Field Operations, Table of Contents
CHAPTER V
EVACUATION HOSPITALS, MOBILE HOSPITALS, MOBILE SURGICAL UNITS, PROFESSIONAL TEAMS, CONVALESCENT DEPOTS, EVACUATION AMBULANCE COMPANIES, MOBILE LABORATORIES
EVACUATION HOSPITALS
NUMBER
A description of our evacuation hospital, as provided for at the beginning of the World War, will be found in the Manual for the Medical Department, which is quoted at length in the Appendix (p. 1026), so far as it pertains to the present subject. It will be noted that the prescribed plan was ordinarily to furnish two such hospitals, each accommodating 432 patients, for each division at the front, and that they were lines of communication units.1
By 1916, the Medical Department had assembled equipment for 20 evacuation hospitals. This equipment was on hand at the beginning of the World War. No such organizations were actually in being in peace times, however, and the only evacuation hospital which we had ever organized, prior to the entry of the United States into the World War, was one which functioned at Galveston, Tex., during American activities near Vera Cruz, Mexico, in 1914.2 The personnel for this evacuation hospital was assigned to it for the time being, assuming other duties as soon as the hospital was broken up.
When the strength of our division was increased in 1917 to some 28,000 men, the prescribed standard capacity of an evacuation hospital was increased to 1,000 beds, based on a recommendation of the chief surgeon, A. E. F.3 On occasions, however, even this number proved quite inadequate; that is to say, some such units cared for more than twice this number at one time; for example, Evacuation Hospital No. 1 at Sebastopol Barracks, in September, 1918, reached a bed capacity of 2,800.4
The great expansion of individual evacuation hospitals was necessitated primarily by the continuous shortage of these units in France, as they did not arrive overseas in the number provided by regulations and in the shipping schedule. As a matter of fact, until the armistice, never was there more than about 25 percent of the authorized quota of evacuation hospitals available,5 for use as such in France. Prior to the armistice, only 37 evacuation hospitals actually reached France (7 arriving after the armistice) to serve the 42 divisions of the United States Army sent there. To this number should fairly be added Red Cross Hospital No. 114, which was taken over by the Army on November 1, 1918, as Evacuation Hospital No.114.6
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Five of the 30 evacuation hospitals which had reached France on or before November 11, 1918, arrived in November; two others had been previously assigned to duty in the Services of Supply (Allerey and Mesves) and two in the Joinville concentration area. Of the remaining 26, 4 (Nos. 18, 20, 22, and 23) were broken up temporarily, though part of No. 18 continued to function as a unit.6 Twenty-two evacuation hospitals, therefore, in the zone of the armies served the 29 divisions which took part in actual combat.
Most of the evacuation hospitals, which served other than in the zone of the armies, operated as base hospitals in the base or intermediate sections.7 As noted above, several were broken up, their personnel being assigned to other units. Other hospitals of this type, while retaining their skeletonized organization, were depleted by the assignment to other organizations of a large part of their personnel as operating teams and the like. It should be remembered that, throughout the war, these teams were drawn not only from base hospitals in rear areas but also from evacuation hospitals in quiet sectors to be assigned to temporary duty with other hospitals most active at the time.7
It was only dire and immediate necessity in other directions which forced diverting these evacuation hospitals from their proper purpose. On the other hand, so desperate were the shifts required to meet the needs of the evacuation hospital service that units not originally intended for this purpose were so used. Twelve mobile hospitals were provided by resort for personnel to all possible formations, including Red Cross Base Hospitals Nos. 110 and 114.8 In the St. Mihiel operation Base Hospitals No. 45 and No. 51, in the Justice Groupe at Toul, though under control of the chief surgeon, S. O. S., operated as part of an evacuation center virtually controlled by the army surgeon.9 With them, in addition to Evacuation Hospitals Nos. 3 and 14, were Red Cross Military Hospital No. 114, a neurologic unit from Base Hospital No. 117, a convalescent unit, and a hospital for gassed cases, the last staffed from three organizations, viz, Evacuation Hospital No. 2, Base Hospital No. 51, and the orthopedic battalion.10
FUNCTIONS
Evacuation hospitals which reached the zone of the armies were operated directly under the jurisdiction of the army surgeon, and not under the chief surgeon of the line of communications, as our regulations had stipulated previous to our entry into the war.11 The army surgeon, cooperating with the deputy of the chief surgeon, A. E. F., at G. H.Q., supervised their distribution, location and expansion, coordinated their activities with the service of the front; and through a medical officer assigned to the regulating station, effected their clearing by hospital trains. In the few instances when evacuation hospitals were not located on a railway line, the army surgeon effected their evacuation to a railway by ambulance companies under his command.11 These evacuation hospitals, too, were supplemented by mobile hospitals which performed similar functions but were smaller and more mobile. (See infra.)
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While in certain respects our field hospital, as in France, continued to be an emergency hospital for the battlefield, it became more nearly a magnified and improved dressing station than a hospital. This made the evacuation hospital the actual theater of our surgical effort there, especially during very active periods. The evacuation hospital, plus the mobile hospital and the mobile surgical unit, thus constituted the hospital for early surgery; upon it, to a very great extent, the patient’s life and limb depended. It proved necessary in this hospital to apply, with great rapidity, to the most urgent cases, the best treatment known to modern surgery in order to secure satisfactory professional results; and at the same time, in order to secure the best administrative service, it was likewise necessary to evacuate its patients as quickly as possible to provide beds for incoming wounded. To a certain degree these needs conflicted, and it was only by the utmost diligence and perspicacity that they could be reconciled in periods of stress, or, that, if this proved impossible, their conflict could be reduced to a minimum.12
It should be explained here that our medical service did not accept the tenet of our allies that the more lightly wounded should receive preferential attention in the zone of the armies because of the greater probability of their return to active service and also because a greater number could thus be cared for in a given period.13 Nor did it accede to the policy, which was followed by our allies generally, of making evacuation hospitals practically immovable and of large size. Some similar establishments in the French army, located from 15 to 20 km.(9 to 12 miles) back of the line, accommodated as many as 5,000 patients, and the English, by grouping their casualty clearing stations, made arrangements which in general effect were the same.14 This had secured prompt treatment of all the wounded it is true, during the long period of trench warfare, but proved to be a tactical error when the war became one of movement; for when the armies which the hospitals served retired in the face of overwhelming onslaughts by the Germans the French lost many thousand beds.15
Increased knowledge of surgery proved that removal of devitalized tissue and foreign bodies from slight wounds could be accomplished successfully back of the zone of the armies and that surgical intervention within 12 hours was not essential in the slighter cases in order to prevent infection by the gas-forming bacilli.14 The earlier belief that early operation was essential in all cases had had an important influence, however, in causing the British and the French to locate so many large, relatively immobile hospitals so close to the front. Their entire evacuation hospital service was also profoundly influenced by the fact that shell wounds, so common in this war, were practically always infected by gas-forming organisms and that, in order to get the best results, operation was advisable within 12 hours after injury.14 At such operations, foreign bodies were removed, the wound debrided and left open until bacteriological examination showed that its closure was warrantable. This last procedure, in uncomplicated flesh wounds, was usually possible in 4 to 5 days and recovery was complete in from 3 to 5 weeks.
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No one questions the necessity for very prompt action in serious wounds, but it had also been believed that return to the colors would be expedited if the slightly wounded as well as the seriously wounded could be operated on within the 12-hourlimit of time. Later observations showed that practically the same results were obtained in the slightly wounded, without retained foreign bodies, if operation were delayed 24hours or even longer. Upon this knowledge was based the American policy of sending such cases farther to the rear for operation if pressure was such that their numbers would overtax an evacuation hospital of approximately 1,000-bed capacity at the front.14
FIG.23.-Evacuation Hospital No. 2, Baccarat, France, June 28, 1918
Our evacuation hospitals then sought especially to give surgical treatment to severely wounded patients whom it was not advisable to send, unoperated upon, farther to the rear, and then to hospitalize such patients until they were fit to be moved, so far as might be necessary, but only, as circumstances permitted, to hospitalize here also the less seriously injured. As a rule, the treatment given the latter was temporary, though sometimes it was definitive, but this was only if the demand for beds was not pressing. In times of great stress there were never enough evacuation hospitals at the front to give full surgical attention to all the wounded; nor was it proposed that there should be, for such provision would have required an excessively large hospitalization in the zone of the armies. Except for the small percentage of very seriously
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wounded who had to be hospitalized in evacuation hospitals because they could not endure transportation to the rear, our evacuation hospitals were merely relay or clearing stations in the hospitalization and evacuation chain.
While the more seriously wounded properly required two weeks, hospitalization after operation before being transferred, sometimes the demand for beds was so great that the more seriously wounded had to be removed in less than half that time. Brain injuries, if operated upon here, were kept, if possible, at least 10 days. Knee-joint, abdominal, and chest wounds were retained from 10 days to 2 weeks when possible, but patients with these wounds sometimes were evacuated after 5 days, or, very rarely, in even less time. Patients with compound fractures of the femur were kept as long as possible.14 It was estimated that about 10 percent of the beds in evacuation hospitals would ordinarily be used for the severely wounded, and the remainder for patients to be evacuated immediately. It was recognized, however, that this proportion, like many others pertaining to evacuation hospitals, was subject to radical modification in order to meet the constantly shifting military situation and its hospital requirements.14 Elasticity of these hospitals proved essential in both size and service.16 The principle of mobility was stressed, except in the case of certain evacuation hospitals, which, because of
FIG.24.-Operating room, Evacuation Hospital No. 2, Baccarat
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peculiar circumstances, were in effect immobilized; for example, Evacuation Hospital No. 1 at Sebastopol Barracks, just north of Toul.4
As has already been noted, our evacuation hospitals had officially 1,000 beds. The capacity and organization of individual evacuation hospitals were based, to a certain extent, on an estimate of what the maximum daily admissions would be. With some exceptions these did not exceed 1,000, but on some occasions there were more than 1,400; for example, in Evacuation Hospital No. 9, on October 10, 1918, during the Meuse-Argonne operation.17Excessive pressure, due to the intake of more patients than an evacuation hospital could care for, was controlled by sending patients out on "preoperative trains, "though some hospitals objected to this practice on the ground that it indicated inability of the institution to handle patients properly. It was contended also that the time which must elapse before these patients could be delivered by train to hospitals in the rear would exceed the length of time they would have to await operation in the evacuation hospital concerned and that their chances of infection would thereby be increased. In any event, these patients were transferred from the evacuation hospital only after very careful examination and re-dressing. The transferable were held to include those with such injuries as fractures caused by rifle and machine-gun bullets, but without much bony destruction; gutter wounds; and flesh wounds with retained bullets.
FIG.25.-Sterilizing plant and tentage, Evacuation Hospital No. 2, Baccarat
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But local demands and the resources available at the time really determined what classes of patients should be transferred. An important factor influencing the use of preoperative trains was the number and rapidity of operating teams available at the evacuation hospitals. The number of operating teams was increased in the evacuation hospitals; their work was speeded up. The number of unoperated patients it was necessary to evacuate from the evacuation hospitals during the Meuse-Argonne operation fell from above 1,370 in the first phase of that engagement to 293 in the second.18
When the 24-hour intake of patients at an evacuation hospital exceeded1,000 the routine plan of work ordinarily had to be changed if all patients were to be cared for locally. The necessary speeding up of operating teams under such circumstances depended on their good organization. Shifts, at the eleventh hour, generally proved unsatisfactory, and it was found that sometimes, due essentially to inadequacy in number, experience, and speed of operation teams, preoperative trains had to be used. How severe the pressure was at times is indicated by the fact that, in the six weeks subsequent to June 13, 1918, Evacuation Hospital No. 7 at Coulommiers, near Chateau-Thierry, received and evacuated 27,000 cases. Between June 14 and November 11, 1918, it admitted more than 50,000 patients,19 while Evacuation Hospital No. 9 admitted more than 32,000 during the Meuse-Argonne operation, September 26 to November 11, 1918.17
Generally speaking, more than half the patients admitted to evacuation hospitals in the zone of the armies were surgical cases, and of these about half were operated upon. Data on this subject, however, are incomplete, and these figures apply only to those hospitals which reported on this subject.
Evacuation hospitals at the front often received patients from several divisions. Thus, during the Aisne-Marne operation, Evacuation Hospital No. 4 received patients from five divisions, and from September 26 to November 11, 1918, it received patients from 11 divisions.20
The most essential details for the successful operation of an evacuation hospital proved to be the following: Location at a suitable place-on a railway siding if possible; free mobility; rapid and systematic pitching and striking of tents; rapid entraining and detraining; elimination of unnecessary materiel which would impair mobility; the use of tentage or movable barracks rather than permanent buildings if these did not lend themselves readily to hospital purposes; provision of tentage and blankets for crisis expansion for at least 500 beds; adequate personnel, each officer and man assigned according to his best abilities; well-balanced, resilient organization; appropriate, systematic local distribution of patients based on their condition and on the availability of beds; instruments for 10 operating teams; high speed without haste or carelessness in examining, distributing, operating upon, and evacuating patients; medical supplies and rations for 10 days for total strength, including crisis expansion; provision for accurate records and for care of patients’ valuables.21
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FIG.26.-Evacuation Hospital No. 1, Sebastopol, Toul
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LOCATION
The site proposed for an evacuation hospital was inspected either by the army surgeon or by a competent assistant.21 The preferable location was one as near the front as possible, yet safe from direct or indirect artillery fire-usually at a distance of from 15 to 25 kilometers (9 to15 miles) from the line-accessible by good roads from the forward area to be served and by hospital trains from the rear. Location at a point not accessible to hospital trains proved to be a tactical error. Even when troops were moving forward, it was found better to retain an evacuation hospital at the railhead and to transport the wounded an increasing distance to it by ambulance than to move it forward and relay its transportation patients to the railhead by ambulance.a 22 Other desiderata in the selection of a site were proximity to fuel and water supplies and separation from ammunition dumps, depots, aviation fields, and cantonments which would be searched by enemy fire. A site on a railway spur at least half a mile from any of these formations was chosen whenever possible. Suitable buildings were another prime de-
FIG.27.-Tentage used by Evacuation Hospital No. 1
aThe French did not call any hospital an evacuation hospital if it was removed from a railway. They designated it an "ambulance," that is, a field hospital or "Groupe d`Ambulance." Our Medical Department learned that an evacuation was such in name only, if an evacuation hospital was located at a distance from a railway. The method of the French in utilizing evacuation hospitals proved exceedingly valuable; they selected a site, built a railway siding to it, prepared the loading quay, and then brought in the unit.
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sideratum, or, failing these, suitable ground space for tentage. Sometimes, as already indicated, existing buildings were supplemented by tentage. Occasionally it was easier to utilize, for an evacuation hospital, tentage which could be pitched where desired than to adapt available buildings to its needs. However, tents did not prove so satisfactory as Adrian barracks, as they could not be so well heated, ventilated, or lighted.
FIG.28.-Conventional ground plan of an evacuation hospital
Having selected a site and having secured for it the approval of the coordinating section of the army general staff concerned (if the evacuation hospital was to occupy a site on a railway, and transportation was available), a request was made in memorandum form to the operating section of the army general staff. This produced the necessary order, which was accomplished by the troop movement bureau of the coordinating section of the army. If the site selected was beyond the limit of army control, a request made upon General Headquarters, A. E. F., by the army commander was necessary.21
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The commanding officer of the hospital prepared, in advance if possible, diagrams for illustrating the layout of tents to supplement available buildings. At any rate he had a typical layout prepared and was ready to use this, or to modify it as required by local conditions.21
In the summer of 1918 an attempt was made to provide separate evacuation hospitals for nontransportable, seriously wounded, and ambulant patients, as the case might be; but this method of disposal usually broke down at times of pressure, probably because of the difficulty attendant upon sorting patients at more advanced positions. Because of this difficulty and of the difficulty of properly routing different classes of patients from the triage, the plan in question was soon abandoned. While it was true, so far as evacuation hospitals were concerned, that it did not prove possible to segregate seriously wounded in certain units, this did not apply to mobile hospitals. These units, which worked nearer the front than did the evacuation hospitals, solely received wounded who would almost certainly have died if transported
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to the evacuation hospitals, and they proved to be of great value for this purpose. With this exception, however, it was found that the provision of special hospitals for special patients was wasteful of transportation and of personnel, even infixed warfare.23
Supplementary professional groups for evacuation hospitals were provided, however, for special types of patients; namely, contagious, neurological, gas patients, and the like. Sometimes, special wards for these were set aside in the hospital itself.
