History

CHAPTER II

GENERAL DIRECTION OF THE MEDICAL SERVICE, THEATER OF OPERATIONS

CHIEF SURGEON, AMERICAN EXPEDITIONARY FORCES

By referring to the Appendix of this volume (p. 1026) it will be seen that the pre-war plans for the organization of the Medical Department in the theater of operations contemplated that the chief surgeon of a field army, as a member of the technical and administrative group of the staff of the commander, act, in general, as an advisory officer, administering directly only the limited personnel of the Medical Department attached to headquarters. Under these conditions-that is, during the period of grand tactical operations, when a line of communications would be functioning-he was to concern himself only with the broad principles underlying Medical Department administration, without maintaining an office of record. The office of record was to be that of the surgeon, base group (line of communications).¹

The chief surgeon, A. E. F., shortly after his appointment as an original member of the technical staff of the commanding general of the American Expeditionary Forces,²organized his office so that it comprised the following divisions:³ Hospitalization, sanitation and statistics, personnel, supplies, records and correspondence, and gas service.

To the chief surgeon, line of communications, was given immediate charge of base hospitals, supplies and Medical Department personnel on duty in the line ofcommunications.⁴

This arrangement of the general direction of the Medical Department, A.E. F., obtained until, as described in Chapter I, General Pershing effected certain changes in the organization provided for by Field Service Regulations and evolved aterritorial rearrangement of the theater of operations in France by which the zone of the advance became a part of the line of communications, the whole being merged in the Services of Supply. Thereafter, the chief surgeon, A. E. F., was geographically detached from General Headquarters, and many of his duties were performed by deputies with the general staff.

The conduct of the affairs of the chief surgeon’s office, in so far as his office concerned the Services of Supply, will not be discussed in this volume.^a However, there were certain activities of the Medical Department which straddled both the zone of the armies and the Services of Supply. Because of this fact, and especially because of the intimate relationship of the activities

^aSee Volume II. Administration, American Expeditionary Forces.

of the Medical Department at the front and in the rear, which made the supervision of these activities so complex a problem, the organization scheme of the Medical Department, A. E. F., as of November 11, 1918, is given.

In this chart it may be noted that the contact between the chief surgeon, A. E. F., and the Medical Department assigned to combat troops was not direct, but was through the general staff, G. H. Q. The control which the general staff maintained over the troops was by authority delegated by the commander in chief, and instructions issued by each assistant chief of staff in charge of the separate sections of the general staff were by the direction of the commander in chief. This must be understood in order to correctly interpret the chart.

CHART I.-Scheme for organization of Medical Department, A. E. F., corrected to November 11, 1918

MEDICAL DEPARTMENT REPRESENTATIVES WITH THE GENERAL STAFF. GENERAL HEADQUARTERS

Prior to the organization of the American Expeditionary Forces, comparatively little attention had been paid to the subject of Medical Department representation with the general staff in war, but as early as July, 1917, it became apparent that such representation must be provided in order to secure coordinated action. The chiefs of the administrative and technical staff services were transferred to Tours, March 21, 1918. Each of them, including the chief surgeon, A. E. F., was authorized to designate an officer of his department to represent him with each section of the general staff at General Headquarters, which remained at Chaumont.⁵Under this arrangement the chief surgeon’s relations with combat forces necessarily became more

remote, being not direct but through the representatives whom he left at Chaumont attached to the first, fourth, and fifth sections of the general staff. The medical officer associated with the first section was charged with supervision of ocean tonnage, requisitions, replacements, welfare work, and similar duties in so far as they affected the Medical Department; those with the fourth section were in charge of Medical Department supplies, construction, transportation, hospitalization, evacuation of the sick and wounded, and assignment of all Medical Department units newly arrived in France; while the medical officer with G-5 supervised the training of Medical Department personnel. No representatives were assigned to the second (intelligence) or third (operations) sections, chiefly because of the great shortage in the Medical Department personnel at the time.⁶

It soon became evident that medical representation on G-2 was not necessary, but as to G-3, it appeared desirable, though no medical officer was assigned thereto, that there should be such representation in order that Medical Department plans might be coordinated with combat operations in general.

As events developed and American troops began actual participation in the war, it was soon apparent that no medico-military operations could be planned or undertaken without consultation and fullest cooperation with the assistant chief of staff,G-4. It was the policy of this officer consistently to take the medical representative of his section into his confidence. The wisdom of so doing was amply demonstrated, and it was equally well demonstrated that without this harmonious cooperation Medical Department service in the field would have been doomed to failure. The stand of the assistant chief of staff, G-4 was particularly to be remarked for the reason that so few of the high ranking officers of the general staff appeared to appreciate that the Medical Department, if it were to accomplish its mission, must have knowledge of the general plan of combatactivities.⁶

Being in immediate touch with all combat troops, the senior medical officer with G-4 carried out, as deputy of the chief surgeon. A. E. F., the policies of the latter and supervised Medical Department activities in the zone of the armies. Gradually almost all of the activities of the Medical Department at general headquarters were concentrated under him, and as he was head of the group under G-4, known as G-4-B,this group soon became the center to which matters affecting the Medical Department, whether arising at General Headquarters or referred to it, were in turn referred for recommendation and action. The composition of G-4-B varied according to circumstances, but usually included four medical officers of field rank, and two officers of the Sanitary Corps charged with office management.⁷ Two of its members were almost constantly in the field representing G-4 in the coordination of hospital and evacuation services. A large clerical force assisted in the performance of office duties.G-4-B submitted questions of policy to the chief surgeon, A. E. F., before ruling on them and thus continued actually to represent him.⁶

Much of the time of this group was taken up with Medical Department problems incident to combat. As the assistant chief of staff, at the head of G-4, kept the medical group of the section informed concerning plans for impending military operations, it was able to assist the surgeons of the various armies, corps, and divisions concerned in preparing for coming needs and to meet them when they arose. To a large degree this section prepared the plans for procurements, hospitalization, and evacuation utilized during the St. Mihiel and Meuse-Argonne operations, and put them into effective operation through personal consultation with the chief surgeons of the First and, later, the Second and Third Armies.⁸It estimated the number of battle casualties which would require care and drew upon every available resource to make due provision for them. Owing to limited resources it frequently became necessary to move sanitary formations and supplies from one sector to another, but as G-4 controlled all transportation facilities, the affiliation of this group therewith assisted materially in these movements. All changes of station of army Medical Department units were carried out on orders issued by G-3, based on recommendations prepared in G-4-B for the signature of the assistant chief of staff,G-4. From a practical standpoint, therefore, G-4-B supervised battle disposition of sanitary units as dictated by military necessity, and eventually thus discharged the important functions of the chief surgeon of a group of armies.⁹

In the early, formative stage, before our First Army was organized, this group, G-4-B, also provided for hospitalization, evacuation, and supply in the immediate rear of separate divisions and corps. This service had not, it is true, been contemplated in the organization of the general staff, but under the circumstances it could be discharged by no other agency, though it placed a very heavy responsibility on the medical group in question.⁸

Thus, it was to effect and supervise hospitalization, evacuation, and supply in rear of the 1st Division that one of the members of G-4-B was sent to the Cantigny sector in May, 1918.¹⁰ Later he went to the Chateau-Thierry region to perform the same service for the divisions and corps in the Marne area. This, it should be understood, was before this same officer was detailed as chief surgeon of the Paris group, as American divisions operating in that area were laterdesignated.¹⁰ With the appointment of corps and army surgeons, in the summer of 1918, G-4-B was gradually relieved of this part of its duties, but even after the formation of corps and armies it continued to exercise very careful supervision over Medical Department activities at the front.

The efficiency of the supervision exercised by G-4-B was greatly facilitated by the geographical location of Chaumont (G. H. Q.) and its excellent system of telegraph and telephone communication which made it possible for the medical group to learn quickly of needs and very rapidly to move army hospitals, ambulance companies, operating teams, and other formations from one sector to another. Without the machiner for coordination of effort and consolidation of resources, the care and removal of battle casualties would have been well-nigh impossible because of the limited Medical Department personnel and other resources available.¹¹

MAINTENANCE OF CONTACT BETWEEN FRENCH AND AMERICAN MEDICAL SERVICES

From the outset of American activities overseas the French stressed the necessity for maintaining contact, or liaison, a need which was not fully appreciated at first by some American officers, but which rapidly became more apparent to all, especially after American divisions were placed under French command in March, 1918. Such contact, as affecting the Medical Department, was maintained through a designated officer of G-4-B and a sub department known as the Franco-American section of the office of the French under secretary for the medical service.¹²An experienced medical officer had been selected by the French Minister of War to handle all matters affecting the relations of the two medical services, exclusive of those pertaining to the zone of the armies. At Chaumont the French high command established a military mission, which included a medical section. This office handled all questions of mutual interest affecting medical services in the zone of the armies. The same American medical officer who maintained contact for our Medical Department also performed like services with the French military mission at Chaumont in matters affecting cooperation of the medical services of French and American forces in the army area.¹²

CONTROL EXERCISED BY G-4-B OVER EVACUATIONS BY HOSPITAL TRAINS

The fourth section of the general staff, General Headquarters, was the supply, coordinating, and evacuating section. It was specifically charged with the supervision of hospitalization and evacuation of the sick and the wounded.⁵Its instrument of control over the movements of hospital trains evacuating sick and wounded was the regulating station.

