Field Operations, Table of Contents
CHAPTER IV
MEDICAL SERVICE OF THE DIVISION IN COMBAT
The following discussion of methods generally employed in divisions in combat for the care and evacuation of sick and wounded comprehends important details of the usual practices. As will be noted, no one method universally was employed; much was left to the initiative, discretion, and resourcefulness of the division surgeon and his subordinates. No orders standardizing the methods in question were issued by higher authority except to a limited degree by corps surgeons and to a lesser degree by army surgeons. Though, in general, the system followed was that prescribed in Field Service Regulations and, in more detail, in the Manual for the Medical Department, the divisions differed not only in the methods of their so doing, but individually they employed different methods at different times under varying circumstances, both in trench and in open warfare. This went so far that methods in one regiment sometimes differed for certain reasons from those of other regiments in the same division. It is not practicable to discuss in this chapter all the numerous differences in the details of medical service which are noted later in the chapters having to do with individual engagements. Here only the most important differences in methods will be mentioned briefly. For further details the reader should consult subsequent chapters.
ORDERS PRESCRIBING METHODS IN PARTICULAR DIVISIONS
Before going into further details it will perhaps be best to quote certain orders prescribing methods actually followed by particular divisions.
In the 42d Division the following plan for the evacuation of sick and wounded and for furnishing a forward flow of medical supplies was prepared by the division surgeon April 4, 1918: 1
MEDICAL SERVICE FROM FRONT TOREAR
For medical service from the front the following will be observed:
Front line trenches.- Wherever possible first aid and splints-when the nature of the injury renders the latter necessary-will be applied where the man falls. Hemorrhage will be controlled at the earliest possible moment. If we can avoid carrying a man with a fractured extremity for even a foot, until a splint has been applied, we will save much pain, shock, infection, and damage to tissue from jagged ends of bone. The patient will be carried by the regimental medical personnel, or by men from combatant troops detailed for that purpose, from place of injury to the battalion aid post.
Battalion aid post.- Here any attention that may be necessary will be given-first aid, splints, and control of hemorrhage, if not already done. See that dressings and splints are properly adjusted. Diagnosis tag will be made out and attached by the first medical officer or member of the Medical Department who treats the man. Antitetanic serum will be administered and proper notation made by a "T" marked on the forehead with indelible pencil and the letters "A.T. S.," with date and hour on diagnosis tag. Warmth
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will be administered to the patient. This is of the utmost importance in the prevention of shock. Patient will not be removed from litter, but another litter, with three blankets and whatever other supplies have been used on the case, will be sent back to the trenches by the bearers to replace those used. Patient will then be carried by litter bearers detailed from the ambulance section, 117th Sanitary Train, to the ambulance dressing station.
Ambulance dressing station.-This will be established at the farthest point forward that ambulance scan reach with reasonable safety. Here any further attention that may be needed will be given. The patient, however, will be disturbed as little as possible and will not be removed from the litter. Warmth will be constantly maintained and hot drinks given to those able to take them but withheld in abdominal cases. The same system of exchange will operate. The ambulance dressing station will return by the litter bearers a duplicate of everything that came with the patient. In addition it will send by these bearers any supplies that the medical personnel at the front may require. To this end it will comply, as far as its supplies permit, with any request for supplies that may reach it from the front. To avoid confusion and mistakes these requests should preferably be by written memorandum. Reserve supplies of antitetanic serum, dressings, and other necessities will be kept on hand for this purpose. Antitetanic serum will be given to those who have not yet received it and the proper notations made as noted above. At the ambulance dressing station cases are selected for distribution to the various hospitals. They will be placed in an ambulance and transported direct to the appropriate hospital.
Ambulance service.- In addition to ambulance service noted under ambulance dressing stations, ambulances will be stationed at various points through the area, to be known as ambulance posts. The location of these ambulance posts will be shown in a later communication. These ambulances will transport to hospitals the sick arising in the various organizations in their vicinity, also wounded that may occur in a locality which would not naturally drain into an ambulance dressing station.
Field hospitals operating the various hospitals noted above.- These hospitals will be prepared to receive and care for sick and wounded at any hour of the day or night. They will keep a reserve supply of material on hand to replace the supplies on ambulances, as noted above. Evacuation of patients to base hospitals will he done only upon direction of the division surgeon, 42d Division.
The following points are emphasized:
(a) Surgical operations are prohibited except in a hospital. Treatment at the front and during evacuation to the hospital will be limited to first aid, splints, control of hemorrhage, and shock. Probing for bullets or fragments of any sort is expressly forbidden.
(b) Every effort will be made to secure delivery of the patient to the proper hospital at the earliest possible moment after receipt or the injury. Saving of time during the early period of the injury may mean life or death of the patient.
(c) During the evacuation of the patient he must be kept as comfortable as it is possible to provide. He must be disturbed as little as possible, and in any event, after the first dressings and splints are applied, only so much as is necessary to see that the dressings, splints, etc., have been properly applied and continue in good shape.
(d) Warmth will be continuously applied. This is our best preventive for shock. It will be secured by hot-water bags, alcohol or oil stoves, hot bottles, etc.
(e) A constant flow of supplies will be kept up from rear to front lines by the system of exchange noted above.
The following order concerning evacuations was issued in the 3d Division, July 23, 1918:2
Regimental surgeons will keep in touch at all times with the ambulance company dressing stations which evacuate their wounded. They will instruct their assistants, commissioned and enlisted, concerning the position of the particular dressing station which evacuates the wounded from the battalion to which their assistants are attached.
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When a call is made for an ambulance the surgeon making the call will state explicitly the number of cases to be evacuated, which of them are litter and which sitting cases. He will also give sufficiently clear directions concerning location of the wounded to enable the ambulance driver to reach his destination with the least possible delay.
Redressing of wounds in the main dressing station should be reduced to a minimum. Arrest of hemorrhage is the principal cause for redressing. Dressings apparently in place should not be disturbed.
On September 6, 1918, additional instructions on this same subject were issued in the 3d Division, as follows:3
Method of supply while inaction.- Regimental and battalion surgeons requiring medical supplies for their battalion aid stations during action will send request for the same to the advance ambulance dressing station evacuating their aid stations. The first ambulance returning to the triage will carry this request to the medical supply officer, who will immediately forward the necessary supplies by an ambulance returning to the advance ambulance dressing station. Wheel litters are an excellent means of transporting supplies to battalion aid stations. If necessary to abandon supplies during movement, they should be turned in at the advance ambulance dressing station.
When calling for ambulances be definite in giving location of the wounded, the number of sitting cases, and number of lying cases. Do not send for ambulances until enough wounded have been collected to fill an ambulance. A few hours of rest, after dressing and nourishment, while waiting for an ambulance is not detrimental and helps to overcome the first shock. Purely exhausted men after being given food and a few hours` sleep at the battalion aid station will often be able to return to duty.
Do not be in too much of a hurry to make a diagnosis of gas poisoning.
Regimental aid stations may usually be dispensed with to advantage, leaving the regimental surgeons free to keep up constant liaison between battalion aid stations and advanced ambulance dressing stations and to encourage as well as to supervise battalion aid surgeons at their work. Conserve the energy of your assistants and yourself by working proper shifts and taking every opportunity when off duty to sleep.
Antitetanic serum must be given at battalion aid stations. Make proper notation on the diagnosis tag and also place a "T," with indelible pencil or iodine, upon patient`s forehead after the serum has been given.
Battalion aid stations should be separated from battalion P. C.
The division surgeon should be informed promptly of any loss in medical personnel. If telephone communication is not available, messages for the division surgeon will be transmitted from the advance ambulance dressing station by ambulance returning to the triage.
Intelligent men should be trained as runners. If a verbal message is sent, have the messenger repeat it to the sender in order to be sure that he thoroughly understands it. Send written messages except when the substance of them would betray matters of military importance.
The following report of the methods adopted in the 30th Regiment is descriptive of the evacuation service in many regiments:4
Advanced aid station company posts were in line with the troops. The first and most essential prerequisite for evacuation from front lines to battalion aid stations was the proper location of the latter. These were placed at the most advanced point to which an ambulance could possibly go; often within one-half kilometer of the front, or, again perhaps, three--rarely four--kilometers away, according to the character of the terrain. The battalion aid station was never placed in advance of the point reached by ambulances if this could be avoided. When situated beyond that point the difficulties of evacuation were doubled. On the Maine in July, 1918, it was found that having the aid station in advance of the ambulance head fully doubled the number of patients who had to he removed by litter, for a large number of patients made their own way to the aid station
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who would not walk farther, and if this station was in advance of ambulances these patients had to be carried back to them. Thus a large number of wounded, and especially psychoneurotics, had to be taken by litter to the ambulances, who otherwise would have walked that distance. Details of litter bearers sent with patients from aid stations back to ambulances did not return readily through shell fire and were not to become disorganized, whereas when sent forward for patients they returned in the quickest possible time.
During the defensive battle of the Maine evacuation was by far the most difficult of any experienced by the 30th Regiment, 3d Division, on account of the extremely heavy bombardment of the support and reserve positions and the back areas, and the formation of the terrain, which made it impossible for ambulances to go nearer than three kilometers to the front, or, during the early part of operations, nearer than four kilometers. Wounded in the front areas could be carried out only at night, and they had to be carried up a steep hill through an arrow, winding trail in the woods. The Medical Department personnel in this battle was wholly inadequate, each battalion having altogether only about 20 medical men and bandsmen. No provisions had been made at this time for furnishing litter bearers from the line troops, although line officers cooperated heartily with the Medical Department in furnishing details for this purpose.
The operation of ambulance companies in the 3d Division is thus described by the division surgeon.5
Main dressing stations were usually established from four to six kilometers back of the front lines, on a good road if possible, with one or more good roads leading to the front and rear. From these places ambulances, medical officers, and a sufficient number of enlisted men were sent to points farther to the front, working in cooperation and at times under direction of the regimental surgeons, but so far as practical it was found best to keep all ambulance personnel under the direction of the ambulance company itself, at the same time furnishing the regimental and battalion surgeons with what help they required. In many instances it was necessary to furnish litter bearers for evacuation from the farthermost posts toward the front. Here the enlisted personnel of the animal-drawn ambulance company proved of great value, it having been found impractical to use animal-drawn ambulances for evacuations from the line when actually under shell fire. This was due to the increased hazard incident to slow progress and the distance it was almost always necessary to transport the wounded.
The litter bearers of the ambulance companies were sometimes in charge of a commissioned officer from the ambulance companies, and functioned from the battalion aid posts back to the farthest advanced ambulance station, which was only far enough to the rear to be reasonably safe. At other times they were under the control of the regimental or battalion surgeons, to augment the regimental medical personnel either on account of a depleted force or to help in the care and transportation of an unusually large number of casualties.
The commissioned personnel of the animal-drawn ambulance company was likewise used to replace the battalion surgeons as casualties occurred among them.
At the main dressing station in some instances where facilities would permit, gassed cases were separated from wounded, all casualties able to take nourishment were given hot chocolate or hot coffee and other refreshment, antitetanic serum was administered, wounds were redressed when necessary, tourniquets were looked for and examined, and only when absolutely necessary, blood vessels were ligated.
Sometimes all of the ambulance companies of a division consolidated. Thus during the Meuse-Argonne operation all the ambulance companies of the Sanitary Train, 3d Division, were stationed at Montfaucon, maintaining one large main dressing station, which was operated by one company under the supervision of the director of the ambulance section.6Every portion of the narrow sector then occupied by the division was accessible by roads from this point. Two of the motor-ambulance companies functioned from the regimental and battalion aid stations back to the main dressing station and no farther.
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Here all patients were removed from the ambulance and attention was given them by the medical officers thereon duty. These medical officers usually numbered from four to six, one of them being an orthopedist. Nearly all splints needed readjustment, and many cases of fractures had not been put in splints before sent to this station because of the limited facilities for such service at the most advanced posts and the great number of casualties occurring at times. Nearly all antitetanic serum was administered at the ambulance company dressingstation.6
Evacuation of patients from the dressing station to the field hospital was effected by the motor ambulances of the company operating the station. By this arrangement a perfect liaison was maintained at all times between the regimental surgeons and the section headquarters, as well as between the main dressing station and the field hospitals.
The practice followed by the regimental surgeon, of notifying ambulance section headquarters of number, location and character of wounded reduced to the minimum half loaded ambulances--an important item when the front was active.
The rate of flow of casualties through the dressing stations depended entirely on the resistance encountered by the combatant troops; during a period of 27 days, when the division was on the offensive, the daily number varied from 52 to 931.6 Likewise, the length of time consumed in transporting wounded from the front lines to field hospitals was subject to wide variation, dependent on the rapidity with which the troops were advancing, road conditions, whether day or night, and amount of traffic. It averaged five hours from the front lines to triage or field hospital during the operation of the 3d Division on the Marne and two and a half hours for the 27 days that division spent in that of the Meuse-Argonne area.6
The following orders concerning field hospital service were published in the First Corps, September 3, 1918.7 In this corps, the divisional triage was operated at a dressing station, staffed by the ambulance company section and such others as the consultants, detailed to that formation.
1. Field hospitals will be utilized as follows during periods of activity. This applies particularly to open warfare where rapid changes are probable. In sector warfare which is practically stationary, location of field hospitals need not follow this plan absolutely, especially as to location, which will be determined by the terrain, buildings available, proximity of evacuation hospital, and other considerations.
2. The four field hospitals of a division will be placed together if conditions of the terrain permit. They will always be plainly marked by the Red Cross emblem in order to protect them from enemy fire. Placing the field hospitals together has been tested in actual open warfare and found to have certain definite advantages: (a)They are much more easily located by ambulance drivers. If located at separate points, depending upon the character of the service they are intended to furnish, ambulances are apt to wander about and have great difficulty in locating their particular hospital. This of course is especially true in new country with which drivers are not familiar. (b) The administration of the hospitals is much simplified by being concentrated at one point.(c) Assistance from the field hospital in reserve is always immediately available for whichever unit may have need of such assistance.
The field hospitals should be placed as close to the ambulance dressing station as is reasonably safe.
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3. The field hospitals will be utilized as follows: (a) Gas hospital. (b) Hospital for nontransportable wounded. (c) Hospital for minor sick, including skin and venereal diseases. (d) One hospital in reserve.
