Field Operations, Table of Contents

CHAPTER XXXIV

GENERAL CONSIDERATIONS, MEDICAL DEPARTMENT ACTIVITIES

BATTLE CASUALTIES

The army chief surgeon reported as follows on battle casualties in the Meuse-Argonne operation:¹

It is interesting in this connection to note that the neurological units returned to duty 59 percent of the patients which they admitted.¹

PATIENTS CARRIED BY ARMY AMBULANCES

The following, which shows the number of patients carried by Army ambulance companies, etc., during the Meuse-Argonne operation, does not include those carried by the ambulance companies in corps sanitary trains, but it comprises those transported by United States Army Ambulance Service sections, evacuation ambulance companies, French sections, and French busses and trucks loaned to the army and operating in the service of its Medical Department.¹

	Trips	Recumbent patients	Sitting patients	Passengers	Kilometers
American sections:
Sept. 26 to Oct. 14	9,800	19,000	21,000	2,200	290,000
Oct. 15 to Nov. 11	10,130	22,210	25,722	2,107	343,794
French sections	3,946	12,000	14,512	---	238,738
French busses	645	---	12,439	---	35,378
Total	24,521	53,210	73,673	4,307	907,910

Average number of patients per trip: Corps, 4.6; army, 4.8.
Average one-way haul: Corps, 22.4 km. (13.9 miles); army, 12.2 km. (7.5 miles).
Percentage of prone patients to total: Corps, 47.6; army, 46.
Average number of kilometers traveled by patients: Corps, 10.3 km. (6.3 miles); army, 5.4 km. (3.3 miles).
Average number of kilometers traveled per diem by Army ambulances, 19,737 km. (12,256.6 miles).

As stated in the description of the first phase of the operation, Army ambulances also transported 4,307 passengers during this operation(chiefly medical officers and nurses changing station, with their baggage).^{1, 2}

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TRAIN EVACUATIONS

 The following evacuations were made by train during the Meuse-Argonne operation:²

The large number of evacuations from the army area was necessitated by lack of an institution equivalent to the French depot des clopps provided to care for the slightly wounded, gassed, and sick who would be incapacitated for a period of 10 days or 2 weeks. The establishment of such a formation, with a capacity of 5,000beds, was contemplated before the armistice was signed, but its organization had been delayed because there was no Medical Department personnel available for its operation. The army surgeon advocated establishment of such an institution for 10,000 patients. One section of it was to have been reserved for venereal cases—a perennial source of trouble at the front.³

As the towns in the rear of the army afforded no buildings such as those in Toul in the Second Army area, and tentage was unobtainable, it was necessary to evacuate these slightly wounded, disabled patients to the advance and intermediate sections, with consequent loss to the front of many thousands of men for along period. This need, in turn, required an injudicious use of hospital trains and congestion of base hospitals, which would have proven calamitous had the offensivecontinued.³

ARMY HOSPITALS^a

MOBILE HOSPITAL NO. 1⁴

On September 24 Mobile Hospital No. 1 proceeded by truck from La Morlette to Les Claires Chenes, where it operated in huts, being one of the most advanced hospitals of that section. "The condition of the wounded received at this point was deplorable. Some wounds had not been dressed; many patients came in without having received antitoxin; some were exposed on the field for two or three days before arrival. Ambulances were sometimes 24 to 36 hours on the road bringing wounded from the dressing stations a few kilometers away. This was due largely to the frightful congestion of the roads."

This hospital was designated for nontransportable wounded, of whom 494 were received and upon whom 411 operations were performed. The problem of burying the dead proved a stupendous one, for from 12 to 20 patients

^aThe reports from the different hospitals vary widely; some are complete and in detail, others fragmentary. The procedure here has been to set down what is considered valuable from each report. It has been quite impossible with the material at hand to balance the account.

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died daily; and the soil being extremely rocky, the digging of graves was very arduous labor.

On October 7 the unit was ordered to Fromereville, Meuse, where on the 9th it was established in tents. The condition of the wounded received at this point was much improved; all had received antitetanic serum, and wounds were well dressed and splinted. Evacuation facilities from this point, however, were bad, and to relieve this situation use was made of a narrow-gauge railroad line which ran past the hospital to Souilly. Five cars were fitted up and equipped to carry eight wounded each, and a private of the Medical Department was assigned to each car under command of a medical officer who was in charge of the train. By this means 163 patients were moved, the time for the trip being about two hours. As the cars were light and tended to leave the rails, they were weighted with concrete blocks. At this station (Fromereville) 658nontransportable wounded were admitted, and 627 operations were performed.

The unit moved on October 27 to Esnes, where it again occupied tents. As the troops at this time were moving forward rapidly, and the hospitals were in consequence left far behind, wounded were now received in a serious condition of shock, largely due to exposure and to the strain occasioned by the long rough ambulance rides, over almost impassable roads. At this location 419 nontransportable wounded were admitted, and 367 operations were performed.

On November 14 the organization moved to Bantheville, Meuse, and 10 days later to Varennes, Meuse.

MOBILE HOSPITAL NO. 2⁴

This unit had entrained August 25 for Souilly, Meuse, whence it moved to Rarecourt, Meuse, where it was stationed on the 28th. On September 24it moved to Chateau de Salvange, near Rarecourt, Meuse, where it operated until November5. It was then closed and all patients evacuated in preparation for a forward movement.

MOBILE HOSPITAL NO. 4⁴

This unit had formed part of the provisional evacuation hospital establishment at Trondes during the St. Mihiel operation but had received only slightly wounded while at that station.

When the Meuse-Argonne operation began, September 26, it was located at Villers-Daucourt, but later moved to La Grange-Aux-Bois, where it occupied a small French "ambulance," consisting of a few permanent buildings expanded by Bessonneau tents. Here it served the First Army Corps, receiving nontransportable cases. These numbered 464, upon whom 351 operations were performed. Because of shock and exposure, the wounded received here were in very serious condition. On October 27, the unit moved to Cheppy, Meuse, where it served the Fifth Corps.

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Total admissions by this unit during the Meuse-Argonne operation were as follows: Wounded, 635; sick, 12; gassed, none; operations performed, 498; deaths, 265. At La Grange-aux-Bois and at Cheppy, 71 cranial injuries were operated, with 26 deaths. The unit also cared for 30 unoperated cranial cases, with 21 deaths. The unoperated cases that did not die were largely those with multiple wounds including minor scalp injuries who were admitted in shock. Eleven spinal cases were operated, with six deaths. In all its service (total) there were 841 surgical admissions to this hospital, of which 606 were non-transportable.

Nitrous oxide and oxygen proved of particular value in the anesthetization of shock patients and those in whom gas gangrene had developed. In these cases, as well as in others, these agents were found to be of great value. The conclusion was reached that there was a definite field for nitrous oxide and oxygen anesthesia for the treatment of serious cases, and for those who require but brief operations.

MOBILE HOSPITAL NO. 5⁴

From September 26 to 30 this unit, at Les Placys, admitted 108 cases, with 14 deaths; from October 1 to 31, inclusive, it had 839admissions, with 119 deaths; from November 1 to 11, inclusive, 6 admissions, 3 deaths; total admissions, 953; total deaths, 136. Percentage of deaths, 14.27.

The following gives a summary of its work:

Operations

Head, penetrating	13	Gunshot wounds:
Chest, penetrating	33	Head and neck, nonpenetrating	17
Abdomen, penetrating	22	Chest, nonpenetrating	10
Amputations:		Abdomen, nonpenetrating	4
Upper extremity	11	Extremities	260
Lower extremity	24	Fracture, comminuted compound:
Multiple wounds	239	Upper extremities	28
Fracture, comminuted compound:		Lower extremities	20
Femur	30	Blood transfusion	7
Knee joint	28	Appendectomy	1
		Dressings under nitrous oxide and secondary operations	152

While at Les Placys this unit occupied six frame huts, in good condition, which were used as wards, and two Bessonneau tents, with a bed capacity of 38. Total bed capacity was 207, providing 48 feet of floor space per capita. Grounds were well drained, bathing facilities were excellent, and facilities for laundering clothes were adequate. The water supply was sufficient, but all water for drinking purposes was chlorinated.

The average strength of the command was 53 during the month of September. During October the average strength was 147, and during November, 162. On November 5 an acute shortage of medical officers was reported, with request that six more be assigned. At this time 10 officers were on duty with the unit, a number of whom were performing several dissimilar duties.

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MOBILE HOSPITAL NO. 6⁴

In the latter part of August and the early part of September, 1918, Mobile Hospital No. 6 was organized by personnel from Base Hospital No. 5and other sources. When ready for duty, on September 25, its strength was 8 officers, 20nurses, and 83 enlisted men. From September 28 to October 16 it was stationed at Deuxnouds-devant-Beauzee, and from the latter date to January 4, 1919, at Varennes, being at both points in the service of the First Army.

At Deuxnouds the unit occupied wooden barracks recently vacated by the French, who had left them partially equipped. As these had a capacity of200 beds and two operating rooms were provided, only a small amount of tentage was pitched. The unit was designated to care for injuries of the head, and its staff was increased by 6 surgical teams headed by neurosurgeons, a neurologist, a roentgenologist, 2opthalmologists, 4 ward surgeons, a mess sergeant, 3 cooks, and 9 privates. The hospital gradually expanded to a capacity of 390 beds, necessitating a temporary increase in its strength by details of French troops, Pioneer Infantry, and prisoners of war.

After it moved to Varennes, 7 km. (4.3 miles) behind the lines, Mobile Hospital No. 6 was attached to the First Corps. Here it cooperated with Field Hospital No. 162 in caring for the nontransportable wounded until the latter unit moved, after which Mobile Hospital No. 6 cared for this class of patients exclusively. Here tents and a portable building—too small for an operating room and therefore used as office—were erected. The operating teams and special officers formerly attached had been transferred, but the command was reinforced by additional enlisted personnel and at times by surgical, splint, and shock teams. Usually there were four and sometimes six teams operating.

The greatest problem encountered here was that of evacuation, for wounded had to be removed by ambulance over crowded roads to railhead; but by keeping well ahead of the situation the hospital never became crowded. During the first48 hours of the third phase of the Meuse-Argonne operation many preoperative cases were sent to evacuation hospitals, but none were forwarded unless it was believed they could well endure the trip. When it became evident that nontransportable cases could not be sent from the front because of the great and rapidly increasing distance they would have to cover, all casualties received were operated. From October 17 to November 3 the time from receipt of wound to admission was seven hours. Preparations were made to advance the unit to Brieullers-sur-Bar, but this was prevented by the armistice.

