CHAPTER XXI
Movement of Patients inthe United States
The movement of patients in the United States, althoughfairly simple early in the war when it involved only the transfer of individualsor small groups from station to general hospitals, began to assume differentcharacteristics about the middle of 1943. A steady increase in the number ofevacuees received from theaters-from about 3,000 per month early in 1943 to apeak of more than 57,000 in May 1945-focused attention on the transportationof patients from debarkation to general hospitals. Meanwhile declining troopstrength in the United States, along with establishment of regional hospitals toserve in lieu of general hospitals for patients from camps in surrounding areas,reduced to a trickle the transfer of zone of interior patients to generalhospitals. Growth of the Army's fleet of hospital cars from 24 early in 1943to 380 by the end of the war, along with a shortage of commercial sleepers anddiners, meant that emphasis shifted from the transportation of patients onregular passenger trains to their movement on Army hospital trains. A change inAir Force policy in the spring of 1944, permitting certain planes to be assignedprimarily to evacuation operations in the United States, resulted in atransition from sporadic to regular movement of patients by air. Finally,compliance with the policy established early in 1943 of transferring patientsfrom debarkation hospitals to hospitals designated as specialized centers andlocated as near as possible to patients' homes complicated the problem ofplanning their transportation.
Regulating the Flow of Patients
Although The Surgeon General was designated by Army directivesas the chief medical "regulator," in the early part of the war heexercised only a general influence over the distribution of patients among Armyhospitals. His office granted ports unlimited bed credits in general hospitalslocated nearest them. Port commanders then transferred patients to suchhospitals, reporting later to the Surgeon General's Office the number receivedfrom theaters, the date of their arrival, and the name of the hospital to whichthey had been transferred.1 Station hospitals transferred patients to generalhospitals in which they held bed credits. General hos-
1(1) WD Cir 120, 21 Jun 41. (2) An Rpt, 1943, NYPE. HD. (3) Ltr, SG to CG HRPE, 14 Aug 42, sub: Rpt of Pnts Arriving from Overseas. SG: 705.-1 (HRPE).
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pitals normally did not hold bed credits in other general hospitals and hencehad to request the Surgeon General's Office to authorize transfers and todesignate receiving hospitals. In order to know which had vacant beds, TheSurgeon General began in April 1943 to require all general hospitals to submitdaily bed status reports to his Office.2 Whengeneral hospitals requested the transfer of patients to other such hospitals inorder to free beds for subsequent arrivals from near-by ports, his Officeauthorized the transfer of groups, sometimes as large as 250. Decisions as toparticular patients to be transferred were left to hospital commanders.Normally, then, in the first part of the war the Surgeon General's Officeauthorized the transfer of patients in bulk and depended upon local commandersto request individual transfers to comply with the policy of hospitalizingpatients near their homes and in specialized centers.3
Later in the war, as the movement of patients in the United States increasedand grew more complex, a new procedure was developed to give the Surgeon General'sOffice greater control over the transfer of individual patients. It involvedreports to the Medical Regulating Unit of patients received at debarkationhospitals and of vacant beds in general and convalescent hospitals. In May 1944the Medical Regulating Officer established a system for debarkation hospitals touse in requesting the transfer of patients to other hospitals. Instead of askingfor authority to transfer a certain number of patients without regard todisabilities or home locations, debarkation hospitals reported in coded teletypemessages the geographical destination (home), diagnosis or special disability,sex and military status, and general physical condition (litter or ambulatory)of each patient received. For example, one male enlisted neurosurgical patientwhose home was in Florida was reported as "6NCY"; ten such patients,as "6NCY10." In August 1944 this system was revised, and additionalmedical classifications or diagnoses were listed, along with more exactdefinitions of each. About the same time, the system of daily bed status reportswas changed. In the fall of 1943 a code had been established for hospitals touse in reporting vacant beds. In August 1944 this code was modified so thathospitals reported vacant beds not in such general categories as medicine,surgery, and neuropsychiatry but in terms of the particular diseases or injuriesfor which they had been designated as specialized centers. For example,hospitals with vacant beds for male neurosurgical patients reported them undercode "12TVKN." Early in 1945 both debarkation and bed status reportswere further revised to reflect changes in specialty designations of hospitalsand thereby to permit a greater degree of accuracy in sending patients to properhospitals. Using both reports together, the Medical Regulating Unit was able todirect debarkation hospitals to transfer patients, in small groups or asindividuals if necessary, to general hospitals that specialized in the diseasesor injuries with which they suf-
2(1) AR 40-600, 6 Oct 42. (2) Ltr, SG to CO Billings Gen Hosp, 26 Apr 43, sub: Daily Bed Rpt. SG: 632.2 (Billings GH). By July 1943 the Hospitalization and Evacuation Division, SGO, was receiving daily reports from 28 hospitals, giving number of patients, number of medical, surgical, and neuropsychiatric beds, and number of patients transferred to and received from other general hospitals.
3Telegrams in which the Surgeon General's Office authorized the transfer of patients are filed in SG: 704.-1 and 705.-1. See also weekly diaries of the Hospital Administration Division. HD.
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fered and that were located as near as practical to theirhome addresses.4
At first this system applied only to patients beingtransferred from debarkation hospitals to general hospitals of definitivetreatment, but gradually it was extended to cover even the transfer of patientsfrom station and regional hospitals to general hospitals. Because of crowdedconditions of general hospitals in the populous northeastern part of the UnitedStates, in July 1944 The Surgeon General directed that no patients should betransferred to certain hospitals in that area without prior approval of the ASFMedical Regulating Officer. In effect, this directive canceled all bed creditswhich station or regional hospitals held in the hospitals listed. About twomonths later additional hospitals were placed in this category, raising thenumber thus restricted from thirteen to thirty-one. Ultimately, early in 1945the system that originated as a means of authorizing the transfer of evacueesfrom debarkation to general and convalescent hospitals was formally extended toinclude all transfers to such hospitals.5 Thedegree of control which the Medical Regulating Officer thus achieved over theuse of beds in general and convalescent hospitals enabled him to authorizetransfers of patients promptly and to use beds effectively when they were at apremium in the first half of 1945.