In order to facilitate delivery of patients from the triages, as the war progressed, evacuation hospitals were grouped as close together as possible; and instead of increasing their number, their size was increased and their evacuation was expedited. The importance of grouping evacuation hospitals must be stressed. It was easier for an ambulance driver to find his proper destination with a few closely grouped hospitals than with many scattered ones, and then, too, concentrated units were more easily coordinated and evacuated than separated ones.23
From the beginning, routes to evacuation hospitals were conspicuously marked by pasteboard signs, but as these were easily destroyed in inclement weather the inspector general, A. E. F., recommended that they be replaced by sheet-iron signs, marked with luminous paint, and that these be made a part of the equipment of the hospital.24 This plan was bettered in the Meuse-Argonne operation by providing a metal box with removable front. At night this contained a lantern. It was posted at crossroads as a signboard. For the box a number of metal sheets, perforated to indicate different hospitals and their locations, were provided. This plan afforded a
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luminous sign at night. The appropriate metal sheet was inserted on notice from the rear, and the stream of wounded men diverted to the hospital best prepared at the time to care for them.23
In locating evacuation hospitals an ideal arrangement was to pitch two of them in juxtaposition, so that, when troops moved, one hospital could transfer the patients to the other and could then participate in the movement without delay, the other hospital clearing its patients and following later if need be. In order to approximate this method it was proposed, in view of the limited number of evacuation hospitals, that each be made to consist of two sections, one of which, much more freely movable than the other because of being supplied with cots instead of beds and other light equipment, should accompany troops, while the other section disposed of remaining patients and rejoined its companion section later when more transportation became available. This plan, however, was put into operation only on a very limited scale, as the 12 mobile hospitals which were organized and the mobile surgical units proved better suited for quick movement than evacuation hospitals.21
To serve as notice to enemy flyers, the site of an evacuation hospital was marked at first by a black cross of tarred stones in a whitewashed circle of stones, by strips of muslin 30 feet long, forming a cross, or by similar devices.21 Later, it was found advisable to equip such hospitals with a cross of white canvas, each arm 9 feet long and 6 feet wide. This was fastened firmly to the ground, preferably on a plot of green grass, before any other detail in respect to locating the hospital was given attention. If green grass was not available, black cinders were placed in the quadrants. Experience showed that a white cross on a green or black background was much more conspicuous than a red cross when viewed from the air.21
The surgeon of the First Army reported that many hospitals were spared by enemy airplanes because of their being marked in the way indicated. A further reason for employing the white cross, instead of the red, was found to be that the former showed up in photographs taken from the air and the red cross did not, as it blended with its background. Enemy observers took photographs during the day, and at night bombing planes discharged their missiles against points indicated in these photographs unless the cross marking a hospital site was plainly observable.21
The amount of transportation required for the 1,000-bed unit (30 French freight cars on 90 three-ton trucks), considerably restricted the mobility of the evacuation hospital, for it was not always obtainable. Sometimes, too, as many as 120trucks were needed to move such a hospital.25
The commanding officer of each evacuation hospital had available at all times a schedule which he had prepared for loading his unit on railway cars.21 This was based on its weight in tons, and on its cubic displacement. Besides the maximum authorized equipment,3,000 rations were included. The number of each class of cars required, that is, passenger, box, or flat cars, was also carefully determined, and requisitions specified exactly the number of cars by class. When possible, the commanding officer obtained,
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with the other cars, a car for use as a kitchen, which was open at the ends to allow, en route, easy communication with passenger cars.
After once being located within the zone of the armies, further movements of evacuation hospitals were made, as a rule, by motor-truck trains, railway trains not usually being available there. It was found that if movement by truck was not along one, the most satisfactory plan was to transport the different departments of a hospital by successive trips of one train made up of not more than 20 trucks.21 This method made a comparatively small draft on the army automobile pool and so facilitated obtaining the necessary vehicles. Neither did it delay reestablishment of the hospital, for after the first truck-train load had been received at the new site, preparations progressed there while, at the same time, property still at the former site was being made ready and forwarded. The commanding officer had a truck-loading schedule which provided that the first personnel and equipment to arrive should be the commissioned officers, nurses, cooks, and surgical department, with a sufficient number of enlisted men to assist in the preparation of the new site, and tentage and equipment for this personnel, for kitchens, and for operating room.21
EQUIPMENT
The equipment originally issued evacuation hospitals proved fairly satisfactory, but tentage for use of personnel during inclement weather and for special wards was sometimes inadequate.13
Three ground sheets similar to paulins were furnished for each tent, lumber for flooring rarely being available, and some floor covering being essential to reduce the discomfort caused by mud and dirt.21
Enough instruments to supply as many operating teams as the hospital might utilize were essential. It was found better to supply each hospital with such equipment for 10 teams rather than to supply individual operating teams with instruments and equipment and thus to restrict their mobility.13 By pooling the necessary instruments it was also found that fewer were necessary.
Throughout the hospital section equipment was kept as simple as possible consistent with efficient service. Each ward was provided with the usual ward furniture, and at the entrance a cubicle was screened off for the nurse. This contained a small apparatus for heating water and food. In the infectious wards beds were cubicled by sheets to prevent cross infections.
Electric lights were found to be superior to acetylene, as acetylene lamps were exhausted after four hours and were extinguished invariably by the jar from the discharge of a near-by gun or bursting shell.21 Duplicate electric generators were provided for illuminating at least the receiving ward, preoperative ward, operating room and office, and for activating the X-ray plant. A telephone system installed by some evacuation hospitals proved of the greatest value both in the saving of messengers and in speeding up interior service.21
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Whenever possible, field laundries were assigned to these hospitals, especially if the hospital were located, as was often the case, at a point where the laundry work could not be done by civilians.21 The output of a field laundry varied considerably but averaged about 1,200 pieces of flat work a day. Field-laundry installations were movable and were operated by two men of the permanent hospital personnel. Field laundries were supplemented by laundries of a less mobile type operated at the army medical depots which afforded a linen exchange. One of the difficulties with these mobile laundries was the extemporization of drying rooms which were found indispensable in winter in the humid climate of France.21 The inspector general, A. E. F., reported as follows, concerning the laundry facilities of these units during the Meuse-Argonneoperation:24
Some hospitals have no laundry facilities, and in others facilities are far below hospital needs. This made it necessary in some cases to salvage soiled linen instead of washing it, and requisition was made on supply depots to replace that salvaged, taxing the linen supply of the dumps. The supply of laundries, though the French sold us all they could, was always limited, and the shortage was made good to some extent before the close of the operation.
PERSONNEL
The personnel of an evacuation hospital, as officially prescribed, consisted of 34 officers and 237 enlisted men, but in practice this number was at times greatly increased.26 For example, Evacuation Hospital No. 1, at its maximum in September, 1918, had 97 officers, 92 nurses, and 674 enlisted men.4 In the Meuse-Argonne operation there was in general a shortage of personnel in all units of this character, especially for their labor, fatigue duty, litter bearing, and grave digging, though the situation improved as the attack progressed.24 As in other hospitals, the commissioned personnel was divided broadly into administrative and professional groups, though many of the officers in the latter category, for example, the chiefs of services, ward surgeons, and others, performed, as well, certain administrative duties. The administrative staff of the hospital performed the duties usually incident to hospital administration, though on account of the peculiar character of their unit these were considerably modified in some respects. In many hospitals the commanding officer was constantly engaged in inspecting and coordinating the services. As a rule, therefore, the adjutant cared for correspondence and assumed certain office duties analogous to those of an executive officer or a chief of staff. The quartermaster, selected from the Quartermaster Corps, was bonded so that he might discharge the duties of a disbursing officer, and he often performed the duties of a medical supply officer as well. In such a case he had charge of all supplies, including clothing, subsistence, fuel, and other necessities which normally pertained to his office, as well as performing the usual duties relating to transportation, installation, and operation of the lighting plant and laundry. Frequently he was the motor transport officer for the unit. The quartermaster also was charged with the maintenance of utilities service and had at his command several artisans, usually carpenters, a plumber, a tin-
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smith, and an electrician. The work required of them was often indispensable, urgent, and of large proportions, so that only exceptionally good workmen were qualified for service on this force.21
Each unit had its fire marshal, fire-fighting force, and salvage squad, detailed from the permanent personnel. These were drilled until proficient and then exercised usually at irregular, unexpected intervals. Despite the inflammable character of the structures which these hospitals habitually occupied-tents or Adrian barracks-it is a noteworthy fact that no serious fire occurred in any of them. This is all the more remarkable because of the occurrence of a number of small fires, usually attributed to lighted cigarette ends, and the paucity of fire-fighting apparatus. Fire risks in these units were very great, and the prevention of serious conflagrations is attributable chiefly to the vigilance to all those concerned.21
Salvage proved difficult because of shortage of personnel, and much property was lost before the Salvage Department arranged to collect property at these units and transport it to dumps.24
A specially qualified officer was selected to command the detachment of enlisted men, Medical Department, to train them in their military duties, to care for their service, pay, and other records, to command the guard, and to supervise police of the unit.21
The registrar, frequently an officer of the Sanitary Corps, usually discharged also the duties of a statistical officer. He supervised the preparation of the cards for sick and wounded, notified the chief surgeon, A. E. F., if epidemic disease appeared, collected and forwarded individual medical record cards, X-ray plates, records, and histories of cases evacuated, and in case of death notified the chief surgeon, A. E.F. At 6 a. m. daily he reported by telephone or by courier to the evacuation officer of the army the number of empty and occupied beds, the number of admissions, classified as sick, wounded, and gassed, for both officers and men, and the number of deaths during the preceding 24 hours. Another of his duties was the daily posting of a diary which gave appropriate data concerning movement of the unit and the number of patients admitted, classified as medical, surgical, or gassed. These patients were subclassified as infectious or noninfectious medical, severe or slight surgical, while the gassed were classified, if possible, according to the kind of gas used. This officer also kept a daily record of the number of operations on patients with slight and severe surgical conditions, and the number of deaths, with name, cause, time and place of death, and number of grave. One of the subjects considered in this war diary was the number and class of patients evacuated, classification being made both according to the condition from which patients were suffering, whether they were sent out recumbent or sitting, and whether they were commissioned or enlisted.21
Still another member of the administrative staff was the mess officer, who was often selected from the professional staff, and who supervised this important service in addition to his other duties. Two diet cooks and a dietitian were provided if possible. Field ranges did not prove so satisfactory as did
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the rolling kitchens, supplemented by five army ranges No. 5, or by gasoline ranges.21
The chief nurse performed the duties usually incident to her position.21
A chaplain proved indispensable. Assignments were made irrespective of the ecclesiastical denomination of the incumbent, who supervised and promoted both religious and moral activities. The latter he interpreted in their broadest sense, including among them diversion for patients and personnel.21
The professional groups were headed by the chiefs of the surgical and medical services, in their respective jurisdictions, but an approved plan in some units was to have the surgical chief limit his activities to the operating area and to entrust to a director of wards the supervision of all other professional matters within this specialty. Usually, however, the chief of the surgical service supervised all triage activities, together with those in the operating room, shock wards, and other surgical sections of the hospital, organized teams to care for special classes of patients, according to the known ability of each member, selected patients for operation, distributed surgical patients to appropriate teams peculiarly well fitted to care for them, and assisted in determining the need for hospital trains. The chief of the medical service supervised the medical work to secure prompt and skillful treatment of medical and gassed patients. Often he was the assistant chief of the triage service, alternating in this duty with the surgical chief.21
The surgical teams were a very important factor in the service of these hospitals. Usually, four of them were organized from the personnel on duty in the hospital, and these were supplemented as occasion required by teams drawn from othersources.21 Usually there were 7 or8 teams on duty, but their number was increased, according to needs, to 14 or more.27 It was found advisable to add to the personnel of each hospital 12 surgical and 2 gas teams, each surgical team consisting of 2 surgeons, 1 anesthetist and 2 nurses.21
Experience showed that the best chiefs for teams were not usually operators with the highest civilian reputation. Such older men often proved unadaptable, unable to learn quickly, and lacking in physical endurance. It was an unfortunate fact that the older men, because of their civilian professional standing, continued to be sent forward with teams long after other nations had learned that such details were better filled by younger men, because of their greater endurance and adaptability.b 13In times of great pressure, teams were sometimes split, but good results were obtained then only if the assistant showed himself unusually competent. On rare occasions it proved better to keep a team on duty 18 hours rather than to split it.13Most operators were able to endure this ordeal during a short emergency, but in order to make the method effective, consideration had to be given, in making details to teams, to take cognizance of each operator’s endurance.
As a rule the medical officers who proved most generally valuable in evacuation hospital service were those who had been graduated not more than 8 or 10 years before entering the Army, as they were more vigorous and more
bOur service fully recognized this principle, but was unable to apply it because of the urgency of our need for operators at the front.
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adaptable than their seniors. Officers were usually assigned in the proportion of one medical to three surgical, an excess of medical trained personnel being detailed to duty in the wards for ambulant wounded, the receiving ward, dressing rooms, and for similar service.13
SPECIAL DEPARTMENTS
The departments of an evacuation hospital, other than the administrative, whose services are discussed above, were the following: Receiving ward, dressing tent, preoperative ward, X-ray room, examination and operating rooms for patients with serious conditions, operating room for patients with minor conditions, sterilizing room, pharmacy, laboratory, dental clinic, shock ward, wards for special patients, other classified wards for retained patients, medical, surgical and gassed (if these latter were not cared for in neighboring hospitals), and wards for transportable patients to be evacuated. Other departments of the hospital which require no discussion here were the mess halls and kitchens for patients, officers, nurses and enlisted men, quarters for duty personnel, and a recreation tent which was provided whenever possible.21
Space allotted the several departments of the hospital varied according to a number of very mutable conditions, that is, severity of combat, number of operating teams available, train service and other considerations. The ground plan varied with the terrain, available buildings, water supply, distribution, and kindred conditions, but whatever plan was adopted, the necessity for short litter carriage received careful consideration. Evacuation Hospital No. 5 arranged five Bessonneau tents in line. These five tens provided successively for admission, dressing, X-ray examination, preoperative treatment and operation. Patients were carried through all of them if necessary, beginning with the admission tent; otherwise they passed out of line to the appropriate ward after being taken to the tents where they received necessary attention. Location of the receiving ward was indicated by a conspicuous sign. For use at night, an illuminated sign, which could not be seen from above, was sometimes employed. This consisted of a metal box, its face perforated by appropriate lettering. Habitually this ward was placed at the side of the hospital opposite to the evacuation ward. It occupied a well-heated tent or barrack large enough to accommodate from 20 to 60 litter patients and had benches for sitting patients. It was also provided with a quantity of blankets, splints, and litters for replacement issue to ambulances which left such articles with patients they delivered. The point where these articles were stored was sometimes designated by a conspicuous sign, "Blanket, Splint, and Litter Exchange."21
At the receiving ward commenced one of the most important procedures of the service of the hospital, that is, the sorting of patients and their proper distribution. This sorting and re-sorting continued throughout all the departments to which patients successively were sent. It was essential that the stream of sick and wounded move systematically, that there be no reverse or cross currents. The method followed differed somewhat in different hospitals, but that described below was the one generally employed.