4. Gas hospital.-One field hospital will be utilized as a gas hospital. To this hospital will be sent all the gas cases from the triage. Therefore, facilities must be provided to give them the necessary special treatment required-proper bathing, alkaline treatment, administration of oxygen, if necessary, venesection. * * *
5. Hospital for nontransportable wounded.-One field hospital will be utilized for the care of nontransportable wounded. This hospital will be supplied with surgical teams, female nurses, and an X-ray outfit, in order that proper surgical treatment and care may be given these cases. To this hospital will be sent direct from the triage only such cases whose transportation farther to the rear will probably mean death. In past experiences, these cases have usually comprised three classes: (a) Sucking chest wounds. (b) Perforating abdominal wounds. (c) Severe hemorrhage cases.
Head and spinal cases stand transportation better before operation than after and should therefore not be stopped here. There has been a tendency in the past to retain at this hospital seriously wounded cases who, however, would be able to stand transportation to the evacuation hospital. This must be discontinued. Only such cases will be retained as are actually nontransportable. When available, the corps surgeon will detail to each division an assistant consultant in surgery, who will be the sole judge of what cases will be operated at this hospital and what cases will be transferred to the evacuation hospital. A shock team will be on duty at this hospital for treatment of all shock cases both pre and post operative.
6. Hospital for minor sick including skin, and venereal diseases.-To this hospital will be sent only those cases which are minor and which will be fit for duty within four days.* * *
7. One field hospital in reserve.-This will be used to give assistance where needed, both in personnel and equipment. A detail of 1 medical officer and 10 enlisted men will be sent to the ambulance dressing station to give the necessary preliminary bathing and alkaline treatment to mustard-gas cases as may be deemed necessary by the division medical gas officer on duty at this station. This detail must, of course, be relieved by another detail at regular intervals, to allow the former to secure the necessary rest and food.
8. * * *
9. Exchange of supplies.-It is of utmost importance that a systematic exchange of supplies as litters, dressings, splints, blankets, hot-water bottles, operating from the frontline all the way back to the final hospital to which the patient is delivered, be instituted at once. When a patient is placed in an ambulance, the ambulance orderly must return to the litter bearers a duplicate of all supplies furnished the patient. Similarly, when the ambulance delivers the patient to a hospital, the orderly must get from the hospital a duplicate of all supplies furnished the patient. This must operate at every point where a change of transportation is made. Otherwise the supplies at the front-line positions will soon become exhausted and unnecessary delay and suffering result. If this system of exchange is enforced, there is a constant steady stream of all necessary supplies going forward and there need be no interruption in the care given to wounded or other casualties. * * *
Methods employed when troops were engaged in trench warfare differed considerably from those followed when they attacked in the open, and for this reason trench warfare and open warfare will now be considered separately. It should be explained, however, that, when troops holding trenches were heavily attacked, the difference was less marked. Yet always in trench warfare, casualties were more localized and Medical Department formations were more fixed, better equipped, and better protected than they were when the troops they accompanied were on the offensive.
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CARE OF CASUALTIES IN COMPANIES, BATTALIONS, AND REGIMENTS
In old, quiet, defensive positions, the front line usually was little more than a line of outposts lightly held, the remainder of the troops being in support trenches or in reserve. Sometimes, as in the 5th Division in the Vosges, a battalion thus held a frontage of 5 km. (3 miles.)8 One battalion surgeon was usually on duty with the advance troops, while the other was in charge of the battalion aid station. Two enlisted men of the Medical Department were normally assigned to each company at the front and staffed what was, in effect, a company aid post located at some sheltered point and near a communicating trench to the rear.9 Frequently, it was provided with some equipment such as litters, splints, bandages, dressings, whale oil, sodium bicarbonate and a few drugs. The Medical Department enlisted men were provided with ammonia ampules and instructed in their use, and were also instructed in other elements of first aid. They were ordered promptly to adjust the respirators of disabled men who had been gassed. The location of the collecting post (company aid post) was made known to the company concerned and here first aid usually was given. Often, however, especially if casualties were few, one of the medical attendants stationed here would leave to give aid to a man where he fell. The function of the company aid post was to give primary, or, if the patient had already received this, supplementary first aid, to return to duty men not in need of further treatment, and to prepare other wounded men for evacuation, grouping those who were able to walk. Professional aid, as given by the battalion surgeons concerned, was limited in general to the control of hemorrhage and to the application of dressings and splints. Those disabled in the front line habitually were brought to the company aid post (if necessary, on litters carried by company bearers), except when their wounds had been dressed where they fell and it was easier to remove them from that place to a battalion aid station.
Patients were taken to the battalion aid station from company aid posts or from the line. It usually was located in a support trench from 240 to 500 yards from the front and so as to be readily accessible from all parts of it that the station served. (In the 89th Division aid stations for the support lines of reserve also were provided.)10 Normally, there was one battalion aid station for each battalion, and it was located near the communicating trench to the rear, utilizing any shelter available. Sometimes it was near the battalion post control, in order that the surgeon might be in close touch with his commanding officer, but in some divisions this was expressly forbidden on the ground that juxtaposition of the two aggravated the danger to both.11 Sometimes it was much farther back than the distance mentioned above, in order that it might be accessible to ambulances. When the distance was more than 1,000yards (in the 4th Division 800 yards) relays of litter bearers were utilized.
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stationed at posts that distance apart. Portage for 1,000 yards was the limit of a squad`s endurance.12 When available, four litter bearers were employed to bring patients to the battalion aid station, and if the moving squad was invisible to the enemy lines the litter was sometimes carried shoulder high. This portage over rough ground, through winding trenches, and by trails deep in mud was slow, arduous, and, when the group was exposed to enemy fire for a considerable time, hazardous.9 After 10 or 12 hours of such work under shell fire, bearers often became nervous and exhausted. While habitually the battalion aid station was located, if possible, at a point accessible by ambulance, this desideratum was regarded of secondary importance, the primary essential being such proximity to the front that the wounded would receive prompt attention.
The battalion aid stations of the American Army in fixed positions were modeled on those of the British andFrench.9 These were rather elaborate installations, for heavy bombardment often necessitated that they retain patients until after dark. In general, such a station as constructed by our allies, and taken over by our troops when serving with them, consisted of a series of communicating rooms, 2 meters (6.5 feet) high and from 2 to 4 meters square (6.5 to 13feet). One room was for office purposes and the reception of patients, one for the application of dressings and for shock treatment, one for the battalion surgeon, one for stores, and one or more for the personnel. It had 2 by 2 meter (6.5 by 6.5 feet) galleries, with two or three tiers of improvised litter racks, which sometimes accommodated 30 patients, but rarely more than 12.9 Usually, in a separate dugout at one side, were two rooms for the bathing, emergency treatment, and re-clothing of gas cases. The doors to these aid-station dugouts were generally 3 feet wide and
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were protected by two tight-fitting blanket curtains placed at least 8 feet apart. These curtains were soaked with alkaline or sometimes hexamethylenamine solution, and were so adjusted that they would fall into place upon touching a release. The first curtain was intended to be shut down before the second was opened. The descent to the battalion-aid dugout was found to be preferably at an angle of 30o;but as dugouts used by line troops were used commonly for aid stations, Medical Department personnel soon adopted the same angle of ramp as that used by line troops. In such cases a litter chute was often made of greased planks nailed on either side of the stairs leading down into the station. An important item of station equipment was a water storage tank or well. Usually, light was furnished by petroleum lanterns, but a few of these dugouts were lighted by electricity. Each attendant generally possessed a flashlight.9
To prevent water dripping into them, dugouts usually had corrugated iron ceilings. Walls were boarded and floors provided. Frequently, ceilings and walls were calcimined, or at least whitewashed. Some dugouts even had dining rooms. The depth of a dugout below the surface of the ground was usually 10 to 12 feet on an average, but in localities subject to shelling by heavy guns a depth of 20 feet was preferred. Dugouts situated on the higher level were unprotected against direct hits by shells of more than 155 mm. caliber.13 Such shells rarely fell on the support trenches except during great activity. Whenever possible, cooking was done below; otherwise, food was brought to the stations in marmites. Coke fires were made in braziers; ventilators, with dampers to exclude gas, tapped the principal rooms. While remarkable ingenuity was displayed in making these dugouts comfortable, it should be understood that the description given above is for the most elaborate ones, and ordinarily they were much simpler.
On taking over French or British sectors, or in occupying them temporarily, the American Army fell heir to these subterranean battalion aid posts. While battalion aid stations actually constructed by American troops were similar to those described above, they usually were much less pretentious. The medical personnel of all our divisions received instruction in the subject of constructing them from the divisional engineers or at the Army sanitary school. In some cases our aid stations would accommodate 25 or 30 patients, but usually the number was 10 or 12.13
PERSONNEL
The personnel on duty at a battalion aid station consisted normally of one medical officer, a dental officer if available, and from four to six enlisted men of the Medical Department.11 These usually were supplemented by two runners and one or more litter squads assigned from an ambulance company, the number of these squads being increased if unusual activity was anticipated.11
SUPPLIES
Equipment, beyond that furnished by Supply Tables, to a battalion included at least two Thomas splints, a shock table for warming patients,
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two 500-liter oxygen tanks, suits of overalls, with gloves and masks, for attendants caring for gas patients, gas fans, and alkalies and sprayers for attendants to use in cleaning out the galleries to which gas had penetrated.11
Supplies were brought forward as far as possible by battalion medical carts or other vehicles. They were replenished by one of several systems.14 That mostly commonly used required empty ambulances to carry forward to the battalion station or the ambulance head articles similar in kind and number to those they had brought back with patients. Another system was that of having the battalion surgeon send, by runner to the dressing station, a list of the article she desired. A third method was that of the automatic replacement first mentioned, supplemented, as required, by the second. The first system worked well except during heavy engagements, when ambulances could not carry forward all supplies required. Then the supplies they could not transport had to be brought forward in trucks. The medical supply carts were not much used. At times of stress there was occasional shortage of litters, blankets, and large dressings, due in the majority of instances to the fact that responsible officers at the front had not foreseen their needs or that transportation was inadequate.11 There was always a large surplus of these articles constantly available in depots.11 If ambulances and trucks could not reach battalion aid stations, supplies were carried forward by litter bearers from the ambulance head or the dressing station.
In order to reduce transportation of equipment, on the relief of an organization in a sector, much of that in its medical dugouts was sometimes left behind when the division moved.11 The 1st Division on one occasion thus transferred to its replacement matériel sufficient to fill several freight cars.15 These "trench stores" usually consisted of all supplies and equipment which would not normally accompany troops in a war of movement.
Service at battalion aid stations included control of hemorrhage, application or readjustment of dressings and splints, administration of antitetanic serum and of morphine, if indicated, emergency treatment of gassed cases, and the preparation of field cards or diagnosis tags. When it was possible to do so, hot food or something hot to drink was given to patients. Slight cases of illness were treated and returned to duty.
The following is taken from the report of the division surgeon, 3d Division: 16
The treatment and evacuation of the wounded from a quiet sector, either with or without a perfected trench system, was not difficult. The wounded were few in number; and as enemy fire was light, first-aid dressers and litter bearers had much freedom of action. Personnel and transportation were more than adequate. At the battalion aid station, gassed cases could be stripped, bathed, and redressed, hot drinks and food given to all, shock cases recuperated, and many comforts administered.
When, however, a quiet trench sector was converted into an active one, the situation became very different from that just described. Time, personnel, supplies, and transportation, heretofore fully adequate, became insufficient, and the character of the work performed at the battalion aid station had to be modified accordingly, influenced chiefly by the number of patients arriving, extent of shelter available, and promptitude of ambulance service. For example, if ambulances were waiting, shelter inadequate for all
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the wounded, as along the Marne, and the action was not severe enough to preclude evacuation, disabled were held only long enough to receive the necessary first-aid and the antitetanic serum.
In order to expedite service, patients were classified into several categories, each of which was cared for according to a definite plan. In the 3d Division the classification was as follows:(1) Very slightly wounded who were able to return to the line; (2) slightly wounded requiring evacuation: (3) seriously wounded; (4) patients with fractures; (5) severely wounded with considerable attendant shock; (6) gassed patients; (7) psychoneurotics; (8) sick.16
The patients in the first class were dressed and retained for the time being. Some of those in the eighth class also were retained. All others were evacuated. Usually those in the second class were dressed only with first-
FIG. 14.- Adjusting improved split on a litter patient, Broussey, France, April20, 1918
aid packets, and most of them were able to reach the ambulance dressing station unaided. Wounds of severely injured patients were lightly painted with iodine and an adequate dressing was applied, antitetanic serum, morphine, and, if needed, a stimulant, were administered, and the patient was evacuated as soon as possible. The dosage of serum was 500 units: that of morphia usually 16 mgms. Their administration was noted on the diagnosis tag, and often the letter "T" was painted with iodine on the forehead of a patient as soon as he had received the serum.16
Fractures were immobilized here by the use of Thomas splints, if these had not already been applied. If a patient had been splinted, the splint was examined and, if necessary, it was readjusted. These patients were handled as little as possible and often placed in the ambulance on the same litters on which they had been brought from the front. Patients in severe shock were held, if possible, until reaction occurred. They were wrapped in
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blankets, given strychnine hypodermatically, and hot coffee or chocolate. As a rule, they reacted well.11
The most difficult patients proved to be those claiming to have been gassed.17 It was impossible for the surgeon to diagnose properly and promptly all patients claiming disability from this cause, for he had no means of knowing whether a doubtful condition was one of delayed gas poisoning or gas fright.17 Some suspected cases of gas poisoning were held for observation and cared for in dugouts, basements, or cellars. After a few hours` rest, almost all patients, doubtfully gassed, were able and willing to return to the front.18 Frank gas-intoxication patients, received during very active operations, were evacuated immediately, taking precedence over all others, for at such times it was impossible to strip and bathe them at the battalion aid station. Not only was personnel inadequate, but sufficient water was unobtainable ,and they could not be retained with other patients because of diffusion of gas from their clothing. The psychoneurotics and sick were evacuated if their condition demanded it. Of the former, patients with gas fright were the most numerous and, as stated above, most of them were returned to the line.17
A battalion aid station`s activities in a moderately active defensive sector, as described, were often somewhat modified by changed conditions. The administration of antitetanic serum was not always possible, as sometimes there was none on hand.17 At some places no fires could be built to prepare hot drinks.17
During periods of intensive bombardment, when the trenches and back areas were subjected to destructive fire from high-explosive shells, patients usually were moved under cover of darkness by ambulances which went directly to the battalion aid stations, if this was at all possible. Removal of patients by daylight, whether by litter or ambulance, under such circumstances would have exposed all concerned to needless risk. By day, it was impossible for ambulances to approach nearer to the front than 3 or 4 km. (1.8 to 2.4 miles) and removal by litter then would have been unwarrantable, though litter bearers frequently ran forward, at great risk, during a lull in the enemy fire. When roads were subject to interdiction fire, patients wounded early in the day did not reach hospital for 18 hours or more. Though, under such circumstances, they received every attention locally, except surgical intervention, the period of detention, dependent on military conditions, as a systematic procedure, was cut to a minimum in order to reduce the danger incident to the development of gas-forming bacilli in wounds. This danger, as noted in other chapters, had a profound influence upon the organization, equipment, location, and service of all medical units as far back as the base hospitals, for surgical interference within 12 hours proved highly desirable and, in the case of extensive wounds, essential.11
The French, in order to meet the requirement for early operation, made provision for a considerable amount of surgical work in their battalion stations, and when the sector concerned was not very active this was accomplished, though not so well as in a fully equipped hospital.19 The Americans
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did not follow this practice, and orders were issued that no operations be performed at such advanced posts.19 They believed the French practice caused dispersion of medical forces, and preferred to take some risks with the ambulance service in order to secure for a patient early operation at better-equipped formation.19 Although ambulances were sometimes lost, their use as far forward as possible and wherever possible presented many advantages. Patients carried by them suffered less danger than those conveyed by litter, for the period of exposure to fire was less. There was a great saving of bearers, and the time of transport was greatly shortened.