Centralized control over the transfer of patients to generaland convalescent hospitals did not assure that policies on the hospitalizationof patients near their homes and in specialized centers would be wholly compliedwith. Hospital beds in the United States were not distributed in proportion todensity of population. Hence, early in 1945 when the patient load became greatenough to fill general and convalescent hospitals, it was impossible for theMedical Regulating Officer to send all patients to hospitals located near theirhomes. Furthermore, the necessity of sending patients to specialized centerssometimes conflicted with and outweighed the desirability of sending them tohospitals near their homes. Finally, debarkation hospitals had time for littlemore than superficial examinations of patients before requesting their transferto other hospitals. As a result, the medical classifications reported bydebarkation hospitals were sometimes incorrect and patients were sent to generalhospitals when they should have been sent to convalescent hospitals.6
Some idea of the complexity of the process of authorizing patient-transfersmay be gained from the work load of the ASF Medical Regulating Unit. In theearly part of 1945 it received bed status reports from 64 general, 12convalescent, and 7 temporary debarkation hospitals. Information from thesereports was posted daily to show at all times the ability of hospitals to acceptpatients. Each day the Unit received approximately 100 telegrams, 10 letters,and 25 telephone calls requesting the transfer of patients in small groups or asindividuals. Every month it received in addition fifty to sixty coded
4(1) History . . . Medical Regulating Service. . . .(2) ASF Cirs 149, 20 May 44; 284, 30 Aug 44; 249, 4 Aug 44; and 89, 10 Mar 45. (3) Ltr, CG ASF (SG) to CO Billings Gen Hosp, 15 Oct 43, sub: Daily Bed Rpt. SG: 632.-2 (Billings GH)K. Identical letters were sent to other general hospitals. Telegrams and correspondence on bed capacities and patient transfers are filed in HD: 705 (MRO Staybacks), 705 (MRO Chart on Pnt Capacities in Hosps), and 705 (MRO Daily Diaries, Daily Bed Status).
5Telg SPMDD-DR, SG (MRO) to all SvCs, 3 Jul 44, 17 Sep 44, 21 May 45, 6 Sep 45. HD: 705 (Med Reg Unit book).
6See above, pp. 211-12, 240-41.
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telegrams from debarkation hospitals requesting the transfer of patients togeneral hospitals; the typical request covered 500 patients who had to betransferred because of their diagnoses, home addresses, sex, and military statusto an average of forty-five different hospitals.7
Procedures for Rail Evacuation
The principal method of moving patients in the United States-other than byambulance-was by train-either regular passenger trains or hospital trainsmade up of Army hospital cars supplemented by commercial equipment. During mostof 1942 patients were moved almost exclusively in Pullman cars of passengertrains, because the necessity of transporting large groups was practicallynonexistent and the Army had only six hospital cars. For groups of patients andattendants numbering fewer than fifty, local transportation officers arrangedwith railroads for cars and routings. For larger groups, the Office of the Chiefof Transportation made necessary arrangements, upon request of localtransportation officers.8
Toward the end of the summer of 1942, SOS headquarters, the Chief ofTransportation, and The Surgeon General began to plan for the operation ofhospital trains. By that time the delivery of additional hospital cars-enoughto serve as the nuclei of eight hospital trains-was expected, and an increasein the number of evacuees was impending. Since several agencies were involved,delineation of their responsibilities for the control and operation of hospitalcars was complicated. Although hospital cars were procured by the TransportationCorps and used by the Medical Department, SOS headquarters decided with theapproval of both The Surgeon General and the Chief of Transportation that theyshould be "attached" to (i.e., placed under the jurisdiction of)service commands. A service command hospital was being constructed near eachport which lacked one, and it was anticipated that patients debarked at portswould be transported by motor vehicles to such hospitals and there turned overto service command control. Hence, ports would have no need for hospital cars.In addition, it was thought that service commands could furnish personnel andmedical supplies for hospital trains more easily than could ports. Experiencehad already shown that service commands where ports were located would needhospital cars most, because general hospitals in such commands would receivelarge numbers of patients for transfer to hospitals further inland. Plans weretherefore made to attach six hospital cars each to the Second, Fourth, and NinthService Commands, four to the Eighth, and two to the Sixth (for use inevacuating patients from areas in Canada), and service commands were directed tofurnish supplies and medical attendants for hospital trains. Any of the hospitalcars could be attached to or detached from service commands by the Chief ofTransportation. Either one unit car and two ward cars, or one ward dressing carand two ward cars, were to form the nucleus of a hospital train. SupplementalPullmans, diners, and other
7Memo, Dirs Hosp and Resources Anal Divs SGO for Dir HD SGO, 18 Jun 45, sub: Add Mat for An Rpt for FY 1945. HD: 319.1-2.
8(1) Memo, CofT for SG, 28 Mar 42, sub: Basic Plan for Evac of Sick and Wounded. HD: 705. (2) AR 30-925, C 2, 22 Aug 42. (3) WD Cir 192, 16 Jun 42. (4) Ltr SPOPH 322.15, CG SOS to CGs and COs of SvCs and PEs, and to SG, 15 Sep 42, sub: Mil Hosp and Evac Oprs, with incl. HD: 705.