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The quota of personnel on duty in the receiving ward also differed somewhat in the several hospitals, but usually it consisted of 2 officers, 1 sergeant, 8 clerks, 2 guards, and 8 or 10 litter bearers. Officers on duty here gave emergency treatment in case of hemorrhage, supervised litter bearers’ activities, the preparation of records, and the care of valuables, made appropriate note on the admission card of a patient if antitetanic serum had not been administered, and distributed patients to wards for gassed and medical patients, to the dressing tent for walking wounded, to the preoperative ward or to the shock ward, as the case might be. Records were made here giving each patient’s name, his military designation, diagnosis and any other necessary data obtained from personal interrogation and from an examination of his field card and diagnosis tag.13 If the patient was unconscious these facts were obtained from other patients accompanying him, and from his identification tag, as well as from the other sources mentioned.21 In some hospitals a nominal list was usually made on the admission of patients, and two copies of Form 52 were made out for each patient in the wards. One of these was sent to the sick and wounded office at once and this furnished the data for reports called for from the hospital. The other copy was turned in to the sick and wounded office when the patient was evacuated. In other units complete records were made, so far as this was possible, in the receiving ward, and these records were supplemented later by data from the operating room and wards. Walking wounded who were seriously injured were sent to the preoperative ward, tagged for immediate attention. Similar tags were placed on shock patients and on those with tourniquets. Gassed patients were classified as medical and were sent to appropriate wards or to a neighboring unit which provided for such patients exclusively.13 If the patient’s condition permitted he was sent to his destination via the bathhouse. There patients were treated or bathed with alkaline soap and solution as indicated. Otherwise they were bathed in the ward. If the patient was to be retained he was furnished pajamas; if he was to be evacuated or returned to duty he was given fresh clothing and sent to the evacuation ward.21 Medical patients were distributed to appropriate wards. Patients suffering from epidemic respiratory disease were masked.21
Attention was given at the receiving ward to the care of patients’ valuables. In this important detail service improved greatly after the St. Mihiel operation. Men sent to evacuation wards sometimes retained their valuables, but all others were relieved of them. All were notified that the hospital disclaimed all responsibility for valuables retained by patients. A noncommissioned officer of established probity placed the patient’s valuables in a bag and gave him an itemized receipt, ticketing the bag in duplicate. These valuables were kept in a locked box or locker until the patient left the hospital, when they were returned to him, his receipt for them was obtained, and the original receipt was collected. These receipts were retained until the hospital was closed, when they were sent with other records to the office of the chief surgeon, A. E. F. In case of death patients’ valuables were turned over to the properauthorities.21
In most instances, food and hot drinks were given at the receiving ward, sometimes by a volunteer aid society, to all patients admitted, but in some units
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refreshments were given here only to such patients as were sent from this point to the medical and gas wards, others receiving nourishment in the dressing tent or in the preoperative ward. Arrangements were made also at the receiving tent to give food and drinks to ambulance drivers.21
The dressing room for the slightly wounded was located near the receiving tent. Its equipment was simple, consisting of one or two operating tables, benches, a table for instruments, and dressings and utensils which had been sterilized in the main sterilizing room.21 One or sometimes two officers, assisted by one or two nurses and by two or three enlisted men, were on duty here. At this point a second sorting was effected. The officer on duty examined, dressed, and recorded patients admitted to this department, giving antitetanic serum to such patients as had not already received it. Patients requiring immediate operation or who might be evacuated at once (on litters, if the pressure was great) were properly tagged and sent to the preoperative ward. Patients, whose conditions were not critical, requiring X-ray examination were sent to the X-ray department. Since patients with very serious injuries-for example, injuries of the large blood vessels and even compound fractures of the skull-were sometimes ambulatory, careful attention was given every wound, however slight it might appear to be. At this point, too, careful search was made for injuries of nerves and blood vessels. Provisional diagnosis and administration of antitetanic serum or morphine were noted on the patient’s field medical card.21
Patients other than those already mentioned were sent to the wards for slightly wounded, or to the evacuation ward, after their wounds had been dressed and they had received hot food or drinks if, as in some hospitals, these had not already been given in the receiving ward. Slightly wounded patients who had developed intercurrent diseases, such as pneumonia, dysentery, or the like, were sent habitually to the appropriate medicalwards.21
Decision as to whether slight wounds should be operated upon was based on the rate of admissions, the number of surgical teams and their speed. It was found that an experienced team operating 2 tables often handled 35 or 40 minor patients during its shift; later this number was notably increased because of better organization and improved skill, until many teams operated upon more than 60, some more than 80, patients, and 1 team more than 90 patients, during the daily shift.23 In periods of comparative quiet, at first practically all surgical patients admitted were operated on, and toward the end of the war this was the case even during periods of great military activity. The chief of the surgical service kept his teams fully occupied, the number of preoperative patients transferred being limited only by the surgical facilities locally available.21
The third major sorting of patients was effected in the preoperative or classification wards, which received the wounded admitted on litters and certain ambulatory patients sent from the dressing tent. Patients received here required 80 per cent of the professional skill available in an
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evacuation hospital. At this point, on alternating day and nightshifts, were stationed the most experienced men on the professional staff, selected with regard to accuracy and rapidity of decision and adjustability to the constantly shifting standards which controlled the disposition of patients. The quota of nurses and orderlies in this department was large; usually there were 1 officer, 1 nurse, and 4 enlisted men to each ward. Day and night shifts were provided. Patients were undressed, bathed, if possible, and their wounds were examined and dressed. When possible they were undressed in one tent and their wounds were dressed in another.13
Provision of adequate bathing facilities was often, indeed usually, very difficult. Furthermore, the use of the bathhouse, if one was provided, and the administration of baths in wards at night were attended by the danger from airplanes incident to the necessary showing of lights. Many patients admitted after nightfall, whose conditions required immediate operation, were bathed in the preoperative ward and were not sent to it via the bathhouse. Whenever possible the bath hut was equipped with instantaneous heaters, 2 boilers containing 50 gallons each, and shower heads, perhaps as many as 8, and floored with duck boards. As patients usually arrived in the hours from 12noon to midnight, these baths, in some evacuation hospitals, were used exclusively by the detachment personnel before 8 a. m., by the nurses from 8 to 10, and by the officers from 10 to 12.21 As noted, bathing was not always feasible, if patients were admitted in great numbers at night and enemy airplanes were attacking all places which showed lights.
In some hospitals a sketch and description of the wound were made when patients were being bathed, and this record accompanied the patient to the operating room. If the patient’s condition was critical, his clothing was not removed until he had been anesthetized, or if he was badly shocked, not until rising blood pressure warrantedit.13
In the preoperative ward waiting patients received morphine, if this was needed, and hot drinks and food if these had not already been administered or ifdesired.21
The success of an evacuation hospital’s service was commensurate in very large degree to its methodical and successive distributions of patients. At the three points mentioned above-receiving ward, dressing room, and preoperative ward-it was essential that there be prompt, accurate diagnosis and immediate distribution inconformity with very changeable demands for evacuations. Distribution from the preoperative ward was determined primarily by the number of patients to be cared for and by the facilities for operating, and not entirely by the patient’s condition. When operating teams were limited in number, or inexperienced, a rapid influx of patients would change the standard of selection of patients for operation from all litter and the more serious walking cases; for example, into a very much more restricted class composed chiefly of patients with abdominal wounds, aspirating chest wounds, and fractures of the femur by shell fragments. Under such circumstances patients had to be sent out on preoperative trains until operat-
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ing teams were furnished in sufficient number and had acquired sufficient speed to care for them.13
Only in exceptional cases were patients sent from the preoperative ward direct to the operating room. These included patients with active hemorrhage, or patients received with tourniquets in place, and with certain fractures without splinting.13
The preoperative ward, X-ray section, operating rooms, and wards for the severely wounded were grouped as near together as possible, for it was essential to reduce carriage by litter to a minimum. If this was not done, it was found that litter squads were exhausted after a week’s offensive.13
Patients were distributed from the preoperative ward according to rate of admission and available operating facilities, into (a) special wards for head, chest, and abdominal patients; (b) shock ward; (c) X-ray ward; (d) operating rooms, and (e) evacuation ward.13
In some hospitals, to facilitate their care, patients with head, chest, or abdominal wounds were segregated in a special ward which accommodated both pre operative and postoperative patients. Such a ward was best located next the shock wards but was not attended by the same personnel, the shock teams being fully occupied in their own department. When this arrangement was followed this special ward received, among others, patients who were too badly shocked to undergo immediate operation.13
The special ward for head, chest, and abdominal patients, containing those both operated and unoperated upon, was in charge of one of the most competent officers available. If patients with head injuries were to be operated upon before evacuation, the operation was performed as soon as possible. Patients with abdominal wounds were operated upon as soon as their condition warranted. In injuries of the chest, immediate operation was indicated in only a small group of cases: (1) Aspirating chest wounds; (2) large retained foreign bodies; (3) severe injury of bones; (4) complicated lesions of the diaphragm.13 Other chest wound cases were sent to this ward for observation and were there placed in the sitting position, given morphine, splinted by adhesive plaster when this was called for, and given other necessary treatment. A combined infection by B. welchii and streptococcus usually required operation, but a large majority of the chest wounds did not require surgical intervention. Those requiring it were X rayed, and in many cases it was found that if the missile had originally been embedded in the lungs it had dropped down and could be removed from the bottom of the chest cavity. A thorough examination of the wound was made and drainage established if needed. Preoperative treatment of head, chest, and abdominal wounds, and decision concerning operation required special care, skill, and judgment. Head wounds usually, no matter how severe, did better if treated at once, but such interference delayed the evacuation of the patients concerned by some two weeks. Whether operation should be performed here or deferred until the patient reached a base hospital where he could remain indefinitely, was a highly controversial subject.13 From a professional standpoint operation on head
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wounds at an evacuation hospital was indicated; from a military standpoint it usually was not. This was one of the instances where general and individual interest conflicted.13
For the shock ward, a Bessonneau tent usually was employed, equipped with all means for treating shock, including heat, posture, morphine, fluids, and gumacacia solution, or citrated blood. It was adjacent to the preoperative ward, and in addition to being kept at a high temperature-90F.-was equipped with hooded tables which further secured warmth to patients in a state of shock. In general, this ward received patients with blood pressure below 100, and other patients as conditionindicated.13 A large proportion of patients admitted here had fractures of the femur, and most of its other patients had severe and multiple injuries. Patients were usually sent to this ward direct from the receiving department, but occasionally those who had developed shock more slowly also reached it from the dressing room, from the preoperative ward, or from the operating room. When a shock patient had improved and his blood pressure was rising, the chief of the surgical service determined when operation should be performed. As delay now meant increased infection or lost opportunity, such patients had precedence over all others except those with active hemorrhage. Patients who developed shock while under operation were sent to the shock ward or, if necessary, were transfused by the shock team while on the operating table.13
It proved convenient to place the X-ray department at one side of the operating room, and the sterilizing room at the other side. If a Bessonneau tent was used for the X-ray department there was room for dental and laboratory departments in the sametent.13
The X-ray ward was also close to the preoperative ward and sometimes connected with it. Its interior was darkened by black cloth or paper. Selection of patients to receive fluoroscopic or screen examination was made by the chief of the surgical service. Most patients so examined were those with fractures or foreign bodies. Clean, uncomplicated, perforating bullet wounds were not examined radiologically, as a rule, unless the missile had passed close to a bone or a joint.21 Shell wounds, on the contrary, required X-ray examination in every case, as otherwise it was impossible to determine the presence or location of shell fragments in the deeper tissues. Injuries to the cranium were photographed both to facilitate immediate care and to furnish a record for the use of other surgeons who would attend the patient infuture.21 However, plates were used only for conditions of peculiar interest and where accurate localization of foreign bodies was desired. Whatever the method of examination employed, the radiographer made a record of his findings in a brief note or sketch on a slip which was affixed to the patient’s field medical card, or entered it on the card itself. As a matter of fact, the majority of patients operated upon were examined radiologically before they were sent to the operating room, though certain types were operated on without this; for example, those with active hemorrhage or those received with a tourniquet in place, and fractures that had not been splinted before admission.13
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From the radiological department the patient was sent to the operating room; or if no fracture or foreign body was found, and (before team service was fully developed) if early operation was not possible, to the evacuation ward.13
Though operating-room facilities differed considerably in the several hospitals, when possible to avoid it, not more than 10 patients were allowed to accumulate, awaiting operation. A Bessonneau tent, floored with wooden sections(transportable) and provided with a sectional table and one sectional shelf under it running the length of the tent, proved very satisfactory, but two such tents were advisable to meet emergency needs. One of these was sometimes used for minor injuriesonly.13 The top of the table mentioned was used for scrubbing basins and sterile instruments, while the shelf below contained packets of gauze, towels, sheets, bandages, and similar articles, and below this, on the floor, was space for splints. The operating tent was made light proof by black linings with hinged window flaps. From 6 to 10 operating tables-usually 8-werespaced on the side of the tent next the long table holding instruments, leaving a 4-footpassage at their other end for litters, which were made to pass in one direction only. One or, if possible, two electric lights-one on a long cord, and each provided with a cone shade to prevent dispersion of light rays, especially upward-were placed over each operating table. Tables were provided also with slings, rigged up on wires. Each operating team used two tables, a method which speeded up work considerably, especially on minor wounds requiring local anesthesia, and head wounds which required shaving of the entire scalp. Patients with abdominal, head, and chest wounds were assigned to special teams.13 Local regulations concerning such matters as suture or non suture of wounds, hours of assignment, and conservation of supplies were posted, especially for the information of surgical teams temporarily assigned.13
Two surgically clean nurses, with all the available instruments boiled and divided equally between them, could supply any number of teams that could operate in a Bessoneau-tent ward. When each shift went off duty, and, as happened much more frequently, a break in asepsis or other condition required, an entirely fresh layout was made.13
An orderly served each shift, noting on each patient’s field medical card a statement of the surgeon’s findings, the operation performed, and the word "evacuate" or "detain." Patients held included especially those with wounds of the head, chest, and abdomen, with fractured femur, and with shock. A copy of the note made was entered in the operating-room book, supplemented by an entry of the patient’s name, his official designation, the interval between injury and operation, the diagnosis, and the X-ray report. The operator’s name followed both entries. Decision as to whether patients were to be evacuated was influenced by admissions, concerning which the chief of the service kept the operating teams informed. The field medical cards of patients who died on the operating tables were completed and turned in to the record office.13
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The operating room was usually in charge of an officer under whom were the recorder, a noncommissioned officer in charge of the enlisted personnel then on duty, a nurse in charge of sterile instruments, an enlisted man who received them from her for each operation, three general utility men to move patients and to hold a leg or an arm to facilitate operation, six litter bearers, one messenger, and one man in charge of sterilizing dressings. The nurse in charge of sterile instruments had a great quantity of these at hand on a table provided for the purpose, and issued them as called for.21
When a patient was carried from the operating room he passed the assignment sergeant, who designated the ward to which he should be taken. This was determined from notes on the patient’s card-evacuate or detain-and from the record kept here of the location of vacant beds.
Sterilization apparatus was installed in a hut or tent near the operating room, but separate from it, as a rule, because of the danger of fire. This equipment approximated the following articles: Autoclaves of 24-inch diameter, numerous drums for dressings, instrument boilers, and three vessels each provided with a faucet and having a capacity of 25 gallons. The last named were supported on an iron foot base, and all were heated by gasoline burners. There was some variation in this equipment, the personnel of a unit sometime showing considerable resourcefulness in extemporizing apparatus.21
The work of sterilization was conducted as a rule by two nurses assisted by two or three enlisted men.21
The wards of the hospital other than those mentioned above were for postoperative patients, for other surgical patients awaiting evacuation, for certain medical and for gassed patients. In postoperative wards alternate shifts of one officer, one nurse, and six enlisted men usually were provided. In some units the operating surgeons spent eight hours a day in ward service. These postoperative wards, like others, were assigned to different ward surgeons who might or might not be members of operating teams. As a rule, ward surgeons dressed postoperative cases except when these were difficult and the admissions few. All surgeons in charge of wards carried out the usual administrative record routine, making needed notations on field cards, daily reports of transportable and detention patients, classifying transportable patients as "walking" or "litter," "medical" or "surgical," "officers," and so on. This classification was made daily; in some hospitals, twice a day. In certain hospitals patients were tagged for removal with distinctly coloredcards.13
In order to utilize the floor space of the evacuation wards to the greatest capacity possible, racks for litters were used, and sometimes for as many as 250patients. Furnishings of these evacuation wards were few and simple, and there were comparatively few attendants, as patients could care for themselves here to some extent.21
Evacuation wards received postoperative patients for evacuation in addition to those sent to it from the receiving ward and the dressing tent.13 As hospital congestion increased to beyond the point where patients could be operated upon locally within a reasonable period, naturally more and more
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severely wounded patients were sorted out of the preoperative wards and sent to the evacuation wards; for example, gutter wounds, clean, perforating wounds, wounds with retained bullets, gunshot fractures of smaller bones, until it might be that only patients with wounds of the most severe type were retained for operation.13
In some hospitals the evacuation officer was the detachment commander; in others he was both receiving and evacuating officer. He usually had charge of the evacuation wards and arranged, under the commanding officer, for hospital trains. Not infrequently he had an assistant who alternated with him, being on duty during the night. The evacuation detail consisted of about 40 men, selected from among the strongest men of the detachment, to perform the exhausting duty of litter bearing.21
In the early part of our activities north of Toul, prior to the St. Mihiel operation, when evacuation hospitals were still lines of communications’ units, evacuation from them was not made automatically, but occurred only when such a hospital became pressed for bed space, or needed to evacuate patients more or less permanently unfit for military duty. Evacuations were then arranged for by the French, under whom our divisions were then serving, and usually occurred only when a full train load of transportable patients was ready. The hospital concerned reported to the chief surgeon of the advance section and also to the chief medical authorities of the area. The latter then notified the hospital of the time of the expected arrival of the train and the number of wounded, sitting and prone, which it would carry. Nominal checklists of patients evacuated were furnished the chief surgeon, advance section, and the commanding officer of the destination hospital. At this time the French required reports of all patients to be evacuated in forward hospitals so that they might be cared for in the event of a hurried retreat.15
Later, during the Meuse-Argonne operation, if an evacuation hospital was not located at a railhead, and it was desired to evacuate by ambulance to one so located, the evacuation officer of the former hospital ascertained how many vacant beds there were in the latter, and upon mutual agreement between the two sent it such a number of patients as it could receive, accompanied by a nominal and classified list of patients.28 The evacuation officer sent to the regulating officer and to G-4, General Headquarters, a copy of this list and a statement of the hospital to which the patients had been sent.