In many divisions the regimental aid station was soon discontinued, while in others it shrank into a formation of very minor importance whose chief function was to give first-aid and medical attention to the regimental headquarters detachment.20 Definite benefits accruing from discontinuance of this station were saving of time and labor, release of medical personnel for duty farther forward, and reduction in the number of points where patients were collected and relayed.
The term "regimental aid station" persisted, it is true, but it often indicated a very different organization from that contemplated in orders before the war began. Frequently it signified merely the station of the regimental surgeon, the location of his office and the liaison point for the medical service of the regiment.20
At the time our Field Service Regulations were drafted the regiment was approximately the size that a battalion assumed during the war, new tables of organization having been published,21sothat the battalion station in point of fact performed the service formerly intended for a regimental station. When employed as originally contemplated, the regimental aid station was similar to the battalion station which has been described above, though it was somewhat larger and more elaborate.22 Sometimes the regimental station was the liaison point between an ambulance company and the battalion aid stations, but more frequently the former maintained direct contact with the battalion aid station by assigning two of its men as runners to each battalion station it served. When the regimental aid station was not used, the dressing station frequently was established at the tactical point which it would have occupied.11
The sanitary train of each division consisted of train headquarters, an ambulance company section, a field hospital section, eight camp infirmaries, and a divisional medical supplyunit.23 Three of the four companies in each of the ambulance and field hospital sections were motorized, the fourth being animal drawn.
Headquarters of the ambulance company section of the sanitary train habitually was located near that of the field hospital, except during active
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periods, when the director of the ambulance companies was usually to be found at the regulating station or at one of the dressing stations.
Each ambulance company had the personnel of the Tables of Organization, and, presumably, 12 ambulances. The company was subdivided into two sections: One operated a dressing station or stations, and, if need be, removed wounded thereto by litter; the other operated the ambulances, whether working in front of the station or in the rear of it.24 Evacuation from fixed trench positions into other fixed formations to the rear was usually a comparatively simple procedure, though it required constant surveillance and adaptation to changing military conditions.
LITTER-BEARER AND AMBULANCE SERVICE
As noted above, in active operations, one or two litter squads and two runners from an ambulance company were frequently attached to each of the battalion aid stations. When a sector became active the number of these squads was greatly increased, and when unusual action was imminent or was in progress, certain divisions, e. g., the 4th, assigned to duty with regiments all the ambulance company personnel that could be spared for the purpose.25 Ambulance companies, especially those whose vehicles were animal-drawn, also furnished replacements for casualties in Medical Department personnel serving regiments and batteries. As the ambulance head often was located considerably farther forward by night than by day--as, for instance, in the 1st Division at Seicheprey--usually actually reaching the battalion aid stations after darkness fell, nonambulant patients were sometimes held at these stations until ambulances could reach them; 26 but it was a general practice to remove patients promptly, especially the most seriously wounded, if battle conditions permitted. As previously stated, if the distance from the battalion aid stations to the dressing station was more than 1,000 yards, relay posts were established similar to those in advance of the former. At each of these, one or more litter squads was stationed. In the 4th Division each of these relay posts was under command of a noncommissioned officer, and the distance between them was 800 yards.27 Such posts were not usually necessary, however, if wheeled litters, or motor cycles with side cars, were available and the terrain permitted their use; but in the Vosges, where the distances were exceptionally long between battalion aid stations and the ambulance head, the 5th Division used these vehicles and also developed relay posts into miniature emergency stations.28 The Anould sector, which this division then occupied, was very rugged, and wheeled litters, either horse-drawn or hand-pushed, proved invaluable. Sometimes two or more were used tandem. Conveyances of this type were employed to advantage also at odd times in places where their use was reasonably safe and other wheel transport was not practicable. For instance, the 37th Division used wheeled litters to carry dressings forward to battalion aid stations inaccessible to ambulances.29 Motor cycles with side cars also at times were used to advantage, those of English make proving preferable, as they were sturdy and usually had 8-horsepower engines.30 The35th Division in the Vosges used the French equipment identical with the Spanish mule litter for that sector.31
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When a division occupied a quiet, defensive sector and had its full complement of vehicles, it usually had one of its motorized ambulance companies in active operation, the second in support on the alert, the third in reserve, and the fourth at rest, while cleaning its vehicles.32
Many divisions, e. g., the 28th,organized motor repair parks.33 The animal-drawn ambulance companies made short hauls from battery positions and from points inaccessible to motor ambulances and between the field hospitals when they were closely grouped. Its personal often supplemented that of other Medical Department units at the dressing station and at points in advance of it, and its wagons sometimes carried fuel and supplies to the dressing station or performed other miscellaneous services. Often only two animals were provided for each ambulance of this company, and animal-drawn vehicles proved too slow and presented too large a target to be used to great advantage near the front in trench warfare.34 Also, if the animals were required to haul the load necessary in active service they soon became exhausted, particularly if the sector was rugged or deep, and if the roads were in bad condition.
In general, the distribution of ambulances in trench warfare was as follows: In advance of the dressing station established by the ambulance company (usually between 3,000 and 6,000 yards from the front) two or three ambulances were parked at one or more points called "ambulance posts" or, more colloquially, "cab stands."32 In a deep, narrow sector there was usually but 1 of these posts, but the 42d Division in the Baccarat sector used 11 of them, with 1 ambulance at each stand.35 These posts were at the points farthest forward where vehicles would be reasonably safe, and beyond that, toward the front, was the ambulance head, the farthest point to which ambulances could reasonably go; sometimes, if the terrain permitted, these points coincided. Distance of penetration beyond the ambulance posts was dependent upon military activity, darkness, and road conditions. While after nightfall the ambulance head was frequently advanced to the battalion aid station, during the day it was usually one or more kilometers in rear of it. In some divisions, as, for example, the 1st,36 an ambulance on call moved up after dark from its ambulance post to the battalion aid station or to the ambulance head, and after taking its load to the dressing station returned to its post. If roads and the military situation permitted, ambulances visited battalion aid stations daily as a matter of routine. In some divisions, as soon as an ambulance had delivered its patients at the dressing station it picked up another load of patients and went on to a field hospital in the rear. It was soon found, however, that service in advance of the dressing station could be performed best by the light Ford cars, which could go through mud and demolished roads more easily than other motor ambulances, while on the better roads in the rear of the dressing station, the heavier and more comfortable G. M. C. ambulances were preferable. This use of transport, first developed in the 1st Division and soon adopted by others, was often spoken of as "ambulance circuits," one set of ambulances making round trips between their posts, battalion aid, and dressing stations, while another set made round
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trips between the last mentioned and the field hospitals. In the early days of American combat activities, before evacuation from field hospitals was taken over by corps and army surgeons, there was a third circuit by ambulances under control of the division surgeon. This comprised the round trip between field and evacuationhospitals.36, 37
During the first operations in which the American Army participated the intradivisional and extradivisional services of ambulance companies were not clearly differentiated. Evacuation ambulance companies were at that time attached to divisions, supplementing other ambulance companies of the sanitary train and operating interchangeably with them. Though the system was satisfactory for conditions then existing, it was not suitable for open warfare as well, for which reason the following system was adopted when the First Army was organized.37, 38
Division ambulance companies will transport patients from battalion or regimental aid stations to the triage and division hospitals; an ambulance station will be established midway between aid stations and triage; a reserve of ambulances will be stationed there, sending one to the front to replace each one returning with patients. The loaded ambulance will return to this station after delivering its load at the triage.
Evacuation ambulance companies will move patients from the triage and field hospitals to evacuation hospitals and loading platforms.
The adoption of this system, which equalized labor and allowed time for rest and repairs, gave such satisfactory results that it was applied to each division successively entering the Toul and Luneville sectors.38
Back of the dressing station each division habitually maintained a relay ambulance post and regulating station, at a point past which all vehicles used for transporting wounded would travel on their way between dressing station and field hospital. At this place were parked most of the vehicles of the company on active duty--if these were not distributed at the ambulance posts--and here the headquarters of the company in question was located. As one loaded vehicle passed on its way to the rear, an empty ambulance moved to the next station ahead, thus keeping up a circuit of empty vehicles to the front.34 If more ambulances were needed, the regulating officer sent them forward from the park at his station. Though this was the most popular method of locating and operating ambulances, it was modified in many ways, in greater or less degree, under varying circumstances. The 5th Division, in the Vosges,39when its sector was quiet, kept an ambulance at each regimental aid station and held five in readiness in the company park near the field hospitals; but when an unusual action was imminent it disposed of its ambulances as follows: From 3 to 4 at ambulance posts, from 3 to 6 at a point midway between them and the field hospitals, and the remainder near the latter.39 Only under exceptional circumstances in trench warfare, as in the Chateau-Thierry and Champagne areas, was it necessary to use trucks for removing the wounded. In such emergencies every kind of vehicle returning from the front was utilized, ambulances being reserved for the severely wounded. The intradivisional service by trucks was employed especially between dressing stations and field hospitals.40
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FIG. 15.-Dressingstation operated by Ambulance Company No. 137, Amperbach, Alsace, August31, 1918
FIG 16.-Dressing station at Betricamp, France, April 26, 1918
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THE AMBULANCE COMPANY DRESSINGSTATION
Each division regularly established one or more dressing stations at a point or points accessible from all parts of the front served and also accessible to vehicles from the rear. Battalion aid stations rarely evacuated direct to field hospitals and even more rarely to evacuation hospitals. Dressing stations functioned properly only when placed on natural evacuation lines, as bearers almost inevitably carried casualties to the nearest point where relief could be given. These stations were usually between 3,000 and 6,000 yards from the front, and, if possible, at relatively protected points, such as in buildings or cellars; sometimes dugouts were constructed like those for battalion stations, but they were more elaborate. Thus in the Baccarat Sector the 42d
Division provided three gas-proof shelters for dressing stations from 2 1/2 to 3 miles behind the front, each shelter accommodating 20 patients, with facilities for bathing, treatment of shock, hemorrhage, etc.41 The number of dressing stations varied from one to three, according to the width and activity of the sector. If the sector was narrow only one station was established, as a rule, to be reinforced if need be by men detailed from other ambulance companies. Occasionally an advance dressing station was established, but in positional combat this substation was relatively unusual, being provided usually only when vehicular traffic was not possible for some distance back of the front. When an advanced station was used, it frequently was from 1,500 to 2,000 yards from the lines, and the main dressing station about the same distance in rear of it, at the ambulance head. If an advanced dressing station was used, its personnel averaged 1 officer and from 8 to 16 men; that of a main dressing station was 2 to 6 officers and from 12 to 25 men. In some divisions one of
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the officers attached to the dressing station was charged with maintaining contact with the troops which the station served and with supervision of the litter-bearer service between it and the battalion aid station, while in others, e. g., the 2d Division,42an officer was especially assigned to the same service without being assigned to the dressing station.
Organization of the dressing station varied considerably, naturally being most elaborate in the comparatively few divisions which used this formation as a triage or sorting station. In the 42d Division, which employed its dressing station as a triage, the organization was that described below.43 This description applies especially to the dressing station, as that division developed it in open warfare, but is given here as the organization was inaugurated in trench sectors. The station consisted of the following departments:43
(1) Receiving and forwarding department, subdivided into two sections concerned with (a) transportation, and (b)sorting and checking of patients. The former section consisted of a transportation officer and a sergeant, who supervised the dispatch of ambulances both to the front and to the rear, controlled the number working in either direction, and supervised the loading and unloading of patients. The last-mentioned service was performed by a group of eight litter bearers. A sorting and checking officer examined all patients on admission, returned to the front those needing no further treatment, and distributed others to proper departments within the station, designating which patients required immediate attention. He was assisted by a few enlisted men who, under instruction from a commissioned officer, gave nourishment, adjusted bandages to minor injuries, administered antitetanic serum, and attended to the comfort of patients. Those not requiring special treatment in this department were held until evacuated, and unnecessary handling of patients was thus avoided. Two or more clerks listed all casualties and checked up the administration of serum.
(2) The general dressing room was manned by from 2 to 4 medical officers and 4 competent noncommissioned officers, all of whom were engaged in adjusting or applying dressings, administering morphia and antitetanic serum, if these had not already been given. In addition to the foregoing, two men were engaged in sterilizing and filling syringes with antitetanic serum.
(3) The orthopedic department cared for all fractures, readjusting or applying splints as required, and giving any other treatment needed, including that for shock. Personnel of this department consisted of the division orthopedist and two trained enlisted assistants.
(4) The gas department was located in a room, not communicating with any room, for wound-dressing purposes. Here, under direction of the divisional gas officer, gassed patients were stripped, bathed, and reclothed with such raiment as could be obtained from the salvage section.
