furnished these units permitted only the performance of routine clinical examinations. No equipment for general bacteriology was issued, the intention being that this would be done in evacuation and mobile hospitals. Several efforts were made to secure transportation for it and the inclusion of the personnel and transportation as a divisional unit was recommended by this office in the proposed revision of the Tables of Organization under consideration during the summer of 1918. This proposed revision had not been approved on the date of the declaration of the Armistice. Had even a motorcycle been available for these units, there is but little doubt that water discipline would have been better throughout the divisions with a consequent decrease in the prevalence of typhoid-paratyphoid fevers and dysentery.

2. Personnel: The personnel of this division consisted of: Medical officers with special training in laboratory procedures, sanitation and epidemiology and with other special qualifications: officers of the Sanitary Corps who were sanitary engineers, who had special knowledge of food and nutritional problems, who were competent to make field surveys and laboratory examinations of water supplies, who had general or special qualifications in laboratory procedure, who were artists, photographers, executives, or with other special qualifications: and enlisted men, many of whom had special technical training. While in May, 1918, less than 140 commissioned officers were engaged in activities under the supervision of this division, by November, 1918, this number had increased to 683. Their distribution by corps, grade and general duties is shown in the following table:

3. Equipment and Supplies: One of the greatest difficulties that confronted the laboratory service in the early months of the war was a shortage of equipment and supplies.

With the exception of the initial equipment of three of the larger laboratories and a few base hospitals, laboratory supplies from the United States were not available for issue in appreciable quantities until a month before the Armistice. Furthermore, laboratory supplies in large quantities have never been available by purchase in France.

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It became apparent early that it would be months before the automatic supply of laboratory apparatus from the United States would become available and that it was necessary to reduce all equipment and supplies to the absolute minimum consistent with efficiency. Lt. Col. Geo. B. Foster, Jr., the Commanding Officer of the Central Medical Department Laboratory, designed a transportable laboratory in which the necessary laboratory equipment and supplies were reduced to approximately 150 items. The equipment and supplies were placed in eight chests so designed that they were capable of expansion in numerous ways so as to meet the essential needs of any type of laboratory. In March 1918, this officer was sent to England to place orders for, and supervise the manufacture of these laboratories. The initial order was for 100 complete laboratories. Deliveries began a month later and each division mobile hospital and evacuation hospital arriving in France was given its equipment before entering the Zone of the Advance. This transportable equipment was also utilized with every satisfactory results in many camp hospitals, base hospitals and even in base hospital centers and base laboratories, pending the arrival of stationary equipment. The satisfactory service that this equipment has given under most varying circumstances leads to the conviction that similar equipment should be procured and stocked in field medical supply depots in time of peace for future expeditionary forces.

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B. SECTION OF INFECTIOUS DISEASES

The section was successively under the charge of Lt. Cal. R. P. Strong, Lt. Col. Hans Zinsser, and Major Ward J. MacNeal.

The conception of the proposed activities of this section were early indicated as follows:

The function of the subdivision of Infectious Diseases is to provide an instrument for the epidemiological and bacteriological investigation of transmissible diseases among troops of the American Expeditionary Forces. It constituted, therefore, a direct liaison between the Division of Sanitation and Inspection and the laboratories and is grouped with the latter only because its activities require the occasional mobilization of laboratory facilities, and because its personnel should be capable of directing on the spot, any laboratory work which the thorough study of any given situation may require. While operating from the laboratories as a basis, therefore, this section constitutes actually a part of the machinery of sanitation.

In Circular No. 40, issued from this office July 20, 1918, the duties of this section were more specifically outlined.

The officer responsible for sanitation in a division was, as hitherto, the Sanitary Inspector, who functioned as an assistant to the Division Surgeon. All ordinary matters of general sanitation were attended to by him with the assistance of two officers, one the division laboratory officer who had charge of a simple laboratory, equipped for clinical pathology but insufficiently supplied for extensive cultural work. The other assistant was the divisional water officer, whose training had been largely in water examination but who had had some training in general bacteriology as well. Later in the work much of this personnel received a short course of instruction before being assigned to a division.

It was intended that the divisional laboratory officer should act not only as a technical laboratory worker for the division but should assist the Sanitary Inspector in making epidemiologic surveys and sanitary inspections. It may be said, in passing, that in many cases this hope was disappointed because of the lack of transportation.

In order that such service might be rendered promptly and efficiently, Bulletin

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No. 32, G. H. Q., was issued, which authorized Chief Surgeons of organizations to communicate directly by telephone or telegraph with the Director of Laboratories and Infectious Diseases when assistance was needed. Mobile laboratory cars, constructed and equipped (with some modifications) according to the English plan, manned usually by one commissioned officer, a driver and a technician, responded to these requests either from the Central Medical Department Laboratory or from Army Laboratory No. 1, according to the area from which the request was received.

Subsequently, as American troops were now concentrating in the Advance Section and in the Zone of the Advance, and more and more divisions were beginning actively to participate in combat, the desirability of a further system of daughter organizations to be split off from the Central Office of the Section of Infectious Diseases, and based upon army corps or field army units, arose. As the result of experiment it was decided that the field army unit was the more desirable in which to construct an organization.

Accordingly, a sanitary inspector, Lt. Col. Hans Zinsser, was assigned to the Second Army and there was planned and put into operation a system more or less similar to that already in vogue in the sections of the S. O. S., but with modifications to meet the problems of combat and mobile troops. In consequence the sanitary organization of a field army, likewise, became largely independent, except for personnel and laboratory supplies, of the central office.

C. FOOD AND NUTFUTION SECTION

The steps leading to this organization may be briefly summarized as follows: In August, 1917, there was organized in the Office of the Surgeon General a Division of Food and Nutrition and its officers were authorized by letter of the Secretary of War dated October 16, 1917, to inspect food supplies in camps, to endeavor to improve the mess conditions, and to study the ration suitability and food requirements of the troops. Officers of this division were sent to camps in the United States and while in camp gave instruction to cooks, mess officers, and unit commanders and also made extensive studies of ration requirements and suitability. In March, 19 18, it was decided to send a group of these officers to the A. E. F. to organize similar work in France. To this end, on March 7, six officers left the states for this purpose. This party proceeded first to England and remained there from March 16 to April 2. Through the courtesy of the British A. M. C., opportunity was afforded to make a thorough study of the British rationing system and a preliminary survey was made of the American rest camps in England. As a result, one officer was left in England to continue the work there and on April 3, the other five officers proceeded to France, reporting to the Chief Surgeon at Tours on April 12. It was decided to send the officers, one each to a different section of the S. O. S. for a preliminary study of conditions, and one to Dijon for duty in the Advance Section under the direction of the Director of Laboratories, under whom the Section in Food and Nutrition was later established. The other officers were assigned to the Chief Surgeons of the Intermediate Section and Base Sections 1, 2 and 5. Each officer visited and inspected organizations in his sector and reported his observances. Later the group came together at Dijon. The following extract from the report of Major P. A. Shaffer, the Director of the Section, summarizes the results of this preliminary survey:

The results of this preliminary inquiry and of the reports and conferences led to the conclusion that although the garrison ration being issued generally to troops was adequate in total food material and the quality of the articles as a rule good, in many places the feeding of the men was poor, due in large part to the unfamiliarity of mess sergeants and cooks with the ration in kind

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and to their general inefficiency under the conditions existing in France, to a lack of interest in or attention to mess conditions by company commanders and higher officers, and in the Advance Section where daily automatic issue was in force, to the issue of too many components on a single day, in correspondingly small amounts, i. e., to an unwise issue system. There was nearly everywhere great waste of food with consequent underfeeding. The rapid growth and multiplication of camps, the scarcity of material for construction of kitchens and mess shacks, delays in transportation and the scarcity of refrigerator cars for fresh meat produced conditions to which officers and men, coming from relatively well equipped camps in the United States found it difficult to adapt themselves. Also the composition of the rations issued appeared in some particulars not suited to the field service.

As a result of this conference it was decided by the Director of Laboratories to establish, with the consent of the Chief Surgeon, a section of Food and Nutrition in that office to which were assigned the following duties: (a) Representing the Chief Surgeon in matters affecting the nutrition of the troops; (b) investigating army food requirements and consumption; (c) acting in an advisory capacity in the formulation of rations and dietaries for the American E. F.; (d) inspecting food supplies and mess conditions with troops, hospitals and prison camps; and (e) giving instruction in food inspection and mess handling, mess management and other measures for the maintenance of nutrition and conservation of food.

