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Learning From the War, WWI, Volume 2
LEARNING FROM THE WAR:
AN ANALYSIS OF THE WARTIME EXPERIENCES OF THE AEF'S MEDICAL DEPARTMENT
An often overlooked appendix entitled the "Report on Organization, Equipment, and Functions of the Medical Department" is tucked away in Volume II: Administration American Expeditionary Forces of multi-volume The Medical Department of the United States Army in the World War. After the Armistice, Brig. Gen. Walter D. McCaw, M. C., chief surgeon, A. E. F. (10 October 1918-15 July 1919), established a special board of medical officers at General Headquarters, A. E. F. "to investigate and report upon the conduct of the Medical Department, A. E. F., and to make recommendations, with a view to the improvement of that department." Col. A. N. Stark, M. C.; Col. Leon C. Garcia, M. C.; and Col. Albert P. Clark, M. C., composed the board and studied the full range of the Medical Department's organization, equipment, and operations. The board's report was completed and submitted to McCaw in April, 1919. It outlined the most important lessons that the Medical Department needed to draw from its wartime performance and recommended significant changes in structure, operations, and doctrine, much of which was implemented within the Medical Department beginning in the 1920s. As this volume was prepared for publication, Col. Joseph H. Ford, M.C., the editor who had extensive experience in France himself as the commander of Base Hospital No. 26 (December 1917-June 1918) and then of the large Hospital Center at Allerey, France, added editorial comments in the footnotes. These noted the changes that had been made in the organization of the Army Medical Department up to the completion of the manuscript in July, 1926. While many additional refinements were made in the Medical Department in the years before World War II based on the introduction of new technologies and various reorganizations of the U.S. Army, much of what was laid out in this report would establish the foundations for the Army Medical Department that fought the next world war.
John T. Greenwood, Ph.D.
Senior Historical Consultant
Office of Medical History
Office of The Surgeon General, U.S. Army
Falls Church, Virginia
COLONEL JOSEPH H. FORD, M. C.
REPORT ON ORGANIZATION, EQUIPMENT, AND FUNCTIONS OF THE MEDICAL DEPARTMENTa
To meet the manifold requirements of both trench and mobile warfare the Medical Department of the American Expeditionary Forces was modified in both personnel and equipment to such an extent that the resultant changes bore but small relation to existent tables of organization and equipment manuals. Adoption of the modified general staff system necessitated expansion of the office of the chief surgeon, A. E. F., and its division into bureaus, the work of all under the chief surgeon being coordinated through the assistant chief of staff, G-4 (coordination), of the American Expeditionary Forces, under whose jurisdiction fell all the services which under the former staff organization enjoyed autonomy, the chiefs of services being members of the administrative staff of the commander in chief.
This control of the services by the A. C. of S., G-4, was applied to the armies, and there being no A. C. of S., G-4, in corps and divisions, the A. C. of S., G-1 (administrative), assumed the coordinating function. Formal inspection of troops made by the surgeons of armies, corps, and divisions, or by the sanitary inspectors, were under the A. C. of S., G-5 (training), for efficiency, and under the A. C. of S., G-4, for supply, the last two duties being under G-1 for corps and divisions.
The office of the chief surgeon, A. E. F., being moved from general headquarters to the headquarters, S. of S., it was necessary to detail an officer of the Medical Corps for duty at general headquarters as deputy of the chief surgeon, A. E. F., who would advise him upon all questions arising with reference to the Medical Department for adjustment, and who was empowered to act for the chief surgeon in emergency. This detail was authorized by G. O. 31, A. E. F., 1918, which order announced the policy of the division of staff control, and established the five general staff sections at general headquarters.
Expediency demanded that mobile operating units, composed of surgical and
X-ray equipment for two operating teams, packed in heavy chests, be supplied in
the proportion of one to each division for use in the nontransportable
hospital. So-called mobile hospitals with a capacity of 150 beds and 2 special
camions, self-propelled, for the necessary surgical and X-ray equipment, each
camion with a trailer containing a small frame-and-canvas hut, in the
proportion of one to each division in line, were found necessary by reason of
the lack of adequate evacuation hospitals during the first engagements of
American forces. Experience and lack of transportation both counseled the
abandonment of these two units.b Neither was mobile in any sense of the word and they were of
little use, especially the mobile hospital, which possessed but little bed
space in proportion to its operating capacity. The latter suffered also from
the disadvantage of special camions, which should never be
a Pursuant to directions of Brig. Gen. Walter D. McCaw, M. C., chief surgeon, A. E. F., a board of officers was convened, subsequent to the signing of the armistice, at general headquarters, A. E. F., to investigate and report upon the conduct of the Medical Department, A. E. F., and to make recommendations, with a view to the improvement of that department. This board, consisting of Col. A. N. Stark, M. C.; Col. Leon C. Garcia, M. C.; and Col. Albert P. Clark, M. C., made an exhaustive study of the organization, personnel, equipment, service, and transportation of the Medical Department, A. E. F., and submitted the findings given herein, in April, 1919. Pertinent editorial comment in the form of appropriate footnotes has been made in order that the most salient features of the board's report may be compared by the reader with the present organization of the Medical Department of the Army of the United States as perfected up to this date (July, 1926).-Ed.
bThe relative lack of mobility of the so-called mobile hospitals employed by the American Expeditionary Forces in France was largely due to the utilization of the only type of tentage and equipment available. These hospitals were devised by the French during the period of trench warfare. In the absence of adequate hospitalization, especially as regards evacuation hospitals, the mobile hospitals of the American Expeditionary Forces played a very important role in bridging over our difficulties. The field hospital for nontransportable wounded, recommended by the board, has been provided for. It is known as a "surgical hospital" and has a normal capacity for 250 patients. See Tables of Organization, 284-W.-Ed.
employed, and they required half the number of trucks needed to move an evacuation hospital. A properly equipped field hospital for nontransportable wounded has been developed. These must be designated corps units and will become a part of the tactical reserves at the disposition of the corps surgeon. They will be organized upon a basis of one for each division of the forces. The functions and organization of these units will be fully discussed under the part devoted to the corps surgeon.
Tables of organization in force at the time of the enemy offensive of 1918 did not afford sufficient enlisted personnel and nursing staff for the proper conduct of evacuation hospitals, necessitating the stripping of base hospitals for nurses and other medical organizations for enlisted personnel, even labor troops being employed to obtain the requisite number, this number, found by experience to be proper, being given, with the duties, in the chapter devoted to evacuation hospitals.
Standardization of equipment is as necessary to efficiency in the medical service of an army as it is in any industry, and to that end the ward tent has been modified to be used for all purposes by the Medical Department in the field, all other makes being discarded for various reasons, such as weight, complicated system of erection, small interior space to spread of canvas, inflammability, and difficulty in transportation. The surgical, X-ray, and lighting equipment, together with the medical and other equipment, has been simplified and so arranged that the evacuation hospital is, as nearly as possible, a multiple of the field hospital in all essential particulars.
Prompt and correct disposition of the slightly wounded and sick of an army taxed the resources of the Medical Department because of lack of an institution similar to the French depot d'eclopés, it being recognized that these cases should not be evacuated from the army zone with great resultant depletion of combat troops, and the solution of this vexing problem has been met by the establishment of the army convalescent camp, which is explained in detail in the chapter devoted to that subject.c
Due to the absence of civil population in the combat zone, the difficulties of having laundry work done for hospitals was enormous, the small so-called mobile laundries purchased in France being too fragile to permit traction over the rough roads, and as experience has proven the absurdity of collecting within the combat zone more mechanical appliances than necessity demanded, it has been decided to have one large demimobile laundry, on flat cars if possible, in the vicinity of the main army medical supply depot to which hospitals could send the bulk of soiled linen to be exchanged for fresh. Divisional field hospitals, corps, nontransportable hospitals, and evacuation hospitals have, in addition, a small gasoline motor-driven laundry for operating-room and ward linen.
Much has been said for and against the horse-drawn ambulance, but the fact remains that this form of transportation for sick and wounded was seldom used and at these times only in the dense Argonne Forest, where motor vehicles could not progress but where the wheeled litter would have proven more valuable than the horse-drawn vehicle.
A motor-propelled vehicle may not keep pace with an infantry column without destruction of the gears, and utility being pari passu with standardization, it has been decided to employ a four-wheeled medical wagon with cut-under front wheels, springs, and roller bearings to permit traction when the artillery has commandeered the animals or they have been killed, this wagon to carry the battalion combat equipment and also to be provided with litters that it may be employed for ambulance purposes, all these wagons being stationed at the camp of the supply company.d The heavy pack saddle to bear combat equipment was never used, and as it was authorized under an entire misapprehension of modern warfare it has been decided to abandon it and substitute for it a harness for the draft animals of the medical wagons which, by releasing the tugs and slipping a numnah beneath the small saddle and applying a light metal pack frame with hooks to receive the loops of the
cThese units have been provided for at the rate of one per field army. Each will have a capacity for at least 5,000 ambulatory patients. They will be known as convalescent hospitals. See Tables of Organization, 285-W.-Ed.
dA medical wagon of this type has been adopted. It is designated as the animal-drawn ambulance, new pattern. It is capable of carrying the field medical set of the battalion and at the same time, if necessary, of transporting patients, thus serving in the dual capacity of a cargo and passenger vehicle.-Ed.
medical panniers which are secured by a surcingle, leaves the animal standing in a simple modified pack harness. The medical wagons will also carry wheel litters which will not only be available for transport of combat equipment forward when animals can not be used, but also will be of great service at battalion aid stations. One of these wagons added to the regimental transportation will serve as solution of the vexing question of transporting the regimental dental equipment and will insure its being at the desired point.
The camp infirmary, and reserve, have been abandoned as useless adjuncts to medical equipment, for the reason of their adoption-the preservation of combat equipment intact-no longer obtains with the changed system of medical supply in the field, and these units make needless draft upon transportation not compensated for by their small use.
Experience soon demonstrated the imperfections of the intradivisional evacuation system as given in manuals and tables of organization. Permanent cadre of the sanitary train of the division must be organized basically upon needs of troops upon the march, with a flexible auxiliary organization of reserve transport units with the corps or army to care for combat problems. This will permit the corps surgeon to supply these transport sections to such divisions of the corps as are most in need. It may later be advisable to extend this system to the hospital section of the train as well.
Separation of our division ambulance companies into a transport and a bearer section also has not proven satisfactory, for the bearer section has seldom been used in its normal function of littering wounded from the battalion and regimental aid station to the dressing station, and never from the front line to the aid station, which would have been the point of greatest usefulness. In addition, dressing stations were seldom established, as they soon were found to be of little use.
While we were not wedded to any particular system, we have found by much experience that the French system of an ambulance service for transport only, and a litter bearer battalion (brancardiers) which could be applied anywhere as needed, gives the most effective service, and to that end we have abandoned the present ambulance company and have formulated the ambulance service (just described) whose elasticity is enormous, and have formed bearer sections into a battalion of litter bearers under control of the division surgeon who may apply them, as a whole or as a part, to the line when needed, thereby not only overcoming the difficulties which formerly obtained under the old system, but minimizing the demand upon combatant troops for this necessary service. There have, however, been retained two dressing station equipments for each division, which will be of service, in a flat terrain, this equipment being carried in two 3 to 4 ton trucks attached to the litter bearer battalion.e
The medical chests as now authorized contain many medicines and appliances that may be eliminated under modern conditions of supply, and the chests being unnecessarily heavy and of small capacity for dressings known to be useful, the development of a light, canvas-covered wicker pannier for all units must be considered.
The medical belt and Medical Department pack for enlisted men have proven a source of much dissatisfaction both as to contents and methods of packing, etc. The contents of the pockets of the belt have been found more or less useless in modern warfare and we have agreed upon the Infantry pack with a belt to maintain it in place. The hatchet has been found of less use than might have been expected and if retained must be modified and strengthened. An infantryman's shovel is considered a far more useful article to the sanitary soldier on the front. Front dressings, a rubber tourniquet, shears, adhesive plaster, iodine swabs, etc., must be carried in a bag similar to the haversack or musette bag, slung
eThe sanitary train has been supplanted by the medical regiment, of which 1 is authorized for each Infantry division, 1 for each army corps, and 4 for each field army. In general the recommendations of the board have been embodied in the new organization. The medical regiment, includes a collecting battalion, which provides a collection station (dressing station) and the litter bearers. The ambulance battalion has two motorized companies and one animal-drawn company and is exclusively a transport unit. The hospital battalion consists of three hospital companies (field hospitals), and in view of the adoption of the surgical hospital (an army unit) is now freed of the necessity of caring for nontransportable wounded. There is also included in the medical regiment a veterinary company, and a service company, containing a laboratory section and a supply section. In the Cavalry division a corresponding type of organization has been provided, which is known as the medical squadron. See Tables of Organization 81-W and 489-W.-Ed.
from the shoulder. The medical officer's belt is useful with combat troops, but its equipment must be modified to include, among other things, the assorted Greely units.
The use of mounts for medical and dental officers must be minimized, since motor transportation has so largely superseded other forms when a column is en route. Motor-cycle side cars must be assigned in numbers sufficient to cover this need.
The laundry question for front-line troops has proven a stumbling block in all armies, and, as a division in line may not be accompanied by such impedimenta, it is recommended that large laundries, to be conducted by the Quartermaster Corps, be established in rest areas for the benefit of divisions relieved from the line, and that delousing and bathing plants with a supply of clothing be established at the same location, all these plants to be under control of the Quartermaster Corps and provision made for their early functioning.
ORGANIZATION OF THE MEDICAL DEPARTMENT FOR FIELD SERVICE IN CAMPAIGN
The enormous and sudden expansion of the United States Army for service against the Central Powers demanded reorganization of all branches of the Military Establishment along new lines. The great changes in military tactics and the marvelous development of lethal weapons necessitated a complete change in preconceived plans for the medical service.