(5) A complete company kitchen was kept in operation day and night, supplying hot food and hot coffee to patients, duty personnel, and casuals. This service proved highly important, especially in cold and wet weather.
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(6) The medical supply department of the station pooled the property of companies serving it, replenishing by issues from the divisional medical supply unit.
(7) The salvage department collected all equipment no longer needed for patients, and from it issued necessary supplies such as blankets and canteens, the latter being used as hot-waterbottles.43
The personnel operating the dressing station triage of the 42d Division was drawn from all four ambulance companies and was assigned in 12-hour shifts, if the rate of admissions did not require longer hours of duty.44
When a dressing station was used as a triage, the division orthopedist, psychiatrist, and gas officer were regularly attached to it, together with an officer possessed of good surgical experience and judgment,45 and sometimes an understudy was assigned for the relief of each of these officers. Usually a dressing station, used as a triage, was located at the point farthest forward, where, with reasonable safety, ambulances could be concentrated, and these were grouped near it. In the Baccarat sector, at one time, the slightly wounded, because of tactical disposition, could be sent direct from the dressing station to an evacuation hospital and all others to the designated field hospital (see order quoted, p. 386), but usually all patients were sent to the appropriate field hospital.
As the great majority of divisions did not use the dressing station as a triage, the personnel of the station, normally, was less numerous than that of the station just described, and was habitually drawn from but one ambulance company; the equipment was less elaborate and the organization was simpler. In all respects, however, there was great mutability and flexibility in all such stations, allowances of personnel especially being changed frequently to meet varying needs.11
At dressing stations the sick and wounded were classified according to the nature of their disability and its degree. By the first classification, injuries caused by gas, miscellaneous sickness, psychic disorders, venereal diseases, skin diseases, and convalescents were separated. The second classification, pertaining to the degree of disability, ranged from malingerers to fatal wounds or illness. It had certain more or less arbitrary and fluctuating subdivisions. For example, the wounded often were classified as "very slight," "slight," "serious, "and "nontransportable." Practical application was given to this gradation, for patients in the first class were returned to duty; those in the second class were sent to hospital, walking or sitting; those in the third class were sent recumbent to hospital; while patients in the fourth class were held until they rallied and then were evacuated with exceptional care. Similarly, the sick, the gassed, and those suffering from gas fright were classified either as "seriously disabled," who should be retained until they rallied or be evacuated at once, and the "slightly disabled" or "subjectively affected," who could be returned to duty. Men claiming mental or nervous disability were especially difficult to classify, for some of them were malingerers, others were slightly affected but magnified their symptoms, and a few were bona fide cases of disability."11
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Whether used for triage purposes or not, at the minimum the functions of a dressing station were to receive and classify patients, give emergency treatment--that is, control hemorrhage, treat shock and gassing, readjust splints, administer antitetanic serum if it had not already been given, and morphine if indicated--supply nourishment, group the disabled, and forward them to their designated destination. Yet, normally, the last was the work of the triage hospital, and as a matter of fact, sorting of patients at the dressing station with a view to direct distribution to appropriate hospitals was unusual except in the divisions of the First Corps,46 or when the seriously wounded were sent direct from dressing station to the proper field hospital without passing through the triage hospital. Few operations were performed at the dressing station, and these were minor ones; but they sometimes included closure of aspirating chest wounds by a few silkworm-gut sutures, and when absolutely necessary, ligations.47 If a hemorrhage was not checked by operation, the wound was packed and a tourniquet applied which was lef tloose in place after hemorrhage had ceased. Ambulance orderlies were instructed to tighten the tourniquet, if necessary, when en route to the hospital.47 Patients in shock usually were held until they rallied, and the sick were retained until a full ambulance load of them could be sent back. Soldiers not incapacitated for performance of duty, after receiving all necessary attention, were returned to their organizations. The field medical cards of patients admitted were made at the dressing station and records of them made, if other work did not prevent. Patients able to walk to field hospitals-about40 percent of the total-were sent back to them in groups.48 In practically all divisions the dressing station was also the Medical Department supply point for regiments and batteries. Supplementary to dressing stations, rest stations for furnishing nourishment and medical aid were established by the 4th Division along its evacuation routes, in connection with relay posts.49
Though the foregoing description gives in general terms the usual operation of a dressing station, certain individual methods were employed by the several divisions at different times; but these were transient or of relatively minor importance. Considerable mutability in personnel, matériel, organization, and thoroughness of treatment characterized practically all these stations, for in all these characteristics they were influenced profoundly by military conditions varying from quietude to intense activity.
The field hospital section of the sanitary train consisted of four of these hospitals,50 each accommodating 216 patients. The personnel authorized for them is noted in Tables of Organization in the Appendix (p. 1054), but in the World War this was augmented by the assignment of divisional specialists and, as occasion required and resources permitted, of operating and shock teams. The equipment of all these hospitals was at first identical, but later--as noted below--it became considerably diversified when the field hospitals were specialized. In some divisions field-hospital facilities for nontransportable wounded were further increased by the assignment to them of mobile surgical units, but
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as only 12 of these formations became available before the armistice, the result was that the plan of supplying one to each combat division did not fully materialize.51
In trench warfare, field hospitals were located from 10 to 15 km. (6 to 8 miles) behind the front, or frequently farther back, in order to be beyond range of ordinary shell fire. The distance varied considerably, being influenced by proximity to the front of suitable buildings, and considerations similar to those affecting the location of evacuation hospitals (q. v.), especially convenient roads and availability of water and fuel. In order to utilize buildings to the best advantage, a field hospital occupying them was at times somewhat scattered, but whenever possible near-by buildings were used.
FIG. 18.-Field Hospital No. 112, 28th Division, Cohan, France, August 12, 1918
Often field hospitals were comfortably, even luxuriously, established in towns, chateaux, or barracks, and when such hospital sites in buildings were taken over from the French, many supplies were sometimes transferred with them, thus expediting putting our field hospitals into operation.52
It should be remarked here as affecting field hospital shelter that, in the early days of American service in France, the use of tentage near the front was disapproved, on the ground that it was readily visible to enemy aviators and betrayed the presence of troops.52
Profiting by developments in the medical service of the 1st Division at Cantigny, field hospitals in all divisions rapidly became specialized.52 Gen-
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erally speaking, one developed into a hospital for nontransportable wounded, and a second into a hospital for gassed patients, with corresponding changes in equipment, the others retaining their original purpose and their original equipment; but there were many modifications of this plan. Very generally the divisional triage or sorting field hospital also received the seriously wounded and sometimes the gassed.52 Almost without exception only one triage was maintained by a division in positional warfare, but the 26th, in the Toul sector (April and May, 1917),having a frontage of 17.6 km. (11 miles), then operated two, one behind either flank.53
FIG. 19.-Field Hospital No. 125 near Jaulgonne, France, July 29, 1918
In a quiet trench sector a common method of dividing the field hospitals was the following: (1) Triage and care of wounded and gassed patients; (2) sick; (3) skin and venereal diseases; and (4) reserve.11
Frequently the last was used as a convalescent camp, to care for transportable patients, or to supplement one of the other field hospitals, as required. When not actively operating, its personnel was often assigned to one of the other field hospitals. Under these conditions it was the practice to retain in the division field hospitals all patients who were likely to be fit for duty in from 10 days to 2 weeks, or who could be treated here as well as farther to the rear; for example, skin and venereal cases. Then, only those requiring definitive surgical treatment or such of the sick as would require prolonged or exceptionally expert treatment were evacuated.14
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When a trench sector became moderately active, a division often continued to hold its cases of war neuroses, slightly gassed and slightly sick, making such use of its field hospitals as the following: (1) Triage and care of non-transportable patients (wounded or gassed); (2) slightly wounded; (3) sick, slightly gassed, convalescents; and (4) reserve. When called into operation the reserve hospital frequently cared for the gassed cases.11
If the enemy was very active, as in the second battle of the Marne, all field hospitals were opened and utilized as described under the caption "Open warfare," evacuating patients as rapidly as possible.
Selection of nontransportable patients, as contrasted with the severely wounded (for the two categories did not exactly correspond) was difficult and subject to change in standards imposed by the changing military situation. When divisions were actively engaged in trench warfare, as along the Marne and in the Champagne areas, many patients who otherwise would have been retained had to be evacuated.
The reports of the Medical Department activities of the several combat divisions, from which this chapter is largely derived, do not differentiate in their descriptions, except in a few matters such as those noted above, the service of field hospitals in trench and in open warfare. Further information on the subject will be found in the section of this chapter which treats of these units in open warfare. It is only necessary to note here that methods in open warfare were similar to those in trench warfare except that in the former field hospitals usually occupied tents, moved frequently, were employed in amore diversified manner, were more subject to enemy fire, underwent greater strain, and had greater difficulties both in bringing up supplies and in effecting evacuation of their patients.
CARE OF CASUALTIES IN COMPANIES, BATTALIONS, AND REGIMENTS
In open warfare the problem of caring for the wounded on the battlefield and of removing them to field hospitals was very different from that presented when troops were in the trenches, and its solution proved much more difficult as well as more varying.
A company aid post was sometimes established, as in the 90th Division, which located it at or near the company post control;54but very few divisional histories make any mention of this formation in open warfare, though that of the 5th Division noted that two enlisted men of the Medical Department continued to be attached to each company as was the case in the trenches.55 When used, this post was located at any shelter available--a shell hole, for instance--and the wounded were brought to it; but much more frequently the wounded were taken to any sheltered place near which they fell, and dressings and splints were there applied. The equipment of the Medical Department men detailed to render company aid was very simple, consisting chiefly of dressings, splints, tourniquets, and stimulants, for it was limited to such
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articles as they could carry when troops moved forward.56 They placed these articles in any receptacles available, such as pouches, sacks, and gun cases. After dressing a patient they again advanced with the troops to which they were attached.
In open warfare, even more than was the case in the trenches, the importance of the battalion aid stations tended toward their substitution for that of the regiment. These stations were placed as near the front as possible. In the 2d Division, in the beginning of the offensive against Soissons, one station was located within 50 yards of the enemy lines.56 During that operation, battalion aid stations in that division were from 1 to 8 km. (0.6 to 4.8miles) in advance of the triage hospital.57 In the 5th Division two aid stations to a battalion, each under a medical officer, were placed in the support lines, in rear of the flanks of the battalion.55 Whenever possible, battalion aid stations were placed as conveniently as possible to natural routes of evacuation, for otherwise they did not function, as litter bearers went to more accessible locations. As the prime considerations for these stations were proximity to
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the front and some shelter from hostile fire, they occupied any well-located spot affording some protection, such as a shell hole, cellar, culvert, quarry, dugout, or behind a ruined wall. Actually they were exposed to heavy fire from infantry, machine guns, and artillery. Occasionally they received direct hits by shells, as in the 90th Division, but sometimes then they escaped injury to patients or personnel.52 Sometimes, as in the 2d Division at Vierzy, in the Chateau-Thierry area,56andin the 3d Division during the Meuse-Argonne operation,58 two or more battalion aid stations--perhaps those of different regiments and, in the latter offensive, even those of neighboring divisions--consolidated. Such a course was rendered advisable at times by the proximity of the organizations which they served, and the paucity of available shelter and of evacuation routes. Furthermore, such consolidations gave opportunity for mutual exchanges of supplies, allowed the personnel to work in shifts instead of continuously, and facilitated ambulance evacuation by reducing the number of stations which the ambulance companies had to locate and clear. Battalion aid stations in open warfare were much more simple
FIG. 21.-First-aidstation, 4th Division, Septsarges, France, September 27, 1918
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than in trench warfare, for there were neither time, facilities, nor transportation for their elaborate development. Habitually, regimental Medical Department detachments were supplemented by details from the ambulance companies. To mention but two of many instances of this practice, the 2d Division in the Chateau-Thierry region assigned160 ambulance company men to duty with the regiments,59 and the 90th Division in the St. Mihiel operation thus assigned 80 men from3 of its ambulance companies.60 The manner of distributing these men varied considerably in the several divisions. Sometimes they were allocated by the regimental surgeon to the battalion aid stations needing them most, where they worked under the battalion surgeons.
FIG. 22.-First-aid station, 325th Infantry, near Fleville, Ardennes, France, October 12, 1918
Sometimes, though assigned to these stations, they remained under control of the officers of ambulance companies detailed with them. In many divisions the ambulance company litter bearers carried patients from the front lines to battalion aid stations as well as thence to the ambulance head. As described earlier, most divisions detailed men from the line companies to act as litter bearers. Bandsmen, when employed, performed similar duties, but, as previously stated, their service as litter bearers was soon discontinued. Prisoners also were used wherever most needed, until their employment near the front was prohibited, and thereafter they carried patients only when on their way back from the front.11
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In open warfare, provision in adequate quantity of even the most necessary supplies was an urgent and difficult problem for battalion aid stations. Frequently, stations could be supplied with only such matériel as enlisted men could bring upon their persons from the dressing station or ambulance head. For this purpose they used any available receptacle; wheeled litters if these were at hand. The battalion medical cart proved too heavy for its one animal, and it usually remained with the train. Whenever possible, supplies were sent up by ambulances, or, in case of need, by trucks of the sanitary train.11If these vehicles could not reach the battalion aid station they transferred their supplies to litter bearers at the ambulance head. The same replacement methods were used as in the trench warfare; that is, for each article sent back from the front an equivalent one was sent forward from the dressing station. Supplies also were sent forward on requisition. If matériel needed by battalion aid stations was not on hand at the dressing station, the first ambulance going from it to the triage carried to the supply "dump" or unit there a request for the needed articles, and they were sent up by the supply officer by the next ambulance going forward.