COORDINATION OF HOSPITALIZATION AND EVACUATION

The first departure from static to mobile warfare devolved upon the 1st Division, which, in April, 1918, had been hurriedly withdrawn from the Toul sector and placed at the disposition of the French in reserve behind the Montdidier salient.¹³

Before May 28, when this division conducted the Cantigny action,¹³G-4-B had received notice of the impending attack and had sent a member of the group to that front for the purpose of providing hospitalization and supply in rear of the division.

At this time our divisions were absolutely under French command. Not only was the evacuation and hospitalization of our wounded in the rear of the divisions a duty of the French, but this was the case with the medical supply of the divisions aswell.¹⁴As it soon became apparent that this arrangement was not workable, it devolved upon the representative of G-4-B to play an important part in securing uninterrupted supply for divisions widely scattered along the front.¹⁵It was in this operation that the medical group with the 4th section of the general staff first adopted the plan of sending one of its members to represent it in all important field operations. Application

of this plan secured very effective coordination, as the representative had a freedom of action and latitude which could not have been exercised by an officer attached to the operating forces. He kept in close touch with G-4, G. H. Q., by telephone or telegraph, and also with the officers in charge of the hospitals to which he directed evacuations, usually making his headquarters with the office of the French corps or army with which our troops were incorporated. The value of his services was increased by the fact that hospital trains operated under jurisdiction of G-4.¹⁶During quiet periods he returned automatically to headquarters and resumed his office duties.

With the beginning of the Aisne offensive by the Germans, in the latter part of May, 1918, when the 1st Division was on the front near Montdidier, it became necessary hurriedly to throw in other American divisions on the enemy front before Paris. The first American divisions to be used in the respulse of this offensive were the 2d and 3d.¹⁶At the height of our activities in the Marne area nine American divisions were intermittently engaged,¹⁶thus creating a new hospitalization and evacuation problem. The French had lost many evacuation hospitals in their retreat from that region and therefore were not in a position to assume the additional burden of caring for American casualties. They now not only permitted but also assisted in evacuating from them by means of French and American trains to fixed American formations in the rear.¹⁷There was no army hospital available in rear of the divisions and no organized machinery higher than a division to effect evacuations. To meet this emergency, as stated elsewhere in this chapter, a medical officer, representing G-4-B in the field, was charged with the duties of a chief surgeon of the divisions scattered through the area. In this capacity he submitted recommendations for coordination of the medical service to the medical group with G-4 and actively conducted the evacuation service in rear of the divisions.¹⁸

Our evacuation hospitals, which were gradually brought up, did not have the necessary mobility to meet changing military conditions existing at that time, chiefly because of shortage of motor transportation. Divisions were withdrawn hurriedly from one part of the line and thrown into another part alongside the French without advance notice to the medical representatives in the field and, at times, evidently without due notice being furnished the tactical headquarters of the "Paris Groupe," then established at La Fertesous-Jouarre and under which all American divisions in the Marne area were operating.¹⁷Not until our troops were massed on the true Chateau-Thierry salient were we able to utilize our limited hospitalization and evacuation facilities to maximum advantage, and even then only by careful husbanding of inadequate resources and by working insufficient personnel to the limit of humanendurance.¹⁹By the work of this personnel day and night, often without proper rest, and by operating hospital trains, ambulances, and trucks to their maximum possibilities, the representative of G-4-B was barely able to meet requirements. Reserve personnel and hospitalization were withdrawn from any organization from which they could be spared and sent to that area for duty.¹⁹

The early phase of battles in the Marne salient found us confronted by shortage not only of personnel and hospital equipment but also of trains and ambulances. Evacuation into Paris, where our nearest fixed hospitals were located, from 40 to 100 km. (24 to 62miles) distant, was effected at first by ambulance, or, if need be, by truck, until the railroad situation permitted the use of hospital trains which G-4-B had garaged near that city to meet this emergency. After railway service was established, evacuation was regulated from the station at Creil and later at the more centralized station at LeBourget.¹⁸Evacuations were effected at first by means of French and later by American hospital trains, our arrangements being intimately identified with those of the French and utilizing their lines of communication.¹⁸

In the early part of operations in the Marne area, G-4, of the Paris district, requested trains, sometimes in anticipation of needs, by telephone call to the regulating station. Because of faulty telephone communication between G-4 and the evacuation hospitals, this system proved unsatisfactory and was corrected later by having evacuation hospitals telephone their bed status direct to the regulating officer. That officer received daily from the chief surgeon of the Paris district a telephoned report of the bed status in that city, and after July 24 he also received from the chief surgeon, A.E. F., daily notification of the bed space in base hospitals in other parts of France. Eventually, the regulating officer at Le Bourget had under his control 17 American, 3British, and 35 French trains which were operated quite constantly, French trains being in adequate even for French evacuations.²⁰

Following the reduction of the St. Mihiel salient, the greatly augmented American First Army began preparations for further and, as it proved, final combat activities in the Meuse-Argonne operation. The Medical Department still faced critical shortages in equipment, personnel, hospitalization, and ambulances.²¹

During the entire progress of these operations a representative ofG-4-B remained at headquarters of the First Army, Souilly, for the purpose of coordinating Medical Department activities, and other representatives of that bureau were frequently at the front.²¹

While the 2d and 36th Divisions were on detached service with the French Fourth Army in the Champagne sector, in October, 1918, they naturally became separated from the administrative and supply control of the American First Army, and it accordingly devolved upon G-4-B to arrange for their hospitalization, supply, and evacuation during this period. To effect this, 2 evacuation hospitals, 1 mobile hospital, 3 evacuation ambulance companies, and 1 medical supply unit were withdrawn from the First Army and assigned to the service of these divisions, with stations at Mont Frenet and LaYeuve, until no longer needed. They utilized tentage exclusively, were located on two French sidings installed for serving French evacuation hospitals at that point, and were entirely self-sustaining in every detail. Hospital trains for casualties arising in these divisions were furnished through the regulating station at St. Dizier and were regulated by the representative of G-4 stationed at the subsidiary regulating station at Connantre.²¹

Jurisdiction of G-4-B, General Headquarters, over the medical service of the American Second Corps was very different from that over other American field medical organizations on the Western Front. The corps was attached to British forces, who provided all the hospitalization required and supervised it exclusively, thus relieving G-4-B,General Headquarters of any responsibility therefor.²²

During the final phase of our combat activities, two divisions (37thand 91st) were detached from the First Army and sent to Belgium to cooperate with the French and Belgian forces in the offensives then taking place on that front.²²For these divisions a regulating station was established at Dunkerque. An evacuation hospital and a mobile hospital and two evacuation ambulance companies were sent by rail and established behind the divisions to care for American sick and wounded. Casualties, happily, were relatively few, although approximately 4,000 patients were received by these units within a brief period. The entire Medical Department activities, connected with hospitalization, evacuation, and supply, were supervised by a medical representative fromG-4-B sent to that sector for the purpose.²²

Activities of G-4-B on the Italian front were practically nil. One regiment of Infantry (the 332d) had been detached from the 83d Division and sent to Italy. With this regiment G-4-B sent a fully equipped field hospital, with such additional X-ray and other surgical facilities as might be needed.²³Extra surgical personnel was also attached to this unit. As forces in France were so short of ambulances, the chief of the United States Army Ambulance Service attached to the Italian Army was directed to provide the necessary ambulance facilities to meet the needs of this regiment. A base hospital, No. 102, was sent to Italy direct from the United States for the purpose of assisting the Italian medical department in the hospitalization of their casualties. With the arrival of our small force in Italy, authority was obtained from the Italian Government to admit to Base Hospital No. 102 such Americans as could not be hospitalized in the field hospital. G-4-B kept in close touch with the senior medical officer on duty with this regiment in order that his supply and other needs might be met. He established in Italy a small medical supply dump. To reinforce its surgicalf acilities., arrangements had been made with the American Red Cross to provide the medical organization, on duty with the regiment, a mobile hospital then at the disposition of the Red Cross in Italy. Combat activities of our troops in that country were so slight, however, it was not necessary to take advantage of this loan.²³

While en route through England, one regiment of Infantry (the 339th)and the 1st Battalion of the 310th Engineers were detached from the 85th Division and sent with the Allied Expeditionary Forces to western Russia. None of the details of hospitalization of that force were handled by the fourth section of the general staff, A.E. F. One field hospital and one ambulance company (337th) which accompanied the forces to Russia furnished all the hospitalization provided by the army throughout their operations there.²³

ADMINISTRATION OF THE SANITARY SERVICE OF THE DIVISION

It would be logical from one point of view to continue the consideration of the management of Medical Department affairs by taking up at this time that of an army, since, in the organization evolved in the American Expeditionary Forces, the army surgeon came next in sequence of importance and control, in so far as the Medical Department was concerned, to General Headquarters, and then the corps followed in due course. However, as the division was the great administration unit of our combatant forces when we entered the World War, and was, in consequence, organized first, it was used largely, especially by the Medical Department, as an administrative model for the management of the affairs of the corps and armies which were organized later; therefore the division will be discussed first.