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rail equipment were to be used to complete it.9
After the decision to attach hospital cars to servicecommands was made, SOS headquarters issued directives establishing proceduresfor their use. The directives conflicted with one another and with Armyregulations governing the transportation of personnel in general. As alreadynoted, War Department regulations permitted local transportation officers toarrange with railroads for the transportation of groups of persons numberingless than fifty (after June 1943 less than forty), but provided that the Chiefof Transportation would arrange for the transportation of all larger groups.This meant arranging with railroads for carrier-owned equipment and for routesand schedules.10 On the other hand, SOSdirectives provided that local transportation officers could arrange for allroutings of hospital cars within the boundaries of service commands to whichthey were attached. Another stated in contradiction that except in emergenciesservice commands would ask the Chief of Transportation for routing instructionsto cover the movement of each hospital car. Two SOS directives stated thatservice command transportation officers would arrange with railroads for allsupplemental rail equipment, while another limited them to arrangements forsupplemental equipment needed when hospital cars were moved within servicecommand boundaries. None of the SOS directives took account of Army regulationsrequiring the Chief of Transportation to arrange for equipment and routings forthe movement of large groups.11 Suchconflicting instructions caused confusion about which both the Office of theChief of Transportation and service commands complained.12
The feasibility of attaching cars to service commands andthen attempting to divide authority for controlling their use was questioned inthe winter of 1942 and again in the spring of 1943. The commanding general ofthe Eighth Service Command believed that hospital cars would be used most in thetransportation of patients arriving from theaters of operations and proposed,therefore, that they should be controlled exclusively by the TransportationCorps and operated by ports.13 TheChief of Transportation considered this possibility, but agreed with the SOSHospitalization and Evacuation Branch to follow plans already made.Nevertheless, in preparation for the reception of casualties from the NorthAfrican invasion, all hospital cars were temporarily transferred to the New Yorkand Hampton Roads Ports and placed under their jurisdiction.14In December 1942 both the Chief of Transportation and the Hospitalizationand Evacuation Branch agreed that they should be returned to
9(l) Memos, CG SOS for CGs 2d, 4th, 6th, 8th, and 9th SvCs, CofT, and SG, 18 and 26 Aug 42, sub: Location and Control of Hosp Tns. AG: 531.4. (2) Ltr, CofT to CGs PEs and SvCs, 9 Sep 42, sub: Control of Hosp Tns. TC: 531.4. For a discussion of different types of Army-owned hospital cars, see below, pp. 372-75, 381-83.
10(1) WD Cir 192, 16 Jun 42. (2) AR 55-130, 28 Dec 42, with C 2, 4 Jun 43.
11(1) Memos cited n. 9(1). (2) Ltr cited n. 8(4).
12(1) Ltr, CG Ft Sam Houston to CG NYPE, 27 Sep 42, sub: Control of Hosp Tns, with inds. HD: Wilson files, 531.4. (2) 3d ind, CG SOS to CG SFPE thru CG 9th SvC, 3 Nov 42, on telg (n d) from CG 9th SvC. AG: 322.38. (3) Memo, Tank Car Br OCT for Col William J. Williamson, OCT, 16 Nov 42, sub: Opr of Hosp Tn Cars. TC: 531.4.
13Rpt, Conf of CGs SvCs, New Orleans, La., 17 Dec 42. HD: 337.
14(1) Ltr, CG SOS to TAG, 31 Oct 42, sub: Hosp and Evac for Special Opr. TC: 531.4. (2) Memo, CG SOS for SG and CofT, 1 Nov 42, same sub. HRS: ASF Planning Div file, "Hosp and Evac No 15."
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service commands.15 Inthe spring of 1943, when plans were being made to receive ninety-six hospitalcars ordered earlier, a representative of The Surgeon General suggested that itwould be advantageous eventually, when large numbers of patients began to arrivefrom theaters of operations, to have service commands supply personnel forhospital trains but to place all hospital cars in pools under the exclusivecontrol of the Chief of Transportation. Presumably such an arrangement wouldhave promoted the more efficient use of cars, but the Transportation Corpspreferred to continue the system of attaching cars to service commands in whichports were located, and The Surgeon General's representative concurred inplans for the allocations of 45 cars to the Second, 24 to the Third, and 27 tothe Ninth Service Commands.16
Later in the war, when a shortage of carrier-owned equipmentcombined with a steadily increasing evacuation load to require the greatestpossible use of Army hospital cars, centralized control was adopted, along withother measures, to achieve that goal. By the winter of 1943-44 it was widelyrecognized that maximum use was not being made of hospital cars. In manyinstances they returned empty to home stations after delivering patients togeneral hospitals. In others, service commands permitted hospital cars to standidle while they arranged for carrier-owned equipment to transport patients. InFebruary 1944 the Surgeon General's Office pointed to this situation andsuggested again that better use could be achieved by centralizing control ofhospital cars in the Office of the Chief of Transportation.17
Before this step was finally taken, a movement already begunto achieve closer co-operation between the Transportation Corps and the MedicalDepartment had to be completed. Late in 1943 the Evacuation Branch of theSurgeon General's Office had agreed to supply the Office of the Chief ofTransportation with copies of all messages authorizing general and debarkationhospitals to transfer patients to other hospitals, enabling the latter toanticipate requests from service commands for rail equipment. A short time laterthe Chief of Transportation established an evacuation unit in his TrafficControl Division. It collaborated with the Surgeon General's Office andservice commands in planning rail movements, and for this purpose kept a currentrecord of the location and use of each hospital car. In May 1944 the transfer(already mentioned) of the Surgeon General's Evacuation Branch to the MedicalRegulating Unit, which was physically located in the Office of the Chief ofTransportation, enabled medical officers who authorized the transfer of patientsfrom debarkation to other hospitals to consult at all times with transportationofficers as to the availability of Army hospital cars and carrier-ownedequipment. Conversely, transportation officers had readily available informationas to the lo-
15(1) Ltr, CofT to CGs NYPE and HRPE, 10 Dec 42, sub: Hosp Cars. TC: 531.4. (2) Diary, Hosp and Evac Br SOS, 22-23 Dec 42. HD: Wilson files, "Diary." (3) Memo, ACofT for CofT, 22 Dec 42, sub: Asgmt of Hosp Tn Cars. TC: 531.4.