Sometimes, after an offensive had begun, no attempt was made for an hour or two to bring in the wounded from the forward area to the aid stations, for the reason that attacking and support troops were under heavy direct fire from the enemy, and any attempt by a litter group to remove the wounded would have been folly. After this time had elapsed, however, enemy fire usually slackened or was directed against the troops as they advanced, and litter evacuation could be conducted with less danger.11 Meantime, Medical Department personnel with the attacking troops dressed the wounded, applied splints and placed patients at any sheltered points accessible. The "first-aid packet" was generally used for bullet wounds, and this or the "front packet," as required, for shell wounds. Fractures were immobilized usually by the Thomas splint. As the troops advanced, the battalion aid station moved forward to successive locations.11 Thus in the 78th Division such a station was scarcely established before its personnel again advanced to open a new-one. In such cases "collecting points," which sometimes corresponded to a centrally placed battalion aid station, were often established, where patients were collected to facilitate evacuation by ambulance company personnel.11
In open warfare service at battalion aid stations was similar to that given at such stations in the trenches so far as facilities permitted. Wounds were redressed and splints adjusted, if necessary; hemorrhage was checked and shock controlled, as well as possible. Gassed patients were given as much relief as practicable. Usually, antitetanic serum was administered here. The 3d Division stressed this point.17 Because of road congestion and heavy enemy fire, patients sometimes had to be kept in a battalion station until nightfall. During the Meuse-Argonne operation it was frequently remarked in the hospitals that patients with comparatively slight wounds were gravely shocked--a condition attributed to cold, exposure to wet, and to exhaustion. Even if supplies were brought forward in considerable quantities, little could be done to combat shock at the battalion stations other than to rectify splinting, to apply blankets properly, and to administer morphine.11 Therefore, the
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wounded were removed systematically as soon as diminished intensity of enemy fire permitted this procedure. Yet the retention of shock patients until they rallied, instead of removing them immediately, was advocated in some divisions, notably the 3d Division,17but, as has just been stated, as a general rule, patients were evacuated as promptly as possible.
As soon as they could be removed, patients who were unable to walk were taken from the battalion aid station either by litter bearers or--oftener after nightfall--by ambulances coming as far forward as the station. This was done despite the fact that this plan caused numerous casualties and the loss of much-needed cars. Their coming to these stations was considered expedient because evacuation was thereby expedited.
The following vivid description of front line and battalion service is taken from the report of the Medical Department activities of the 1st Division in the offensive toward Soissons:61
Battalion surgeons and enlisted personnel accompanied their units and established aid stations and collecting point sas close to the firing line as the terrain would permit. They moved forward almost hourly during the five days of battle. While advantage was always taken of protected points, the collecting stations during the greater part of the advance were in hastily dug holes, in open fields, shell holes, old gun emplacements, etc.; at other times under shelter of hills, in cellars, or behind ruins of buildings or low embankments along the sides of the roads. After the first two days in this offensive there was a great shortage of litters, and other supplies proved insufficient. These had been carried by corps men in pouches, sacks, or "feed bags." German equipment was hunted for on the field. Litter bearers were constantly in the open, under machine-gun and shell fire, and a number of them were killed. German prisoners were used as litter hearers, and some wounded were removed (contrary to existing orders) by men of the line. First-aid dressings and splints were applied at the first point behind the line when there was comparative protection. Litters were often improvised, that extemporized from the blouse, with rifles for side bars, being the most common. Often, because of heavy fire, the wounded were kept in shell holes until nightfall. As no hot refresh men was available in advance of the dressing station, the wounded reached that point in much worse condition than would otherwise have been the case. It was impossible for the rolling kitchens or water carts to get up close to the line, and the dressing stations therefore dealt with wounded whose vitality had been lowered by lack of food and water.
In the early part of the St. Mihiel operation the 5th Division transported by litter such of its wounded as were unable to walk, but the supply of litters was insufficient to meet the need, as was also the number of bearers. This condition was attributed to the irresponsibility of bearers from the line, for though provision had been made for their detail, these bearers had not then been organized into squads under noncommissioned officers. In this extremity additional litters were brought up, and prisoners also were used as bearers.62
Because it was impracticable to use mounted messengers or to have direct telephonic communication from the more advanced formations, maintenance of contact, or liaison, between the battalion aid stations and the dressing station was much more difficult in open than in trench warfare. Enemy fire, shell holes, dense brush or forest, barbed-wire entanglements, abandoned trenches, movement of stations, ignorance of the newly occupied terrain, and--during the time when the wounded could be moved with the greatest safety--darkness, all conspired to aggravate the difficulties of maintaining contact.
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The report of the Medical Department activities of the 35th Division records that line officers supplied medical officers with insufficient information concerning forward movements and that battalion and ambulance company personnel had inadequate knowledge of each other`s locations.63 Usually, contact in the several divisions was maintained by two runners detailed from the ambulance companies to each battalion aid station, and if these failed, returning litter bearers were interrogated. In the 90th Division five men were assigned to each brigade for liaison service.64 In the 5th Division contact was maintained between regimental and battalion stations--which were located near their respective control posts--by runners from the regimental medical personnel or from the regimental and battalion message centers and by telephone between them.65 Battalion medical officers usually maintained direct contact, through runners or litter bearers, with the ambulance company and, with line officers, before each engagement made a reconnaissance of the terrain, with a view of determining the location of future stations.11 The regimental surgeon was required to keep himself informed at all times of the location of his aid stations and of dressing stations and to keep subordinates acquainted with the exact location of dressing stations, relaying his information in both directions. He required that whenever one of the battalion stations moved he be notified and that whenever one of these required an ambulance he be given clear directions concerning the station`s position. In the Meuse-Argonne operation, however, battalion aid stations in some regiments of this division maintained direct contact with ambulance companies without the regimental surgeon acting as an intermediary. This was the habitual practice in other divisions.11
In the 2d Division the divisional litter bearer officer (so detailed) and his subordinates knew where the battalion aid station would be located at the jump-off, and had determined, after reconnaissance with line officers, where they would be located if the attack progressed as anticipated.66 He determined, likewise, the present and future sites of the dressing stations, with the roads and paths leading to them from battalion aid stations. Before the attack, litter squads were placed well forward toward the stations they would be required to evacuate. In these duties he was assisted by two officers from each ambulance company, both before the attack and during its progress, who commanded the litter bearers details and gave them full information concerning the present and future locations of the formations with which they were concerned. He continued to perform the duties of reconnaissance and supervision throughout the attack.66
The two outstanding lessons developed by experience in the 78th Division were recorded as follows:67
Arrangements must be made in advance and personnel trained to maintain an absolute chain of liaison, no matter what troop movements may occur in a sector, say, 10 km. (6 miles) in width and 20 km. (12 miles) in depth, and that in preparation for an expected military operation of whatever nature it is extremely important to prescribe, not the actual location of dressing stations and field hospitals, but the road or roads along which Medical Department communications, including supply and evacuation and liaison, will be conducted.
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Difficulties of liaison arose through the following causes: (1) Difficulties of terrain. (2) Lack of training of medical personnel. (3) Failure of front line personnel to send back to the sanitary train or division surgeon information concerning location.(4) Interchange of battalions between front line and brigade or division reserve. Since cipher telephone calls followed organizations to their new locations, it was only by obtaining from G-3 the names of organizations occupying certain aid posts that the reserve station could communicate with these aid posts except through its own evacuation service.67
Eventually, in many divisions, responsibility for maintenance of contact was placed on ambulance company commanders, who effected it in front of the dressing station, as described above, by assigning runners to aid stations, and to the rear by ambulances and motorcycles.
Few divisional histories make mention of the regimental aid station toward the end of the war, for it was generally discontinued then for its original purpose; but some divisions continued so to use it. For example, one regiment of the 5th Division in the Meuse-Argonne operation established both regimental collecting stations and regimental aid stations, the former in advance of the latter.68 Six bearers from each line company carried patients to these points from the battalion stations. In the 3d Division, during the same action, the7th Infantry at one time evacuated through a regimental aid station, while other troops evacuated direct from the battalion aid station to the dressingstation.69 Liaison between the regimental aid station and the dressing station was maintained by runners, by litter bearers, and by telephone from the advance post control. Whenever possible, collecting points for regiments were on roads.
Control of the walking wounded presented a grave problem. The need of military police to direct the movements of these was remarked by some of the divisions in the Meuse-Argonne, especially when the country was open and rolling and hills afforded some shelter. Men seeking cover or escape from enemy fire would leave the roads and follow hill contours or would attempt short cuts, with the result that some wandered until exhausted. The situation was met to a degree by sending wounded men to the rear in groups under escort.11
MEDICAL SERVICE OF ARTILLERY AND MACHINE-GUN COMPANIES
Medical service of batteries and machine-gun companies was similar to that of the Infantry. Two enlisted men of the Medical Department were attached to each battery or company, and sometimes utilized selected shelter as an aid station. For example, the medical detachment with the 13th Machine Gun Battalion of the 5th Division occupied a dugout 100 yards in the rear of its position at the commencement of the St. Mihiel operation.70 In the Meuse-Argonne, when this battalion was split, one company going to each flank of an Infantry battalion, its aid station was established in a shell hole midway between and behind them.70 In the 19th Field Artillery the regimental and battalion aid stations were located near the respective posts of command.71
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The methods of the sanitary train in open warfare also differed from those in trench warfare. Difficulties were augmented greatly by the prolonged increase in enemy fire, road congestion, movement of troops and of Medical Department formations serving them, limited facilities for supply, increased numbers of wounded, greater need for Medical Department replacements, inexperience of these replacements on arrival, and by physical exhaustion caused by long-continued hard labor and by exposure. During the Meuse-Argonne operation the strain on the Medical Department was further intensified by an epidemic of influenza, which nearly decimated its effectives. These subjects will be discussed in more detail in appropriate chapters.
The method for employing ambulance companies in trench warfare was, in general, followed when our troops assumed the offensive in open warfare, but there were some differences in detail. Sometimes two or more ambulance companies were consolidated, as in the2d Division in the offensive against Soissons.72 Much larger details of litter bearers were commonly assigned with regimental detachments; and at times, when regimental personnel could not cover the field, every man who could be spared from the ambulance companies was thus assigned. Usually, the ambulance personnel with regiments was drawn from several companies; much less frequently one company was so assigned almost in its entirety, or more than one company might be so used. At times, as in trench warfare, and as noted above, the ambulance company bearers serving with regiments were placed under the orders of the battalion surgeons concerned, but sometimes they operated under their own officers. Both practices were followed in some divisions (as in the 3d)73 at different times, the latter method coming to be more highly regarded. The 2d Division reported that the system of having patients brought to aid stations and collecting points by litter bearers with regiments--including details from line and from ambulance companies if these were needed--and of having evacuations back of these effected as usual by the litter-bearer sections of the ambulance companies proved highly satisfactory.74
As in positional warfare, in all divisions the litter-bearer sections of the ambulance company cleared the battalion aid stations, if these were not accessible to ambulances, and frequently established collecting points at convenient places, preferably convenient to vehicles. Here patients from battalion stations were gathered, and thence they could be carried by litter to the dressing station or could be reached from there by ambulances. The 5th Division, for example, established eight such collecting points during the Meuse Argonne.75 Just as in trench warfare, the litter-bearer sections established relay points if necessary, but there was a progressive tendency to advance the ambulances, even at considerable risk, and collecting points were, in fact, relay points as well, if litter-bearer service back of them was necessary. Habitually they were accessible to ambulances if battalion aid stations were not. Often a subsidiary or advanced dressing station was established and
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patients were brought to it by litter. If this advanced station was not accessible to ambulances by daylight--as was often the case--patients had to be carried by litter farther back to the main dressing station, the advanced station then being used as an elaborated relay point.11
In the 2d Division during the St. Mihiel operation, as battalion aid personnel moved forward to open new stations, detachments of the Medical Department with support and reserve troops successively took over care of the casualties in stations left behind, until in turn they were taken over and evacuated by an ambulance company.74 Later the ambulance company took over these unfortunates direct from medical personnel in the advance lines.
After the delay in evacuation experienced at Soissons, this division designated a divisional litter-bearer officer and two commissioned assistants from each ambulance company. Under the general direction of the litter-bearer officer, the noncommissioned assistants had command of the litter-bearer squads used to clear battalion aid stations. When the battalion surgeons advanced they were accompanied by runners who, for the ambulance companies, maintained liaison between the new aid station and the former one, so that after clearing the one farther to the rear the ambulance company could locate with certainty the one farther advanced. As a result of this arrangement the battalion surgeon and his detachment kept near the troops they served, and battalion litter bearers, evacuating patients from the place where they fell, had to go no farther back than the battalion aid station last established. When the ambulance company took over a station the battalion surgeon had to give it no further thought.76 But until that time, if he and his personnel moved farther forward, it was the usual practice to leave one or two attendants until the station was taken over by a detachment with support troops, or until the ambulance company came up. The method employed in the 2d Division at Mont Blanc is described as follows.77
The enlisted men of the Medical Department with the companies followed the attack, dressing the wounded, who were carried back to battalion aid stations by company litter bearers (12 men from each infantry and machine-gun company) as provided by divisional order.* * * As battalion aid stations advanced, the old stations were taken over and cleared by ambulance company litter bearers under their litter-bearer officers, who maintained liaison with advancing battalion aid stations. The division litter-bearer officer, meanwhile, was everywhere, seeing that the work of litter bearers was coordinated and that ambulance posts were kept well advanced. With two Army ambulance sections operating Ford cars and G. M. C. ambulances assisting when needed, the wounded were rapidly removed from the sector and congestion rarely occurred.
In general, ambulances were operated under the system developed during trench warfare; that is, with a regulating station, ambulance posts, an ambulance head, service by circuits, the light Ford cars operating in advance of the dressing stations, the heavier G.M.C. or other cars in the rear of it. As in trench warfare, usually the ambulance companies on active duty rotated by roster, in order that one or more might repair cars while resting; but in periods of stress this arrangement was not feasible. There were so many differences in the details of applying the ambulance company system that it is considered advisable merely to mention here the more usual, typical practices, reserving more lengthy discussion for appropriate chapters.
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One of the most conspicuous differences between ambulance service in trench and in open warfare was that, in open warfare, especially during the Meuse-Argonne operation, animal-drawn ambulances proved of great value and were much more frequently employed. This was due chiefly to the fact that they could go over routes impassable to motor vehicles, and often, by leaving the road, could pass obstructions which blocked other traffic.
In narrow sectors it was a common practice during the Meuse-Argonne operation for a division to operate but one ambulance head, served by several companies through one regulating station. The 90th Division reported that in that engagement its ambulances often reached battalion aid stations 300 yards from the line, but that at first roads were in such frightful condition and so crowded that not more than two round trips could be made in 24 hours.78 In other divisions in the early part of this operation one round trip sometimes required as long as this.