A study of the operation of the medical departments of the British and French Armies threw but little light upon the problem, inasmuch as the equipment of American units and the organization of the units themselves differed so materially from both in the services of the British and the French.
The first employment of American troops in corps formations during the Marne offensive in July, 1918, disposed of many preconceived ideas to which the Medical Department of the United States Army had long adhered and served to outline a medical organization which would be effective in either mobile or trench warfare.
It is feared that too much attention was given to the study of phases of trench warfare to the exclusion of the phases of mobile warfare, for the former is an undesirable and unfortunate condition forced upon a commander who has lost the power of offense, and which, if continued, soon develops special routine to the great detriment of the force should mobile warfare suddenly supervene.
In the long and indecisive period of trench warfare special hospitals for the care and treatment of head, chest, abdominal, fracture, and gas cases soon grew up behind the lines, and great importance was attached to these institutions by medical observers and writers who failed to note that immobility-the greatest error in sanitary or military tactics-had insidiously developed, and few foresaw what would occur should the enemy suddenly give over defensive tactics and assume the offensive.
Fortunately, the few who realized what did actually occur when the enemy advanced in March, 1918, when our allies lost their special immobile hospitals, took steps so to organize the field and evacuation hospitals of the American Army that they would function alike in either trench or mobile warfare and still retain that mobility which is the sine qua non of any field unit.
No time was wasted in instructing the personnel of these units in such subjects as visibility problems, for the advent of the aerial observer disposed for all time of the question of visibility for sanitary units and imbued sanitary commanders with an intense desire to obtain the most conspicuous Red Cross emblem available, as observations taken by the aerial observers made accurate indirect fire possible both day and night, and only common sense was necessary to avoid direct fire.
Function and speed in establishing, in demounting, and in moving were instilled thoroughly, and the results amply justified this radical departure from established custom. The increase in sanitary units to meet the requirements of such a large force as was finally nominated an army demanded the assignment of competent officers to duties never before contemplated, and while other assignments did not bear the approval of Tables of Organization, they did receive the approval of competent authority, and the results amply justified the assignments.
f The individual professional kits of all officers and enlisted men of the Medical Department now embody the bag principle recommended by the board. For example, a medical officer carries on his person, slung from the shoulder, an officer's medical kit. A medical private carries a private's medical kit, etc.-Ed.
MEDICAL DEPARTMENT SANITARY SERVICE
THEATER OF OPERATIONS, EXPEDITIONARY FORCES
The office organization and duties of the chief surgeon of an expeditionary force have been touched upon under another heading (q. v.), but the relations of his office to general headquarters, to his deputies, and to his representatives and subordinates in the zone of the armies must be amplified to gain a comprehensive understanding of the otherwise intricate chain of liaison and delegation of duties given in the accompanying chart.
In the accepted scheme of organization the chief surgeon is a member of the administrative staff of the commander in chief, but the complex duties required of him in modern warfare demand that the burden of detail be removed from his shoulders and placed upon those of his assistants to afford him time and opportunity to deal with larger questions of policy and to become familiar through personal observation with all the activities of his department.
The chief surgeon, though not his office force, will be located at general headquarters, which places him in close touch with the chief of staff of the forces and with the chief surgeon of the group of armies. In this position he still maintains his liaison with his deputy upon the staff of the commanding general, the services of supply, from whose office medical activities in the territory of the services of supply are controlled.
While frequent visits to, and even temporary location at the headquarters services of supply, will be necessary, there must be a deputy chief surgeon at those headquarters to assume responsibility required in this situation. So also must there be a deputy chief surgeon within the general headquarters group. This officer, however, will deal only with the larger questions of policy and coordination, but in the absence of his chief will act for him in all questions arising in connection with Medical Department activities within the zone of the armies or the general headquarters group. Furthermore, he must exert technical supervision and control over the medical officers detailed to represent the chief surgeon upon the various general staff sections, although these latter officers are assistants to the assistant chief of staff of the sections to which attached.
As a member of the administrative staff of the commander in chief, the chief surgeon must spend much of his time away from the two administrative headquarters, for only in this way can he keep himself well informed as to the status of the Medical Department with the armies and the activities of his department throughout the larger zone of the services of supply. It therefore becomes necessary for him to maintain a temporary office, so to speak, within the office of each of the two deputies.
The deputy at general headquarters will maintain an office and office force wherever such facilities are available. In practice, excellent results have been obtained by making this office a part of the coordination section of the general staff, with the deputy actually a member of that section and in charge of a subgroup of the section (the medical section, G-4-B). This has been true largely because this general staff section coordinates with the greater part of Medical Department activities. It is quite possible, however, that it was true somewhat because of the personalities of the individuals concerned. No machine, however perfectly organized, can be expected to function just as efficiently with the personal equation eliminated, but the organization adopted for the Medical Department must be so flexible as to permit the elimination or utilization of this equation when such elimination or utilization would obviously work to better ends. Arbitrarily to say, therefore, that the office of the deputy must be located with the medical officer representatives with the coordination section would be a mistake, since it might be found that better results might be obtained if the medical section "grew up" as a part of, we will say, the operations section. For this reason, also, although medical officers detailed to the sections should be detailed general staff officers, it would seem better that the deputy at general headquarters as well as the deputy as services of supply headquarters remain a member of the Medical Corps.
At general headquarters and the services of supply headquarters a medical officer must be detailed to each general staff section. These officers must truly represent the chief surgeon and must possess the confidence of their immediate general staff chiefs as well, else such details are useless to both. Medical Department questions arising within all sections
should come before these officers for comment before being finally decided. So much of all plans for the future as affect the Medical Department must, in confidence, be given these officers in order that the chief surgeon and his staff may be kept informed along lines where the commander in chief will expect him to obtain results. Only officers known to be trustworthy will be selected for such positions, and if not acceptable to both parties they should neither be detailed nor continued in office. But so long as they are acceptable they must be not only with the section but also a part of it and admitted to daily conferences.
It is understood therefore that such officers are detailed for the purpose of giving and receiving technical information with reference to the Medical Department and for the purpose of coordinating efforts thereof with the efforts of other departments and those of their own section. The mere fact, however, of the existence of such a detail must not be considered as precluding in any way the direct official intercourse which the situation demands between the chief surgeon, or, in his absence, his deputies, or his representatives within the armies or services of supply sections, and the respective chief of staff concerned.
The deputy chief surgeon at services of supply headquarters is a part of the office of the chief surgeon. In the absence of the chief surgeon, he directly controls that office and exercises technical control over the medical officers detailed as medical representatives with the general staff sections at those headquarters. When the chief surgeon is present the deputy acts as his chief executive in all matters pertaining to the management of the office or the supervision of Medical Department activities within services of supply sections, the latter function being exercised, of course, through the chief surgeons of the sections therein.
Relationships between the chief surgeons or surgeons, as the case may be, of groups of armies, armies, corps, or divisions, their medical representation with the general staffs of these units and the respective chiefs of staff, are exactly as has been indicated for the general headquarters and services of supply groups.
In the cases of army groups and armies, medical officers should be detailed to all sections of the general staff which are present at the headquarters of such units. With corps and divisions a representative with the administrative and supply section should suffice, and allowance for all such details should be made upon tables of organization of the unit concerned. Below the army group, these officers should be assigned to the general staff section concerned but should remain officers of the Medical Corps and not be detailed general staff officers.
Attention is invited to the linking up of the division surgeon and the commanding officer of the sanitary train and the division surgeon and the regimental surgeon. In the case of the former a hazy relationship has existed heretofore wherein the commander of divisional trains was in a position to exercise technical control over the sanitary train even when trains were not merely on the march and together as a unit. When on the march and acting as a unit the need of such road control is conceded, but all other technical and tactical control of the sanitary train must revert to the division surgeon when contact with the enemy is imminent. The commanding officer of the sanitary train is therefore one of the important assistants of the division surgeon, and the direct official intercourse so necessary to the proper functioning of the intradivisional evacuation system must be made possible and considered essential.g Relationship of army, corps, or division chief surgeons or surgeons to the respective sanitary inspector deserves careful consideration. A status has slowly developed within certain larger combatant units wherein the sanitary inspector has been considered essentially a staff officer of the unit commander, with more or less independence of the chief surgeon or surgeon. The opinion is held that such assumption is erroneous and that this officer is an important assistant to the Medical Department head in question who, furthermore, must carefully supervise and control his activities in groups of armies, armies, corps, or divisions.
In the case of the regimental surgeon the status is quite different. The surgeon of a regiment must be a staff officer of the regimental commander, and as such he is his technical adviser on all matters medical or sanitary. He is therefore tactically and in all other ways directly under the regimental commander through his adjutant. This may be taken for
gIn the present organization the commanding officer of the medical regiment (sanitary train) also serves as division surgeon. The medical inspector (sanitary inspector) serves as his assistant.-Ed.
granted, and the linking up of these officers with the division surgeon is merely to indicate the technical supervision which must be exercised by the division surgeon over these juniors who are, morally at least, his assistants.
A carefully organized liaison must be maintained between the medical department of an expeditionary force and similar groups of allied armies with which our troops may be operating. Through such an organization a multitude of details will be handled. Officers of rank, experience and tact, speaking the language of the foreign office concerned, must be assigned these important details. It is highly important that these offices be so organized as readily to permit direct communication between them and the offices of the chief surgeon or his deputies. In the zone of the armies a similar status must exist. The direct communication referred to must be limited, or course, to technical subjects and matters of approved policy not requiring further reference to American or allied staffs.
The organization as presented above, therefore, is considered essential to the success of the sanitary service with an expeditionary force. Acceptance of such an organization will only duplicate, for combat units and their staffs, that which was in actual existence at general headquarters in France for more than a year, and will largely counteract the loss of efficiency developing for the Medical Department from the separation of the larger combat, headquarters into echelons and placing of the chief surgeon of an army, for instance, back with the second or third echelon.
By such a chain the chief surgeon, his deputies, and representatives with the fighting troops-in all of which positions the necessity for prompt information is great-may be kept informed regarding the expected activities, shortages, unusual occurrences, or the like. This information is essential not only that those interested may be duly advised, but also to preclude the loss of time which the usual channels of communication entail, such loss resulting only in useless suffering and a sacrifice of human lives.
In this plan of organization the army service zone has been incorporated, since it is believed certain that such an element will replace the advance section, services of supply, in any organization scheme adopted for an expeditionary force of any magnitude. This geographical division places the advance section within the zone of the armies and therefore under army control.
For the Medical Department the objective is to provide the means for relieving the group chief surgeon of the multitudinous duties attendant upon the supply, equipment, sanitation, discipline and training of the large numbers of Medical Department units and personnel making up the group command. The larger the force the greater the necessity for perfect liaison. Information and orders alike travel slowly in huge, dispersed commands. The medical service, by reason of its large establishments and the mass of impedimenta and transportation, requires time to be in a position of readiness. It must be apparent, therefore, that tardy information of any activity will eventuate in calamity and will detract from the success of the venture if not entirely nullify it.
OFFICE OF THE CHIEF SURGEON, EXPEDITIONARY FORCES
The chief surgeon of an expeditionary force, with the rank of major general, is a member of the administrative staff of the commander in chief, and his activities, in common with those of all other chiefs of services, are coordinated through the coordination section of the general staff, at general headquarters.
The office of the chief surgeon will be located at general headquarters, or at the headquarters of the services of supply, such location depending upon facilities and administrative convenience.
Should conditions prescribe the location of the office at headquarters of the services of supply, the chief surgeon assumes the dual function of chief surgeon of the forces and of the services of supply, and his activities are coordinated through the commanding general, services of supply and his general staff, but should he be located at an intermediate point he must have a deputy to perform the duties of chief surgeon of the services of supply. Even should his office be located at general headquarters, he must have a deputy at this point. The deputy at general headquarters is in perfect liaison with the chief surgeon's office
and with the chief surgeons of combat organizations, and while normally he advises the chief surgeon of policies promulgated by the general staff relating to the Medical Department and transmitted to him by the A. C. of S., coordinating section, he must be empowered to act in emergency for the chief surgeon, particularly in those cases in which the element of time is the determining factor, advising the chief surgeon promptly of the action taken.
The deputy at general headquarters must have assistants and a clerical force commensurate with the volume of work devolving upon him; and the chief surgeon, whether located at general headquarters or elsewhere, must have one or more representatives with clerical assistants on each section of the general staff in conformity with existing regulations, to the end that there may be effective coordination between the sections in their relation to the Medical Department.
The deputy at general headquarters is in a peculiarly favorable position for liaison with the armies of the expeditionary forces, and the location of the chief surgeon at an intermediate point, with a deputy at both general headquarters and the services of supply, places him in a most advantageous position, as this disposition leaves him free from the mass of routine in which he would be involved in another situation and affords him time for study of problems confronting the Medical Department and opportunity for personal investigation of the adequacy of measures both at the front and the rear.
Experience has developed the office and determined its division into sections and subsections as follows, a brief résumé of the scope of each being given:
1. Chief surgeon.-General control of Medical Department and policies dealing with the department at home and abroad.
2. Deputy chief surgeon.-Coordinating control of divisions of office, and acts for chief surgeon in the latter's absence.
3. Deputy chief surgeon: General headquarters; duties outlined in text.
(a) Medical officer attached to administrative section: Concerned with tonnage, forecasts and priority of tonnage, priority shipment schedules, organization and equipment and tables of organization, and authorized aid societies affecting the Medical Department and not under other sections.
(b) Medical officer attached to intelligence section: Concerned with intelligence of value to the Medical Department.
(c) Medical officer attached to operations section: Concerned with operations and in close liaison with deputy chief surgeon.
(d) Medical officer attached to coordination section: Concerned with hospitalization, transportation, evacuation, supply, troop movement, veterinary service, and in close liaison with deputy chief surgeon, general headquarters.