Forty-five percent of the wounded admitted to this hospital were not operated, for this was not indicated in many of the cases admitted while the unit was at Deuxnouds, and a number of those admitted while it was at Varennes were either admitted dead or dying (32 cases) or were sent on for operation at the evacuation hospitals (135 cases). The following statistics were furnished.

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1. Both stations, September 29 to November 11; 43 days:

2. Deuxnouds station (battle casualties received were gunshot wounds of head only):

3. Varennes station (nontransportable wounded):

Throughout its service this unit was complete in itself. It received, with few exceptions, only the cases it was designed to treat, for whose service its equipment proved entirely satisfactory. Injuries cared for were chiefly those of the brain, lungs, abdominal viscera, and multiple wounds or fractures which were in bad condition because of hemorrhage or shock. The most seriously wounded were transfused and anesthetized with nitrous oxide and oxygen. Blood donors were obtained in sufficient numbers.

MOBILE HOSPITAL NO. 8⁴

In September, 1918, Mobile Hospital No. 8 was organized from personnel of Base Hospital No. 10 and casuals, the initial nucleus consisting of 4 medical officers, 20 nurses, and 30 enlisted men. On October 15, it relieved Mobile Hospital No. 6 (q. v.) at Deuxnouds-devant-Beauzee. This unit, like the unit it relieved, received head cases only. Among these the mortality was high, and the period of recovery among those cases which eventuated favorably was disproportionately long.

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Toward the end of October, orders were received to admit no more patients, to evacuate all possible, and to prepare to move to a point near Varennes. All attached officers, except one surgical team and one faciomaxillary specialist, were relieved, and on November 3 the command moved to Exermont, leaving a small detail to care for patients not yet evacuated. This detail rejoined on the 5th, by which time the unit, now reinforced by three additional teams, was receiving patients. Evacuation to railhead was effected by Ambulance Companies No. 542 and No. 604, and occasionally by French ambulances. Surgical work slackened after the armistice, and on November 16 orders were received to admit no more patients, and canvas was gradually struck in anticipation of a move.

This unit, while at Deuxnouds, from October 16 to November 5, admitted 214 patients, with 23 deaths, and while at Exermont, from November 6to December 2, admitted 368 patients, with 18 deaths.

EVACUATION HOSPITAL NO. 3⁴

Evacuation Hospital No. 3, after serving at Toul, was attached, from September 26 to October 1, to American Red Cross Military Hospital No. 114, at Fleury-sur-Aire, where it occupied a large French evacuation hospital. The plant was already equipped with the exception of the operating room, laboratory, and pharmacy. A large ward was turned into a 12-table operating room.

When the first phase of the operation began, wounded began to arrive in great numbers, over 1,400 being received in one day. Many preoperative trains were dispatched, only cases requiring immediate surgical attention being operated. Generally speaking, the wounded were in a poor condition when received, and a large percentage of wounds were from 36 to 72 hours old.

On October 1, the unit left for Mont Frenet, where it served the 2d and 36th Divisions attached to the French Fourth and Fifth Armies in the Champagne sector, west of the Meuse-Argonne battle field. On November 9 it left this station and moved to Fontaine de Routon, where it arrived the next day for service of the First Army.

EVACUATION HOSPITAL NO. 4⁴

On arrival at Fontaine de Routon, Evacuation Hospital No. 4 occupied some temporary structures, but erected no tentage before the night of September 25. It then pitched all its tentage, and in four hours had a large part of the ward equipment in readiness for patients, who began to arrive within a few hours after thr offensive began. Most of those received during the first few days had been wounded from 24to 72 hours previously. Transportation was very limited, and considerable difficulty was experienced in obtaining rations, fuel, medical, and other supplies. A portable French laundry was here added to the equipment, but it proved inadequate. The hospital moved to Fromereville on October 29, where it was shelled November 2 by 8-inch guns, 12 missiles falling in its area and causing 12 casualties among the hospital personnel.

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Patients were removed to a distance from the establishment and then evacuated, and all nurses were also transferred to the rear.

During this operation the hospital received 4,543 patients from 11 divisions, performed 2,448 operations, and had 176 deaths. From the 11th to the 25th of November it received 838 other patients, with 2 deaths. While at Fromereville the strength of the command was 48 officers, 54 nurses, and 254 enlisted men—an increase of 70 of all grades over that which it had when stationed at Fontainede Routon.

EVACUATION HOSPITAL NO. 5⁴

After completion of its duty with the 32d Division at Villers-Cotterets, Evacuation Hospital No. 5 proceeded to Souilly and thence to Ville-sur-Cousances, Meuse, where it arrived September 16. Here the unit was held in reserve, some of its personnel assisting other hospitals in the vicinity during emergencies. It left, on October 3, for La Veuve, Marne, for service of the American divisions (2 and 36) assigned to the French Fourth Army in the Champagne sector to the west of the Argonne Forest. During its total period of activity it handled 15,195patients, classified as follows: Surgical, 8,050; medical, 5,470; gas, 1,706.

EVACUATION HOSPITAL NO. 6⁴

At Souilly, Evacuation Hospitals No. 6 and No. 7 had been established prior to the St. Mihiel operation in a French hospital building, which was transferred with practically all its equipment except instruments. In addition to its official equipment there was a large quantity of material supplied by a French patroness, who had assisted in this manner a number of other hospitals in the Marne area. She remained at the hospital during the greater part of American service there and was of great assistance in many ways. The part of this large plant utilized by Evacuation Hospital No. 6 had a capacity of 1,000 beds, but later, after the Meuse-Argonne operation was well under way, this was expanded by the use of tentage, the capacity of the unit then increasing to 1,200 beds, while that of Evacuation Hospital No. 7 was even greater. In addition these units operated an evacuation area where accommodations were provided for600 patients from Evacuation Hospitals Nos. 4, 5, and 8, Mobile Hospitals No. 1 and No. 5,the Gas Hospital at Rambluzin, and the neurological and contagious hospitals. Patients accommodated in this area were those awaiting the arrival of hospital trains, for none of the units mentioned was located on a railway. Such an area was further necessitated by the fact that there was no replacement camp among the armies to which these patients could have been sent.

Most of the cases sent to Evacuation Hospital No. 6 camefrom the Third Corps, but many were also received from other sources, such as the French Seventeenth Corps, to which American troops had been attached. It had been planned thatthis hospital should receive the slightly wounded only, but in point of fact, it received wounded of all degrees of severity, and medical cases as well.

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One of the greatest difficulties encountered was provision of facilities for caring for the slightly wounded and sick. Cases which would have been ready for duty within a few days had to be evacuated in order to make room for others, thus necessitating a greatly increased use of hospital trains. Though from three to six trains daily were dispatched from Souilly, Evacuation Hospitals No. 6 and No. 7 and their evacuation area were constantly crowded, the number of patients at one time being over 3,800.

About November 3 Evacuation Hospital No. 6 took over the entire formation, and three days later Evacuation Hospital No. 7 moved to St. Juvin, in the vicinity of Grandre. The capacity of the entire establishment was then reduced to1,800 beds, nearly all of which were constantly occupied, 1,400 cases being admitted on November 11. Thereafter, the work was almost entirely medical until the unit closed on December 8 and packed to move into Germany. (For a discussion of the organization of this unit see Chapter XVIII.)

During the period September 12 to December 8, while Evacuation Hospital No. 6 was stationed at Souilly 68 percent of its cases were medical. As the capacity of the unit was expanded, wards were set aside for contagious cases and those with bronchopneumonia, for a general order had been received directing that no patients with fever be evacuated. Causes of admission included diarrhea (in diminishing numbers), typhoid fever (occasional and mild), diphtheria, meningitis (sporadic), and influenza, frequently complicated by bronchopneumonia, which gave a mortality of 42 percent.

Patients were classified in three categories—sick, seriously wounded, and slightly wounded. All patients who, on admission, had fever or quickened respiration were sent at once to the pneumonia ward without the usual bath, for the early physical signs of pneumonia in many cases were very obscure, and it was found preferable that each patient be given the benefit of any doubt. If the complication mentioned did not develop, the patient was then transferred to another ward. The clinical course of bronchopneumonia varied widely, and treatment was almost entirely symptomatic.

Seriously wounded were undressed, bathed, prepared for operation, and X rayed, but the slightly wounded were merely undressed and the wounded area X rayed and prepared for operation. Cases requiring only a dressing were cared for in the dressing room, through which slightly wounded passed, excepting cases of shock, which were sent immediately to the shock ward, where a shock team was on duty at all times. No surgical cases were sent to a ward until after operation or dressing. For the seriously wounded two operating rooms were provided, and one for the slightly wounded. Each of the former had three tables at which two teams worked. The slightly wounded were treated by two of the most skillful teams available, who utilized four tables. Rapid anesthesia was practiced by employing ether according to the Rausch method or in combination with chloroform, or ethyl chloride was utilized.

The orthopedic service was considerably developed while this hospital was at Souilly, for under the general supervision of the surgical service this service

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was made responsible for the splinting of all fractures and other cases that required mechanical support and the preparation of such patients for transportation. A ward was set aside for these cases, and to this two splint teams were assigned, each consisting of 1 officer and 2 enlisted men. From September 1 to December 10the splints utilized were as follows: Thomas leg splint with traction, 222; Cabot posterior splint, 246; Jones traction splint, 15; hinged modification of Thomas arm splint, 180; Jones "cock-up" or "crab" splint, 16; Hodge, 5; long Liston, 4; wire ladder, 618; wood, l50; plaster of Paris jackets, 2. Wire ladder material was used for posterior angular splints of the arm, forearm, wrist, hand, ankle, and foot, when traction was not required.

The average number of patients operated daily was about175. Schedules for all teams were such that they allowed each team a full night’s sleep every other night.

From September 1 to December 8 this hospital performed 7,124 operations, of which 6,951 were performed between September 12 and November 12. This was exclusive of dressings, which were not counted. Surgical deaths from September 1 to December 8 numbered 211.

In the eye, ear, nose, and throat clinic 480 important cases were treated while the unit was stationed at Souilly. The total number of cases treated in this clinic was 5,303. The X-ray department at Souilly examined 8,535 cases, during rush periods averaging 600 cases in 24 hours.

Admissions during the Meuse-Argonne operation were as follows: Total, 22,174, including 14,095 sick, 324 gassed, 7,755 wounded. Operations numbered 6,591, deaths 204. In addition, before and after this operation this unit here admitted 11,038 cases. It also served as a collecting point for Evacuation Hospitals, Nos. 4, 8, 15, and Mobile Hospital No. 1.

