Summary and Conclusions
In concluding this volume with a brief review of the generalsubject it is pertinent to give first of all certain summary figures whichindicate the Medical Department's total accomplishment in the field ofhospitalization and evacuation during the war. In the period from January 1942through August 1945, there were approximately 5,100,000 admissions to Armyhospitals in theaters of operations and 8,900,000 to hospitals in the zone ofinterior.1 In the same period, more than518,500 patients were debarked by the Army at ports plus 121,400 by aircraft inthe United States for transportation to zone of interior hospitals. (Table16) Meanwhile, evacuation units that were organized and trained in theUnited States transported many thousands of patients from front-line areas tomedical stations and hospitals in theaters of operations. The number of patientson the registers of hospitals in theaters reached a peak of almost 266,500 atthe end of January 1945.2 In a single month-May1945-more than 57,000 patients were evacuated from theaters to the zone ofinterior. And by the end of June 1945 the number of patients on the rolls ofArmy hospitals in the United States rose to more than 318,000. (Table 13) Themanner in which the Medical Department prepared for and discharged thisunprecedented task of hospitalization and evacuation has been the subject ofthis volume. From the details already presented, certain generalizations can bemade and certain conclusions drawn to emphasize some of the problems involved inthe accomplishment of this mission.
Like the rest of the Army and the War Department, the SurgeonGeneral's Office and the Medical Department were in the midst of preparationsand therefore not ready for a global war when it overtook them in December 1941.The partial mobilization that began with the passage of the Selective Trainingand Service Act in the fall of 1940 had caused only a partial adjustment frompeacetime to what might be expected in wartime. Tables of organization, tablesof equipment, and equipment lists of medical units had been revised, but morewith considerations of desirability than possibility in mind. Data onhospitalization and evacuation in World War I had been analyzed and wereavailable as a basis for estimating requirements. They had already been used inthe establishment of an authorized ratio of beds to troops for hospitals in theUnited States, but whether or not World War I experience would be applicable toWorld War II remained to be seen. Hospitalization and evacuation units had beenorganized and were being trained, but they were few in number. Also, there wasuncertainty as to the role of these particular units-whether they would remainin the
1These figures are "preliminary pending publication of final tabulations based on the individual medical records." Memo, Eugene L. Hamilton, Chief Med Statistics Div SGO for Clarence Smith, Historical Unit AMS, 3 Mar 53, sub: Hosp Admissions during World War II. HD: 705.
2Statistical Review, World War II, App R, p. 237.
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United States as training units or be sent overseas asfunctional units. Plans had been made to call others into active service in theevent of war, that is, reserve hospital units affiliated with civilian schoolsand hospitals. With regard to hospital service in the United States and itsterritories, experience in expanding hospital facilities had shown theundesirability of depending upon existing buildings and had revealed manyunsatisfactory features in plans for cantonment-type hospitals. Blueprints weredrawn, therefore, for hospitals of a new type, to be of two-story semipermanentconstruction. An improved general-service ambulance had been developed and putinto use; but plans for motor vehicles of other types, such as multipatientambulances, were still in the experimental stage. Two unit and four ward carsfor hospital trains had been delivered, but they had not yet been used in theactual transportation of patients. Although the ships' hospitals of sometransports had been enlarged and improved, it was uncertain whether the Army orNavy would operate transports, and therefore evacuate patients from overseasareas during wartime. Moreover, basic decisions as to whether hospital shipswould be authorized or not, and as to whether the Army or the Navy would operatethem, remained to be made. Evacuation from theaters and transportation ofpatients from ports to general hospitals in the United States proceededaccording to peacetime procedures, with little indication of changes that wouldbe required for a wartime load. Plans for air evacuation were in the hopefulmore than the practical stage. And plans for the internal administration ofhospitals and the global operation of a system of hospitalization and evacuationwere in terms of expanding peacetime procedures rather than of substituting newprocedures designed for the task that lay ahead. Finally, a shortage of medicalsupplies and equipment plagued medical officers from the highest to the lowestlevels of command.
