Divisional Medical Service in the American Expeditionary Forces (AEF)
CHAPTER IV
MEDICAL SERVICEOF THE DIVISION IN COMBAT
The following discussion of methodsgenerally employed in divisions in combat for the care and evacuation ofsick and wounded comprehends important details of the usual practices.As will be noted, no one method universally was employed; much was leftto the initiative, discretion, and resourcefulness of the division surgeonand his subordinates. No orders standardizing the methods in question wereissued by higher authority except to a limited degree by corps surgeonsand to a lesser degree by army surgeons. Though, in general, the systemfollowed was that prescribed in Field Service Regulations and, in moredetail, in the Manual for the Medical Department, the divisions differednot only in the methods of their so doing, but individually they employeddifferent methods at different times under varying circumstances, bothin trench and in open warfare. This went so far that methods in one regimentsometimes differed for certain reasons from those of other regiments inthe same division. It is not practicable to discuss in this chapter allthe numerous differences in the details of medical service which are notedlater in the chapters having to do with individual engagements. Here onlythe most important differences in methods will be mentioned briefly. Forfurther details the reader should consult subsequent chapters.
ORDERSPRESCRIBING METHODS IN PARTICULAR DIVISIONS
Before going into further detailsit will perhaps be best to quote certain orders prescribing methods actuallyfollowed by particular divisions.
In the 42d Division the followingplan for the evacuation of sick and wounded and for furnishing a forwardflow of medical supplies was prepared by the division surgeon April 4,1918: 1
MEDICAL SERVICE FROM FRONT TOREAR
For medical service from the frontthe following will be observed:
Front line trenches.- Whereverpossible first aid and splints-when the nature of the injury renders thelatter necessary-will be applied where the man falls. Hemorrhage will becontrolled at the earliest possible moment. If we can avoid carrying aman with a fractured extremity for even a foot, until a splint has beenapplied, we will save much pain, shock, infection, and damage to tissuefrom jagged ends of bone. The patient will be carried by the regimentalmedical personnel, or by men from combatant troops detailed for that purpose,from place of injury to the battalion aid post.
Battalion aid post.- Hereany attention that may be necessary will be given-first aid, splints, andcontrol of hemorrhage, if not already done. See that dressings and splintsare properly adjusted. Diagnosis tag will be made out and attached by thefirst medical officer or member of the Medical Department who treats theman. Antitetanic serum will be administered and proper notation made bya "T" marked on the forehead with indelible pencil and the letters "A.T. S.," with date and hour on diagnosis tag. Warmth
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will be administered to the patient.This is of the utmost importance in the prevention of shock. Patient willnot be removed from litter, but another litter, with three blankets andwhatever other supplies have been used on the case, will be sent back tothe trenches by the bearers to replace those used. Patient will then becarried by litter bearers detailed from the ambulance section, 117th SanitaryTrain, to the ambulance dressing station.
Ambulance dressing station.-This will be established at the farthest point forward that ambulancescan reach with reasonable safety. Here any further attention that may beneeded will be given. The patient, however, will be disturbed as littleas possible and will not be removed from the litter. Warmth will be constantlymaintained and hot drinks given to those able to take them but withheldin abdominal cases. The same system of exchange will operate. The ambulancedressing station will return by the litter bearers a duplicate of everythingthat came with the patient. In addition it will send by these bearers anysupplies that the medical personnel at the front may require. To this endit will comply, as far as its supplies permit, with any request for suppliesthat may reach it from the front. To avoid confusion and mistakes theserequests should preferably be by written memorandum. Reserve supplies ofantitetanic serum, dressings, and other necessities will be kept on handfor this purpose. Antitetanic serum will be given to those who have notyet received it and the proper notations made as noted above. At the ambulancedressing station cases are selected for distribution to the various hospitals.They will be placed in an ambulance and transported direct to the appropriatehospital.
Ambulance service.- In additionto ambulance service noted under ambulance dressing stations, ambulanceswill be stationed at various points through the area, to be known as ambulanceposts. The location of these ambulance posts will be shown in a latercommunication. These ambulances will transport to hospitals the sick arisingin the various organizations in their vicinity, also wounded that may occurin a locality which would not naturally drain into an ambulance dressingstation.
Field hospitals operating thevarious hospitals noted above.- These hospitals will be prepared toreceive and care for sick and wounded at any hour of the day or night.They will keep a reserve supply of material on hand to replace the supplieson ambulances, as noted above. Evacuation of patients to base hospitalswill he done only upon direction of the division surgeon, 42d Division.
The following points are emphasized:
(a) Surgical operations are prohibitedexcept in a hospital. Treatment at the front and during evacuationto the hospital will be limited to first aid, splints, control of hemorrhage,and shock. Probing for bullets or fragments of any sort is expressly forbidden.
(b) Every effort will be made tosecure delivery of the patient to the proper hospital at the earliest possiblemoment after receipt or the injury. Saving of time during the early periodof the injury may mean life or death of the patient.
(c) During the evacuation of thepatient he must be kept as comfortable as it is possible to provide. Hemust be disturbed as little as possible, and in any event, after the firstdressings and splints are applied, only so much as is necessary to seethat the dressings, splints, etc., have been properly applied and continuein good shape.
(d) Warmth will be continuously applied.This is our best preventive for shock. It will be secured by hot-waterbags, alcohol or oil stoves, hot bottles, etc.
(e) A constant flow of supplies willbe kept up from rear to front lines by the system of exchange noted above.
The following order concerning evacuationswas issued in the 3d Division, July 23, 1918:2
Regimental surgeons will keep intouch at all times with the ambulance company dressing stations which evacuatetheir wounded. They will instruct their assistants, commissioned and enlisted,concerning the position of the particular dressing station which evacuatesthe wounded from the battalion to which their assistants are attached.
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When a call is made for an ambulancethe surgeon making the call will state explicitly the number of cases tobe evacuated, which of them are litter and which sitting cases. He willalso give sufficiently clear directions concerning location of the woundedto enable the ambulance driver to reach his destination with the leastpossible delay.
Redressing of wounds in the maindressing station should be reduced to a minimum. Arrest of hemorrhage isthe principal cause for redressing. Dressings apparently in place shouldnot be disturbed.
On September 6, 1918, additionalinstructions on this same subject were issued in the 3d Division, as follows:3
Method of supply while inaction.- Regimental and battalion surgeons requiring medical suppliesfor their battalion aid stations during action will send request for thesame to the advance ambulance dressing station evacuating their aid stations.The first ambulance returning to the triage will carry this request tothe medical supply officer, who will immediately forward the necessarysupplies by an ambulance returning to the advance ambulance dressing station.Wheel litters are an excellent means of transporting supplies to battalionaid stations. If necessary to abandon supplies during movement, they shouldbe turned in at the advance ambulance dressing station.
When calling for ambulances be definitein giving location of the wounded, the number of sitting cases, and numberof lying cases. Do not send for ambulances until enough wounded have beencollected to fill an ambulance. A few hours of rest, after dressing andnourishment, while waiting for an ambulance is not detrimental and helpsto overcome the first shock. Purely exhausted men after being given foodand a few hours' sleep at the battalion aid station will often be ableto return to duty.
Do not be in too much of a hurryto make a diagnosis of gas poisoning.
Regimental aid stations may usuallybe dispensed with to advantage, leaving the regimental surgeons free tokeep up constant liaison between battalion aid stations and advanced ambulancedressing stations and to encourage as well as to supervise battalion aidsurgeons at their work. Conserve the energy of your assistants and yourselfby working proper shifts and taking every opportunity when off duty tosleep.
Antitetanic serum must be given atbattalion aid stations. Make proper notation on the diagnosis tag and alsoplace a "T," with indelible pencil or iodine, upon patient's forehead afterthe serum has been given.
Battalion aid stations should beseparated from battalion P. C.
The division surgeon should be informedpromptly of any loss in medical personnel. If telephone communication isnot available, messages for the division surgeon will be transmitted fromthe advance ambulance dressing station by ambulance returning to the triage.
Intelligent men should be trainedas runners. If a verbal message is sent, have the messenger repeat it tothe sender in order to be sure that he thoroughly understands it. Sendwritten messages except when the substance of them would betray mattersof military importance.
The following report of the methodsadopted in the 30th Regiment is descriptive of the evacuation service inmany regiments:4
Advanced aid station company postswere in line with the troops. The first and most essential prerequisitefor evacuation from front lines to battalion aid stations was the properlocation of the latter. These were placed at the most advanced point towhich an ambulance could possibly go; often within one-half kilometer ofthe front, or, again perhaps, three--rarely four--kilometers away, accordingto the character of the terrain. The battalion aid station was never placed in advance of the point reached by ambulances if this could be avoided.When situated beyond that point the difficulties of evacuation were doubled.On the Maine in July, 1918, it was found that having the aid station inadvance of the ambulance head fully doubled the number of patients whohad to he removed by litter, for a large number of patients made theirown way to the aid station
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who would not walk farther, and ifthis station was in advance of ambulances these patients had to be carriedback to them. Thus a large number of wounded, and especially psychoneurotics,had to be taken by litter to the ambulances, who otherwise would have walkedthat distance. Details of litter bearers sent with patients from aid stationsback to ambulances did not return readily through shell fire and were notto become disorganized, whereas when sent forward for patients they returnedin the quickest possible time.
During the defensive battle of theMaine evacuation was by far the most difficult of any experienced by the30th Regiment, 3d Division, on account of the extremely heavy bombardmentof the support and reserve positions and the back areas, and the formationof the terrain, which made it impossible for ambulances to go nearer thanthree kilometers to the front, or, during the early part of operations,nearer than four kilometers. Wounded in the front areas could be carriedout only at night, and they had to be carried up a steep hill through anarrow, winding trail in the woods. The Medical Department personnel inthis battle was wholly inadequate, each battalion having altogether onlyabout 20 medical men and bandsmen. No provisions had been made at thistime for furnishing litter bearers from the line troops, although lineofficers cooperated heartily with the Medical Department in furnishingdetails for this purpose.
The operation of ambulance companiesin the 3d Division is thus described by the division surgeon.5
Main dressing stations were usuallyestablished from four to six kilometers back of the front lines, on a goodroad if possible, with one or more good roads leading to the front andrear. From these places ambulances, medical officers, and a sufficientnumber of enlisted men were sent to points farther to the front, workingin cooperation and at times under direction of the regimental surgeons,but so far as practical it was found best to keep all ambulance personnelunder the direction of the ambulance company itself, at the same time furnishingthe regimental and battalion surgeons with what help they required. Inmany instances it was necessary to furnish litter bearers for evacuationfrom the farthermost posts toward the front. Here the enlisted personnelof the animal-drawn ambulance company proved of great value, it havingbeen found impractical to use animal-drawn ambulances for evacuations fromthe line when actually under shell fire. This was due to the increasedhazard incident to slow progress and the distance it was almost alwaysnecessary to transport the wounded.
The litter bearers of the ambulancecompanies were sometimes in charge of a commissioned officer from the ambulancecompanies, and functioned from the battalion aid posts back to the farthestadvanced ambulance station, which was only far enough to the rear to bereasonably safe. At other times they were under the control of the regimentalor battalion surgeons, to augment the regimental medical personnel eitheron account of a depleted force or to help in the care and transportationof an unusually large number of casualties.
The commissioned personnel of theanimal-drawn ambulance company was likewise used to replace the battalionsurgeons as casualties occurred among them.
At the main dressing station in someinstances where facilities would permit, gassed cases were separated fromwounded, all casualties able to take nourishment were given hot chocolateor hot coffee and other refreshment, antitetanic serum was administered,wounds were redressed when necessary, tourniquets were looked for and examined,and only when absolutely necessary, blood vessels were ligated.
Sometimes all of the ambulance companiesof a division consolidated. Thus during the Meuse-Argonne operation allthe ambulance companies of the Sanitary Train, 3d Division, were stationedat Montfaucon, maintaining one large main dressing station, which was operatedby one company under the supervision of the director of the ambulance section.Every portion of the narrow sector then occupied by the division was accessibleby roads from this point. Two of the motor-ambulance companies functionedfrom the regimental and battalion aid stations back to the main dressingstation and no farther.
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Here all patients were removed fromthe ambulance and attention was given them by the medical officers thereon duty. These medical officers usually numbered from four to six, oneof them being an orthopedist. Nearly all splints needed readjustment, andmany cases of fractures had not been put in splints before sent to thisstation because of the limited facilities for such service at the mostadvanced posts and the great number of casualties occurring at times. Nearlyall antitetanic serum was administered at the ambulance company dressingstation.6
Evacuation of patients from the dressingstation to the field hospital was effected by the motor ambulances of thecompany operating the station. By this arrangement a perfect liaison wasmaintained at all times between the regimental surgeons and the sectionheadquarters, as well as between the main dressing station and the fieldhospitals.
The practice followed by the regimentalsurgeon, of notifying ambulance section headquarters of number, locationand character of wounded reduced to the minimum half loaded ambulances--animportant item when the front was active.
The rate of flow of casualties throughthe dressing stations depended entirely on the resistance encountered bythe combatant troops; during a period of 27 days, when the division wason the offensive, the daily number varied from 52 to 931.6 Likewise, the length of time consumed in transporting wounded from thefront lines to field hospitals was subject to wide variation, dependenton the rapidity with which the troops were advancing, road conditions,whether day or night, and amount of traffic. It averaged five hours fromthe front lines to triage or field hospital during the operation of the3d Division on the Marne and two and a half hours for the 27 days thatdivision spent in that of the Meuse-Argonne area.6
The following orders concerning fieldhospital service were published in the First Corps, September 3, 1918.7In this corps, the divisional triage was operated at a dressing station,staffed by the ambulance company section and such others as the consultants,detailed to that formation.
1. Field hospitals will be utilizedas follows during periods of activity. This applies particularly to openwarfare where rapid changes are probable. In sector warfare which is practicallystationary, location of field hospitals need not follow this plan absolutely,especially as to location, which will be determined by the terrain, buildingsavailable, proximity of evacuation hospital, and other considerations.
2. The four field hospitals of adivision will be placed together if conditions of the terrain permit. Theywill always be plainly marked by the Red Cross emblem in order to protectthem from enemy fire. Placing the field hospitals together has been testedin actual open warfare and found to have certain definite advantages: (a)They are much more easily located by ambulance drivers. If located at separatepoints, depending upon the character of the service they are intended tofurnish, ambulances are apt to wander about and have great difficulty inlocating their particular hospital. This of course is especially true innew country with which drivers are not familiar. (b) The administrationof the hospitals is much simplified by being concentrated at one point.(c) Assistance from the field hospital in reserve is always immediatelyavailable for whichever unit may have need of such assistance.
The field hospitals should be placedas close to the ambulance dressing station as is reasonably safe.
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3. The field hospitals will be utilizedas follows: (a) Gas hospital. (b) Hospital for nontransportable wounded.(c) Hospital for minor sick, including skin and venereal diseases. (d)One hospital in reserve.