A regulating station often was operated in conjunction with the dressing station, and ambulances were parked near. Under such circumstances the directors of ambulance companies worked in conjunction. Here, the wounded were not out of danger from shells and gas after being placed in ambulances, for roads and approaches to dressing stations which occupied sites known by the enemy to afford some shelter were often shelled and bombed.
Ambulances were sent up regularly after nightfall or on demand of the battalion surgeons, as in the 5th Division,80to battalion aid stations, if the military situation permitted. The 2d and 32d Divisions, like practically all others, increased their evacuation resources, in times of stress, by using the trucks of the sanitary train and any other trucks obtainable.81 In the 32d Division the sanitary trucks carried six litters lengthwise on the bottom of each truck and six crosswise on the sideboards, lashed in place by wires engaging the hooks provided for the cover fastening. Sitting cases were removed in groups of 24.81 On their return trips these trucks brought up supplies. They were used especially to clear field hospitals, but if need arose they also cleared dressing stations. Supply and ammunition trucks returning empty were also used to carry the wounded, for without exception the ambulances available in large engagements during open warfare proved utterly inadequate. One result of this was the increased difficulty in renewing medical supplies at forward points, for trucks returned to the front filled with their normal loads, and the ambulances moving forward did not have capacity to carry matériel sufficient to replace fully all supplies that had been sent back with patients.82 Trucks of the divisional sanitary trains relieved this condition, but later, in many divisions they were pooled with those of other trains, after which any trucks obtainable were utilized for wounded. This pooling of sanitary train trucks with others interfered with the availability of these vehicles to the medical authorities, but apparently was necessitated by military exigencies.
The most serious difficulty experienced in ambulance company service in open warfare in the early part of the war was the necessity for sending ambulances to points far in the rear. During the early activities along the Maine, though additional evacuation ambulance companies were provided
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to evacuate divisional hospitals, ambulances proved inadequate at times; for example, when they had to carry patients 60 km. (37.2 miles) or more to evacuation hospitals. The 2d Division, during its action along the Maine, had a total of 200 serviceable ambulances, including those of its own sanitary tram and those assigned to it.51 Before the St. Mihiel operation arrangements were made to avoid the necessity for these long trips by divisional ambulances by providing ambulance companies operated by the corps and army to clear the field hospitals.83
The supplies of ambulances were increased as the war progressed. In the 42d Division the following articles were added to their regulation equipment: Ammonia, ampules, boxes, 10; catheters, 4; coats, gas, 2; masks, M2, French, 4; mittens, gas, 2; oxygen tanks, small, and connections, 4.
As a rule, two or three dressing stations to a division were established according to the width of its sector, availability of roads, and military activity. It was a common practice in some sectors to utilize two ambulance companies in the service of one main dressing station, while a third operated an advance station and the fourth was held in reserve except during periods of especial stress, when all--particularly the litter bearers--were active; but there were many departures from this method, even in the same division, at different times. Tactical needs determined disposition. Thus, in the 3d Division, three ambulance companies during the Meuse-Argonne operation served a main dressing station at Montfaucon, the fourth being in reserve, while at other times individual ambulance companies operated their own stations.85The 90th Division, which at one time utilized two companies at the main dressing station, a third company at an advance station, and held the fourth in reserve, on another occasion, when two roads were available, operated parallel evacuation routes, assigning one company to each station, while two companies were in reserve.86 Under other circumstances it used a third disposition, one company operating an advance station, another a main station in the rear of it, the third operating a main station for a different part of the line, while the fourth company was in reserve. The changes of tactical arrangements in these divisions were typical of all the divisions. The 77th Division habitually kept two ambulance companies in action and two in reserve, the personnel of one of the latter companies assisting one of the active companies if needed.87
Only one main dressing station was established by a division in a narrow sector, and if communication to this point was delayed or obstructed--as it usually was during the Meuse-Argonne operation--an advance station was operated. Under such circumstances two ambulance companies often were assigned to the main station and one to that in advance, the fourth being held in reserve to leapfrog when needed; or two companies operated both the main and advance stations and two were held in reserve. When the advance was rapid one company was usually kept at rest behind another, the rear one leapfrogging when another station was needed farther forward.84 Evacuation serv-
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ice was very exhausting; it was carried on night and day, and difficulties were aggravated by the loss of personnel and of vehicles. Dressing stations were located as near the front as possible, the 80th Division reporting that those which it established were often within 0.3 km. (1/2 mile) of the front line and were never more than 0.6km. (1 mile from it).88 In the St. Mihiel operations the5th Division established its dressing stations approximately in the lineof regimental stations but more centrally located and often somewhat in the rear of them.80 The 1st Division at Cantigny, placed its station in advance of the command post of the division surgeon;89and the 2d Division, at Vaux, on July 1, 1918, sent up a dressing station to reinforce the regimental aid station of the 9th Infantry.59This formation also established a Medical Department "dump" farther forward, at a point accessible to ambulances. Dressing stations were often established in or near villages, if their location was suitable from a military standpoint, because these villages were marked on maps and were on roads and thus more easily accessible. Such sites, however, were shelled frequently; oftener, perhaps, than other locations would have been.
Sometimes, two divisions located their stations in the same village: for example. at Montfaucon during the Meuse-Argonne operation. The site was often at a place affording some shelter, and a tendency developed to locate stations at points which could be used later for triage purposes. The method of advancing various medical units is illustrated by the following extract from the report of the division surgeon. 2d Division:90
Following the attack on Blanc Mont, an ambulance dressing station personnel furnished by the 1st Ambulance Company was established at Somme-Py on the afternoon of October 3, the 16th Ambulance Company dressing station taking its stand at Souain. On the 4th the ambulance head had advanced to Somme-Py and the 15th Ambulance Company dressing station leapfrogged to a point 2 km. north of Somme-Py, while the triage--1st Field Hospital--had set up at Souain. On the 5ththe 23d Ambulance dressing station leapfrogged to a position near Medeah Ferine and the 1st Field Hospital advanced to Somme-Py, as did the surgical unit--15th and 23d Field Hospitals.
Divisions frequently established an advanced dressing station if the main dressing station was at the ambulance head; but, as noted above, whenever possible, ambulances brought patients to the latter station direct from battalion posts and collecting points. Either tile advanced station, if established, or the main dressing station, took over the site of what would have been a regimental station formerly and served tile troops as tile regimental station had been designed todo originally. When information was received that the battalion aid station had advanced, one or two officers and a small detachment of enlisted men went forward with matériel carried perhaps by ambulances, and established a new station. In the 81st Division, if the advance dressing station moved, a man was left posted until the director of ambulance companies had received report of the new location.91 All divisions found that these stations must be centrally located and on natural evacuation routes.
The stations utilized tentage, but frequently their tentage afforded very limited shelter, it sometimes being no more than a tent fly. Toward the end of the Meuse-Argonne operation each division in the Third Corps was or-
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dered to establish a field hospital near its main dressing station, where patients often collected in large numbers before they could be removed.92
Sometimes, the dressing station operated the triage, methods being much the same in tins respect as those previously described under trench warfare. In order to relieve the dressing station, the 89th Division93 and a few other divisions maintained a station for ambulant patients--the slightly wounded, slightly ill, or fatigued--but this formation was very unusual.
Dressing station equipment was often limited in variety, consisting chiefly of dressings, splints, litters, blankets. antitetanic serum, a few drugs and instruments, and anti gas supplies. An important factor in the equipment of a dressing station was a kitchen with ample cooking facilities.11
In open warfare, the service of dressing stations was similar to that when troops were in the trenches. The personnel often worked in shifts, except during periods of stress, when all were constantly on duty. At such times, records were fragmentary and incomplete. Redressing of wounds at these times was reduced to a minimum and was confined chiefly to wounds with hemorrhage. Dressing stations in narrow sectors frequently received patients from neighboring divisions. The majority of casualties usually occurred close together, as to both time and location, and stations would be congested for a period followed by an interval of comparative calm. It was a general practice to give morphine to all the seriously wounded.11
The main dressing station operated a small medical supply dump, which was replenished constantly, as already described under trench warfare, by ambulances returning from the rear and by trucks. This was a highly important feature in the service of these stations, and their maintenance of adequate supplies in the Meuse-Argonne operation required constant effort because of road congestion and limitedtransportation.11
Another very important service here was that of supplying hot food. The 5th Division reported that from one of its dressing stations more than 3,000 men were fed in 48 hours.94Many of those seeking the station required no other care, and some, after receiving food, returned to their companies of their own volition.
Treatment of patients before they reached the hospital was generally reported as good. Thus, the 90th Division reported that 99 percent of cases reaching hospital had been well splinted and dressed.95 The 5th Division reported that less than10 percent required antitetanic serum.96 The same division reported that fracture cases invariably reached field hospitals in good condition, owing to the very careful and judicious application of the Thomas splint--which proved to be a great boon during the war.96Thebenefits of special training, given regimental medical personnel in the application of the Thomas splint, were shown by the good condition in which patients were received at hospitals.
The 2d Division reported that the average time consumed in transferring the wounded to field hospitals was a little more than one hour in the St. Mihiel operation, some nontransportable patients reaching the operating table at Thiaucourt within 20 minutes after being wounded.97 At Soissons,
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however, because of road conditions, the ambulances of this division frequently needed from seven to eight hours to make a trip. The 5th Division, in the St. Mihiel operation, had its patients in hospital in from 4 to 6 hours, and in the Meuse-Argonne in from 10 to 12 hours, except in some few instances where 24 hours elapsed after individual patients had been gassed or wounded.98
Usually, in open warfare, field hospitals were located from 4.8 to 9.6 km. (3 to 6 miles) from the front, the site often being determined to a large extent by conjunction of the roads of the sector served. As field hospitals in open warfare habitually used tentage, the location of available buildings became a matter of minor importance. In many divisions field hospitals were so near the front that they were hit by enemy shells; for example, Field Hospital No. 360, 90th Division, on October 25, 1918.99 Field hospitals of the 5th Division were habitually at some distance from towns or crossroads, but placed on some highway from front to rear.100
During the second phase of the Meuse-Argonne operation the Third Corps, which had a rather narrow front and good road facilities, grouped the field hospitals of its three component divisions at Bethincourt, designated three hospitals--one from each division in line--to perform triage service, and operated in effect a corps triage, though divisions retained control over their respective field hospitals composing it, each division thus having a field hospital to receive, classify, and record its own casualties.101 One division then established a hospital for all nontransportable wounded; another, one for all gassed patients; and third one for overflow; each of the three last-named units receiving patients from all three divisions composing the corps front. The third field hospital of each division remained outside the battle area to receive sick daily, and served as a relay station, while the fourth was held in reserve to leapfrog if necessary.
Mobility of field hospitals depended largely upon the expedition with which they were cleared by corps ambulance companies. At times, transportation for this purpose could not be furnished in sufficient amount. Although all divisional Medical Department units suffered from this lack, the field hospitals were most gravely affected by it.102 At times it was impossible, because of military exigencies, for field hospitals to keep their trucks even after they had received them. The animal-drawn field hospital, though usually a rear formation, could sometimes advance over ground impassable by motor vehicles, and its mobility under such circumstances proved of definite assistance in solving the Medical Department problems of the division.
A very important service of field hospitals was that of supplying hot food to all who needed it, whether patients or not, thus alleviating fatigue and maintaining morale, as did the same service at the dressing stations.
No orders prescribing the use or distribution of divisional field hospitals were issued by authorities higher than the corps. Much was left to local initiative. In general terms--to which many exceptions may be found in
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active offense the field hospitals were used as follows: (1) Triage and non-transportable wounded; (2) slightly wounded; (3) gassed and sick; (4) reserve.
For convenience the triage will be discussed at this point in connection with field hospitals, with which, usually, it was associated both in trench and in open warfare.
The triage, or sorting station, whence patients were distributed to appropriate hospitals, was a new formation in the American Army, the idea having been borrowed from our Allies after the United States entered the war,103 and it was first used, with some modifications, in the 1st Division.104 Though operated in all divisions in trench as well as in open warfare, no orders from higher authority required it or standardized it in personnel, organization, equipment, or operation, each division following its own methods except when a corps surgeon prescribed for divisions within his jurisdiction. Several divisions operated the triage at the dressing station, but usually it was a department of a field hospital or, less frequently, was attached to a field hospital. Between the several divisions there was some difference in what was understood by the term "triage." Not infrequently it meant only the sorting station which either belonged to a hospital or was attached to it, and, rarely, it was made to include the neighboring hospitals to which patients were distributed. Sometimes, as already indicated, it was a main dressing station more elaborately developed than these formations usually were, from which sorted patients were distributed direct to appropriate hospitals.
The manner in which the triage was operated at a dressing station has already been described. When operated in conjunction with a field hospital it functioned habitually with the one farthest forward. In some divisions the triage hospital received all nontransportable patients whether sick, wounded, or gassed; in others it received the seriously wounded only; in yet others, as in the 36th Division, this hospital retained no patients, but was used solely as a distributingagency.105 In trench warfare a designated hospital usually performed triage service as long as a division occupied a given sector, a change being made only when the division was moved to another part of the line, when sometimes another field hospital was assigned to triage duty; in open warfare, on the contrary, field hospitals often alternated in triage service.