Reasons for the unpreparedness of the Medical Department for war-or atleast some of them-are reasonably clear. Planning of the Army for many yearshad been in terms of defending the United States against sudden attack, and evenduring the period of peacetime mobilization there was uncertainty as to whetherUnited States troops would be employed overseas. Furthermore, appropriations forpreparedness were meager, and there was hesitancy even on the part of thePresident to appear aggressive in planning for a possible war. Finally, theSurgeon General's Office-and perhaps the entire Medical Department-foundit difficult, apparently, to break peacetime habits of thought and action and toplan imaginatively for the accomplishment of its mission during a possiblefuture war.
For the Medical Department, as for the rest of the Army, the first year and ahalf of the war was a time of meeting emergency needs and completingmobilization, while at the same time preparing for full scale war. Needs of themoment received first consideration. As they were met, emphasis graduallyshifted to evaluating experience as it accumulated and to planning moreeffectively for the future. Despite many difficulties, sufficient hospitals wereconstructed and placed in operation to meet the Army's requirements during itsrapid growth and training in the United States. The necessity of speed andeconomy, however, dictated abandonment of new plans for hospitals ofsemipermanent construction and the erection of canton-
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ment-type hospitals on unsatisfactory existing plans, withattendant alterations, additions, and repairs. Eventually, availability ofmaterials and general dissatisfaction with the hospitals under constructionresulted in the erection of buildings of a third type-one-story buildings ofbrick or tile-considered by the Surgeon General's Office to be the best foremergency construction. Toward the completion of the construction program,efforts were made to co-ordinate plans of the Army for hospital constructionwith those of other agencies and with postwar needs. Concurrently with theestablishment of additional hospitals in the United States, hospitalization andevacuation units were sent overseas, and others were organized and placed intraining for later service. Contrary to earlier plans, standard Army hospitalunits rather than affiliated reserve units constituted the primary means ofmeeting the first needs for hospitals overseas. Some of the latter-as well asnonaffiliated hospital units-remained in training in this country for longperiods after their activation, and the question arose of whether or not theymight be used-as evacuation units were-to provide medical serviceconcurrently with and as a part of their training in the United States. TheSurgeon General withstood the demands of higher headquarters to plan toward thatend, and the problem of making effective use of numbered hospital units in theUnited States remained unsolved. By the spring of 1943, after the most urgentneeds of theaters had been met, measures were taken to evaluate their existingfacilities for hospitalization and evacuation and to plan more effectively tomeet their future needs.
The early part of the war was also a time of establishingbasic policies and procedures that were to endure throughout the conflict. Anearly decision of importance was that the Army would operate transports andevacuate patients aboard them. A corollary decision toward the middle of 1943was that the Army would also operate hospital ships to supplement the spaceavailable for evacuation on transports. Procedures that required only minoradjustments later in the war were established to co-ordinate the activities oftheaters, ships' surgeons, ports of embarkation, and corps areas (later calledservice commands) in the evacuation of patients from theaters to hospitals inthe zone of interior. In addition, a procedure for evacuating patients fromtheaters in regularly scheduled transport airplanes was also established, but itwas policy during this period to keep air evacuation to a minimum. Despite thewishes of The Surgeon General and the Air Surgeon, AAF headquarters ruled thatairplanes would not normally be set aside or built for evacuation only. Hopefulplans for forward-area air evacuation were thereby shelved. Procedures were alsodeveloped-albeit directives announcing them were unclear and in some instancescontradictory-for the movement of patients by hospital train in the UnitedStates. While hospitals and the hospital system in the zone of interiorcontinued for the most part to operate under peacetime procedures, thedesignation of general hospitals as centers for specialized treatment and theestablishment of a policy of hospitalizing patients near their homes occurredearly in 1943. These actions came too late to influence the location of generalhospitals, and had not had time by the middle of 1943 to affect appreciablyprocedures for evacuation in the zone of interior. The desirability ofshortening the length of time patients stayed in
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hospitals was recognized and efforts toward that end werebegun. They pertained primarily to procedures in administrative channels outsideArmy hospitals. Finally, attempts of the Air Surgeon to set up separateconvalescent facilities for Air Forces patients, along with an awareness by theSurgeon General's Office and other Medical Department officers of thedesirability of convalescent-reconditioning programs, caused the establishmentearly in 1943 of convalescent centers and annexes-the forerunners ofconvalescent hospitals of later years.