4. Gas hospital.-One fieldhospital will be utilized as a gas hospital. To this hospital will be sentall the gas cases from the triage. Therefore, facilities must be providedto give them the necessary special treatment required-proper bathing, alkalinetreatment, administration of oxygen, if necessary, venesection. * * *
5. Hospital for nontransportablewounded.-One field hospital will be utilized for the care of nontransportable wounded. This hospital will be supplied with surgical teams, female nurses, and an X-ray outfit, in order that proper surgicaltreatment and care may be given these cases. To this hospital will be sentdirect from the triage only such cases whose transportation farther tothe rear will probably mean death. In past experiences, these cases haveusually comprised three classes: (a) Sucking chest wounds. (b) Perforatingabdominal wounds. (c) Severe hemorrhage cases.
Head and spinal cases stand transportationbetter before operation than after and should therefore not be stoppedhere. There has been a tendency in the past to retain at this hospitalseriously wounded cases who, however, would be able to stand transportationto the evacuation hospital. This must be discontinued. Only such caseswill be retained as are actually nontransportable. When available, thecorps surgeon will detail to each division an assistant consultant in surgery,who will be the sole judge of what cases will be operated at this hospitaland what cases will be transferred to the evacuation hospital. A shockteam will be on duty at this hospital for treatment of all shock casesboth pre and post operative.
6. Hospital for minor sick includingskin, and venereal diseases.-To this hospital will be sent only thosecases which are minor and which will be fit for duty within four days.* * *
7. One field hospital in reserve.-Thiswill be used to give assistance where needed, both in personnel and equipment.A detail of 1 medical officer and 10 enlisted men will be sent to the ambulancedressing station to give the necessary preliminary bathing and alkalinetreatment to mustard-gas cases as may be deemed necessary by the divisionmedical gas officer on duty at this station. This detail must, of course,be relieved by another detail at regular intervals, to allow the formerto secure the necessary rest and food.
8. * * *
9. Exchange of supplies.-Itis of utmost importance that a systematic exchange of supplies as litters,dressings, splints, blankets, hot-water bottles, operating from the frontline all the way back to the final hospital to which the patient is delivered,be instituted at once. When a patient is placed in an ambulance, the ambulanceorderly must return to the litter bearers a duplicate of all supplies furnishedthe patient. Similarly, when the ambulance delivers the patient to a hospital,the orderly must get from the hospital a duplicate of all supplies furnishedthe patient. This must operate at every point where a change of transportationis made. Otherwise the supplies at the front-line positions will soon becomeexhausted and unnecessary delay and suffering result. If this system ofexchange is enforced, there is a constant steady stream of all necessarysupplies going forward and there need be no interruption in the care givento wounded or other casualties. * * *
Methods employed when troops wereengaged in trench warfare differed considerably from those followed whenthey attacked in the open, and for this reason trench warfare and openwarfare will now be considered separately. It should be explained, however,that, when troops holding trenches were heavily attacked, the differencewas less marked. Yet always in trench warfare, casualties were more localizedand Medical Department formations were more fixed, better equipped, andbetter protected than they were when the troops they accompanied were onthe offensive.
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CARE OF CASUALTIESIN COMPANIES, BATTALIONS, AND REGIMENTS
In old, quiet, defensive positions,the front line usually was little more than a line of outposts lightlyheld, the remainder of the troops being in support trenches or in reserve.Sometimes, as in the 5th Division in the Vosges, a battalion thus helda frontage of 5 km. (3 miles.)8 One battalion surgeon wasusually on duty with the advance troops, while the other was in chargeof the battalion aid station. Two enlisted men of the Medical Departmentwere normally assigned to each company at the front and staffed what was,in effect, a company aid post located at some sheltered point and neara communicating trench to the rear.9 Frequently, it wasprovided with some equipment such as litters, splints, bandages, dressings,whale oil, sodium bicarbonate and a few drugs. The Medical Department enlistedmen were provided with ammonia ampules and instructed in their use, andwere also instructed in other elements of first aid. They were orderedpromptly to adjust the respirators of disabled men who had been gassed.The location of the collecting post (company aid post) was made known tothe company concerned and here first aid usually was given. Often, however,especially if casualties were few, one of the medical attendants stationedhere would leave to give aid to a man where he fell. The function of thecompany aid post was to give primary, or, if the patient had already receivedthis, supplementary first aid, to return to duty men not in need of furthertreatment, and to prepare other wounded men for evacuation, grouping thosewho were able to walk. Professional aid, as given by the battalion surgeonsconcerned, was limited in general to the control of hemorrhage and to theapplication of dressings and splints. Those disabled in the front linehabitually were brought to the company aid post (if necessary, on litterscarried by company bearers), except when their wounds had been dressedwhere they fell and it was easier to remove them from that place to a battalionaid station.
Patients were taken to the battalionaid station from company aid posts or from the line. It usually was locatedin a support trench from 240 to 500 yards from the front and so as to bereadily accessible from all parts of it that the station served. (In the89th Division aid stations for the support lines of reserve also were provided.)10 Normally, there was one battalion aid station for each battalion, and itwas located near the communicating trench to the rear, utilizing any shelteravailable. Sometimes it was near the battalion post control, in order thatthe surgeon might be in close touch with his commanding officer, but insome divisions this was expressly forbidden on the ground that juxtapositionof the two aggravated the danger to both.11 Sometimesit was much farther back than the distance mentioned above, in order thatit might be accessible to ambulances. When the distance was more than 1,000yards (in the 4th Division 800 yards) relays of litter bearers were utilized.
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stationed at posts that distanceapart. Portage for 1,000 yards was the limit of a squad's endurance.12 When available, four litter bearers were employed to bring patients tothe battalion aid station, and if the moving squad was invisible to theenemy lines the litter was sometimes carried shoulder high. This portageover rough ground, through winding trenches, and by trails deep in mudwas slow, arduous, and, when the group was exposed to enemy fire for aconsiderable time, hazardous.9 After 10 or 12 hours ofsuch work under shell fire, bearers often became nervous and exhausted.While habitually the battalion aid station was located, if possible, ata point accessible by ambulance, this desideratum was regarded of secondaryimportance, the primary essential being such proximity to the front thatthe wounded would receive prompt attention.
The battalion aid stations of theAmerican Army in fixed positions were modeled on those of the British andFrench.9 These were rather elaborate installations, for heavybombardment often necessitated that they retain patients until after dark.In general, such a station as constructed by our allies, and taken overby our troops when serving with them, consisted of a series of communicatingrooms, 2 meters (6.5 feet) high and from 2 to 4 meters square (6.5 to 13feet). One room was for office purposes and the reception of patients,one for the application of dressings and for shock treatment, one for thebattalion surgeon, one for stores, and one or more for the personnel. Ithad 2 by 2 meter (6.5 by 6.5 feet) galleries, with two or three tiers ofimprovised litter racks, which sometimes accommodated 30 patients, butrarely more than 12.9 Usually, in a separate dugout at oneside, were two rooms for the bathing, emergency treatment, and re-clothingof gas cases. The doors to these aid-station dugouts were generally 3 feetwide and
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were protected by two tight-fittingblanket curtains placed at least 8 feet apart. These curtains were soakedwith alkaline or sometimes hexamethylenamine solution, and were so adjustedthat they would fall into place upon touching a release. The first curtainwas intended to be shut down before the second was opened. The descentto the battalion-aid dugout was found to be preferably at an angle of 30o;but as dugouts used by line troops were used commonly for aid stations,Medical Department personnel soon adopted the same angle of ramp as thatused by line troops. In such cases a litter chute was often made of greasedplanks nailed on either side of the stairs leading down into the station.An important item of station equipment was a water storage tank or well.Usually, light was furnished by petroleum lanterns, but a few of thesedugouts were lighted by electricity. Each attendant generally possesseda flashlight.9
To prevent water dripping into them,dugouts usually had corrugated iron ceilings. Walls were boarded and floorsprovided. Frequently, ceilings and walls were calcimined, or at least whitewashed.Some dugouts even had dining rooms. The depth of a dugout below the surfaceof the ground was usually 10 to 12 feet on an average, but in localitiessubject to shelling by heavy guns adepth of 20 feet was preferred. Dugouts situated on the higher level wereunprotected against direct hits by shells of more than 155 mm. caliber.13 Such shells rarely fell on the support trenches except during great activity.Whenever possible, cooking was done below; otherwise, food was broughtto the stations in marmites. Coke fires were made in braziers; ventilators,with dampers to exclude gas, tapped the principal rooms. While remarkableingenuity was displayed in making these dugouts comfortable, it shouldbe understood that the description given above is for the most elaborateones, and ordinarily they were much simpler.
On taking over French or Britishsectors, or in occupying them temporarily, the American Army fell heirto these subterranean battalion aid posts. While battalion aid stationsactually constructed by American troops were similar to those describedabove, they usually were much less pretentious. The medical personnel ofall our divisions received instruction in the subject of constructing themfrom the divisional engineers or at the Army sanitary school. In some casesour aid stations would accommodate 25 or 30 patients, but usually the numberwas 10 or 12.13
PERSONNEL
The personnel on duty at a battalionaid station consisted normally of one medical officer, a dental officerif available, and from four to six enlisted men of the Medical Department.11 These usually were supplemented by two runners and one or more litter squadsassigned from an ambulance company, the number of these squads being increasedif unusual activity was anticipated.11
SUPPLIES
Equipment, beyond that furnishedby Supply Tables, to a battalion included at least two Thomas splints,a shock table for warming patients,
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two 500-liter oxygen tanks, suitsof overalls, with gloves and masks, for attendants caring for gas patients,gas fans, and alkalies and sprayers for attendants to use in cleaning outthe galleries to which gas had penetrated.11
Supplies were brought forward asfar as possible by battalion medical carts or other vehicles. They werereplenished by one of several systems.14 That mostly commonlyused required empty ambulances to carry forward to the battalion stationor the ambulance head articles similar in kind and number to those theyhad brought back with patients. Another system was that of having the battalionsurgeon send, by runner to the dressing station, a list of the articleshe desired. A third method was that of the automatic replacement firstmentioned, supplemented, as required, by the second. The first system workedwell except during heavy engagements, when ambulances could not carry forwardall supplies required. Then the supplies they could not transport had tobe brought forward in trucks. The medical supply carts were not much used.At times of stress there was occasional shortage of litters, blankets,and large dressings, due in the majority of instances to the fact thatresponsible officers at the front had not foreseen their needs or thattransportation was inadequate.11 There was always a largesurplus of these articles constantly available in depots.11 If ambulances and trucks could not reach battalion aid stations, supplieswere carried forward by litter bearers from the ambulance head or the dressingstation.
In order to reduce transportationof equipment, on the relief of an organization in a sector, much of thatin its medical dugouts was sometimes left behind when the division moved.11 The 1st Division on one occasion thus transferred to its replacement matérielsufficient to fill several freight cars.15 These "trenchstores" usually consisted of all supplies and equipment which would notnormally accompany troops in a war of movement.
Service at battalion aid stationsincluded control of hemorrhage, application or readjustment of dressingsand splints, administration of antitetanic serum and of morphine, if indicated,emergency treatment of gassed cases, and the preparation of field cardsor diagnosis tags. When it was possible to do so, hot food or somethinghot to drink was given to patients. Slight cases of illness were treatedand returned to duty.
The following is taken from the reportof the division surgeon, 3d Division: 16
The treatment and evacuation of thewounded from a quiet sector, either with or without a perfected trenchsystem, was not difficult. The wounded were few in number; and as enemyfire was light, first-aid dressers and litter bearers had much freedomof action. Personnel and transportation were more than adequate. At thebattalion aid station, gassed cases could be stripped, bathed, and redressed,hot drinks and food given to all, shock cases recuperated, and many comfortsadministered.
When, however, a quiet trench sectorwas converted into an active one, the situation became very different fromthat just described. Time, personnel, supplies, and transportation, heretoforefully adequate, became insufficient, and the character of the work performedat the battalion aid station had to be modified accordingly, influencedchiefly by the number of patients arriving, extent of shelter available,and promptitude of ambulance service. For example, if ambulances were waiting,shelter inadequate for all
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the wounded, as along the Marne,and the action was not severe enough to preclude evacuation, disabled wereheld only long enough to receive the necessary first-aid and the antitetanicserum.
In order to expedite service, patientswere classified into several categories, each of which was cared for accordingto a definite plan. In the 3d Division the classification was as follows:(1) Very slightly wounded who were able to return to the line; (2) slightlywounded requiring evacuation: (3) seriously wounded; (4) patients withfractures; (5) severely wounded with considerable attendant shock; (6)gassed patients; (7) psychoneurotics; (8) sick.16
The patients in the first class weredressed and retained for the time being. Some of those in the eighth classalso were retained. All others were evacuated. Usually those in the secondclass were dressed only with first-
FIG. 14.- Adjusting improved split on a litter patient, Broussey, France, April20, 1918
aid packets, and most of them wereable to reach the ambulance dressing station unaided. Wounds of severelyinjured patients were lightly painted with iodine and an adequate dressingwas applied, antitetanic serum, morphine, and, if needed, a stimulant,were administered, and the patient was evacuated as soon as possible. Thedosage of serum was 500 units: that of morphia usually 16 mgms. Their administrationwas noted on the diagnosis tag, and often the letter "T" was painted withiodine on the forehead of a patient as soon as he had received the serum.16
Fractures were immobilized here bythe use of Thomas splints, if these had not already been applied. If apatient had been splinted, the splint was examined and, if necessary, itwas readjusted. These patients were handled as little as possible and oftenplaced in the ambulance on the same litters on which they had been broughtfrom the front. Patients in severe shock were held, if possible, untilreaction occurred. They were wrapped in
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blankets, given strychnine hypodermatically,and hot coffee or chocolate. As a rule, they reacted well.11
The most difficult patients provedto be those claiming to have been gassed.17 It was impossiblefor the surgeon to diagnose properly and promptly all patients claimingdisability from this cause, for he had no means of knowing whether a doubtfulcondition was one of delayed gas poisoning or gas fright.17 Somesuspected cases of gas poisoning were held for observation and cared forin dugouts, basements, or cellars. After a few hours' rest, almost allpatients, doubtfully gassed, were able and willing to return to the front.18 Frank gas-intoxication patients, received during very active operations,were evacuated immediately, taking precedence over all others, for at suchtimes it was impossible to strip and bathe them at the battalion aid station.Not only was personnel inadequate, but sufficient water was unobtainable,and they could not be retained with other patients because of diffusionof gas from their clothing. The psychoneurotics and sick were evacuatedif their condition demanded it. Of the former, patients with gas frightwere the most numerous and, as stated above, most of them were returnedto the line.17
A battalion aid station's activitiesin a moderately active defensive sector, as described, were often somewhatmodified by changed conditions. The administration of antitetanic serumwas not always possible, as sometimes there was none on hand.17 At some places no fires could be built to prepare hot drinks.17
During periods of intensive bombardment,when the trenches and back areas were subjected to destructive fire fromhigh-explosive shells, patients usually were moved under cover of darknessby ambulances which went directly to the battalion aid stations, if thiswas at all possible. Removal of patients by daylight, whether by litteror ambulance, under such circumstances would have exposed all concernedto needless risk. By day, it was impossible for ambulances to approachnearer to the front than 3 or 4 km. (1.8 to 2.4 miles) and removal by litterthen would have been unwarrantable, though litter bearers frequently ranforward, at great risk, during a lull in the enemy fire. When roads weresubject to interdiction fire, patients wounded early in the day did notreach hospital for 18 hours or more. Though, under such circumstances,they received every attention locally, except surgical intervention, theperiod of detention, dependent on military conditions, as a systematicprocedure, was cut to a minimum in order to reduce the danger incidentto the development of gas-forming bacilli in wounds. This danger, as notedin other chapters, had a profound influence upon the organization, equipment,location, and service of all medical units as far back as the base hospitals,for surgical interference within 12 hours proved highly desirable and,in the case of extensive wounds, essential.11
The French, in order to meet therequirement for early operation, made provision for a considerable amountof surgical work in their battalion stations, and when the sector concernedwas not very active this was accomplished, though not so well as in a fullyequipped hospital.19 The Americans
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did not follow this practice, andorders were issued that no operations be performed at such advanced posts.19 They believed the French practice caused dispersion of medical forces,and preferred to take some risks with the ambulance service in order tosecure for a patient early operation at better-equipped formation.19 Although ambulances were sometimes lost, their use as far forward as possibleand wherever possible presented many advantages. Patients carried by themsuffered less danger than those conveyed by litter, for the period of exposureto fire was less. There was a great saving of bearers, and the time oftransport was greatly shortened.