16(1) Memos, Mtg, Off Chief Rail Div OCT, 22 Apr and 18 May 43. SG: 453.-1. (2) Ltr, CG ASF to CGs 2d, 3d, and 9th SvCs, 22 May 43, sub: Location of Add Hosp Cars. TC: 531.4. (3) Memo, Mvmt Div OCT for ACofT, 2 Jul 43, sub: Mtg of SvC Comdrs. Same file.
17(1) Memo for Record, on 3d ind, CG ASF to CofT, 10 Sep 43, on unknown basic ltr. HD: Wilson files, "Day File." (2) Ltr, Dir Hosp Admin Div SGO to Surg 9th SvC, 4 Dec 43. SG: 705.-1 (9th SvC)AA. (3) Hosp and Evac: Re-estimate of Pnt Load and Facs, pp. 25-26. HD: 705-1. (4) Rpt, Conf CGs of SvCs, Dallas, Tex, 17-19 Feb 44. HD: 337.
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cation, destination, number, and types of patients to bemoved by rail.18
As the offices of The Surgeon General and the Chief ofTransportation developed closer co-operation in planning the movement ofpatients by rail, measures were adopted to centralize the control of hospitalcars. At the end of 1943, SOS directives that had caused confusion by attemptingto divide responsibility for their use between service commands and the Officeof the Chief of Transportation were superseded by a War Department circularwhich agreed in its provisions with general transportation regulations. Therouting, including scheduling for train connections, of all hospital cars-whetherempty or loaded and whether moving within or beyond service command boundaries-wascentralized in the Office of the Chief of Transportation. Moreover, localtransportation officers were specifically limited in the arrangements which theycould make for supplemental rail equipment to instances when fewer than fortypersons were to be carried on hospital trains. When larger groups were moved theOffice of the Chief of Transportation alone could make all arrangements. Forseveral months this Office was indulgent, accepting generally therecommendations of service commands as to dates of hospital train movements andthe make-up (that is, the combination of Army-owned with carrier-owned cars) ofhospital trains. Later, in the spring of 1944, it began to exercise itsauthority to arrange without consultation with service commands for the railtransportation of groups of patients numbering forty or more. Informed by theMedical Regulating Unit of the patients to be moved and of their destinations,the Traffic Control Division determined the make-up of hospital trains and setthe dates of their departure. Upon the recommendation of the Medical RegulatingOfficer it diverted hospital cars to places where they were needed, informingservice commands to which they were attached only if this action delayed theirreturn to home stations for more than ten (later five) days. This meant, forexample, that a car attached to the Second Service Command, carrying patients toa hospital in the Fifth Service Command, might be loaded with other patients atthe latter place and diverted to a destination in the Fourth Service Commandbefore being returned to its home station.19
Further centralization in rail evacuation operations and moreextensive use of hospital cars was achieved during 1945 when the size of groupsfor which service commands might independently arrange commercial transportationwas reduced from a maximum of thirty-nine to fourteen. As long as servicecommands could arrange for the movement of groups of patients that were largeenough to warrant the addition of a special tourist or sleeping car to aregularly scheduled train (that is, any group of fifteen or more persons), itwas possible for such a car to be procured to move patients along a route
18(1) Memo, CofT for SG, 23 Oct 43, sub: Opr of Hosp Tn Cars. SG: 453.-1. (2) Memo, Maj Samuel N. Farley, TC, for Lt Col I. Sewell Morris, TC, 27 Oct 43, sub: Conf in SGO re Better Util of Govt-Owned Hosp Cars. Off file, Hosp Evac Unit, OCT. (3) Memo, Same for Same, 17 Jan 44, sub: Functions of the Hosp Evac Unit. Same file.
19(1) Interv, MD Historian with Samuel N. Farley, 9 Oct 52. HD: 000.71. (2) WD Cir 316, 6 Dec 43. (3) ASF Cir 147, 19 May 44. (4) Memo, Lt Col John C. Fitzpatrick for Gen [Raymond W.] Bliss, 23 May 44, sub: Util of Hosp Tns. HD: 705 (MRO, Fitzpatrick Stayback, 1334). (5) Memo, SG for Fiscal Dir ASF, 26 Jul 44. SG: 322 (Hosp Tns). (6) ASF Cir 328, 30 Sep 44. (7) Transcript of Proceedings, Hosp Tn Conf, 15-16 Feb 45. HD: 531.4.