The early period of the war also afforded an opportunity toreview plans already made and to adjust them to the new situation. The mobilityof war on land masses and the character of operations in island areashighlighted the necessity of modifying existing hospitalization and evacuationunits. In some instances, new units were developed. In others, theaters wereleft to adapt existing units to new uses. Several conditions-shortages ofpersonnel and shipping space, and the nature of combat operations-combined toinitiate a trend that was to be carried to greater lengths later-the reductionof personnel and equipment authorized for units and installations of all typesand sizes. In this connection, certain other practices began: the substitutionof Medical Administrative for Medical Corps officers in administrative positionsin theater of operations units and in zone of interior installations, and thereplacement of general service men with limited service men, civilians, andenlisted women in hospitals in the United States. Experience with unit cars forhospital trains revealed their impracticability, and the Surgeon General'sOffice substituted for them a new type of car, called a ward dressing car. TheOffice successfully opposed a proposal to develop at this time a fourth type ofcar-one that would include not only a dressing room and berths for patientsbut also a small kitchen. The Surgeon General's recommendation for thedevelopment of a forward-area ambulance was disapproved by higher authority, butthe general-service ambulance was modified to facilitate its shipment to and usein theaters of operations. Experiments with multipatient ambulances wereunsuccessful, but other vehicles-such as surgical trucks-were developed foruse in the evacuation system in theaters.
The task of providing hospitalization and evacuation in thefirst year of the war was complicated by the fact that it had to be accomplishedwhile a major reorganization in the War Department was taking place. Thecreation of three major commands-Ground, Air, and Service Forces-requireddelineations of responsibility for hospitalization and evacuation, and raisedquestions concerning the extent of The Surgeon General's authority.Responsibility for units to be used in theaters of operations was readilydivided between The Surgeon General and the Ground Surgeon, but the Air Surgeon'sresponsibility and authority, and his relationship with The Surgeon General,were not sufficiently delineated to prevent recurring instances of frictionbetween them, particularly when the Air Surgeon attempted to set up a completelyseparate hospital system for the Air Forces. The establishment within ASFheadquarters of a group concerned with hospitalization and evacuation and headedby a Medical Corps officer had a variety of effects. This group assumed the leadin planning and in coordinating the activities of the many agencies involved inevacuation operations, with the full concurrence, apparently, of
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the Surgeon General's Office. When it entered the field ofhospital operations it encountered opposition. Whether the good it accomplishedin this field counterbalanced the ill-feeling and friction which it engenderedis difficult to determine accurately even now. Progress had been made by themiddle of 1943 in composing differences and solving problems arising from thereorganization, but further adjustments in relations and authority remained tobe made in the latter part of the war.
The last two years of the war were characterized by thenecessity of providing hospitalization and evacuation for an all-out war withmore limited resources than had been anticipated. The problem of estimatingrequirements therefore demanded continual and increasing attention. By thelatter half of 1943 it began to be evident that estimates based on World War Istatistical data were too high for World War II. In the fall of 1943, whenevacuation policies were established and bed ratios were authorized for theatersfor the first time, there occurred the first attempt to use World War IIexperience as a source of data for estimating requirements. Soon afterward theSurgeon General's Office completed an estimate of the patient load for 1944for use in planning evacuation from theaters and in determining hospitalizationfor both theaters and the zone of interior. Facilities provided on the basis ofthis estimate seemed excessive during 1944 and, as the personnel situationbecame more restrictive, various agencies of the War Department urgedretrenchment. Reductions followed in the ratio of beds (to troops) authorizedfor station hospitals in the United States and for fixed hospitals in mosttheaters of operations. Early in 1945, when requirements increased, general andconvalescent hospitals in the United States had to be expanded rapidly, morehospital train cars had to be procured, and additional hospital ships had to berushed to completion. Experience in estimating requirements during 1944 and 1945pointed up the importance of collecting casualty and disease data early in thewar for planning purposes. It also highlighted the necessity and difficulty ofcorrelating far in advance estimates of requirements with estimates of the timewhen they would occur. Furthermore, it emphasized the importance of co-ordinatingplans for hospitalization in theaters with plans for evacuation and forhospitalization in the zone of interior in order to avoid duplication and theuneconomical use of limited resources.