In many divisions the regimentalaid station was soon discontinued, while in others it shrank into a formationof very minor importance whose chief function was to give first-aid andmedical attention to the regimental headquarters detachment.20 Definite benefits accruing from discontinuance of this station were savingof time and labor, release of medical personnel for duty farther forward,and reduction in the number of points where patients were collected andrelayed.
The term "regimental aid station"persisted, it is true, but it often indicated a very different organizationfrom that contemplated in orders before the war began. Frequently it signifiedmerely the station of the regimental surgeon, the location of his office and the liaison point for the medical service of the regiment.20
At the time our Field Service Regulationswere drafted the regiment was approximately the size that a battalion assumedduring the war, new tables of organization having been published,21sothat the battalion station in point of fact performed the service formerlyintended for a regimental station. When employed as originally contemplated,the regimental aid station was similar to the battalion station which hasbeen described above, though it was somewhat larger and more elaborate.22 Sometimes the regimental station was the liaison point between an ambulancecompany and the battalion aid stations, but more frequently the formermaintained direct contact with the battalion aid station by assigning twoof its men as runners to each battalion station it served. When the regimentalaid station was not used, the dressing station frequently was establishedat the tactical point which it would have occupied.11
The sanitary train of each divisionconsisted of train headquarters, an ambulance company section, a fieldhospital section, eight camp infirmaries, and a divisional medical supplyunit.23 Three of the four companies in each of the ambulanceand field hospital sections were motorized, the fourth being animal drawn.
Headquarters of the ambulance companysection of the sanitary train habitually was located near that of thefield hospital, except during active
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periods, when the director of theambulance companies was usually to be found at the regulating station orat one of the dressing stations.
Each ambulance company had the personnelof the Tables of Organization, and, presumably, 12 ambulances. The companywas subdivided into two sections: One operated a dressing station or stations,and, if need be, removed wounded thereto by litter; the other operatedthe ambulances, whether working in front of the station or in the rearof it.24 Evacuation from fixed trench positionsinto other fixed formations to the rear was usually a comparatively simpleprocedure, though it required constant surveillance and adaptation to changingmilitary conditions.
LITTER-BEARERAND AMBULANCE SERVICE
As noted above, in active operations,one or two litter squads and two runners from an ambulance company werefrequently attached to each of the battalion aid stations. When a sectorbecame active the number of these squads was greatly increased, and whenunusual action was imminent or was in progress, certain divisions, e. g.,the 4th, assigned to duty with regiments all the ambulance company personnelthat could be spared for the purpose.25 Ambulance companies,especially those whose vehicles were animal-drawn, also furnished replacementsfor casualties in Medical Department personnel serving regiments and batteries.As the ambulance head often was located considerably farther forward bynight than by day--as, for instance, in the 1st Division at Seicheprey--usuallyactually reaching the battalion aid stations after darkness fell, nonambulantpatients were sometimes held at these stations until ambulances could reachthem; 26 but it was a general practice to remove patientspromptly, especially the most seriously wounded, if battle conditions permitted.As previously stated, if the distance from the battalion aid stations tothe dressing station was more than 1,000 yards, relay posts were establishedsimilar to those in advance of the former. At each of these, one or morelitter squads was stationed. In the 4th Division each of these relay postswas under command of a noncommissioned officer, and the distance betweenthem was 800 yards.27 Such posts were not usually necessary,however, if wheeled litters, or motor cycles with side cars, were availableand the terrain permitted their use; but in the Vosges, where the distanceswere exceptionally long between battalion aid stations and the ambulancehead, the 5th Division used these vehicles and also developed relay postsinto miniature emergency stations.28 The Anould sector,which this division then occupied, was very rugged, and wheeled litters,either horse-drawn or hand-pushed, proved invaluable. Sometimes two ormore were used tandem. Conveyances of this type were employed to advantagealso at odd times in places where their use was reasonably safe and otherwheel transport was not practicable. For instance, the 37th Division usedwheeled litters to carry dressings forward to battalion aid stations inaccessibleto ambulances.29 Motor cycles with side cars also attimes were used to advantage, those of English make proving preferable,as they were sturdy and usually had 8-horsepower engines.30 The35th Division in the Vosges used the French equipment identical with theSpanish mule litter for that sector.31
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When a division occupied a quiet,defensive sector and had its full complement of vehicles, it usually hadone of its motorized ambulance companies in active operation, the secondin support on the alert, the third in reserve, and the fourth at rest,while cleaning its vehicles.32
Many divisions, e. g., the 28th,organized motor repair parks.33 The animal-drawn ambulancecompanies made short hauls from battery positions and from points inaccessibleto motor ambulances and between the field hospitals when they were closelygrouped. Its personal often supplemented that of other Medical Departmentunits at the dressing station and at points in advance of it, and its wagonssometimes carried fuel and supplies to the dressing station or performedother miscellaneous services. Often only two animals were provided foreach ambulance of this company, and animal-drawn vehicles proved too slowand presented too large a target to be used to great advantage near thefront in trench warfare.34 Also, if the animals were requiredto haul the load necessary in active service they soon became exhausted,particularly if the sector was rugged or deep, and if the roads were inbad condition.
In general, the distribution of ambulancesin trench warfare was as follows: In advance of the dressing station establishedby the ambulance company (usually between 3,000 and 6,000 yards from thefront) two or three ambulances were parked at one or more points called"ambulance posts" or, more colloquially, "cab stands."32 In a deep, narrow sector there was usually but 1 of these posts, but the42d Division in the Baccarat sector used 11 of them, with 1 ambulance ateach stand.35 These posts were at the points farthestforward where vehicles would be reasonably safe, and beyond that, towardthe front, was the ambulance head, the farthest point to which ambulancescould reasonably go; sometimes, if the terrain permitted, these pointscoincided. Distance of penetration beyond the ambulance posts was dependentupon military activity, darkness, and road conditions. While after nightfallthe ambulance head was frequently advanced to the battalion aid station,during the day it was usually one or more kilometers in rear of it. Insome divisions, as, for example, the 1st,36 an ambulance oncall moved up after dark from its ambulance post to the battalion aid stationor to the ambulance head, and after taking its load to the dressing stationreturned to its post. If roads and the military situation permitted, ambulancesvisited battalion aid stations daily as a matter of routine. In some divisions,as soon as an ambulance had delivered its patients at the dressing stationit picked up another load of patients and went on to a field hospital inthe rear. It was soon found, however, that service in advance of the dressingstation could be performed best by the light Ford cars, which could gothrough mud and demolished roads more easily than other motor ambulances,while on the better roads in the rear of the dressing station, the heavierand more comfortable G. M. C. ambulances were preferable. This useof transport, first developed in the 1st Division and soon adopted by others,was often spoken of as "ambulance circuits," one set of ambulances makinground trips between their posts, battalion aid, and dressing stations,while another set made round
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trips between the last mentionedand the field hospitals. In the early days of American combat activities,before evacuation from field hospitals was taken over by corps and armysurgeons, there was a third circuit by ambulances under control of thedivision surgeon. This comprised the round trip between field and evacuationhospitals.36, 37
During the first operations in whichthe American Army participated the intradivisional and extradivisionalservices of ambulance companies were not clearly differentiated. Evacuationambulance companies were at that time attached to divisions, supplementingother ambulance companies of the sanitary train and operating interchangeablywith them. Though the system was satisfactory for conditions then existing,it was not suitable for open warfare as well, for which reason the followingsystem was adopted when the First Army was organized.37, 38
Division ambulance companies willtransport patients from battalion or regimental aid stations to the triageand division hospitals; an ambulance station will be established midwaybetween aid stations and triage; a reserve of ambulances will be stationedthere, sending one to the front to replace each one returning with patients.The loaded ambulance will return to this station after delivering its loadat the triage.
Evacuation ambulance companies willmove patients from the triage and field hospitals to evacuation hospitalsand loading platforms.
The adoption of this system, whichequalized labor and allowed time for rest and repairs, gave such satisfactoryresults that it was applied to each division successively entering theToul and Luneville sectors.38
Back of the dressing station eachdivision habitually maintained a relay ambulance post and regulating station,at a point past which all vehicles used for transporting wounded wouldtravel on their way between dressing station and field hospital. At thisplace were parked most of the vehicles of the company on active duty--ifthese were not distributed at the ambulance posts--and here the headquartersof the company in question was located. As one loaded vehicle passed onits way to the rear, an empty ambulance moved to the next station ahead,thus keeping up a circuit of empty vehicles to the front.34 If more ambulances were needed, the regulating officer sent them forwardfrom the park at his station. Though this was the most popular method oflocating and operating ambulances, it was modified in many ways, in greateror less degree, under varying circumstances. The 5th Division, in the Vosges,39when its sector was quiet, kept an ambulance at each regimental aid stationand held five in readiness in the company park near the field hospitals;but when an unusual action was imminent it disposed of its ambulances asfollows: From 3 to 4 at ambulance posts, from 3 to 6 at a point midwaybetween them and the field hospitals, and the remainder near the latter.39 Only under exceptional circumstances in trench warfare, as in the Chateau-Thierryand Champagne areas, was it necessary to use trucks for removing the wounded.In such emergencies every kind of vehicle returning from the front wasutilized, ambulances being reserved for the severely wounded. The intradivisionalservice by trucks was employed especially between dressing stations andfield hospitals.40
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FIG. 15.-Dressingstation operated by Ambulance Company No. 137, Amperbach, Alsace, August31, 1918
FIG 16.-Dressing station at Betricamp, France, April 26, 1918
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THE AMBULANCE COMPANY DRESSINGSTATION
Each division regularly establishedone or more dressing stations at a point or points accessible from allparts of the front served and also accessible to vehicles from the rear.Battalion aid stations rarely evacuated direct to field hospitals and evenmore rarely to evacuation hospitals. Dressing stations functioned properlyonly when placed on natural evacuation lines, as bearers almost inevitablycarried casualties to the nearest point where relief could be given. Thesestations were usually between 3,000 and 6,000 yards from the front, and,if possible, at relatively protected points, such as in buildings or cellars;sometimes dugouts were constructed like those for battalion stations, butthey were more elaborate. Thus in the Baccarat Sector the 42d
Division provided three gas-proofshelters for dressing stations from 2 1/2 to 3 miles behind the front,each shelter accommodating 20 patients, with facilities for bathing, treatmentof shock, hemorrhage, etc.41 The number of dressing stationsvaried from one to three, according to the width and activity of the sector.If the sector was narrow only one station was established, as a rule, tobe reinforced if need be by men detailed from other ambulance companies.Occasionally an advance dressing station was established, but in positionalcombat this substation was relatively unusual, being provided usually onlywhen vehicular traffic was not possible for some distance back of the front.When an advanced station was used, it frequently was from 1,500 to 2,000yards from the lines, and the main dressing station about the same distancein rear of it, at the ambulance head. If an advanced dressing station wasused, its personnel averaged 1 officer and from 8 to 16 men; that of amain dressing station was 2 to 6 officers and from 12 to 25 men. In somedivisions one of
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the officers attached to the dressingstation was charged with maintaining contact with the troops which thestation served and with supervision of the litter-bearer service betweenit and the battalion aid station, while in others, e. g., the 2d Division,42an officer was especially assigned to the same service without being assignedto the dressing station.
Organization of the dressing stationvaried considerably, naturally being most elaborate in the comparativelyfew divisions which used this formation as a triage or sorting station.In the 42d Division, which employed its dressing station as a triage, theorganization was that described below.43 This descriptionapplies especially to the dressing station, as that division developedit in open warfare, but is given here as the organization was inauguratedin trench sectors. The station consisted of the following departments:43
(1) Receiving and forwarding department,subdivided into two sections concerned with (a) transportation, and (b)sorting and checking of patients. The former section consisted of a transportationofficer and a sergeant, who supervised the dispatch of ambulances bothto the front and to the rear, controlled the number working in either direction,and supervised the loading and unloading of patients. The last-mentionedservice was performed by a group of eight litter bearers. A sorting andchecking officer examined all patients on admission, returned to the frontthose needing no further treatment, and distributed others to proper departmentswithin the station, designating which patients required immediate attention.He was assisted by a few enlisted men who, under instruction from a commissionedofficer, gave nourishment, adjusted bandages to minor injuries, administeredantitetanic serum, and attended to the comfort of patients. Those not requiringspecial treatment in this department were held until evacuated, and unnecessaryhandling of patients was thus avoided. Two or more clerks listed all casualtiesand checked up the administration of serum.
(2) The general dressing room wasmanned by from 2 to 4 medical officers and 4 competent noncommissionedofficers, all of whom were engaged in adjusting or applying dressings,administering morphia and antitetanic serum, if these had not already beengiven. In addition to the foregoing, two men were engaged in sterilizingand filling syringes with antitetanic serum.
(3) The orthopedic department caredfor all fractures, readjusting or applying splints as required, and givingany other treatment needed, including that for shock. Personnel of thisdepartment consisted of the division orthopedist and two trained enlistedassistants.