(e) Medical officer attached to training section: Concerned with training of medical personnel and inspection of same, and conduct of sanitary schools.
(NOTE.-These officers, except the deputy, must be members of the general staff and be regularly assigned.)
Close liaison between these officers assigned to staff sections facilitates the coordinating function of the deputy chief surgeon and accelerates the work of the chief surgeon and also that of deputy at the headquarters of the services of supply, thereby insuring promptitude in movement of personnel, transportation, and matériel to meet the requirements of military operations.
The division into sections and subsections of the chief surgeon's office, with duties assigned each, are as follows:
1. Sanitation.-A medical officer of the rank of colonel, with the proper number of commissioned and enlisted assistants, conducts this division, which is subdivided into the following sections:
(a) Sick and wounded: Deals with inspection, auditing, correction, and compilation of all statistical data relating to the sick and wounded and correspondence pertaining thereto.
(b) Sanitation, laboratories, and communicable diseases: Deals with general and special sanitary administration, laboratories, inspections, epidemiology, and sanitary reports, sanitary publications and reference library, and venereal disease control.
2. Hospitalization.-This large and important division would normally be under control of a brigadier general of the Medical Corps, with the proper number of commissioned and enlisted assistants, and subdivided into the following sections:
(a) Procurement and construction: Deals with hospital projects, transfer of hospitals and property to the Medical Department and vice versa, offers of lands and buildings for hospital purposes, leasing of lands and buildings and the inventories and lease papers of same, hospital plans and construction in liaison with the chief engineer or with civil contractors, repairs to hospitals, sanitary appliances for hospitals, procurement and distribution of tentage, coordination with rents, requisitions, and claims bureau and Quartermaster Corps, reference maps and graphic charts of projects completed, under construction and proposed, and inspection and reports relating to above items.
(b) Administration and policy: Deals with hospitals, boards, inspections, instruction, personnel requirements, regulations, war diary hospitalization section, coordination of administration with other divisions and sections.
(c) Statistical and liaison: Deals with daily bed report of base hospitals and convalescent camps, weekly reports of all hospitals, monthly bed reports and authorization reports of all hospitals, statistical tables, liaison with chief quartermaster, office reference, care and location of Medical Department units arriving from the United States, installation of new hospitals transportation for new hospitals, instruction and assembly park for hospitals for nontransportable wounded, and assembly and shipment of same.
(d) Evacuation and transportation: Deals with primary, secondary, and special evacuation of sick and wounded, collection of evacuables of class D, transportation and assembly of special classes of patients, estimates for basis of procurement of motor ambulances, hospital trains, motor cycles, etc., for Motor Transport Corps, liaison with Navy, troop movement bureau, armies, and general headquarters, records and statistics of evacuation, hospital train assignment, motor ambulance transportation, services of light railways and waterways, and liaison with railway transport service.
3. Personnel.-A medical officer of the rank of colonel, with the proper number of commissioned and enlisted assistants, conducts this division, which is of the first importance in that the function of all units of the expeditionary force depends upon its conduct. It is subdivided into the following sections:
(a) Army Nurse Corps: A nurse of recognized executive ability is assigned as supervisor, for upon her depend the administration, policy, assignment, discipline, and replacements of the nursing personnel (female) and aides, if any, for the entire medical establishment.
(b) Medical Corps, Sanitary Corps, civilian clerical force, and enlisted men of the Medical Department: The medical officer in charge of this section must possess an accurate file of all personnel of the Medical Department and civilian attachés, and his office concerns itself with assignments, orders, transfers, returns, personal reports, files, location, organization, and commissions.
(c) Promotions: This section deals with correspondence relating to promotions, records of recommendation and subsequent promotion, and notification of promotion, and the officer in charge must be ever upon the qui vive to obviate injustice being done deserving officers.
4. Professional services.-This division must be in charge of a medical officer of the regular establishment with the rank of colonel, to insure an accurate knowledge of administrative routine, and he must also possess a wide knowledge of the professional qualifications of the large number of civilian practitioners in the United States who form the commissioned medical reserve in time of war, that assignment to duty with the greatest efficiency in performance may be made.
This office is in direct liaison with the personnel and administrative divisions, and should be empowered to issue orders involving the travel of medical officers, nurses, and enlisted men of the Medical Department selected to form surgical and medical teams to the end that these teams may be transported with the utmost dispatch to points where their services are indicated.
The officer in charge also is in direct liaison with the division of supplies to the end that equipment is supplied in proper amount for effective performance of function by the teams and surgical and medical staffs of hospitals, and is assigned a proper number of assistants and clerical help. He maintains a file and record system that enables prompt action to be taken at all times.
To insure efficiency he must be empowered to make personal inspections in all units of the expeditionary force.
This division is subdivided into two subdivisions:
The surgical subdivision, under charge of a medical officer of the highest surgical attainments, is subdivided into the following sections:
(a) General surgery.
The medical subdivision, under a medical officer of high professional attainments, is subdivided into the following sections:
(a) General medicine.
It is imperative that each subdivision and section thereof be in charge of officers who are preeminent in that particular branch and who at the same time possess administrative ability. In addition to routine duty, these officers prepare the bulletins issued from time to time, announcing the latest approved methods of technique, for the information of medical officers of the expeditionary force, and give stated lectures on the same subject to each class of medical officers at the sanitary schools.
5. Dental.-An officer of the Dental Corps with the rank of colonel and with the proper number of commissioned and enlisted assistants conducts this division, which is in part administrative and in part technical, the former dealing with current reports and returns, records, statistics, equipment, personnel, schools, and supplies, and the latter with the teaching, apparatus and supplies of the complex branches of prosthetic and maxillofacial dentistry.
6. Administration.-This division is in charge of an officer of field rank, and he, with a proper number of assistants, conducts the office, which, for convenience, is directly in liaison with all divisions:
(a) Records, dealing with numbering and filing of permanent records, receipt, and dispatch of official mail.
(b) Administration, dealing with general supervision of entire force of chief surgeon's office, information, courier service, chauffeurs, orderlies, printing, and stenographic work.
(c) Detachment, dealing with entire detachment on duty in chief surgeon's office, its records and reports, discipline, instruction and equipment, censoring of mail, office property, mess, and quarters.
7. Supplies.-This division is in charge of an officer of the Medical Corps with the rank of colonel who is accomplished in all branches of supply work and who with a proper number of assistants conducts the procurement, statistics, and distribution of supplies, and maintains a careful liaison with the medical officers detailed to the general staff sections dealing with tonnage and supplies at the various headquarters.
The office is divided into the following sections:
(a) Procurement, dealing with foreign purchase, United States automatic, requisitions, and Red Cross medical supply activities.
(b) Statistics, dealing with graphics showing locations and functions of depots, cables relating to supplies, records, personnel, and car movements.
(c) Distribution, dealing with medical supply depots, inspections, controlled storage depots.
8. Finance and accounting.-This division is under charge of an officer of the Sanitary Corps, for he must be expert in all forms of auditing and accounting, subjects entirely foreign to the professional education of a medical officer.
With a proper number of assistants, and provided with the most approved time and labor saving mechanical devices for the work, the office is subdivided into the following sections:
(a) Finance, dealing with disbursing, examination of money vouchers, examination of hospital funds, liaison, and final clearance, billing, financial reports.
(b) Property, dealing with examination of property vouchers and returns.
(c) Legal, dealing with legal reference and recommendations based thereon.
9. Veterinary.-This division will be under the charge of an officer of the Veterinary Corps of field rank. With a proper number of assistants, he conducts the office which deals with administration, personnel, supply, organization, statistics, construction, inspection, liaison, appointments, assignments, promotions, veterinary hospitals, and instruction.
10. Organization and equipment.-This is a new division, the necessity for creation of which has been manifested constantly throughout the late war and the lack of which has made it necessary for officers already engrossed to the fullest to put aside temporarily most important duties to perform this labor.
It is the duty of this division to study the equipment and organization of the Medical Department with a view to constant improvement, and this is based upon reports and observations concerning every unit of the medical service, new offices being recommended to meet conditions not contemplated and the abolition of others found to be excessive and of little importance, and modifications, increase or decrease in equipment to enhance efficiency.
Officers detailed to this division should be permanently assigned as long as they possess creative faculties and demonstrate ability, and promptly relieved upon evidence of failure in either. The division is subdivided into three sections, as follows:
Shipment schedules and tables of organization: This section prepares the priority shipment schedules with reference to units of personnel, keeps the schedules up to date and furnishes extracts thereof to the personnel and supply divisions in advance of their realization in order that the former division may be fully acquainted with expectations in personnel and units and that the supply division may prepare its tonnage forecasts, prepares recommendations for changes deemed necessary, and keeps up to date the existing Tables of Organization.
Maps, charts, graphics, and manuals: This section prepares and maintains the correctness of all maps showing the location of all Medical Department units, all charts and graphics dealing with the duties of personnel or the layout of any unit, and circulars announcing changes, revocations, or additions to the Manual of the Medical Department or other Medical Department service publications.
Hospital and combat equipment: This section studies the equipment of the medical service from all angles and makes comparison with that of foreign services, recommending such changes in any part of the equipment as will reduce weight or volume, increases efficiency, mobility and durability, and facilitate standardization. It must be provided with draftsmen, mechanics, etc., as the work is of a technical nature, particularly in the combat section. All modifications effected and accepted by the chief surgeon must be checked over to the hospitalization and supply divisions in order that these offices may keep their projects and schedules up to date.h
hAn organization and equipment division under the title of planning and training division has been in operation in the office of The Surgeon General since 1919, and a corresponding division will be maintained in the office of the chief surgeon of any expeditionary force.-Ed.
ATTENDING SURGEON'S OFFICEi
Attending surgeons will be detailed for all large military headquarters within an expeditionary force. Officers so assigned will be field officers of the Medical Corps and must possess tact, administrative ability, and be well versed in the branches of their profession. A competent complement of commissioned and enlisted assistants, including dental surgeons, will be assigned to the attending surgeon's office.
The function of this office is to provide medical and dental attendance for the commissioned, enlisted, and civilian personnel forming the command of which the office is a part. Attending surgeons are members of the staff of post or headquarters commandants and as such will make necessary recommendations with reference to sanitation and schedules for the authorized sick calls and physical and medical inspections.
Boards of officers will be convened from time to time at the various headquarters for the purpose of conducting investigations which may be of the utmost importance. It is frequently necessary to have medical officers detailed to these boards for the purpose of conducting required physical examinations, and attending surgeons must be prepared to sit as members of such boards.
Sick calls will be held ordinarily twice a day for enlisted and civilian personnel. For officers, a morning hour sick call will be held daily. At other times officers will be permitted to consult the attending surgeon, or his assistants, as needed. One medical officer will be detailed for night duty at the office of the attending surgeon. He will be constantly on duty for emergency calls during the hours between 7 p. m. and 7 a. m. A well-organized eye, ear, nose, and throat clinic will be a pressing need in such an organization, and suitable personnel will be assigned this work.
Sanitary supervision of messes and disposal facilities connected therewith is a function of an attending surgeon. He recommends sites for the establishment of bathing facilities for officers and enlisted men, and subsequently keeps in close touch with the sanitation of these establishments.
Although the closest attention being paid to laundry and bathing facilities offers the best means of maintaining a command free from louse infestation, such infestations are certain to occur, and a power-driven, high-pressure disinfestor, adequately manned, should be part of the regular quartermaster equipment of a large headquarters.
A regular course of lectures covering prophylaxis against and the danger of venereal disease, personnel hygiene, and sanitation will be arranged for all enlisted personnel of the command.
The establishment and supervision of adequate facilities for venereal prophylaxis within the environs of a military headquarters is an important duty of this office. These stations must be maintained within easy and natural reach of the men and will be distributed throughout the city in which headquarters are located, in number sufficient to meet the need adequately. One such station will be established near the entrance of each camp associated with a headquarters. Supervision of these stations, if delegated, will be delegated to a commissioned officer only, and their operation intrusted to the highest type of enlisted personnel. These men must be impressed with the great responsibility they bear in helping to keep their comrades free from venereal diseases.
It is frequently impossible for personnel connected with administrative and tactical staffs to avail themselves of opportunity for proper exercise, rest, and recreation. These men can rarely take advantage of leaves, and then only at long intervals and for short periods. Work within offices at a headquarters is intensive and often continued without regard to hours, and a tendency will exist for individuals to continue at such duties without due regard to health. A grave responsibility in this respect therefore rests upon the attending surgeon. He must use all known means to reduce to a minimum the effects of wear and tear, during work at high tension, upon officers and men of his command. He will find of material assistance in this work a small corps of trained masseurs who have been recruited and trained from among the enlisted personnel at large. These men should be attached to the attending surgeon's office for duty.
I The organization formerly alluded to as the "attending surgeon's office" is now known as the dispensary. The standardized unit of this type is the general dispensary. See Tables of Organization, 677-W.-Ed.
THE SANITARY SERVICE OF ARMY GROUPS, ARMIES, CORPS
The chief surgeon of an army group is the adviser of the group commander upon all sanitary matters arising within the territory occupied by the armies and auxiliary forces comprising the group command, relating to both the military and civil population, his duties being largely administrative and, upon occasion, tactical.
He coordinates all sanitary administrative measures between the armies and grand headquarters; through his assistant, the chief surgeon, army service area, he sees to the sufficiency of sanitary personnel, hospitalization, supplies, and transportation within the group zone; he advises the surgeon of the zone in his immediate rear of the imminence of battle, that the latter may clear his hospitals of evacuables, and, through the coordinating section of the group command, causes a sufficiency of hospital trains to be garaged as near the front as conditions warrant. He announces to the chief surgeons of the armies and of the army service area policies authorized for the sanitary service by both the group and group command.