EVACUATION HOSPITAL NO. 7⁴

In conjunction with Evacuation Hospital No. 6,Evacuation Hospital No. 7 operated at Souilly during the St. Mihiel and the Meuse-Argonne operations, but its history furnished no detailed information concerning its organization or methods during those actions separately. The unit moved to St. Juvin on November 6 where it remained until after the armistice.

During the Meuse-Argonne operation, total admissions numbered 18,791, of whom 6,375 were wounded, 12,374 were sick, and 42 gassed. Operations totaled 1,991 and deaths 302. During its operations in France, this unit received a grand total of 50,252 patients, including 18,380 admitted because of gunshot wounds.

EVACUATION HOSPITAL NO. 8⁴

Arriving at Petit Maujouy on August 26, Evacuation Hospital No. 8 established 1,000 beds in Adrian barracks and tents on the hillside sloping toward the north. Here it received seriously wounded and some other cases during the St. Mihiel and Meuse-Argonne operations.

In order to make available for professional work as many officers as possible, the administrative functions of the hospital were centered in the

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commanding officer, adjutant and registrar, and the quartermaster. The last mentioned also performed the duties of supply officer, disbursing officer, summary court, and was in charge of the effects of deceased patients, of salvage, and of the Graves Registration Service. Medical supplies were obtained from medical dumps and from the Red Cross, and commissary supplies from the railhead and from the American Red Cross warehouses. Owing to inability to purchase an adequate supply of subsistence stores through a sales commissary, the greater portion of the subsistence supplies were procured on ration returns. Two kitchens were operated. The officers on day and night duty in charge of the admission of patients collected and receipted for all valuables. As this unit received very few medical cases, the chief of the medical service was placed in charge of evacuations and also acted as official censor of the organization. The adjutant and registrar had charge of all hospital records and correspondence, and supervised the preparation of the reports of sick and wounded.

The receiving department was one of the most vital parts of the entire organization, as it was at this point that all the patients were admitted, examined, and appropriately distributed, records made, clothing removed and salvaged, and valuables collected. It occupied the largest structure conveniently available. Teams organized from the enlisted men of the hospital prepared patients at this point for operation before they entered the X-ray department. These teams served in rotation throughout the 24 hours in order to prevent delay in the surgical service. The work here was all carried on under the direction of day and night triage officers, whose duty it was to examine all wounds, select the cases that required attention first, and see that every patient requiring X-ray examination was provided with a distinctive slip which insured his being taken to the radiologic department before he entered the operating room. The triage also had charge of the enlisted personnel and was responsible that each team did the work required of it. A noncommissioned officer and eight litter bearers were stationed at the entrance ready to unload the ambulances as they arrived. Conveniently accessible and ready for distribution were piles of litters, blankets, hot-water bottles, and splints, which could be put in the ambulances and sent back to the front in exchange for such articles as they had brought in with patients. After removal from the ambulances, patients were carried to one of the receiving tents to await their turn to be sent to the record and preparation room. If their condition was such as to require it, they were allowed to remain on the litters. Two other litter-bearer squads, working under the control of the triage officer, then carried the patients into that portion of the receiving department where the necessary records were made on the two or more typewriters utilized for this purpose. The required entries were made on the patient’s field card; but in case a patient had none, one of these cards was started at this point. For the convenience of the hospital, and in order to provide a directory which could be used as an alphabetical index to all patients admitted, Medical Department Form No. 52 was made out in duplicate down to and including the diagnosis, the duplicate placed in the patient’s

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field envelope with his other papers, and sent with him to the ward. The original of this form was put into the file and became part of an index to patients in the hospital. This arrangement was found to be of great value, as numerous telegraphic requests were constantly being received from the central records office relative to the character of the injuries received by specified officers and men and the points to which they had been evacuated after treatment. This latter information was entered on each patient’s card as soon as he was evacuated from the hospital.

All slightly wounded patients were directed by the triage officer to be carried to the section provided for care of patients of this character; if seriously wounded they were sent to the undressing and preparation room, which occupied a section of the receiving department. At this point the patient was cared for by a team composed of two orderlies; one of the orderlies removing or cutting away his clothing, while the other collected his valuables and made out duplicate receipts for them. These receipts were signed and the original went with the patient in his field envelope. A suit of pajamas was given him, and he was then moved on his litter to a rack which raised him about 3 feet above the ground, and which permitted another attendant to give him treatment preparatory to operation. The parts adjacent to the wounds were shaved and a small sterile binder was applied. It was found impracticable to bathe the severely wounded men, many of whom were suffering from multiple wounds and could not stand the amount of manipulation involved. Four of the teams mentioned worked side by side simultaneously on day and night shifts in charge of a noncommissioned officer, removing clothing, collecting valuables, and preparing wounds for operation.

The patient was then carried to the X-ray room. The triage officer gave each patient requiring X-ray investigation a special green slip, with entries thereon of the wounds requiring examination. This proved to be of great advantage and facilitated the work. Two specially designated litter-bearer squads moved each patient having one of these slips in his envelope to the X-ray room as soon as he could be admitted for examination. An attendant wrote on the slip the findings dictated by the officer making the examination, and returned it to the field envelope, which went with the patient to the operating room. Indelible markings were made on the skin of the patients by using silver nitrate, wherever foreign bodies were seen under the X ray, and an accurate description of the size and shape was noted on the green slip above mentioned.

The chief of the surgical service selected the personnel of the operating teams which were organized from the hospital staff, and designated the type of cases each team was to treat. He also assigned the nurses and orderlies in the operating room, determined the tours of duty there, formulated regulations governing treatment of certain wounds, and was the hospital consultant in his specialty. An assistant alternated with him. Operators continued care of their cases after these had been sent to the wards, thus reducing the number of ward surgeons. The most satisfactory arrangement for tours of duty was from 8 to 8, being in fact, however, slightly less than a 12-hour

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shift, as half an hour at the end of each period was devoted to cleaning and replenishing the operating room. At one time the hospital had over700 severely wounded patients, who required such an amount of care that the operating-room force had to be reorganized in order that nurses might be released for duty in the wards. When possible each team used three tables, one patient being anesthetized or splinted while two were being operated. With 12 operating teams this hospital ordinarily was able to perform the work required, by continuous day and night shifts.

The operating was performed in an Adrian barrack in which 18 operating tables were set up, half of the building, running lengthwise, being the "sterile" portion for dressings, instruments, etc., and the other half being "nonsterile." Patients were brought in on litters from one end of the structure through the "nonsterile" portion. After litter bearers had received the necessary instructions from the chief of the surgical service they carried the patient to the table indicated. At the middle of the building, on the sterile side, an opening was cut through, and a large storage tent was put up at right angles to the opening and adjoining the building. In this tent all instruments were cleaned and sterilized by men especially trained for this work. The "nonsterile" nurse from each group of teams carried the instruments to and from this tent. All surgical dressings and gloves were sterilized and stored in a structure immediately adjoining the operating room, where they were under the charge of a day or a night nurse, whose duty it was to see that each team was furnished with an adequate supply at all times. Eight litter bearers, with a sergeant, first class, in charge, were detailed to move the patients from the tables as soon as the operations were finished and transfer them to the wards, leaving the operating room by the door at the lower end. Litters thus moved through the operating room in one direction only and thereby saved much confusion. The noncommissioned officer kept a list of the vacant beds in all surgical wards and also a list of the wards designated for the reception of evacuable and nonevacuable cases, respectively. Certain wards were reserved for special cases, such as injuries of the head and spine, chest, abdomen, fractures, and joints. The operator indicated on the field card the type of case to be sent out, and the noncommissioned officer directed the litter bearers where the patient should be carried. The portion of the hospital area devoted to the evacuable cases was made easily accessible to the ambulances by constructing roads in such a manner that patients could easily be evacuated without interfering with the ambulances which were carrying patients to the receiving department. Many patients were admitted who were unable to undergo operative treatment immediately, and these the triage officer sent to the shock wards. These consisted of two large Dickson tents where patients came under the care of the shock team, made up of 1 medical officer, 2 nurses, and 2 orderlies. These cases were held undertreatment until their condition improved sufficiently to enable them to withstand the shock of operative procedures.

A space apart from the general operating room was provided for the treatment and dressing of the slightly wounded patients and those able to walk. It was not always easy to determine whether such cases should be

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sent to this department or to the general operating room, for it frequently happened that wounds which on the surface appeared to be trivial proved in reality to be extensive and oftentimes serious. Proper classification of such cases required considerable experience on the part of the triage officer. All walking cases, however, were without exception cared for in the room for slightly wounded, for otherwise the operating room became badly crowded, resulting in confusion and lack of discipline.

The hospital was provided with its own electric lighting system. The calcium carbide apparatus furnished light for a few hours at a time, but habitually soon developed some defect so that it could not be used. The Delco system gave good results in a small way, but was entirely unfitted to bear the burden which was finally required of it. A lighting arrangement which proved to be satisfactory was the installation of four incandescent bulbs for each table, one attached to an extra long cord which permitted it to be used in any situation. Two dynamos which were set up by the engineers, and were maintained by them, gave satisfactory service both day and night. A regulation in force throughout the zone of advance required that all lights must be shutoff from observation after dark, owing to the danger from hostile airplanes. As this required the entire hospital area to be kept in total darkness, tarred paper screens were used to prevent rays of light from emerging from the operating room, wards, or other tents or structures. This requirement caused considerable difficulty for at times patients were received continuously through the night and often had to be evacuated by night.

One of the important fields of activity was the evacuation service, for upon the success with which bed space was freed by patients who were able to be transferred depended in large measure the ability of the hospital properly to function. Every medical officer was impressed with his responsibilities in this matter, and urged to mark every case for evacuation as soon as his condition would permit. Cases leaving the operating room who would be fit for evacuation within a period of 12 hours were sent to the group of wards for evacuable cases; these wards were emptied each day. In the nonevacuable group of wards a careful check was made daily by the ward surgeon with a view to determining which cases were fit for evacuation; they were reported to the registrar’s office. Necessary arrangements were then made at frequent intervals with the ambulance service to carry out the evacuation of these serious cases. The wards were notified at what hour the evacuation ambulances were expected to begin removals, a distinctive marker was placed on the bed of each evacuable to indicate to the litter bearers that he had been selected for transfer. Numerous blankets were provided, one or two being placed folded double on the litter, and one or two over the patient. The successful administration of the hospital was dependent largely upon the promptness with which patients ready for evacuation were removed.