Limited resources affected hospitalization and evacuation inmore ways than in demanding repeated estimates of requirements. Shortages ofpersonnel led to widespread application in the latter half of the war ofpractices already begun on a small scale. Further reductions occurred in therelative amounts of personnel authorized for hospitalization and evacuationunits as well as for named hospitals in the United States. MedicalAdministrative Corps officers were used more extensively to replace MedicalCorps officers in administrative and semiprofessional positions; and limitedservice enlisted men, civilians, and enlisted women replaced the major portionof able-bodied enlisted men in zone of interior installations. The extent towhich reductions and substitutions of personnel were made supports the beliefthat hospitalization and evacuation organizations were overgenerous in their useof personnel at the beginning of the war. It also suggests that the MedicalDepartment might have avoided many difficulties in adjusting to changeseventually required
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by circumstances and higher authorities if it had been more realistic in thefirst place, reducing amounts of personnel authorized for various units andinstallations to that actually required and using from the start greaterproportions of Medical Administrative Corps officers, limited service enlistedmen, civilians, and enlisted women. Personnel shortages also required theadoption of new practices in the latter half of the war, such as the use ofprovisional platoons to care for patients on transports, the employment of enemyprotected-personnel in the medical service of theaters and the zone of interior,and the substitution of small units that could be used in flexible combinationsfor larger rigid table-of-organization units, such as regiments and battalions,in combat areas.
Restrictions on new construction in the latter part of the war led to thepractice of expanding existing hospitals by using medical-detachment barracksfor hospital patients, theater-of-operations-type barracks for detachments, andpost barracks for convalescent patients. While several station hospital plantswere converted into general hospitals, earlier plans and proposals to meet inthe same manner a growing need for general hospital beds in the latter part ofthe war proved impractical because of a shortage of specialists to manadditional general hospitals. Toward the end of the war, the removal ofrestrictions on the use of certain materials formerly in short supply permitteda program of hospital improvement to correct some of the deficiencies incantonment-type buildings erected earlier. Although hospital construction wascurtailed about the middle of 1943, the major portion of the program ofconstructing hospital cars and ships occurred after that time-primarilybecause the need for them was either not fully comprehended or not recognized inthe form of authorizations earlier. Demands from theaters in the Pacific in thelatter part of the war focused attention upon the need for prefabricatedhospital buildings for use in overseas areas. The war ended before this needcould be satisfactorily met.
Important changes were made in the zone of interior hospitalsystem in the latter part of the war-partly because of limitations uponavailable resources but also for other reasons, such as competition between theAir Surgeon and The Surgeon General for the control of segments ofhospitalization, the desirability of providing a helpful psychologicalatmosphere for convalescent patients, and the emergence of new needs. Theexisting program of specialization in general hospitals was extended to promotethe effective use of scarce specialists. The development of regional hospitalsrepresented an attempt to eliminate duplication inherent in the operation ofdual sets of hospitals (Air and Service Forces) by providing hospitalization ona regional or geographic instead of a command basis. The establishment ofconvalescent hospitals not only provided a better psychological environment forconvalescent patients but also permitted their care in less expensive facilitiesthan general hospitals. The operation of specific general hospitals solely forprisoner-of-war patients reduced administrative and security problems andcontributed eventually to personnel economy. Although there were no significantchanges in the system of hospitalization and evacuation in overseas areas,efforts were made to provide theaters with additional types of units, such asmedical holding battalions, mobile army surgical hospitals, and convalescentcamps, in order to meet existing and emerging needs effectively. Changes
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did occur in the system of evacuation from theaters to theUnited States. Aside from improvements in procedures already established, themost important modification was the creation of a Medical Regulating Unit inWashington to centralize control over the use of hospital beds and over the flowof patients and to co-ordinate the movement of patients by sea, rail, and air.This step reflected a growing use of hospital ships, airplanes, andgovernment-owned hospital cars in the evacuation process, contributed tostricter observance of the policies of caring for patients in specializedcenters and in hospitals near their homes, and revealed the desirability oflocating general and convalescent hospitals in relation to population densityrather than troop concentrations.