The chief surgeon, army group, forwards important communications upon sanitary subjects from the chief surgeons of the armies to the chief surgeon of the forces, but, beyond this infrequent usage does not conduct an office of transmittal. He maintains no office of record beyond keeping a loose-leaf file of communications of immediate interest and telegrams, but should examine and note requisitions and inventories of all lands, buildings, and matériel acquired from allied or civil sources and should forward them to the rents, requisitions, and claims bureau through the chief surgeon of the forces, that adjustment may be promptly effected when the use is terminated. He examines and forwards, after approval, to the chief surgeon's office all vouchers for purchases or personal service arising in the sanitary units under his immediate control.
He keeps informed of morbidity within the zone for both military and civil population, and when an epidemic arises beyond the power of subordinate chief surgeons to control, under the authority of the group commander, assumes charge and takes the necessary steps for its suppression. From time to time he makes personal inspections to assure himself of the correct performance of duties assigned army chief surgeons and other surgeons in charge of various sanitary details in both the military and civil establishments. He sees to the adequacy of medical attention and hospitalization for personnel attached to group headquarters.
When the group command assumes control of the armies for a tactical movement he prepares a sanitary paragraph of the battle order upon which the battle order of the individual armies is based; he controls activities of the auxiliary societies attached and all voluntary aid.
The chief surgeon of an army is the adviser of the army commander upon all matters relating to the sanitary service within the zone of the army, his duties being both administrative and tactical.
Under the authority of the army commander he commands the evacuation and army field hospital, the medical parks and depots, and the army ambulance service through assistants assigned to direct these units; through consultants attached to this office during military activity, he directs the surgical and medical services of army units, corps, and divisions; he maintains liaison with adjoining armies through the medium of an officer of tact and judgment detailed for that duty.j He coordinates sanitary activities of all elements
jNormally each army surgeon will have under his immediate jurisdiction 15 evacuation hospitals, 12 surgical hospitals, 1 convalescent hospital, 1 army medical supply depot, 1 army medical laboratory, 4 medical regiments, and in addition requisite veterinary units for the care and evacuation of animal casualties.-Ed.
of the command; he sees to the sufficiency of personnel, transport, supply, and hospitalization within the zone of the army. He supervises the sanitation of the command and of the civil population within the zone of the army, personally assuming charge in any epidemic that subordinates fail to control, acting in such case with authority of the army commander. He directs establishment of evacuation and army field hospitals at carefully selected locations, and through his assistant, the director of the army ambulance service, applies ambulance sections and individual ambulances where needed.
He keeps in constant touch with the operations section of the army general staff in order that he may at all times be cognizant of contemplated movements, and, possessed of this knowledge, he prepares the sanitary paragraphs of battle orders issued from time to time in which it is clearly stated what evacuation hospitals are to receive severely and slightly wounded, medical, gassed, and neuropsychiatric cases, and the location of medical supply parks. He advises the chief surgeon of the group command of the imminence of battle, that hospitals to the rear may be freed of evacuables and hospital trains garaged as near the front as conditions warrant.
When the army is acting independently of the group command he advises the surgeon of the army service zone that he may clear his hospitals. He clears his evacuation hospitals of evacuables in a steady flow at all times, and especially when battle is imminent.
His operations are coordinated through the coordination section of the army in all matters requiring the sanction of the general staff of the army that are not routine in character. He promulgates the sanitary code of the army, reconciling it with any orders from higher authority. He maintains no office of record beyond a loose-leaf file and diary for current use, and index of commissioned personnel of evacuation and army field hospitals, the army ambulance service, the medical supply depot and parks, the corps and divisional medical staff, and the surgeons of army units. He transmits important communications from division, corps, and army unit surgeons going to higher authority relating to sanitary subjects, indicating his approval or disapproval. He does not transmit routine reports of divisions and corps, but does transmit sanitary reports from army units.
He approves or disapproves vouchers for authorized purchases or payments for personal services arising in army units, forwarding the approved vouchers to the office designated by the chief surgeon of the forces. He approves or modifies the maximum stock allowances of the medical supply depots of the army, forwarding a copy of the first one to the chief surgeon of the forces for his information. In any emergency he uses the telegraph freely, and, acting under authority of the army commander, takes steps to meet the emergency, and makes report of his action to proper authority. He sees to the adequacy of medical attendance and hospitalization for personnel attached to army headquarters. He controls the conduct of the army convalescent camp, through the senior officer on duty thereat. He controls activities of the auxiliary societies attached, and all voluntary aid.
The sanitary inspector must be an officer of experience in field sanitation and must be possessed of broad views, that he may separate theoretical from practical sanitation, as the former has no place in an army engaged in combat. He should make prearranged plans with the coordination section of the army for the employment of labor battalions or Engineer regiments in the prompt burial of human and animal dead, in the proportion of one or more battalions to each corps sector. While regulations and sentiment direct the burial of human dead by their comrades in arms, it is rarely possible for combatant troops to be so employed, and in spite of sentiment surrounding the dead fallen on the field of honor, there is no more depressing duty imposed upon combatant troops than paying the last tribute to their dead compatriots, nor one which tends to lower their morale to a greater degree. Human dead should be promptly interred in the vicinity of the place where death came, and the location and number of bodies, with names reported to an officer of the graves registration service.
Men engaged in combat in modern warfare have not the same sense of nicety in the disposal of excreta and waste, obtaining in back areas and in peace-time camps, and it is folly to expect troops in combat to even make a pretense of digging straddle trenches for the disposal of their excreta or to bury kitchen and other waste material. This being an irrefutable fact, it behooves the sanitary inspector not only to make provision for labor battalions to follow the corps and bury human and animal dead and to thoroughly police the ground
over which troops have passed but also to so instruct the corps and division sanitary inspectors that they may not make futile attempts to have combatant troops perform duties which military exigencies preclude and from which they should be relieved in the interest of the first consideration; i. e., defeat of the enemy.
The sanitary inspector should concern himself intimately with the sanitation of army units and troops not in combat and which should be held strictly to the standard of sanitation. He controls sanitary squads and locates them at points selected for the most efficient service, these locations of necessity being in rear of the divisional line in open combat, though nearer to the front in stable or trench warfare. Beginning in the training area, he should maintain constant search for "carriers," and all cooks and kitchen helpers must be subjected to thorough examination to discover typhoid or paratyphoid sources. He must see to the chlorination of all water for drinking purposes and have the water tested for chlorination sufficiently. In the presence of infectious diseases within the army zone he should see to the prompt disposal of the infected and to observance of the rules governing contacts and disinfection, and, in diseases disseminated by the mouth and nasal secretions see that patients are masked immediately under all conditions of transport and hospitalization. In case of friction or inefficiency arising in the sanitary service he should investigate and report his findings to the proper authority for adjustment.
Under instructions of the administrative section of the army, he makes stated sanitary inspections of the command, and under the training section of the army inspections of Medical Department organizations and units, his routine duties being under the army chief surgeon. Inspection of either line or sanitary troops conform to custom and the Manual of the Medical Department, and report is made upon the prescribed form.
Should his duties prove too onerous or too much time be required for their performance, he should request, through the army chief surgeon, the assistance of corps or division inspectors, or both, the work being divided in accordance with its importance. In the inspection of combat troops, great attention should be paid to the sufficiency of food for the front line and the means to insure its reaching there hot; to the measures for drying clothing and shoes, and to facilities near the front for bathing and disinfecting, the latter manifestly being impossible during open combat, with a constantly shifting line. All complaints of inadequate treatment in sanitary formations should receive prompt investigation, as also should shortage of necessities.
Procurement and distribution of medical supplies, management of army supply depots, and the functioning of the supply service within the zone of the armies is fully covered under the heading "Medical Department supply service."
The director of hospitals, under the supervision of the army chief surgeon, controls activities of the hospitals and makes tentative selection of location for future establishment for the approval of the army chief surgeon, having in mind protection from direct fire, accessibility to rail and wagon roads, water and suitability of terrain. He notifies the army chief surgeon when a hospital is prepared to function, or to close prior to change of location, so that the latter may notify the operation section of the general staff of the fact, which is immediately published to the command served by this particular hospital. He should charge himself with prompt establishment of telephonic communication between the hospitals and the main trunks, giving timely notification to the army chief signal officer. By constant supervision, and instruction if necessary, he should assure himself that evacuating officers thoroughly understand the prescribed method of evacuation by hospital train and the preparation of reports of evacuables for the coordinating section of the army and for the regulating officer.
Marked attention should be paid to the work of registrars in the preparation of statistical reports and the prompt completion and forwarding of case records with evacuated patients and of those dying in hospital. This office keeps a file of daily admissions for all hospitals, by class, officers and men separately; deaths, return to duty, and evacuations, which should be compared frequently with the daily report made by all corps and division surgeons and hospital evacuating officers to the evacuation officer in G-4 of the general staff, and also with a weekly report of train evacuations which should be made by the regulating officer. Data contained in this file serve as a basis for the final report of the army chief surgeon upon conclusion of a campaign.
The director of the army ambulance service controls the army ambulance park and the companies which make up the service,k together with the repair unit, under supervision of the army chief surgeon. It is essential that the officer selected for this duty be familiar with motor ambulances and truck technic in order that he may supervise intelligently this very necessary part of the service. He should maintain a card record of every motor ambulance and truck in the service (the United States and motor numbers, and make), together with a card record of the personnel, both chauffeurs and mechanics, noting in brief their qualifications. Upon receipt of advice from the army chief surgeon the director of the army ambulance service assigns as many companies as are deemed necessary to divisions, corps, army troops, and evacuation service, making note of the length of time each company serves, as a guide to relief for rest and repair, the length of service to be contingent upon military conditions and not made for any stated period. During times of military stress this officer should maintain close liaison with the army chief surgeon and corps surgeons in order that he may, under authority of the army chief surgeon, increase the number of companies at points where the greatest number of casualties are occurring.
The director of army ambulance service maintains the sanitary courier service between sanitary units of the army and the army chief surgeon's office, using for this purpose the motor cycles of companies in rest, and upon request of the officer in charge of medical supply parks, he furnishes transportation for medical supplies or for emergency articles for the front. Location of the park is left to his discretion, subject to the approval of the army chief surgeon, and the vicinity of the central medical supply park should have preference. At all times he should instill into company commanders, and through them into drivers and mechanics, the vital necessity for esprit de corps so that the whole command may work for the common end-the rapid and careful transportation of the sick and wounded. In order to make this possible, vehicles should be kept in thorough repair and their cleanliness and immediate availability be insisted upon.
The adjutant of the service supervises the routine reports and returns demanded by existing regulations from the commanding officer of each company attached to the park and evacuation service, those serving with corps, divisions, and army troops making and forwarding theirs through the command to which they are attached. Each company commander should keep a record of the number of trips, the number of miles run, the number of sick persons, both sick and well, transported, making to the next higher commander prompt report of any abuse of ambulances, turning in to the ambulance service director this record upon completion of his detail. In case of abuse of an ambulance not meeting with swift action on the part of the next higher commander, the company commander should be authorized to make report of the occurrence direct to the director of army ambulance service, stating nature of the occurrence, date and time, with the names of witnesses, that the matter may be reported to the army inspector for investigation and action. The quartermaster makes requisition for rations for all personnel at the park and for clothing for the entire enlisted personnel of the service, and for spare parts, gasoline, and oil for every motor vehicle employed in the service, forwarding such requisitions through prescribed channels.
The assistants necessary for maintenance of the park should be officers of the Sanitary Corps selected for their knowledge of motor vehicles and who, with the mechanics for the repair of machines, are assigned by the chief surgeon of the forces, upon request made through the army chief surgeon. (See section on Army ambulance service.)
The officer in charge of correspondence and records performs routine duties prescribed by higher authority in orders from time to time, keeps the service records of the enlisted personnel attached to the office, prepares the daily statistical report for the adjutant general's office, and also transmits to him all statistical reports from army units received in the army chief surgeon's office.
The chief consultants assigned the army chief surgeon's office are ordinarily attached during campaign only, each coordinating the particular service to which assigned, down through the divisions and, under authority of the army chief surgeon derived from the army commander, directs the services, especial attention being given to perfection of technic and in-
kThe army ambulance service comprises an ambulance battalion from each of the four army medical regiments, and ambulance troops pertaining to medical squadrons of cavalry divisions belonging to the army.-Ed.
struction. These officers maintain no records beyond those necessary for a report of the services upon the completion of a campaign, for incorporation in the report of the army chief surgeon. They merely make recommendation where error is discovered, reporting the facts to the army chief surgeon for correction if subordinate surgeons fail to take action.
The furnishings and supplies of an army chief surgeon's office should be as meager as will be consistent with proper functioning and should be devoid of any matériel which would preclude complete removal in two 3-ton trucks upon a half-hour's notice.
THE ARMY CONVALESCENT CAMPl
(Numbered from 1 up)
When military operations are decided upon, the first duty of the group chief surgeon or the army chief surgeon, if the army is operating independently of a group command, is the selection of a site for the concentration of sick and slightly wounded of each army, to be located at the rear of the army combat zone in proximity to the replacement camp, and its prompt establishment, though independent of it. These convalescent camps should have a capacity of 10,000 for each army, the men to be housed in huts, buildings, or under canvas, and should receive sick and slightly wounded patients evacuated from army hospitals who are incapacitated for duty for a period of two weeks or less. They should also receive all venereal cases in the infective period.
These camps should be under medical control and the patients given such graded exercises as will improve their physical condition, healthful amusement being added in abundance to preclude depression. Venereal patients should be segregated within wire enclosures, partly for the protection of other occupants of the camp and of civilian population and partly for punitive purposes, their presence in 90 out of 100 cases denoting a breach of discipline.