When an evacuation hospital was at a railhead and a train was desired, the evacuation officer of the hospital notified the evacuation officer of the army, on duty with G-4 of the army concerned, stating the number of transportable patients, classified as to medical, surgical, and gassed, prone and sitting; officers and menseparately.21 G-4 of the army supplied this information to the regulating officer, who then dispatched a train. In time of great activity, as during the Meuse-Argonne operation, the evacuating officer of a group of hospitals in an evacuation center notified the regulating officer twice daily concerning the number of patients to be evacuated, classified as above. With this information the regulating officer reduced the necessity for requests for trains to a minimum, as these figures showed where trains were needed. The
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situation was further simplified during the Meuse-Argonne operation by providing that in time of stress the commanding officer of an evacuation hospital could notify the regulating station of his number of transportable patients in detail; with this information, and without any specific request for a train, the regulating officer would supply his need. During all the latter part of our combat activities this method became the rule and not the exception. But, in order to diminish need for such reports, a certain number of trains arrived daily in each evacuation area.29
Trains usually arrived on from one to six hours’ notice, but sometimes they were spotted before orders to evacuate were received. If possible, medical and surgical patients were sent out on separate cars. When possible, patients with infectious diseases were segregated when placed on the hospital trains, but this was not always possible, especially during the influenza epidemic. Psychiatric patients were reported to the train commander and placed in a separate group. Weapons of all kinds were removed from the men evacuated and were turned in to the salvage officer, and the patients concerned informed of their disposition.21
Litter surgical patients were segregated from ambulant surgical and medical patients, when conditions permitted, especially if the latter were infectious. As a rule, litter patients were loaded first, but when American trains were used it was often possible to load ambulant and litter patients simultaneously. The time necessary for loading a train was determined largely by the number of litter patients, usually from 40 minutes to 2 hours. Between September 8 and December 12, 1918, Evacuation Hospital No. 9 evacuated 36,204 patients on 106 trains, the largest number on one train being 787 (all ambulant).17
When possible the morgue at evacuation hospitals was equipped with demountable racks for four litters, washing facilities, and galvanized-iron cans. It was often located in the same hut with the lighting unit and the carpenter shop.21
Graves were dug by neighboring labor troops if their services could be obtained. This did not always prove practicable, and, with the exception of litter bearing, grave digging proved the hardest physical labor imposed on enlisted men serving at these hospitals,21and one the proper performance of which was attended with great difficulty. Demands on hospital personnel were such that most careful arrangements were essential in order that patients might be adequately cared for, and, at the same time, the dead be properly interred.
MOBILE HOSPITALS AND MOBILE SURGICAL UNITS
Our Medical Department found in the French service two medical units, previously unknown in our Army, organized and equipped to care for the seriously wounded at locations well up toward the front,30 and quickly undertook to provide similar units for like duty with our troops. These were the mobile hospital and the mobile surgical unit called, respectively, by the French auto-chir and groupe complimentaire.31 Until the latter part of 1917,
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the French auto-chirs were being improved and modified so constantly that scarcely any two were alike in the earlier years of the war. The type they generally used early in 1917 had no hospital facilities, and for this reason it habitually operated in conjunction with an evacuation hospital. Toward the fall of 1917, the need of a hospital section had become evident to the French, and this was added in the Plisson-Proust model (type 1917). This model occupied wooden barracks when these were available, otherwise, large and small Bessonneau tents. The mobile equipment was divided into the following units, each of which was carried in a motor van:31 (1) Operating-room truck, with operating tables and other equipment; (2) X-ray truck, with generator for lighting; (3) sterilizing truck; (4) kitchen truck; (5) truck for tentage and bedding. The personnel consisted of two groups, one permanent, as follows:4 surgeons and 4 assistants; 1 quartermaster; 1 bacteriologist and an assistant; 4anesthetists; 1 pharmacist; 1 chemist; 1 radiologist and an assistant; 10 nurses, and 35orderlies. This personnel was considered sufficient to allow the auto-chir to function continuously for 24 hours.32 For periods of great activity a second group of emergency personnel, when available, was added as required.
FIG.32.-Mobile Hospital No. 2, loaded on trucks, and prepared for change of location
Since the function of the auto-chir was to receive seriously wounded close to the front and to give them thorough X-ray examination and surgical treatment before sending them farther to the rear ,its value depended largely upon
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its elasticity, which permitted it to extend its bed capacity from 100to 500, and upon its mobility, which permitted it to be pushed forward beyond the railhead, and rapidly from one point to another.
Prime features in the operation of the auto-chir were: (1) Early receipt of patients, within six to eight hours; (2) retention of patients with wounds of the head, chest, or abdomen; (3) debridement, with Carrel-Dakin treatment later; (4)primary suture; (5) X-ray examinations; (6) laboratory study; (7) delayed evacuation.32
Trucks enabled the auto-chir to follow troops closely, and it could be made ready for work in a few hours. When possible it was grouped about some building which could be used for receiving and retaining patients. In such a case it might be necessary to send forward only the first three trucks. It was intended that, in connection with suitable barracks, an auto-chir would care for 550 patients. Two of them, in connection with an evacuation hospital, could thus accommodate 2,100 cases. Under such circumstances, each separate surgical group remained on duty until 400 patients had been received, then the companion group went on duty for a like period.31
The groupe complimentaire was a lighter form of auto-chir which carried operating and X-ray equipment and was generally used for some special service; for example, for operations on the face.32
Under date of February 25, 1918, the chief surgeon, A. E. F., wrote the Surgeon General as follows:33
1. The chief surgeon, A. E. F., has entered a contract for the manufacture of 20 auto-chirs and 20 complementary groups for use in connection with the field hospitals and evacuation hospitals. Delivery of these units will be begun on March 1 and continue until August 30 of the present year.
2. As each unit will be equipped with complex machinery, dynamo, X-ray machine, sterilizer, autoclave, boiler, etc., it is very evident that it should not been trusted to non-skilled labor but should be supplied with sufficient skilled technical personnel to operate and make repairs on the machinery.
3. To this end it is recommended that the following personnel be sent to France in increments of 12 per month for the next five months, the first 12 to be started at the earliest practicable date and the remainder to follow at the rate of 12 per month. Each auto-chir should be provided with a team composed of the following men:(a) An electrical and mechanical engineer who is an officer in the Sanitary Corps; (b) a steam fitter who is able to run boiler, autoclave, gas engine, etc., and make repairs to same; (c) an expert automobile mechanic able to repair auto trucks. In addition, a handy man with carpenters’ tools would be available.
4. It is requested that a search be made for the above men among the personnel of the ambulance companies at Allentown, Pa., and 4 teams be shipped to France each month until the entire 20 teams are sent.
5. Immediately upon arrival in France it is intended to have these men undergo a course of instruction at the factory near Paris, where the auto-chirs are manufactured, so that they may be able to study the assemblage, the operation, and the repairs to the same prior to being put into service.
The auto-chir and groupe complimentaire were adopted by our service, and their organization was prescribed by General Orders, No. 70, General Headquarters, A. E. F., May 6, 1918,which reads in part as follows:
II. 1. The developments of modern warfare have necessitated the adoption by the Medical Department of the A. E. F. of two types of mobile sanitary formation which in the French Army are known as auto-chirs (autonomes) and groupes complimentaires.
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These units have been designed in order that facilities for immediate surgical aid to the seriously injured may be brought to the man instead of removing any chance of recovery that the nontransportable wounded have by conveying them an uncertain distance to the hospital.
2. As supplied from time to time, these organizations will be given numerical designations, in a single series for each class, and known, respectively, as "Mobile Hospital No. -----, A. E. F.," and "Mobile Surgical Unit No. -----, A. E. F."
3. A mobile hospital consists of FIXED sterilizing, X-ray, and electric lighting plants mounted on two motor trucks. In addition, and transported upon ordinary motor trucks to be temporarily assigned as required, are a light frame operating room, tentage, and hospital material sufficient to establish a surgical hospital of 120 beds. The operating features are designed to provide all modern facilities for six surgical teams. Mobile hospitals may function independently, or they may be attached to other advanced sanitary formation to reinforce their X-ray and surgical departments.
4. A mobile surgical unit consists of PORTABLE sterilizing X-ray, and electric-lighting plants, a light frame operating room, and surgical material mounted on two motor trucks, or on a truck and trailer. It does not provide hospitalization facilities, and therefore can not function independently. This unit supplements the equipment of the advanced field hospital of the division and provides requisite surgical facilities for immediate surgical aid to the nontransportable wounded.
5. The above organizations will be attached to tactical organizations to meet the varying requirements of field service. They will be withdrawn from such organizations when their services are no longer required or there exists a more urgent need for them elsewhere. Their assignment to duty will be regulated by G-4 of the Army to which they are attached.
6. In conformity with the above, Auto-Chir No. 1, now being operated by the personnel of Base Hospital No. 39, is hereby designated and will hereafter be known as "Mobile Hospital No. 39, A. E. F." Groupes Complimentaires Nos. 1 and 2, now in operation, are hereby designated and will hereafter be known as "Mobile Surgical Unit No. 1, A. E. F.," and "Mobile Surgical Unit No. 2, A. E. F."
7. For these new-type organizations, and as they are organized from time to time in the future, the following personnel is authorized:
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A MOBILE HOSPITAL | |
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(a) Commissioned: | |
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1 |
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10 |
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1 |
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(b) Enlisted: | |
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1 |
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17 |
|
62 |
|
(c) Army Nurse Corps: | |
|
22 |
|
A MOBILE SURGICAL UNIT | |
|
(a) Commissioned: | |
|
1 |
|
(b) Enlisted: | |
|
1 |
|
3 |
|
8 |
Mobile hospitals, numbered from 1 to 11 and No. 39 operated in France. Six others, Nos. 100 to 105, inclusive, organized in the United States, and three others, Nos. 12 to 14, inclusive, organized in France, were ready too late to par-
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ticipate in the war.34 It had been planned to provide one for each combat division.
Twelve mobile surgical units were organized at Paris and four others at Joinville, but the latter were not completed in time to see active service.34
Concerning the organization of mobile hospitals in the American Expeditionary Forces, the following extracts have been made from the report to the chief surgeon, A. E. F., by the officer charged with the mobilization of these formations. This was made in the spring of1919:35
During the latter part of August, 1918, I was instructed by the chief surgeon’s office to find a suitable location for assembling mobile hospitals, the place to be suitable for assembling equipment, mobilizing, and giving preliminary training to the personnel, and to have sufficient space for setting up two or more mobile hospitals at one time. As the mobile hospitals had as a nucleus the equipment of the French auto-chir, obtained from the French Government at Fort De Vavnes, near Paris, it was necessary to find such a location in the vicinity of Paris.
Previous to this Mobile Hospitals Nos. 1, 2, and 3 had been equipped in the polo field near Paris. This was accomplished by the personnel being ordered to Paris and the equipment obtained by the commanding officer as it became available from the French and from our Quartermaster and Medical Department supply divisions. At that time Mobile Hospital No. 4 was being equipped at the polo field, and the personnel of No. 5were there awaiting equipment.
What was believed to be an ideal place was found at the Parc des Princes, Port St. Cloud, just outside the city wall of Paris, 5 miles from Fort De Vavnes, and three-quarters of a mile from the Gare Grinelle freight yards. It was being used at the time by the French as an auto park. It had barracks and kitchen facilities for a personnel of 400, automobile sheds covering approximately 48,000 square feet, storehouses with 25,000 square feet of floor space, a building suitable for use as a machine shop; macadamized roads, electric lights, telephone, and sewer systems. The surrounding grounds were well drained, having a hard cinder surface, and were of sufficient size for assembling three mobile hospitals at one time.
This park was obtained and the personnel of Mobile Hospital No. 4 moved from the polo field on September 4.
It was planned to have a sufficient personnel on duty at the park to handle supplies, do the necessary guard duty, and to act as instructors for the mobile hospitals. This personnel was to consist of 4 officers and 68 enlisted men.
Owing to the shortage of Medical Department personnel at that time the above number could not be assigned; so authority was obtained to transfer to the park for duty such personnel of Mobile Operating Unit No. 1 as had not been assigned to other duty. There were also assigned for duty at the park, Lieut. Seldon Rose, S. C., who had previously been on duty with Mobile Hospital No. 39, was familiar with the French equipment of mobile hospitals and, in addition, spoke French fluently; 2 sergeants and 2privates from Medical Repair Shop No. 1, who were familiar with the French sterilizer truck and portable laundry; and 1 sergeant from Mobile Hospital No. 39, who was familiar with the setting up of tentage and arranging the equipment of mobile hospitals.
With the assignment of this personnel an attempt was made to organize a permanent working force as above outlined, using Lieutenant Rose, on duty at Fort DeVavnes, as liaison officer, and checking the French property as it was delivered; one sergeant and one private on duty at Fort De Vavnes as inspectors during the assembling and testing of the sterilizer and electrical trucks; the mobile operating unit personnel distributed according to their qualifications. During the latter part of September the personnel of Machine Shop Unit No. 352, which had been assigned to Mobile Operating Unit No. 1, arrived from the United States and was retained at the park as part of the permanent personnel. The
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attachment of this organization was of the greatest benefit, as practically all of the motor equipment, as received from the French, had to be completely overhauled. Up to this time there had not been personnel at the park qualified to do this work.
Request was made that 5 officers and 30 men be sent to the park for each new unit before the equipment of that unit was received, the idea being that this personnel would be selected from the ones who were to handle the technical equipment and this personnel could be given training by the permanent personnel so that when the equipment was complete the organization could be reported ready for duty without unnecessary loss of time and still have sufficient personnel trained in pitching the hospital, running the laundry and the sterilizer, electrical and cargo trucks. It was planned to have the nurses join a few days before the organization was ready to leave, and the balance of the personnel to join at the time of leaving, or at the new station.
The above plan was carried out in most instances, and as soon as the personnel of a new organization arrived the commanding officer was given a typewritten list of the equipment of the mobile hospital and instructed to make the following assignment of his personnel, and after such assignments were made to have this personnel report to the officer in charge of instruction, who would detail them as follows:
(a) The supply officer, one other officer, and such enlisted men as were required, would report to the park supply officer and check the property and become familiar with its location and packing.
(b) The truck drivers would report to the transportation officer for instruction in driving.
(c) The sterilizer man would report to the sergeant in charge of the sterilizer for instruction.
(d) The laundryman would report to the man in charge of laundry for instruction.
(e) The X-ray man would report to the X-ray technician for instruction.
(f) Balance of the personnel would report to the sergeant in charge of tentage for instructions in erecting the hospital.
Attempt was made to have each organization pitch the entire tentage at least twice, do the laundry work of the camp twice, and run the sterilizer and X-ray equipment until all became familiar with the different details of the work. Truck drivers were kept on the trucks until found proficient in handling them. Nurses when they arrived prepared dressings and were made familiar with the sterilizing apparatus, operating room, and plan of hospital. No attempt was made to give instruction in hospital administration, paper work, except the statistical reports, or obtaining and caring for supplies, as instructions of this character could not have been given with any degree of success in the short time available. All the available time was concentrated in familiarizing the personnel with the technical equipment of a mobile hospital, where it differed from that of a base hospital. This proved to be a very serious mistake, one that was not realized until just before the armistice was signed. It has since been learned that the majority of these organizations could erect their hospitals, operate their laundries, sterilizing apparatus, and X-ray equipment, but were practically helpless when it came to administering a hospital, obtaining supplies, or having their organizations function as such. It was also considered to have been a mistake not to have ordered the entire personnel of the new organization to the park at one time, as men selected by the commanding officer of the unit for particular duty were often found to be hopeless when it came to instructing them in that duty. If the entire organization had been on hand these men probably could have been replaced by better ones.
The question of standardizing the equipment of mobile hospitals was one of the most difficult problems presented. The chief difficulty was that previous organizations had had a free hand in obtaining what they believed they required, obtaining their supplies from the French, the Medical Department, the Quartermaster Department, and the Red Cross. Each new commanding officer obtained the list showing the equipment thatthe previous organization had started out with, and he not only obtained what this list called for but also such additional articles as he individually believed necessary. These, of course,
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varied according to the specialty of the commanding officer. For example, one commanding officer was an eye specialist. He not only wanted all the equipment that previous organizations had taken out, but also all the equipment, instruments, and supplies which an eye specialist might require.
Before attempting to standardize the equipment mobile hospitals in operation at the front were visited and the opinion of commanding officers who had had the most active experience obtained as to what articles of equipment could be dispensed with and as to what additional articles they required. After obtaining this information a list was made up, and this standard list of equipment was given to Mobile Hospital No. 10 and to those that followed it. This equipment could be moved with 20 three-ton trucks, not including the personnel, as compared with anywhere from 35 to 60 trucks required by previous organizations.
Below is a list of organizations that were instructed and equipped at the park from the time of its organization until the armistice was signed, with date of arrival and departure. They were usually reported ready for duty, in so far as their training was concerned, two weeks after arrival. Delay in departure, as a rule, was due to failure to receive supplies from the Medical Department or to difficulty in obtaining transportation after organizations were reported ready.
Mobile Hospital No. 5,mobilized September 4, left for duty September 20.