The functions of the section have fallen naturally into two classes: First, of a technical and scientific character having to do with a general study of the food situation, the inspection and analysis of food, the investigation of the suitability of the ration and the formulation of desirable changes on the basis of food requirements and the nutritive value of food stuffs, and advisory relationship with the Chief Quartermaster and General Staff on these matters: and second, field work in mess inspection and instruction for the improvement in the handling and preparation of food.

To carry out the second phase and to secure data for the first phase, necessitated an organization of field parties. These were organized through the cooperation of G-5, G. H. Q., and consisted of an officer and instructor, mess sergeants and butcher supplied by the Quartermaster Department. These parties served with combat divisions, in sections of the S. O. S. and wherever there were detachments or other units of troops. They studied the needs at first hand and continued active instruction to mess officers and cooks and sergeants in the field. Their reports formed the basis for the formulation of ration recommendations and this section wrote G. O. 176, which was adopted with few changes by the Quartermaster General and G. H. Q.

A food laboratory was established at the Central Medical Laboratory and this has conducted analyses for the Quartermaster Department on varied materials submitted for this purpose.

Another phase of the work to which this section has contributed was a series of investigations in connections with the bread making for the army in which one of our officers cooperated with the bakery service. This officer later made inspections of factories of the American E. F. and through his efforts succeeded in producing satisfactory sanitary conditions in the French factories manufacturing food for the American E. F. The section also cooperated with the Quartermaster in saving beef through proper instruction to medical officers and others as to its proper handling. It has through its field officers also kept the Quartermaster informed as to ration shortages and by communicating directly with regulating officers and the Supply Department of the Quartermaster Department, been able to secure prompt remedy of these conditions in many places. In addition to field instructions, it has cooperated with G-5 in planning the formulation of schools for cooks and mess sergeants and the automatic menu maker is part of its contribution

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to this sort of work. One phase of its work has been the investigation of needs of labor troops and advice to the Quartermaster on this subject.

In this work, the section has utilized a personnel of some forty officers, largely supplied from the Food Division of the Surgeon General`s Office. In addition, it has had the assistance of some sixty mess instructors and butchers from the enlisted personnel of the Quartermaster Department.

D. THE WATER SUPPLY SECTION

The Water Supply Section, under the direction of Lt. Col. Edward Bartow, San. Corps, was organized early in 1918 in accordance with an agreement between the Chief Surgeon, American E. F., the Water Supply Officer, Office of the Chief Engineer, American E. F. and the Water Supply Officer, Office of the Chief Engineer, Lines of Communication.

Officers and enlisted men of the Sanitary Corps were detailed as representatives of the Medical Department for service with the Engineer Department Water Supply Service, A personnel, familiar with water purification and control was chosen from men already present in the American E. F., including officers and men attached to the 26th Engineers, Water Supply Troops, the Sanitary Corps personnel attached to the 301st and 302d Water Supply Trams, and the Division Sanitary Inspectors of Water. Additional men were obtained from the United States. At the time of the signing of the Armistice, the section had expanded to an organization having eleven laboratories or sections of laboratories in the S. O. S. and five transportable or mobile laboratories in the Zone of the Advance. The personnel consisted of nearly 100 officers and more than 100 men devoting their time almost exclusively to the control of the quality of water supplies.

Approximately 150 water purification or sterilization plants, were under the general supervision of the Sanitary Corps officers. Laboratory work was handicapped by delay in receiving apparatus and chemicals.

Sanitary Inspectors of Water acting as assistants to the Division Sanitary Inspectors have been made responsible for the quality control of water furnished troops. This has included sanitary surveys and the supervision of chlorination of water in Lyster bags and water carts whether the divisions were in the Training Areas or in the Zone of the Advance.

E. SUMMARY

The work of this division may then be summed up by saying that each of its four sections, Laboratories, Infectious Diseases, Food and Nutrition, and Water Supplies, has attacked its special problems promptly, vigorously and intelligently. Though each at all times has been greatly undermanned and handicapped for lack of personnel, equipment, supplies, and transportation, in no instance has it been defeated in its attempts to grapple with the serious sanitary and health emergencies of the American E. F. An inestimable amount of sickness has been prevented. Though, in the presence of unavoidable conditions, serious epidemics of communicable diseases have developed, in most instances the flames have been extinguished before they became a conflagration. Only influenza has leaped all barriers and that has overwhelmed the civilized world. The wounded have been infected but the infective agents have been found and the means of neutralizing their effects pointed out. Men have died before their condition was rightly understood, but even they have not died in vain since the laboratory has gleaned the naked truth concerning them and placed it where it has saved others. And yet, when the war ended the division was but catching its stride, a few months more and this most efficient organization for the combat of preventable disease and the maintenance of high

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standards of medical and surgical diagnosis and treatment under war conditions would have been perfected to a degree not hitherto known.

REPORT OF ACTIVITIES, PERSONNEL DIVISION

In describing the activities of the personnel division, it is necessary to consider the Office of the Chief Surgeon, American E. F., of the Chief Surgeon, L. O. C., the Liaison Officer in England, and the Special Services.

The medical personnel of all American units in France, England and Italy was under the supervision of the Chief Surgeon, American E. F.

On March 21, the Chief Surgeon`s Office moved from Chaumont to Tours and from that time until the date of the Armistice functioned in Tours as a part of Headquarters, S. O. S. Orders were issued through the S. O. S. Headquarters covering the medical personnel on duty under the jurisdiction of the S. O. S., and through G. H. Q. for personnel not under the jurisdiction of the S. O. S.; that is, personnel belonging to army, corps, divisions, and the Army Ambulance Service.

Replacements were handled entirely through the S. O. S., the Medical Casual Depot being at Blois until July 1918, when it was transferred to the 1st Depot Division at St-Aignan. This transfer was made with a view to establishing a short course of training in field work at the 1st Depot Division: but it was never possible to carry out this plan because of the constant shortage of Medical Department enlisted personnel which necessitated using all available men at all times, the longest stay in the depot being as a rule not more than two weeks. This change from Blois to St-Aignan was a disadvantage in that it caused some delay in getting officers and men shipped to points where they were needed at once. This delay was mainly due to lack of transportation.

The main feature of the work of the personnel division has been the effort to keep the machinery going with a constantly increasing shortage of medical personnel. This shortage, while marked, was not critical until June 1918, when the activities of the American army at the front increased so tremendously. The Paris Group had hardly been organized when it became apparent that the fears of the Medical Department as to the shortage of personnel had been justified: and in an official investigation of the evacuation of wounded from the Paris Group, the Inspector General recommended: That further provision be made for emergency reserve surgical teams, and that steps be taken to secure an increase of the sanitary personnel, both commissioned and enlisted.

The Chief Surgeon, in a memorandum of July 30, 1918, to G-4, on this matter, brought out clearly the situation as regards the shortage of personnel: The present surgical teams are obtained by stripping the base hospitals to a considerable extent of their surgical staffs at the very time when their services are needed at the hospitals because of the active evacuation of wounded from the front.

Between June and November, 1918, replacements came in increasing numbers, but combatant troops came in much greater proportion and heavy casualties occurred in the great battles of those months. Consequently the strain on the Medical Department, instead of being relieved, became intensified. The situation was, however, saved by the fine quality and self-devotion of the medical personnel, which in many hospitals worked to the limit of human endurance. Operating surgeons and nurses were on duty at times as long as seventy-two hours at a stretch without opportunity to sleep more than a few minutes now and then between operations. Some base hospitals, originally planned to care for 500 patients, were forced to take as many as 2,100, with very small additions to their original personnel. Practically every base hospital cared for 1,500, and some of them as high as 3.000 patients. One hospital center with a total nursing staff of 110 nurses, cared for 4,500 patients.

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Priority: In the priority schedule adopted in August 1917, the Medical Department was allowed a total strength of 7.65% of the total strength. This was slightly over half of the strength estimated by the Chief Surgeon as necessary, and experience has proved that it was much too small. This percentage was, however, not reached until October 1918.

The percentage on which estimates submitted by the Medical Department were based, were in the spring of 1918, stated at the following:

a grand total of 11.6% of the American Expeditionary Forces exclusive of the Medical Department. This is believed at to be a fair estimate of the number which would insure that the Medical Department would be able to meet its obligations properly, and if the given could have been reached there is no doubt that it could have faced almost any emergency with confidence.