(4) The gas department was locatedin a room, not communicating with any room, for wound-dressing purposes.Here, under direction of the divisional gas officer, gassed patients werestripped, bathed, and reclothed with such raiment as could be obtainedfrom the salvage section.
(5) A complete company kitchen waskept in operation day and night, supplying hot food and hot coffee to patients,duty personnel, and casuals. This service proved highly important, especiallyin cold and wet weather.
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(6) The medical supply departmentof the station pooled the property of companies serving it, replenishingby issues from the divisional medical supply unit.
(7) The salvage department collectedall equipment no longer needed for patients, and from it issued necessarysupplies such as blankets and canteens, the latter being used as hot-waterbottles.43
The personnel operating the dressingstation triage of the 42d Division was drawn from all four ambulance companiesand was assigned in 12-hour shifts, if the rate of admissions did not requirelonger hours of duty.44
When a dressing station was usedas a triage, the division orthopedist, psychiatrist, and gas officer wereregular1y attached to it, together with an officer possessed of good surgicalexperience and judgment,45 and sometimes an understudy was assignedfor the relief of each of these officers. Usually a dressing station, usedas a triage, was located at the point farthest forward, where, with reasonablesafety, ambulances could be concentrated, and these were grouped near it.In the Baccarat sector, at one time, the slightly wounded, because of tacticaldisposition, could be sent direct from the dressing station to an evacuationhospital and all others to the designated field hospital (see order quoted,p. 386), but usually all patients were sent to the appropriate field hospital.
As the great majority of divisionsdid not use the dressing station as a triage, the personnel of the station,normally, was less numerous than that of the station just described, andwas habitually drawn from but one ambulance company; the equipment wasless elaborate and the organization was simpler. In all respects, however,there was great mutability and flexibility in all such stations, allowancesof personnel especially being changed frequently to meet varying needs.11
At dressing stations the sick andwounded were classified according to the nature of their disability andits degree. By the first classification, injuries caused by gas, miscellaneoussickness, psychic disorders, venereal diseases, skin diseases, and convalescentswere separated. The second classification, pertaining to the degree ofdisability, ranged from malingerers to fatal wounds or illness. It hadcertain more or less arbitrary and fluctuating subdivisions. For example,the wounded often were classified as "very slight," "slight," "serious,"and "nontransportable." Practical application was given to this gradation,for patients in the first class were returned to duty; those in the secondclass were sent to hospital, walking or sitting; those in the third classwere sent recumbent to hospital; while patients in the fourth class wereheld until they rallied and then were evacuated with exceptional care.Similarly, the sick, the gassed, and those suffering from gas fright wereclassified either as "seriously disabled," who should be retained untilthey rallied or be evacuated at once, and the "slightly disabled" or "subjectivelyaffected," who could be returned to duty. Men claiming mental or nervousdisability were especially difficult to classify, for some of them weremalingerers, others were slightly affected but magnified their symptoms,and a few were bona fide cases of disability."11
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Whether used for triage purposesor not, at the minimum the functions of a dressing station were to receiveand classify patients, give emergency treatment--that is, control hemorrhage,treat shock and gassing, readjust splints, administer antitetanic serumif it had not already been given, and morphine if indicated--supply nourishment,group the disabled, and forward them to their designated destination. Yet,normally, the last was the work of the triage hospital, and as a matterof fact, sorting of patients at the dressing station with a view to directdistribution to appropriate hospitals was unusual except in the divisionsof the First Corps,46 or when the seriously wounded were sentdirect from dressing station to the proper field hospital without passingthrough the triage hospital. Few operations were performed at the dressingstation, and these were minor ones; but they sometimes included closureof aspirating chest wounds by a few silkworm-gut sutures, and when absolutelynecessary, ligations.47 If a hemorrhage was not checkedby operation, the wound was packed and a tourniquet applied which was leftloose in place after hemorrhage had ceased. Ambulance orderlies were instructedto tighten the tourniquet, if necessary, when en route to the hospital.47 Patients in shock usually were held until they rallied, and the sick wereretained until a full ambulance load of them could be sent back. Soldiersnot incapacitated for performance of duty, after receiving all necessaryattention, were returned to their organizations. The field medical cardsof patients admitted were made at the dressing station and records of themmade, if other work did not prevent. Patients able to walk to field hospitals-about40 percent of the total-were sent back to them in groups.48 In practically all divisions the dressing station was also the MedicalDepartment supply point for regiments and batteries. Supplementary to dressingstations, rest stations for furnishing nourishment and medical aid wereestablished by the 4th Division along its evacuation routes, in connectionwith relay posts.49
Though the foregoing descriptiongives in general terms the usual operation of a dressing station, certainindividual methods were employed by the several divisions at differenttimes; but these were transient or of relatively minor importance. Considerablemutability in personnel, matériel, organization, and thoroughnessof treatment characterized practically all these stations, for in all thesecharacteristics they were influenced profoundly by military conditionsvarying from quietude to intense activity.
The field hospital section of thesanitary train consisted of four of these hospitals,50 eachaccommodating 216 patients. The personnel authorized for them is notedin Tables of Organization in the Appendix (p.1054), but in the World Warthis was augmented by the assignment of divisional specialists and, asoccasion required and resources permitted, of operating and shock teams.The equipment of all these hospitals was at first identical, but later--asnoted below--it became considerably diversified when the field hospitalswere specialized. In some divisions field-hospital facilities for nontransportablewounded were further increased by the assignment to them of mobile surgicalunits, but
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as only 12 of these formations becameavailable before the armistice, the result was that the plan of supplyingone to each combat division did not fully materialize.51
In trench warfare, field hospitalswere located from 10 to 15 km. (6 to 8 miles) behind the front, or frequentlyfarther back, in order to be beyond range of ordinary shell fire. The distancevaried considerably, being influenced by proximity to the front of suitablebuildings, and considerations similar to those affecting the location ofevacuation hospitals (q. v.), especially convenient roads and availabilityof water and fuel. In order to utilize buildings to the best advantage,a field hospital occupying them was at times somewhat scattered, but wheneverpossible near-by buildings were used.
FIG. 18.-FieldHospital No. 112, 28th Division, Cohan, France, August 12, 1918
Often field hospitals were comfortably,even luxuriously, established in towns, chateaux, or barracks, and whensuch hospital sites in buildings were taken over from the French, manysupplies were sometimes transferred with them, thus expediting puttingour field hospitals into operation.52
It should be remarked here as affectingfield hospital shelter that, in the early days of American service in France,the use of tentage near the front was disapproved, on the ground that itwas readily visible to enemy aviators and betrayed the presence of troops.52
Profiting by developments in themedical service of the 1st Division at Cantigny, field hospitals in alldivisions rapidly became specialized.52 Gen-
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erally speaking, one developed intoa hospital for nontransportable wounded, and a second into a hospital forgassed patients, with corresponding changes in equipment, the others retainingtheir original purpose and their original equipment; but there were manymodifications of this plan. Very generally the divisional triage or sortingfield hospital also received the seriously wounded and sometimes the gassed.52 Almost without exception only one triage was maintained by a division inpositional warfare, but the 26th, in the Toul sector (April and May, 1917),having a frontage of 17.6 km. (11 miles), then operated two, one behindeither flank.53
FIG. 19.-Field Hospital No. 125 near Jaulgonne, France, July 29, 1918
In a quiet trench sector a commonmethod of dividing the field hospitals was the following: (1) Triage andcare of wounded and gassed patients; (2) sick; (3) skin and venereal diseases;and (4) reserve.11
Frequently the last was used as aconvalescent camp, to care for transportable patients, or to supplementone of the other field hospitals, as required. When not actively operating,its personnel was often assigned to one of the other field hospitals. Underthese conditions it was the practice to retain in the division field hospitalsall patients who were likely to be fit for duty in from 10 days to 2 weeks,or who could be treated here as well as farther to the rear; for example,skin and venereal cases. Then, only those requiring definitive surgicaltreatment or such of the sick as would require prolonged or exceptionallyexpert treatment were evacuated.14
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When a trench sector became moderatelyactive, a division often continued to hold its cases of war neuroses, slightlygassed and slightly sick, making such use of its field hospitals as thefollowing: (1) Triage and care of non-transportable patients (wounded orgassed); (2) slightly wounded; (3) sick, slightly gassed, convalescents;and (4) reserve. When called into operation the reserve hospital frequentlycared for the gassed cases.11
If the enemy was very active, asin the second battle of the Marne, all field hospitals were opened andutilized as described under the caption "Open warfare," evacuating patientsas rapidly as possible.
Selection of nontransportable patients,as contrasted with the severely wounded (for the two categories did notexactly correspond) was difficult and subject to change in standards imposedby the changing military situation. When divisions were actively engagedin trench warfare, as along the Marne and in the Champagne areas, manypatients who otherwise would have been retained had to be evacuated.
The reports of the Medical Departmentactivities of the several combat divisions, from which this chapter islargely derived, do not differentiate in their descriptions, except ina few matters such as those noted above, the service of field hospitalsin trench and in open warfare. Further information on the subject willbe found in the section of this chapter which treats of these units inopen warfare. It is only necessary to note here that methods in open warfarewere similar to those in trench warfare except that in the former fieldhospitals usually occupied tents, moved frequently, were employed in amore diversified manner, were more subject to enemy fire, underwent greaterstrain, and had greater difficulties both in bringing up supplies and ineffecting evacuation of their patients.
CARE OF CASUALTIESIN COMPANIES, BATTALIONS, AND REGIMENTS
In open warfare the problem of caringfor the wounded on the battlefield and of removing them to field hospitalswas very different from that presented when troops were in the trenches,and its solution proved much more difficult as well as more varying.
A company aid post was sometimesestablished, as in the 90th Division, which located it at or near the companypost control;54but very few divisional histories make any mentionof this formation in open warfare, though that of the 5th Division notedthat two enlisted men of the Medical Department continued to be attachedto each company as was the case in the trenches.55 When used,this post was located at any shelter available--a shell hole, for instance--andthe wounded were brought to it; but much more frequently the wounded weretaken to any sheltered place near which they fell, and dressings and splintswere there applied. The equipment of the Medical Department men detailedto render company aid was very simple, consisting chiefly of dressings,splints, tourniquets, and stimulants, for it was limited to such
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articles as they could carry whentroops moved forward.56 They placed these articles inany receptacles available, such as pouches, sacks, and gun cases. Afterdressing a patient they again advanced with the troops to which they wereattached.
In open warfare, even more than wasthe case in the trenches, the importance of the battalion aid stationstended toward their substitution for that of the regiment. These stationswere placed as near the front as possible. In the 2d Division, inthe beginning of the offensive against Soissons, one station was locatedwithin 50 yards of the enemy lines.56 During that operation,battalion aid stations in that division were from 1 to 8 km. (0.6 to 4.8miles) in advance of the triage hospital.57 In the 5th Divisiontwo aid stations to a battalion, each under a medical officer, were placedin the support lines, in rear of the flanks of the battalion.55 Whenever possible, battalion aid stations were placed as conveniently aspossible to natural routes of evacuation, for otherwise they did not function,as litter bearers went to more accessible locations. As the prime considerationsfor these stations were proximity to
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the front and some shelter from hostilefire, they occupied any well-located spot affording some protection, suchas a shell hole, cellar, culvert, quarry, dugout, or behind a ruined wall.Actually they were exposed to heavy fire from infantry, machine guns, andartillery. Occasionally they received direct hits by shells, as in the90th Division, but sometimes then they escaped injury to patients or personnel.52 Sometimes, as in the 2d Division at Vierzy, in the Chateau-Thierry area,56andin the 3d Division during the Meuse-Argonne operation,58 twoor more battalion aid stations--perhaps those of different regiments and,in the latter offensive, even those of neighboring divisions--consolidated.Such a course was rendered advisable at times by the proximity of the organizationswhich they served, and the paucity of available shelter and of evacuationroutes. Furthermore, such consolidations gave opportunity for mutual exchangesof supplies, allowed the personnel to work in shifts instead of continuously,and facilitated ambulance evacuation by reducing the number of stationswhich the ambulance companies had to locate and clear. Battalion aid stationsin open warfare were much more simple
FIG. 21.-First-aidstation, 4th Division, Septsarges, France, September 27, 1918
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than in trench warfare, for therewere neither time, facilities, nor transportation for their elaborate development.Habitually, regimental Medical Department detachments were supplementedby details from the ambulance companies. To mention but two of many instancesof this practice, the 2d Division in the Chateau-Thierry region assigned160 ambulance company men to duty with the regiments,59 andthe 90th Division in the St. Mihiel operation thus assigned 80 men from3 of its ambulance companies.60 The manner of distributingthese men varied considerably in the several divisions. Sometimes theywere allocated by the regimental surgeon to the battalion aid stationsneeding them most, where they worked under the battalion surgeons.
FIG. 22.-First-aid station, 325th Infantry, near Fleville, Ardennes, France, October12, 1918
Sometimes, though assigned to thesestations, they remained under control of the officers of ambulance companiesdetailed with them. In many divisions the ambulance company litter bearerscarried patients from the front lines to battalion aid stations as wellas thence to the ambulance head. As described earlier, most divisions detailedmen from the line companies to act as litter bearers. Bandsmen, when employed,performed similar duties, but, as previously stated, their service as litterbearers was soon discontinued. Prisoners also were used wherever most needed,until their employment near the front was prohibited, and thereafter theycarried patients only when on their way back from the front.11
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In open warfare, provision in adequatequantity of even the most necessary supplies was an urgent and difficultproblem for battalion aid stations. Frequently, stations could be suppliedwith only such matériel as enlisted men could bring upon their personsfrom the dressing station or ambulance head. For this purpose they usedany available receptacle; wheeled litters if these were at hand. The battalionmedical cart proved too heavy for its one animal, and it usually remainedwith the train. Whenever possible, supplies were sent up by ambulances,or, in case of need, by trucks of the sanitary train.11If thesevehicles could not reach the battalion aid station they transferred theirsupplies to litter bearers at the ambulance head. The same replacementmethods were used as in the trench warfare; that is, for each article sentback from the front an equivalent one was sent forward from the dressingstation. Supplies also were sent forward on requisition. If matérielneeded by battalion aid stations was not on hand at the dressing station,the first ambulance going from it to the triage carried to the supply "dump" or unit there a request for the needed articles, and they were sent upby the supply officer by the next ambulance going forward.