Mobile Hospital No. 6, mobilized September 4, left for duty September 26.
Mobile Hospital No. 7, mobilized September 16, left for duty October 2.
Mobile Hospital No. 8, mobilized September 20, left for duty October 13.
Mobile Hospital No. 9, mobilized September 20, left for duty October 20.
Mobile Hospital No. 10, mobilized September 25, left for duty November 11.
Mobile Hospital No. 11, mobilized September 29, left for duty November 11.
Mobile Hospital No. 12, mobilized September 26, left for duty January 23, 1919.
Mobile Hospital No. 13 was equipped and assembled, and on November 11was ordered delivered to the Belgians. Mobile Hospital No. 14 was equipped and assembled November 14, but no personnel was assigned, the equipment remaining at the park.
In October, 1918, Medical Repair Shop No. 1 was moved from Neuilly to the park. The building assigned to this organization was ideal for the character of the work. It had a cement floor, was well lighted, and had sufficient space on the second floor for quarters for the personnel and for storerooms. This not only increased the capacity of the shop but set free a certain number of instrument makers and opticians for work in the shop who previously had been used for running the enlisted men’s mess and for guard duty.
The equipment of Mobile Operating Unit No. 1 was received from the United States during October, 1918, and was overhauled at the park, the intention being to send the equipment when completed to the Medical Department concentration area, Joinville(Haute Marne), where the personnel was to be mobilized. Two of the five sections of this unit were ready for transfer on November 10 and the other three the following week, but owing to the signing of the armistice this transfer was not made.
The question of spare parts and replacements for the mobile hospitals after they left the park was taken up and a list compiled covering the principal articles that most frequently became unserviceable. This list was made up after consultation with commanding officers of mobile hospitals who had seen the most active service and from data obtained from the French records at Fort De Vavnes showing the replacements required by the French for their mobile hospitals during the last three years. Request was made for six months’ supply of these spare parts, the idea being to furnish mobile hospitals that were operating with the spare parts required direct from the park instead of having organization commanders sending to the French, as had previously been the practice. The armistice was signed before the requisition was filled.
The difficulty in shipping spare parts to the mobile hospitals at the front and in having these parts reach the hospital before it was moved, was to be overcome by having a point nearer the front where all supplies for mobile hospitals could be shipped from the
191
park and then transferred from that point by truck. This plan was in process of materializing, using the Medical Department concentration area, Joinville(Haute Marne), as the point from which spare parts were to be sent forward by truck, when the armistice was signed and the plan abandoned.
Sometimes our mobile hospitals operated in conjunction with evacuationhospitals,36 but sometimes they served with field hospitals37 or operated independently. Their distribution is exemplified on the map of the Meuse-Argonne operation. Like evacuation hospitals, they were army units. They habitually remained under the command of their respective commanding officers without coming under the administrative jurisdiction of the units to which they were attached. Sometimes a mobile hospital operated independently of any other sanitary formation from a geographic as well as from an administrative standpoint. Thus, Mobile Hospital No. 39 for much of its service at Aulnois was located northwest of Sebastopol, quite independent in every sense of any other hospital.
FIG. 33.-Mobile Hospital No.39, when at Challons, France
The administrative methods of the mobile hospital, given below, exemplify the arrangements in mobile hospitals generally, though inevitably there were numerous departures from them in certain details because of differing conditions, resources, etc.
MOBILE HOSPITAL NO. 39 AT AULNOIS
The Yale unit, organized as a Red Cross base hospital, and later changed to Mobile Hospital No. 39, was the first mobile hospital which saw service in the American Expeditionary Forces. Its history is given here at some length, as it was the prototype of other mobile hospitals. Its commanding officer had reached France with funds privately raised to purchase a French
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auto-chir, preliminary arrangements having been made in the United States through the French ambassador.38 In point of fact the equipment of this unit was finally paid for by the United States Government, except that instruments, etc., to the value of $11,000 were purchased by the unit. The equipment was not ready for delivery when the personnel arrived in France, a circumstance which gave its commanding officer an opportunity to familiarize himself with the needs, functions, and organization, of similar units in the French Army. As soon as it was equipped, the unit moved to Aulnois, where it occupied tents and Adrian barracks.
For the St. Mihiel operation it was expanded to 524 beds. An estimate then made of the personnel necessary for a hospital of this type with 500 beds and 200 admissions per day, was as follows:39
|
|
Miscellaneous |
Triag |
Wards |
Teams operating |
Splints |
X-ray |
Total |
|
Officers |
--- |
2 |
11 |
19 |
2 |
4 |
38 |
|
Nurses |
7 |
--- |
44 |
10 |
--- |
--- |
61 |
|
Enlisted men |
126 |
--- |
44 |
10 |
--- |
--- |
180 |
The number actually on duty was much less, the following being present during this operation: Surgical teams, 14; resuscitation teams, 2; nurses, 14; enlisted men, 180.Several officers, about 6, from Evacuation Hospital No. 11, also reenforced the hospital.40
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With the personnel then available it was estimated (on the basis of 1case per team per hour) that 144 major cases could be cared for per day. The hospital was designed for seriously wounded only and it was estimated that 50 percent of such cases would be nontransportable.40 It followed that the limit of bed capacity would be reached, by accumulation of patients, in six days.
As it was anticipated that the reception and operating rooms would be points of congestion, every possible attention was given to the organization of these parts of the hospital in order that wasted motion and unnecessary delay might be avoided. It was laid down as a fundamental rule that from the time when the wounded entered the front door until they left the operating room, movement must be in one direction only. Every unnecessary maneuver and record was dispensed with so that a maximum output should be secured with a minimum personnel. In general the barrack wards were assigned to nontransportable patients, who gradually accumulated, while the tents of the auto-chir were used for transportable patients. This plan allowed the speedy forward movement of the hospital when necessity required.40
FIG.35.-Reception ward, Mobile Hospital No. 39
It was recognized that three essential points would determine efficiency of operation and that these points must be absolutely coordinated. These were:(1) The admission office; (2) the bed assignment office; and (3) the evacuation office.40
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During inclement weather the porte-cochere protected the wounded and served as a storeroom for a stock of blankets. Immediately on entering the door, accommodation was provided for two ambulance loads of the wounded. These passed to the admission desk, where a team took care of patients’ valuables, field cards, and clinical briefs, and made records of casualties and changes. Patients were then passed onto the undressing section, where were installed a series of racks for 16 litters, a chute for soiled or infested clothing, and 2 bathing tables; beyond these were racks for 16 more litters. Here were held patients awaiting X-ray examination. On either side of this portion of the reception ward were shock rooms, kept at a temperature of 90. Patients in shock were removed at once from the main channel of progress and treated until in condition to be forwarded. If they became operable they were returned to circulation. Both shock rooms were in charge of resuscitation teams.41
FIG.36.-Operating room, Mobile Hospital No. 39
Two operating rooms were provided, one of which was connected with the reception room by a covered passageway. The other had an X-ray room at one end, with a few litter racks, for patients awaiting operation after X-ray examination. Patients not needing to be so examined could be short-circuited by a passage along the side of the room. This operating room had space for five teams and the other room for three, working simultaneously at double tables provided with every improvement and convenience. After operation patients were taken into an end vestibule, where bearers were stationed, under the direction of the bed assignment office located just beyond the vestibule.
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The sterilization room, between the two operating rooms, contained the sterilization truck, splint racks, and storage for dressings. A reserve space for preoperative patients was provided in the front end of the operating rooms at the right.42
Admissions - The admission team consisted of three men for the night shift and four for the day shift. Work was so organized that the field card and envelope, brief (Form 55A), and valuables were handled at the rate of 1 card in three minutes, or 480 per day. A clerk at a typewriter kept the report of casualties and changes posted to the minute. A fourth or fifth man was necessary in order to care for the record of deaths, to complete inadequate diagnoses, to make corrections, and to serve as a reserve. Promptly at 12 o’clock daily the report of casualties and changes was given to the courier. In the routine one man made out this report (Form 22 A. G. O.), another made the brief (Form 55A), and a third made the register card (Form 52). Valuables were placed in a paper bag, marked with the name and hospital number of the patient, and sent to the evacuation office.43
Undressing team - Immediately behind the admission desk was the undressing station, where clothing was removed by the undressing team and placed in the clothes chute. Three men here could keep pace with four bathing and preoperativetables.44
Bathing and preparation of patients - Two bathing tables, with water heater, formed the equipment of this station. The patient was bathed and his wound prepared for operation. While this was being done, an officer took brief clinical notes and made the diagnosis, while an enlisted man made a sketch of the wound. The team here normally consisted of one officer, a barber, and two other enlisted men.41
Shock room - This room, on a siding or detour from the main route, was kept heated by a stove and contained two electric pads. These devices allowed rapid heating of the patient and continued treatment on litters in the open room. On the opposite side of the main pavilion was another shock room used for overflow and for postoperative patients.44 Teams also worked the shock room.
Surgical teams - These teams were in two groups, alternating on eight-hour shifts.45 During their rest periods they were expected to do the ward work needed for patients upon whom they had operated. There were two regular teams and nine attached, casual teams. A third regular team did "class B" work. The special emergency teams were made up by cooperation of the ophthalmological consultants. The assignment of the main teams was so arranged that the directors of surgery in the operating room headed the two groups which took alternating periods of duty. One ophthalmological team was assigned to each group, so that there would always be such a team available. There was also a special team for maxillofacial as well as one for neurological surgery.46
There were two shifts of six main teams each. These worked during two periods on one day and the next but one. Their rotation brought about an automatic alternation in periods.
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Output of operating room - The output of the six teams, operating continuously during 24 hours, should have been 144 operations in the first 24 hours. During that period in the St. Mihiel operation, 201 patients were admitted and 170 passed through the operating room. It was surprising to see how quickly the teams fell into their stride and, after the first few hours, how smoothly the machine worked.47
X-ray department - The X-ray rooms were also arranged to work on the one-way traffic principle. Four teams were on duty, in alternating shifts; they found no difficulty in keeping ahead of the six surgical teams.
FIG.37.-X-ray truck, Mobile Hospital No. 39
Sterilizing room- Two teams worked in the sterilizing room on12-hour shifts. One team (two men) cleaned and scrubbed instruments, while another team cleaned and repaired gloves and sharpened instruments. A nurse superintended sterilization and the storage of instruments in standard sets. Surgeons were required to use standard sets of instruments and dressings, but when needed complementary sets for lung, head, abdominal, or other operations could be called for. Dressings likewise were standardized, a certain set of dressings being provided for each operation. The system worked well and surgeons appeared satisfied with the instruments and dressings furnished.48
During the entire period the sterilizing truck functioned perfectly. Hot air was employed for sterilizing a supply of instruments in advance, but dur-
197
FIG.38.-Sterilizing truck, Mobile Hospital No. 39
198
ing an offensive instruments usually were boiled. Tin cans of various kinds were used as containers. The sterilizer truck was managed by two teams of three men each, one for firing and two for operating the sterilizing equipment.
Bed assignment office - When an operation was completed the orderly knocked on the door of the vestibule, and two bearers entered, removed the patient, and deposited him in the vestibule until the bed assignment was made. The bed assignment officer was stationed in the vestibule in the rear of the sterilizing rooms, between the two operating rooms.49 Here, assignments to wards were governed by colored tags, attached to the patients by the operating teams. A white tag indicated the patient was to be immediately evacuated (after recovery from ether); brown, evacuation in 10 to 24 hours after recovery from ether; and gray, that the patient was to be retained-usually this was because of head, chest, and abdominal operations.
Ward assignments - Wards were so assigned that each surgeon had half of a ward for transportable patients and half of a ward for nontransportable. Assignments were so made that one team would be on duty in the wards while the corresponding team was operating, thus making it possible for surgeons to follow up their cases and also making impossible the neglect of any wounded man.50
Evacuation and consultation team - In order to control the evacuation of patients, to check dressings, and to survey the condition of patients before their evacuation, one team was constantly detailed for work as an evacuation team. To it was also assigned the duty of consultation in any emergency which might arise in the wards in the absence of the ward surgeon. This plan was necessitated by the fact that operating surgeons also cared for ward cases.51
Evacuation - In the evacuation ward some readjustment of cases was made necessary by delayed departure of trains. Evacuation was accomplished by ambulances and by narrow-gauge railways.52
Laundry - During part of the time the laundry operated day and night, handling 4,285 pounds of work in 44 hours. The following supplies were used during that period: Soap, 43 pounds; soda, 168 pounds; gasoline, 22 gallons. It was estimated that 2,300 pounds of laundry could have been handled daily for any reasonable period. The plan of using pieces of muslin in the operating room instead of sheets and towels resulted in marked economy in the laundry. A full output necessitated two teams of four men each, working in 12-hour shifts, each under general charge of a sergeant.53
Litter bearers.-Experience demonstrated that five different groups of bearers were necessary: (1) Four men to unload ambulances and carry patients to the bathing tables; (2) four men to carry patients to the X-ray room; (3) a supervisor and four men to handle patients in the X-ray room; (4) a supervisor and six men to remove patients from operating tables and carry them to wards; (5) eight men for evacuating patients. One supervisor and one man were required to remove soiled litters and blankets from the admission room. For a 500-bed hospital, running 6 double teams continuously, two shifts of 28 men each were required. The nature of the work was such that 8-hour periods proved better than those of 12 hours.54
199
MOBILE SURGICAL UNITS (COMPLEMENTARY GROUPS)
Unfortunately, there is no individual history of a mobile surgical unit on file in the Office of the Surgeon General of the Army, nor can such a history be found elsewhere. Records of these units were obtained from divisional and other reports of Medical Department activities.
On April 22, 1918, the chief surgeon, A. E. F., cabled the Surgeon General that equipment for 20 complementary groups (later known as mobile surgical units)was being manufactured in France and requested that personnel for these units, each to consist of 1 roentgenologist, 1 sergeant, first class, 3 sergeants, and 8 privates(including 1 X-ray operator), be organized in the United States and sent to France. Twelve such units were to be cleared in May and eight in June, 1918.55 On November 11, as has been noted, of the 20 mobile surgical units required, the following 16 were in service: No. 1 to No. 12, inclusive, and No. 100 to No. 103, inclusive.33
FIG.39.-Evacuation office, Mobile Hospital No. 39
The following extract on mobile surgical units is quoted from a report of the Medical Department group of the fourth section of the general staff, G. H. Q.: "This formation enabled us to provide portable sterilizing, X-ray, and electric-lighting facilities and a small operating room for divisional, corps, and army field hospitals, thus enabling these to carry on surgical operations on nontransportablewounded."22 The Medical Department group of the fourth section, general staff, also reported that these mobile surgical units should be retained in our equipment manuals and transportation pro-
200
201
vided for them on the basis of one per division.22 Though they functioned under the army and were assigned to divisions and withdrawn from them as occasion demanded, their assignment for duty with the corps was advocated by many officers. It should be noted that nontransportable patients-that is, those for whom these units were especially designed-were usually relatively few in number, comprising only the gravely shocked, patients with abdominal wounds complicated with hemorrhage, and patients with open chest wounds. The value of the mobile surgical unit is attested not only by the above recommendation but also the Medical Department reports of many divisions.
MOBILE OPERATING UNIT NO. 1
A unique formation was Mobile Operating Unit No. 1. In August, 1917, a medical officer, who had been in charge of a hospital in France, proposed to the Surgeon General that there be provided a mobile operating unit mounted on automobile trucks and provided with a well-lighted and heated operating room, electric lighting, steam and sterilizing plants, these to be fully equipped in such a manner as to insure the best hospital conditions and at the same time capable of being erected and in action in less than an hour.56 The following month he wrote to the War Department of an offer by Mr. George E. Turnure, of New York, of such a unit. This voluntary offer was promptly accepted by the Secretary of War.57, 58 Shortly thereafter the medical officer in question was assigned to the Surgeon General’s Office to organize the mobile operating unit.59
The unit was provided with 64 officers, 50 nurses, and 218 enlisted men, and with equipment consisting of 5 touring cars, 5 motor cycles with side cars, 20 three-ton trucks, 20 one-half-ton trailers, and 50 Ford trucks.60 Attached to it was one machine-shop truck unit, with a quartermaster detail of 1 officer and 25 men.60 In its final form the unit consisted of five sections, each of which was a complete surgical hospital which could care for 40 patients and could be operated independently. Equipment of this unit was much more elaborate and complete than that of any other surgical hospital sent to France.60 It was forwarded in sections which were concentrated in the training area at Joinville, but as the entire organization, because of the priority schedule, did not arrive until shortly before the armistice, it did not see service in battle.60
PROFESSIONAL TEAMS
The professional services of field, mobile, evacuation, and base hospitals were all improved by the use of appropriate professional teams. These teams varied in number and in specialty. The large expansion of facilities for emergency surgical work in individual evacuation hospitals, by means of surgical teams, was imperative on account of the shortage in number of these hospitals. On June 6, 1918, we had 42 surgical teams, of which 12 were on duty with the French and 30 with base hospitals of the American Expeditionary Forces.61 Each of these teams (they were modeled on teams already organized by the
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FIG.41.-Boiler car, sterilizing unit, Mobile Operating Unit No. 1
203
FIG.42.-Sterilizing truck, Mobile Operating Unit No. 1
204
French) consisted of 1 surgeon, 1 assistant surgeon, 1 anesthetist, 2 nurses, and 2 orderlies taken ordinarily from the base hospitals.61 Following the same plan, splint and shock teams were developed later, the former to work with the operating teams and the latter as emergency medical formations.61
SURGICAL TEAMS
The director of professional services, A. E. F., issued the following letter of instructions, May 13, 1918:62
1. Hereafter surgical teams will be classified as follows:
(a) Teams detailed from base hospitals for duty with advanced A. E. F. formations.