Admissions to this hospital during the Meuse-Argonne operation were 4,340 wounded, 135 sick, 261 gassed; total, 4,736. Operations numbered 6,134; deaths, 338. The total number of wounds among those admitted during that period was 6,204, and the total cases of gas gangrene were 288. The total number of surgical admissions to the hospital during its service was 6,922.

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EVACUATION HOSPITAL NO. 9⁴

Evacuation Hospital No. 9 was stationed at Vaubecourt, Meuse, from August 29 to December 12. Its receiving ward during the Meuse-Argonne operation was staffed by 2 commissioned officers, 1 sergeant, 8 clerks, 2 guards, and 10litter bearers. Though patients were received at all hours, the most active period of this department was from 1 p. m. to 7 p. m.

With the arrival of troops in the Meuse-Argonne area, this hospital became progressively more and more active, receiving a number of medical cases before the offensive began. Attempts were made properly to segregate infectious cases into different tents, but after the influenza epidemic began this was not wholly practicable. The medical section of the hospital provided 1,300 beds, but these sometimes proved inadequate in number and patients were then placed on litters. A section with 360 beds was provided for those ill with influenza or mild respiratory disease. The activity of this section was evidenced by the fact that during one period of 24 hours it received and evacuated 824 cases. Another section of 162 beds received the serious medical cases, half its beds being reserved for influenza and pneumonia patients and half for other infectious cases. In general, medical cases were distributed according to the following classification: Pneumonia, other respiratory diseases including influenza, noncontagious cases and diarrheal diseases, miscellaneous contagious cases, and gassed patients.

The following table shows the number of admissions for the various groups of diseases, by months:

	September	October	November	December	Total
Respiratory diseases, including influenza, but not pneumonia	2,517	7,018	2,733	23	12,291
Diarrheal diseases	348	3,953	2,309	11	6,621
Pneumonia	63	373	91	---	527
Contagious diseases	83	246	110	---	439
Gassed	40	186	19	---	245
Others (about)	500	1,500	600	---	2,600
Total	3,551	13,276	5,862	34	22,723

Many gassed cases (not included in the above figures)passed through without being admitted to the gas ward, for some required operation forwounds and others were lightly gassed. Practically all gassed patients had been incapacitated by mustard gas, causing burns, conjunctivitis, laryngitis, gastroenteritis, and bronchitis.

Surgical cases were distributed as follows: In the receiving ward where surgical and medical cases were sorted, the former were classified as for 1, immediate operation; 2, operation after X-ray examination; 3, dressing, or 4, doubtful cases for X-ray examination. These last were sent to the operating room if the Xray showed a foreign body, but were returned to the dressing room if it did not.

Routine methods were quickly evolved to promote this classification and consequent distribution. Six litters supported by trestles received recumbent cases, ambulant patients occupying benches in the receiving ward proper, while

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an annex with 38 beds received an overflow. Clothes were removed, wounds inspected, and if the patient was to go direct to the operating room, he was entirely undressed, the wound area was shaved and drained, and a light dressing was applied. Similar preparations were made if he was routed to the operating room via the X-ray laboratory. Simple wounds not requiring debridement were taken to the adjoining dressing room and thence to their wards. As in other hospitals of this class, a shock ward received patients in need of such treatment. In the operating room 2 tables were provided for each team, and the total 12 tables utilized was served by a splint team. Two of these teams were provided alternating in 12-hour shifts. Instruments were sterilized in quantity, laid on a large sterile table, whence they were issued to all teams. On most active days, the average number of patients operated in 24 hours was slightly over 200.Patients were evacuated in from 24 to 36 hours, except a few suffering from shock, wounds of the head, thorax, or abdomen, or in danger of hemorrhage or gas infection. These were sometimes held as long as 10 days.

During the Meuse-Argonne operation this unit admitted33,910 patients, of whom 23,582 were sick, 9,809 wounded, and 519 gassed. Operations numbered 3,437 and deaths 259. The number of patients received by this unit in France totaled 36,322. Total admissions to the surgical service were 13,765, of whom 10,200 were dressed without operation and the remainder operated. Gas bacillus infections numbered 57,of whom 2 died without operation and 5 after it. Most of the wounded had received injuries of the extremities, there being 2,094 admissions for wounds of the upper extremities and1,449 for those of the lower. In 1,931 cases, fragments of high-explosive foreign bodies were discovered, of which number 1,496 were removed. In 287 cases, machine-gun or rifle bullets were lodged and in but 5 cases shrapnel bullets. In 1,131 wounds examined no foreign body was found, more of these wounds having been caused by machine-gun or rifle bullets. In one patient 13 machine-gun bullets were located.

The time elapsing between injury and operation was less than 6 hours in 2.5 percent of the cases, from 6 to 12 in 18.5 percent, from 12 to 18 in27.5 percent, from 18 to 24 in 26.5 percent, from 24 to 30 in 10 percent, from 30 to 36in 6 percent, and over 36 hours in 9 percent.

The conditions of most patients on arrival was good, only 11 being shocked and 33 being gassed. The number of cases debrided was 3,265. Of these, 2,903 received a general anesthesia, while for the others local anesthesia was employed.

Orthopedic activities were closely associated with general surgery and consisted chiefly in the temporary splinting of fractured or severely wounded extremities for immobilization during evacuation. Three hundred and ninety-seven splints were applied.

The laboratory performed indispensable service in the performance of its technical examinations.

The eye, ear, nose, and throat service cared for a large number of patients both in its clinic and throughout the wards.

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The X-ray department performed 4,804 examinations while this unit was at Vaubecourt. The dental department treated 630 patients, including 32 cases of gunshot wound of the jaws.

The evacuation area consisted of a large Bessonneau hangar and 18 smaller tents where litter cases were collected shortly before a train was due and ambulant cases immediately after it arrived. As a rule from 6 to 8 hours’ notice was given before the arrival of a train. The largest number evacuated in 24 hours was 2,128 and the largest number on any train 787, all of the latter members being sitting patients. The average number evacuated on American trains was 480 and on French trains 270, about 90 percent of all patients being placed on board at night.

Throughout its service in France, this unit received assistance from the Red Cross, which supplied it with large quantities of bandages, cotton, sponges, medicines, surgical instruments, blankets, pajamas, and other necessities and maintained a canteen department which served hot cocoa, sandwiches, cigarettes, and chewing gum to all arrivals. Its personnel also prepared the special diets, some of the material for which was furnished also by the Red Cross.

EVACUATION HOSPITAL NO. l0⁴

Evacuation Hospital No. 10, on September 21, took over from the French barracks at Froidos equipped with a quantity of supplies. After September 26, when the first patients were admitted, the operating rooms were constantly in service. The total number of surgical cases received from September 27 to November 15, inclusive, was 5,419. Total cases operated were 3,343; total cases evacuated without operation, 2,056; total patients dead on arrival, 10; total died after operation, 112; total died without operation, 109. A very large proportion of the patients admitted to this hospital were seriously wounded, and because of delay in getting them to hospital many cases were complicated with gas infection. For the same reason there was a large mortality from abdominal wounds. Of the patients operated, 2,476 had single wounds and 865 multiple wounds. The X-ray department examined 3,037 cases before the end of December, 1918,fluoroscopic examinations for battle injuries numbering 2,934. The contagious disease section of the hospital occupied buildings previously used by the French for the same purpose. These were 24 in number, most of which were of barrack construction and of which13 were used as wards, the others being used for miscellaneous staff purposes and as quarters. Over 3,000 medical cases were admitted during the operation, the most common ailments being, in the order mentioned, mumps, influenza, diarrhea, toxic gassing, acute bronchitis, and rheumatic fever. Laboratory examinations from September 12 to January 1,1919, numbered 1,853.

EVACUATION HOSPITAL NO. 11⁴

After reinforcing Mobile Hospital No. 39, at Aulnois, and Field Hospital 41, for 10 days during and after the St. Mihiel operation Evacuation Hospital No. 11 located, September 21, about 1 mile north of Brizeau. This

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location was well toward the front, but suffered from the great disadvantage of not being on a railway. This situation required that supplies be brought in by truck and that patients be evacuated by ambulance from 11 to 15 km. (6.6 to9 miles) to Evacuation Hospital No. 10, at Froidos; to American Red Cross Hospital No.114, at Fleury sur Aire; to American Red Cross Hospital No. 110, at Viller Daucourt; or to Evacuation Hospital No. 9, at Vaubecourt. The capacity of the unit was 460 beds, but two annexes of 200 beds each were established, one on October 5, at Camp Raton, 1.2 km. (0.75mile) distant, for influenza, pneumonia, and other cases of infectious diseases; the other, opened October 27, at Brizeaux Village, 1.6 km. (1 mile) distant, received only mumps cases. The hospital proper was ordered to receive only seriously wounded cases, but toward the end of the Meuse-Argonne operation some slightly wounded were admitted and after the armistice became effective, medical cases. While at this site the hospital with its annexes received 2,273 medical cases and 3,292 surgical cases. Of the latter, 2,792were serious and among them 216 deaths occurred. The largest number of seriously wounded operated in one day was 195. In order to expedite care of patients still carrying tourniquets or suffering from shock, abdominal wounds, aspirating chest wounds, or hemorrhage, an "emergency tag" was used carrying the following notations: Name; urgency, 1, 2, 3; preoperative ward; X ray; evacuation ward; shock ward. In filling out this card the triage officer circled the number, 1, 2, or 3, according to circumstances, a circle around the figure "1" signifying "rush," and made appropriate check opposite the other entries.