It should also be noted in considering the division that the basis for its Medical Department operation was originally the Manual for the Medical Department.

The administration of the sanitary service of the division in a theater of operations, as outlined by the Manual for the Medical Department, is given in Appendix I. However, many departures from this plan, which obtained at the beginning, were effected during the course of the war. Some of these departures were directed by official promulgations; others came about through the adoption of methods used in foreign armies, or as the result of necessity.

One of the first changes in the organization of the Medical Department of the division which had a bearing on the conduct of its affairs was the provision of a sanitary train commander.²⁴This, though it did not relieve the division surgeon of any ultimate responsibility for the operation of the sanitary train, divorced him from a relation with it that had been likened to that of a regimental commander, thus affording him more time for the direction of the activities of his department as a whole.

With the division as the administrative unit, it was the duty of the division surgeon to make definite recommendations concerning the announcement in the battle order of the location of dressing stations and of field hospitals. With the organization of the corps, however, control of the locations of division field hospitals was, in some instances, taken by corps headquarters.

The equipment of the field hospitals, when they arrived in France, was similar throughout. To meet the conditions which existed in France, it was found necessary to make additions to this equipment. It was likewise necessary to increase the personnel of these units to enable them to carry on the specialized form of treatment required infield hospitals during the World War.²⁴

The most important of the changes in the equipment of the field hospitals was the addition of surgical equipment to one in order that it might function on a larger scale as a surgical hospital to care for seriously wounded, including the injured classed as nontransportable. To one of the other hospitals was added the equipment for the treatment of gassed patients.²⁴

The operation of these specialized hospitals required the provision of teams of personnel, highly trained to function in their specialty in the most expeditious manner. These teams, comprising surgical, shock, splint, gas, and other teams, were usually organized from the personnel of the field hospitals themselves or were obtained from other Medical Department units of the division. When a mobile surgical unit was attached to a division field hospital, during active operations, the personnel of that unit was likewise attached to the divisional Medical Department for the time being.

With the specialization of the field hospitals there was evolved what might be called a normal distribution of the four field hospitals of the division, especially after the type of warfare in France had changed from trench to open. The open warfare was the character of warfare with which the American Expeditionary Forces was mostly concerned. Bearing in mind that the terrain usually determined the tactical distribution of the field hospitals, the chief requirement in making this distribution was found to be to provide for the following classes of sick and wounded: Seriously wounded; slightly wounded; gassed; and the sick, including the contagious sick and those with warneuroses.²⁵

In each division there was established a triage (sorting station) for the reception, classification, and distribution of those being evacuated.²⁵At each triage the specialist medical personnel was stationed, especially the psychiatrist, orthopedist, gas medical officer, and other medical officers who possessed the soundest medical and surgical judgment in the division.²⁵

The triage had long been an established feature in the organization of the French Service de Sant?. It was universally adopted by the American Expeditionary Forces.

An advanced triage was occasionally established at what was planned, by the Medical Department, to be the ambulance company dressing station-an institution that had little employment on the Western Front.²⁵

The sorting of casualties was done, naturally, wherever practicable, by any medical officer through whose hands the casualties passed. The term triage, however, generally referred to the one or more field hospitals established for the specific purpose of effecting a logical sorting of the wounded.²⁵

Because no general instructions were ever issued requiring a uniform distribution and employment of the field hospitals of the division,²⁵and especially since there was a lack of personnel in the Medical Department that had been well grounded by similar training, there was a diversity of administrative arrangements in our divisions that was limited only by the number of divisions employed. This lack of uniformity was overcome, in a measure, when the corps and armies were organized and there was opportunity for coordination. This coordination resulted in what came to be known as a normal distribution of the field hospitals in the area of adivision.²⁵The normal distribution varied, dependent upon whether the division was actively engaged, holding a position in line but not on an offensive, or whether it was in line in a quiet sector or in training.

When the division was in line and actively engaged, three field hospitals were used as a triage for the wounded, gassed, and medical cases. Here the patients were classified as being nontransportable, transportable sitting, and transportable lying. One field hospital was held in reserve, such portion of its personnel as necessary being used to augment the triage or sometimes for other purposes. Under such conditions as those outlined, the main considerations were the treatment of the wounded and the gassed, and the maintenance of the mobility of the hospitals. In effecting a forward movement of the hospitals, the hospital held in reserve was habitually used to open a new triage before the old one was closed.²⁵

A large number of cases were received into the divisional triages classified as "war neuroses" varying in degree from the pronounced psychoneuroses-so-called "shell-shock" cases-to those that were in fact shell fright, gas fright, hysteria, mental and physical fatigue, malingering, and cowardice.²⁶ There were few of the last named, but the situation in having to differentiate all these seriously complicated the problems of evacuation. After unfortunate experiences up to and including the St. Mihiel operation, during which many cases not requiring evacuation were unnecessarily evacuated to base hospitals, a plan for their more effective control, retention, and care was put into operation. This was based on careful examination and classification by the divisional psychiatrist at the triage, the retention of mild cases within the division, and the transfer of others to special neurological hospitals established by the army and conducted by specially trainedpersonnel.²⁶The result of this method was the return to duty of 65 percent of the cases which reached divisional hospitals and the transfer of 35 percent to the army neurological hospitals.²⁶Of this latter group, 57 percent were returned to duty and 43 per cent were evacuated by special ambulances or busses (to avoid mental contamination of the actually wounded from association) to Neurologic Base Hospital No. 117, situated at La Fauche, in the advance section, Services of Supply; i. e., only 15 percent of war neuroses were evacuated from the Army area. Of this number, in turn, 20 percent were returned to duty, 73 percent were classified for special kinds of service in the rear areas, and 7 percent were evacuated to the United States as totally unfit for military duty.²⁶

When the division was in line in a quiet sector, or when it was training, one field hospital was used for triage and the treatment of the wounded and gassed, one for sick, one for men afflicted with skin and venereal diseases, and one was held in reserve to meet the demands of an epidemic, a gas attack, and for use in evacuating patients to be hospitalized in the rear, or to establish a convalescent camp. Under such conditions as these, the Medical Department of the division made every effort, consistent with the military situation, to retain with the division all patients except those requiring definitive surgical treatment, and the sick requiring prolonged treatment, or expert treatment in a more fully equipped institution.²⁷

As the motor transportation of most divisions was pooled and was assigned to field hospitals only when they were moved, it made little differ-

ence which field hospital was supposed to be animal drawn, as contemplated in Tables of Organization, No. 28, since moves were nearly always made by trucks assigned for the purpose.²⁴

ADMINISTRATION OF THE SANITARY SERVICE OF THE CORPS

COMPOSITION OF CORPS

The American First Army Corps was created by General Orders, No. 9, G. H. Q., A. E. F., January 15, 1918, with headquarters at Neufchateau, other corps being created later as troops became available. The organization of a corps was later modified so that at the time of the armistice it consisted of a permanent staff and corps troops and of those divisions which were temporarily under its tactical control. There also developed a geographic element in their limitation, for the corps sector was always accurately described, and as divisions moved in or out of the sector they simultaneously entered or left the corps. The number of divisions assigned to a corps, therefore, changed materially from time to time. On one occasion the Third Corps began the day with five divisions; that night there were four, only one of which had been present in the morning. During 24 hours there had been 9 divisions under the corps control.²⁸