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over which an Army hospital car-under orders of the Office of the Chief ofTransportation-was traveling empty at approximately the same time. The Chiefof Transportation therefore recommended in May 1945 that arrangements for themovement of all groups of patients and attendants numbering fifteen or morepersons should be centralized in his Office. This recommendation was approvedand in June 1945 local transportation officers were limited to makingarrangements for the movement of individuals and of groups of patients andattendants numbering fourteen or less. Knowing the locations and routes of allArmy hospital cars, the Chief of Transportation could then arrange to use themin moving some of the groups which service commands had formerly dispatched inextra sleeping and tourist cars of regularly scheduled passenger trains.20
Despite the fact that centralized control of hospital cars and hospital trainmovements was not wholly approved by service commands, the Surgeon General'sOffice considered such control essential. One service command surgeon felt thathis lack of control over the personnel on hospital cars from other commandsjeopardized the loading and care en route of patients whom he was transferring.A local transportation officer in another service command believed that he couldexpedite the movement of patients from the debarkation hospital which he servedif he were permitted to arrange rail movements independently. Still anotherservice command complained of the use elsewhere of personnel which it suppliedto care for patients being transported from its own debarkation hospital. Otherobjections arose from the difficulty service commands encountered in propertyand mess management on hospital cars attached to them but diverted elsewhere foruse. In reply to such complaints, The Surgeon General repeatedly explained thatcentralized control of the movement of hospital cars and hospital trains wasnecessary to insure the maximum use of all available rail equipment, both Army-and carrier-owned, in the orderly transportation of large numbers of patients.21
Measures other than centralization of control were adopted toachieve better use of hospital cars, conserve medical personnel, and relieverailroads of furnishing more sleeping cars. In June 1944 the TransportationCorps requested carriers to return hospital cars in passenger rather than infreight service. In this way hospital cars that had to be moved without patientsspent less time idle than they might have otherwise.22By the early part of 1945 the Transportation Corps itself began to arrangehospital-car routes and schedules, without reference to railroadrepresentatives. Though this procedure was a departure from the Army'sagreement with the railroads, the latter apparently inter-
20(1) Memo, CofT for ACofS G-4 WDGS, 16 May 45, sub: Routing Control and Carriers' Equip for Mvmt of Pnts and/or Med Attendants in Groups of 15 or More. . . .TC: 511 (AR 55-130). (2) WD Cir 177, 15 Jun 45.
21(1) Ltr, Surg 2d SvC to Brig Gen Raymond W. Bliss, SGO, 3 Feb 44. SG: 531.2 (2d SvC)AA. (2) Diary, Evac Br MRU Oprs Serv SGO, 20 Jun 44. HD: 024.7-3. (3) Ltr, CG Letterman Gen Hosp to Lt Col John C. Fitzpatrick, MRO, 14 Nov 44. HD: 705 (MRO, Maloney Stayback, 127). (4) Memo cited n. 19(4). (5) Ltr, MRO to CG Letterman Gen Hosp, 21 Nov 44. SG: 705.1 (Letterman GH). (6) Ltr, Dep Chief for Hosp and Domestic Oprs, Oprs Serv SGO to Surg 2d SvC, ca. 28 Dec 44. SG: 531.2 (2d SvC)AA. (7) Memo, Maj Frederick H. Gibbs, MAC, for Surg 4th SvC, 29 Jan 45, sub: Hosp Tn Serv, Stark Gen Hosp, with 2 inds. SG: 453 (Stark GH)K.
22Ltr, Lt Col I. Sewell Morris, TC, to A. H. Gass, Mil Trans Sec AAR, 6 Jun 44, with reply dated 8 Jun 44. TC: 531.4.
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posed no objection. Its chief advantage was that hospitalcars could be sent along unauthorized routes (those not normally used byrailroad companies) to reduce mileage and to deliver groups of patients atdifferent hospitals. The higher cost which railroads charged for such movementswas considered by the Surgeon General's Office to be fully justified by theends achieved.23
In addition to the larger problem of using hospital cars tothe best advantage, others were encountered in the operation of hospital trains.One of them, feeding patients on hospital trains, was partially solved by theprocurement of Army hospital kitchen cars and the installation ofbuffet-kitchens in other hospital cars.24 Togovern the procurement of food for these cars, along with the bookkeepingprocedures involved, the ASF Control Division, the Surgeon General's Office,and the Office of The Quartermaster General collaborated in the preparation of astandard subsistence procedure for hospital trains in the last part of 1944.25Other problems arose in accounting for hospital cars and their equipment, and intheir maintenance. In September 1944 a circular governing accounting procedureswas published by ASF headquarters, while some months earlier the TransportationCorps prepared technical bulletins on the maintenance of hospital cars.26Another problem involved the position of hospital cars in trains. In thewinter of 1943-44 the Transportation Corps requested carriers to place hospitalcars on regular passenger trains in such a position that the public would nothave to use them as passageways. Carriers agreed to place them either directlyahead of or directly behind other passenger cars in the same train. Furthermorethe carriers agreed, upon the request of the Chief of Transportation and therecommendation of The Surgeon General, to place "buffer" cars (cars inwhich no patients were carried) between hospital cars and locomotives whenspecial hospital trains were made up.27 Thecarriers also co-operated in observing a request of The Surgeon General thatpatients be transported only in air-conditioned cars. By Army regulations and anagreement with railroads, patients were authorized "sleeping caraccommodations in tourist sleeping cars if available, otherwise standardsleeping cars." Of the entire fleet of Pullman tourist cars, only fourhundred were air-conditioned, and it was therefore impossible for carriersalways to supply air-conditioned tourist cars when they were requested. For atime during 1944 they supplied higher-priced air-conditioned standard sleepingcars without any increase in cost, but in December of that year they revised anearlier agreement
23(1) Memo, CofT for SG (MRO), 14 Feb 45, sub: Routing of Hosp Tn Travel, with inds. SG: 531.4. (2) Ltr, Lt Col E. B. White, TC, to Interterritorial Mil Cmtee, 9 Mar 45. TC: 531.4. After the war ended, in November and December 1945, the Army and Navy agreed upon a procedure for the joint use of Army hospital cars in the United States. This agreement contributed to the conservation of carrier-owned equipment and still greater use of Army-owned hospital cars. ASF Cir 441, 11 Dec 45.