The personnel on duty in the receiving and sorting section of the hospital consisted of 6 officers and 58 enlisted men, divided into two shifts. The greatest number of admissions in one day was 224, all of whom were seriously wounded. After operation, abdominal cases were held 10 days, head cases, in the event the dura had not been opened, were evacuated at the discretion of the operator, but those in which the brain was involved were held at least 7 days. Hemothorax complicating chest cases with a through and through injury were operated in 48 hours and evacuated as soon as it was shown that the hemothorax was not likely to recur. If a foreign body remained in the thoracic cavity no attempt was made to remove it. No localized abscess developed up to the time of evacuation, and there were but two cases of infected hemothorax in 35 cases. Compound fractures, including those of joints, were held from 3 to 7 days, but simple fractures were evacuated at once. All amputations were held from 7 to 10 days and then evacuated as ordered by the chief of service. Spinal cases were at first held 7 days, but when it was learned that they were prone to develop bed sores and fatal spinal meningitis, they were evacuated as quickly as possible on well-padded litters. Cases infected with gas-forming bacilli were segregated, but it was never possible to give them a ward by themselves. The shock ward treated 240 patients, of whom 54 died. Stimulants used in this ward in order of their frequency were camphorated oil, caffeine, adrenalin, digitaline, strychnine, and whisky. Normal salt solution proved more satisfactory than gum acacia solution for intravenous injections. The hours of operating teams were at first 8 hours, but were later changed to 12, which proved more satisfactory. Teams were

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then required to dress their own cases. The two splint teams, which alternated in service, found the Thomas leg splint and the Murray modification of the Thomas arm splint to be the most suitable for outgoing patients, employing 126 of the former and 122 of the latter. Other splints applied were Cabot, 166; Liston, 10; Jones, 8; wire ladder, 85; and wood support splints, 90. Splinting was required in 6 of the 13 cases of maxillofacial injuries. The number of fluoroscopic examinations made was 3,143.

During the Meuse-Argonne operation, Evacuation Hospital No. 11 admitted 3,654 patients, of whom 265 were sick, 4 gassed, 3,365 wounded. Operations numbered 3,364 and deaths 208. The annex at Brizeaux received during this operation 469 patients and that at Camp Raton 366; of the latter, 25 died.

EVACUATION HOSPITAL NO. 14⁴

On September 21 Evacuation Hospital No. 14 arrived at Villers-Daucourt from Toul, transporting its equipment on 90 trucks and the officers and men in the vehicles of Evacuation Ambulance Company No. 12. At this point the unit prepared to take over part of a French evacuation hospital, but orders to that effect were countermanded, and until October 11 a detachment of 102 of its enlisted men assisted Army Red Cross No. 110, at that station. On October 6 it moved to Les Islettes, reaching its destination the next day. Here from October 11 to November 6 it received seriously wounded only, operating entirely under canvas, except that the office, laboratory, the field officers, and nurses were quartered in a neighboring chateau. This location was very satisfactory, except that there was only a one-way road into the premises and that it was at some distance from railhead.

The operating room consisted of a Dickson tent containing 10 improvised wooden tables whereon the litters carrying patients were placed—an expedient found more satisfactory than the use of metal tables, to which patients were lifted from their litters. Electric light for the unit was furnished by its own dynamo. Evacuations were made by Evacuation Ambulance Company No. 6, usually to Villers-Daucourt, some 24 km. (15 miles) distant. As practically all cases thus transferred were postoperative litter cases, and as 75 percent of them were evacuated at night, this removal was an arduous and difficult task.

On November 6 the hospital moved to Varennes, where its site was a low muddy flat, pitted by shell craters which had to be filled in; the approach was over a very difficult road quite unsuitable for ambulance transport.

These disadvantages were partially offset by proximity to a railway siding, though patients had to be carried to this by litter through very deep mud. At this location the hospital received all classes of patients, until several days after the armistice, after which its admissions were chiefly medical.

Admissions numbered 1,757 at Les Islettes and 1,045 at Varennes (before the armistice became effective). Total operations were 1,425. There were71 preoperative and 58 postoperative deaths among surgical patients. Seventy-five cases of gas gangrene developed, necessitating 23 amputations.

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At no time did the hospital have enough transportation to haul supplies, usually only one truck being available for all service of this character, after the hospital had reached its location.

EVACUATION HOSPITAL NO. 15⁴

Evacuation Hospital No. 15, organized at Fort Riley, Kans., March 21, 1918, arrived in France September 3, 1918. On September 21 it reached Revigny, where it took over a French hospital, which it operated in conjunction with Base Hospital No. 83 until October 12, when it left for Glorieux. Service at Revigny was not very active, and many officers belonging to this unit were sent out on temporary duty to various other evacuation hospitals.

During its entire period of active service, this hospital admitted 4,761 medical and 4,214 surgical cases.

EVACUATION HOSPITAL NO. 16⁴

After arriving in France September 7, 1918, Evacuation Hospital No. 16 remained at Pontanezen, near Brest, until September 18, when it moved to Le Mans, then to Bazoilles-sur-Meuse and, on October 12, to Revigny, where it took over the management of a hospital and 495 patients from Base Hospital No. 83. It operated this hospital until November 13, when it returned its management to Base Hospital No. 83, and reinforced same until January, when it closed.

In the interval October 15 to November 13 the unit admitted 2,840 patients, of whom 508 were returned to duty and 2,197 evacuated, while 80died and 8 went absent without leave. The surgical admissions, operative and nonoperative, totaled 132. Medical admissions included 1,140 cases of influenza, 99 cases of lobar pneumonia, and 69 cases of bronchopneumonia. The dental work consisted of 548 sittings and treatment of 11 cases of fracture of the jaw. Examinations made by the X-ray laboratory totaled 365 (of which 70 percent were fluoroscopic chest examinations), and those by the pathological laboratory 686.

EVACUATION HOSPITAL NO. 20⁴

After landing at Brest, September 8, Evacuation Hospital No. 20 moved successively to Le Mans, Bazoilles-sur-Meuse, and Souilly, where the hospital in effect was broken up, its personnel being distributed among other units until November18.

EVACUATION HOSPITAL NO. 21⁴

After the arrival of Evacuation Hospital No. 21 at Rimaucourt, on September 20, 1918, many members of its personnel were assigned to duty with other units, until the hospital moved to Villers-Daucourt, October 14, when it was attached to American Red Cross Military Hospital No. 110. This was a small unit consisting of but 3 officers and 2 nurses and 2 enlisted men, while the personnel of Evacuation Hospital No. 21 then consisted of 30

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officers and 226 enlisted men. On October 14, however, half of its commissioned personnel was assigned, by orders of headquarters, First Army, to duty with American Red Cross Military Hospital No. 114, at Fleury, with which they remained until November 30. Forty-two enlisted men were assigned to Evacuation Hospital No. 9, at Vaubecourt, and 1 officer and 15 men to the gas-treatment annex of Evacuation Hospital No. 10, at Julvecourt. Three officers and 18 enlisted men, between November 4 and15, relieved Field Hospital No. 41, operating the gas-treatment annex of American Red Cross Military Hospital No. 110, at Villers-Daucourt. From November 4 to 15 one officer and three enlisted men operated the gas-treatment annex of Evacuation Hospital No. 6, at Rambluzin, and one officer was assigned to the train regulating office. Two surgical teams operated continuously at American Red Cross Military Hospital No. 110.

Ambulance Company No. 120 was assigned to duty with Evacuation Hospital No. 21.

Four operating rooms were provided at Villers-Daucourt, the three largest having three tables each. One of these rooms was used for minor cases and as a preoperative ward, whence patients were taken to the shock ward or to the X-ray examination room. During all his successive moves through the hospital, except when placed in bed, a patient remained on the litter which had brought him in, apparently a minor detail, but in emergencies of considerable importance. On November 1, 985 patients were admitted in 12 hours, and 2 hospital trains were loaded in 8 hours. When teams operated in12-hour shifts, the best results were secured if 2 teams utilized 3 tables, but when the shift was 8 hours, 1 team using 3 tables proved as effective as did 2 teams using the tables in conjunction, for the former arrangement prevented confusion. Patients were evacuated as soon as they could endure transportation, usually in from 12 hours to 3 days. The last patient was evacuated on November 15, when the gas-treatment hospital, which had a capacity of 275 beds, was closed. In addition to caring for its own cases, Evacuation Hospital No. 21 received for train transfer all patients from Evacuation Hospital No. 14,at Les Islettes.

EVACUATION HOSPITAL NO. 22⁴

After reaching Brest, September 12, 1918, Evacuation Hospital No. 22 was sent to the hospital center at Allerey on September 20, but on October3, entrained for Souilly, arriving there October 6, where the unit was broken up and its personnel assigned to 11 other hospitals in the zone of the army. On November 19 the unit was reassembled at Vaubecourt, and moved the next day to the Medical Department concentration area around Joinville.

EVACUATION HOSPITAL NO. 23⁴

Arriving in France September 16, 1918, Evacuation Hospital No. 23 moved first to Beaune and thence to Souilly, where it arrived October 10.

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Here the unit was broken up and its personnel distributed among 12 other army hospitals, where they served until the unit was reassembled at Souilly on November 20 for movement to the Joinville area.

NEUROLOGICAL HOSPITAL NO. 1⁴

On September 2, 5 officers and 15 men were sent from Base Hospital No. 117, at La Fauche—the neurological center—to Benoite Vaux for temporary duty in the neurological hospital there, whose staff was to number 15 medical officers. Plans at this time contemplated that Base Hospital No. 117 be expanded to 1,000beds, and the neurological hospital at Benoite Vaux to 500 beds, that 10 field hospitals provide 300 beds for neurological cases, and that Base Hospital No. 45, at Toul, provide 500 beds for cases of this character. Temporary overflow accommodations at Rimaucourt were to provide 500 beds, thus giving a total of 2,800 for neurological cases. Shortly thereafter authority was also given to expand the hospital at La Fauche to 2,000 beds; 2officers were sent to Base Hospital No. 45 for temporary duty in its neurological wards and 7 were sent for distribution to tactical divisions.

AMERICAN RED CROSS MILITARY HOSPITAL NO. 110⁴

From September 25 to November 20 this unit operated as an evacuation hospital at Villers-Daucourt, though it was not so designated. It was directed to receive seriously wounded and gassed cases only, and its personnel was drawn both from the Army and, to a small degree, from the Red Cross. This unit admitted a total of 10,679 patients, not including 2,978 from other hospitals in the evacuation area. Shock cases to the number of 470 were sent to the shock wards before operation, except when intervention was necessary to check hemorrhage. When the patient’s condition permitted, as indicated by the blood pressure, he was sent to the X-ray department and thence to the operating room. The total number of operations performed was 4,575. Of the 3,088 cases admitted to the operating room, 138 were suffering from gas gangrene and 242were received in shock. The average number of hours between injury and admission to the operating room was 24 hours, the shortest period being 1 hour and the longest period 4 days. Total deaths in the hospital numbered 194. Total foreign bodies removed were 1,277. The percentage operated was 37.4, the percentage of deaths from all causes being 1.8. Of these, 14.6 percent were preoperative in the shock ward. The percentage of surgical to other cases was 78.5. Shock-ward statistics were as follows: Total admissions, 470;preoperative admissions, 242; preoperative deaths, 28; postoperative admissions, 228; postoperative deaths, 53; total deaths, 81. Normal saline transfusions, 80; gum-acacia-saline transfusions, 42; glucose (3 percent) transfusions, 6; citrate of blood transfusions, 80. Deaths after blood transfusions numbered 26. Total admissions by this hospital during its service in this and other areas numbered 18,867.