On May 22, 1918, an analysis of the state of the Medical Department propriety made by the Medical Department representative under G-1 at General Headquarters showed a total personnel shortage of 13,671, while the total Medical Department strength was only 48,768; thus showing the Medical Department 30 per cent below the low percentage allowed by the priority schedule. In units the shortage on approved priority included the following:

In August the shortages on approved priority were much larger and a cable sent on August 10, called for a total Medical Department personnel of 21,700 to be given priority insofar as possible over divisional units. In the personnel were the following units:

On September 30, the total shortage on approved priority was 26,497, including:

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The personnel expected in October amounted to 34,868, while only about 1,800 arrived.

On November 11, the shortage on approved priority was as follows:

The following tabulation covering Medical Department personnel from June 1 to December 28, 1918, shows the monthly totals, which in some cases are only approximate on the date given as mail reports on arrivals of personnel were often delayed:

The largest total of personnel recorded is that of the week ending January 11, 1919, when 17,330 officers, 10,008 nurses and 145,386 men were on our records. These totals should really show as of the first week of December, as no Medical Department arrivals were reported for that date, but due to delay in obtaining reports of arrivals they were not finally transferred to the records of this office until the week ending January 11, 1919.

Promotions: Very few promotions were made during the first 10 months of the existence of the American Expeditionary Forces, because a definite and methodical scheme of promotion which would as nearly as possible, do justice to all, had to be found before the Commander-in-Chief would be willing to make promotions except in very exceptional cases. Such a scheme was finally worked out and presented to the Commanding General, S. O. S., May 17, 1918, by whom it was approved, May 19, with the following endorsement:

Heretofore I have generally disapproved recommendations for promotions in the Medical Corps because they have come as isolated cases and presented no facts by which a reasonable judgment could be formed as the relative merits of the particular case in comparison with the entire body of medical officers. As this paper presents a plan which appears to me to be comprehensive, legal and reasonable, I approve it and recommend that it be adopted as the basis for promotions of officers in this corps serving with the A. E. F. in Europe.

This plan was for the application of the principle of selection for the two lower grades by means of a roster on which each man took his place according to a roster number obtained by the addition of certain factors which were:

1. Age, which represents in a general way professional experience.

2. Military Service, which represents military experience.

3. Character of Service and Special Qualifications, which are given a numerical value in accordance with a special report made in each case by the immediate superior officer.

This scheme was finally approved by the Commander-in-Chief on June 27, 1918.

Although approved in principle the practical results of the application of this scheme were, during the summer of 1918, far from giving practical relief. The necessity of having to refer all promotions to Washington, with the inevitable delays which they experienced in the War Department, would have made any system ineffective, even if prompt action could have been secured at General Headquarters. A great step forward was taken when the Commander-in-Chief was authorized (G.O. 78, War Department, 1918) to make promotions in the A. E. F., subject to confirmation by the War Department. Owing to an unfortunate misunderstanding, the benefits of this order were, not, extended to the Medical and Dental Corps until November 7, and the stoppage of all temporary promotions after the Armistice put a stop to promotions almost immediately.

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Although it does not properly belong to this writing, which covers the period up to and including the signing of the Armistice, it is nevertheless of interest lo know that before this book went to press there was forwarded on January 16, a list of recommendations for promotions embracing 85 lieutenant colonels to grade of colonel, 282 majors to grade of lieutenant colonel, 932 captains to grade of majors and 2,457 lieutenants to grade of captain, all of whom were promoted during the month of February, with the exception of regular officers and of the temporary officers, who had, meanwhile, left France for the United States. This list did not by any means exhaust the vacancies which existed under the law in the Medical Corps, as there remained 241 in the grade of colonel, 293 in the grade of lieutenant colonel, 1,151 in the grade of major, and 1,323 in the grade of captain, still unfilled.

Personnel Division, Office of Chief Surgeon, L. O. C.: The first division of the Office of the Chief Surgeon, L. O. C., into personnel, supply and sanitation divisions was made during September, 1917. The personnel division handled all medical personnel of the L. O. C. directly until January, 1918, when the control of personnel was decentralized and the sections handled all personnel in the sections except that of base hospitals. A Medical Replacement Camp at Blois was planned and was practically organized when it was taken up as the Casual Officers` Depot: but still handled Medical Department casuals.

The supply of officers and men for medical replacements was very small up to September 30, 1917, when about 650 men landed. Due to the lack of a replacement camp, it was necessary to assign these soldiers in groups to various base hospitals which had already arrived and had barrack space to accommodate them. Another casual detachment of 250 men arrived in November, 1917. This was the last detachment of any size which arrived for several months and it was only after urgent appeals had been sent to The Adjutant General that casuals began to arrive in the latter part of February and March 1918.

The greatest difficulty during January and February of 1918 was in tracing Medical Department men who arrived in France and it was estimated that practically a thousand men badly needed by the Medical Department succeeded in transferring to the line while passing through the 41st Division, which, at that time was acting as a depot division. Another factor which led to a great need of Medical Department soldiers, was lack of labor troops which could be used in the construction of base hospitals. This necessitated the use of the Medical Department soldiers attached to base hospitals in hastening the construction of the buildings and there were complaints from all sides of the lack of sufficient labor to handle the construction as well as the routine work about buildings already constructed.

The situation, on the arrival of Base Hospital No. 34, December 27, 1918, was such that this hospital for a time practically ceased to exist as a unit, the personnel being scattered in camps located in many different parts of France. At one time this hospital had personnel in eleven different stations.

The growth of the expeditionary forces constantly led to an increase in the number of camps and camp hospitals. The policy of General Headquarters was that no permanent personnel should be supplied camp hospitals. This led to the use of the medical personnel attached to units in training at the camps and when these units left, the medical personnel naturally had to accompany them and it was therefor necessary that a certain percentage of permanent personnel be assigned to each camp hospital. The policy mentioned above was later changed and estimates made for permanent personnel for all camp hospitals. This subject was presented very forcibly by Major General Francis J. Kernan in his letter to the Commander-in-Chief, under the date of February 8, 1918. In this letter he makes the following statements:

I may say that no organization arrives in France without a large distribution of measles, mumps, meningitis, and scarlet fever. It requires personnel

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to decently care for these unfortunates and I am sure that they are at this moment getting the care they might have were the personnel available.

This undoubtedly was the only solution to the difficulties arising through the use of personnel passing through camps, in handling sick in camp hospitals, as their interest in the camp hospitals was not great and the interference in their training for field work was a marked handicap to them upon their departure for the front. Also when an organization left camp it naturally desired to take its medical personnel with it. But this could not be done without an abandonment of the sick remaining in camp hospitals.

The Liaison Office in London: The Liaison Office in London was established in June, 1917, for the purpose of handling questions concerning the officers, nurses and men who were loaned to the British. A constant average of approximately 800 officers, 600 nurses and 1,100 men of the Medical Department of the American army was on duty with the British.

The six Base Hospitals, Nos. 2, 4, 5, 10, 12 and 21 arrived in May, 1917, and the casual officers arrived in June, July, August and September of 1917. The officers connected with the base hospitals serving at General Hospitals of the B. E. F. were in much closer contact with the American army than those casual officers assigned to British units. There was great difficulty at first in reaching casual officers, and due to their ignorance of Regulations, General Orders, etc., they very seldom reported change of status and in many cases officers served with the British for months before the Chief Surgeon`s Office had record of them.

It was very difficult to obtain recommendations concerning their promotion and a great many of them have come to feel that the Medical Department did not care sufficiently for their interests. It undoubtedly would have led to smoother work if there had been a representative of the Medical Department attached to the British Headquarters in France for the purpose of keeping in touch with these casual medical Officers and informing them of the various orders which might effect their status.

The Special Services: The special services were established in September, 1917, with headquarters at Neufchateau. The eight branches: surgery, medicine, x-ray, neuro-psychiatry, skin and G. U., eye, and ear, nose and throat each had a director. This designation was later changed to Senior Consultant. The consultants, while handling the professional supervision of the work of medical officers specializing in their branches, were in fact also acting as agents for the personnel division and assignments recommended by them were approved in practically all cases, the only exceptions being such officers as might be held in certain positions for disciplinary reasons.

The orders issued on the recommendations of the senior consultants were at first issued through the personnel division of the Chief Surgeon`s Office, but later because of the large increase in work involved, were issued through the Director of Professional Services. This led to complications at times because of the possibility of G. H.Q. and S. O. S. Headquarters issuing conflicting orders on the same officer.