In connection with changes in the hospitalization andevacuation system came changes in the internal organization and procedures ofzone of interior hospitals. They occurred near the end of the war and camelargely as a result of emphasis by ASF headquarters on the achievement ofefficiency and economy through management engineering. Attempts to standardizehospital organization-a prerequisite to the simplification of administrativeprocedures-amounted to conformance with the standard organization of ASF postsmore than improvements and innovations in hospital organization as such. Theintroduction of management engineering led to work-load studies,work-simplification measures, and the streamlining of certain administrativeprocedures, especially those affecting the length of time patients remained inhospitals and, consequently, the number of beds required. Another factoraffecting bed requirements-the performance of adequate diagnostic proceduresto permit the admission to hospitals of only those patients needing hospitalcare-was not touched, and the work of dispensaries in this respect remained"one of the weakest links in the whole medical program."3
Growth of the patient load in the later war years, coupledwith changing policies, procedures, and circumstances, led to the development ofnew transportation facilities for evacuation. Despite its earlier objection to aproposal for a hospital car with a dressing room, berths for patients, and asmall kitchen, the Surgeon General's Office adopted the idea when itsnecessity became obvious. That Office also promoted the procurement of kitchencars for hospital trains when it became apparent that railroad companies wouldbe unable to supply the Army with sufficient dining cars. To assist in themovement of patients from ports to near-by hospitals, The Surgeon Generalproposed, and higher authority approved, the development of a multipatientambulance. A front-line ambulance was developed experimentally, but it was notauthorized for procurement because ASF headquarters and the War DepartmentGeneral Staff insisted upon the use of standard Army vehicles only. Toward theend of the war litter racks that could be attached to jeeps to enable them toevacuate patients from forward areas were standardized for issuance toevacuation units. While airplane ambulances were never authorized or developed,improvements in litter supports permitted increases in the capacities oftransport planes for evacuation. Eventually, an increase in the availability ofplanes led to a modification of existing policy and the as-
3Comment by Dr. Eli Ginzberg, formerly Dir, Resources Anal Div SGO, incl to Ltr to Col Calvin H. Goddard, 5 Nov 51. HD: 314 (Correspondence on MS) V.
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signment to several commands of planes for use primarily in the movement ofpatients.
Further adjustments to the new organization of the War Department occurred inthe latter half of the war. The Surgeon General expanded and strengthened hisOffice, particularly the divisions concerned most immediately withhospitalization and evacuation. Concurrently, ASF headquarters abolished itsHospitalization and Evacuation Branch and transferred many of its functions andsome of its personnel to the enlarged and strengthened Surgeon General'sOffice. Eventually, The Surgeon General was restored to his former position ofhaving direct contact with the War Department General Staff. Meanwhile, thoughstill under ASF headquarters, his Office developed means of exercising closersupervision over service command hospital activities, and limits of therespective jurisdictions of the Air Surgeon and The Surgeon General graduallyevolved. The Surgeon General was never in a position, though, to exercise acontrolling influence over the entire hospitalization and evacuation system ofthe Army. Perhaps an important reason for this was that, as a result of the dualposition he held, he seemed at times to be bidding against himself. As TheSurgeon General of the entire Army, he was responsible-to some extent, atleast-for apportioning medical resources among major commands (Air, Ground,and Service Forces) and between the zone of interior and theaters of operations.On the other hand, as surgeon on the staff of the commanding general, ArmyService Forces, he was responsible for providing as good a medical service inthe zone of interior as possible. This required him to act in a disinterestedmanner on matters involving him as an interested party. Nevertheless, despitedifficulties caused by its organizational structure, the War Department and itsagencies, including the Surgeon General's Office, managed successfully withlimited resources to provide adequate hospitalization and evacuation for an Armyof over 8,000,000 men engaged in a global war.