When they first entered the lines, American corps were under the tactical command of the French or British, but eventually they operated under American command, except the Second Corps, which continued under the British in Flanders. Corps headquarters consisted of the commanding general, a general staff, and departments commonly termed the technical services. The Medical Department pertained to the first or coordinating section (G-1) of the general staff. Officers and personnel of corps headquarters were divided into two echelons-often stationed in different towns-the first consisting of the commanding general and the general staff sections, and the second of all other officers. In both echelons were officers of many different grades.²⁹

In the developmental stage of the corps, before it assumed tactical command, the corps surgeon was obliged to maintain liaison with his French colleagues in the same sector and army, for evacuation and hospitalization in rear of our divisions were then effected, to a certain extent at least, by them.³⁰This arrangement did not always give satisfactory results, especially in the service of the 1st and 2d Divisions in their attack against Soissons. On this occasion the surgeon of the Third Corps to which these divisions belonged, was informed that the plan of evacuation was a military secret, and as the representative of G-4-B in that area likewise received no preliminary information, the hospital services of the French were not at first supplemented by any American units.³¹ In the Third Corps, as operations in the Marne area progressed, there was notable improvement in the evacuation service which the corps surgeon attributed in part to the training of all concerned in general staff work. The surgeon of the First Corps stressed the fact that the success of the corps medical service depended eventually upon the attitude of the assistant chief of staff, G-1, of the corps staff, under whom the

Medical Department functioned.³² The surgeon of the Third Corps attributed to the hearty cooperation of G-1, much of the success in evacuating the wounded. In this and the First Corps the surgeon received from G-1 full information and careful consideration of all his recommendations, and after conference with the chief of the section he wrote the paragraph of the administrative order pertaining to evacuation.³³

DETAILS OF ACTIVITIES, CORPS SURGEON’S OFFICE

Maps furnished the corps surgeon of the Third Corps were of two kinds, those which gave vague battle lines and approximate corps sectors, and those which were issued preparatory to a battle. The former, posted in the corps surgeon’s office, gave accurate details of the location of Medical Department units of the divisions, corps, and army. The latter were absolutely secret, and though given the corps surgeon to study, it was ordered that their details should not be communicated to anyone.³⁴

Other maps, used and posted up to date, were one of the general battlefield on which battle lines were marked in charcoal so that they could be changed readily, and the corps circulation map, which indicated available roads and the regulations concerning traffic. Some 10 days before the beginning of the Meuse-Argonne operation the surgeon of the Third Corps was given a map showing in detail the phases of the coming battle, with a very full, written description of military plans. Only the day and the hour, designated as "D" and "H," respectively, were kept secret, and these were whispered to officers some time before the battle began.³⁴

Organization of the corps medical staff in the First Corps was so effected eventually that there was an officer corresponding to the head of each similar department in the division surgeon’s office. As contemplated, and as later carried out, the organization was as follows:³⁵

Corps surgeon.-In charge.

Assistant corps surgeon.-In charge of corps troops, and in charge of office during the absence of the corps surgeon. Duties relative to corps troops were very similar to those of a division surgeon.

Executive officer.-In charge of office, and all records.

Corps sanitary inspector.-Sanitary inspector for corps troops, and supervision of the work of the division sanitary inspectors.

Corps consultant in surgery.-Supervision of all surgery done in division and corps field hospitals (which should be extremely limited);supervision of surgery in mobile surgical hospitals, when the latter were under the control of the corps surgeon as they should always be.

Corps consultant in medicine.-Supervision of medical care in the division and corps field hospitals, particularly supervision of shock work (his most important function in active periods).

Corps consultant in urology.-Supervision of the work of division urologists. Conduct venereal work and prevention and treatment of skin diseases for corps troops.

Corps consultant in orthopedics.-Supervision of division orthopedists. Conduct splint teaching for corps troops.

Corps consultant in psychiatry.-Supervision of the work of division psychiatrists; conduct psychiatric work for corps troops.

Corps medical gas officer.-Supervision of the work of the division medical gas officer. Conduct the same for corps troops.

Commanding officer corps sanitary trains.-Commands sanitary train of the corps; supervision evacuation of wounded in the various divisions; and conducts evacuation from field to evacuation hospitals.

Necessary clerks.

The specialist officers circulated constantly throughout the divisions constituting the corps, for the purpose of giving assistance wherever it was needed. Aside from the performance of their duties specified above they proved invaluable for keeping the corps surgeon constantly informed concerning all the Medical Department activities of the various divisions of the corps. Each specialist officer being carefully selected because of the knowledge he possessed of his branch of medicine or surgery, was able to give expert opinions on conditions found and sound advice for the correction of defects.

As it was not proposed that the office of the corps surgeon should be one of record, its clerical personnel and equipment in the First Corps were very limited. Retained records of all papers passing through this office were held in the files of the corps adjutant, where they were always available for reference, the corps surgeon’s office keeping copies of a few important documents only.³⁶In the Third Corps records were kept at a minimum, but a weekly sanitary report was required from all divisions and from corps troops, and from the same source was received by telephone twice daily (or oftener during battle) a numerical classified report of sick and wounded. In these latter reports promptness was regarded as being of more importance than was absolute accuracy. The accurate nominal lists, which came later were not prepared by the Medical Department. In the Third Corps, sick were classified as suffering from communicable or noncommunicable diseases, foot disorders, scabies and other skin diseases, and after November 1, 1918, reports of venereal diseases were required. Reports of communicable diseases gave the name of the ailment and the location of the case. Battle casualties were numerically differentiated as wounded, gassed, and psychopathic.³⁷

In the Fifth Corps the corps surgeon required the following information from division surgeons immediately upon joining the corps:³⁸(1) Numerical list of medical personnel and transportation. (2) Roster of medical officers including specialists, dental, sanitary corps and veterinary officers. (3) Daily: Casualty report. (4) Weekly: Personnel and transportation (Form 9, A. G. O., S II). (5) Contagious diseases (for the allied commander). (6) Venereal (name, rank, organization, and number of each new case).

Reports required from corps were: Daily casualties and changes, adding number of cases evacuated direct to evacuation hospital.

In addition to the foregoing, the usual routine reports passed through the corps surgeon’s office.

Originally, the office equipment of the Third Corps was that authorized for a division surgeon, but later was somewhat increased. It included, as its most important items, a box for maps and map-making instruments, another

which contained live records, and three typewriters. These, with the officers’ bedding rolls and the men’s equipment, were sent forward in charge of an officer when the office moved. During moves it was necessary to divide the office equipment into two shipments. Tables, chairs, and boxes of files gradually accumulated, the total weight of essentials amounting to about 600 pounds. A 3-ton truck provided for the office was more than adequate to move both the office and its enlisted personnel.³⁷

The chief functions of the corps surgeon in the evacuation of wounded were to systematize the operation of division triages, to supervise the location and operation of field hospitals, to evacuate those units, and to regulate the flow of casualties from them into the army hospitals according to the army plan of evacuation.³⁹This plan was issued as part of the operations order of the army. As it was essential that he maintain close contact with the army surgeon or his representative in order to equalize evacuation into different hospitals in the army zone and to divert it from one to another in accordance with changing conditions, the corps surgeon assigned to a capable assistant the duty of maintaining such contact and of coordinating evacuation. This officer was designated in the different corps as the transportation, evacuation, or regulating officer, as the case might be. He maintained active liaison with division surgeons, on the one hand, and, on the other, with the chief surgeon of the army (through the army hospitalization and evacuation officers), who advised the army evacuation officer frequently during active operations concerning available bed space in army hospitals and the additional transportation on hand. In this way the routing of ambulances was directed to those hospitals best prepared to receive casualties at a given time. Courier service was maintained between corps and divisions and the army evacuation and mobile hospitals. Traffic regulators (traffic police) were posted at appropriate places along the roads leading from divisional triages to evacuation hospitals, and at night illuminated signs directed the ambulance convoys.⁴⁰ Corps sanitary trains, each consisting of four field hospitals and four ambulance companies, were authorized; but these trains were not actually available until some time after the organization of corps. It was their duty to clear field hospitals, if need arose to supplement the deficiencies of intradivisional resources, and to hospitalize those patients who could not endure the full journey to evacuation hospitals and those who would be fit for duty within a few days. Frequently, in the earlier operations, demands upon corps transportation were such that the quota of corps vehicles was inadequate; for example, in the First Corps, in the Marne area, when its ambulances had to make roundtrips 70 miles in length.⁴¹ Difficulties of the corps evacuation service were aggravated by the fact that, while the ambulance quota for a division was generally adequate in trench warfare, it was quite inadequate for an offensive and then needed reinforcements from the corps at the very time when, if the attack were successful, the distance which the corps ambulances had to travel progressively increased. Under such circumstances, unless reinforced by transport assigned by the army, and unless army hospitals were well advanced, many wounded had to be moved by trucks both in divi

sions and in rear of them. The corps surgeon distributed his transportation where it was most urgently needed. At first there was no corps reserve, because of lack of vehicles, but when this need had been met his ambulance companies often served in rotation, if possible, in order that opportunity might be given for personnel to rest and to repair ambulances.