(b) Teams for duty with allied formations.
2. With reference to the formation of surgical teams available for duty with all formations, the senior medical officer of the team will forward, through his commanding officer, a report of its composition, giving full name and rank of each officer, nurse, and enlisted man, and station of each, if the team is recruited from different organizations.
3. When a team or the members of any team are detached from their permanent station, the senior medical officer will forward a report, giving date of departure, destination, and name and rank of each individual.
4. No member of a surgical team will be detached from his station without orders from competent authority, and when assigned to temporary duty elsewhere, will not absent himself from the station to which assigned nor return to his proper station without orders from the same or higher authority. Members of teams will be informed that they are not to determine when their services can be spared, and that they must await the receipt of orders.
5. No change in the composition of any team during the time it is on detached service will be made without authority, and except in cases of illness or other urgent necessity, recommendations for such changes will not be made without consultation with the chief consultant, surgery, A.E. F.
6. Medical officers and nurses on teams will, when serving with allied formations, equip themselves with sufficient funds to defray all expenses for subsistence.
7. The senior medical officer with a team will submit a monthly report of the work performed, where done, and under what circumstances. After return of the team to its proper station, he will forward a final report covering the entire period of detached service.
8. The above-mentioned reports will be forwarded in duplicate to the chief consultant, surgery, A. E. F., who will forward one copy to the director of professional services, A. E. F.
9. Operating teams should familiarize themselves with the regulations and customs of the hospitals to which they are assigned, and faithfully observe them.
That the professional staffs of evacuation hospitals must be reinforced early became apparent. This was in fact very clear by July of 1918, as only 8 such hospitals, instead of the 52 authorized by Tables of Organization, had then arrived inFrance.61 The situation could be met only by enlarging the evacuation hospitals which were available by assigning to them personnel drawn from other sources. So, plans were at once made to increase the number of surgical teams, and, in addition, to organize casual surgical teams. A casual surgical team had the same personnel as a surgical team except that it had one nurse and oneorderly.61
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The total number of teams organized by the professional services were shown as follows in a table submitted December 31, 1918:61
| Teams | Personnel | |
| Surgical: | ||
| 244 | 1,708 |
| 95 | 475 |
| Splint | 30 | 90 |
| Shock | 78 | 390 |
| 447 | 2,663 |
The brunt of the work was borne by less than 200 of these teams.61
GAS TEAMS
Organization of gas teams at base hospitals was authorized by the chief surgeon, A. E. F., by an endorsement to the director of professional services dated June2, 1918.63 The chief consultant in medicine previously had expressed the desire to have two gas teams organized in each base hospital which could be called on for service elsewhere as desired. Such teams were formed in several base hospitals (e. g., Base Hospital No. 8, Base Hospital No. 27). Each of these teams consisted of 1 officer, 2 nurses, and 2 enlisted men. A course of degassing instruction at the central laboratory at Dijon was provided for officers designated to perform degassing service.63 Their attendance was contingent, however, on the possibility of releasing them from other duties for the time being.
MISCELLANEOUS TEAMS
In various hospitals teams other than those mentioned were organized from local sources. Thus the field hospital which cared for nontransportable wounded would organize surgical teams, sometimes from its own personnel and sometimes from selected personnel assigned to it from other organizations of the divisional sanitary train. Surgical hospitals generally, whether divisional or army, organized teams from their own personnel. In some of these units two dressing teams to dress the slightly wounded and to assist in the operating room were organized, replacing each other every eight hours.
Similarly, two shock teams were organized in each hospital, composed of an officer, 1 or (usually) 2 nurses, and 1 or (usually) 2 orderlies. The officers had received an intensive course of instruction in the central laboratory at Dijon, where they had attended lectures on traumatic shock and its treatment by heat, transfusions of blood, by gum solution, and kindred matters, and had learned the use of instruments of precision by which they checked the shocked patient’s condition and response to treatment.13 It was essential that these officers be highly trained, for the lives of many patients admitted to their department were often in the balance.
A number of evacuation hospitals organized two orthopedic or splint teams, each consisting of one specially trained officer and two enlisted men whose duty it was to maintain a supply of splints in the operating room and
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other parts of the hospital and to apply them after operation. These teams operated in 12-hour shifts, and were of great benefit to the operating surgeons not only by applying splints for them, but by preventing breaks in asepsis on their part.21 They supervised the distribution and use of splints in other parts of the hospital as well as in the operating room, reapplying the min the wards or supervising their application there, and maintained at the receiving ward an exchange for splints with ambulance orderlies, replacing those which had been brought in on patients.
One or, if at all possible, two radiologic teams were made up from the permanent personnel of the hospital. These teams consisted of one officer skilled in radiology, fluoroscopy, and screen technique, and one or two orderlies. It was found essential that these teams be composed of young men, because of the long hours that they had to be on duty.21
Despite the shortage in personnel and the pressure under which all had to labor at times, it proved very desirable, in fact almost imperative, that alternating teams for shock, splinting, and radiology be provided, as well as alternating surgical teams. Usually the shock, splint, and radiologic teams operated in 12-hour shifts.21
Specialists in the eye, ear, nose, and throat and dental surgeons operated under the supervision of the chief of surgery.
It was found that there should be available at least two surgeons proficient in operations on the brain and eye.21
If the hospital received gassed patients, degassing teams (usually three men) were organized under the chief of the medical service though under the direct supervision of another officer.
The laboratory officer, selected from the permanent personnel, was one well versed in wound bacteriology and in pathology. As a rule, this officer had taken the prescribed course in wound bacteriology in the central laboratory at Dijon, his place being filled temporarily at the time by some other officer already qualified. The laboratory officer not only performed routine bacteriological examinations and made smears from wounds to insure their control, but he also prepared Dakin’s solution, made post-mortem examinations, and collected specimens of pathological material for the Army Medical Museum. In some hospitals the laboratory, pharmacy, and dental departments were located in the same tent, but in others their location was somewhat different.21
In all gas hospitals degassing teams were organized. This tendency to work by means of more or less permanent teams was remarked also in the hospitals in other directions than in the purely professional services, for a number organized definite groups, such as those for the receiving and evacuating departments, which served as teams in rotation, each of whose members was given specific duties.
CONVALESCENT DEPOTS
It was found that, in the height of an offensive, particularly if it was prolonged, many patients with slight illness or injury who would soon have
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been fit for return to duty were sent to the evacuation hospitals; and then as these hospitals needed their beds for the casualties which were constantly arriving, they were obliged to send the slightly sick and injured to the rear. This practice not only burdened the railway rolling stock and the base hospitals, but also lost these men to their divisions for several weeks. In order to meet this situation, attempts were made to provide army and corps convalescent depots, and only on account of the lack of medical personnel was a convalescent depot for the First Army not completed at the time the armistice was signed.64 The establishment of this depot, which was located at Revigny, was then well under way.64 At this time, for the Second Army, the barracks at Toul were available for hospital purposes and this, plus the fact that its casualties were comparatively small in numbers, made the need for such a depot less urgent in it than in the First Army. By the time of the armistice the several corps, especially the First Corps, were caring for slightly incapacitated patients in field hospitals of the corps train set apart for this purpose, designating and employing them as convalescent depots.65
EVACUATION AMBULANCE COMPANIES
In the edition of the Manual for the Medical Department, issued in1916, the designation of the then so-called transport column, which had been authorized in1910, was changed to the evacuation ambulance company, and provision was made that its personnel and equipment would be those of an ambulance company with such modifications as the conditions of its particular service warranted, specifying that "motor ambulances should if practicable be substituted for horse-drawn vehicles." It was further provided that when a battle was imminent the number of vehicles and bearers should be increased by the officer in charge of the advance section. The primary duty of these units was to clear the field hospitals and to transport patients to evacuation, base or other hospitals or to points with rail or boat connections. They also were to transport wounded on occasion from dressing stations, stations for slightly wounded, and from other places in the field.
In November, 1917, the Surgeon General wrote the chief surgeon, A. E.F., 3 evacuation ambulance companies were being organized at home, each consisting of 2officers and 60 enlisted men, that it was hoped to have 1 such unit with each division, and that the equipment would be that of a motor ambulance company with 12 ambulances less dressing station equipment.66 He requested recommendations. The chief surgeon, A. E. F., replied, advocating 20 ambulances per ambulance company instead of 12.67 The Surgeon General ordered the commanding officers, Medical Officers’ Training Camps at Fort Riley and at Fort Oglethorpe to organize the companies in question, one at the former and two at the latter.68
In the meantime, the chief surgeon, line of communications, had recommended (November 27, 1917) that ambulance personnel and transport within his jurisdiction be organized into evacuation ambulance companies, each consisting of 5 sections with 20 ambulances each.69 He also urged that, if it were possible, 30 sections of the United States Army Ambulance Service, then in
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the United States but ready for shipment, be secured for the A. E. F., in order to avoid the complete breakdown in transport which he considered imminent. He remarked that the need of evacuation ambulance companies was becoming more and more apparent, both to the transportation department of the chief surgeon’s office and to the hospitalization department, General Headquarters. The need for motor ambulance companies, conveniently located to meet current needs, instead of individual ambulances distributed among many combat and other organizations and the special need for such a unit(under the control of the advance section, Services of Supply) in the vicinity of the training areas were emphasized. Other companies as required would be located at other places in the line of communications. It was anticipated that personnel and materiel might ultimately be supplied for the evacuation ambulance companies from the sections of the United States Army Ambulance Service which had been assembled, but that until that service’s resources were more than enough to meet its own needs, our evacuation ambulance companies might be developed quickly though temporarily by drawing in from various base and other hospitals all available transport and personnel. It was believed that even though this organization would lack symmetry it would meet the situation temporarily until units of the United States Army Ambulance Service could be made available. The memorandum further remarked that 88 sections of that service in the United States, not yet assigned, might be considered available for requisition for service on the line of communications. The necessity for a maintenance department with ample spare parts and other equipment was noted as was also that for the immediate establishment of an ambulance park in the vicinity of the training areas.
The same date (November 27, 1917) the chief surgeon, A. E. F., cabled the Surgeon General that evacuation ambulance companies should be organized from the equipment and personnel of sections of the United States Army Ambulance Service.70
Under date of December 8, 1917, in a memorandum for the Surgeon General, the chief surgeon, A. E. F., emphasized the need for organizing on a large scale transportation for casualties, noted the limited amount of transport and inadequate ambulance spare parts available at camp and base hospitals; and to establish a precedent, requested that the chief of United States Army Ambulance Service loan the United States Army one ambulance company section. He further requested that The Adjutant General authorize necessary transport or its purchase.71 A few days later (December 13) the chief surgeon, A. E. F., received a report from one of his subordinates who had been ordered to investigate transportation requirements, in which emphasis was laid upon the need for evacuation ambulance companies; the wasteful results of assigning ambulances to small scattered commands; the difficulty of making evacuations in training areas, and suggesting number and locations of companies, sources of personnel and materiel, facilities for repairs, etc.72
On December 18, 1917, the Surgeon General notified the commanding officers of the home training camps above mentioned that the personnel of an
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evacuation ambulance company would be 1 lieutenant, Medical Corps, 3noncommissioned officers, and 34 privates.73 On December 28, 1917, the War Department formally prescribed this personnel and authorized the organization of 20 such companies with 12 G. M. C. ambulances each.74
On January 14, 1918, the chief surgeon, line of communications, reported that it was imperatively necessary to make provision for more motor ambulance transport in that area in order to evacuate the field hospitals, and recommended that a provisional motor ambulance company be organized from the resources(116th Sanitary Train) of the 41st Division (the First Depot Division).75 The organization he recommended was that mentioned above in the letter from the Surgeon General dated November 12. This recommendation was approved and the organization of this provisional company was ordered January 17, 1918.76 This unit first designated the 116th Evacuation Ambulance Company, and later Provisional Evacuation Ambulance Company No. 1 was the first evacuation ambulance company of the American Expeditionary Forces. It was located at Toul.
On January 30, 1918, the Surgeon General initiated with The Adjutant General the following correspondence:77
1. In cable from the commanding general, American Expeditionary Forces, No. 322, par. 3, subpar. A, it was stated that it was the unanimous opinion that evacuation ambulance companies be organized with the equipment and personnel of the sections of the U. S. Army Ambulance Service. This request was referred to again in a letter from the chief surgeon, A. E. F., written December 24.
2. In cable No. 486, par. 8, from the commanding general, A. E. F., the recommendation was made that the remaining 73 sections, U. S. Army Ambulance Service, be used in organizing the ambulance companies of the Army sanitary train, item M 201, and evacuation ambulance companies, M 406, and that the remainder be drawn on all ambulance personnel for replacement draft according to par. 4, cablegram 318.
3. The sections of the American Ambulance Service referred to are those now mobilized at Allentown, Pennsylvania.
4. It is the understanding in this office that when these sections were organized they were intended for service with the French Army, and they have heretofore been used for that purpose.
5. A decision is requested as to whether these sections could be used for the purpose indicated in General Pershing’s cables.
6. It is to be noted that in some cases the officers attached to these sections are not medical officers. Also that they are equipped and have been trained with Ford ambulances, and that the ambulances provided for the ambulance companies of the Army are G. M. C.’s. Should the use of these sections be allowed, the personnel will differ from that as authorized for evacuation ambulance companies in the second indorsement of The Adjutant General’s Office, dated December 28, par. 3, subpar. 8.
[1st ind.]
To the Chief of Staff
A. G. O., February 1, 1918.
[2d ind.]
WAR DEPARTMENT, A. G. O., March 12, 1918.
322.35 (Misc. Div.)
To the SURGEON GENERAL OF THE ARMY:
There is no objection to the use of the enlisted personnel of the American Ambulance Service now at Allentown, Pennsylvania, organized under section 2, General Orders, No. 75, War Department, June 23, 1917, as amended by section 1, General Orders, No. 124, War Department, September 20, 1917, for any purpose for which the enlisted personnel
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of the Medical Department may be used. The commissioned personnel maybe used in a like manner, except that those officers who are not doctors of medicine will be assigned to such duties as their technical training permits. It is, however, to be understood that this authorization in so far as it relates to these officers is not to be construed as in any way modifying the provisions of paragraph 3, Manual for the Medical Department, 1916, which prescribes that: "An applicant for appointment in the Medical Corps of the Army * * * must be a graduate of a reputable medical school legally authorized to confer the degree of doctor of medicine," and as fast as these officers are separated from the service their places will be filled by the appointment of medical officers.
By order of the Secretary of War:
The chief surgeon, A. E. F., on March 5, 1918, in an estimate of the total Medical Department transportation needed for the American Expeditionary Forces, included 1 evacuation ambulance company for each division, the transportation of each such unit to be 1 motor car, 1 motor cycle with side car, 20 motor ambulances, and 2 motortrucks.78
The 22d of the same month, the Surgeon General wrote The Adjutant General, United States Army, as follows:79
1. Subparagraph "H," paragraph 3, of 2d indorsement, Adjutant General’s Office, December 28, 1917 (322.3 Medical Department, Misc. Div.), gives the personnel of evacuation ambulance companies as 1 lieutenant, Medical Corps, 3 noncommissioned officers, 34 privates.
2. It is requested that this be amended to read as follows: 1 captain or lieutenant, Medical Corps; 3 noncommissioned officers; 3 mechanics; 2 cooks; 24 wagoners: 5 privates, first class, and privates.
3. In General Pershing’s organization project for evacuation ambulance companies all transportation is motorized and consists of 20 motor ambulances, 1touring car, 1 motor cycle with side car, 2 motor trucks.
4. The unit is liable to expansion by the addition of other ambulances.
5. The 2 cooks for the organization are necessary; the 3 mechanics are required to keep the motor transportation in proper order, and the 24 wagoners are the chauffeurs.
This request was granted in the following terms:
[1st ind.]
A. G. O., March 26, 1918.
To the Chief of Staff (R. A. H.).
[2d ind.]
WAR DEPARTMENT, A. G. O., April 15, 1918.
To the SURGEON GENERAL OF THE ARMY.
Returned.