This unit was assisted by personnel from Ambulance Company No. 120, Field Hospital No. 41, Evacuation Hospital No. 14, Mobile Hospital No. 4,

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Ambulance Company No. 310, United States Army Ambulance Service Section No. 610, Evacuation Hospitals Nos. 21, 22, and 23, and by numerous surgical teams. It was also supplied with individual officers and nurses from Army and Red Cross personnel.

The summarized report of this unit from the four month sending November 10 was as follows:

AMERICAN RED CROSS MILITARY HOSPITAL NO. 114⁴

After arriving at Fleury, this Red Cross unit was known as American Red Cross Military Hospital No. 114, and eventually was taken over entirely by the Medical Department, United States Army. Certain Red Cross nursing personnel continued with the formation until it closed. On November 1 this unit became Evacuation Hospital No.114.

Until reinforced October 15, by 15 officers from Evacuation Hospital No. 21, the commissioned personnel of this unit consisted of 5officers, supplemented by teams temporarily assigned. The officers from Evacuation Hospital No. 21 were now assigned to administrative and ward services and to other duties not performed by attached teams. Service was handicapped by the limited number of nurses.

Routine service was as follows: Patients in shock were taken at once to the adjoining shock ward, the slightly injured and walking cases to the receiving ward for patients of that class, whence they were sent to the evacuation ward, where they remained from 12 to 24 hours. The number of patients in this category, who were evacuated without operation, depended directly upon the number of serious cases requiring such attention that could be cared for in 24 hours. As a rule, the most serious cases were selected for operation. These and all litter cases (many of whom had arrived in bad condition as ambulant patients) passed through the receiving ward for patients of this class, which was on the opposite side of the general receiving ward from that to which the slighter cases were sent. All litter and serious cases were completely undressed and bathed, all dressings renewed except the larger splints, wounds inspected, re-dressed, and re-splinted, or splints were readjusted. Clothed in pajamas, patients were taken to the X-ray department, whence, after fluoroscopic examination, they were taken to the operating room. This was equipped with from 15 to 20 tables arranged in 2 rows, 1 or 2 being assigned to each team. These teams consisted usually of an operator and his assistant, an anesthetist (a commissioned officer), a nurse, and an enlisted man. In general no specialized work was assigned to individual teams except for some cases of head injuries. Teams worked in 12-

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hour shifts. Beside each operating table was a small table holding only a scalpel, pair of scissors, hemostatic forceps, anatomical forceps, a needle, and catgut. Other instruments and dressings were kept on a large table in the middle of the room in charge of a nurse, who distributed them on call. From the operating room, cases were carried to the postoperative ward, unless in need of treatment in the shock department. All cases reaching the wards bore tags marked "hold" or "evacuate," the former tag being affixed to the severe cases, which were held 24hours or more. Head, thorax, and abdominal cases were held from 3 to 10 days, according to the pressure for beds, but all others except these usually were evacuated in 36 hours. The ward surgeons redressed patients every 24 hours, or oftener if dressings became soiled, and verified the application of splints.

As was to be expected, after the armistice the proportion of medical cases increased greatly, due chiefly to influenza, pneumonia, and dysentery. From September 26 to December 11 the total number of evacuations was 28,139, of whom 21,078 were surgical, not including 575 wounded prisoners and 6,477 medical cases. These patients were removed by 93 trains.

GAS HOSPITALS⁴

Four gas-treatment hospitals were provided in the area of the First Army. On September 24, the officer charged with degassing service reported that the total number of officers assigned to these units, including teams, but not including 3 officers assigned for instruction, was 13, and the total of enlisted men was 231. None of the units were fully equipped and none had transportation. Gas Hospital No.1, with 3 officers and 288 beds, was at Rambluzin; No. 2, with 6 officers and 300 beds, was at Julvecourt; No. 3, with 1 officer and 325 beds, was at La Morlette, and No. 4, with 3 officers and 350 beds, was at Rarecourt.

Gas Hospital No. 1 had reached Rambluzin August 29 and opened the next day. On October 5 its personnel consisted of 2 officers and 37 men. During October the number of gassed patients it admitted averaged 8 daily, but at the end of that month it was ordered to discontinue service as a gas hospital and to receive contagious cases.

Gas Hospital No. 2, at Julvecourt, with a bed capacity of 300, was caring for 475 patients on October 2. Thereafter its patients usually numbered less than 300, though occasionally they exceeded that figure. This unit was provided with excellent bathing facilities and a portable laundry. From November 5 to 25, when it closed, it was designated as Annex B of Evacuation Hospital No. 10, and operated under its general jurisdiction. During the Meuse-Argonne operation this unit admitted 4,267patients, among whom were 37 deaths.

Gas Hospital No. 3, at La Morlette, was staffed by 1officer and 19 enlisted men, but this number was augmented, for part of its service, by 2officers and 40 men from Field Hospital 338.

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Gas Hospital No. 4, at Rarecourt, was staffed by 3officers and 47 enlisted men. From November 5 to November 17, when it closed, this unit was known as Annex A to Evacuation Hospital No. 10.

BASE HOSPITALS AT TOUL

On October 9 the hospitals at Toul were transferred from the First to the American Second Army, but they are discussed at this point as they were more active during the period of their service in the First Army, and during that time they cared for more battle casualties than they did later.

Like the other hospitals located at Toul, Base Hospitals No. 45 and No. 51 received casualties from the Meuse-Argonne operation, but because of their distance from the front, relatively few were admitted. Most of the surgical work which they performed consisted of secondary closures and care of postoperative cases.

BASE HOSPITAL NO. 51⁴

Base Hospital No. 51 had arrived at Toul and taken over French barracks. The unit received patients from the First Army and later in much smaller numbers from the Second Army.

Admissions during the last week of September totaled 812, and weekly admissions thereafter were as follows: October 8, 496; October 15, 851; October 22, 105; October 29, 534; November 5, 66; November 12, 252. Of this number, about 1,200 were surgical, 271 gassed, and the remainder medical.

After the installation of its X-ray plant, which had begun operations September 11, surgical work was limited for a time by lack of instruments. Nevertheless, the unit was able to care for from 50 to 150 cases daily and in emergencies for even larger numbers.

BASE HOSPITAL NO. 55⁴

This unit arrived at Toul September 28. On October 8 it had a normal capacity of 924 beds, with emergency expansion of 1,163. By the addition of tentage its bed capacity could be increased to approximately 2,000.

BASE HOSPITAL NO. 78⁴

On September 23 this unit arrived at Toul, where it became a part of the Justice hospital group, occupying 3 three-story and 3 two-story structures and about 10 smaller buildings.

The first patients were admitted September 29. During the months of September and October its activities were practically those of an evacuation hospital. It received some cases from evacuation hospitals and mobile hospitals, but most of its patients from divisional units. During the height of its activities this hospital functioned with less than 50 nurses on duty and only 150 enlisted men, exclusive of patients assigned to miscellaneous duties. The original equipment was not received until December, 1918. Patients were

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carefully classified in the receiving ward and distributed to the appropriate departments of the hospital. Operating teams were made up of three medical officers, an operator, an assistant, and an anesthetist. The schedules of service were so arranged that not more than 12 hours continuous service was required of a team, night and day service alternating. Much of the operating was performed at night, for the convoys usually arrived after dark. A large number of preoperative cases were received a few hours after the injury had been sustained. Except the shock cases, which were cared for in their special ward, surgical cases were X-rayed and promptly operated. Patients were handled as little as possible; most of the cases did not leave the stretcher upon which they arrived from the ambulance until they were put to bed after operation.

Extensive debridement was practiced, followed by the Carrel-Dakin method of wound treatment. Because of early evacuation of patients there was but little opportunity for secondary closures of wounds.

During the early part of its activities this hospital was the surgical unit of the group, but after the armistice it took over the treatment of infectious and suppurating cases and still later the treatment of genitourinary diseases.

From September 29, 1918, to April 29, 1919, it admitted 3,205 cases to the surgical service, performing 343 operations. Among these patients 25 deaths occurred, 12 of them being preoperative.

Although designated as a surgical unit, this hospital always had a fairly large proportion of its cases in medical wards, receiving a total of2,388 medical cases, with respiratory diseases predominating, in October and November. Preventive measures for these were the use of masks and the "cubiculizing" of wards by means of sheets strung across the room on wires. Total deaths from disease numbered 65, of which 45 occurred in October.

There were few unusual features in connection with the laboratory work. Pneumonia, especially that following influenza, was very severe, with an overwhelming toxemia and a high mortality. Hemorrhagic conditions in the intestines were found by post-mortem in a number of cases which primarily had presented pulmonary symptoms. There were many cases of enteritis, which seemed largely due to dietetic errors. Many influenza cases presented abdominal symptoms resembling those of appendicitis in the severity of pains in the right lower abdomen.

The X-ray department utilized a total of 489 plates and 754 films. The number of X-ray examinations was 966.

The dental service cared for 800 patients, giving 1,074sittings.

BASE HOSPITAL NO. 82⁴

This unit, with 34 officers and 192 men, moved to Toulon September 27, 1918, where it occupied the Luxembourg Barracks. By the 28th it had a normal capacity of 1,120 beds, 250 emergency beds, and space in a receiving tent and an annex. At that time there were enough surgical supplies for three or four tables. The laboratory had supplies for clinical work, but the X-ray laboratory was not equipped. There were no orthopedic appliances, but

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there was a sufficiency of beds, quarters, bedding, mess equipment, ward equipment, food, and medicines. Material to meet all deficiencies had been requisitioned and was expected within a few days. The American Red Cross equipped this unit almost completely. It occupied 30 buildings which had been turned over by that organization through an arrangement made with the French Government, 10 being one-story structures which accommodated 150 patients each, and 10 being other structures of six rooms; the latter were set aside for nurses and officers. The other buildings were used as offices, storerooms, etc. This formation operated as an Army hospital and was not considered a Red Cross unit, though it occupied buildings and utilized equipment which had belonged to that society. Its official numerical designation, however, was followed by the words "Red Cross Foundation," in parentheses, thus indicating its obligation. This unique addition to the official title of Base Hospital No. 82 was due to the following facts: A Red Cross unit, commonly known as "McCoy’s unit," from the name of the officer of the Medical Corps who was placed on duty with it when the Red Cross placed it in control of a hospital at Chateau-Thierry, had been sent from the Marne area to operate a hospital at Toul during the St. Mihiel operation. The hospital was one which the American Red Cross had been operating for French civilians, but in this emergency the society agreed to evacuate its patients and to turn it over, with its equipment, to the Army. The hospital, which was then designated Army Red Cross Evacuation Hospital No. 114, was reinforced by the personnel of a field hospital. After the St. Mihiel operation, "McCoy’s unit," which now consisted almost entirely of army officers and enlisted men and Red Cross nurses, was moved to Villers-Daucourt, where it operated during the Meuse-Argonne operation. Base Hospital No. 82 took over the premises and equipment which had been supplied by American Red Cross Military Hospital No.114.