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The Sick and Wounded Division of the Chief Surgeon`s Office was established August 22, 1917. At that time, it consisted of one medical officer and two enlisted men whose function was to audit the few sick and wounded reports that were received from the scattered units then in France, before forwarding them to the Surgeon General of the Army. On November 11, the Sick and Wounded Division occupied offices in a large three-story building in Tours, an old French residence which was altered and renovated for the purpose. The personnel consisted of one medical officer, five officers of the Sanitary Corps, 86 enlisted men and 80 French women.

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As early as September 1917, when the American troops began to arrive in France in large numbers and the period of activity increased and changes in organization and replacements were being inaugurated, it was realized that the peace-time method of reporting the sick and wounded, as called for in the Manual for the Medical Department, was inadequate and unsuitable to the conditions confronting the American Expeditionary Forces. Orders for special reports and information of all sorts were received from the Commander-in-Chief, General Staff and other agencies of the A. E. F., which could not be filled. The Chief Surgeon being convinced of the impossibility to furnish the required information under the old system and the impracticability of its being carried on in times of active combat at the front, appointed a Board of Medical Officers to revise the method to meet the needs of the A. E. F.

About this time The Adjutant General`s Department was undertaking the organization of the Statistical Section (later became the Central Records Office). Their program required numerous and elaborate reports from hospitals. The necessity for coordination in this matter was obvious in order to reduce the clerical work of hospitals to a minimum and at the same time furnish the necessary information to both The Adjutant General and Medical Department.

The members of the board appointed by the Chief Surgeon were Colonel Fife, Colonel Tuttle, and Lt. Colonel Harmon. All of these officers had had experience in large British hospitals in which great numbers of patients were received, treated and evacuated. After careful study and frequent consultation on the subject with authorized representatives of The Adjutant General`s Department, a system was proposed which in brief comprised:

(a) Field Medical Card and Envelope, which was attached to the patient at the first dressing station to which he was admitted, and accompanied him until his case was finally disposed of.

(b) A Daily Report of Casualties and Changes for Patients in Hospitals and infirmaries functioning as hospitals.

(c) A telegraphic report of communicable diseases.

(d) Special venereal report.

(e) A monthly report consisting of a complete sick and sounded card for every case completed in the A. E. F., and for every case evacuated to the United States. The latter report to constitute the permanent record of the soldier in the War Department.

The plan outlined by the board was approved by the Chief Surgeon and Adjutant General. The details of the system were worked out by Lt. Colonel D. W. Harmon, M. C. and Captain Frank A. Ross, Sanitary Corps. The final product was issued in the form of a pamphlet of instructions for the preparation of sick and wounded reports by authority of the Commander-in-Chief, effective May 1, 1918. Due to delays in procuring field medical cards, envelopes and blank forms, the system was not inaugurated until June 15, 1918.

In order to obtain complete records of our troops serving with the Allied Armies, arrangements had to be made with the French and British authorities in France and England for reporting American patients in their hospitals. This was effectually accomplished and suboffices were established at the Service de Sante in Paris in charge of Captain George W. McKenzie, Sanitary Corps: at the 3d Echelon, B. E. F. in Rouen in charge of Lt. C. E. Horton, later replaced by Lt. A. B. Crean, and at London under the direction of the Surgeon, Base Section No. 3. Each of these officers in charge were experienced Registrars. All reports of patients in Allied hospitals were sent to one or the other of these branch officers where they were transcribed on A. E. F. forms and forwarded to the Chief Surgeon, A. E. F.

The adoption of the new system meant the handling of thousands of reports in the office of the Chief Surgeon. The monthly sick and wounded reports from some five

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hundred or more units has to be checked and corrected in detail before they could be forwarded to the War Department as a final and permanent record. The daily report of casualties and changes from the same number of hospitals showing every change of status of patients in hospitals had to be made available for statistical purposes, and for answering hundreds and thousands of inquiries regarding the whereabouts and condition of sick and wounded soldiers. To handle this great volume of work the Hollerith Tabulating Equipment was installed under the direction of Major R. H. Delafield, Sanitary Corps. Under this system, the information on the daily reports is transferred by numerical code to medical and traumatic cards, according to whether the case is one of disease or injury. The information on the Medical Card is as follows: Name, rank, number, organization, diagnosis, disposition of the case and date, hospital to which admitted, transferred or from which discharged. The traumatic card in addition to the above information shows the nature and location of the traumatism and causative agent.

When the cards have been coded by reports they are perforated by punch clerks on machines designed for the purposes. All original punching is verified by different operators and other machines. After the cards have been punched and verified they are passed through the sorting machines where they are sorted for the medical statistical data required by the various reports.

A set of books are kept which correspond to a ledger, in which daily entries are made of the number of admissions and dispositions of each disease and injury reported. This ledger constitutes a ready reference record and a basis for special reports that may be called for.

After all statistical tabulations have been made, the cards are finally sorted by name, so that the card for each soldier is mechanically filed in alphabetical order. This file constitutes the master file for all cases reported by A. E. F. and French hospitals and by British hospitals in France and England. On November 11, the file consisted of more than two million cards, arranged in dictionary order. It constitutes an information bureau and news agency for sick and wounded soldiers.

HISTORY OF THE DENTAL SERVICE, A. E. F.

A history of the Dental Service, A. F. F., begins with the departure of the original 26 dental officers from the United States, during the latter part of July, 1917. Of this number five were of the Regular Dental Corps of the army and 21 were of the Dental Reserve Corps. The five Regular officers in conjunction with one specialist of the Reserve Corps constituted the first Army Dental Unit ordered overseas, which came prepared to accomplish all operations of dental and oral surgery. In contemplating the initial representation of dental officers in the A. E. F., the 13 Dental Reserve Board Officers who came over with the six General Hospitals loaned to the British service must be included. These hospitals arrived in France during the latter part of May and June, 1917, and although functioning under British control, their dental officers were considered part of and therefore listed with the commissioned dental personnel of the A. E. F.

From this small beginning the strength of the dental personnel grew steadily through the number of dental officers arriving from time to time with the different organizations sent over from the United States. During the month of November, 1918, the high water mark was reached showing a maximum of 1,873 dental officers, with approximately 2,000 enlisted men, which included dental assistants and dental mechanics.

The commissioned personnel was distributed through the several grades as follows: three colonels, nine lt. colonels, 42 majors, 322 captains and 1497 lieutenants. Of this large number of dental officers, seventy-nine belonged to the Dental Corps,

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U. S. A., (Regular), twelve to the Dental Corps, United States Navy, about 225 to National Guard organizations, and the remainder to the original Dental Reserve Corps. The service rendered by officers of the Navy Dental Corps was of the highest professional type and characterized by laudable devotion to duty at all times, and by an admirable esprit and dash during combat activities. The first name on our roll of honor belongs to the navy. It is with sincere condolence to the Navy Dental Corps we thus announce the first death of a dental officer on the field of battle. Lt. Weedon E. Osborne, D. C., U. S. Navy, was killed in action May 10, 1918, by enemy shell fire, while actively engaged in caring for wounded of the 2d Division, A. E. F. The services of National Guard officers were of the type of military and professional quality expected of them by reason of their long experience in the service. The splendid services rendered by the great number of Reserve officers has been marked by close application to duty, willingness to meet any requirements of the service however arduous, and by a degree of loyalty and devotion that is highly commendable. Many of these officers have been men of outstanding professional and educational qualifications in civil life. Their special services rendered in higher professional and educational positions have redounded greatly to their credit and to the distinction of the Dental Service of the A. E. F. All the higher offices of administration were filled by selection from the older and more experienced officers of the army.

While the greater number of dental officers were serving in France, a large number arriving in England were detained there for duty at the several hospitals, aviation camps and instruction centers of the American army sent there for training to subsequently operate under British direction. Several dental officers with their enlisted assistants were also detailed for organizations serving in Italy and with organizations sent to northern Russia in the region of Archangel.

Of the original 26 dental officers arriving, disposition was made as follows: 20 were assigned to duty with organizations of the 1st Division then arriving in France. Those composing the First Army Dental Unit were distributed and assigned to duty in administrative positions. One to the Office of the Chief Surgeon, A. E. F., one to the 1st Division as Division Dental Surgeon, one to school duty for the initial instruction of the new inexperienced Dental Reserve Officers, one to the Headquarters of the Artillery Brigade at La Valdahon, one to the Medical Supply Depot, and one (the specialist), to G. H. Q., as Attending Dental Surgeon.