The following personnel for evacuation ambulance companies has been approved: 1 captain or lieutenant, Medical Corps; 3 noncommissioned officers; 3 mechanics; 2 cooks; 23 wagoners; 6 privates, first class, and privates.
This authorization must not be construed to change the numbers or grades of medical officers provided for the Medical Department in W. P. D. 9199-25, approved February 4, 1918.
By order of the Secretary of War.
On September 26, 1918, the chief surgeon, A. E. F., recommended to the chief of staff, General Headquarters, the issuance of a general order, which he had prepared, concerning the operation of ambulances in the Services of Supply.80 This, in brief, was to provide that all ambulances in that territory be assigned to 18 definite evacuation ambulance companies, with the enlisted personnel then assigned to duty with these vehicles. The personnel of each
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unit, it was recommended, should be 2 officers (captains or first lieutenants, Medical Department), 2 sergeants, first class, 4 sergeants, 23 wagoners, 1 cook, 1 mechanic, 20 privates, first class, and 5 privates. The units were to be equipped with 20 ambulances or more, 1 motor cycle with side car, and such temporary additional machines and personnel as might be necessary; and the vehicles, so far as possible, were to be garaged at hospital centers, base hospitals, camp hospitals, and other camps where they were used, but at all times would be under the orders of the commanding officers of the respective companies. A list showed that from 9 to 22 ambulances were garaged at the more important localities in the Services of Supply. In support of this proposed arrangement the chief surgeon, A. E. F., urged that this organization would promote service by the pooling of ambulances, and would provide units which, in emergency, could be sent to the Zone of the Advance. To these recommendations the chief of staff replied that, as the assignment of ambulances was under the jurisdiction of the chief surgeon, it was believed that they could be distributed by him as required for the purpose mentioned; and further that:81
If it is desired to organize evacuation ambulance companies, a cablegram should be prepared outlining how many can be organized in the A. E. F., and requesting that numbers be assigned for the units. Upon receipt of reply authority will be granted for the formation of the companies under approved tables of organization.
A total of 82 evacuation ambulance companies (including Provisional Ambulance Company No. 1) saw service in the American Expeditionary Forces. Twenty-one arrived before the armistice and sixty-one after the armistice. Twelve of those which arrived after the armistice were disbanded and their personnel reassigned in Base Section No. 2.34
Those which served overseas before the armistice, November 11, were thefollowing:34
Provisional Ambulance Company No. 1, organized, as above described, from the 116th Sanitary Train of the 41st Division, which arrived December 31, 1917. Located at Toul.
Evacuation Ambulance Company No. 1 arrived May, 1918. Attached to 26th Division October, 1918. In November it was at Rochefort.
Company No. 2 arrived May 30, 1918. Paris during August, September, and October, 1918; at Fromereville, Meuse, during November. Transported 69,925 patients, including those moved more than once.
Company No. 3 arrived April 22, 1918. At Staden, Belgium, October, November, December.
Company No. 4 arrived May 5, 1918. Attached to 89th Division until September, 1918. At Royaumeix, Meurthe-et-Moselle, September; Commercy, Meuse, October; Mars-la-Tour, Meurthe-et-Moselle, November to March.
Company No. 5 arrived July 19, 1918. With First Army, August, September, October, and November. Assigned to different hospitals at different times in clearing field and evacuation and mobile hospitals. Army troops in St. Mihiel, cleared field hospital and served 10th French Army at Chateau-Thierry. Moved into Germany. Transported 10,332 patients, not including 3,000 in Germany.
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Company No. 6 arrived July 19, 1918. At Vaux-les-Palameix, Meuse, September and October; Virten, Belgium, November.
Company No. 7 arrived July 19, 1918. With Second Army. Served with Evacuation Hospital No. 3 in Marne area and with Justice group, Toul, evacuating the hospital to railhead; answered emergency calls and here operated the motor transport park for the hospital group; participated in the offensive against Mont Blanc east of Rheims by the 2d and 38th Divisions. It worked between the dressing station and the hospitals. Then assigned to Evacuation Hospital No. 15, near Verdun.
Company No. 8 arrived July 19, 1918. At Rimaucourt, Haute Marne, until ordered to proceed to Le Mans.
Company No. 9 arrived September 14, 1918. Operated at St. Nazaire, Base Section 1. Detained there until ambulances were received; that is, until after the armistice. On November 25 Ambulance Company No. 144, with 121 men, and Evacuation Ambulance Company No. 9, with 37 men, were organized into an evacuation ambulance battalion which evacuated hospital trains to the transport and moved sick and wounded in and out of hospitals. The battalion moved 80,000 patients by July.
Company No. 10 arrived August 12, 1918. At Froidos, Meuse, September, October, and November.
Company No. 11 arrived August 13, 1918. At Camp 1, Base Section 1,August to January, 1919.
Company No. 12 arrived August 13, 1918. At Vaubecourt, Meuse, October to December.
Company No. 13 arrived September 9, 1918. At St. Nazaire, September and October.
Company No. 14 arrived September 3, 1918. At St. Nazaire, September and October. Then at Bordeaux.
Company No. 15 arrived September 18, 1918. Camp Capelette, Base Section No. 6, October. Reception park, Base Section 6, November and December.
Company No. 16 arrived September 18, 1918. At Camp Capelette, Base Section 6, October; motor reception park, Base Section 6, November. Never received ambulance equipment nor moved patients. Operated as a motor transport unit and assembled cars.
Company No. 17 arrived October 13, 1918. Brest motor ambulance pool formed December 28, including this unit.
Company No. 18 arrived October 8, 1918; on October 12 assisted in assembly of carts, trucks, and ambulances at Bordeaux.
Company No. 19 arrived October 12, 1918. At St. Nazaire, October; Bordeaux, November.
Company No. 20 arrived October 12, 1918. At Bordeaux, October and November.
The rest of the evacuation ambulance companies were employed at base sections, hospital centers, and with the Army of Occupation.
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MOBILE LABORATORIES
Prior to the World War, our Medical Department had no mobile laboratories. Yet, as may be seen in the Appendix, p. 1044, provisions had been made so that laboratory work might be accomplished in the theater of operations, though only in the line of communications.82 That is to say, the organization of the Medical Department in war, as outlined in the last pre-war edition of the Manual for the Medical Department, provided for field laboratories and for the equipment of evacuation and base hospitals with laboratory facilities. As regards the field laboratory, it was intended to be a relatively fixed institution, conveniently located somewhere on the line of communications; and as regards the laboratories of evacuation and base hospitals, they were mobile, but only to the extent of the mobility of their parent organizations.
The arrangement thus outlined necessitated that all laboratory work required in the zone of the advance be accomplished in the line of communications.
In the summer of 1917, when the chief surgeon, A. E. F., was formulating his plans for the Medical Department of the American Expeditionary Forces, he appreciated the necessity for laboratories which could be made a part of the organization of the Medical Department attached to the combatant forces. On August 12, 1917, he forwarded to the Surgeon General an outline of the tentative organization for the laboratory service of the American Expeditionary Forces.83 This outline provided, on the basis of five corps of six divisions each, for stationary army and corps laboratories, and for mobile field laboratories staffed by two officers and four men each for every division. It was planned that the principal work of the division mobile laboratory would be the chemical and bacteriological examination of water supplies, the examination of smears, and the securing of cultures for examination in the laboratories of the corps or army. It was further planned to include in the work of the mobile laboratory all necessary chemical analyses.
One week after the chief surgeon, A. E. F., forwarded to the Surgeon General his tentative plan for the laboratory service overseas, he initiated plans for securing equipment for mobile laboratory units. On August 19, 1917, he placed an order with a British firm for two "motor bacteriological laboratories," each to consist of a small but well-equipped outfit mounted on a 3-ton chassis.84 However, delivery of these laboratories was delayed until early in the following year because of the difficulty experienced in securing from the British Government a release of the chassis for them.85
On January 11, 1918, the director of laboratories, A. E. F., submitted to the chief surgeon, A. E. F., an elaborated plan, which had already been approved in principle by the chief surgeon, for the organization of the division of laboratories and infectious diseases.86 This plan isgiven in full in Volume II of this history and will not be reproduced here. It is sufficient, for present purposes, to state that it contemplated two classes of laboratory equipment for service in the zone of the armies, immobilized and portable. The immobilized(army laboratory) equipment was for installation in permanent buildings in the zone of the advance, or in the advance section. The portable equipment
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was of two classes: Equipment installed in a specially constructed motor vehicle (mobile laboratory) and that packed in standardized chests (portable equipment). The mobile laboratories were designated corps laboratories and were given serial numbers. However, these mobile laboratories were not assigned definitely to corps but were attached to armies, corps, and to other units as demands for them arose. The portable equipment, in contradistinction to the mobile laboratory, being packed in standardized chests could be readily transported in any kind of vehicle. This was the equipment that was assigned for the laboratory work of a division; it was adequate for such routine work, including bacteriological and chemical examinations of water supplies. The personnel was 2 medical officers, 1 officer of the Sanitary Corps, and 4 enlisted men.
On January 14, 1918, the director of laboratories reported to the chief surgeon, A. E. F., that plans for the newly adopted portable equipment for the laboratories of divisions, mentioned in the preceding paragraph, had been completed, and that a model was being constructed at the Pasteur Institute, Paris.87
On May 22, 1918, the two types of transportable laboratories which had received consideration were available and in use.88 As previously indicated, one of these was a bacteriological motor car, the other a set of chests which could be transported on trucks. It was found the British utilized the former because of the assurance that the laboratory transportation was thereby provided, the French the latter because of its greater convenience. Our division of laboratories now decided that the former equipment had several disadvantages, viz, its initial cost was much greater ($7,500 as contrasted with $4,400), it was constructed by one firm only; its equipment was not flexible; and its operation was dependent on the proper functioning of other parts of a special vehicle, for example, the motor.88 It was reported that the French had given up the use of the bacteriological motor cars in favor of transportable laboratories packed inchests.88 After a thorough investigation, the division of laboratories adopted the transportable laboratory in chests, but it was also decided that for different units of this character different sets of chests would be employed. Thus an army laboratory would be issued in eight chests, a division laboratory in three. The transportation required would be either a -ton or a 1-ton truck, according to the number of chests.88
On July 7, 1918, in Memorandum No. 5, published by the Division of Laboratories and Infectious Diseases, the personnel, transportation, and duties of the divisional laboratory unit were discussed in some detail. The provisions of this circular were later republished, somewhat amplified, in Memorandum No. 7 from the same office under date of August 14, the revised document reading as follows:89
1. In the organization of the laboratory service for the American Expeditionary Forces provision was made for a divisional laboratory unit to serve with each division.
The personnel, equipment, and proposed transportation for each unit is as follows:
Personnel:
1 captain or first lieutenant, Medical Corps or Medical Reserve Corps.
1 captain or first lieutenant, Sanitary Corps, Medical Department.
4 enlisted men, Medical Department.
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Equipment:
Chest 1, standard equipment for clinical pathology.
Chest 2, standard equipment for clinical pathology.
Chest 3, standard bacteriological incubator.
Transportation:
1 light truck(1-ton Ford or other standard).
1 motor cycle with sidecar.
2. It is contemplated that these laboratory units shall constitute apart of the sanitary staff of the division surgeon and that they will be used by the divisional sanitary inspector in the investigation and control of communicable diseases and in the inspection, supervision, and control of sterilization of water supplies. While the question of immediate control of these units is a matter of internal administration, it is deemed advisable to place the medical officer in charge of the divisional laboratories because of the relative importance of the fields covered by the members of these units.
Some division surgeons have found it most practicable to attach the laboratory unit to the divisional sanitary train. When in divisional training or rest areas it is contemplated that the laboratory unit will be attached to the camp hospital functioning for the division. At the front it is attached to an immobilized field hospital, preferably the one through which infectious diseases and medical cases are evacuated.
3. To properly perform its functions it is contemplated that the medical officer and officer of the Sanitary Corps attached to this unit shall, on arrival in France, be sent to the central Medical Department laboratory for temporary duty for a brief course of instruction in the epidemiology of communicable disease and supervision of water supplies, respectively, and to obtain their laboratory equipment. Further practical instruction will be given these officers by specially trained officers of the infectious diseases and water supply sections of this office, who will visit them from time to time for the purpose of giving aid in the solution of local problems.
4. When an epidemic disease prevails in a division in such proportions as to make it seem desirable to temporarily reinforce the divisional personnel and to have special epidemiological and laboratory studies made for the control of the disease, the division surgeon is authorized by Bulletin No. 32, General Headquarters, American Expeditionary Forces, to communicate directly with the director of laboratories and infectious diseases, who will dispatch special personnel and mobile equipment to reinforce the divisional authorities in controlling the epidemic. In the zone of the advance these units are usually located in close proximity to evacuation and mobile hospitals. These organizations are provided with a complete laboratory equipment, which is available for use by the members of the divisional laboratory units when highly technical laboratory examinations are required.
Many of the evacuation and mobile hospital laboratories are prepared todo Wassermann tests, and the officer in charge of the divisional laboratories should consult with the laboratory staff of the organization to determine whether demands for such examinations can be met. (See revised Memorandum No. 0, this office.)
5. The equipment to be supplied the divisional laboratory unit has been standardized and arranged in chests in order that it may be packed and moved at a moment’s notice.
Chest 1 (weight 230 pounds, dimensions 24 by 24 by 36 inches);
Chest 2 (weight 140 pounds, dimensions 21 by 24by 30 inches);
Chest 3 (weight 180 pounds, dimensions 30 by 22by 28 inches);
constitute the divisional laboratory equipment. Chests 1 and 2 contain the equipment and supplies for routine clinical pathology, while chest 3 contains a bacteriological incubator complete, arranged for heating with coal oil. The coal oil is to be secured from the divisional supply officer.
6. With the equipment mentioned above the following classes of work can be done:
Sputum: Microscopic examinations of smears for the tubercle, pneumococcus, influenza, and animal parasites.
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Urine: Appearance, color, odor, reaction, specific gravity, and qualitative tests for albumin, sugar, acetone, and diacetic acid. Microscopic examinations of urinary sediments. In suspected cases of typhoid fever about 10 c. c. of the urine should be sent to the central Medical Department laboratory of the nearest base or army laboratory in a bottle of bile medium, for isolation of the suspected microorganism.
Venereal lesions: Microscopical examinations of smears for gonococci and Fontana stained preparations from venereal sores for spirochetes.
Blood: Hemoglobin estimations (Tallquist), leucocyte counts, red-cell counts, and differential leucocyte counts. Microscopical examinations of stained preparations for pathological changes, plasmodia, etc. In every case of undetermined fever of over 48 hours’ duration, 2 to 5 c. c. of blood should be collected in a bottle of bile medium and the culture sent to the central Medical Department laboratory or nearest base or army laboratory for further study. Sera for agglutination tests, the Wassermann test, etc., should be collected in the serum capsules furnished with this equipment and sent to the nearest of the laboratories mentioned above.
Feces: Microscopical examinations of fresh specimens for parasites, ova, blood, mucus, and pus cells.
In suspected cases of typhoid fever, paratyphoid fever, or dysentery, about a gram of the feces should be sent to the central Medical Department laboratory, or the nearest base or army laboratory, in a bottle of bile medium, for insolation of the specific microorganism.
Transudates and exudates: Microscopical examinations of stained specimens for tubercle bacilli, gonococci, spirochetes, etc., and cytological changes.
Spinal fluid: Microscopical examinations (cytologic and bacteriologic).
7. It is not intended that highly technical bacteriological and serological work shall be done by these units. In epidemics requiring epidemiological study and laboratory control, it is contemplated as noted in paragraph 3, above, that special personnel and mobile equipment will be sent to reinforce the local authorities on request from the division surgeon.
8. It is not contemplated that the Sanitary Corps officer attached to this unit for supervision of water supplies shall do any extensive chemical or bacteriological work. In so far as his water work is concerned, usually it will be confined to sanitary surveys of sources of supply, recommendations concerning quality of water, and supervision and instruction of sanitary detachments in the detail of the sterilization of water by chlorination or otherwise. His work will be done under the supervision of the divisional sanitary inspector. Where bacteriological or chemical analyses are deemed advisable, the specimens will be collected by the water supply officer of the laboratory unit and forwarded to the nearest army or base laboratory or mobile water laboratory. A chlorine testing outfit for use in controlling the chlorination of water supplies will be issued to divisional laboratory units. When extensive surveys requiring laboratory control are necessary, the Medical Department representative on the staff of the water supply officer for the army, will be called on for assistance. He has under his control mobile water analysis laboratories designed to carry out such investigations.
* * * * * * *
12. At the present time no transportation is provided for these units in tables of organization, and request had been made that one motor cycle with side car and one light truck (1-ton Ford or other standard) be included in the revised tables of organization for this unit. This request has not as yet been approved.