24See below, pp. 381-86.
25WD Cir 480, 22 Dec 44. Also see WD Cir 184, 21 Jun 45.
26(1) ASF Cirs 286, 1 Sep 44; 401, 9 Dec 44. (2) TB 55-285-1, 24 Jul 44; TB 55-285-2, 24 Aug 44, on Echelon Maintenance for Hosp and Kitchen Cars. A complete manual for operation of the new unit cars (TM 55-1254, 15 Dec 45, Car, Railway, Hospital Unit) was issued after the end of the war.
27(1) Ltr, Hosp Tn Comdr to CG 2d SvC, 21 Oct 43, sub: Trans Rpt of Hosp Tn Mvmt HT-69, Main 57616, 14-19 Oct 43, with inds. SG: 453.-1. (2) Ltr, CofT (Tfc Control Div) to AAR, 24 Jan 44. TC: 531.4 (Placement of Hosp Cars on Regular Tn). (3) Ltr, SG to SvCs, 2 Dec 44, sub: Use of Buffer Cars in Connection with Mvmt of Pnts by Rail. SG: 453 (SvCs).
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with the Army to provide special rates for standard sleeping car equipment.28
The problems just reviewed are representative only, in no way intended to bean exhaustive listing, of those encountered by authorities on a higher levelthan hospital train commanders. These commanders were faced with other problemswhich were perhaps even more varied and complex. Solutions for most of them hadto be found locally, for there was no War Department manual on hospital trainoperations. During 1945 a series of conferences of hospital train commanders,attended by representatives of The Surgeon General and the Chief ofTransportation, were held to discuss such common questions as linen exchangeprocedures, feeding difficulties, the handling of baggage, entraining anddetraining plans, personnel and equipment requirements, means of providingrecreation aboard trains, and problems of hospital car maintenance andoperation.29
Some idea of the scope of hospital train operations may be gained from thefollowing figures. During 1944, 172 hospital trains carrying 37,371 patientswere dispatched from the Second Service Command to general and convalescenthospitals scattered throughout the United States. During the period from 26 June1944 to 15 October 1945, 205 hospital trains evacuated 35,697 ambulatorypatients and 17,320 litter patients from Stark General Hospital. From January toAugust 1945, inclusive, the hospital train detachment of the First ServiceCommand made 232 trips to 1,334 destinations, covering 48,888 miles and moving67,608 patients. Between July 1944 and December 1945, the Ninth Service Commandmoved 56,061 patients in hospital cars and 29,439 in Pullmans.30
Despite the widespread use of centrally controlled hospitaltrains, service commands retained throughout the war the authority to arrangewith common carriers for the movement of patients as individuals or in smallgroups. The main difficulty they encountered was in securing accommodations forthem in sleeping or parlor cars occupied also by civilians. In November 1943 theASF Control Division investigated complaints of hospitals about delays ingetting reservations for patients and found that they were justified. Theaverage period that elapsed between the time transportation was requested andwas made available for 27,265 patients was 3.8 days. In some instances it rangedas high as 15.3 days. Continuation of this situation would mean not only thatthe treatment of patients would be delayed but also that some hospitals in timewould become hopelessly overcrowded. In February 1944, therefore, ASFheadquarters directed The Surgeon General, with the assistance of the Chief ofTransportation and service commands, to arrange with railroads for securingpromptly rail accommodations for Army patients.31
28(1) AR 55-125, 9 Jan 43; C 1, 4 Jun 43; C 2, 4 Aug 43. (2) Memo, CofT for SG, 22 Aug 44, sub: Accommodations in Air-Conditioned Sleeping Cars, with inds. SG: 531.2. (3) WD Cir 240, 7 Aug 45. (4) Ltr, CofT (Tfc Control Div) to GAO (Claims Div), 1 Oct 45. TC: 531.4.
29(1) Mins, Hosp Tn Conf, 15-16 Feb 45, Miller Fld, NY; Hosp Tn Unit Comdrs Conf, 10-13 Jul 45, Presidio of San Francisco. HD: 531.4 (Conf). (2) An Rpts, 1st, 2d, 4th, and 9th SvCs, 1944 and 45. HD. (3) Ltr, 9956 TSU Letterman Gen Hosp to SG, 22 Mar 50, sub: Ref Mat for Util of Hosp Tns. HD: 453.1.
30An Rpts, 1st, 2d, 4th, and 9th SvCs, 1944 and 45. HD.
31(1) AR 55-130, 28 Dec 42, with C 2, 4 Jun 43. (2) WD Cirs 229, 24 Sep 43; 316, 6 Dec 43. (3) History of Control Division, ASF, 1942-45, App, Project 95-2. HD.