SCHOOLS

It was early recognized that a course of instruction would be required for the great number of inexperienced dental reserve officers coming into the service. Although these officers had been carefully selected as to their professional qualifications, and were undoubtedly good dentists, it was necessary to give them preliminary instructions for the purpose of making military dental surgeons out of them, and acquaint them in methods of carrying on a military dental practice: customs of the service, the system of obtaining supplies, military correspondence, making and forwarding reports, etc.

This was first accomplished by organizing division schools in charge of the Division Dental Surgeon, under direction of the Division Surgeon, with instructions to convene the dental officers two afternoons a week for this purpose. The benefits derived thereby were readily apparent and a great improvement in the coordination of the dental service of the 1st Division and the character of service rendered was manifest after the first month. This plan was carried out with the several divisions arriving in France during the following four months. It afterward gave way to the course of instruction carried on by the Dental Section, Army Sanitary School.

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The Dental Section, Army Sanitary School, was organized in November and its first session began Dec. 3, 1917, at the Hqs., Army School Area, Langres. The term of instruction covered two weeks intensive study and application. The course was conducted under direction of an experienced dental officer termed Director, who was assisted by a number of specially qualified instructors. This course embraced all the subjects laid down for division schools and in addition took up the subjects of approved methods of practice in war dentistry and a practical knowledge of face and jaw surgery. In view of the probabilities that all medical personnel would undoubtedly be called on to function in any capacity in which it could best perform during stress of active military operations, it was deemed prudent to incorporate sufficient instruction in the duties of medical officers, as would qualify dental officers for service as auxiliary medical officers. It was realized that inasmuch as the preliminary education of both dental and medical officers were along similar lines, it would be comparatively easy to prepare these men for the special duties that might be required of them. Therefore, instructions in minor surgery, bandaging, splinting, first aid for wounded and gassed cases, transportation of wounded, duties in advance dressing and triage stations, special drill instructions, the administration of antitetanic serum and anaesthesia were incorporated in the course.

The wisdom of the creation of this school has been proven many times since in the improvement shown in military dentistry and by the splendid work dental officers have performed as auxiliary medical officers during combat activities. Letters and citations of special meritorious service have been given dental officers by many division commanders and division surgeons for excellence of the service thus rendered, and for good loyal fearless devotion to duty.

Realizing that after the American army entered into active combat there would be great necessity for a large number of specially qualified officers in face and jaw surgery, a post graduate course in oral, plastic, and prosthetic surgery was organized at American Red Cross Military Hospital No. 1. (Old American Ambulance, Neuilly). A competent faculty of well qualified instructors were assembled at this hospital: a schedule of lectures and clinical instructions prepared, and the school ready to function April 1, 1918. but owing to the enemy`s offensive which started March 21, and the necessity for all hospitals within the Paris District to function as casualty clearing stations or evacuation hospitals, this course of instruction was indefinitely postponed and finally abandoned on account of the continuous battle activities immediately north of Paris.

A special school for instruction of enlisted men, as dental assistants, was organized at Hq, 1st Depot Division, St-Aignan, and two schools for special instruction of dental mechanics were organized. One at Hq. 1st Depot Division, St.-Aignan, for course in primary dental laboratory work, and a second at American Red Cross Military Hospital No. 1, for advanced instruction in swedged and cast metal splints and other fracture jaw appliances required in maxillo-facial surgery. In addition to the above cited schools, general instruction was carried on by correspondence from the Chief Surgeon`s Office in subjects of general military administration, technical dentistry, and official procedure.

ORGANIZATION

A great majority of base hospitals arriving in France had two dental officers with enlisted assistants and full equipment, base outfits, including laboratories. Wherever this plan was deviated from, dental officers were assigned to make up this quota. The senior dental officer was designated Chief of the Dental Service and instructed in all duties pertaining to that position. It soon became evident that twenty dental officers to a division, of the size of division adopted for the American army, (approximately

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28,000 men), were not sufficient for the dental needs of the command. This number, therefore, was increased to thirty dental officers which, with the Division Dental Surgeon, made 31 commissioned dental personnel for a division. While this number exceeded the proportion of one to 1,000 men, the excess number became necessary on account of the incohesion of some of the division commands.

With the intention of making the dental service of a division a complete entity, wherein any character of dental defect could be remedied, each division was provided with a portable dental laboratory and a specially qualified dental mechanic assigned to duty therewith as assistant to the specially selected dental officer. Thus the necessary prosthetic service was assured. The dental laboratory was usually located with one of the Division Field Hospitals.

In proportion to the development of the A. E. F., and the organization of the army corps units and field armies, the dental service was accordingly developed; therefore, administrative officers for field armies, termed chief dental surgeons, and administrative officers for army corps, termed corps dental surgeons, were created and appointed. To meet the demands for better dental service in the sections of the Line of Communications (later known as the Services of Supply), experienced dental officers were selected for each and designated supervising dental surgeons of the respective sections. Their duties were to coordinate the service within their area: inspect, supervise, instruct, and render reports on same to the Chief Surgeon`s Office. Local dental supervisors were appointed from among specially qualified officers at each hospital center and for each army area.

These officers functioned as coordinating officers and were instructed to organize a central dental laboratory and dental clinics in the several centers or areas: to take charge of requisitions and receipts for supplies: the storing of same, reissue as required, centralization of the service, and generally supervising, inspecting and assuming control of instruction of the dental officers in their respective areas.

The several detached organizations located throughout the different sections of the S. O. S., namely: engineer regiments, labor battalions; coast and railway artillery batteries; tank corps organizations; gas service; remount stations, graves registration service; motor reception parks; antiaircraft organizations; salvage depots; prisoner of war camps; storage depots, stevedore companies, forestry camps, signal corps and school areas, were each supplied with the necessary dental service. The dental officers functioning therewith came under the instruction and administrative control of the supervising dental surgeon of their respective sections in the S. O. S.

The need for dental ambulances, mobile dental offices, has been manifest throughout the entire dental service of the A. E. F. All efforts prior to the cessation of hostilities, Nov. 11, 1918, to obtain tonnage priority for their transportation to France has met with failure. The use of these dental ambulances with outlying commands or detachments within divisional training areas or in rear of combat sectors would have proven of great value inasmuch as the mobile units could proceed from place to place with little loss of time, either in actual transportation or in the unpacking and repacking of equipment ordinarily required of a dental officer on itinerary service.

Only two dental ambulances have been utilized in the A. E. F., both of which were presented to the service: one through individual donation and the other through the American Red Cross. Dental Ambulance No. 1, which was the first acquired, has been functioning with Mobile Motor Transport organizations in the Zone of the Armies, and Dental Ambulance No. 2, has been operating with various squadrons of the Aviation Service in the Advance Section.

A group of 40 speciailists in general surgery and dental surgery for special duty in the Maxillo-Facial Surgical Service was sent over by the Surgeon General`s Office early in May, 19 18. The dental personnel of this group soon afterward came under

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administrative control of the Chief Surgeon`s Office. Maxillo-Facial Teams, composed of one surgeon and one dental surgeon, were sent to the important hospitals or hospital centers, and several specially qualified officers were sent to the Vichy Hospital Center, where Base Hospital No. 115, was designated the Head Hospital. This group of specialists came over under direction of a well known specialist in this mine of surgery, who upon arrival was designated the Chief Consultant of maxillo-facial surgery. The excellent results obtained in this class of special surgery will no doubt be shown in special reports, surgical, rendered through the Surgical Section.

ARMY DENTAL BOARDS

Army dental boards for the examination of candidates for appointment and commission in the Dental Reserve Corps, have been appointed from time to time as required. The candidates for these examinations were from two classes of professional men: American dental surgeons then engaged in the practice of their profession in Europe who desired to enter the American service; and graduate practitioners of dentistry from among the enlisted men of the A. E. F., who had been drafted into the service. We secured, in this manner, the services of about 40 dental officers. The last examination held at which 88 candidates were successful, was finished shortly after the signing of the Armistice, but this large number of dentists were not permitted to enter the service on account of cable instructions from Washington prohibiting further appointments in view of the cessation of hostilities.