Circular No. 40 of the chief surgeon’s office, A. E. F., published July 20, 1918, provided that the laboratories of the American Expeditionary Forces would be of two general types, stationary and transportable, the latter to serve evacuation and mobile hospitals and divisions. It was directed that equipment of the transportable laboratories consist of standardized expendable units in chests and that their personnel be especially trained for the duties they were
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to perform. This training was accomplished by sending newly arrived personnel to the central laboratory at Dijon and there giving them an intensive course of instruction.
On September 19 the Surgeon General informed the chief surgeon, A. E.F., that it was desirable that the mobile laboratories be numbered and allotted to the chief surgeon, numbers from 1 to 45, inclusive, for such of these formations as were already overseas or en route.90 Records of the Surgeon General’s Office at that time showed that mobile laboratories had been sent to France with 31 divisions but had not accompanied 6 others.91 The director of laboratories stated in reference to this that, in point of fact, many of these units had not actually accompanied their divisions from the United States; that some had come after them; and that, in some instances, it had been necessary for the director of laboratories to find personnel in the American Expeditionary Forces who could be trained and assigned to their service. In view of the signing of the armistice the proposed numbering of the mobile laboratories never became effective.
In his report for the week ending October 28, 1918, the director of laboratories reported to the chief surgeon, A. E. F., in part as follows:91
(a) Additional transportable laboratory equipment arrived relieving acute shortage in this equipment. Sufficient number of those units now on hand to meet the requirements for about one month. Original order (placed last March) for 100 of these outfits now complete and received at central Medical Department laboratory. Additional orders to meet further needs have been placed by supply division, your office.
(b) Your attention is invited to the fact that the divisional laboratory units, attached to each division, are having the greatest difficulty in performing their functions because of the utter lack of transportation. It was intended that the two officers forming this unit should function as assistants to the sanitary inspector, one in general sanitation (more particularly the prevention and control of epidemic diseases) and the other supervision of the sterilization of water supplies. Actual laboratory work was to be of secondary importance. Several months ago it was requested that a light truck (1-ton) and motor cycle with side car be supplied these units. This recommendation has been repeated on a number of occasions. The recommendation was incorporated in the proposed revision of Tables of Organization but this revision has not yet been approved at General Headquarters. It is suggested that a strong effort be made to secure this transportation as soon as the transportation problem eases up. Either the light truck or the motor cycle, preferably the truck, if furnished these units, would enable them to perform their duties in part.
On November 4 the chief surgeon wrote the director, Motor Transport Corps, that the time consumed in the manufacture of specially constructed laboratory trucks and bacteriological cars had been so protracted and the difficulty of their transport to France so great that ordinary cargo trucks had been substituted for them and that the first-mentioned classes of vehicles were not needed.92
REFERENCES
(1) Manual for the Medical Department, U. S. Army, 1916, par. 793.
(2) Letter from the Surgeon General, U. S. Army, to The Adjutant General, May 2, 1914. Subject: Organization hospital. On file, Record Room, S. G.O., 148897.
218
(3) 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, 45. On file, Historical Division, S. G. O.
(4) Report of Medical Department activities, Evacuation Hospital No. 1, prepared under the direction of the commanding officer, undated. On file, Historical Division, S. G. O.
(5) Report on the activities of G-4-B, medical group, fourth section, general staff, G.H. Q., A. E. F., by Col. S. H. Wadhams, M. C., chief of section, December 31, 1918, 37. On file, Historical Division, S. G. O.
(6) Reports of Medical Department activities of evacuation hospitals in the A. E. F., undated. On file, Historical Division, S. G. O.
(7) Report of the chief surgeon, A. E. F., to the commanding general, S. O. S., April17, 1919, 58. On file, Historical Division, S. G. O.
(8) Reports of Medical Department activities of mobile hospitals, A. E. F., undated. On file, Historical Division, S. G. O.
(9) Report of Medical Department activities of the Justice Hospital Groupe, Toul, France, by Lieut. Col. H. C. Maddux, M. C., undated. On file, Historical Division, S. G.O.
(10) Report of Medical Department activities of the gas hospital, Justice Hospital Groupe, Toul, by Lieut. Col. H. U. Goodall, M. C., commanding officer, undated. On file, Historical Division, S. G. O.
(11) Evacuation system of a field army, by Col. C. R. Reynolds, M. C., undated, 6. On file, Historical Division, S. G. O.
(12) Report on evacuation hospitals, by Maj. George W. Crile, M. C., undated. On file, Historical Division, S. G. O.
(13) Cutler, E. C., Maj., M. C.: Organization, Function, and Operation of an Evacuation Hospital. The Military Surgeon, Washington, 1920, xlvi, 9.
(14) The evacuation hospital, Lecture No. 146, Army Sanitary School, Langres, France, by Col. B. K. Ashford, M. C., undated. On file, Historical Division, S. G. O.
(15) Evacuation system of a field army, by Col. C. R. Reynolds, M. C., undated, 20. On file, Historical Division, S. G. O.
(16) Report on the activities of G-4-B, medical group, fourth section, general staff, G. H. Q., A. E.F., by Col. S. H. Wadhams, M. C., chief of section, December 31, 1918, 45. On file, Historical Division, S. G. O.
(17) Report of Medical Department activities, Evacuation Hospital No. 9, A. E. F., prepared under the direction of the commanding officer, undated. On file, Historical Division, S. G. O.
(18) Report on the evacuation of wounded in the Meuse-Argonne operation, by Col. H. H.M. Lyle, M. C., undated, 26. On file, Historical Division, S. G. O.
(19) Report of Medical Department activities, Evacuation Hospital No. 7, prepared under the direction of the commanding officer, undated. On file, Historical Division, S. G. O.
(20) Report of Medical Department activities, Evacuation Hospital No. 4, A. E. F., prepared under the direction of the commanding officer, undated. On file, Historical Division, S. G. O.
(21) Report of Medical Department board, G. H. Q., A. E. F., 1919, undated. On file, Historical Division, S. G. O.
(22) 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, 44. On file, Historical Division, S. G. O.
(23) Report on Evacuation of the wounded in the Meuse-Argonne operation, by Col. H. H.M. Lyle, M. C., undated, 36. On file, Historical Division, S. G. O.
(24) Report of the inspector general, A. E. F., December 11, 1918. On file, Historical Division, S. G. O.
219
(25) Report of Medical Department activities, Evacuation Hospital No. 5, prepared under the direction of the commanding officer, undated. On file, Historical Division, S. G. O.
(26) Second indorsement to letter from The Adjutant General of the Army, May 21, 1918. Subject: Personnel for evacuation hospitals. On file, Record Room, S. G. O.
(27) Report of Medical Department activities, Evacuation Hospital No. 6, A. E. F., prepared under the direction of the commanding officer, undated. On file, Historical Division, S. G. O.
(28) Evacuation system of a field army, by Col. C. R. Reynolds, M. C., undated, 31. On file, Historical Division, S. G. O.
(29) Exhibit "S" to report on activities of G-4-B, medical group, fourth section, general staff, G. H. Q., A. E. F.: Report of hospital evacuation section, Regulating Station "B," St Dizier, undated. On file, Historical Division, S. G. O.
(30) Report on activities 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.
(31) Report and observations on French Auto-Chir No.17, by Maj. J. J. Moorhead, M. C., undated. On file, Historical Division, S. G. O.
(32) Report on Evacuation Hospital No. 18, French, by Lieut. Col. J. M. Flint, M. C., undated. On file, Historical Division, S. G. O.
(33) Letter from the chief surgeon, A. E. F., to the Surgeon General, February 25, 1918. Subject: Auto-chirs and complementary groups. On file, A. G. O., World War Division, Medical Records Section (Chief Surgeon’s Files, 322.3211).
(34) Index to Medical Department organizations, chief surgeon’s office, A. E. F. On file, Historical Division, S. G. O.
(35) Organization and operation of mobile hospital units, by Lieut. Col. E. C. Jones, M. C., undated. On file, Historical Division, S. G. O.
(36) Report of Medical Department activities, Mobile Hospital No. 1, prepared under the direction of the commanding officer, undated. On file, Historical Division, S. G. O.
(37) Report of Medical Department activities, Mobile Hospital No. 4, prepared under the direction of the commanding officer, undated. On file, Historical Division, S. G. O.
(38) Report of Medical Department activities of Mobile Hospital No. 39, A. E. F., from organization to St. Mihiel operation, by Lieut. Col. J. M. Flint, M. C., undated, 2. On file, Historical Division, S. G. O.
(39) Report of Medical Department activities of Mobile Hospital No. 39, A. E. F., during the St. Mihiel operation, by Lieut. Col. J. M. Flint, M. C., undated, 2. On file, Historical Division, S. G. O.
(40) Ibid., 4, 5.
(41) Ibid., 14.
(42) Ibid., 16.
(43) Ibid., 18.
(44) Ibid., 19.
(45) Ibid., 20.
(46) Ibid., 21.
(47) Ibid., 29.
(48) Ibid., 24.
(49) Ibid., 31.
(50) Ibid., 22.
(51) Ibid., 23.
(52) Ibid., 32.
(53) Ibid., 34.
(54) Ibid., 35.
220
(55) Cable from the chief surgeon, A. E. F., to The Adjutant General, April 22, 1918. On file, Historical Division, S. G. O.
(56) Letter from Capt. P. R. Turnure, M. C., to the Surgeon General of the Army, August 27, 1917. On file, Historical Division, S. G. O.
(57) Letter from Capt. P. R. Turnure, M. C., to the Surgeon General of the Army, September 3, 1917. On file, Historical Division, S. G. O.
(58) Letter from the Surgeon General of the Army to Capt. P. R. Turnure, M. C., September 18, 1918. On file, Historical Division, S. G. O.
(59) Memorandum from the Surgeon General to The Adjutant General of the Army, September 25, 1918. On file, Historical Division, S. G. O.
(60) Report of Medical Department activities, Mobile Operating Unit No.1, prepared under the direction of the commanding officer, undated. On file, Historical Division, S. G. O.
(61) Report on the activities of the chief surgeon’s office, A. E.F., to the Surgeon General, U. S. Army, May 1, 1919, 115. On file, Historical Division, S.G. O.
(62) Letter from the director of professional services, A. E. F., to commanding officers of hospitals, May 13, 1918. Subject: Surgical Teams. On file, A. G.O., World War Division, Medical Records Section (Chief Surgeon’s Files 322.3282).
(63) Letter from the chief surgeon, A. E. F., to the director of professional services, A. E. F., June 2, 1918. Subject: Gas teams. On file, A. G. O., World War Division, Medical Records Section (Chief Surgeon’s Files 321.621).
(64) 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, 47. On file, Historical Division, S. G. O.
(65) Report of Medical Department activities, First Army Corps, A. E.F., by Col. J. W. Grissinger, M. C., corps surgeon, undated. On file, Historical Division, S. G. O.
(66) Letter from the Surgeon General to the chief surgeon, A. E. F., November 12, 1917. Subject: Evacuation hospitals and ambulance companies. On file, A. G.O., World War Division, Medical Records Section (Chief Surgeon’s Files, 322.3211).
(67) Letter from the chief surgeon, A. E. F., to the Surgeon General, December 24, 1917. Subject: Evacuation hospitals and ambulance companies. On file, A. G.O., World War Division, Medical Records Section (Chief Surgeon’s Files, 322.3211).
(68) Letter from the Surgeon General to the commanding officers, training camps, Fort Riley, Kans., and Fort Oglethorpe, Ga. Subject: Evacuation ambulance companies. On file, Medical Records Section (Chief Surgeon’s Files 322.3211).
(69) Letter from the chief surgeon, Line of Communications, to the chief surgeon, A. E. F., November 27, 1917. Subject: Evacuation ambulance companies. On file, A. G. O., World War Division, Medical Records Section (Chief Surgeon’s Files322.3211).
(70) Cable No. 322-S, from the chief surgeon, A. E. F., to the Surgeon General, November 27, 1917. On file, A. G. O., World War Division, Medical Records Section(Chief Surgeon’s Files 322.3211).
(71) Memorandum from the chief surgeon, A. E. F., to the Surgeon General, December 8, 1917. Subject: Transportation of sick and wounded. On file, Medical Records Section, A. G. O., (Chief Surgeon’s Files, 322.321).
(72) Memorandum from Maj. A. P. Clark, M. C., to the chief surgeon, A.E. F., December 13, 1917. Subject: Need of evacuation ambulance companies. On file, A. G.O., World War Division, Medical Records Section (Chief Surgeon’s Files, 333.3211).
(73) Letter from the Surgeon General to commanding officers, training camps, December 18, 1917. Subject: Personnel of evacuation ambulance companies. On file, Record Room, S. G. O., 322.3.
(74) Second indorsement to letter from the Surgeon General, December28, 1917. Subject: Personnel for evacuation ambulance companies. On file, Record Room, S.G. O., 322.3.
221
(75) Letter from the chief surgeon, A. E. F., to the commander in chief, A. E. F., January 14, 1918. Subject: Provisional ambulance companies for immediate need. On file, A. G. O., World War Division, Medical Records Section (Chief Surgeon’s Files, 322.3211).
(76) Telegram No. 196, from the commander in chief, January 17, 1918, to the chief surgeon, A. E. F. On file, A. G. O., World War Division, Medical Records Section(Chief Surgeon’s Files 322.3212).
(77) Letter from Surgeon General to The Adjutant General, January 30, 1918. Subject: Use of U. S. Army Ambulance Service sections as evacuation ambulance companies. On file, A. G. O., World War Division, Medical Records Section (Chief Surgeon’s Files,322.3211).
(78) Memorandum from chief surgeon, A. E. F., to Chief of Motor Transport Service, March 5, 1918. Subject: Motor transportation for Medical Department. On file, A. G. O., World War Division, Medical Records Section (Chief Surgeon’s Files, 451).
(79) Letter from Surgeon General to The Adjutant General, March 22, 1918. Subject: Personnel of evacuation ambulance companies. On file, Records Section, S. G. O., 322.3.
(80) Letter from chief surgeon, A. E. F., to the chief of staff, A. E. F., September26, 1918. Subject: Proposed general orders for evacuation ambulance companies. On file, A.G. O., World War Division, Medical Records Section (Chief Surgeon’s Files, 300.42).
(81) Memorandum from the assistant chief of staff, G-1, G. H. Q., A. E. F., to the chief surgeon, A. E. F., October 18, 1918. On file, A. G. O., World War Division, Medical Records Section (Chief Surgeon’s Files, 300.42).
(82) Manual for the Medical Department, 1916, par. 586, 778.
(83) Letter from the chief surgeon, A. E. F., to the Surgeon General, August 12, 1917.Subject: Outline of laboratory organization, A. E. F. On file, A. G. O., World War Division, Medical Records Section (Chief Surgeon’s Files 322.3271).
(84) Letter from the chief surgeon, A. E. F., to the general purchasing agent, September 20, 1917. Subject: Purchase of mobile laboratories. On file, A. G. O., World War Division, Medical Records Section (Chief Surgeon`s Files, 322.3271).
(85) Letter from Baird and Tatlock, London, Ltd., to Maj. D. P. Card, M. C., December 12, 1917. Subject: Motor bacteriological laboratories. On file, A. G. O., World War Division, Medical Records Section, (Chief Surgeon’s Files, 322.3271).
(86) Letter from the director of laboratories, A. E. F., to the chief surgeon, A. E.F., January 11, 1918. Subject: Organization of the division of laboratories and infectious diseases. On file, A. G. O., World War Division, Medical Records Section (Chief Surgeon’s Files, 321.630).
(87) Weekly report on the activities of the division of laboratories and infectious diseases, Dijon, for the week ending January 13, 1918, to the chief surgeon, A. E. F. On file, A. G. O., World War Division, Medical Records Section (Chief Surgeon’s Files,321.630).
(88) Letter from the director of laboratories, A. E. F., to the chief surgeon, A. E.F., May 22, 1918. Subject: Transportation for transportable laboratory units. On file, A.G. O., World War Division, Medical Records Section (Chief Surgeon’s Files, 322.3271).
(89) Memoranda Nos. 5 and 7 (revised), chief surgeon’s office, division of laboratories and infectious diseases, A. E. F., July 7, 1918, and August 14, 1918. On file, A. G. O., World War Division, Medical Records Section (Chief Surgeon’s Files,321.360).
(90) Letter from the Surgeon General to the chief surgeon, A. E. F., September 19, 1918. Subject: Mobile laboratories. On file, A. G. O., World War Division, Medical Records Section (Chief Surgeon’s Files, 322.327).
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(91) Weekly reports from director of laboratories to the chief surgeon, A. E. F. On file, A. G. O., World War Division, Medical Records Section (Chief Surgeon’s Files, 322.3271).
(92) Memorandum from the chief surgeon, A. E. F., to the director, Motor Transport Corps, A. E. F., November 4, 1918. Subject: Trucks for mobile laboratories. On file, A. G.O., World War Division, Medical Records Section (Chief Surgeon’s Files, 322.3271).