Sometimes, after an offensive had begun, no attempt was made for an hour or two to bring in the wounded fromthe forward area to the aid stations, for the reason that attacking and support troops were under heavy direct fire from theenemy, and any attemptby a litter group to remove the wounded would have been folly. After thistime had elapsed, however, enemy fire usually slackened or was directedagainst the troops as they advanced, and litter evacuation could be conductedwith less danger.11 Meantime, Medical Departmentpersonnel with the attacking troops dressed the wounded, applied splintsand placed patients at any sheltered points accessible. The "first-aidpacket" was generally used for bullet wounds, and this or the "front packet,"as required, for shell wounds. Fractures were immobilized usually by theThomas splint. As the troops advanced, the battalion aid station movedforward to successive locations.11 Thus in the 78th Divisionsuch a station was scarcely established before its personnel again advancedto open a new-one. In such cases "collecting points," which sometimes correspondedto a centrally placed battalion aid station, were often established, wherepatients were collected to facilitate evacuation by ambulance company personnel.11
In open warfare service at battalionaid stations was similar to that given at such stations in the trenchesso far as facilities permitted. Wounds were redressed and splints adjusted,if necessary; hemorrhage was checked and shock controlled, as well as possible.Gassed patients were given as much relief as practicable. Usually, antitetanicserum was administered here. The 3d Division stressed this point.17 Because of road congestion and heavy enemy fire, patients sometimes hadto be kept in a battalion station until nightfall. During the Meuse-Argonneoperation it was frequently remarked in the hospitals that patients withcomparatively slight wounds were gravely shocked--a condition attributedto cold, exposure to wet, and to exhaustion. Even if supplies werebrought forward in considerable quantities, little could be done to combatshock at the battalion stations other than to rectify splinting, to applyblankets properly, and to administer morphine.11 Therefore, the
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wounded were removed systematicallyas soon as diminished intensity of enemy fire permitted this procedure.Yet the retention of shock patients until they rallied, instead of removingthem immediately, was advocated in some divisions, notably the 3d Division,17but, as has just been stated, as a general rule, patients were evacuatedas promptly as possible.
As soon as they could be removed,patients who were unable to walk were taken from the battalion aid stationeither by litter bearers or--oftener after nightfall--by ambulances comingas far forward as the station. This was done despite the fact that thisplan caused numerous casualties and the loss of much-needed cars. Their coming to these stations was considered expedient because evacuation wasthereby expedited.
The following vivid description offront line and battalion service is taken from the report of the MedicalDepartment activities of the 1st Division in the offensive toward Soissons:61
Battalion surgeons and enlisted personnelaccompanied their units and established aid stations and collecting pointsas close to the firing line as the terrain would permit. They moved forwardalmost hourly during the five days of battle. While advantage was alwaystaken of protected points, the collecting stations during the greater partof the advance were in hastily dug holes, in open fields, shell holes,old gun emplacements, etc.; at other times under shelter of hills, in cellars,or behind ruins of buildings or low embankments along the sides of theroads. After the first two days in this offensive there was a great shortageof litters, and other supplies proved insufficient. These had been carriedby corps men in pouches, sacks, or "feed bags." German equipment was huntedfor on the field. Litter bearers were constantly in the open, under machine-gunand shell fire, and a number of them were killed. German prisoners wereused as litter hearers, and some wounded were removed (contrary to existingorders) by men of the line. First-aid dressings and splints were appliedat the first point behind the line when there was comparative protection.Litters were often improvised, that extemporized from the blouse, withrifles for side bars, being the most common. Often, because of heavy fire,the wounded were kept in shell holes until nightfall. As no hot refreshmentwas available in advance of the dressing station, the wounded reached thatpoint in much worse condition than would otherwise have been the case.It was impossible for the rolling kitchens or water carts to get up closeto the line, and the dressing stations therefore dealt with wounded whosevitality had been lowered by lack of food and water.
In the early part of the St. Mihieloperation the 5th Division transported by litter such of its wounded aswere unable to walk, but the supply of litters was insufficient to meetthe need, as was also the number of bearers. This condition was attributedto the irresponsibility of bearers from the line, for though provisionhad been made for their detail, these bearers had not then been organizedinto squads under noncommissioned officers. In this extremity additionallitters were brought up, and prisoners also wereused as bearers.62
Because it was impracticable to usemounted messengers or to have direct telephonic communication from themore advanced formations, maintenance of contact, or liaison, between thebattalion aid stations and the dressing station was much more difficultin open than in trench warfare. Enemy fire, shell holes, dense brush orforest, barbed-wire entanglements, abandoned trenches, movement of stations,ignorance of the newly occupied terrain, and--during the time when thewounded could be moved with the greatest safety--darkness, all conspiredto aggravate the difficulties of maintaining contact.
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The report of the Medical Departmentactivities of the 35th Division records that line officers supplied medicalofficers with insufficient information concerning forward movements andthat battalion and ambulance company personnel had inadequate knowledgeof each other's locations.63 Usually, contact in the severaldivisions was maintained by two runners detailed from the ambulance companiesto each battalion aid station, and if these failed, returning litter bearerswere interrogated. In the 90th Division five men were assigned to eachbrigade for liaison service.64 In the 5th Division contactwas maintained between regimental and battalion stations--which were locatednear their respective control posts--by runners from the regimental medicalpersonnel or from the regimental and battalion message centers and by telephonebetween them.65 Battalion medical officers usually maintaineddirect contact, through runners or litter bearers, with the ambulance companyand, with line officers, before each engagement made a reconnaissance ofthe terrain, with a view of determining the location of future stations.11 The regimental surgeon was required to keep himself informed at all timesof the location of his aid stations and of dressing stations and to keepsubordinates acquainted with the exact location of dressing stations, relayinghis information in both directions. He required that whenever one of thebattalion stations moved he be notified and that whenever one of theserequired an ambulance he be given clear directions concerning the station'sposition. In the Meuse-Argonne operation, however, battalion aid stationsin some regiments of this division maintained direct contact with ambulancecompanies without the regimental surgeon acting as an intermediary. Thiswas the habitual practice in other divisions.11
In the 2d Division the divisionallitter bearer officer (so detailed) and his subordinates knew where thebattalion aid station would be located at the jump-off, and had determined,after reconnaissance with line officers, where they would be located ifthe attack progressed as anticipated.66 He determined,likewise, the present and future sites of the dressing stations, with theroads and paths leading to them from battalion aid stations. Before theattack, litter squads were placed well forward toward the stations theywould be required to evacuate. In these duties he was assisted by two officersfrom each ambulance company, both before the attack and during its progress,who commanded the litter bearers details and gave them full informationconcerning the present and future locations of the formations with whichthey were concerned. He continued to perform the duties of reconnaissanceand supervision throughout the attack.66
The two outstanding lessons developedby experience in the 78th Division were recorded as follows:67
Arrangements must be made in advanceand personnel trained to maintain an absolute chain of liaison, no matterwhat troop movements may occur in a sector, say, 10 km. (6 miles) in widthand 20 km. (12 miles) in depth, and that in preparation for an expectedmilitary operation of whatever nature it is extremely important to prescribe,not the actual location of dressing stations and field hospitals, but theroad or roads along which Medical Department communications, includingsupply and evacuation and liaison, will be conducted.
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Difficulties of liaison arose throughthe following causes: (1) Difficulties of terrain. (2) Lack of trainingof medical personnel. (3) Failure of front line personnel to send backto the sanitary train or division surgeon information concerning location.(4) Interchange of battalions between front line and brigade or divisionreserve. Since cipher telephone calls followed organizations to their newlocations, it was only by obtaining from G-3 the names of organizationsoccupying certain aid posts that the reserve station could communicatewith these aid posts except through its own evacuation service.67
Eventually, in many divisions, responsibilityfor maintenance of contact was placed on ambulance company commanders,who effected it in front of the dressing station, as described above, byassigning runners to aid stations, and to the rear by ambulances and motorcycles.
Few divisional histories make mentionof the regimental aid station toward the end of the war, for it was generallydiscontinued then for its original purpose; but some divisions continuedso to use it. For example, one regiment of the 5th Division in the Meuse-Argonneoperation established both regimental collecting stations and regimentalaid stations, the former in advance of the latter.68 Six bearers from each line company carried patients to these points fromthe battalion stations. In the 3d Division, during the same action, the7th Infantry at one time evacuated through a regimental aid station, whileother troops evacuated direct from the battalion aid station to the dressingstation.69 Liaison between the regimental aid stationand the dressing station was maintained by runners, by litter bearers,and by telephone from the advance post control. Whenever possible, collectingpoints for regiments were on roads.
Control of the walking wounded presenteda grave problem. The need of military police to direct the movements ofthese was remarked by some of the divisions in the Meuse-Argonne, especiallywhen the country was open and rolling and hills afforded some shelter.Men seeking cover or escape from enemy fire would leave the roads and followhill contours or would attempt short cuts, with the result that some wandereduntil exhausted. The situation was met to a degree by sending wounded mento the rear in groups under escort.11
MEDICALSERVICE OF ARTILLERY AND MACHINE-GUN COMPANIES
Medical service of batteries andmachine-gun companies was similar to that of the Infantry. Two enlistedmen of the Medical Department were attached to each battery or company,and sometimes utilized selected shelter as an aid station. For example,the medical detachment with the 13th Machine Gun Battalion of the 5th Divisionoccupied a dugout 100 yards in the rear of its position at the commencementof the St. Mihiel operation.70 In the Meuse-Argonne, whenthis battalion was split, one company going to each flank of an Infantrybattalion, its aid station was established in a shell hole midway betweenand behind them.70 In the 19th Field Artillery the regimentaland battalion aid stations were located near the respective posts of command.71
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The methods of the sanitary trainin open warfare also differed from those in trench warfare. Difficultieswere augmented greatly by the prolonged increase in enemy fire, road congestion,movement of troops and of Medical Department formations serving them, limitedfacilities for supply, increased numbers of wounded, greater needfor Medical Department replacements, inexperienceof these replacements on arrival, and by physical exhaustion caused bylong-continued hard labor and by exposure. During the Meuse-Argonne operationthe strain on the Medical Department was further intensified by an epidemicof influenza, which nearly decimated its effectives. These subjects willbe discussed in more detail in appropriate chapters.
The method for employing ambulancecompanies in trench warfare was, in general, followed when our troops assumedthe offensive in open warfare, but there were some differences in detail.Sometimes two or more ambulance companies were consolidated, as in the2d Division in the offensive against Soissons.72 Muchlarger details of litter bearers were commonly assigned with regimentaldetachments; and at times, when regimental personnel could not cover thefield, every man who could be spared from the ambulance companies was thusassigned. Usually, the ambulance personnel with regiments was drawn fromseveral companies; much less frequently one company was so assigned almostin its entirety, or more than one company might be so used. At times, asin trench warfare, and as noted above, the ambulance company bearers servingwith regiments were placed under the orders of the battalion surgeons concerned,but sometimes they operated under their own officers. Both practices werefollowed in some divisions (as in the 3d)73 at different times,the latter method coming to be more highly regarded. The 2d Division reportedthat the system of having patients brought to aid stations and collectingpoints by litter bearers with regiments--including details from line andfrom ambulance companies if these were needed--and of having evacuationsback of these effected as usual by the litter-bearer sections of the ambulancecompanies proved highly satisfactory.74
As in positional warfare, in alldivisions the litter-bearer sections of the ambulance company cleared thebattalion aid stations, if these were not accessible to ambulances, andfrequently established collecting points at convenient places, preferablyconvenient to vehicles. Here patients from battalion stations were gathered,and thence they could be carried by litter to the dressing station or couldbe reached from there by ambulances. The 5th Division, for example, establishedeight such collecting points during the MeuseArgonne.75 Just as in trench warfare, the litter-bearer sections established relaypoints if necessary, but there was a progressive tendency to advance theambulances, even at considerable risk, and collecting points were, in fact,relay points as well, if litter-bearer service back of them was necessary.Habitually they were accessible to ambulances if battalion aid stationswere not. Often a subsidiary or advanced dressing station was establishedand
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patients were brought to it by litter.If this advanced station was not accessible to ambulances by daylight--aswas often the case--patients had to be carried by litter farther back tothe main dressing station, the advanced station then being used asan elaborated relay point.11
In the 2d Division during the St.Mihiel operation, as battalion aid personnel moved forward to open new stations, detachments of the Medical Department with support and reservetroops successively took over care of the casualties in stations left behind,until in turn they were taken over and evacuated by an ambulance company.74 Later the ambulance company took over these unfortunates direct from medicalpersonnel in the advance lines.
After the delay in evacuation experiencedat Soissons, this division designated a divisional litter-bearer officerand two commissioned assistants from each ambulance company. Under thegeneral direction of the litter-bearer officer, the noncommissioned assistantshad command of the litter-bearer squads used to clear battalion aid stations.When the battalion surgeons advanced they were accompanied by runners who,for the ambulance companies, maintained liaison between the new aid stationand the former one, so that after clearing the one farther to the rearthe ambulance company could locate with certainty the one farther advanced.As a result of this arrangement the battalion surgeon and his detachmentkept near the troops they served, and battalion litter bearers, evacuatingpatients from the place where they fell, had to go no farther back thanthe battalion aid station last established. When the ambulance companytook over a station the battalion surgeon had to give it no further thought.76 But until that time, if he and his personnel moved farther forward, itwas the usual practice to leave one or two attendants until the stationwas taken over by a detachment with support troops, or until the ambulancecompany came up. The method employed in the 2d Division at Mont Blanc isdescribed as follows.77
The enlisted men of the Medical Departmentwith the companies followed the attack, dressing the wounded, who werecarried back to battalion aid stations by company litter bearers (12 menfrom each infantry and machine-gun company) as provided by divisional order.* * * As battalion aid stations advanced, the old stations were taken overand cleared by ambulance company litter bearers under their litter-bearerofficers, who maintained liaison with advancing battalion aid stations.The division litter-bearer officer, meanwhile, was everywhere, seeing thatthe work of litter bearers was coordinated and that ambulance posts werekept well advanced. With two Army ambulance sections operating Ford carsand G. M. C. ambulances assisting when needed, the wounded were rapidlyremoved from the sector and congestion rarely occurred.
In general, ambulances were operatedunder the system developed during trench warfare; that is, with a regulatingstation, ambulance posts, an ambulance head, service by circuits, the lightFord cars operating in advance of the dressing stations, the heavier G.M. C. or other cars in the rear of it. As in trench warfare, usually theambulance companies on active duty rotated by roster, in order that oneor more might repair cars while resting; but in periods of stress thisarrangement was not feasible. There were so many differences in the detailsof applying the ambulance company system that it is considered advisablemerely to mention here the more usual, typical practices, reserving morelengthy discussion for appropriate chapters.
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One of the most conspicuous differencesbetween ambulance service in trench and in open warfare was that, in openwarfare, especially during the Meuse-Argonne operation, animal-drawn ambulancesproved of great value and were much more frequently employed. This wasdue chiefly to the fact that they could go over routes impassable to motorvehicles, and often, by leaving the road, could pass obstructions whichblocked other traffic.
In narrow sectors it was a commonpractice during the Meuse-Argonne operation for a division to operate butone ambulance head, served by several companies through one regulatingstation. The 90th Division reported that in that engagement its ambulancesoften reached battalion aid stations 300 yards from the line, but thatat first roads were in such frightful condition and so crowded that notmore than two round trips could be made in 24 hours.78 In other divisions in the early part of this operation one round trip sometimesrequired as long as this.