EQUIPMENT AND SUPPLIES

Under original instructions from the Surgeon General`s Office, each dental surgeon leaving for overseas duty was to be fully equipped with a portable dental outfit for field service. If these plans had not miscarried, through the exigencies of transportation, by reason of the great number of fighting men and battle supplies hurriedly sent to the A. E. F., little difficulties would have accrued, but owing to the fact that many dental officers arrived in France without the equipment supposed to have been shipped with them, and never again found their original equipment, the problem of supplying them with dental outfits has proven one of considerable magnitude. Arrangements were made at an early date by the Medical Supply Division, prior to the arrival of the 2d Division in France, for an adequate supply stock of dental equipment and supplies for field service. This supply was augmented later by the establishment of an automatic monthly dental supply, based upon the embarkation of every 25,000 men for overseas duty. Owing to accidents in overseas shipments, to congestion of supplies at base ports, to lack of facilities for early rail shipment to locations in France, and to other causes, it became necessary to make emergency purchases of dental supplies in France. This was carried out through the medical member of the General Purchasing Board and proceeded to such extent that an embargo was placed by the French authorities upon the purchases of dental supplies by the American army. This embargo prevailed a few weeks when the restrictions was removed to the extent of permitting 1,000 franc purchases only.

It was therefore found necessary to develop the resources of supply in England, and a large amount of dental laboratory equipment and supplies were purchased in London and ordered shipped to the supply depots in France. A restriction was placed upon further purchases of dental material in England as soon as the British War Office learned of the extensive purchases made. This restriction was never removed. This particular purchase of much needed dental laboratory equipment never reached the A. E. F., depots, as the ship carrying it was sunk by enemy submarines in crossing the channel.

This serious loss of dental materiel was followed by the loss of several tons of equipment on one of the U. S. transports sunk off the Irish Coast. It then became necessary

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to strain to the utmost our supply resources, and to modify our field equipment accordingly.

About this time, experience in combat divisions taught us that much of the so-called portable dental outfits for field service would have to be cut down in bulk and weight to meet the transportation problems of mobile divisions. This resulted in a reclassification of dental equipment into camp equipment: (full portable outfits), for such detached organizations in the S. O. S., as could furnish transportation for same: modified portable outfits for combat divisions, consisting of only the essential equipment and supply in three chests for carrying on field dentistry, and campaign equipment for divisions in battle areas, consisting of one dental engine chest and contents, plus the contents of an emergency dental kit, containing cloth instrument rolls, for a few of the essential instruments and medicines with a small amount of supplies, which were to be contained in hospital corps pouches, carried slung over the shoulder. (This was later augmented by addition of a folding aluminum trench chair of 4 l/2 lbs., weight, carried in container slung over the assistant`s shoulder.)

Instructions were issued that every dental surgeon in combat divisions would carry with him, at all times, one of these emergency kits, equipped with a few practical instruments and standard remedies and thus be available at any time to render first aid dentistry for the relief of pain, and for minor oral surgical or dental operations.

These modifications of dental equipment helped solve many of the transportation problems of the dental service in combat divisions, and while it increased the physical burden of dental officers, yet it was made possible for anyone requiring emergency dental service to obtain same at any time from dental officer of his command.

During the period of combat activities from May to November 11, 1918, only the simpler dental operations and services of an emergency character were attempted in combat divisions. This naturally resulted in very meagre reports of dental operations being forwarded to the Chief Surgeon`s Office. These reports show comparatively a large number of extractions, palliative treatments, minor oral surgical operations, and a few fillings of a temporary character. Incidentally this furnishes ample testimony of the attentive occupation of all concerned in the pursuance of the important work at hand, that of completely engaging the enemy. In contradistinction to said reports, the reports recently received, covering the months subsequent to the cessation of hostilities and for the period since the several armies have gone into rest areas, billeting areas, embarkation areas and winter quarters generally, indicate that a bona-fide practice of high class dentistry has been seriously and consistently carried on, wherein tooth conservation, repairative and reconstructive dentistry, and the long arduous treatments for tooth reclamation are every day achievements and that masticatory restoration through various methods of prosthesis is being afforded those officers and men who have lost teeth through the enforced dental negligence of battle activities. These reports are in marked contrast to those submitted during the preceding months and illustrate pleasing resumption of magnificent professional activity, that is commendable in the highest degree.

Transportation of dental equipment and supplies in combat divisions has ever been a problem, and a source of irritation to division commanders, transportation officers, and division surgeons. This was largely due to the fact that no accounting has ever been made in Tables of Organization for the accommodation of dental personnel, commissioned and enlisted, and the dental equipment. The results of this failure to mention the dental service, and equipment, has resulted in the loss of much equipment and the consequent loss of dental service in several of the divisions: one of which, the 1st Division, lost all it`s dental equipment in the first big move of the division into combat area in May 1918. All their equipment was abandoned and subsequently salvaged on account of lack of transportation facilities for same. It required all the resources of Intermediate Medical Supply Depot No. 3 to resupply dental equipment of an

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emergency character for this division after its arrival in the new area. In this connection, it is hoped that adequate provision will be made in Tables of Organization for both dental personnel, and dental equipment, and adequate transportation for each.

Sufficient dental personnel, selected from specially qualified officers of the Regular Dental Corps were assigned to duty at medical supply depots for the purpose of assisting the medical supply officer in handling this special class of materiel. Adequate plans for the development of this scheme and the assignment of a dental officer at each of the supply depots, and at the receiving depots at base ports was proposed, but never put into operation.

The officers of the maxillo-facial units arrived in France without the special instruments and equipment for their service. It therefore became necessary to improvise it, making careful selection from surgical and dental equipment on hand, purchase such as could be found in French markets, and specially manufacture appliances necessary in this class of surgery. This lack of preparation has, in certain instances, retarded the activities of the maxillo-facial services. Eventually all the necessary equipment was procured, issued to the several hospitals, and utilized to the fullest extent. In this connection, attention is invited to the development and manufacture of the so-called Amex Casque, which was used to great advantage in this special service in maintaining fixation, of both osseous and soft parts, in reconstruction of faces and jaws, for this class of battle casualties.

A Dental Equipment Board operating in conjunction with the Medical Equipment Board, was convened for consideration of the essential dental equipment for dental officers with combat divisions for an army on campaign. The findings and recommendations of this board, will result in greatly modifying the old portable dental outfits for field service, and will reduce to the minimum, the size and number of containers for articles deemed necessary in field dental surgery.

INSPECTIONS

The need for special technical inspections of dental officers, by officers thoroughly conversant with dentistry, was early manifest. Directions were issued which resulted in regular and systematic inspections being carried on by division dental surgeons within their divisions, corps dental surgeons with corps troops and the divisions of their command. Army dental surgeons with field army troops and their respective corps and division dental surgeons: and by supervising dental surgeons of the several sections S. O. S., with the dental officers of their respective sections. This has also been augmented by inspections, when deemed practicable, by the Chief Dental Surgeon, A. E. F. Adequate reports covering said inspections have been forwarded to the Chief Surgeon`s Office, with the result that the dental service in the several commands and areas, has been greatly improved.

CASUALTIES

Several dental officers in combat divisions have been killed on the field of honor and a large number have been wounded or gassed during the combat activities during the period from May to November, 1918. * * *

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Most of these officers were killed while performing the duties of auxiliary medical officers. Commendation and citation orders and special reports of division commanders and division surgeons have been forwarded for a number of dental officers in the A. E. F. Several officers have been awarded the distinguished service cross

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(two posthumous awards), and the Croix de guerre. In addition to the dental officers listed in the roll of honor, we have several records where enlisted dental assistants have also made the supreme sacrifice in the service of their country, and several that have been wounded or gassed in the discharge of their duty. These names will appear in another report of enlisted men of the Medical Department.

ROBT T. OLIVER,

Col., D. C., U. S. A.

HISTORY OF VETERINARY CORPS, A. E. F.,

FROM AUGUST 24, 1918 TO MARCH 1, 1919.

By an act of Congress, on June 3, 1916, the Veterinary Corps of the Am. army was transferred from the Q. M. Corps to the Medical Department. At the outbreak of the present war the Surgeon General took steps to have the Veterinary Corps put on an efficient basis, and on October 4, 1917, G. O. 130, W. D., was published. This G. O. authorized one veterinary officer and sixteen enlisted men of the Veterinary Corps for each four hundred animal strength.

On Sept. 18, 1917, G. O. 39, G. H. Q., A. E. F., was published, which created a Remount Service in the Q. M. Corps and placed the Veterinary Service under the Remount Service.