The medical staff of a rest camp should be composed of men of mature judgment and great tact, as their knowledge of the young soldier and of his shortcomings is invaluable in the conduct of the camp and in the prompt selection of cases to be returned to duty through the replacement camp. Auxiliary associations will find in these camps a field for their activities and should be encouraged in all legitimate endeavors to promote the welfare and recreation of the men, all possible facilities being given them.
Attention to the perfection of kitchen and bathhouses is necessary, for both are important in recuperation. The men should not spend their time in idleness, and after finishing camp police duty, physical drills should be given under the guidance of an officer selected for his knowledge of these exercises. Drills being finished, as many men as possible should be bathed, these several activities occupying the morning hours. In the afternoon out-of-door games should be indulged in, under direction of a qualified officer, the men who were unable to get a bath in the morning being given opportunity to bathe after games are over.
For men not yet able to indulge in physical drills or sports, and for all in inclement weather, recreation and reading rooms should be provided. Disinfecting and laundry plants must be provided to render the men free from vermin upon admission, and not only to keep them clean but also to incline them to the desire for cleanliness. Drills savoring of military movements or of the Manual of Arms should not be introduced, the object being to promote physical and mental well-being and to take the men's minds from their disabilities and the environment at the time of disablement. This, of course, applies to the sick and wounded and not to venereal cases. Men suffering from venereal diseases are disabled through their own misconduct and not as a result of military activity, though they too should be given exercise and indoor recreation when off duty.
The venereal section should be a part of the camp and necessary guards furnished from permanent camp personnel. The section should house a thousand men, should be conducted by an urological unit and supplied with all facilities for the care of venereal cases. The location of these camps as regards distance from the army is of little importance if only a railroad is near. When a man from either the venereal or the convalescent camp is pronounced by an examining board as of class A, he is transferred to the near-by replacement camp for equipment, after which he is returned to his unit through the regulating station.
l The army convalescent camp is now known as a convalescent hospital, with a minimum capacity of at least 5,000 patients. See Tables of Organization, 285-W.-Ed.
ARMY AMBULANCE SERVICE
(Companies numbered from 1 up)
Experience demonstrated that the system so long in vogue of assigning to divisions, corps, and evacuation hospitals, ambulance companies of 12 machines each, while excellent in theory was wrong in principle and in fact, in that one company might have too great a burden to bear while another had too little and no opportunity was afforded either for rest or repairs. The system of pooling all ambulances into an ambulance service with 20 machines to a company, all under control of an army director of ambulance service who, in turn, was assistant to the army chief surgeon, gave the most effective service in that it made possible the assignment of ambulance companies to divisions, corps, and evacuation hospitals in sufficient numbers and also afforded opportunity for relief of the personnel and the repair of machines which other systems precluded.m
The assistant director, army ambulance service, in charge of personnel, should be an expert in driving motor vehicles and should impart this knowledge to the ambulance company personnel to the end that every man may be made proficient. One man should drive while his partner is resting or doing orderly duty, so that the driver will at all times have unimpaired faculties. In the course of instruction-which should begin the day that a company arrives at an ambulance park-the rules of the road should be carefully taught, particularly observance of rules of circulation governing transit in the combat zone, and the correct methods of traction by truck or tractor when road conditions preclude progress alone.
The assistant director army ambulance service (in charge of equipment, transportation and repair) conducts the function of the repair unit and also instructs members of the company at rest in the use and care of the gas motor, methods of detecting loss of function in a part, and in the methods of making quick temporary repairs to engines and running gear while en route, company mechanics assisting in the overhaul and repair of all cars in their companies.
Motor ambulance companies for all requirements of the theater of operations should be supplied at the rate of eight companies per division from front to rear. Of these eight companies, three should be equipped with machines of the light type, all others heavy, and all companies should have 20 motors each, whichever the type.n A maximum of 10 per cent of ambulances will be needed as reserve. This estimate therefore requires 176 motor ambulances to be shipped per division to an expeditionary force, and the basis is not confined to combat divisions. Of the eight ambulance companies per division, seven companies per combat division will be required for the zone of the armies, including the army service zone, and one company per division will be required by the services of supply for base ports, hospital centers, base hospitals, etc. This number should be increased by the additional eight companies per division shipped for replacement or depot division which must accrue to the credit of the Services of Supply.
Ambulance companies attached to divisions normally transport the wounded from forward aid stations to the divisional triage or sorting station or to the other divisional hospitals. These companies function under direction of the director of ambulance companies of the division, and he in turn under control of the commander of the divisional sanitary train.
The corps surgeons should each be assigned four companies of heavy ambulances, three operating at a time while the fourth is resting and repairing, the companies being under control of the corps director of ambulance companies, the latter's activities being directed by the corps sanitary train commander. The function of these ambulance companies is the transport of the wounded from "triage" to the mobile surgical hospital (corps), in which duty in times of stress they are assisted by the companies assigned to evacuation hospitals, and from the mobile surgical hospital (corps) to the designated evacuation hospitals.
m Twenty ambulances are now authorized for each ambulance company or ambulance troop.-Ed.
n Two types of field ambulances have been devised. The heavy provides a capacity for six patients lying, and the light for four patients lying.-Ed.
The machines assigned army troops are eight companies in number, of heavy type, permitting service with Engineers, Artillery, labor, salvage, and pioneer troops and the transport of the sick and wounded of these organizations to evacuation hospitals, and also rest and repair.
To an army of four corps of four combat divisions each the above assignment, which is the minimum for proper service, would give:
For the army just given, which totals approximately 675,000 troops, there should be 112 companies in the army zone. In addition to the eight companies in reserve there should be held at the ambulance parks a just proportion of the 10 per cent reserve of ambulances. These companies and extra ambulances will be necessary to insure prompt and easy transport and to preclude recourse to motor trucks to the detriment alike of the wounded and of troops remaining in the line.
Each machine should have a large white cross painted on its top and a red cross on the sides, the color of the ambulance being khaki, against which background the red and the white crosses are emphasized. The white cross on top is necessary for protection against enemy aircraft. All ambulances should be equipped with disk type of demountable wheels, with one spare wheel, complete with casing and tube, ready for use, as part of their equipment each. Running and head lights should have the red cross painted on the glass to insure free passage of the circulating route and to gain assistance of the military police in case of a road block.
A study of the various uses of the gasoline exhaust for the purpose of heating the interior of ambulance warrants the rejection of them all, and the simple thermosiphon was recommended. This thermosiphon requires only a small pipe leading from near the top of the radiator on one side back beneath the floor of the ambulance, where it is connected with a small coil, the return pipe running from the lower strand of the coil to near the bottom of the radiator on the side opposite the one on which the lead began. The coil should be located beneath a perforated disk, with a hinged cover to exclude heat when not desired. This simple appliance is really a small hot-water heating system acting under the double effect of expansion of water by heat and of gravity, and it requires but little mechanical ingenuity to install at small expense in any car. It affords an even heat, which is felt after a few minutes' running of the engine. In cold weather the car may be warmed quickly by filling the radiator with hot water or by running the engine a short time before patients are placed on board.
Each ambulance will carry four litters upon each side in racks, and in the top should be slung arm and leg Thomas splints, two each, to automatically replace those worn by a patient, the same kind of splint being returned to the hospital from which patient was received. This simple system insures a steady supply of splints to the front. Eight blankets and four hot-water bags or metal cans should be carried on each ambulance for replacements.
Experience on sandy roads of the Mexican border warranted the rejection of ambulance trailers, but these vehicles, identical with the ambulance itself minus the machine and steering gear, would have been of great value on the hardpan roads of France. Their further development must be considered.
In very muddy soil an ambulance may, on occasion, be stuck, and in such a predicament the services of a heavy truck, of a tractor, or even a tank must be solicited by the ambulance company commander, and with this possibility in view all ambulances, whatever their type, should be provided with a short towrope, with hooks borne on swivel joints at each end.
In addition to its repair truck, each ambulance company should have assigned to it one 2-ton or 3-ton truck for carrying supplies and the personal effects of the personnel, one trailmobile kitchen, and one water cart, the two last named to have roller-bearing axles to prevent the burning out of the running gear.
As ambulance companies usually camp in the vicinity of other sanitary units, their medical attendance can be provided by the nearest hospital; but every ambulance company should have a pannier filled with dressing packets, bandages, adhesive tape, iodine swabs, etc., for use in case of emergency.
The commanding officer supervises the preparation and forwarding of current reports and returns. He keeps a record of the number of patients or persons transported, miles traveled, the amount of gasoline and lubricating oil used, all in a small book, the data serving as a basis for his report to the chief surgeon of the army, through the director of ambulance service, upon conclusion of service period or of a campaign.
THE EVACUATION HOSPITAL
(Numbered from 1 up)
The evacuation hospital is the keystone of the sick and wounded system of a field army, and these units should be organized in the proportion of one for each division, this ratio being sufficient for the needs of army troops, it being recognized that at no time, except under the most unusual conditions, are all the divisions of an army in the line at the same time.
Evacuation hospitals must of necessity be movable units, capable of functioning in such buildings as exist in the zone of the armies or under their own tentage. They should be self-contained in the fullest sense, with a standardized equipment, and should have a capacity of 500 cots and 250 litters over and above the space occupied by permanent and temporarily assigned personnel, and are under the control of the army chief surgeon, through his assistant, the director of hospitals.
The assignment of evacuation hospitals to the care and treatment of special types of surgical and medical cases exclusively is unwise and even in fixed warfare is wasteful of personnel and transportation.
If terrain permits, these hospitals should be placed in pairs, each retaining independence of the other. This arrangement permits one to fill and close, the other one opening when the first closes, thus enabling the first one to deal with its quota and free itself of evacuables. If rail facilities offer, evacuation hospitals should be located as near as possible to a siding, for without this means of establishing a constant flow of sick and wounded to the rear they quickly fill and cause a reflex congestion in divisional hospitals; a condition which should never be permitted to arise. The sole departure which should be allowed from this rule would be the possession by the sanitary service of an adequate number of motor ambulances, motor trucks, and busses, in which evacuables could be transported to a second line or echelon of evacuation hospitals or to advanced base hospitals.
With the consent of military authorities (coordinating section, general staff, army) advantage should be taken of every railroad siding in the battle area to which the regulating officer can dispatch a hospital train without undue interference with supply trains, and no location should be definitely decided upon by the army chief surgeon without specific agreement with the coordinating section, as above, and the regulating officer, as to the availability of a siding for containing a hospital train for a specified loading schedule, and the number of trains allowed on this siding in a period of 24 hours.
In selecting sites for establishing evacuation hospitals the army chief surgeon should make a personal reconnaissance beforehand, or have a competent assistant do it, to determine the existing facilities as to railways, buildings, wood, water, ground space for the erection of tents, and safety from enemy fire, either direct or indirect. Having made a selection which receives the approval of the coordinating section, army, if the unit to occupy the site is on a railway and transportation is available, a request in memorandum form to the operations section, army, will produce the necessary order, which is accomplished by the troop movement bureau of the coordinating section, army; if beyond the limits of army
control, request made by the army commander upon general headquarters by wire will produce the desired result. Once within the army zone the transport of these units is usually made on trucks from place to place, as but small dependence can be placed upon available trains.
The average number of trucks of 3-ton capacity to transport an evacuation hospital is 50 for a single trip, so unless a long move is to be made it is economy to use not more than 20 at a time. This enables one portion to be made ready to function at the new location while the remainder is being transported. When the new establishment is prepared to receive personnel all the commissioned officers, except the adjutant and one or more assistants to superintend the loading, and the female nurses, should be transported in ambulances to the new location. A sufficient number of enlisted personnel with all but two cooks will have already proceeded there on the first trucks.
On assignment to a unit each commanding officer should immediately prepare a truck-loading schedule in such a manner that the equipment and tentage necessary for commissioned personnel and nurses, the cooks, surgical department, and lighting and heating units will arrive first at the new location. It is incumbent upon each commanding officer to familiarize himself with the amount of space necessary to contain the hospital when tentage is erected and to prepare a diagram to scale for each tent employed, whatever the make, and also of the application of tentage to buildings. Every officer and enlisted man of the permanent personnel should be drilled in this demounting and erection by schedule and diagram until that proficiency so essential in time of activity is acquired. The new location may not lend itself exactly to the prearranged plan, but in no instance is more than slight alteration necessary, and that in the wards. The receiving ward or triage should always be located at the opposite side from the evacuating section, and the surgical and bathing sections should be near the triage. By remembering this simple rule, novices will avoid much confusion.
Every hospital should be provided with a cross of white canvas, each arm 9½ feet in length and 6 feet wide, to be pinned firmly to the earth, preferably on green grass-before any other detail is given attention. If no grass plot is available, black cinders or rock should be placed in the quadrants to make the white cross conspicuous. Investigation has proven that a white cross on a green or black background is far more conspicuous than red when viewed from the air, and gives perfect definition in pictures taken from airplanes. The adoption of this expedient saved many hospitals from enemy fire. The importance of placing this white cross before any part of the unit is erected lies in the fact that aerial observers take photographs in the daytime and bombing planes discharge their missiles by night upon any point indicated in the picture, unless this cross is observed, and as red does not show up in a picture the usual distinguishing mark for a hospital is useless for this purpose.
Upon assuming command, the commanding officer should prepare a loading schedule for rail transportation based upon the known weight of the hospital equipment in tons and also the cubic space occupied. This schedule should be that of the maximum equipment, which should never be exceeded, and also the space necessary for 3,000 rations to be taken by every evacuation hospital, as cars for personnel, including temporary teams, box cars, and flat cars, must be accurately determined and made a matter of quick reference. It is essential that a car be included in the string with end doors opening upon the personnel cars, for the installation of a range so that cooks can perform their duties en route and the train continue without stop for feeding the personnel.