The personnel conducting a triage consisted in part of the divisional consultants; i. e., the divisional chief of surgery or his representative, orthopedist, psychiatrist, urologist, tuberculosis expert, and gas-treatment officer.103 Often the chief of surgery was replaced here by a carefully selected officer chosen for his surgical judgment rather than for his operating ability. Members of the professional group often were supplemented by other officers and by enlisted men permanently, or, more commonly, temporarily assigned to triage duty. Triage officers were required to make quick but unhurried diagnoses and to estimate correctly the patient`s needs in their relationship to available facilities for treatment. To the finest discrimination and most unerring
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judgment had to be superadded, thorough knowledge of medicine and surgery, and of human nature. The task became especially difficult when most important; that is to say, when hospitals were filling and evacuation facilities were limited. Then, too, often at this time the diagnosticians were worn out by the long-continued admission of many patients. In the 2d Division, a permanent triage group was organized consisting of the specialists above mentioned and, in addition, of officers drawn from all the field hospitals. This group was independent, performing triage and consultant duty. In the 90th Division one ambulance company in conjunction with a field hospital established the divisionaltriage.107 The triage hospital of this division consisted of four sections, the triage proper, gas, nontransportable, and psychopathic. In the Meuse-Argonne operation, unlike its practice at St. Mihiel, the triage of the 90th Division retained no gas patients unless it was imperative to do so to save life, evacuating all others to appropriate units, and operating day and night shifts.108
In the 77th Division, two triage units were organized by drawing on the personnel of two field hospitals, and surgical, shock, gas, and medical teams were organized.109 Enlisted personnel, carefully selected, were assigned in the proportion of two to each officer, the group remaining a permanent team. Other qualified enlisted men were designated for special duties, such as the administration of morphine and serum, and the application of bandages and splints. Permanent details were assigned for litter bearing, clerical work, policing, and the serving of food. The detachment on duty in the operating room was composed of men who in civil life had been hospital orderlies. The triage equipment was selected from tile two field hospitals concerned. The Medical Department supply table was ignored for this purpose, and much of the hospital equipment was salvaged, being replaced by other articles which were thought to be more useful: for example, additional blankets and litters.110
The triage of the 80th Division consisted of two field hospitals, usually combined, and included a receiving ward and wards for slightly wounded, seriously wounded, shocked, gassed, sick, transportable patients, an operating room, and a mortuary.111
At the triage of the 5th Division, patients were redressed, if necessary, and emergency treatment, such as for shock or gassing, was given.100 In the 2d Division the triage carried bathtubs and other facilities for gas treatment.112
Though sorting of patients was practiced in every stage of tile evacuation service, each division habitually operated but one official triage. In the St. Mihiel operation the 82d Division had a triage on each side of the Moselle River,113 and in the second phase of the Meuse-Argonne the 33d Division had two, one at Glorieux and the other at Bethincourt. The 78th Division, in the second phase of the Meuse-Argonne operation, attacked on a rather wide front, through heavy brush and timber, traversed by so few roads and trails that the wounded could not be collected at any one point reasonably near tile front. For this reason it organized two triages from its ambulance companies and located one with two hospitals behind either flank.115 There were several
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other instances in which two triages were operated by divisions, but the foregoing illustrates the conditions which usually necessitated this--a long front, or such a one that evacuation from its flanks to a central point was difficult because of enemy fire, location of roads, ruggedness of terrain, or bisection by a river.
The following quotation illustrates certain phases of triage service:116
In the Meuse-Argonne offensive, the triage hospital was opened about 6 km. behind the line, and with it were the three other hospitals and the medical supply depot. Two of the hospitals cared for the sick and wounded and one operated as a gas hospital. The fourth hospital was held in reserve. This was found to be a very satisfactory arrangement on that particular front, since it gave wide expansion under canvas, with the necessary personnel to care adequately for all cases received. Also, it allowed the three hospitals to open immediately all their wards, while the personnel of the reserve hospital could do the necessary roadbuilding and police work. Triage of cases was conducted by Field Hospital No. 27, which cared also for the seriously wounded, and the direction of the whole field hospital section was under the supervision of the director of field hospitals.
The professional work was about the same as on the Marne front except that fewer operations were performed. Patients as a whole arrived in better condition, but there was a large number of shock cases, the weather being cold and rainy. Many cases of exhaustion were received, due to the exposure and hardships of long-continued service in the front line.
Usually simple records were made of all patients at the triage. Cases were rapidly classified, hemorrhage was controlled, dressings were readjusted if necessary, shock was treated, antitetanic serum was injected if it had not been administered previously, hot food was given, and emergency operations were performed on a few nontransportable patients by the hospital staff or by operating units assigned by the chief surgeon of the army.
If a mobile surgical unit was assigned to a division it was operated in conjunction with the field hospital for nontransportable patients.102Often the personnel of a field hospital was increased by surgical teams; for example, in the Chateau-Thierry sector the 2d Division received a number of surgical teams, including 18nurses, and the personnel of an overworked field hospital was often reinforced by details from others in reserve.117 Thus, on June 6, 1918, the 2d Division ordered half the personnel of Field Hospital No.23 to Bezu to assist Field Hospital No. 1.
The triage was usually the first hospital reached by patients, and others were grouped as near it as was practicable, the rearmost one being held in reserve. (This arrangement of hospitals was called the "diamond formation" in the 32d Division.)81 As troops advanced, the rear hospital moved forward past the others and established the triage, the other units following it as soon as practicable and the former triage then going into reserve. There were many departures in details from this practice. Sometimes, as in the 90th Division, half the triage group accompanied the newly-advanced forward hospital while the remainder, after the new one had opened, continued to operate the former triage.118 Sometimes two full triage groups were organized
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which leapfrogged each other, as in the 77th Division.110 In the 32d Division the rear surgical hospital evacuated its patients and moved forward to takeover triage work, and the gas hospital moved up beside the advanced surgicalhospital.81
There were further departures from these uses of field hospitals, of which only a few will be mentioned here. Though generally following the foregoing disposition, the 1st Division had at times only two field hospitals open, keeping two in reserve.119The 2d Division consolidated two hospitals into one establishment for the wounded, and sought to maintain its capacity at 250 beds.120In the St. Mihiel operation one hospital of the 78th Division received gassed patients, another the sick and slightly wounded, and a third field hospital cared for nontransportable patients, the fourth being held inreserve.121 The triage was operated by an ambulance company which called on a field hospital for additional personnel if needed.122At one period the 36th Division operated one hospital as a triage, sending nontransportable patients to another, gassed patients to a third, and all others to evacuation hospitals.105 In the Aisne-Marne operation the 42d Division set up one field hospital near the dressing station after its evacuation became difficult because of road congestion.123
The following quotation, which covers the activities of the gas hospital of a division, is made from the report of the 3d Division: 124
The gas hospital was fitted up with the following equipment: A large shower bath, a large supply of blankets, pajamas, bed sacks, and an extra number of ward tents in order to accommodate several hundred patients. In addition to the regular field-hospital equipment, the following were provided: Oxygen-inhalation sets, sodium bicarbonate 1 percent solution, novocaine 1 percent solution, albolene, camphorated oil in ampules, caffeine citrate in ampules, quarter-grain solution of morphine in ampules. This equipment and supplies were placed in each ward. Shower baths were provided, with a large supply of soap, towels, and sodium bicarbonate.
Patients were divided into three classes: (1) Those suffering from surface contact with mustard gas; (2) those intoxicated by the inhalation of noxious gases; (3) cases suffering from both these conditions. Those in the third class were numerous.
Patients were admitted through a receiving ward, where the diagnosis was verified and proper records were made. They were sent at once to the baths, where clothing was removed and each patient given a thorough bath, soap being used freely. Water used in the showers contained sodium bicarbonate (1 pound to 15 gallons). A fountain syringe was supplied with a 1 percent solution of sodium bicarbonate, and the eyes, ears, nose, and throat of every patient were irrigated. All cases with blisters were then sent to the dispensary, where blisters were opened and the escaping fluid caught on gauze or cotton to prevent its coming in contact with the healthy skin. Gauze wet with a 1 percent solution of sodium bicarbonate was applied to burned surfaces. Often, when a burn was slight, the sodium bicarbonate was dusted on. Patients were then sent to the wards, where they were given hot, stimulating drinks, such as coffee, cocoa, and broths, and morphine was administered as required. Most patients with mustard-gas burns had a complicating conjunctivitis, either slight or severe. Slight conjunctivitis was relieved by irrigating the eyes with sodium-bicarbonate solution, followed by a few drops of albolene. Severe conjunctivitis was treated with a 1 percent solution of novocaine as often as required to relieve pain, and gauze wet with a 1 percent solution of sodium bicarbonate was placed over the eyes. Patients gassed by inhalation were given a bath while recumbent. Severe cases were given a sponge bath in the wards as soon as their condition
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permitted, but if the patient had difficulty in breathing he was at once given oxygen by inhalation for five minutes. Then followed an intermission of five minutes, and oxygen again applied. In five minutes` time there was usually a great improvement, and it was not often necessary to repeat its administration. Some patients who were unconscious were restored to consciousness by the first application; others remained unconscious for 30 minutes or longer. Hypodermic injections of camphorated oil, 1 c. c., or caffeine citrate, 2 grains were then given. The patient was kept warm by the use of blankets, and by heat, if necessary, and was given hot drinks as soon as he could take them. The majority of these patients soon recovered.
The rapidity with which patients were evacuated to and from field hospitals varied widely, being dependent chiefly upon the number and character of casualties and the intensity of enemy fire, which delayed the removal of the wounded in forward areas, road conditions back of the forward areas, and transportation.
In times of great stress, few patients were returned to duty from field hospitals, a fact largely due to the impossibility of temporary retention on account of the demand for beds, to the elimination at the dressing station of patients with trifling conditions, and to the disposition to give the benefit of any doubt to those whose need of further hospital care was questionable. It was then quite impossible to hold patients in the division, as beds had to be provided for later casualties. The 2d Division reported that the average time men were held in its field hospitals, if not evacuated, was four days, and that in very active warfare it evacuated most of them.125 This was in striking contrast to the experience of this division in quiet sections, where 32.4 percent of patients were returned to duty. In the 89th Division the average time patients spent in field hospitals was two hours, and the average time for nontransportable wounded was from five to eight days.126
In the 26th Division the factors determining transportability of patients were regarded as intrinsic and extrinsic. The former comprised the patient`s condition; the latter, bed space and other local factors, such as distance, time, means of evacuation, and road conditions.127 Surgical conditions warranting evacuation, therefore, varied considerably at different times in this division, as in others. Specialists decided which patients should be transferred, while the director of field hospitals and the commanding officer of the triage kept them informed concerning extrinsic conditions governing selection of patients to be evacuated. In periods of stress, nontransportable patients in this division comprised only those with hemorrhage, aspirating chest wounds, severe abdominal wounds, partial traumatic amputations, and deep shock.
The activity of the field hospitals is indicated from the statistics quoted in other chapters concerning the casualties during different engagements. The celerity with which patients could be cared for by the divisional medical service is evidenced by the report of the 2d Division.120 In that division, miscellaneous casualties were received, distributed, treated, and evacuated (if need be) at the rate of 120 per hour, and operated upon at the rate of 50 a day. The total number of patients operated upon in the field hospitals of the 2d Division during its entire experience in France was 1,665, 90 percent of whom were nontransportable.120
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Divisional medical supply units performed services similar to those in the 3d Division. Extracts from the report of the 3d Division (concerning the medical supply unit) read as follows:128
When the Germans launched their great offensive along the Marne on the night of July 14-15, the medical supply unit, 3d Division, was called upon to furnish supplies in abundance. Owing to the vast number of wounded men pouring into aid stations it was necessary that surgeons have sufficient blankets and litters on which to lay them. Trucks were sent to advance medical supply depots and to American Red Cross warehouses, bringing back with them sufficient litters, blankets, shell-wound packets and splints to meet the demand. In the interim after the night of the attack until early August, when the division was relieved, no shortages of any kind arose.
While the division was at this front a great demand was made for Thomas traction arm and leg splints, Cabot splints, and a vast number of shell-wound packets. Snowshoe and wheel litters were used to great advantage, but when the division went into action in the Meuse-Argonne sector these items were rarely, if ever, called for.
The work of the medical supply unit at this latter station was to equip organizations after their long stay at the front, during which time many of them had lost a considerable portion of their equipment, some from enemy shell fire and others while moving. This reequipment was duly accomplished, and in anticipation of a situation similar to that existing on the Marne, the medical supply officer requested that four trucks be assigned. These were provided and requisition was made for a 10-days` supply of articles that would be in greatest demand while troops were in action.
During the Meuse-Argonne operation the medical supply officer made frequent trips to the regimental infirmaries of the various organizations, bringing with him an assortment of medical supplies which in his judgment might be needed.
October 2 found the unit proceeding overland to join the field-hospital section of the sanitary train, located near Very, arriving there that night. The depot was established in a ward tent and supplies were sent out the same night. Litters and blankets were most in demand, and in order to meet the situation, trucks were dispatched hack to Souilly day and night during the remainder of the stay here.
A branch distributing station of the medical supply unit was established with the ambulance section of the sanitary train at Montfaucon. This proved a vantage point for the reason that it was the dispatch point for the ambulance service. The stock maintained at this point consisted chiefly of emergency dressings, medicines, and food supplies.
The medical supply unit functioned at all times near the triage hospital of the division, employing ambulances returning to aid stations to transport supplies to tile medical officer at the point. Trucks belonging to the unit carried patients to evacuation hospitals in the rear, and brought up supplies on return trips.
In some divisions, the 78th, for instance, trucks of the medical supply unit carried matériel as far forward as the battalion aid stations.129
In the American Expeditionary Forces transportable laboratories were added to the sanitary trains of the divisions,130and proved of great value in the examination of water supplies and of pathological specimens and in determining wound bacteriology.131 The1st Division found that the usefulness of the field laboratory was impaired by the limited amount of transportation at its disposal, and that it was of less value in active operations than when
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the division occupied quiet or semipermanentsectors.132 Under the latter conditions it was a necessity to the sanitary inspector in his epidemiological work and to ward surgeons treating certain classes of the divisional sick.
The dead were buried in small plots selected with reference to prompt location. Very few, in the St. Mihiel or Meuse-Argonne operations, were buried at isolated places, and then only when the bodies were in such condition and at such a distance from the burial plot that local interment was necessary. The 3d Division reported, as did others, that the bodies of those who died on the field in No Man`s Land remained unburied for many days.133 Trench burial was employed near some hospitals, but only when facilities were not available for the preparation of individual graves. The work of preparing graves was very toilsome for men already well-nigh exhausted, and at times graves were dug by pioneer troops, and at other times the work was done by details from the line. Habitually the dead were buried in blankets, with an identification tag, and the grave was marked by a cross bearing the decedent`s name and his official number inscribed upon it. If a second identification tag was available, this was affixed to the cross.
(1) Letter from the division surgeon,42d Division, to the commanding general, 42d Division, April 4, 1918. Subject: Evacuation of sick and wounded. On file, Historical Division. S. G. O.
(2) Memorandum No. 66, division surgeon`s office, 3d Division, A. E. F., July 23, 1918. On file, Historical Division, S. G. O.
(3) Memorandum No. 82, division surgeon`s office, 3d Division, A. E. F., September 6, 1918. On file, Historical Division, S. G. O.