In November, 1917, the Surgeon General sent to the A. E. F., two selected veterinary officers to be placed at the disposition of the C-in-C, with a view of organizing the Veterinary Service, A. E. F., on similar lines to that in the United States. The recommendations made by these two veterinary officers were not acted upon favorably at this time and the Veterinary Service remained under the Remount Service until August 24, 1918.

On July 26, 1918. G. O. 122, G. H. Q., was published, revoking G. O. 39, G. H. Q., 1917. This G. O. designated a field officer of the Mounted or Remount Service as Chief of Remount Service, A. E. F., as Assistant to the Chief Quartermaster, A. E. F., and an officer of the Veterinary Corps was detailed as Assistant to the Chief of Remount Service, and was to be designated as Chief of Veterinary Service, who was to have technical supervision of the Veterinary Service, A. E. F.

The failure to accept the comprehensive organization as outlined by S. R. 70, W. D., 19 17, and as outlined by the two veterinary officers that were sent to the A. E. F. from the Surgeon General`s Office in November 1917, was a grave error and indicated a lack of understanding of what the animal situation was to become in the A. E. F.

On account of the absolute inefficiency of the Veterinary Service in the A. E. F., a change was necessary, and on August 24, 1918, G. O. 139, G. H. Q. was published directing the Veterinary Service, A. E. F. to be organized in accordance with S. R. 70, W. D., 1917, and transferring the Veterinary Corps from the Office of the Chief Quartermaster to the Office of the Chief Surgeon, A. E. F. A Chief Veterinarian was designated who was charged, under the Chief Surgeon, with the administration of the Veterinary Service.

On August 27, 1918. G. O. 142, G. H. Q., A. E. F., was published and announced Lt. Col. David S. White as Chief Veterinarian, A. E. F.

The adopting of S. R. 70, W. D., 1917, and the appointing of Lt. Col. White as Chief Veterinarian, A. E. F., marked the real beginning of the Veterinary Service as it stands today. This new organization provided a simple, direct and efficient mechanism for the evacuation of sick and inefficient animals from combatant forces to Veterinary Hospitals in the S. O. S., where organized and specially trained units cared for these animals. From these S. O. S. hospitals, the animals that were cured and free from disease were evacuated to the Remount Depots. The animals when received, if they were

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considered as not fit for reissue were sold to butchers, sold to civilians, or slaughtered, as the case might be.

Veterinary hospitals were placed under command of their own officers and steps were immediately taken to collect scattered companies and half-companies of such hospitals into whole working organizations. The issue of convalescent animals from veterinary units back to organizations was stopped, and the policy of passing all convalescent animals through Remount Depots for reissue was instituted. The prompt rendering of weekly animal sick report and their accurate compilation was insisted upon. Requirements were anticipated and reinforcements, already overdue, were cabled for. Further hospital accommodation was sought and, with difficulty, an insufficient amount procured.

The use of railhead for evacuation of sick animals was absolutely refused by the First Army, without reference to G. H.Q., in spite of their use being emphatically demanded by the Chief Veterinarian, The result was that while this question was being decided, hundreds of animals were lost, through being evacuated long distances overland, when in a debilitated and sick condition, often suffering from serious wounds, while literally thousands were retained with divisions through the inability of the veterinary personnel to cope with the requirements of long overland evacuation. Eventually the necessity of evacuating by railroads was conceded and the policy adopted, but again a difficulty arose. Instead of it being realized that this was a Veterinary Service, it was considered to come directly under the staff of the armies. This meant that, this portion of the evacuating mechanism being out of the control of the army veterinarian, adequate arrangements could not be made to send trainloads of sick animals to the hospitals prepared to receive them. They were sent to hospitals deemed most suitable by the staff of the army, which did not always possess adequate knowledge of the receiving capacity of such hospitals. Presently this obstacle was removed, however, and veterinary evacuating stations, formed by the Chief Veterinarian in place of corps and army hospitals (sections) and commanded by their own officers, took over the evacuated animals from divisions and moved them by railroad to allotted hospitals.

On account of military necessity, it was impossible to evacuate all animals affected with disease, as it would have made our armies absolutely immobile as far as animal transportation was concerned, as animal replacements were not available in sufficient numbers. Upon the removal of a great percentage of the sick, the efficiency of the animals left was markedly increased.

Sick animals had been so long retained with divisions, however, that their evacuation in bulk, although absolutely necessary, threw great strain on all veterinary hospitals. Under this strain some hospitals perilously approached collapse. Help however was near, no less than ten veterinary hospitals were on the water or ordered to port. The assistance of the labor companies had been asked for to meet the personnel shortage until the arrival of these hospitals. These were promised and some were on their way. The final result, however, of an efficient veterinary service, gradually bringing the animal efficiency of the Am. army to a standard compatible with the Armies of the Allies was not reached before the signing of the Armistice on November 11.

Per telegraphic instructions to C. G., S. O. S., from the C-in-C, Lt. Col. D. S. White was relieved as Chief Veterinarian, A. E. F., on November 1, 1918 and Lt. Col. B. T. Merchant, Cavalry, was detailed as Chief Veterinarian, A. E. F.

On November 1, there were fifteen veterinary hospitals established but not all construction completed. At this time, we had approximately 12,000 V. H. Capacity, but it was necessary to handle many more animals than their capacity, using picket lines, corrals, paddocks, etc. On this date there were 14,861 animals in the hospitals.

A determined effort was made to locate new hospital sites and have more labor troops assigned to Veterinary Corps to aid in evacuation and care of sick animals until veterinary hospital personnel should arrive from the States, which were on the water or

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cabled for. At this time, there were approximately 750 veterinary officers and 6,000 veterinary enlisted personnel, and 600 labor troops assigned to Veterinary Corps.

On this date, March 1, there are 20 veterinary hospitals, excluding army veterinary hospitals, with a capacity for 26,664 animals, and animals in hospitals on this date are approximately, 20,000. There are 885 veterinary officers, 9,282 veterinary enlisted personnel, and approximately 2,000 labor troops assigned to Veterinary Corps for duty.

While to a large extent it was impossible to evacuate all sick animals before the Armistice on account of military necessity, immediately on the signing of the Armistice the evacuation began, and to cite one instance of what the Veterinary Corps had to contend with, the First Army evacuated approximately 3,000 animals to the Veterinary Hospital at Verdun within twenty-four hours after the personnel arrived there for station, and the stabling capacity of this hospital is only 1,625.

COMMUNICABLE DISEASES

Upon the appointment of Lt. Co1 White as Chief Veterinarian, a determined effort was made to have the proper statistical reports rendered, which had not been rendered complete before this time.

The principal communicable diseases that have affected the animals of the A. E. F. are strangles, mange, and glanders.

INFLUENZA

Until the Veterinary Corps was transferred to the Medical Department the practice of placing veterinary hospitals in remount depots was carried out, and upon bringing animals just purchased from the French civilians into the remount depots and veterinary hospitals the whole remount depot would become infected with disease and especially influenza in the A. E. F. By separation of the Remounts and Veterinary Hospitals and proper segregation of the sick, the number of cases of this disease dropped in October 5, 1918 to 900 cases. In the early winter months this disease again climbed to an average of about 1,500 cases, but now on this date, March 1, 1919, there are about 700 cases of this disease on sick report in the entire A. E. F.

MANGE

On August 31, 1918, the most complete reports obtainable show that we had taken up on sick report for the month of August 72,118 cases, or about 44% of the total animal strength. This included 19,316 cases of mange, or about 27% of total sick. On Feb. 15, 1919, the last complete report on this date shows total number of animals taken up on sick report 48,975 or 27% of total animal strength. This includes 30,736 cases of mange, or 62% of total on sick report.

A determined effort is being made and has been made to stamp out mange, and it is succeeding. The above number of mange cases include not only the active cases of mange, but also the contacts.

The First Army has constructed sulphuration chambers to treat mange, while the Second and Third Armies have constructed dipping vats. The treatment is progressing favorably. While it is not believed possible to stamp out this disease entirely, it is under control and as a means of diminishing the animal efficiency of the A. E. F., it need not be considered to a great extent, provided the Veterinary Corps can continue to control the treatment and evacuation as they are now doing.

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GLANDERS

In all former campaigns glanders was a disease that took rapid and the great toll of the animal strength of armies.