An evacuation hospital should have the following departments:
1. Receiving, triage, or sorting.
In times of activity the personnel should be increased by the addition of 12 operating and 2 gas teams, each operating team being composed of 2 surgeons, 2 nurses (1 anesthetist), and 1 orderly, and gas teams being each composed of 1 officer and 2 orderlies.o
Every unit should have 4 operating teams among its permanent personnel, so that with the addition of 12 temporary teams 8 would be available for intensive operations during a "push," the 2 sections relieving each other every 8 hours-which is the longest period that a team can operate with justice to the wounded. Two dressing teams for slightly wounded dressing and operating rooms are organized within the unit, these also relieving each other every 8 hours.
Two medical teams for shock work, each team composed of 1 officer, 2 nurses, and 2 orderlies, all trained in approved measures for combating shock, are indispensable during battle. Their personnel should be especially trained in transfusion.
Two splint teams, organized from the permanent personnel, are indispensable. Each team should have 1 specially trained medical officer and 2 privates, for the correct application of splints, 1 team for day and 1 for night duty. By splinting a fracture or an orthopedic case these groups relieve the operating team and save time that otherwise would be consumed in changing operating gloves and gowns.
At least two surgeons with the permanent or temporary operating teams should be proficient in surgery of the brain and eye, so that patients in each of these two classes may receive prompt and correct attention.
A medical officer of recognized ability, member of the permanent personnel, should be assigned as chief of the medical service and should so supervise the service that it will be prepared at all times to give correct treatment both to toxic gas cases and medical cases of all classes. He is also the assistant to the chief triage officer, the two working alternately and assisted by others detailed for this duty as required.
Two medical officers thoroughly versed in radiologic, fluoroscopic, and screen technic, one for day and the other for night service, with one or more assistants for each, and all members of the permanent personnel, should be assigned for X-ray work. Young men are preferred for this service on account of the long hours necessary during times of stress and also on account of the necessity for keeping X-ray records ahead of operating teams in order that no delay may ensue and throw a surgical team behind its schedule.
A medical officer proficient in wound bacteriology and in pathology should be assigned from the permanent personnel. His duties should consist primarily in routine bacteriological procedure, in making Dakin solution, in preparing smears from wounds to insure their control, and in performing post-mortem examinations in cases of peculiar interest, preserving such anatomical specimens as are deemed worthy of forwarding to the Surgeon General's office.
An officer of the Quartermaster Corps, preferably one with experience, should be permanently assigned to the unit, for a multiplicity of most important duties devolve upon this officer, who of necessity must be familiar with existing regulations concerning subsistence, clothing, transportation, heating, lighting, and equipment. He must also be bonded, so that he can assume the duties of disbursing quartermaster of the unit.
The registrar should be an officer of the medical administrative service, thoroughly familiar with the intricacies of the sick and wounded report and the necessity for correct and prompt preparation of statistical reports (A. G. O.), the notification required by the chief surgeon's office upon the origin of infectious epidemic diseases, the collection and forwarding of individual medical cards, X-ray plates and records, and histories of all cases evacuated, and the prompt forwarding of all records in case of death. He should report the status of the hospital every day as of 6 a. m. to the evacuation officer attached to the coordinating section, army, giving admissions, the number of surgical, medical and gassed patients, officers and men separately, the number evacuated and dead, and the number remaining as classified above, this report being made by telephone or courier. He should also keep a thoroughly posted diary giving data upon all movements of the unit, with orders, the number
o These teams have been provided for in an organization known as the auxiliary surgical group, which is assigned to general headquarters reserve, normally at the rate of one group for each field army. See Tables of Organization, 689-W.-Ed.
of cases admitted, designating them as surgical (the class being given by the nature and degree of injury); medical, the number and class being given; gassed, the number, specifying the kind of gas used, if known; the number of operations by classes; the number of evacuations, both sitting and lying, medical, surgical and gassed; the number remaining, by classes; and the number of dead, with name, cause, time, place of burial and grave number, the last being obtained from a member of the graves registration service, who should be attached to the registrar's office.
A mess officer, member of the medical administrative service and permanently assigned, assisted by three noncommissioned officers, is in charge of the various messes, keeps the records, and makes provision with the railhead officer for supplies.
On the successful service of the receiving ward or triage depends the successful function of the unit, and for this reason officers selected for this duty need to possess a knowledge of both medicine and surgery and the ability to make quick decisions based upon good judgment and diagnostic powers.
The clerical force should be gifted with quick perception and be capable of recording quickly the data noted upon diagnosis tags and field medical cards, such data being the basis of important statistical reports (A. G. O.). One member of this force needs to be a man of known probity whose sole duty should be the collection of valuables from unconscious patients, those in extremis or those who desire it, valuables being placed in small bags provided for the purpose and retained in the custody of the receiving officer. The patient should be given an itemized receipt which is placed in the field envelope, a duplicate of this receipt being attached or affixed to the bag of valuables. Care in this procedure will preclude the loss of valuables and unpleasant investigation and explanations, this system enabling each ward surgeon to secure and return to patients prior to evacuation the valuables receipted for. It also secures for the receipting officer the original receipt, which, with the duplicate, should be retained as part of the records as long as the unit functions and then transferred to the chief surgeon's office with other historical records.
Two evacuating officers should be detailed, one for day duty (the detachment commander) and one for night duty (a detailed assistant), each with a number of litter bearers from the personnel, the strongest being selected for this very exhausting duty, to the number of 40, all trained in the correct procedure in loading and unloading ambulances, trucks, and hospital trains.
Having received notice of the imminent arrival of a hospital train, these officers should ascertain the number and names of patients to be evacuated, medical, surgical and gassed, recumbent and sitting, officers and men separately, and should prepare the entraining list for the train commander, a duplicate of this list being sent to the registrar.
When evacuation by train is desired, these officers notify the coordinating section, army, of the fact, furnishing the information noted in the preceding paragraph, which the coordinating section transmits to the regulating officer, and the latter, having a daily report of the entire hospital bed status is in a position to know to which hospital in the rear a loaded train should be dispatched.
Evacuating officers of each unit should inform the regulating officer by telephone or wire twice daily of the number of evacuables, officers and men separately, sitting and lying, of surgical, medical, and gassed.
When evacuation by ambulance convoy is desired, the evacuating officer ascertains the vacant bed status of the other evacuations or base hospitals in the immediate rear, and dispatches the convoy to the one mutually agreed upon, a list of cases by name and class being furnished. This information, with the name of the hospital receiving the cases, is transmitted both to the coordinating section, army, and to the regulating officer.
The chief nurse controls the activities of nurses and nurses' aides, assigns those with operating room training to the operating section, and others to ward service and diet kitchens. She keeps the nurses' records, preparing for the commanding officer's approval and forwarding the required reports.
A chaplain is indispensable, and selection should be made without regard to denomination. The duties are onerous and divided between religious ministrations and conduct of amusement features of the unit, the latter being very necessary for the relief of the dreadful monotony and sadness that soon pervade an active evacuation hospital during hostilities.
The cuisine of an evacuation hospital is second only in importance to the operating section, for the importance of diet in the treatment of wounded and gassed should not be underestimated. Two of the sixteen cooks assigned to an evacuation hospital should be competent diet cooks who, with the assistance of the diet nurses, prepare food for patients with capricious appetites and for those placed on liquid and light diets. Two rolling kitchens and five ranges, gasoline or No. 5, Army, should be supplied each unit, field ranges not proving a success in these units.
A laundry is absolutely essential to the proper functioning of a hospital, and particularly so in the case of an evacuation hospital as it is always situated in a region away from civil population. Experience demonstrated that a portable gasoline motor-driven laundry gives the best service for small, flat work, the main laundry of demimobile type with a linen exchange being established at the army medical supply depot. A laundry capable of washing 1,200 pieces of flat work per day needs the services of two enlisted men of the permanent personnel. A drying chamber can be easily extemporized.
Five mechanics, assigned permanently, should be attached to an evacuation hospital; one tinsmith, two carpenters, one plumber and one electrician. These are indispensable, for the amount of work required of them is enormous, and often a unit is unable to function properly for lack of them.
The remainder of the enlisted personnel should be assigned the usual police, mess hall, orderly, barber, tailor, telephone, quartermaster, record office duties, etc., but all should be trained in litter-bearer service.
The commanding officer should detail his assistant as fire marshal and the adjutant as assistant fire marshal, with the entire male personnel divided into (a) rescue squads, (b) fire-fighting squads, (c) salvage squads, all being drilled in their duties daily until proficient, and thereafter drilled once a week. In fighting fire in wooden huts or tents it should be remembered that blankets soaked in water and applied to the roofs and exposed sides of adjacent huts and tents is the surest method of isolating fire and preserving near-by structures. Every hut or tent should be provided with two fire extinguishers equivalent to Pyrene, and tubs, barrels, or buckets should be filled with water and kept close to each hut or tent.
The establishment of a post exchange at an evacuation hospital is unnecessary, as auxiliary societies perform the functions which pertain to this, and also establish recreation rooms or tents.
The receiving triage or sorting department should be one or more large rooms, if buildings are occupied, or a small hangar or several ward tents, if tentage is used. Capacity should be at least 60 litters, and rooms or tents should be warm. The receiving or triage officer, with the clerks, is located here, and upon admission of a patient the decision is made whether operative procedure is necessary or not, whether further antigas treatment is indicated, if assignment is to be made to a medical ward, to the shock ward, if the case can be evacuated, or returned to duty.
The patient's name, number, organization, diagnosis, and all the data necessary for a record are obtained here from personal interrogation and from the diagnosis tag and field medical card, or from the latter and questioning of those who accompany the patient if he is unconscious. Valuables are placed in a small bag, a receipt for them signed by the triage officer, and they are placed in a field envelope, duplicate receipt being affixed to the bag, the contents of which have been listed on both original and duplicate. All conscious patients should be informed that the hospital can not be held responsible for valuables left in the possession of a patient who refuses to take advantage of the facilities offered for their care.
If examination shows that operative measures are necessary, the patient is now transferred by litter, via the bath if conditions warrant, to the preoperative room, where his injury is reexamined and the case assigned to a team unless shock treatment is indicated, when the case is taken in charge by the shock team. If the triage officer decides that operation is unnecessary, the patient is sent to the dressing room for the slightly wounded, by way of the bathing and washing room, and after dressing and the administration of antitetanic serum, if not previously given, the patient is sent to the evacuation section, whether considered as suitable for evacuate or for a return to duty.
A case designated as gassed is sent to the bathing room and bathed with alkaline soap and solution as indicated, the clothing entirely removed, and in a fresh suit of pajamas assigned to a ward, if not to be evacuated; or if evacuable or to be returned to duty, sent to the evacuation section. Medical cases are disposed of similarly, and if an infectious disease is diagnosed the case is removed immediately to a ward set apart for such. In the event of epidemic respiratory diseases occurring in the Army area, the receiving officer should see that every case admitted is masked, to minimize infection.
One of the auxiliary societies may establish a light refreshment counter at the triage for the benefit of patients who may take light food and also for ambulance drivers and orderlies.
A large supply of litters and blankets and a smaller supply of splints should be kept, both day and night, near the entrance to the triage, under charge of a noncommissioned officer, whose duty it is to see that a blanket or litter or splint is returned to the ambulances for every one brought in with a patient. This is most important, insuring the automatic supply of these articles to front divisions. A sign should be conspicuously placed bearing the legend "Litter, Blanket, and Splint Exchange." The triage or receiving ward should also be conspicuously indicated, both day and night, as should all roads within a radius of 4 miles toward the front. This marking of roads leading to evacuation hospitals is the duty of each hospital, and for obvious reasons it should never be neglected. Road markers should be of metal, black bodied, with directions in luminous letters preferably, for the guidance of ambulances by night. All signs belonging to a unit should be collected when it moves to a new location.
The bath hut or tent should be floored with "duck boards," should have a drain either open or piped, as resources permit, and two so-called instantaneous heaters of the jacketed type, with 50-gallon tanks supported on iron tripods, each heater supplying eight shower heads, with a cut-off and the necessary pipe. There should be two heaters, one on each side of the middle, with two partitions of either board or canvas, one section being for the use of officers and nurses, the other side for enlisted men. Nurses should have exclusive use of the allotted section from 8 to 10 a. m., and officers from 10 to 12, as the wounded arrive in large numbers between noon and midnight. The importance of these bath units can not be overestimated. They are a necessity, not a luxury.
The dressing station for slightly wounded not requiring operation should be located in a tent or hut near the triage, and requires only simple provision: An operating table, a few benches, a small table for dressings-prepared and sterilized in the main surgical section-and the usual instruments and utensils found in dressing rooms. This section is under the charge of two officers with surgical experience, assisted by two men. If a wounded man is found not to have received a prophylactic dose of tetanus antitoxin previous to admission, it should be administered here and proper notation made on his field medical card.
The main surgical department should be divided into an operating, an X ray, and a preoperating section, the latter having shock beds adjacent. The preoperative section is either a portion of a hut or a tent fitted with litter racks upon which litter-borne patients may rest previous to operation. This tent or hut requires no furniture nor fittings except litter racks, but it should have a good heating stove. The adjacent shock ward should be heated at high temperature by a suitable number of stoves, even in warm weather, and litters containing patients should be placed on racks, a cradle of half-barrel hoops placed over each patient, a blanket beneath and over him, and heat from a small lamp or a can of solidified alcohol or a small stove conducted beneath the blanket by means of an elbow pipe. It is here that highly trained personnel thoroughly familiar with the treatment of shocked cases find their work, for patients' lives are always in the balance and it is essential that shock teams be prepared to administer Cannon's gum-salt solution or to transfuse, or both, as the case demands. After operative procedure it is often necessary to place a patient in this ward until it is safe for him to be transferred to a general ward.