(4) Report of Medical Department activities, 3d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part III, 156. On file, Historical Division, S. G. O.
(5) Ibid., Part II, 81.
(6) Ibid., Part V, 72.
(7) Memorandum, September 3, 1918,Headquarters. First Army Corps, Subject: Evacuation sick and wounded. On file, Historical Division, S. G. O.
(8) Report of Medical Department activities, 5th Division. A. E. F., prepared under the direction of the division surgeon, undated, Part III, S. On file, Historical Division, S.G. O.
(9) Report of the Medical Department activities of the combat divisions, by Col. B. K. Ashford, M. C., undated,11. On file, Historical Division, S. G. O. Evacuation system of a field army, by Col. C. R. Reynolds, M. C., undated, 19. On file, Historical Division, S. G. O.
(10) Report of Medical Department activities, 89th Division, A. E. F., prepared under the direction of the division surgeon, undated, 52. On file, Historical Division, S. G. O.
(11) From reports of Medical Department activities of divisions in the A. E. F., undated. On file, Historical Division, S. G. O.
(12) Report of Medical Department activities, 4th Division, A. E. F., prepared under the direction of the division surgeon, undated, 3. On file, Historical Division, S.G. O.
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(13) Report of Medical Department activities of the combat divisions, by Col. B. K. Ashford, M. C., undated,12. On file, Historical Division, S. G. O.
(14) Ibid, 19.
(15) Report of Medical Department activities of 1st Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 11. On file, Historical Division, S.G. O.
(16) Report of Medical Department activities of 3d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part V, 35. On file, Historical Division, S.G. O.
(17) Ibid., Part V, 36.
(18) Ibid., Part V, 37.
(19) Report of Medical Department activities of the combat divisions, by Col. B. K Ashford, M. C., undated, 17. On file, Historical Division, S. G. O.
(20) Ibid., 15.
(21) Tables of Organization and Equipment U. S. Army, Series A, Table 4, August, 1917.
(22) Report of Medical Department activities, 3d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part IV, 68. On file, Historical Division, S.G. O.
(23) Tables of Organization and Equipment, U. S. Army, Series A, Table 28, April 17, 1918.
(24) Manual for the Medical Department, U. S. Army, 1916, par. 674.
(25) Report of Medical Department activities, 4th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 5. On file, Historical Division, S.G. O.
(26) Report of Medical Department activities, 1st Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 5. On file, Historical Division, S.G. O.
(27) Report of Medical Department activities, 4th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 3. On file, Historical Division, S.G. O.
(28) Report of Medical Department activities, 5th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 7. On file, Historical Division, S.G. O.
(29) Report of Medical Department activities, 37th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 9. On file, Historical Division, S.G. O.
(30) Report of Medical Department activities, 5th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 11. On file, Historical Division, S.G. O.
(31) Report of Medical Department activities, 35th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 16. On file, Historical Division, S.G. O.
(32) Report of Medical Department activities of the combat divisions, A. E. F., by Col. B. K. Ashford, M.C., undated, 25. On file, Historical Division, S. G. O.
(33) Report of Medical Department activities, 28th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 4. On file, Historical Division, S.G. O.
(34) Report of Medical Department activities of the combat divisions, A. E. F., by Col. B. K. Ashford, M.C., undated, 26. On file, Historical Division, S. G. O.
(35) Report of Medical Department activities of the 42d Division, prepared under the direction of the division surgeon, undated, Part I, 38. On file, Historical Division, S. G. O.
(36) Report of Medical Department activities of 1st Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 42. On file, Historical Division, S.G. O.
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(37) The evacuation system in the zone of the armies, by Col. A. N. Stark, M. C., undated, 1. On file, Historical Division, S. G. O.
(38) Ibid., 2.
(39) Report of Medical Department activities of the 5th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 10. On file, Historical Division, S. G. O.
(40) The evacuation system in the zone of the armies, by Col. A. N. Stark, M. C., undated, 3. On file, Historical Division, S. G. O.
(41) Report of Medical Department activities, 42d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 39. On file, Historical Division, S.G. O.
(42) Report of Medical Department activities, 2d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 5. On file, Historical Division, S.G. O.
(43) Report of Medical Department activities, 42d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 48. On file, Historical Division, S.G. O.
(44) Ibid., 51.
(45) Report of Medical Department activities of the combat divisions, A. E. F., by Col. B. K Ashford, M.C., undated, 34. On file, Historical Division, S. G. O.
(46) Memorandum, Headquarters, First Army Corps, September 3, 1918. On file, Historical Division, S. G. O.
(47) Report of Medical Department activities of the combat divisions, A. E. F., by Col. B. K. Ashford, M.C., undated, 27. On file, Historical Division, S. G. O.
(48) Report on activities of G-4-B,medical group, fourth section, general staff, G. H. Q., A. E. F., by Col. S. H. Wadhams, M. C., chief of section, December 31, 1918, 62. On file, Historical Division, S. G. O.
(49) Report of Medical Department activities, 4th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 10. On file, Historical Division, S.G. O.
(50) Tables of Organization and Equipment, U. S. Army, Series A, Table 28, April 17, 1918.
(51) Report on activities of G-4-B,medical group, fourth section, general staff, G. H. Q., A. E. F., by Col. S. H. Wadhams, M. C., chief of section, December 31, 1918, 43. On file, Historical Division, S. G. O.
(52) Report of the Medical Department activities of the combat divisions, A. E. F., by Col. B. K. Ashford, M.C., undated, 32. On file, Historical Division, S. G. O.
(53) Report of Medical Department activities of the 26th Division, A. E. F., prepared under the direction of the division surgeon, undated. Part II, 13. On file, Historical Division, S. G. O.
(54) Report of Medical Department activities of the 90th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part III, 2. On file, Historical Division, S. G. O.
(55) Report of Medical Department activities, 5th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part IV, 41. On file, Historical Division, S. G. O.
(56) Report of Medical Department activities, 2d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 30. On file, Historical Division, S.G. O.
(57) Ibid., Part III, 17.
(58) Report of Medical Department activities, 3d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part V, 38. On file, Historical Division, S.G. O.
(59) Report of operations, MedicalDepartment, 2d Division, May 31 to July 10, 1918, from the division surgeonto the commanding general, 2d Division, February 24, 1919. On file, Historical Division, S. G. O.
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(60) Report of Medical Department activities, 90th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 6. On file, Historical Division, S. G. O.
(61) Report of Medical Department activities, 1st Division, A. E. F., prepared under the directionof the division surgeon, undated, Part II, 24. On file, Historical Division, S. G. O.
(62) Report of Medical Department activities, 5th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 37. On file, Historical Division, S.G. O.
(63)Report of Medical Department activities, 35th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 3. On file, Historical Division, S.G. O.
(64) Report of Medical Department activities, 90th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 21. On file, Historical Division, S.G. 0.
(65) Report of Medical Department activities, 5th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 7. On file, Historical Division, S.G. O.
(66) Report of Medical Department activities, 2d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 34. On file. Historical Division, S.G. O.
(67) Report of Medical Department activities, 78th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 32. On file, Historical Division, S.G. O.
(68) Report of Medical Department activities, 5th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part IV, 41. On file, Historical Division. S.G. O.
(69) Report of Medical Department activities, 3d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part IV, 71. On file, Historical Division, S.G. O.
(70) Report of Medical Department activities, 5th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 38. On file, Historical Division, S.G. O.
(71) Ibid., Part II, 11.
(72) Report of operations, Medical Department, 2d Division, A. E. F., March 16, 1918, to December 31, 1918,from the division surgeon to the commanding general, 2d Division, February25, 1919, 7. On file, Historical Division, S. G. O.
(73) Report of Medical Department activities, 3d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part V, 37. On file, Historical Division, S.G. O.
(74) Report of Medical Department activities, 2d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 35. On file, Historical Division, S.G. O.
(75) Report of Medical Department activities, 5th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 46. On file, Historical Division, S.G. O.
(76) Report of Medical Department activities, 2d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 34. On file, Historical Division, S.G. O.
(77) Ibid., Part I, 41.
(78) Report of Medical Department activities, 90th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 23. On file, Historical Division, S.G. O.
(79) Report of Medical Department activities, 36th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 9. On file, Historical Division, S.G. O.
153
(80) Report of Medical Department activities, 5th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part IV, 2. On file, Historical Division, S.G. O.
(81) Report of Medical Department activities, 32d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 42. On file, Historical Division, S.G. O.
(82) Report of the Medical Department activities of the combat divisions, A. E. F., by Col. B. K. Ashford, M. C., undated, 29. On file, Historical Division. S. G. O.
(83) Ibid., 31.
(84) Memorandum 142, Headquarters,42d Division, office of the surgeon, June 10, 1918. On file, Historical Division. S. G. O.
(85) Report of Medical Department activities, 3d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part IV, 17. On file, Historical Division, S.G. O.
(86) Report of Medical Department activities, 90th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 9. On file, Historical Division. S.G. O.
(87) Report of Medical Department activities, 77th Division, A. E. F., prepared under the direction of the division surgeon, undated. 12. On file, Historical Division, S. G. O.
(88) Report of Medical Department activities, 80th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 21. On file, Historical Division, S.G. O.
(89) Report of Medical Department activities, 1st Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 22. On file, Historical Division, S.G. O.
(90) Report of Medical Department activities, 2d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part III. 37. On file, Historical Division, S. G. O.
(91) Report of Medical Department activities, 81st Division, A. E. F., prepared under the direction of the division surgeon, undated, 21. On file, Historical Division, S. G.O.
(92) Memorandum from the surgeon, Third Corps, to division surgeons, Third Corps, October 19, 1918. On file, Historical Division. S. G. O.
(93) Report of Medical Department activities, 89th Division, A. E. F., prepared under the direction of the division surgeon, undated, 35. On file, Historical Division, S. G. O.
(94) Report of Medical Department activities, 5th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 51. On file, Historical Division, S.G. O.
(95) Report of Medical Department activities, 90th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 12. On file, Historical Division, S.G. O.
(96) Report of Medical Department activities, 5th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part IV, 29. On file, Historical Division, S.G. O.
(97) Report of Medical Department activities, 2d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 6. On file, Historical Division, S.G. O.
(98) Report of Medical Department activities, 5th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part III, 9. On file, Historical Division, S.G. O.
(99) Report of Medical Department activities, 90th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 37. On file, Historical Division, S.G. O.
154
(100) Report of Medical Department activities, 5th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part IV, 30. On file, Historical Division, S.G. O.
(101) Report of Medical Department activities, Third Corps, by Col. James L. Bevans, M. C., corps surgeon, undated, 33. On file, Historical Division, S. G. O.
(102) Report on activities of G-4-B,medical group, fourth section, general staff, G. H. Q., A. E. F., by Col. S. H. Wadhams, M. C., chief of section, December 31, 1918, 42. On file, Historical Division, S. G. O.
(103) Report of the Medical Department activities of the combat divisions, A. E. F., by Col. B. K. Ashford, M.C., undated, 34. Ga file, Historical Division, S. G. O.
(104) Report of Medical Department activities, 1st Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 41. On file, Historical Division, S.G. O.
(105) Report of Medical Department activities, 36th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 5. On file, Historical Division, S. G. O.
(106) Report of Medical Department activities, 32d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 64. On file, Historical Division, S.G. O.
(107) Report of Medical Department activities, 90th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 22. On file, Historical Division, S.G. O.
(108) Ibid., Part II, 29.
(109) Report of Medical Department activities, 77th Division, A. E. F., prepared under the direction of the division surgeon, undated, 12. On file, Historical Division, S. G. O.
(110) Ibid., 18.
(111) Report of Medical Department activities, 80th Division, A. E. F., prepared under the direction of the division surgeon, undated, 24. On file, Historical Division, S. G. O.
(112) Report of Medical Department activities, 2d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 14. On file, Historical Division, S.G. O.
(113) Report of Medical Department activities, 82d Division, A. E. F., prepared under the direction of the division surgeon, undated, 9. On file, Historical Division. S. G. O.
(114) Report of Medical Department activities, 33d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 7. On file, Historical Division, S.G. O.
(115) Report of Medical Department activities, 78th Division, A. E. F., prepared under the direction of the division surgeon, undated, 27. On file, Historical Division. S. G. O.
(116) Report of Medical Department activities, 3d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part IV, 44. On file, Historical Division, S.G. O.
(117) Report of Medical Department activities, 2d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 25. On file, Historical Division, S.G. O.
(118) Report of Medical Department activities, 90th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 10. On file, Historical Division, S.G. O.
(119) Report of Medical Department activities, 1st Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 42. On file, Historical Division, S.G. O.
155
(120) Report of Medical Department activities, 2d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 14. On File, Historical Division, S.G. O.
(121) Report of Medical Department activities, 78th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 62. On file, Historical Division, S.G. O.
(122) Ibid., Part II, 64.
(123) Report of Medical Department activities, 42d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part 1, 51. On file, Historical Division, S.G. O.
(124) Report of Medical Department activities, 3d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part IV, 44. On file, Historical Division, S.G. O.
(125) Report of Medical Department activities, 2d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 13. On file, Historical Division, S.G. O.
(126) Report of Medical Department activities, 89th Division, A. E. F., prepared under the direction of the division surgeon, undated, 57. On file, Historical Division, S. G. O.
(127) Report of Medical Department activities, 26th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 76. On file, Historical Division, S.G. O.
(128) Report of Medical Department activities, 3d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part IV, 46. On file, Historical Division, S.G. O.
(129) Report of Medical Department activities, 78th Division, A. E. F., prepared under the direction of the division surgeon, undated, Part II, 83. On file, Historical Division, S.G. O.
(130) Letter from the chief surgeon, A. B. F., to the Surgeon General, U. S. Army, August 12, 1917. Subject: Outline of laboratory organization, A. E. F. On file, A. G. O., World War Division, Medical Records Section (Chief Surgeon Files, 322.3271).
(131) Report on the division of laboratories and infectious diseases in the A. E. F., by Col. J. F. Siler, M. C., chief of division, undated. On file, Historical Division. S. G. O.
(132) Report of Medical Department activities, 1st Division, A. E. F., prepared under the direction of the division surgeon, undated, Part I, 84. On file, Historical Division, S.G. O.
(133) Report of Medical Department activities, 3d Division, A. E. F., prepared under the direction of the division surgeon, undated, Part V, 81. On file, Historical Division, S.G. O.