BASE HOSPITAL NO. 83⁴

On arrival in France Base Hospital No. 83 moved to Revigny, where it arrived September 22 and was united with Evacuation Hospital No. 15.Here 6 officers and 20 enlisted men were detached to organize a 200-bed hospital for influenza and pneumonia cases, as an annex to Evacuation Hospital No. 11, at Camp du Raton, Brizeaux Forrestiere. Other officers and men were distributed among Evacuation Hospitals Nos. 6, 7, 10 and American Red Cross Military Hospital No. 114. On or before November 10 all the detached personnel was reunited at Revigny where, until November 13,Base Hospital No. 83 was under the command of the commanding officer of Evacuation Hospital No. 16. On November 14 the former unit assumed command of the hospital there.

The service rendered at Revigny was chiefly that of an evacuation hospital.

BASE HOSPITAL NO. 87⁴

This unit arrived at the Justice hospital group on October 8, where it took over control of the gas and neurological services of the group, with a bed capacity of 1,700. Only about 1,100 beds were available at first and these were filled by October 11. The unit occupied large stone and cement buildings

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divided into rooms that had from 14 to 18 beds each and averaged about 100 beds to each floor. The personnel, both commissioned and enlisted, was about equally divided between the gas and neurological services.

The personnel attached to the organization by local orders consisted of 12 officers, 33 nurses, and 153 enlisted men, but it was anticipated that later their numbers would be considerably reduced, as orders would be issued returning them to their original units. On October 10 total strength of the organization was 48 officers, 33 nurses, and 327 enlisted men. Four surgical teams were organized on the 11th, each consisting of 3 medical officers, 1 nurse, and 2 enlisted men. The laboratory began operations on the 25th. The X-ray plant had already been established in connection with the neurological service. By the date the armistice was signed bed capacity had increased to 1,825, the number of patients varying from 1,200 to 1,500.

Admissions, by weeks, prior to the armistice were as follows:

The gassed and neurological sections were situated about0.8 km. (0.5 mile) apart. The latter was known also as Neurological Unit No. 2. This was located at the western end of the Justice hospital group, where it had a normal capacity of 650 beds and facilities for 300 additional beds under canvas. The greatest difficulties which this unit experienced were those incident to crude sanitary facilities, including inadequate bathing equipment.

The gas hospital section occupied structures which formerly had been used as a hospital by the French for the La Marche Barracks. These buildings, of stone and cement, were all in good condition and were equipped October 3 to care for 1,000 patients. There was sufficient space to provide for considerable expansion.

CONTAGIOUS DISEASE HOSPITAL AT TOUL⁴

On October 4 the contagious disease hospital at Toul was located in buildings formerly known as the Perrin-Brichambault Annexe. These buildings, previously a French military hospital, were two and one-half stories high, of brick and cement construction, with a spacious central court. On October 9 the unit had 600 beds erected ready to receive patients. On December 22, it was recommended that the official capacity of the contagious hospital be 564, with an emergency expansion to 700.

Admissions from October 2 to January 10 varied from 4 to71 per day, the highest average being for November, when an average of 44 patients was admitted daily. The number of patients during November was about 500, also slightly more than during the preceding and succeeding months. The personnel on duty averaged 6 medical officers and 84 enlisted men.

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The unit treated a great variety of infectious diseases, comprising in fact practically every type which appeared in the army overseas.

In a report on meningitis cases for the month of December, note was made that only a few occurred in the same company. The meningococcus of Weichselbaum was isolated in the cerebrospinal fluid of all cases. Twenty-six percent of the patients were of the fulminating type, 48.1 percent of the ordinary type, 12 percent of systemic type, 7.8 percent chronic, 4.6 percent intermittent. The total number of cases in this series (that of December) was 64, with a mortality of 35.93 percent.

SANITATION

Throughout this action, pioneer and labor troops were too strenuously engaged in repairing roads and railways and in assisting to forward ammunition and rations to perform, as formerly, police duties on the battle field, while combatant troops were too fully occupied in defeating the enemy to give attention to the simplest rules of sanitation. It had been made clear to the command that every other consideration must be subordinated to the defeat of the enemy and in responding to this supreme requirement troops often resorted to primitive sanitary practices. Frequently, latrines were not provided, and thousands of animals were, for a time, unburied; but, because of the cold weather, such lack of sanitary precautions was faulty more from anesthetic than from an hygienic standpoint.⁵

With the knowledge that American forces were at death grips with a powerful and ruthless enemy, medical officers at the front refrained from making recommendations that common sense declared impracticable, confining their efforts in sanitation chiefly to the provision of good water and food to the troops in line and to the prevention of the spread of epidemic disease. They insisted, however, and with success, that labor troops police the battle field when discharge of this duty did not interfere with their assistance to the supply service. In the terrain back of the battle lines customary standards of sanitation were maintained despite the handicaps imposed by torrential rains and deep mud. As was the case at the front, provision of good water and suitable food and control of epidemics were considered the primary sanitary requirements. Notwithstanding the adverse circumstances under which all labored and the hardships to which troops were exposed, the rate for admission for influenza was lower in the First Army than among troops in the base sections and training areas.⁵

REPORT OF THE INSPECTOR GENERAL ON MEDICAL DEPARTMENT ACTIVITIES IN THE MEUSE-ARGONNE OPERATION

The following extracts are from the report of the inspector general, A. E. F., made on December 11, 1918, to the commander in chief, concerning activities of the Medical Department in the Meuse-Argonne operation.⁶ In common with such reports generally, it especially stresses defects noted.

Notes made by the Inspector General, A. E. F. During active operations from 12th of September, 1918, to 11th of November, 1918.

* * * * * * *

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IV. HOSPITALIZATION:

A. Evacuation of wounded.—

1. Evacuation of wounded from the battle field: The succor of wounded in the battle field was, on the whole, prompt, and patients began to pass through the battalion and regimental aid stations in a short time after the offensive began. When the line became stationary and resistance of the enemy increased, it was often very difficult to get the wounded in, even the walking wounded, for the enemy machine-gunfire was very heavy and many lay for hours in shell holes and other protected places before litter bearers could reach them, or ambulatory patients could walk back to the aid stations with any safety.

2. Personnel: The supply of personnel for succor of wounded varied as the divisional sanitary personnel was in some divisions augmented by a certain number of line troops from each company. These were trained in first-aid work and were available as litter bearers when needed. This personnel was provided for by corps orders in the First Corps, while in the Fifth Corps the detail of line troops as litter bearers was not permitted. This made a shortage of bearers in divisions of this corps, and it was necessary to augment the regimental sanitary personnel by a certain number of soldiers from ambulance companies when they were available.

Under the new tables of organization, the regimental sanitary personnel will be very materially increased, but the present allowance of personnel is not adequate to care for the wounded when casualties are heavy, and it would seem wise to make uniform provisions in all corps to provide for additional personnel to assist the regimental litter bearers in case of emergency.

3. Evacuations of battalion and regimental aid stations were made, as a rule, by divisional ambulances, but frequently heavy shell fire prevented ambulances from reaching these stations, and the patients were littered back to ambulance heads or to advance dressing stations by personnel of ambulance companies. Evacuations from dressing stations to triage and field hospitals was always by field ambulances.

Many divisions arriving in the area reported heavy shortages of ambulances, mounting often to entire ambulance companies. These shortages were made good, as far as possible, by evacuation ambulance companies and S. S. U. units, etc.

Evacuation of triage and field hospitals were under the control of the corps surgeons and made by evacuation ambulance companies. A large number of trucks were also used for transportation of the wounded. Most of the less seriously wounded were transported by trucks, and a relatively small number of litter patients were similarly transported.

4. Evacuation time was, on the whole, satisfactory. The time between the receipt of wound and arrival at the triage averaged about 5 or 6 hours, and to evacuation hospitals, 10 to 16 hours. Many patients arrived in much shorter time, and again, in some cases, considerable delay occurred. The delay mentioned above in evacuating battle fields was due to very heavy machine-gun fire directed at sanitary personnel and wounded, as well as at combatant troops; shell-riddled terrain making litter bearing extremely difficult; and a local shortage of litter bearers. Instances have occurred where four litter bearers consumed as many hours in the transportation of one patient from the battle field to the advance dressing station. Delays in reaching dressing stations were mainly due to extremely bad condition of roads, road congestion, and block, which frequently held ambulances for many hours. This was especially the case after the preliminary advance of October 26. There were isolated instances where the triage and field hospitals were taxed to their limit through the delays in evacuating, sometimes due to the shortages of evacuation ambulance companies or delay in their reaching these stations. This caused temporary congestion at the hospitals, but no hardships to the patients, as they were sheltered, fed, and given the required treatment.

With the improvements in road conditions and road policing, as well as increased experience and efficiency on the part of the hospital personnel, these delays became less frequent and during the advance, beginning November 1, the evacuation time was excellent in spite of the great distance between the line and the various evacuation hospitals.

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5. Distribution of wounded to evacuation and mobile hospitals: Under the system in vogue at the beginning of the offensive of October 26, for distribution of patients to the various evacuation and mobile hospitals, some hospitals received fewer wounded than their bed and operating capacity justified, while others were running to the limit of their capacity, and at times were temporarily overcrowded. This was later corrected by placing guards on the feeding roads leading south, and these guards, under the direction of the office of the chief surgeon, directed the flow of ambulances so that all hospitals received a proportion of the wounded corresponding to their bed and operating capacity. This plan tended to make most effectual use of all facilities, prevented overcrowding, and tended to reduce to a minimum the number of wounded evacuated preoperative.

6. Hospital trains: Evacuations to the base hospitals in the rear were made by trains, many French trains being used for this purpose. The supply of trains was at all times sufficient to prevent undue congestion at advanced hospitals, though they were at times taxed to the limit of their capacity. The French trains, especially those of box-car type, are not by any means ideal for the transportation of the wounded, especially seriously wounded, and it is believed that only the less serious cases should be transported on these trains.