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In conferences held in Chicago and Washington during April and May 1944,representatives of The Surgeon General, the Chief of Transportation, and theRailroad Interterritorial Military Committee agreed upon procedures forobtaining reservations for individuals and for groups of fewer than fifteenpersons. For this purpose, patients were divided into five classes. Class Ipatients were those who were acutely sick or injured and whose immediatemovement to hospitals staffed and equipped to care for them was "a matterof extreme urgency." Class II patients were similar cases whose movementmight be delayed safely for forty-eight hours. Class III patients were those whoneeded to be moved for medical reasons but whose transfer could be delayedapproximately seventy-two hours; this group included patients received fromtheaters of operations at debarkation hospitals. Class IV patients were thosebeing moved, not for medical reasons, but for their own convenience; theirtransfer might be delayed for approximately six days. Class V patients werethose being discharged from the service, being returned to duty, or being senton sick leave; their movement could be delayed about ninety-six hours. Thecarriers agreed to appoint special representatives for each individual railroadto assist hospital commanders in obtaining accommodations for patients of allclasses within the time limits established for each. Hospital commanders wereenjoined to co-operate with such representatives and, when requestingtransportation for patients in either of the first two classes, were required tosubmit certificates attesting that transportation for Class I patients wasnecessary immediately and for Class II patients within forty-eight hours.32
The question of priorities for patients over civilians came up when thisagreement was reached. Army authorities agreed with railroad representativesthat establishment of such priorities would carry the unintentional implicationthat railroads were not "doing the job." Therefore they decidedagainst it. In the following June, representatives of The Surgeon General, theChief of Transportation, and railroad companies maintained a like position whenthe Office of Defense Transportation proposed a system of priorities. Soonafterward, however, the Interstate Commerce Commission, on the recommendation ofthe Office of Defense Transportation, issued an order which provided for thedispossession of passengers to obtain accommodations for patients. While thisaction protected railroads against unwarranted lawsuits by civilians who weredisplaced, the Surgeon General's Office feared that it might createunjustified hysteria on the part of the public instead of dissuading it fromunnecessary travel and, at the same time, might endanger the Army's goodrelations with the railroads. To avoid the latter contingency, and particularlythe unwarranted use of priorities by general hospitals, the Army in October 1944revised the circular describing the voluntary agreement worked out in May.Restating that agreement, the revised version of the circular required hospitalcommanders to submit to railroads, along with each request for reservations,certificates attesting the classifica-
32(1) Memo, SG for CG ASF thru CofT, 20 Mar 44, sub: Delays in Trans of Pnts to Hosps, with inds. SG: 531.2. (2) Memo, CofT (Mvmt Br) for SG, 16 May 44, sub: Delays in Trans of Pnts to Hosps. Same file. (3) Ltr, CofT to SG, 29 Apr 44, sub: Apmt of RR Rep at US Army Gen Hosps in Arranging Accommodations for Litter and Ambulatory Cases. SG: 705. (4) Ltr, Western Mil Bu to Member RR Assn, 9 May 44, sub: Accommodations for Litter and Ambulatory Cases. SG: 531.2. (5) WD Cir 234, 12 Jun 44.
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tion of each patient, those in Classes III, IV, and V as well as in Classes Iand II, and indicating the period of time within which accommodations should beprovided. In addition it provided that the Interstate Commerce Commission ordershould be invoked only in accordance with the provisions of this circular. Italso forbade the use of priorities to dispossess passengers to secureaccommodations for medical attendants returning to home stations.33Presumably, so long as railroads lived up to terms of the May agreement,the Army would not dispossess passengers to secure accommodations for patients.
Procedures for Air Evacuation
Air evacuation in the United States in the early part of the war was limitedto the movement of individuals or groups of three to four patients from scenesof crashes to hospitals or from one hospital to another. In 1942, for instance,Maxwell Field transported a few patients by plane to Lawson General Hospital,and MacDill Field sent others to both Lawson and Walter Reed General Hospitals.At the time of the North African invasion, the Hampton Roads Port arranged forthe flight of a patient suffering from a brain injury to Walter Reed GeneralHospital.34 Such flights were exceptional andthe first sizable air evacuation of patients in the United States did not occuruntil the beginning of 1944. For sporadic flights prior to that time, the AirForces normally set aside no single group of planes, and it was thereforeimperative that air evacuation be carried out normally in administrative,training, or transport planes.35 Moreover,until the latter part of 1942, no personnel was trained especially for airevacuation operations. Air station surgeons either arranged with localoperations officers for the transportation of patients by planes belonging totheir stations or called upon the surgeons of training centers to supply thenecessary accommodations. They either accompanied patients themselves or sentnurses or doctors from air station hospitals as attendants. AAF headquartersauthorized SOS installations to submit requests for the air transportation ofpatients to near-by Air Forces installations, the Air Transport Command, troopcarrier commands, and the Air Surgeon's Office.36
During the winter of 1943-44 there were widespread demands,for a variety of reasons, for air transportation of patients in the UnitedStates. On 16 November 1943, for example, the commander of Ashford GeneralHospital requested air evacuation to relieve congestion on railroads in thatarea. A few weeks later the commandant of the School of Air Evacuation suggestedit to provide training for air evacuation personnel and to increase the comfortof patients.37 Early the next Janu-
33(1) ICC, Order 213, Title 49, Transportation and Railroads, 27 Jun 44. HD: 531.4. (2) Memo, Col A[lbert] H. Schwichtenberg for SG, 26 Jun 44, sub: Rail Trans of Pnts. SG: 531.2. (3) WD Cir 405, 14 Oct 44. See also WD Cirs 61, 26 Feb 45, and 471, 15 Dec 44.
34(1) Ltr, Base Surg AAB MacDill Fld to CG AAF (Air Surg), 17 Nov 42. AAF: 370.05 (Evac Book No 1). (2) Ltr, Surg HRPE to CO Langley Fld, 16 Dec 42, sub: Air Trans for Overseas Sick and Wounded Arriving at HRPE. AAF: 452.1 (Amb Plane).
35See below, pp. 429-33.
36(1) 3d ind, Hq AAF to Port Surg HRPE, 5 Jan 43, on Ltr, HRPE to CO Langley Fld, 16 Dec 42, sub: Air Trans for Overseas Sick and Wounded Arriving at HRPE. AAF: 452.1 (Amb Planes). (2) Ltr, 6th SvC to AAF (Air Surg), 16 Apr 43, sub: SOP, with ind. AAF: 370.05 (Evac).
37Ltrs, CO Ashford Gen Hosp to CO AAB, Richmond, Va., 16 Nov 43; AAF School of Air Evac, Bowman Fld, Ky., 6 Dec 43, sub: Trans of Pnts by Air. AAF: 370.05 (Evac, Book 1).