The X-ray room or tent should be connected with the preoperative ward, and it is necessary to make provision in advance for darkening the interior either with black cloth or paper. The chief of the surgical service directs which cases are to have fluoroscopic or screen examination, for plates are used only in cases of peculiar interest or where accurate
localization is desired, it being essential that the X-ray operator make the quickest possible examination and record of findings, so that he may always be several cases ahead of operating teams and thus avoid any delay. It is a waste of time to examine clean perforating machine-gun and rifle wounds and it is only when the projectile has passed close to a bone or joint that X-ray examination is called for. Shell wounds, on the contrary, demand examination in every case, for in this class of wounds it is impossible to determine by visual examination the presence or absence of shell fragments in the deeper tissues. Cranial injuries also require plate record for the purpose of avoiding possible error at the time of operation and also to furnish a permanent record for those to whose care patients will subsequently pass. Whatever the method of examination employed, the operator makes a simple slip of his findings, this being affixed to the field medical card or diagnosis tag for the information of the operating team assigned to the case, a duplicate being retained for hospital records.
The main operating hut or tent should have at least eight operating tables down the center, a row of double shelves running the entire length of one side. These shelves should be smooth planks resting on folding horses, the upper shelves for holding sterile dressings, utensils, etc., and basins for lavage of the hands of those required to be sterile; the lower shelves for nonsterile dressings, utensils, etc. This row should be on the side next the head of operating tables, leaving the space between the foot of the tables and the side of the room or tent free for the passage of litter bearers. The use of the long shelves does away with the need for a multiplicity of small tables and increases available space. When a building with small rooms is occupied, the shelves being sectional are easily adapted to the space afforded.
Every operating table should have a brilliant electric light suspended over it, and these lights should be provided with a cone shade to prevent the dispersion of rays, particularly upward. As the major part of operating is done after nightfall, it is imperative that a black lining be applied to the entire interior of a tent, with hinged window flaps; or if a building is used, the windows must be made light proof, as otherwise an inviting target is offered to enemy airplanes. As stated under duties of personnel, each hospital should have 16 operating, 2 shock, 2 gas, 2 dressing, and 2 splint teams, of which 12 operating and 2 gas teams are supplied at the time of the unit's engagement in activity, by the director of professional services, upon antecedent request of the army chief surgeon. This arrangement affords 8 operating teams, 1 shock, 1 gas, 1 dressing, and 1 splint team for duty every eight hours, the longest period that a team may work on battle casualties with justice to the patient. There needs to be among the operating personnel at least one surgeon proficient in cranial surgery and one in ophthalmic surgery, in order that cases requiring special technic may receive the best treatment.
When an operating team has completed its work upon a wound of the extremities involving fracture or a joint, instead of wasting time and effort in applying a splint, the case is taken charge of by the splint team. They apply the additional external dressings and the splint on a table or a litter placed on rack in a corner of the room or tent, leaving the operating team free to proceed with another case. The dressing team is for service in the dressing room for slightly wounded.
Adjacent to the operating hut or tent should be the hut or tent containing
the sterilizing apparatus. This should be simple in construction and adequate
to the requirements of perfect sterilization of dressings, instruments,
utensils, and water. Three autoclaves of 24-inch diameter and three stock pots,
25-gallon, with faucets, each with an iron foot base
The supplies department, both medical and quartermaster, must be in charge of the quartermaster, who also manages the laundry and linen room. At least 3 noncommissioned officers and 14 privates or privates, first class, are needed to conduct this department, 2 of the men operating the laundry. This laundry should be run by a gas motor, the set consisting of washer, extractor, and tumbler, and it should be easily transportable.
Laboratory, pharmacy, and dental offices should be located together for convenience, and these require no special comment.
The hospitalization section, surgical, medical, and gas, should be as simply equipped as possible, cots with thin mattresses being used, each cot in the infectious wards being separated from those on each side by means of a triangularly folded sheet suspended, to preclude cross infection. Wards should be supplied with the necessary amount of beddings, towels, urinals, close stools, etc., and the nurse should have a small room or a corner screened off where a small stove can be installed for heating water, food, and for other purposes. For each bed there should be a head net, as flies in enormous numbers always appear in a battle area during the greater portion of the year and annoy patients exceedingly.
The morgue may be a hut or tent and should be furnished with light, four litter racks, washing facilities, and several galvanized-iron cans. The carpenter shop and lighting unit are also located in a corner of this tent or hut.
The evacuating section may be in huts or tents and should have racks for litters to the number of 250, and the simple furnishings of a ward. A few nurses and ward masters are sufficient for its conduct, as the majority of patients are capable of helping themselves to some extent.
Notice of psychiatric cases should be sent to the train commander in order that they be afforded such segregation on the train as possible, and infectious cases should be placed in the compartment set aside for such patients. Weapons of every sort must be taken from all patients who are to be evacuated and turned over to the salvage officer, the owners being informed of the fact. This procedure is most important if regrettable incidents are to be avoided. The entraining area should be placed under police control to prevent unauthorized persons from boarding trains and to regulate road traffic during the period of entrainment.
The salvage officer and his assistants find an enormous accumulation of Government property at the triage, bath and operating sections daily, and he has this listed according to service and taken to the nearest salvage dump or depot.
Next to litter bearing, the preparation of graves is the hardest duty which an evacuation hospital has to perform; and as the personnel is barely sufficient to meet strictly professional demands during a "push," it is incumbent upon the commanding officer to solicit aid from near-by labor troops, or enemy prison camps if the hospital is 25 km. behind the line, or in any other way to secure the personnel necessary to dig the number of graves estimated. For esthetic reasons as well as for the sake of morale it is necessary that the dead be buried promptly.
Evacuation hospitals should be permanently equipped with interphone systems. In every case the chief signal officer (army) must be advised of the location in advance and request for trunk connection made, as it is imperative that the hospital be in communication promptly.
Experience demonstrated the impossibility of an evacuation hospital functioning to the standard necessary unless equipped with a portable electric generator in duplicate for both lighting and the activation of the X-ray.p The acetylene flame is not the equal of ordinary illuminating oil, for it ceases to be of use after four hours, and the atmospheric jar of a field gun or bursting shell invariably extinguishes it. The triage, operating department, and offices at least should be electrically lighted, as the greater part of the work in these hospitals is performed at night.
Every evacuation hospital should be equipped with heavy painted canvas ground sheets on a basis of three to a tent, as it often is necessary to hurriedly erect tentage on wet or dust-covered ground, and timber for floors is seldom obtainable.
When a commanding officer receives orders to move to a new location it is
his duty to ascertain as promptly as possible from the coordinating section
(army) the railhead at which he will draw rations at the new location.
p A special electric generator and lighting unit for an evacuation hospital has been provided.-Ed.
THE ARMY MOBILE LABORATORY
(Numbered from 1 up)
The brief stay of the wounded in evacuation hospitals rendered laboratory equipment at first supplied these units very excessive, and for this reason the question of utility has been considered, with the result that marked curtailment of laboratory equipment has been effected, as explained above, under "Evacuation hospitals." The consensus of opinion was in favor of one large, well-equipped mobile laboratory in the proportion of one to an army, to be located in the vicinity of the army ambulance park and the army medical supply depot, for facility in supply and transportation.q
Equipment should be elaborate enough for all requirements of field laboratory work and yet capable, even with a special ward tent, of being transported upon two trucks. As freedom from dust and dampness are important, advantage should be taken of existing buildings, tentage being used only in case of necessity, and personnel should be billeted. Messenger service for the collection of specimens should be furnished by the army ambulance park, use being made of ambulances and motor cycles of companies in rest.
THE SANITARY SQUAD
A sanitary squad is a small services of supply unit required in the proportion of two and one-half per division for the maintenance of sanitary apparatus and instruction in its correct usage, its members being familiarized with the routine of sanitary inspection in relation to the care of latrines, water supply, preparation of food, suitability of billets for occupation, the disposal of wastes, including horse droppings, diseases among the civil population, especially those of a communicable nature. Every member of the squad should be required to keep a thoroughly posted notebook with all the necessary information for the unit commander to make a report to the officer responsible for defects, with recommendations for remedy, and to sanitary inspectors if responsible commanders fail to take action.
In practice it is found that units within the zone of the armies function best under the chief surgeon advance section area. If these units are assigned to combat areas their activities may best be controlled by the army sanitary inspector. If such assignments are found necessary, one squad to each division gives a force sufficiently large to meet the requirements of the sector occupied. For administrative convenience the area should be divided into sections by vertical and horizontal lines, each section being assigned to a squad, which is held responsible for maintenance of sanitation within its particular section and also for the equipment installed.
The major portion of these units will be required in the services of supply at hospital centers, base ports, etc. It must be made plain to all that the duties of a sanitary squad do not contemplate the performance of police duty, as this is part of the routine work of troops occupying the area, and that the members of this squad are really inspectors and instructors. The sanitary squad is, however, responsible for maintenance of sanitary apparatus and to that end should possess the necessary tools and a suitable place in which to make or repair the simple appliances used in the field.
Upon detection of a sanitary defect that is remediable, the unit commander should inform the responsible officer, recommending the remedy, and only in the event of the failure of this officer to make correction should report be made to the sanitary inspector.
The commander of the unit should be both resourceful and tactful and should keep himself thoroughly posted upon all matters of sanitary and local interest, in order that he may be in a position to give full information to the commanding officers of newly arrived commands.
* * * * * * *
q An army medical laboratory of a mobile type is assigned to each field army. See Tables of Organization 286-W.-Ed.
BASE SECTION CHIEF SURGEON'S OFFICE
A medical officer with the rank of colonel will be recommended by the chief surgeon of the forces for the duty of chief surgeon of each base section. Officers so detailed should have had long administrative experience and should possess a thorough knowledge of sanitation and epidemiology. Selection for these positions should be made from among those of known organizing ability.
The size and importance of base sections vary with the port facilities which they contain and the rapidity with which the expeditionary force is reinforced. Development of facilities within base sections is dependent upon the distance from them to the fighting line. Establishment of a port within a base section may in itself constitute a combat problem, in which case the service of the rear will develop only as fast as is permitted by advancement of the combat forces. Unless a base section, and port facilities therefor, be taken over complete from an ally, it is reasonable to assume that these projects will develop gradually.
Base sections should be under command of a line officer, usually of the rank of brigadier general. Each base section should be organized along the lines of the services of supply group in general. The staff, therefore, of a base section commander consists of a chief of staff, a general staff, and administrative and technical assistants. The administrative, intelligence and coordination sections are the only sections of the general staff represented at the headquarters of base sections. The base section chief surgeon is a member of the administrative and technical staff of the section commander, and as such is his adviser upon all questions connected with the sanitary service of the section. The chief surgeon should be represented in the general staff sections by a medical officer detailed to the administrative and coordination sections. Officers so detailed should be possessed of tact and ability and familiar in all details with the organization of the sanitary service of the section and the stage of completion of the various projects connected therewith. These officers must be acceptable to the chief surgeon and to the chief of the general staff section to which detailed if they are to be of value to the staff and at the same time really represent the chief surgeon of the section. These officers are detailed for the purpose of giving and receiving technical information with reference to the Medical Department and under direction of the chief of the section they coordinate the work of their own departments with that of others. The officers should be members of the Medical Corps and not detailed to the general staff.
Just as the section in general is organized along lines similar to the services of supply, so the chief surgeon's office of a base section is organized in a manner similar to that of the office of the chief surgeon of the forces (q. v.). The chief surgeon of a base section should so organize his office as to be free to circulate, within the section, among his various and well dispersed activities. Not only is he responsible for the correct functioning of his office proper, but he exercises supervisory control over various Medical Department activities such as hospital centers, camp hospitals, the attending surgeon's office attached to headquarters, the embarkation-debarkation camps or centers, ambulance companies, sanitary squads, medical supply depots and storage stations, medical laboratories, veterinary units, leave areas, and the Medical Department detachments attached to the various services of supply battalions or regiments.
In the absence of the chief surgeon he is to be ably represented by his first assistant, who is in all respects his understudy. This officer will have been selected for the position by the chief surgeon from amongst officers of his own organization and preferably will be one who has had experience in several of the important divisions of that office. He should have the rank of lieutenant colonel and should be a member of the Medical Corps.
The administrative section of the office should be headed by a field officer of the medical executive service, assisted by the necessary noncommissioned officers and enlisted men. He assumes the responsibilities of detachment commander for the Medical Department enlisted men on duty in the office of the chief surgeon and should have entire charge of all transportation assigned to the office from the local pool. He establishes a complete office
of record, with all necessary blank forms, equipment and files. A mimeograph and an adding machine are essential items in this equipment. Within the record office there should be maintained a pool of stenographic and typist help for general use throughout the office. Reports, correspondence, etc., going to or coming from the various divisions of the office are transmitted through and coordinated by the administrative division of the office.
In addition to the administrative division the staff of the section chief surgeon consists of professional or technical assistants and those whose duties are largely administrative. Those of the former class are as follows: Foreign liaison; general surgery; general medicine; orthopedic surgery; supervisory dental surgeon; naval liaison.
The divisions of the administrative class are as follows: Personnel; evacuation; sanitation; hospitalization; property and finance.
Administrative divisions of the office are further divided into sections, the most important of these being the embarkation-debarkation service section of the sanitation division. Activities of this section will be covered, with personnel and organization thereof, under a separate heading.
TECHNICAL AND PROFESSIONAL GROUP
Should a base section be established upon allied territory, thereby making use of foreign ports, it becomes necessary to establish immediately a reciprocal liaison with the various groups of allied forces present. Through the central liaison office the chief surgeon of the forces should request the assignment of the requisite number of medical officers from the allied army concerned, detailing upon request of these forces officers from his own office to represent him whenever necessary with the allied forces in question.
The foreign officer detailed to assist the base section chief surgeon should be familiar with the details involved in a large embarkation-debarkation problem and with the organization and personnel of the local governing powers. All divisions of the office coming in contact with allied local military or civil functionaries should maintain close and tactful liaison with the foreign representative detailed to the office of the chief surgeon of the section. This applies particularly to the evacuation service and the sick and wounded and epidemiological sections in their relations with local boards of health with reference to the movement of communicable disease curves.