A regulating station often was operatedin conjunction with the dressing station, and ambulances were parked near. Under such circumstances the directors of ambulance companies worked inconjunction. Here, the wounded were not out of danger from shells and gasafter being placed in ambulances, for roads and approaches to dressingstations which occupied sites known by the enemy to afford some shelterwere often shelled and bombed.
Ambulances were sent up regularlyafter nightfall or on demand of the battalion surgeons, as in the 5th Division,80to battalion aid stations, if the military situation permitted. The 2dand 32d Divisions, like practically all others, increased their evacuationresources, in times of stress, by using the trucks of the sanitary trainand any other trucks obtainable.81 In the 32d Divisionthe sanitary trucks carried six litters lengthwise on the bottom of eachtruck and six crosswise on the sideboards, lashed in place by wires engagingthe hooks provided for the cover fastening. Sitting cases were removedin groups of 24.81 On their return trips these trucksbrought up supplies. They were used especially to clear field hospitals,but if need arose they also cleared dressing stations. Supply and ammunitiontrucks returning empty were also used to carry the wounded, for withoutexception the ambulances available in large engagements during open warfareproved utterly inadequate. One result of this was the increased difficultyin renewing medical supplies at forward points, for trucks returned tothe front filled with their normal loads, and the ambulances moving forwarddid not have capacity to carry matériel sufficient to replace fullyall supplies that had been sent back with patients.82 Trucks of the divisional sanitary trains relieved this condition, but later,in many divisions they were pooled with those of other trains, after whichany trucks obtainable were utilized for wounded. This pooling of sanitarytrain trucks with others interfered with the availability of these vehiclesto the medical authorities, but apparently was necessitated by militaryexigencies.
The most serious difficulty experiencedin ambulance company service in open warfare in the early part of the warwas the necessity for sending ambulances to points far in the rear. Duringthe early activities along the Maine, though additional evacuation ambulancecompanies were provided
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to evacuate divisional hospitals,ambulances proved inadequate at times; for example, when they had to carrypatients 60 km. (37.2 miles) or more to evacuation hospitals. The 2d Division,during its action along the Maine, had a total of 200 serviceable ambulances,including those of its own sanitary tram and those assigned to it.51 Before the St. Mihiel operation arrangements were made to avoid the necessityfor these long trips by divisional ambulances by providing ambulance companiesoperated by the corps and army to clear the field hospitals.83
The supplies of ambulances were increasedas the war progressed. In the 42d Division the following articles wereadded to their regulation equipment: Ammonia, ampules, boxes, 10; catheters,4; coats, gas, 2; masks, M2, French, 4; mittens, gas, 2; oxygen tanks,small, and connections, 4.
As a rule, two or three dressingstations to a division were established according to the width of its sector,availability of roads, and military activity. It was a common practicein some sectors to utilize two ambulance companies in the service of onemain dressing station, while a third operated an advance station and thefourth was held in reserve except during periods of especial stress, whenall--particularly the litter bearers--were active; but there were manydepartures from this method, even in the same division, at different times.Tactical needs determined disposition. Thus, in the 3d Division, threeambulance companies during the Meuse-Argonne operation served a main dressingstation at Montfaucon, the fourth being in reserve, while at other timesindividual ambulance companies operated their own stations.85 The 90th Division, which at one time utilized two companies at the maindressing station, a third company at an advance station, and held the fourthin reserve, on another occasion, when two roads were available, operatedparallel evacuation routes, assigning one company to each station, whiletwo companies were in reserve.86 Under other circumstances itused a third disposition, one company operating an advance station, anothera main station in the rear of it, the third operating a main station fora different part of the line, while the fourth company was in reserve.The changes of tactical arrangements in these divisions were typical ofall the divisions. The 77th Division habitually kept two ambulance companiesin action and two in reserve, the personnel of one of the latter companiesassisting one of the active companies if needed.87
Only one main dressing station wasestablished by a division in a narrow sector, and if communication to thispoint was delayed or obstructed--as it usually was during the Meuse-Argonneoperation--an advance station was operated. Under such circumstances twoambulance companies often were assigned to the main station and one tothat in advance, the fourth being held in reserve to leapfrog when needed;or two companies operated both the main and advance stations and two wereheld in reserve. When the advance was rapid one company was usually keptat rest behind another, the rear one leapfrogging when another stationwas needed farther forward.84 Evacuation serv-
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ice was very exhausting; it was carriedon night and day, and difficulties were aggravated by the loss of personneland of vehicles. Dressing stations were located as near the front as possible,the 80th Division reporting that those which it established were oftenwithin 0.3 km. (1/2 mile) of the front line and were never more than 0.6km. (1 mile from it).88 In the St. Mihiel operations the5th Division established its dressing stations approximately in the lineof regimental stations but more centrally located and often somewhat inthe rear of them.80 The 1st Division at Cantigny, placedits station in advance of the command post of the division surgeon;89 and the 2d Division, at Vaux, on July 1, 1918, sent up a dressing stationto reinforce the regimental aid station of the 9th Infantry.59 This formation also established a Medical Department "dump" farther forward,at a point accessible to ambulances. Dressing stations were oftenestablished in or near villages, if their location was suitable from amilitary standpoint, because these villages were marked on maps and wereon roads and thus more easily accessible. Such sites, however, were shelledfrequently; oftener, perhaps, than other locations would have been.
Sometimes, two divisions locatedtheir stations in the same village: for example. at Montfaucon during theMeuse-Argonne operation. The site was often at a place affording someshelter, and a tendency developed to locate stations at points which couldbe used later for triage purposes. The method of advancing various medicalunits is illustrated by the following extract from the report of the divisionsurgeon. 2d Division:90
Following the attack on Blanc Mont,an ambulance dressing station personnel furnished by the 1st AmbulanceCompany was established at Somme-Py on the afternoon of October 3, the16th Ambulance Company dressing station taking its stand at Souain. Onthe 4th the ambulance head had advanced to Somme-Py and the 15th AmbulanceCompany dressing station leapfrogged to a point 2 km. north of Somme-Py,while the triage--1st Field Hospital--had set up at Souain. On the 5ththe 23d Ambulance dressing station leapfrogged to a position near MedeahFerine and the 1st Field Hospital advanced to Somme-Py, as did the surgicalunit--15th and 23d Field Hospitals.
Divisions frequently establishedan advanced dressing station if the main dressing station was at the ambulancehead; but, as noted above, whenever possible, ambulances brought patientsto the latter station direct from battalion posts and collecting points.Either tile advanced station, if established, or the main dressing station,took over the site of what would have been a regimental station formerlyand served tile troops as tile regimental station had been designed todo originally. When information was received that the battalion aid stationhad advanced, one or two officers and a small detachment of enlisted menwent forward with matériel carried perhaps by ambulances, and establisheda new station. In the 81st Division, if the advance dressing station moved,a man was left posted until the director of ambulance companies had receivedreport of the new location.91 All divisions found thatthese stations must be centrally located and on natural evacuation routes.
The stations utilized tentage, butfrequently their tentage afforded very limited shelter, it sometimes beingno more than a tent fly. Toward the end of the Meuse-Argonne operationeach division in the Third Corps was or-
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dered to establish a field hospitalnear its main dressing station, where patients often collected in largenumbers before they could be removed.92
Sometimes, the dressing station operatedthe triage, methods being much the same in tins respect as those previouslydescribed under trench warfare. In order to relieve the dressing station,the 89th Division93 and a few other divisions maintained a station forambulant patients--the slightly wounded, slightly ill, or fatigued--butthis formation was very unusual.
Dressing station equipment was oftenlimited in variety, consisting chiefly of dressings, splints, litters,blankets. antitetanic serum, a few drugs and instruments, and antigas supplies.An important factor in the equipment of a dressing station was a kitchenwith ample cooking facilities.11
In open warfare, the service of dressingstations was similar to that when troops were in the trenches. The personneloften worked in shifts, except during periods of stress, when all wereconstantly on duty. At such times, records were fragmentary and incomplete.Redressing of wounds at these times was reduced to a minimum and was confinedchiefly to wounds with hemorrhage. Dressing stations in narrow sectorsfrequently received patients from neighboring divisions. The majority ofcasualties usually occurred close together, as to both time and location,and stations would be congested for a period followed by an interval ofcomparative calm. It was a general practice to give morphine to all theseriously wounded.11
The main dressing station operateda small medical supply dump, which was replenished constantly, as alreadydescribed under trench warfare, by ambulances returning from the rear andby trucks. This was a highly important feature in the service of thesestations, and their maintenance of adequate supplies in the Meuse-Argonneoperation required constant effort because of road congestion and limitedtransportation.11
Another very important service herewas that of supplying hot food. The 5th Division reported that from oneof its dressing stations more than 3,000 men were fed in 48 hours.94Many of those seeking the station required no other care, and some,after receiving food, returned to their companies of their own volition.
Treatment of patients before theyreached the hospital was generally reported as good. Thus, the 90th Divisionreported that 99 percent of cases reaching hospital had been well splintedand dressed.95 The 5th Division reported that less than10 percent required antitetanic serum.96 The same divisionreported that fracture cases invariably reached field hospitals in goodcondition, owing to the very careful and judicious application of the Thomassplint--which proved to be a great boon during the war.96Thebenefits of special training, given regimental medical personnel in theapplication of the Thomas splint, were shown by the good condition in whichpatients were received at hospitals.
The 2d Division reported that theaverage time consumed in transferring the wounded to field hospitals wasa little more than one hour in the St. Mihiel operation, some nontransportablepatients reaching the operating table at Thiaucourt within 20 minutes afterbeing wounded.97 At Soissons,
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however, because of road conditions,the ambulances of this division frequently needed from seven to eight hoursto make a trip. The 5th Division, in the St. Mihiel operation, had itspatients in hospital in from 4 to 6 hours, and in the Meuse-Argonne infrom 10 to 12 hours, except in some few instances where 24 hours elapsedafter individual patients had been gassed or wounded.98
Usually, in open warfare, field hospitalswere located from 4.8 to 9.6 km. (3 to 6 miles) from the front, the siteoften being determined to a large extent by conjunction of the roads ofthe sector served. As field hospitals in open warfare habitually used tentage,the location of available buildings became a matter of minor importance.In many divisions field hospitals were so near the front that they werehit by enemy shells; for example, Field Hospital No. 360, 90th Division,on October 25, 1918.99 Field hospitals of the 5th Divisionwere habitually at some distance from towns or crossroads, but placed onsome highway from front to rear.100
During the second phase of the Meuse-Argonneoperation the Third Corps, which had a rather narrow front and good roadfacilities, grouped the field hospitals of its three component divisionsat Bethincourt, designated three hospitals--one from each division in line--toperform triage service, and operated in effect a corps triage, though divisionsretained control over their respective field hospitals composing it, eachdivision thus having a field hospital to receive, classify, and recordits own casualties.101 One division then established ahospital for all nontransportable wounded; another, one for all gassedpatients; and third one for overflow; each of the three last-named unitsreceiving patients from all three divisions composing the corps front.The third field hospital of each division remained outside the battle areato receive sick daily, and served as a relay station, while the fourthwas held in reserve to leapfrog if necessary.
Mobility of field hospitals dependedlargely upon the expedition with which they were cleared by corps ambulancecompanies. At times, transportation for this purpose could not be furnishedin sufficient amount. Although all divisional Medical Department unitssuffered from this lack, the field hospitals were most gravely affectedby it.102 At times it was impossible, because ofmilitary exigencies, for field hospitals to keep their trucks even afterthey had received them. The animal-drawn field hospital, though usuallya rear formation, could sometimes advance over ground impassable by motorvehicles, and its mobility under such circumstances proved of definiteassistance in solving the Medical Department problems of the division.
A very important service of fieldhospitals was that of supplying hot food to all who needed it, whetherpatients or not, thus alleviating fatigue and maintaining morale, as didthe same service at the dressing stations.
No orders prescribing the use ordistribution of divisional field hospitals were issued by authorities higherthan the corps. Much was left to local initiative. In general terms--towhich many exceptions may be found in
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active offense the field hospitalswere used as follows: (1) Triage and non-transportable wounded; (2) slightlywounded; (3) gassed and sick; (4) reserve.
For convenience the triage will bediscussed at this point in connection with field hospitals, with which,usually, it was associated both in trench and in open warfare.
The triage, or sorting station, whencepatients were distributed to appropriate hospitals, was a new formationin the American Army, the idea having been borrowed from our Allies afterthe United States entered the war,103 and it was first used,with some modifications, in the 1st Division.104 Though operatedin all divisions in trench as well as in open warfare, no orders from higherauthority required it or standardized it in personnel, organization, equipment,or operation, each division following its own methods except when a corpssurgeon prescribed for divisions within his jurisdiction. Several divisionsoperated the triage at the dressing station, but usually it was a departmentof a field hospital or, less frequently, was attached to a field hospital.Between the several divisions there was some difference in what was understoodby the term "triage." Not infrequently it meant only the sorting stationwhich either belonged to a hospital or was attached to it, and, rarely,it was made to include the neighboring hospitals to which patients weredistributed. Sometimes, as already indicated, it was a main dressing stationmore elaborately developed than these formations usually were, from whichsorted patients were distributed direct to appropriate hospitals.
The manner in which the triage wasoperated at a dressing station has already been described. When operatedin conjunction with a field hospital it functioned habitually with theone farthest forward. In some divisions the triage hospital received allnontransportable patients whether sick, wounded, or gassed; in others itreceived the seriously wounded only; in yet others, as in the 36th Division,this hospital retained no patients, but was used solely as a distributingagency.105 In trench warfare a designated hospital usuallyperformed triage service as long as a division occupied a given sector,a change being made only when the division was moved to another part ofthe line, when sometimes another field hospital was assigned to triageduty; in open warfare, on the contrary, field hospitals often alternatedin triage service.