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ary the director of the Surgeon General's Hospital Administration Divisionconferred with the Deputy Chief of Air Staff on the "feasibility of movingpatients by air from port hospitals."38The following month, at a conference of service commanders, the commandinggeneral of the Second Service Command stated that air transportation forpatients was "most desirable," and suggested its use particularly forsmall groups who needed to be moved without delay.39In April the flight surgeon assigned to Brooke General Hospital propoundedstill another reason: the evacuation of patients by air would be economical,saving the Government, according to his estimate, at least fifty dollars perpatient.40 A combination of such reasons, alongwith increases in aircraft production, a shortage of Pullman cars, and theabsolute necessity of moving large numbers of patients who arrived in the UnitedStates from theaters of operations, were responsible for the extensive use ofair evacuation in this country during the latter half of the war.
The first large-scale movement of patients by air in the United States wasmade in January 1944. At that time three troop carrier command planes, withpersonnel from the School of Air Evacuation, were sent to Stark General Hospitalto move patients being debarked from two hospital ships. In a period of tenflying days, between 7 and 19 January, these planes flew 661 patients in 29loads to 5 general hospitals. No cases of air sickness occurred and only twelvepatients required medication, such as the administration of aspirin or morphine,during flight. The success of this mission prompted the commanding general ofthe Service Forces to congratulate the Air Forces and to express the hope thatpatients might be evacuated by air from ports of debarkation "repeatedly inthe future."41
During the spring of 1944 plans were made to convert thathope into a reality. In April the Air Transport Command was made responsible forthe movement of patients by air in the United States (as it had been maderesponsible earlier for air evacuation from theaters of operations). Soonafterward it assigned to its Ferrying Division as a special mission the movementof about 700 patients from coastal medical installations to various hospitalsthroughout the United States. The next month the Transport Command delegated itsresponsibility for domestic air evacuation to the Ferrying Division, and beganto earmark transport planes for evacuation only.42In June representatives of AAF and ATC headquarters, the FerryingDivision, the Air Surgeon, and The Surgeon General agreed upon procedures fordomestic air evacuation operations. When the ASF Medical Regulating Officerdesired to move patients by air, he informed the AAF Medical Regulating Officer,requesting necessary arrangements. The latter telephoned the Ferrying Divisionin Cincinnati, Ohio, to determine availability
38Diary, Hosp Admin Div (SGO), 8 Jan 44. SG: 314.8.
39Rpt, Conf CGs of SvCs. Dallas, Tex., 17-19 Feb 44. HD: 337.
40Ltr, Off Flt Surg Brooke Gen Hosp to CG AAF thru Central Flying Tng Comd, 28 Apr 44, sub: Trf by Air of AAF Pnts from Brooke Gen Hosp to AAF Conv Ctr. AAF: 370.05 (Evac, Book 2).
41(1) Ltr, CG ASF to CG AAF, 4 Feb 44. AAF: 370.05 (Evac). (2) Ltr, AAF Sch of Air Evac to CG AAF, 16 Feb 44, sub: Air Evac, with incl. Same file. (3) The Air Surgeon's Bulletin, Vol. I, No. 4 (1944), pp. 12-13.
42(1) Initial Medical History (11 February 1943 to 30 June 1944), Headquarters Ferrying Division, Air Transport Command. HD: TAS. (2) Memo, Lt Col Richard L. Meiling for Air Surg, 27 Apr 44, sub: Air Evac 19-25 Apr 44. AAF: 370.05. (3) See below, pp. 436-37.
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and location of planes and then informed the ASF MedicalRegulating Officer if the mission could be accomplished within the time limitsdesired. If so, the ASF Medical Regulating Officer directed hospitals to preparepatients for the movement planned and the AAF Medical Regulating Officerinformed the Ferrying Division of the mission to be accomplished.43
The Ferrying Division co-ordinated plans for each flight withthe hospital from which patients were being transferred at least 24 hours inadvance of the plane's departure. Flight attendants supplied by this Divisionto care for patients en route also arranged to have them properly tagged foridentification and to have their records and valuables carried along with them.To permit hospitals receiving patients to prepare for their reception, flightattendants notified them in advance by telephone of the expected time ofarrival.44
During the period from April 1944 to August 1945 the FerryingDivision transported about 100,000 patients from debarkation hospitals togeneral and convalescent hospitals throughout the United States. Each patientwas flown an average of 1,388 miles.45 Theprocedure by which this was accomplished made it possible, after control ofhospital train movements was also centralized in Washington, for the ASF MedicalRegulating Officer to co-ordinate the use of planes and trains in domesticevacuation, thereby relieving railroads of a tremendous burden. It also enabledthe Regulating Officer to observe more closely than might have been otherwisepossible the policy of transferring patients promptly and directly fromdebarkation hospitals to installations where they would receive final treatment.
43(1) Rpt, Conf on Air Evac, 7 Jun 44. SG: 580. (2) Memo, SG for CG AAF attn Reg Off, 7 Jul 44. SG: 580.-1.
44(1) Organizational History of the Ferrying Division, June 20, 1942 to August 1, 1944. ATC: Hist Div. (2) 1st ind, CG Ferrying Div ATC (Surg) to CG ATC attn Surg, 24 Sep 44, on Ltr, CG 2d SvC to CG ASF attn SG, 29 Aug 44, sub: Air Evac. SG: 580.
45Andres G. Oliver and Hampton C. Robinson, Jr., "Domestic Air Transportation of Patients," The Air Surgeon's Bulletin, Vol. II, No. 11 (1945), p. 400.