The field hospitals which formed a part of the corps sanitary train were utilized as convalescent depots (First Corps) or as rest or relay stations (Third Corps). As a rule they were located midway between division triages and the evacuation hospitals serving a corps.⁴²Surgeons of all corps emphasized the desirability of adding a mobile hospital to the corps sanitary train.

The surgeon, Fifth Corps, reported that during the Meuse-Argonne operation no division entered that corps with its full quota of ambulances or with anything approaching the allowance of trucks for field hospitals or of motor cycles or motor cars.⁴³The corps sanitary train, authorized by Tables of Organization, was lacking except that three field hospitals reported in the first part of November entirely without transportation at first, and with no cots, stoves, extra blankets, or tents for officers. At the beginning of this offensive four United States Army Ambulance Service and two French ambulance sections were attached to the corps, giving a total of 88 ambulances, of which about 74 were fit for service.⁴⁴ At the time, this allowance was adequate, but it became progressively less and less so as division triages advanced, a round trip eventually taking from 20 to 24 hours. Great difficulty was experienced in obtaining spare parts for vehicles.

Trains of the several corps were gradually increased as resources of any kind became available, until at the time of the armistice they conformed approximately or actually to the authorized quota.

There was some confusion, at first, in the corps evacuation service. There were several reasons for this. Division medical officers did not sort cases properly, but loaded into one ambulance patients who had to be distributed to several army hospitals. Ambulance drivers occasionally did not go to the hospitals to which they were sent, but went to some other than the one designated. Receipt of notification that certain hospitals were filled and that casualties, already en route, would have to be diverted to some other point, was belated.⁴⁵

The multiplicity of evacuation and special hospitals in the army area increased the difficulties of ambulance evacuation and caused confusion, delays, and waste of transportation. At one time in October, 1918, there were 11 hospitals in different places draining the front of one corps. Hospitalization facilities and the military situation often determined the location of evacuation hospitals, but experience during the Meuse-Argonne operation demonstrated the desirability of grouping them wherever practicable and condemned the establishment of separate institutions to receive special cases of casualties. The ideal arrangement, so far as evacuation was concerned, was reached when the number of evacuation points was minimized and evacuation hospitals were generalized, that is, prepared to receive all kinds of casualties.⁴⁰

One of the principal difficulties encountered in effecting evacuation from divisions was due to the fact that their evacuation methods were not standardized and that in order to promote coordination it was necessary to harmonize their different practices so far as possible. The difficulty was increased by the frequent changing of divisions in a given corps and by the fact that methods in different corps were often dissimilar. Thus, the First Corps required that dressing stations perform triage service for divisions,⁴⁶while in the Third Corps this duty was performed at field hospitals.⁴⁷Standing orders on this subject were issued in some corps, the First, for example.⁴⁸Field hospitals of a division generally were located by the division surgeon after consultation with the corps surgeon; but in preparation for an offensive the original location usually was made by the corps surgeon because of his superior knowledge of supply points and road conditions.

In some corps, especially in the First, it was the practice to designate as evacuation officer the commanding officer of the sanitary train, and he was assisted by officers from this train, stationed at each division triage. The corps evacuation officer was thus kept constantly apprised of conditions in division field hospitals, on the one hand, and of those in army hospitals, on the other, and he was therefore in a position to route casualties to the best advantage. In addition, especially during periods of battle activity, the corps surgeon was in daily personal contact with the evacuation officer of the army and with division surgeons, and he visited daily, if possible, all the division triages. It soon became apparent that personal inspection of the location and operation of dressing stations and field hospitals was necessary to obtain the best results and the highest degree of coordination. Location of these by maps was less satisfactory than were results obtained by reconnaissance.

Evacuation methods utilized by different corps varied considerably, not only one from another but also in a given corps at different times, on account of mutable conditions. The following memorandum order, covering the evacuation of sick and wounded, was promulgated in the First Corps as a means of standardizing the various methods of evacuation practiced by the divisions becoming parts of the corps:

HEADQUARTERS FIRST ARMY CORPS,
3 September, 18-11.30 a. m.

G-1
___

Memorandum: Evacuation sick and wounded.

The following plan of evacuation of sick and wounded for each division in the corps will be put into effect at once.

AMBULANCE DRESSING STATION

1. Ambulance dressing station: This will be placed at the farthest point forward where ambulances can be concentrated with reasonable safety. It should be on a good road, with shelter, if possible, and with water available. It will be established by the ambulance section of the division sanitary train. Care must be exercised that it be established at a point which will not interfere with traffic. It should be on a return road.

At this point, patients, brought in by litter or by ambulance from the frontline, will be examined; dressings adjusted, and hemorrhage controlled, if necessary; antitetanic serum administered, if not already done; food and hot drinks given where permissible; shock treated when the patients’ condition makes it necessary; and the patients placed under shelter while awaiting transportation to the rear.

A shock table will be installed so that patients needing shock treatment can be properly cared for. Patients in shock will be held, if military conditions permit, on the shock table until their condition permits transportation to the rear.

2. The ambulance dressing station will also be a triage. Patients will be sorted, placed in an ambulance, and sent direct to the appropriate hospital, the idea being to reduce to the minimum, handling of the patient from the time he is wounded until he arrives in hospital.

3. At this ambulance dressing station will be stationed the following medical officers in addition to the personnel of the ambulance section conducting the station: Division psychiatrist, division orthopedist, division medical gas officer, and a medical officer with good surgical experience and judgment. Each of these officers should have an understudy who can relieve him when necessary to secure rest or food.

4. The division psychiatrist will examine all cases of shellshock, simulated shell shock, and other nervous conditions that may pass through this station. He will return to the front such patients that he considers fit for duty and to the rear those requiring hospitalization.

5. The division orthopedist will examine all patients with fracture and joint injuries and will see that all such are properly splinted before being sent to the rear.

6. The division medical gas officer will examine all gassed patients, returning to the front line all deemed fit for duty. He will return to the rear all that require hospitalization. He will also supervise the preliminary gas treatment at this point. Bathing facilities will be provided so that mustard gas patients will get the earliest possible attention and thus prevent subsequent burning.

7. The medical officer with good surgical experience and judgment who is selected for duty at this point will examine all wounds and direct to which hospital each wounded patient will be sent. The wounded will fall under one of three heads: (a) Very slight, who after the necessary dressing and antitetanic serum will be able to return to the front for duty; (b) nontransportable wounded, who will be sent to the field hospital designated for that purpose; and (c) all other wounded, who will be sent to the nearest evacuation hospital.

8. In past experience during open warfare, it has been found that large numbers of men return from the front diagnosed as shell shock or gas casualties. The great majority of these men present neither of the above conditions, but are simply exhausted, mentally and physically. They are disabled for the time being, but should not be sent to evacuation hospitals. They must be held in divisional sanitary organizations, given the necessary food, a bath when possible, and an opportunity to thoroughly rest. It will be found that within one to four days they will be able to return to full duty at the front, thus saving a very marked loss of man power when the maintenance of the man power of a division at its full strength is most important. Any such subsequently developing serious symptoms will at once be transferred to an evacuation hospital.

9. During active operations when the number of casualties becomes very large, it will be found that the available ambulance transportation will be entirely insufficient to carry all wounded to the rear and to prevent congestion of wounded in the front areas. It therefore is necessary for division surgeons to maintain liaison with the division motor transport officer and to secure the use of as many trucks as possible to carry back slightly wounded and gassed patients. Severely wounded and gassed must be carried in ambulances only. The corps surgeon will give every possible assistance to division surgeons during such periods of stress and will utilize for this purpose all available ambulances within the corps.

10. Close liaison must be maintained in the division between the director of the ambulance company section and the director of the field hospital section of the divisional

sanitary train. The commanding officer of the sanitary train under the supervision of the division surgeon will see that this liaison is constantly maintained. It is particularly important that the director of the ambulance section know immediately when any change is made in the location of a field hospital so that ambulances may be properly directed. Otherwise much confusion and loss of valuable time will result.

11. The station of the director of the ambulance section, divisional sanitary train, will normally be at the ambulance dressing station; of the director of field hospitals at the place where the field hospitals are grouped.