The personnel conducting a triageconsisted in part of the divisional consultants; i. e., the divisionalchief of surgery or his representative, orthopedist, psychiatrist, urologist,tuberculosis expert, and gas-treatment officer.103 Oftenthe chief of surgery was replaced here by a carefully selected officerchosen for his surgical judgment rather than for his operating ability.Members of the professional group often were supplemented by other officersand by enlisted men permanently, or, more commonly, temporarily assignedto triage duty. Triage officers were required to make quick but unhurrieddiagnoses and to estimate correctly the patient's needs in their relationshipto available facilities for treatment. To the finest discrimination andmost unerring
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judgment had to be superadded, a thorough knowledge of medicine and surgery, and of human nature.The task became especially difficult when most important; that is to say,when hospitals were filling and evacuation facilities were limited. Then,too, often at this time the diagnosticians were worn out by the long-continuedadmission of many patients. In the 2d Division, a permanent triage groupwas organized consisting of the specialists above mentioned and, in addition,of officers drawn from all the field hospitals. This group was independent,performing triage and consultant duty. In the 90th Division one ambulancecompany in conjunction with a field hospital established the divisionaltriage.107 The triage hospital of this division consistedof four sections, the triage proper, gas, nontransportable, and psychopathic.In the Meuse-Argonne operation, unlike its practice at St. Mihiel, thetriage of the 90th Division retained no gas patients unless it was imperativeto do so to save life, evacuating all others to appropriate units, andoperating day and night shifts.108
In the 77th Division, two triageunits were organized by drawing on the personnel of two field hospitals,and surgical, shock, gas, and medical teams were organized.109 Enlistedpersonnel, carefully selected, were assigned in the proportion of two toeach officer, the group remaining a permanent team. Other qualified enlistedmen were designated for special duties, such as the administration of morphineand serum, and the application of bandages and splints. Permanent detailswere assigned for litter bearing, clerical work, policing, and the servingof food. The detachment on duty in the operating room was composed of menwho in civil life had been hospital orderlies. The triage equipment wasselected from tile two field hospitals concerned. The Medical Departmentsupply table was ignored for this purpose, and much of the hospital equipmentwas salvaged, being replaced by other articles which were thought to bemore useful: for example, additional blankets and litters.110
The triage of the 80th Division consistedof two field hospitals, usually combined, and included a receiving wardand wards for slightly wounded, seriously wounded, shocked, gassed, sick,transportable patients, an operating room, and a mortuary.111
At the triage of the 5th Division,patients were redressed, if necessary, and emergency treatment, such asfor shock or gassing, was given.100 In the 2d Divisionthe triage carried bathtubs and other facilities for gas treatment.112
Though sorting of patients was practicedin every stage of tile evacuation service, each division habitually operatedbut one official triage. In the St. Mihiel operation the 82d Division hada triage on each side of the Moselle River,113 and in the secondphase of the Meuse-Argonne the 33d Division had two, one at Glorieuxand the other at Bethincourt. The 78th Division, in the second phase ofthe Meuse-Argonne operation, attacked on a rather wide front, through heavybrush and timber, traversed by so few roads and trails that the woundedcould not be collected at any one point reasonably near tile front. Forthis reason it organized two triages from its ambulance companies and locatedone with two hospitals behind either flank.115 There wereseveral
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other instances in which two triageswere operated by divisions, but the foregoing illustrates the conditionswhich usually necessitated this--a long front, or such a one that evacuationfrom its flanks to a central point was difficult because of enemy fire,location of roads, ruggedness of terrain, or bisection by a river.
The following quotation illustratescertain phases of triage service:116
In the Meuse-Argonne offensive, thetriage hospital was opened about 6 km. behind the line, and with it werethe three other hospitals and the medical supply depot. Two of the hospitalscared for the sick and wounded and one operated as a gas hospital. Thefourth hospital was held in reserve. This was found to be a very satisfactoryarrangement on that particular front, since it gave wide expansion undercanvas, with the necessary personnel to care adequately for all cases received.Also, it allowed the three hospitals to open immediately all their wards,while the personnel of the reserve hospital could do the necessary roadbuilding and police work. Triage of cases was conducted by Field HospitalNo. 27, which cared also for the seriously wounded, and the direction ofthe whole field hospital section was under the supervision of the directorof field hospitals.
The professional work was about thesame as on the Marne front except that fewer operations were performed.Patients as a whole arrived in better condition, but there was a largenumber of shock cases, the weather being cold and rainy. Many cases ofexhaustion were received, due to the exposure and hardships of long-continuedservice in the front line.
Usually simple records were madeof all patients at the triage. Cases were rapidly classified, hemorrhagewas controlled, dressings were readjusted if necessary, shock was treated,antitetanic serum was injected if it had not been administered previously,hot food was given, and emergency operations were performed on a few nontransportablepatients by the hospital staff or by operating units assigned by the chiefsurgeon of the army.
If a mobile surgical unit was assignedto a division it was operated in conjunction with the field hospital fornontransportable patients.102Often the personnel of a fieldhospital was increased by surgical teams; for example, in the Chateau-Thierrysector the 2d Division received a number of surgical teams, including 18nurses, and the personnel of an overworked field hospital was often reinforcedby details from others in reserve.117 Thus, on June6, 1918, the 2d Division ordered half the personnel of Field Hospital No.23 to Bezu to assist Field Hospital No. 1.
The triage was usually thefirst hospital reached by patients, and others were grouped as near itas was practicable, the rearmost onebeing held in reserve. (This arrangement of hospitals was called the "diamondformation" in the 32d Division.)81 As troops advanced,the rear hospital moved forward past the others and established the triage,the other units following it as soon as practicable and the former triagethen going into reserve. There were many departures in details from thispractice. Sometimes, as in the 90th Division, half the triage group accompaniedthe newly-advanced forward hospital while the remainder, after the newone had opened, continued to operate the former triage.118 Sometimes two full triage groups were organized
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which leapfrogged each other, asin the 77th Division.110 In the 32d Division therear surgical hospital evacuated its patients and moved forward to takeover triage work, and the gas hospital moved up beside the advanced surgicalhospital.81
There were further departures fromthese uses of field hospitals, of which only a few will be mentioned here.Though generally following the foregoing disposition, the 1st Divisionhad at times only two field hospitals open, keeping two in reserve.119 The 2d Division consolidated two hospitals into one establishment for thewounded, and sought to maintain its capacity at 250 beds.120 In the St. Mihiel operation one hospital of the 78th Division receivedgassed patients, another the sick and slightly wounded, and a third fieldhospital cared for nontransportable patients, the fourth being held inreserve.121 The triage was operated by an ambulance companywhich called on a field hospital for additional personnel if needed.122 At one period the 36th Division operated one hospital as a triage, sendingnontransportable patients to another, gassed patients to a third, and allothers to evacuation hospitals.105 In the Aisne-Marne operationthe 42d Division set up one field hospital near the dressing station afterits evacuation became difficult because of road congestion.123
The following quotation, which coversthe activities of the gas hospital of a division, is made from the reportof the 3d Division: 124
The gas hospital was fitted up withthe following equipment: A large shower bath, a large supply of blankets,pajamas, bed sacks, and an extra number of ward tents in order to accommodateseveral hundred patients. In addition to the regular field-hospital equipment,the following were provided: Oxygen-inhalation sets, sodium bicarbonate1 percent solution, novocaine 1 percent solution, albolene, camphoratedoil in ampules, caffeine citrate in ampules, quarter-grain solution ofmorphine in ampules. This equipment and supplies were placed in each ward.Shower baths were provided, with a large supply of soap, towels, and sodiumbicarbonate.
Patients were divided into threeclasses: (1) Those suffering from surface contact with mustard gas; (2)those intoxicated by the inhalation of noxious gases; (3) cases sufferingfrom both these conditions. Those in the third class were numerous.
Patients were admitted through areceiving ward, where the diagnosis was verified and proper records weremade. They were sent at once to the baths, where clothing was removed andeach patient given a thorough bath, soap being used freely. Water usedin the showers contained sodium bicarbonate (1 pound to 15 gallons). Afountain syringe was supplied with a 1 percent solution of sodium bicarbonate,and the eyes, ears, nose, and throat of every patient were irrigated. Allcases with blisters were then sent to the dispensary, where blisters wereopened and the escaping fluid caught on gauze or cotton to prevent itscoming in contact with the healthy skin. Gauze wet with a 1 percent solutionof sodium bicarbonate was applied to burned surfaces. Often, when a burnwas slight, the sodium bicarbonate was dusted on. Patients were then sentto the wards, where they were given hot, stimulating drinks, such as coffee,cocoa, and broths, and morphine was administered as required. Most patientswith mustard-gas burns had a complicating conjunctivitis, either slightor severe. Slight conjunctivitis was relieved by irrigating the eyes withsodium-bicarbonate solution, followed by a few drops of albolene. Severeconjunctivitis was treated with a 1 percent solution of novocaine as oftenas required to relieve pain, and gauze wet with a 1 percent solution ofsodium bicarbonate was placed over the eyes. Patients gassed by inhalationwere given a bath while recumbent. Severe cases were given a sponge bathin the wards as soon as their condition
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permitted, but if the patient haddifficulty in breathing he was at once given oxygen by inhalation for fiveminutes. Then followed an intermission of five minutes, and oxygen againapplied. In five minutes' time there was usually a great improvement, andit was not often necessary to repeat its administration. Some patientswho were unconscious were restored to consciousness by the first application;others remained unconscious for 30 minutes or longer. Hypodermic injectionsof camphorated oil, 1 c. c., or caffeine citrate, 2 grains were then given.The patient was kept warm by the use of blankets, and by heat, if necessary,and was given hot drinks as soon as he could take them. The majority ofthese patients soon recovered.
The rapidity with which patientswere evacuated to and from field hospitals varied widely, being dependentchiefly upon the number and character of casualties and the intensity ofenemy fire, which delayed the removal of the wounded in forward areas,road conditions back of the forward areas, and transportation.
In times of great stress, few patientswere returned to duty from field hospitals, a fact largely due to the impossibilityof temporary retention on account of the demand for beds, to the eliminationat the dressing station of patients with trifling conditions, and to thedisposition to give the benefit of any doubt to those whose need of furtherhospital care was questionable. It was then quite impossible to hold patientsin the division, as beds had to be provided for later casualties. The 2dDivision reported that the average time men were held in its field hospitals,if not evacuated, was four days, and that in very active warfare it evacuatedmost of them.125 This was in striking contrast to theexperience of this division in quiet sections, where 32.4 percent of patientswere returned to duty. In the 89th Division the average time patients spentin field hospitals was two hours, and the average time for nontransportablewounded was from five to eight days.126
In the 26th Division the factorsdetermining transportability of patients were regarded as intrinsic andextrinsic. The former comprised the patient's condition; the latter, bedspace and other local factors, such as distance, time, means of evacuation,and road conditions.127 Surgical conditions warrantingevacuation, therefore, varied considerably at different times in this division,as in others. Specialists decided which patients should be transferred,while the director of field hospitals and the commanding officer of thetriage kept them informed concerning extrinsic conditions governing selectionof patients to be evacuated. In periods of stress, nontransportable patientsin this division comprised only those with hemorrhage, aspirating chestwounds, severe abdominal wounds, partial traumatic amputations, and deepshock.
The activity of the field hospitalsis indicated from the statistics quoted in other chapters concerning thecasualties during different engagements. The celerity with which patientscould be cared for by the divisional medical service is evidenced by thereport of the 2d Division.120 In that division, miscellaneouscasualties were received, distributed, treated, and evacuated (if needbe) at the rate of 120 per hour, and operated upon at the rate of 50 aday. The total number of patients operated upon in the field hospitalsof the 2d Division during its entire experience in France was 1,665, 90percent of whom were nontransportable.120
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Divisional medical supply units performedservices similar to those in the 3d Division. Extracts from the reportof the 3d Division (concerning the medical supply unit) read as follows:128
When the Germans launched their greatoffensive along the Marne on the night of July 14-15, the medical supplyunit, 3d Division, was called upon to furnish supplies in abundance. Owingto the vast number of wounded men pouring into aid stations it was necessarythat surgeons have sufficient blankets and litters on which to lay them.Trucks were sent to advance medical supply depots and to American Red Crosswarehouses, bringing back with them sufficient litters, blankets, shell-woundpackets and splints to meet the demand. In the interim after the nightof the attack until early August, when the division was relieved, no shortagesof any kind arose.
While the division was at this fronta great demand was made for Thomas traction arm and leg splints, Cabotsplints, and a vast number of shell-wound packets. Snowshoe and wheel litterswere used to great advantage, but when the division went into action inthe Meuse-Argonne sector these items were rarely, if ever, called for.
The work of the medical supply unitat this latter station was to equip organizations after their long stayat the front, during which time many of them had lost a considerable portionof their equipment, some from enemy shell fire and others while moving.This reequipment was duly accomplished, and in anticipation of a situationsimilar to that existing on the Marne, the medical supply officer requestedthat four trucks be assigned. These were provided and requisition was madefor a 10-days' supply of articles that would be in greatest demand whiletroops were in action.
During the Meuse-Argonne operationthe medical supply officer made frequent trips to the regimental infirmariesof the various organizations, bringing with him an assortment of medicalsupplies which in his judgment might be needed.
October 2 found the unit proceedingoverland to join the field-hospital section of the sanitary train, locatednear Very, arriving there that night. The depot was established in a wardtent and supplies were sent out the same night. Litters and blankets weremost in demand, and in order to meet the situation, trucks were dispatchedhack to Souilly day and night during the remainder of the stay here.
A branch distributing station ofthe medical supply unit was established with the ambulance section of thesanitary train at Montfaucon. This proved a vantage point for the reasonthat it was the dispatch point for the ambulance service. The stock maintainedat this point consisted chiefly of emergency dressings, medicines, andfood supplies.
The medical supply unit functionedat all times near the triage hospital of the division, employing ambulancesreturning to aid stations to transport supplies to tile medical officerat the point. Trucks belonging to the unit carried patients to evacuationhospitals in the rear, and brought up supplies on return trips.
In some divisions, the 78th, forinstance, trucks of the medical supply unit carried matériel asfar forward as the battalion aid stations.129
In the American Expeditionary Forcestransportable laboratories were added to the sanitary trains of the divisions,130and proved of great value in the examination of water supplies and of pathologicalspecimens and in determining wound bacteriology.131 The1st Division found that the usefulness of the field laboratory was impairedby the limited amount of transportation at its disposal, and that it wasof less value in active operations than when
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the division occupied quiet or semipermanentsectors.132 Under the latter conditions it was a necessityto the sanitary inspector in his epidemiological work and to ward surgeonstreating certain classes of the divisional sick.
The dead were buried in small plotsselected with reference to prompt location. Very few, in the St. Mihielor Meuse-Argonne operations, were buried at isolated places, and then onlywhen the bodies were in such condition and at such a distance from theburial plot that local interment was necessary. The 3d Division reported,as did others, that the bodies of those who died on the field in No Man'sLand remained unburied for many days.133 Trench burialwas employed near some hospitals, but only when facilities were not availablefor the preparation of individual graves. The work of preparing graveswas very toilsome for men already well-nigh exhausted, and at times graveswere dug by pioneer troops, and at other times the work was done by detailsfrom the line. Habitually the dead were buried in blankets, with an identificationtag, and the grave was marked by a cross bearing the decedent's name andhis official number inscribed upon it. If a second identification tag wasavailable, this was affixed to the cross.
(1) Letter from the division surgeon,42d Division, to the commanding general, 42d Division, April 4, 1918. Subject:Evacuation of sick and wounded. On file, Historical Division. S. G. O.
(2) Memorandum No. 66, divisionsurgeon's office, 3d Division, A. E. F., July 23, 1918. On file, HistoricalDivision, S. G. O.