The handling of patients on these trains showed certain defects, the most serious of which arose from the fact that the French orderlies could not understand any English, and the American patients, as a rule, could speak no French, and were in consequence unable at times to communicate their needs and secure appropriate attention.

Arrangements were being made to supply American orderlies to interpret and to assist the French attendants.

B. Care of wounded.—

1. The first-aid dressing and splints were applied on the battle field or at the battalion aid station. Where these stations were established in dugouts and shattered buildings, some hot food was also given wounded, though frequently with an advancing line this was impossible.

2. Antitetanic serum: In a large proportion of cases, A.T. S. was not administered until the wounded reached the advance dressing station, and in a small percentage of cases had not been given upon their arrival at the field hospitals. Conditions in this respect improved with experience, though even toward the close of the period many injections of the serum were still given at the dressing stations, having been omitted by the regimental personnel.

3. Dressings and splints: The dressing of wounds and the splinting of fractures were, on the whole, well done. A small number of undressed wounds and unsplinted fractures which occurred were investigated, traced to their sources, and by taking early corrective measures their number was kept down to a minimum.

4. Triages and field hospitals: Triages varied as regards their organizations, being in some divisions under charge of the personnel of ambulance companies, while in others a field hospital served as a triage and the other field hospitals were grouped near by, serving as divisional gas, nontransportable, and hospitals for divisional sick.

5. Gassed cases: At the beginning of the offensive, especially in less experienced divisions, there was a large number of patients evacuated from their divisions and diagnosed as "gas suspect," who on their arrival at the various evacuation gas hospitals showed no symptoms of gas intoxication. Some of these were returned to their organizations, but others, because of the difficulty in returning patients to organizations, or because of the congestion of the hospitals incident to the large number of admissions, were evacuated by train to the rear, their services being temporarily and unnecessarily lost. This condition was promptly corrected by retaining all mild and indefinite cases in divisions and evacuating only the more serious clear-cut cases.

A very large proportion of these patients held in divisions were returned to their organizations within a few days.

Many so-called "gas patients" were in reality suffering from exhaustion, diarrhea, etc., as demonstrated by further observation. Accuracy of diagnosis in gas cases is especially important, as symptoms are frequently delayed, in mild cases they are vague.

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and the fact that wound stripes are allowed "gas patients," has a tendency to make some men complain of the symptoms of gas poisoning. By retaining these men in divisions, accuracy of diagnosis was assured and malingering discouraged.

6. Nontransportable hospitals: At the beginning of the offensive, October 27, the field hospital groups were located mainly in shattered buildings only slightly in advance of some of the evacuation hospitals. Facilities for operating and postoperative care were very inferior to those available at the latter hospitals, and performing of operations on nontransportable cases under these conditions were not justified.

After the advance of the line, and with it the divisional sanitary organizations, a large number of life-saving operations were done. In some divisions the equipment of these hospitals was elaborate, operating teams were on hand as a correspondingly large amount of work was done, while in others, facilities were very limited and frequently no operative interference was attempted, nontransportable cases being sent to corps hospitals for operation.

7. The work of the Second Division, whose triage and field hospitals were located near Charpentry during the offensive beginning November 1,was of the highest order. The group was well located and planned, and a stone road constructed by the sanitary personnel made ingress and egress of ambulances very easy. All the wards were well heated, the beds clean and comfortable, and the attention given patients compared favorably to that given at evacuation hospitals. Litter racks and bedrests for all beds were improvised from the metal supports of barbed-wire entanglements collected in the neighborhood. The discipline of the personnel was of a high order. The work done was a great credit to the division surgeon, Lieut. Col. Richard Derby, and to the personnel of the various hospitals of the group.

The triages and field hospital groups of other divisions, though less elaborate than those of the Second Division, showed nevertheless a high degree of efficiency and indicated that much had been learned through experience in each of these offensives.

C. Records.—

1. In some divisions field cards and envelopes were prepared at the triage, while in others diagnosis tags alone accompanied patients to the rear. This was due to the fact that the supply of cards and envelopes was insufficient to furnish all divisions and that there was also a shortage in some of the evacuation hospitals. This shortage was later corrected to some extent, a considerable number of the forms having been received at the supply dump and distributed to the organizations.

In some inexperienced divisions patients, especially gas suspects, arrived at various hospitals without diagnosis tags, but this was promptly corrected.

In a large percentage of cases diagnosis tags were not signed by the officer who treated the patient, but by the attendant who made out the tag. This is a bad procedure, as it prevents fixing of responsibility for the diagnosis and treatment of any particular case. All cards should be signed, or at least initialed, by the medical officer. Some improvement in this respect was brought about toward the close of the period.

D. Evacuation hospitals.—

The work done by the various evacuation hospitals was very creditable, both as regards operations performed and the preoperative and postoperative treatment. The hospitals at the bases to which patients were evacuated were visited to determine after results; the report was favorable both as to the condition of patients on arrival and results of operations performed.

1. Personnel: There was in general a shortage of personnel, especially personnel for labor work, fatigue, litter bearing, and digging of graves. This was especially the case at the beginning of the offensive, but was later much improved on the arrival of additional personnel and labor elements assigned to hospitals.

2. Care of property of patients: During the St. Mihiel offensive provision was not made in most hospitals for the care of property of patients, and a considerable number of officers and soldiers were robbed of money, watches, and other valuables. These cases were investigated, and one thief who had stolen 250 francs from a dying patient

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apprehended and the money recovered. Adequate provisions for the safeguarding of the effects of patients were immediately instituted in all hospitals, and only a very few isolated cases of loss of property were later reported.

A large number of officers and some soldiers arriving at hospitals wounded have on their persons considerable sums of money and other valuables, and in several cases company funds of organizations which they command. Several officers stated that they had not been able to deposit this money, though they had frequently attempted to do so, as there were no depositories for company funds. Provision was later made for depositories for company funds in divisions.

3. Salvage of property: This was on the whole very badly handled at first, the quantity of property salvaged from patients, including uniforms, overcoats, puttees, slickers, gas masks, shoes, infantry packs, etc., being tremendous. Labor for caring for and sorting the same and space for storing it were inadequate. This was later corrected by the Salvage Department arranging to collect the same and transport it to the dumps.

4. Laundry facilities: Some hospitals have no laundry facilities, and in others facilities were far below hospital needs. This made it necessary in some cases to salvage soiled linen instead of washing it, and requisition was made on supply depots to replace that salvaged, taxing the linen supply of the dumps. The supply of laundries was always limited, but the shortage was made good to some extent before the closing of the offensive.

5. Signs for hospitals: Cardboard signs were conspicuously placed indicating the location of various hospitals. Due to inclement weather, some of these became effaced, blown down, or destroyed. It is recommended that sheet-iron signs be included in the equipment of these hospitals. These would be posted when hospitals are established and would be taken down and reposted as the hospitals moved forward. If these signs could be marked with luminous paint, it would do very much toward preventing ambulances from losing their way when traveling at night and especially when running without lights.

6. Return of patients to organizations: Many patients admitted to the evacuation hospital, especially early in the offensives, soon recovered, and would have been able to return to duty had suitable machinery been in force to effect their return to their organizations. Under the conditions existing, many of them were evacuated to the rear. Arrangements were later made to send patients marked "duty" to replacement battalions, from which they were forwarded to their proper organizations, thus preventing wholesale evacuations to the rear.

V. BURIAL OF DEAD:

A. During the offensives in the Chateau-Thierry area very little attention was paid to the burial of the dead; many of the dead lay for days without being buried; a large number of isolated burials occurred; and many of the dead were improperly or partially buried in shell holes. In many cases no attempt was made to identify the dead, and approximately 10 percent were buried unidentified. Strict orders covering the entire subject of the burial of the dead was issued at that time.

B. There has been considerable improvement, but that the technique as yet is by no means perfect is indicated by the fact that an investigation at present being made had revealed neglect on the part of the 2d Division. A large number of isolated burials have been made, and in some cases several of the dead have been buried in a single grave and improperly identified. This condition is an exception, and as a whole chaplains and other burial officers are now carrying out their work in an efficient manner.

C. Sanitation: Sanitation was, on the whole, poor in the entire areas. Buildings, towns, and the terrain in general was left in a filthy condition by the retreating armies, and the American forces had little opportunity to correct the sanitary defects during active operations. This was especially manifested in primitive methods used to dispose of excreta and waste. Latrines were rarely, if ever, constructed along line of march, and men were constantly seen defecating in fields beside roads and soiling the terrain of the villages. This was also characteristic of organizations at the front. Organiza-

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tions at rest behind the lines generally built straddle trenches and insisted upon the use of them in general, though numerous exceptions were noted.

As regards kitchen waste and refuse in general, they were at times carted away, though frequently simply left in piles or scattered when organizations left the territory.

D. Water supply: Men during advances frequently had no access to pure water and drank from shell holes or any other source that they could find. In some organizations, even at rest, there were no Lister bags or other facilities for chlorinating water. These conditions were very markedly improved during the latter part of the period, and in some cases marked decrease in gastrointestinal disturbances were brought about through improvements in the supply of pure water to the troops.

E. Clothing: In many divisions there was a shortage of clothing to permit of a change as the men were bathed, and a large proportion of the men were infested with lice. The clothing situation was cleared up through the establishment of a very large dump at Fleury, from which all necessary winter underwear, overcoats, blankets, and other clothing were supplied in sufficient amounts to equip the entire personnel of all divisions.

REFERENCES

(1) Final report of the chief surgeon, First Army, A. E. F., upon the St. Mihiel and Meuse-Argonne operation, November 18, 1918, 18. On file, Historical Division, S. G. O.

(2) Evacuation of the wounded in the Meuse-Argonne operation, by Col. H. H. M. Lyle, M. C., December 10, 1919, 26. On file, Historical Division, S. G. O.

(3) Medical activities in the Zone of the Armies, by Col. A. N. Stark, M. C., undated, 19. On file, Historical Division, S. G. O.

(4) From reports of Medical Department activities of individual hospitals, prepared under the direction of commanding officers, undated. On file, Historical Division, S. G. O.

(5) Medical activities in the Zone of the Armies, by Col. A. N. Stark, M. C., undated, 21. On file, Historical Division, S. G. O.

(6) Notes made by the inspector general, A. E. F., during active operations from September 12 to November 11, 1918. Copy on file, Historical Division, S. G. O.