12. Roads in the vicinity of the ambulance dressing station and of the field hospitals will be plainly marked so that litter bearers and ambulance drivers may locate them without trouble. The divisional assistant provost marshal will be kept advised of the location of all sanitary units and of any changes made so that the military police will be competent at all times to give necessary and intelligent instructions as to their locations.

FIELD HOSPITALS

1. Field hospitals will be utilized as follows during periods of activity. This applies particularly to open warfare where rapid changes are probable. In sector warfare which is practically stationary, location of field hospitals need not follow this plan absolutely, especially as to location, which will be determined by the terrain, buildings available, proximity of evacuation hospital and other considerations.

2. The four field hospitals of a division will be placed together if conditions of the terrain permit. They will always be plainly marked by the Red Cross emblem in order to protect them from enemy fire. Placing the field hospitals together has been tested in actual open warfare and found to have certain definite advantages.

(a) They are much more easily located by ambulance drivers. If located at separate points depending upon the character of service they are intended to furnish, ambulances are apt to wander about and have great difficulty in locating their particular hospital. This, of course, is especially true in new country with which drivers are not familiar.

(b) The administration of the hospital is much simplified by being concentrated at one point.

(c) Assistance from the field hospital in reserve is always immediately available for whichever unit may have need of such assistance.

The field hospitals should be placed as close to the ambulance dressing station as is reasonably safe.

3. The field hospital will be utilized as follows: (a) Gas hospital, (b) hospital for nontransportable wounded, (c) hospital for minor sick, including skin and venereal diseases, and (d) one hospital in reserve.

4. Gas hospitals: One field hospital will be utilized as a gas hospital. To this hospital will be sent from the triage all patients who have been gassed. Therefore, facilities must be provided to give them the necessary special treatment required-proper bathing, alkaline treatment, administration of oxygen and, if necessary, venesection. As soon as the necessary treatment has been given and their condition permits, such patients as require further hospitalization will be sent to the nearest evacuation hospital. However, during open warfare, it will be found as noted before that the majority of gassed patients or the so-called gassed, will not require anything beyond a few days’ rest, sleep, and food. These must not be sent to evacuation hospitals but must be retained until fit for duty (provided this does not require more than four days)and then returned to the line. At this hospital, there will also be installed a shock table for the treatment of those needing shock treatment at this point.

5. Hospital for nontransportable wounded: 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 surgical treatment and care may be given these cases. To this hospital will be sent direct from the triage only patients whose transportation farther to the rear will probably mean death. In past experiences these have usually comprised three classes: (a) Sucking chest wounds, (b) perforating abdom-

inal wounds, and (c) severe hemorrhages. Patients with heart and spinal conditions stand transportation better before operation than after, and should, therefore, not be stopped here. There has been a tendency in the past to retain at this hospital the seriously wounded who, however, would be able to stand transportation to the evacuation hospital. This must be discontinued. Only such patients will be retained as are actually nontransportable. When available, the corps 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 hospital and what cases will be transferred to the evacuation hospital. A shock team will be on duty at this hospital for treatment of all shock cases both pre and post operative.

6. Hospital for minor sick including skin and venereal diseases: To this hospital will be sent only patients with minor conditions who will be fit for duty within four days. All seriously sick must be sent to an evacuation hospital at once. This includes the minor sick sent to this hospital who later develop serious symptoms. During active operations, patients with venereal diseases, except those having disabling complications, such as orchitis, epididymitis or cystitis, or who are in the infectious stages of syphilis, must be retained for full duty at the front.

7. One field hospital in reserve: This will be used to give assistance where needed both in personnel and equipment. A detail of 1 medical officer and 10enlisted men will be sent to the ambulance dressing station to give the necessary preliminary bathing and alkaline treatment to patients with mustard gas burns as may be deemed necessary by the division medical gas officer on duty at this station. This detail must of course be relieved by another similar detail at regular intervals to allow the former to secure the necessary rest and food.

8. It must always be borne in mind that divisional hospitals must be as rapidly cleared as is possible in order that they may be mobile at all times. Necessarily, a hospital for nontransportable wounded must be more or less immobilized, but it also must be evacuated as rapidly as the condition of the patients will permit so that it, too, may advance with the troops when occasion requires. The corps surgeon will give the necessary assistance in replacing the personnel and equipment of field hospitals with corps sanitary train units when such are available.

9. Exchange of supplies: It is of utmost importance that a systematic exchange of supplies-as litters, dressings, splints, blankets, hot water bottles, operating from the front line 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 ambulance orderly must return to the litter bearers a duplicate of all supplies furnished the patient. Similarly, when the ambulance delivers the patient to a hospital, the ambulance orderly must get from the hospital a duplicate of all supplies furnished the patient. This must operate at every point where a change of transportation is made. Otherwise the supplies at the frontline positions will soon become exhausted and unnecessary delay and suffering will result. If this system of exchange is enforced, there is a constant steady stream of all necessary supplies going forward and there need be no interruption in the care given to wounded or other casualties.

* * * * * * *

ADMINISTRATION OF THE SANITARY SERVICE OF THE ARMY

Organization of the First Army, with headquarters at LaFerte-sous-Jouarre, was announced to take effect on August 10, 1918.⁴⁹On October 10, during the second phase of the Meuse-Argonne operation, the Second Army wascreated,⁵⁰occupying that portion of the American front extending from Port-sur-Seille east of the Moselle to Fresnes-en-Woevre, southeast of Verdun.⁵¹ Plans had been made before the armistice forthe organization of a Third Army, and after the armistice, on November 14, this was designated the Army of Occupation.⁵²

The army surgeon not only supervised and coordinated the Medical Department activities of corps, divisions, and regiments, but he also had at his disposition the following formations, varying in numbers according to resources and needs: An army sanitary train, mobile hospitals, special neurologic, gas, and contagious disease hospitals, ambulance companies, sections of the United States Army Ambulance Service, hospital trains of standard 1-m. and 60-cm. gauge, medical supply parks and "dumps," convalescent depots, field medical laboratories, sanitary squads, specialists, including consultants and epidemiologists, operating, shock, splint, and gas teams, radiologic groups, sanitary inspectors, attending surgeons, mobile degassing units, courier service, disinfection units for prisoners of war and repatriates, labor battalions, prisoners-of-war companies, the Medical Department concentration area, the medical group at the regulating station, and American Red Cross stations and supply parks in the army area.

ORGANIZATION OF THE OFFICE OF THE ARMY CHIEF SURGEON

War Department Tables of Organization provided for the following personnel of the Medical Department for the operation of the office of the chief surgeon of an army:⁵³ 1 colonel; 1 lieutenant colonel; 1 major; 1captain; 1 sergeant, first class; 2 sergeants; and 8 privates, first class, or privates.

The experiences of the three armies which were organized in the American Expeditionary Forces differed materially; therefore the demands made on the Medical Department of each of these armies likewise varied. Consequently, the organization of the office of the chief surgeon of each of the armies differed.

The problems which engrossed the army chief surgeons were hospitalization, transportation, medical supply, sanitation, administration, professional supervision, and evacuation. These were all problems of considerable magnitude, and their immediate supervision could not be intelligently accomplished by one person.

As in the corps, the organization of the army chief surgeon’s office had to be perfected with practically no precedent as a guide. The pioneer work in this direction was done by the first chief surgeon of the First Army, which, as has been seen, was organized August 10, 1918. In his preparations for the part which the Medical Department was to play in the St. Mihiel operation that took place within a month, the chief surgeon, First Army, so organized his office as to have the following heads ofdepartments:⁵⁴ Assistant to the chief surgeon; medical supply officer; officer in charge of correspondence; statistical officer; sanitary inspector; supervising dental surgeon. On September 25, 1918, when the chief surgeon moved his office from Neufchateau to Ligny-en-Barrois, Meuse, and the strength of the First Army exceeded 1,000,000 men,⁵⁵ there were the following officers in the chief surgeon’s office, additional to those mentioned above:⁵⁵ Motor transport officer; representative chief surgeon, a tthe front; assistant to director, ambulance service; 3 assistant medical supply officers. Though there were consultants in the special

subdivisions of surgery and medicine assigned to the First Army, the chief surgeon did not carry them as a part of his office organization.

In the development of the organization of the office of the chief surgeon, Second Army, it became necessary to expand the personnel to 20 officers in charge of the following administrative sections under his immediate supervision:⁵⁶

Hospitalization - Direction and supervision of evacuation, mobile and special army hospitals, and mobile surgical units. Organization, supervision, and assignment of surgical, shock, and fracture teams, and auxiliary professional personnel. Control of hospitalization within the army.

Transportation - Direction and supervision of all Medical Department means of transportation within the army, except that with army artillery.