In recent years, a substance called mallein has been placed at the disposal of veterinarians, which, when properly applied, distinguishes the animals that have this disease before clinical symptoms appear and before there is great danger of spreading the disease. The application of this substance, mullein, is called the mallein test, of which there are a number.

The intradermal palpebral mallein test was declared the official test of the A. E. F. on account of the simplicity and the rapidity with which large numbers of animals could be tested. This was practically a new test to the veterinary officers of the A. F. F., and instructing the veterinary officers in the use of this test has been a big undertaking. The veterinary officers not being familiar with this test, and with the reactions, a few cases of glanders undoubtedly escaped their attention.

The average weekly report on glanders showed 6 eases of glanders per week until on Nov. 23, when the report increased to 34 cases. On the increase of this number of cases, an investigation was started by the Chief Veterinarian. It was found on this investigation that some veterinary officers had not been using the test properly, and instructions were issued immediately on the technique and reading of reactors to this test. In addition to these instructions, veterinary officers that knew this test were sent to all different units in the A. E. F. to instruct and demonstrate the palpebral test. On account of a more accurate test the number of cases of glanders steadily increased until the week ending January 18, there were 391 cases reported. While it was found there was a general infection in the A. E. F., the veterinary hospitals and remount depots in the base sections were the worst infected.

On February 7, 1919, the Chief Veterinarian called a meeting of all Asst. Chief Veterinarians, commanding officers of veterinary hospitals, and senior veterinarians of Remount Depots to a conference at St-Nazaire to evolve comprehensive rules for the technique and reading of reactors to the intradermal palpebral test. These instructions have been approved by the C. G., S. O. S., and have been sent to all veterinary officers of the A. E. F. These instructions were published February 25, 1919, in

Bulletin No. 16, G. H. Q.

From January 18, to the present time, there was a rapid decline in the number of cases, and on March 1, there were only 44 cases reported which shows that the glanders situation is well in hand. The veterinary officers of the A. E. F. now understand the test thoroughly, and it is considered that this disease will not give more trouble than the usual number of glanders cases that is always found in large numbers of animals.

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SPECIAL DEVELOPMENTS

PROFESSIONAL SERVICES, A. E. F.

Originating with the selection of directors in the different surgical and medical subdivisions by the Chief Surgeon, the organization of Professional Services first functioned as an A. E. F. activity with the arrival of such designated officers in France. They had been chosen with a view to acting as consultants in various special lines, and represented in every case the highest types of specialists in civil practice.

The title of Director was from the first a misnomer, giving to these consultants an improper impression of the work to be performed. It was planned that the chosen officers should not act entirely in an advisory capacity, whereas the term Director implied an entirely different thing. As a result of this misunderstanding, it was at

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once realized by the Chief Surgeon that steps to rectify the error must be made at once, for upon arriving at Neufchateau, the designated administrative center, each director established his own service, with a resulting grave lack of coordination. No actual head of the service had been authorized, and after some weeks of unsatisfactory results, General Order No. 88, G. H. Q., A. E. F., June 6, 1918, was published, augmented by Circular No. 25, A. E. F. This changed the title of these professional advisors to Consultant, and placed over them a director for the purpose of coordination and military control.

To more clearly show the organization in its new form, parts of the order affecting Professional Services is herewith quoted:

I. 1. For the coordination and supervision of the professional care of sick and wounded the following will be appointed:

For the A. E. F.

A director of Professional Services, A. E. F.

A Chief Consultant, Surgical Services, A. E. F.

A Chief Consultant, Medical Services, A. E. F.

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Under the above table of organization, the Professional Services, A. E. F., were placed on an efficient basis: activities were centralized. Shortly after the reorganization the Director of Professional Services was granted authority by the Chief Surgeon to procure orders without reference to the Chief Surgeon`s Office.

The large expansion of facilities for emergency surgical work in evacuation hospitals by means of operating teams was made imperative by the shortage of these hospitals. It has been mentioned elsewhere that in the beginning of the important offensives in July, only eight of the fifty-two evacuation hospitals called for in Tables of Organization, had been brought to France. This was due to failure in obtaining priority. Operating teams, therefore, had to be secured by depleting surgical staffs of base hospitals: depleting these staffs at a most untimely period, the period of ever increasing battle casualties.

On June 6 there were forty-two operating teams, twelve on duty in French hospitals and the remaining in A. E. F. base hospitals. These teams, modeled after the French operating teams, were taken from base hospitals. Plans were at once made to increase the number, and to further augment this, casual teams were organized. Surgical teams from base hospitals consisted of one surgeon, one assistant, one anaesthetist, two nurses, and two orderlies. Casual teams were organized in the same manner, but with one nurse and one orderly. Following the same plan, splint teams and shock teams were later developed: the former to work with operating teams, the latter as emergency medical formations.

Totals of Professional Services teams were shown in a table presented December 31, 1918, as follows:

Owing to prevailing conditions, the above figures are to an extent misleading, inasmuch as the brunt of team work was accomplished by less than 200 organizations.

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In conclusion, it might be stated that the value of a centrally organized Professional Services organization is highly essential in present-day Medical Department work, and that in future periods of activity, surgical and similar teams will be recognized and necessary units. Generally speaking, these teams showed remarkable achievements, while the personnel deserves credit and high commendation.

MOBILE HOSPITALS

Another present-war development of the Medical Department is the Mobile Hospital, patterned after the French auto-chir assemblages. In itself, the name describes the unit. The mobile hospital is nothing less than a transportable hospital: a hospital with sufficient personnel, tentage, and equipment, furnished with sufficient trucks to move the complete organization.

It will, of course, be realized that while surgical equipment and other more compact supplies could be transported with little trouble, comparatively few beds and mattresses could be included. Because of this, only upon rarest occasions of great emergency were they called upon to act as independent formations. The actual function of the mobile hospital, then, resolved itself into work of an auxiliary nature. Because of its trained personnel and additional surgical equipment, such units were sent from place to place to assist in overcrowded evacuation and base hospitals. Their mobility saved many situations, and their actual worth has been proven time and again.

During the latter part of March, 1918, the first assemblage was received from the French. Following that time and until August, but three actual units, Numbers 1, 2 and 3, were functioning with the American forces. Having as they did, the auto-chir as a nucleus, it was deemed advisable to acquire from the French command a park suitable for the assembling mobile hospitals. In August, then, arrangements completed, equipment and personnel was collected at Parc-de-Princes, a point about five miles from Paris. The Polo Field, Paris, had been the organization center for Mobile Hospitals, 1, 2 and 3. Number 4 was being equipped at the same point, while the personnel of No. 5 had already reported. Both of these hospitals were ordered to the Parc-de-Princes, and here further training was given, both in technical and practical work.

In further mobilizations, request was made that five officers and thirty enlisted men be sent to the training center before equipment was requisitioned. From this personnel, was to be selected the particular men who would later handle technical equipment. Nurses were to join the units just before the hospitals were ordered away.

In the training period, an attempt was made to pitch the tentage at least twice, to do the laundry and sterilizing twice, and to run X-Hay equipment until the personnel was sufficiently capable to work efficiently under actual conditions. The nurses upon arriving, were instructed in dressing and bandage making. Officers who were later to do administrative work were schooled in army paper work.

The matter of standardizing equipment for Mobile Hospitals was gravely considered, the chief difficulties of this phase lying in the fact that the various specialists deemed special equipment necessary. Until the time Mobile Hospital No. 10 was mobilized, standard equipment was not decided upon. Number 10 could be transported with twenty three-ton trucks, while its predecessors required from thirty-five to sixty. With such conclusive figures in mind, equipment was standardized, and the units following Number 10 carried approximately the same materials.

Between September 4 and September 26, 1918, eight mobile hospitals were mobilized. The ninth hospital so mobilized was delivered to Belgium on November 11, 1918. A

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tenth hospital, No. 14, was equipped and assembled by November 14, but cessation of hostilities resulted in its abandonment, its equipment remaining in the park.

Undoubtedly the future will find mobile hospitals, along with dozens of other experiments, as accepted Medical Department units. Their usefulness is marked by the demands made.

HOSPITAL CENTERS

Among these newer developments is the A. E. F. Hospital Center, veritable hospital cities, justified because of the necessary economy in medical personnel, transportation, buildings, and medical supplies. The subject is completely covered in the section of this report dealing with hospitalization.

WALTER D. McCAW,

Brigadier General, Medical Corps,

Chief Surgeon.