(3) Memorandum No. 82, divisionsurgeon's office, 3d Division, A. E. F., September 6, 1918. On file, HistoricalDivision, S. G. O.
(4) Report of Medical Departmentactivities, 3d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part III, 156. On file, Historical Division,S. G. O.
(5) Ibid., Part II, 81.
(6) Ibid., Part V, 72.
(7) Memorandum, September 3, 1918,Headquarters. First Army Corps, Subject: Evacuation sick and wounded. On file, Historical Division, S. G. O.
(8) Report of Medical Departmentactivities, 5th Division. A. E. F., prepared under the direction of thedivision surgeon, undated, Part III, S. On file, Historical Division, S.G. O.
(9) Report of the Medical Departmentactivities of the combat divisions, by Col. B. K. Ashford, M. C., undated,11. On file, Historical Division, S. G. O. Evacuation system of a fieldarmy, by Col. C. R. Reynolds, M. C., undated, 19. On file, Historical Division,S. G. O.
(10) Report of Medical Departmentactivities, 89th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, 52. On file, Historical Division, S. G. O.
(11) From reports of Medical Departmentactivities of divisions in the A. E. F., undated. On file, Historical Division,S. G. O.
(12) Report of Medical Departmentactivities, 4th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, 3. On file, Historical Division, S.G. O.
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(13) Report of Medical Departmentactivities of the combat divisions, by Col. B. K. Ashford, M. C., undated,12. On file, Historical Division, S. G. O.
(14) Ibid, 19.
(15) Report of Medical Departmentactivities of 1st Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 11. On file, Historical Division, S.G. O.
(16) Report of Medical Departmentactivities of 3d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part V, 35. On file, Historical Division, S.G. O.
(17) Ibid., Part V, 36.
(18) Ibid., Part V, 37.
(19) Report of Medical Departmentactivities of the combat divisions, by Col. B. K Ashford, M. C., undated,17. On file, Historical Division, S. G. O.
(20) Ibid., 15.
(21) Tables of Organization andEquipment U. S. Army, Series A, Table 4, August, 1917.
(22) Report of Medical Departmentactivities, 3d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part IV, 68. On file, Historical Division, S.G. O.
(23) Tables of Organization andEquipment, U. S. Army, Series A, Table 28, April 17, 1918.
(24) Manual for the Medical Department,U. S. Army, 1916, par. 674.
(25) Report of Medical Departmentactivities, 4th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 5. On file, Historical Division, S.G. O.
(26) Report of Medical Departmentactivities, 1st Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 5. On file, Historical Division, S.G. O.
(27) Report of Medical Departmentactivities, 4th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 3. On file, Historical Division, S.G. O.
(28) Report of Medical Departmentactivities, 5th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 7. On file, Historical Division, S.G. O.
(29) Report of Medical Departmentactivities, 37th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 9. On file, Historical Division, S.G. O.
(30) Report of Medical Departmentactivities, 5th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 11. On file, Historical Division, S.G. O.
(31) Report of Medical Departmentactivities, 35th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 16. On file, Historical Division, S.G. O.
(32) Report of Medical Departmentactivities of the combat divisions, A. E. F., by Col. B. K. Ashford, M.C., undated, 25. On file, Historical Division, S. G. O.
(33) Report of Medical Departmentactivities, 28th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 4. On file, Historical Division, S.G. O.
(34) Report of Medical Departmentactivities of the combat divisions, A. E. F., by Col. B. K. Ashford, M.C., undated, 26. On file, Historical Division, S. G. O.
(35) Report of Medical Departmentactivities of the 42d Division, prepared under the direction of the divisionsurgeon, undated, Part I, 38. On file, Historical Division, S. G. O.
(36) Report of Medical Departmentactivities of 1st Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 42. On file, Historical Division, S.G. O.
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(37) The evacuation system in thezone of the armies, by Col. A. N. Stark, M. C., undated, 1. On file, HistoricalDivision, S. G. O.
(38) Ibid., 2.
(39) Report of Medical Departmentactivities of the 5th Division, A. E. F., prepared under the directionof the division surgeon, undated, Part I, 10. On file, Historical Division,S. G. O.
(40) The evacuation system in thezone of the armies, by Col. A. N. Stark, M. C., undated, 3. On file, HistoricalDivision, S. G. O.
(41) Report of Medical Departmentactivities, 42d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 39. On file, Historical Division, S.G. O.
(42) Report of Medical Departmentactivities, 2d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 5. On file, Historical Division, S.G. O.
(43) Report of Medical Departmentactivities, 42d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 48. On file, Historical Division, S.G. O.
(44) Ibid., 51.
(45) Report of Medical Departmentactivities of the combat divisions, A. E. F., by Col. B. K Ashford, M.C., undated, 34. On file, Historical Division, S. G. O.
(46) Memorandum, Headquarters, FirstArmy Corps, September 3, 1918. On file, Historical Division, S. G. O.
(47) Report of Medical Departmentactivities of the combat divisions, A. E. F., by Col. B. K. Ashford, M.C., undated, 27. On file, Historical Division, S. G. O.
(48) Report on activities of G-4-B,medical group, fourth section, general staff, G. H. Q., A. E. F., by Col.S. H. Wadhams, M. C., chief of section, December 31, 1918, 62. On file,Historical Division, S. G. O.
(49) Report of Medical Departmentactivities, 4th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 10. On file, Historical Division, S.G. O.
(50) Tables of Organization andEquipment, U. S. Army, Series A, Table 28, April 17, 1918.
(51) Report on activities of G-4-B,medical group, fourth section, general staff, G. H. Q., A. E. F., by Col. S. H. Wadhams, M. C.,chief of section, December 31, 1918, 43. On file, Historical Division,S. G. O.
(52) Report of the Medical Departmentactivities of the combat divisions, A. E. F., by Col. B. K. Ashford, M.C., undated, 32. On file, Historical Division, S. G. O.
(53) Report of Medical Departmentactivities of the 26th Division, A. E. F., prepared under the directionof the division surgeon, undated. Part II, 13. On file, Historical Division,S. G. O.
(54) Report of Medical Departmentactivities of the 90th Division, A. E. F., prepared under the directionof the division surgeon, undated, Part III, 2. On file, Historical Division,S. G. O.
(55) Report of Medical Departmentactivities, 5th Division, A. E. F., prepared under the directionof the division surgeon, undated, Part IV, 41. On file, Historical Division,S. G. O.
(56) Report of Medical Departmentactivities, 2d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 30. On file, Historical Division, S.G. O.
(57) Ibid., Part III, 17.
(58) Report of Medical Departmentactivities, 3d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part V, 38. On file, Historical Division, S.G. O.
(59) Report of operations, MedicalDepartment, 2d Division, May 31 to July 10, 1918, from the division surgeonto the commanding general, 2d Division, February 24, 1919. On file, HistoricalDivision, S. G. O.
152
(60) Report of Medical Departmentactivities, 90th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 6. On file, Historical Division,S. G. O.
(61) Report of Medical Departmentactivities, 1st Division, A. E. F., prepared under the directionof the division surgeon, undated, Part II, 24. On file, HistoricalDivision, S. G. O.
(62) Report of Medical Departmentactivities, 5th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 37. On file, Historical Division, S.G. O.
(63)Report of Medical Departmentactivities, 35th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 3. On file, Historical Division, S.G. O.
(64) Report of Medical Departmentactivities, 90th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 21. On file, Historical Division, S.G. 0.
(65) Report of Medical Departmentactivities, 5th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 7. On file, Historical Division, S.G. O.
(66) Report of Medical Departmentactivities, 2d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 34. On file. Historical Division, S.G. O.
(67) Report of Medical Departmentactivities, 78th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 32. On file, Historical Division, S.G. O.
(68) Report of Medical Departmentactivities, 5th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part IV, 41. On file, Historical Division. S.G. O.
(69) Report of Medical Departmentactivities, 3d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part IV, 71. On file, Historical Division, S.G. O.
(70) Report of Medical Departmentactivities, 5th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 38. On file, Historical Division, S.G. O.
(71) Ibid., Part II, 11.
(72) Report of operations, MedicalDepartment, 2d Division, A. E. F., March 16, 1918, to December 31, 1918,from the division surgeon to the commanding general, 2d Division, February25, 1919, 7. On file, Historical Division, S. G. O.
(73) Report of Medical Departmentactivities, 3d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part V, 37. On file, Historical Division, S.G. O.
(74) Report of Medical Departmentactivities, 2d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 35. On file, Historical Division, S.G. O.
(75) Report of Medical Departmentactivities, 5th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 46. On file, Historical Division, S.G. O.
(76) Report of Medical Departmentactivities, 2d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 34. On file, Historical Division, S.G. O.
(77) Ibid., Part I, 41.
(78) Report of Medical Departmentactivities, 90th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 23. On file, Historical Division, S.G. O.
(79) Report of Medical Departmentactivities, 36th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 9. On file, Historical Division, S.G. O.
153
(80) Report of Medical Departmentactivities, 5th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part IV, 2. On file, Historical Division, S.G. O.
(81) Report of Medical Departmentactivities, 32d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 42. On file, Historical Division, S.G. O.
(82) Report of the Medical Departmentactivities of the combat divisions, A. E. F., by Col. B. K. Ashford, M. C., undated, 29. On file, Historical Division. S. G. O.
(83) Ibid., 31.
(84) Memorandum 142, Headquarters,42d Division, office of the surgeon, June 10, 1918. On file, HistoricalDivision. S. G. O.
(85) Report of Medical Departmentactivities, 3d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part IV, 17. On file, Historical Division, S.G. O.
(86) Report of Medical Departmentactivities, 90th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 9. On file, Historical Division. S.G. O.
(87) Report of Medical Departmentactivities, 77th Division, A. E. F., prepared under the direction of thedivision surgeon, undated. 12. On file, Historical Division, S. G. O.
(88) Report of Medical Departmentactivities, 80th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 21. On file, Historical Division, S.G. O.
(89) Report of Medical Departmentactivities, 1st Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 22. On file, Historical Division, S.G. O.
(90) Report of Medical Departmentactivities, 2d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part III. 37. On file, Historical Division,S. G. O.
(91) Report of Medical Departmentactivities, 81st Division, A. E. F., prepared under the direction of thedivision surgeon, undated, 21. On file, Historical Division, S. G.O.
(92) Memorandum from the surgeon,Third Corps, to division surgeons, Third Corps, October 19, 1918. On file,Historical Division. S. G. O.
(93) Report of Medical Departmentactivities, 89th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, 35. On file, Historical Division, S. G. O.
(94) Report of Medical Departmentactivities, 5th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 51. On file, Historical Division, S.G. O.
(95) Report of Medical Departmentactivities, 90th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 12. On file, Historical Division, S.G. O.
(96) Report of Medical Departmentactivities, 5th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part IV, 29. On file, Historical Division, S.G. O.
(97) Report of Medical Departmentactivities, 2d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 6. On file, Historical Division, S.G. O.
(98) Report of Medical Departmentactivities, 5th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part III, 9. On file, Historical Division, S.G. O.
(99) Report of Medical Departmentactivities, 90th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 37. On file, Historical Division, S.G. O.
154
(100) Report of Medical Departmentactivities, 5th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part IV, 30. On file, Historical Division, S.G. O.
(101) Report of Medical Departmentactivities, Third Corps, by Col. James L. Bevans, M. C., corps surgeon,undated, 33. On file, Historical Division, S. G. O.
(102) Report on activities of G-4-B,medical group, fourth section, general staff, G. H. Q., A. E. F., by Col.S. H. Wadhams, M. C., chief of section, December 31, 1918, 42. On file,Historical Division, S. G. O.
(103) Report of the Medical Departmentactivities of the combat divisions, A. E. F., by Col. B. K. Ashford, M.C., undated, 34. Ga file, Historical Division, S. G. O.
(104) Report of Medical Departmentactivities, 1st Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 41. On file, Historical Division, S.G. O.
(105) Report of Medical Departmentactivities, 36th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 5. On file, Historical Division,S. G. O.
(106) Report of Medical Departmentactivities, 32d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 64. On file, Historical Division, S.G. O.
(107) Report of Medical Departmentactivities, 90th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 22. On file, Historical Division, S.G. O.
(108) Ibid., Part II, 29.
(109) Report of Medical Departmentactivities, 77th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, 12. On file, Historical Division, S. G. O.
(110) Ibid., 18.
(111) Report of Medical Departmentactivities, 80th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, 24. On file, Historical Division, S. G. O.
(112) Report of Medical Departmentactivities, 2d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 14. On file, Historical Division, S.G. O.
(113) Report of Medical Departmentactivities, 82d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, 9. On file, Historical Division. S. G. O.
(114) Report of Medical Departmentactivities, 33d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 7. On file, Historical Division, S.G. O.
(115) Report of Medical Departmentactivities, 78th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, 27. On file, Historical Division. S. G. O.
(116) Report of Medical Departmentactivities, 3d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part IV, 44. On file, Historical Division, S.G. O.
(117) Report of Medical Departmentactivities, 2d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 25. On file, Historical Division, S.G. O.
(118) Report of Medical Departmentactivities, 90th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 10. On file, Historical Division, S.G. O.
(119) Report of Medical Departmentactivities, 1st Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 42. On file, Historical Division, S.G. O.
155
(120) Report of Medical Departmentactivities, 2d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 14. On File, Historical Division, S.G. O.
(121) Report of Medical Departmentactivities, 78th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 62. On file, Historical Division, S.G. O.
(122) Ibid., Part II, 64.
(123) Report of Medical Departmentactivities, 42d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part 1, 51. On file, Historical Division, S.G. O.
(124) Report of Medical Departmentactivities, 3d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part IV, 44. On file, Historical Division, S.G. O.
(125) Report of Medical Departmentactivities, 2d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 13. On file, Historical Division, S.G. O.
(126) Report of Medical Departmentactivities, 89th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, 57. On file, Historical Division, S. G. O.
(127) Report of Medical Departmentactivities, 26th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 76. On file, Historical Division, S.G. O.
(128) Report of Medical Departmentactivities, 3d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part IV, 46. On file, Historical Division, S.G. O.
(129) Report of Medical Departmentactivities, 78th Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part II, 83. On file, Historical Division, S.G. O.
(130) Letter from the chief surgeon,A. B. F., to the Surgeon General, U. S. Army, August 12, 1917. Subject:Outline of laboratory organization, A. E. F. On file, A. G. O., World WarDivision, Medical Records Section (Chief Surgeon Files, 322.3271).
(131) Report on the division oflaboratories and infectious diseases in the A. E. F., by Col. J. F. Siler,M. C., chief of division, undated. On file, Historical Division. S. G. O.
(132) Report of Medical Departmentactivities, 1st Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part I, 84. On file, Historical Division, S.G. O.
(133) Report of Medical Departmentactivities, 3d Division, A. E. F., prepared under the direction of thedivision surgeon, undated, Part V, 81. On file, Historical Division, S.G. O.