Supply.-Medical, dental, and veterinary supply of division, corps, and army troops except initial equipment. Organization and administration of army advance medical supply depots.

Sanitation.-Supervision of sanitation of divisions, corps, and army; activities of sanitary squads; preparation of sanitary reports, control of epidemics, organization and administration of area sanitary service, control of army and mobile laboratories in conjunction with Engineers’ Water Service.

Medical service of army troops.-Organization and administration of the medical service of army troops other than army artillery in the capacity of a division surgeon for these units.

Statistics and record - Duties of personnel adjutant. Preparation of the statistical reports of Medical Department units as prescribed in orders. Organization and internal administration of the army surgeon’s office. Records, reports, charts, returns, and correspondence of administrative and consulting sections.

Evacuation (G-4) - Medical representative on staff of G-4.Supervision of evacuation from the army and transportation of army hospitals in the army area. Action on medical requisitions in conformity with General Orders, No. 44, G. H.Q., A. E. F., 1918.

Medical consultant - Supervision of clinical medicine in division, corps, and army hospitals. Selection and instruction of subordinate consultants and chiefs of medical services for army hospitals. Organization and supervision of shock teams. Adviser of chief surgeon concerning the professional service of the army.

Surgical consultant - Duties similar to those of medical consultant.

Orthopedic consultant - Duties similar to those of other professional consultants. Organization and instruction of fracture teams, distribution of splints and splint material, and instruction of Medical Department personnel in their use.

Neuropsychiatry consultant - Duties similar to those of medical consultant. Cooperation with judge advocate in examinations contemplated by par.219, Manual of Courts-Martial.

Urology consultant - Supervision of clinical work pertaining to urology, dermatology, and prophylaxis of venereal and skin diseases, in amanner similar to the services of the medical and surgical consultants.

Medical gas treatment officer - Duties analogous in this field to those of medical and surgical consultants. Supervision of instruction of all medical personnel in treatment and management of gassed cases.

Roentgenologist.-Supervision of clinical work and other duties pertaining to this specialty, including procurement and maintenance of fixed and portable X-ray apparatus.

Dental surgeon - Supervision of dental service throughout the army, and, in cooperation with supply sections, distribution of dental supplies.

Attending surgeons and attending dental surgeons were attached to army headquarters and to headquarters troops.

Though plans had been made before the armistice for the organization of the Third Army, it was not until November 14 that this army was given a mission-the American army of occupation on the Rhine.⁵²Active hostilities had ceased, but, because of the plan for the advance of the Third Army, which was to follow up the retreating Germans, to see that the terms of the armistice were carried out by them, it was necessary to maintain as effective an organization for it as though hostilities were still going on. The organization of the office of the chief surgeon, Third Army, differed slightly from that adopted by the chief surgeon, Second Army. Beside the chief surgeon, there were in the former’s office a chief dental surgeon, a medical supply officer, an officer in charge of hospitalization; consultants in medicine and surgery, a director of laboratories, an evacuation officer and representative of the chief surgeon; consultants in urology, ophthalmology, otology and laryngology, neuropsychiatry, and orthopedics; and an officer in charge of finance and accounting; a sanitary inspector; an epidemiologist; an officer in charge of water supply; an executive officer; an assistant to the chief dental surgeon.⁵⁷

Though all the several kinds of Medical Department formations under the immediate jurisdiction of the army surgeon were indispensable, the most important of these were regarded as the evacuation and mobile hospitals and the mobile surgical units and ambulance companies. These are discussed in Chapter V. Army hospitals received the wounded from the front, operated upon them if necessary and possible, prepared them for transportation to base hospitals, and placed them on hospital trains.

Evacuation from the army zone was hampered by the considerable number of hospitals provided, especially when these were scattered, for not only did their multiplicity tend to confuse incoming ambulance drivers and thus to delay delivery of patients at the proper destination, but it also made more difficult the coordination of evacuation from these army hospitals. It had been intended that evacuation hospitals should receive all classes of cases, but because of their inadequacy to do so despite their expansion, it proved essential that they be supplemented by other units, especially after the appearance of the influenza epidemic in the autumn of 1918.²⁶The evacuation hospitals were distributed according to needs, roads, sites available, etc., and it was in order to facilitate coordination of evacuation from these scattered units that they were grouped into evacuation areas during the Meuse-Argonne operation.

No plan of evacuation, issued as part of a field order prior to an engagement, could automatically continue to meet changing conditions: nor was it practicable to issue a new order from army headquarters whenever the situation in the line, or in evacuation hospitals, demanded a change in the original scheme. Plans of evacuation quoted at various points in succeeding chapters express only general policies for collecting the sick and wounded into the army hospitals severally designated for the reception of different classes of cases-normal sick, contagious, seriously wounded, slightly wounded, gassed, and psychopathic. Execution of such plans required, of course, a coordinated division of labor.

All transportation belonging to the Medical Department of an army was pooled and operated and distributed under an officer charged with the evacuation ambulance service who was attached to the office of the army surgeon.⁵⁸This transportation consisted of ambulance companies, evacuation ambulance companies, and all other motor transport assigned to the army for the evacuation of casualties. The transportation officer who was immediately charged with its control utilized it to evacuate corps and army hospitals, located off the railroad, to other hospitals from which railway evacuations were made, to reinforce the corps and division evacuation service, and in emergencies to transport Medical Department personnel (teams and nurses) changingstations.⁵⁸Four or five ambulance companies and 10 sight-seeing busses were assigned to each corps in the Meuse-Argonne operation in addition to the corps quota, and an army reserve was established consisting of 7 ambulance companies and 30 trucks fitted for transporting the slightly wounded.

The policy was maintained for attaching sections of this army reserve, as needed, to the several corps for temporary duty. By this means the reserves were used where most required, were readily shifted, and after a period of hard service were withdrawn for rest of personnel and repair of vehicles.

Until a short time before the St. Mihiel operation, September 12, 1918,the system employed for evacuation of casualties from the zone of the armies was an adaptation of the system used by the French and was operated to a large extent through their facilities and with their aid. When, however, the First Army was organized and took over its designated sector, it adopted a definite system of its own which, operating over its own lines of communication, provided for the movement of casualties from the front to base hospitals. For the successful operation of this system it was necessary that there be close coordination between the activities of the Medical Department and those of the Services of Supply. This was effected through the agency of the general staff, which so far as possible centralized in one bureau information concerning the following subjects:⁵⁹ (1) Army hospitals: Location, number, capacity, number of operating teams, and number of patients classified in reference to their evaluability. (2) Hospital trains: Number, type, capacity, routes, and schedules in coordination with military activities and traffic. (3) Base hospitals, distance, available bed space, classified.

The machinery or organization of the system adopted required: (a)An evacuation officer, attached to G-4 of the army. (b) A regulating officer, in

charge of hospital train service, also operating under G-4. (c) A hospitalization officer, in the office of the chief surgeon, A. E. F.

Evacuations were coordinated by the Medical Department representatives with the fourth section of the general staff, one member of the group being charged with this duty and also representing here in such matters the chief surgeon of the army in the field.

Priority right in field telephone communication was secured and a medical officer was assigned to each corps sector, charged with the duty of collecting information concerning casualties and those to be evacuated and of transmitting it to the medical officer-an assistant to the army surgeon-who was attached to the fourth section of the general staff of the army concerned. This officer, charged solely with the evacuation of casualties, received twice every 24 hours the casualty reports of division, corps, and army troops by classes and the reports of army hospitals, with their statements of the number of casualties and empty beds. Upon these figures he based his reports to the army surgeon and his requests to the regulating stations for trains. His communication with the army surgeon and the regulating office was by telephone, as these officers were located at points having direct trunk-line communication.^60-61

The method above described, known as the second plan of evacuation, as determined and directed by General Headquarters, became effective on August 29, 1918; but though it was satisfactory in quiet periods, certain changes were found necessary in the active periods of an offensive, for then the situation in army hospitals changed from hour to hour, and a more automatic system, utilizing more frequent reports, was found necessary. It was essential that there be closer, more intimate contact between the army hospitals and the regulating officer. To effect this, the evacuation office of G-4, army, was decentralized, representatives taking station at evacuation centers.⁶¹Each of these centers consisted of the army hospitals which, whether grouped or scattered in a certain defined area, were evacuated as an entity. The extent of these centers was determined by railhead facilities. Ambulance companies to carry patients to the railway sidings were distributed among the centers according to the distance of hospitals from their entraining points, their capacity, and the character of disabilities which they treated. At these centers reports could be received hourly, if necessary, and whenever possible such reports were telephoned by a preferred wire direct to the regulating officer. The area representative of the evacuation officer did not now call for a certain kind of train or for a specific number, but simply gave the number and type of cases to be evacuated and named the hospital or group of hospitals to be served.⁶¹This close contact with the regulating station enabled the evacuating officer to control the stream of casualties and to divert it to the best advantage into the various army hospitals. This duty required the utmost diligence, for the hospitals’ capacity was measured by the amount of their bed space, by their operating teams and evacuation facilities, and over taxation of any of these would cause congestion or necessitate sending patients out on preoperative trains. When a certain limit was reached beyond which a hospital could

not, with its available operating teams, clear its patients within four hours, for instance, admissions were stopped and the stream of wounded was diverted to other hospitals.⁶²

The services of the evacuation officer, who supervised evacuations and coordinated them with other military activities, were supplemented by those of the army hospitals officer, who was in immediate control of evacuation, mobile and special hospitals; and mobile surgical units. This officer performed in the zone of the armies duties similar to those of the hospitalization officer in the office of the chief surgeon, A. E. F., at Tours, who controlled hospitalization in the advance, intermediate, and base sections. Thus he assigned and supervised surgical, shock, and fracture teams and other professional personnel, selected new sites for army hospitals, and supervised their opening, operation, and closing. During engagements he kept close watch over these units and maintained liaison with the corps surgeons in order to direct the flow of casualties according to changing conditions. In this duty he collaborated with the evacuation officer, with whom he was in constant touch. During the Meuse-Argonne operation the hospitalization officer in the First Army became assistant to the evacuation officer.⁶²

The plan thus developed eventuated in a simple but efficient system in which evacuations were controlled by one bureau.⁶¹ Kept informed of needs at the front and of resources at the rear, the regulating officer could send his trains to the best advantage in each direction. To meet normal daily needs, during the Meuse-Argonne operation (q. v.) a specified number of trains were sent daily to each evacuation center, and in emergencies other trains than those normally provided were sent upon call. But such special trains were relatively infrequent.

Arrangements for the hospitalization of casualties in the zone of the armies were preliminary to their further transfer, for definitive treatment, to base hospitals farther to the rear. These were located in the base, intermediate, and advance sections of the Services of Supply, while in the district of Paris were American Red Cross hospitals discharging similar duties. The area of the Services of Supplies covered all that territory of France which was not included in the zone of the armies or the district of Paris.

REFERENCES

(1) Manual for the Medical Department, U. S. Army, 1916, par. 828.

(2) G. O. No. 1, G. H. Q., A. E. F., 1917.

(3) Report of the chief surgeon, A. E. F., to the commanding general, S. O. S., April 17, 1919, 6. On file, Historical Division, S. G. O.

(4) Ibid., 5.

(5) G. O. No. 31, G. H. Q. A. E. F., February 16, 1918.

(6) Report on the activities of G-4-B, medical group, fourth section, general staff, G. H. Q., A. E. F., by Col. S. H. Wadhams, M. C., chief of section, December 31, 1918, 6. On file, Historical Division, S. G. O.

(7) Ibid., 5.

(8) Ibid., 7.

(9) Ibid., 8.

(10) Ibid., 51.

(11) Ibid., 9.

(12) Wadhams, S. H., and Tuttle, A. D.: Some of the Early Problems of the Medical Department, A. E. F. The Military Surgeon, Washington, D. C., 1919, xlv, No. 6, 626.

(13) Report of the assistant chief of staff, G-4, G. H. Q., to the commander in chief, A. E. F., undated, 27. On file, Historical Division, S. G. O.

(14) The French supply control installation for the field forces, by Lieut. Col. J. W. Beacham, Inf.; The French control of Evacuation, by Col. S. H. Wadhams, M. C. Supply Course No. 45, March 23, 1921. (Remarks delivered at the General Staff College, Washington, D. C.) On file, Historical Division, S. G. O.

(15) Report of assistant chief of staff, G-4, G. H. Q., A. E. F., to the commander in chief, undated, 28. On file, Historical Division, S. G. O.

(16) Report on the activities of G-4-B, medical group, fourth section, general staff, G. H. Q., A. E. F., by Col. S. H. Wadhams, M. C., chief of section, December 31, 1918, 52. On file, Historical Division, S. G. O.

(17) Ibid., 53.

(18) Ibid., 55.

(19) Ibid., 54.

(20) Exhibit "S" to the report on activities of G-4-B, medical group, fourth section. general staff, G. H. Q., A. E. F.: Report of hospital evacuation section, Regulating Station B, St. Dizier, France, undated, Part IV, 21. On file, Historical Division, S. G. O.

(21) Report on the activities of G-4-B, medical group, fourth section, general staff, G. H. Q., A. E. F., by Col. S. H. Wadhams, M. C., chief of section, December 31,1918, 57. On file, Historical Division, S. G. O.

(22) Ibid., 58.

(23) Ibid., 59.

(24) Evacuation system of a field army, by Col. C. R. Reynolds, M. C., undated,1. On file, Historical Division, S. G. O.

(25) Ibid., 2.

(26) Ibid., 8

(27) Ibid., 3.

(28) Report of Medical Department activities, Third Army Corps, by Col. James L. Bevans, M. C., corps surgeon, undated, 1. On file, Historical Division, S. G. O.

(29) Ibid., 8.

(30) Ibid., 10.

(31) Ibid., 13.

(32) Report of Medical Department activities, First Army Corps, by Col. J. Grissinger, M. C., corps surgeon, undated, 13. On file, Historical Division, S. G.O.

(33) Report of Medical Department activities, Third Army Corps, by Col. J. L. Bevans, M. C., corps surgeon, undated, 23. On file, Historical Division, S. G. O.

(34) Ibid., 30.

(35) Report of Medical Department activities, First Army Corps, by Col. J. W. Grissinger, M. C., corps surgeon, undated, 11. On file, Historical Division, S. G. O.

(36) Report of Medical Department activities, First Army Corps, by Lieut. Col. R. M. Culler, M. C., corps surgeon, undated, 50. On file, Historical Division, S. G. O.

(37) Report of Medical Department activities, Third Army Corps, by Col. J. L. Bevans, corps surgeon, undated, 50. On file, Historical Division, S. G. O.

(38) Report of Medical Department activities, Fifth Army Corps, by Col. W. R. Eastman, M. C., corps surgeon, November 18, 1918, 41. On file, Historical Division, S. G.O.

(39) Evacuation system of a field army, by Col. C. R. Reynolds, M. C., undated, 35. On file, Historical Division, S. G. O.

(40) Ibid., 36.

(41) Report of Medical Department activities, First Army Corps, by Col. J. W. Grissinger, M. C., corps surgeon, undated, 66. On file, Historical Division, S. G. O.

(42) Ibid., 7.

(43) Report of Medical Department activities, Fifth Army Corps, by Col. W. H. Eastman, M. C., corps surgeon, November 18, 1918, 7. On file, Historical Division, S. G.O.

(44) Ibid., 34.

(45) Ibid., 35.

(46) Report of Medical Department activities, First Army Corps, by Col. J. W. Grissinger, M. C., corps surgeon, undated, 17. On file, Historical Division, S. G. O.

(47) Report of Medical Department activities, Third Army Corps, by Col. J. L. Bevans, M. C., corps surgeon, undated, 32. On file, Historical Division, S. G. O.

(48) Memorandum on evacuation of sick and wounded, headquarters, First Army Corps, September 3, 1918. On file, Historical Division, S. G. O.

(49) G. O. No. 120, G. H. Q., A. E. F., July 27, 1918.

(50) G. O. No. 175, G. H. Q., A. E. F., October 10, 1918.

(51) Final Report of Gen. John J. Pershing, September 1, 1919, 48.

(52) Ibid., 56.

(53) Tables of Organization and Equipment, U. S. Army, Series C, Table 202, July 30, 1918.

(54) Final Report of the Chief Surgeon, First Army, November 20, 1918, 1. On file, Historical Division, S. G. O.

(55) Ibid., 6.

(56) Report of the Chief Surgeon, Second Army, undated, 2. On file, Historical Division, S. G. O.

(57) Report of the Chief Surgeon, Third Army, June 20, 1918, 1. On file, Historical Division, S. G. O.

(58) Evacuation system of a field army, by Col. C. R. Reynolds, M. C., undated, 11. On file, Historical Division, S. G. O.

(59) Ibid., 14.

(60) Evacuation system in the Zone of the Armies, by Col. A. N. Stark, M. C., undated, 4. On file, Historical Division, S. G. O.

(61) Evacuation system in the Zone of the Armies, by Col. C. R. Reynolds, M. C., undated, 16. On file, Historical Division, S. G. O.

(62) Ibid., 10.