An officer of the Medical Corps experienced in general surgical procedure should be detailed from the consultant body by the director of professional services, chief surgeon's office. It is the duty of this officer to standardize and supervise the work of general surgeons throughout the sanitary service of the base section. He is the adviser of the section chief surgeon upon all questions relating to general surgery. He is empowered to investigate the sufficiency of surgical personnel and matériel throughout hospitals of the base section, making necessary reports and recommendations to his chief upon completion of an inspection tour. In this work all consultants are expected to correct minor defects upon the spot, without recourse to correspondence. The granting of such authority, however, requires that only officers with mature judgment and tact be assigned the duties in connection therewith. Consultants should observe the results of triage in the forward hospitalization echelons by noting the percentages of cases arriving within base sections that properly should have remained within the zone of the armies. This procedure, with the necessary reports, will materially assist in the efficient administration of the sanitary service in forward areas.
The duties, jurisdiction, etc., of this office and that of general surgery are analogously constituted, differing only in the different nature of the professional work involved. It is the duty of the officer detailed to this work to carefully supervise the after-treatment of toxic gas cases. Should the number of cases warrant, assistants who are experts in psychiatry and diseases of the lungs should be assigned.
What has been said upon the duties, etc., of consultants in general medicine and surgery aptly applies to such a detail for the division of orthopedic surgery. Like all consultants on duty in base sections, the officer detailed to this work concerns himself with supervising the selection of cases for evacuation to home territory and to the rapid elimination of the unfit in incoming drafts prior to the necessity of hospitalizing such within the zone of the armies with attendant embarrassment of the bed situation in that zone. The consultant in orthopedic surgery carefully supervises and standardizes the methods of application of all orthopedic splints and appliances. He should observe and report upon all evident failures in this respect in areas outside of his section as indicated by the condition of such cases arriving upon hospital trains from the front, following active engagement of combat forces.
SUPERVISING DENTAL SURGEON
This division of the office should be under a lieutenant colonel of the Dental Corps empowered to act for the chief surgeon of the section in all matters relative to the maintenance of an efficient dental service throughout the base section and the hospitalization units contained therein. He investigates the sufficiency of personnel, supplies, and equipment and passes upon requests for replacements of both personnel and matériel checked over to him from the personnel or matériel divisions. He supervises the activities of the dental surgeons of outlying and detached organizations, insisting upon their proper performance of the required inspection of teeth of the members of incoming drafts. Base sections should have assigned to them an adequate number of dental surgeons to properly complete necessary reparative dental work on troops intended for forward areas, thus precluding, as far as possible, the necessity for other than emergency dental work with combat units at the front. The major part of this work should be done in the camps or centers of the embarkation-debarkation service, and equipment should be sufficiently elaborate to cover the need fully.
A naval medical officer, a member of the staff of the naval port officer, should be detailed to act in liaison with the office of the chief surgeon of the section. This officer must be fully cognizant of the general situation at the ports and familiar with the needs of the Army and with the facilities which the naval authorities have to offer. It should be his duty to transmit information relative to the suitability and capacity, for patients, of all ships operating under naval control and having such facilities. Such data will clearly indicate numbers of the various classes of cases which can be transported.
When a board of officers is appointed to determine questions relative to suitability and capacity which may have become controversial, the naval liaison medical officers, with proper representatives of the chief surgeon's office, should be detailed to such boards. These officers should transmit to the proper office all details relative to the arrival, departure, destination, change in plans, etc., with reference to all patient-carrying transports. As it is manifestly impossible for naval authorities to maintain Medical Department personnel and matériel in sufficient amounts to care for all the sick on board ship, it is the duty of the naval liaison medical officer to transmit requests to the personnel and supply divisions of the office for additional medical officers, nurses, and enlisted men and for such supplies and equipment as may be needed to meet all conditions.
THE ADMINISTRATIVE DIVISIONS
The personnel division of the office should be under the direction of a field officer of the Medical Corps, assisted by one officer of the medical administrative service and by a member of the Army Nurse Corps acting as supervisor of the nursing service of the section. This force should be augmented by the requisite number of noncommissioned officers and men for the numerous administrative and clerical duties connected with the office. The division should be subdivided into sections dealing with orders and assignments, qualifications and classification, and records and reports.
The subsection dealing with orders is concerned mainly with drafting orders necessary properly to shift Medical Department personnel amongst the various activities of the base section. Chief among these assignments are those to naval transports above described. Should it be found necessary and possible to establish a Medical Department casual camp as a personnel pool, this unit will be administered and supervised by the section chief surgeon through subsections of the personnel division. Assignments and requisitions for replacements of personnel should be passed upon by the orders and assignments subsection, which will be assisted in that work by the detailed data relative to the classification, qualifications, etc., of the individuals concerned, compiled in the section devoted to this work. Routine reports, special reports, records, etc., relative to Medical Department personnel are prepared, filed, forwarded, or transmitted, as the case may be, by the office force of the records and reports subsection.
The supervising nurse maintains close touch with the entire nursing service of the section, including the facilities provided for the shelter, subsistence, amusement, and recreation of the members of the Army Nurse Corps. It is important that the nurse assigned to this important position be well equipped in tact and possessed of broad vision and knowledge of human nature if she is to succeed in a position fraught with so many difficulties and delicate situations. Every possible assistance should be afforded the various aid societies in their efforts to increase the comfort, and thereby the contentment, of the nursing personnel.
This division of the office is responsible for the organization, maintenance, and supervision of the entire evacuation system within a base section. The chief of this division should be an officer of exceptional qualifications if he is to succeed in organizing and administering a service of this magnitude, and he should be a field officer of the Medical Corps. He should be assisted by two officers of the medical administrative service and the necessary number of noncommissioned officers and enlisted men of the Medical Department. In no other division of the chief surgeon's office is it so necessary to maintain careful coordination of the work with that of all other divisions as in the evacuation division. The work of this office is intimately associated with that of practically every other activity, and the development of a smoothly working machine requires the establishment of excellent liaison affecting particularly the professional and technical divisions and those of hospitalization, personnel, and sanitation (embarkation-debarkation service). The work of this office will be divided amongst the subsections of transportation, records, reports and statistics, and schedules.
The transportation subsection controls all Medical Department transport units such as ambulance companies, hospital trains, barges, etc., available and in use in the evacuation system. It makes all assignments of ambulances and motor-cycle side cars in accordance with Tables of Organization or equipment manuals, due consideration being given to available reserves upon these items of equipment. In cooperation with the records, reports, and statistics section, accurate card records should be maintained, covering transport units available. These records indicate the personnel assigned, United States numbers of vehicles or trains, location, periods of service, state of repairs, consumption of fuel, etc., and should be constantly kept up to date. All reports required by higher authority, and requisitions for replacement relative to transportation should be prepared in this office.
The statistical office consolidates information received in reports from the various offices of the base section relative to the subject of evacuation. Such reports are sent to it by hospitals and hospital centers and by the superintendents of the Army Transport Service and railway transportation office. After consolidation of this data the schedules section is in possession of information regarding cases for evacuation and concerning facilities available for accomplishing the movement. Necessary schedules are prepared and needed instructions for filling requisitions sent to the hospitalization unit affected. All transportation units concerned and railway or shipping offices should be notified at the same time concerning details of intended evacuations, train schedules, loading and unloading points, time of arrival or departure, and time and place of arrival and departure of the ship which it is intended to have used.
Where an ambulance service between hospital and ship or train is required, the necessary instructions should be issued by the transportation section following conference with the schedules section. Arrangements should be made within the evacuation division to organize and supervise the checking out of patients baggage, records, and valuables. If this be well systematized and carefully supervised embarrassing complaints will be minimized.
After final disposition of evacuables, detailed reports relative to evacuations should be made to the chief surgeon of the forces through the administrative section of the general staff of the base section. This data is used as the basis of cable reports to embarkation authorities in home territory.
Should there be patients requiring special treatment or consideration upon shipboard, such details should be taken up with the naval liaison medical officer for adjustment and the patients not evacuated until proper arrangements have been completed.
This division should be under the direction of an officer of the Medical Corps with the rank of lieutenant colonel, with organizing ability and trained in epidemiology and practical field sanitation. He will succeed largely through his ability to meet and get along with other officers not members of his own corps, and through his ability to handle men. He must, therefore, have tact and force and also possess vision and imagination. Officers who lack the elements of compromise should be detailed to such position only when their manifest advantages outweigh this serious shortcoming.
The officer in charge of the division of sanitation needs in his work the assistance of three district sanitary inspectors of the rank of majors, and the officers in charge of the various subsections of his office. The total personnel allowed this important division can be seen at a glance by consulting the organization chart for the section chief surgeon's office, and that for the embarkation-debarkation service section of the sanitation division.
The district sanitary inspectors are field officers of the Medical Corps. Actual organization of sanitary inspection work, including the districting of the section, supervision of sanitary squads, etc., is decentralized to these officers. They must completely cover the area to which assigned, carefully investigating water and food supplies, kitchens and mess facilities, ventilation and heating within shelter, bathing, laundry and disinfesting facilities, and, in general, the environs of all inhabited areas, civil or military, in a searching quest for either public nuisance or sanitary menace. Once discovered, the hygienic defect should be followed up with recommendations and repeated inspections until corrected. In this work sanitary squads are the assistants to district inspectors.
The subsections of the division are as follows: Food and nutrition; epidemiology; embarkation-debarkation service; urology; laboratory service.
The embarkation-debarkation service is covered by separate text under appropriate heading.
FOOD AND NUTRITION
This office is controlled by a field officer of the Medical Corps or the medical administrative service (allied science branch). He is assisted by an officer of the administrative branch and by the necessary enlisted stenographers. The officer in charge of the section should be a trained practical food expert, and his activities confined to organizations within the base section and to ships plying between home territory and the ports of the section. He should direct his efforts toward the practical improvement of all food and messing facilities and the conservation of foodstuffs, developing to the utmost the salvage of waste. His activities should not be confined to casual investigations and inspections, but he should give practical demonstrations and instruction in the kitchens of the various commands. Food and nutrition experts should be prepared at all times to decide questions arising in connection with the sufficiency of the army ration.
This office is concerned with statistical records of epidemic diseases, the standization and supervision of methods of control thereof, and those details relative to sick and wounded reports which it will be necessary for the chief surgeon's office to handle.
Through the office of the foreign liaison officer this office maintains liaison with the local health authorities, each reciprocating with necessary information relative to outbreaks of communicable disease and progress made toward the elimination thereof.
Charts and graphs showing prevalence, case incidence, location, noneffective rates and similar information with reference to sickness and injury of troops within the section are to be maintained in this office.
An officer of the Medical Corps with known ability in the prevention and care of skin and genitourinary diseases should be in charge of this section. The detail will ordinarily be made by the director of professional services, chief surgeon's office, and the officer so detailed becomes the section consultant in urology, but be functions directly under the sanitation division, since his problems are so intimately connected with those of sanitation and hygiene. He standardizes the methods of prevention and treatment of all diseases under his specialty. He investigates fully all sources of infection and makes the necessary recommendations toward eradication of such sources whenever discoverable. He should maintain "spot maps" indicating cases and sources, and should be prepared to take the most energetic steps when unusual percentages appear in connection with any locality or command.
The section urologist should personally investigate the sufficiency and adequacy of both personnel and matériel for the prevention and treatment of skin and venereal diseases. Where shortage exists in matériel or there is inefficiency in personnel charged with this work, he should make report of the same to the chief of his division, recommending the necessary action. He should devote a considerable part of his time to the development and execution of a plan for liberal instruction of the members of the command with reference to the social evil and its connection with noneffective rates. Dealing as he does with a disease that walks by night, and confronted as he is at every turn by obstacles seemingly thrown in the path by Mother Nature herself, he needs to be fearless and bold if he would reap even a measure of success in his truly philanthropic task.
A trained laboratory expert who has had administrative experience should be detailed to the charge of this section of the sanitation division. He should be a field officer of the Medical Corps, assisted by one Medical Department sergeant. The base section Medical Department laboratory (stationary unit) should be attached to the office of the section chief surgeon, and the activities of this unit, its personnel, function, etc., supervised and coordinated through the division of sanitation. The laboratory service sub section acts as liaison between the director of laboratories of the office of the chief surgeon of the forces and the entire laboratory service within the base section.
All laboratory methods and technic should be standardized and supervised by this office, with the advice and assistance of the officer in charge of the section laboratory. The two should work in close cooperation with the other subsections of the sanitary division. Laboratory work connected with special sanitary investigations or of a routine character for all commands, other than hospital centers and base hospitals, are to be performed by the section laboratory. Units having laboratory facilities should complete their own examinations. Exception to this rule will be made, in the interests of uniformity in result, in the case of Wassermann reactions or of such other examinations requiring specialized apparatus or technic. This work should be carried on within the section laboratory.
From such data as it may possess the laboratory service should assist other divisions or sections of the office in the preparation of graphic charts dealing with epidemic diseases, etc. Routine reports, etc., required by the chief surgeon of the forces and higher authority will be prepared in this office.
BASE SECTION EMBARKATION-DEBARKATION SERVICE
Medical Department personnel attached to the embarkation-debarkation service at base sections is controlled through the division of sanitation. The service usually consists of one or more large concentration camps or centers conveniently located as regards the base
port. Each camp or center should be under the command of a line officer, he to have as a member of his staff a medical officer as the camp or center surgeon. The surgeon of an embarkation-debarkation camp bears the same relation to the commanding officer of the camp as a surgeon to the commanding officer of a garrison, with other duties imposed by the arrival or departure of troops and casuals. His duties are manifold and he must be both energetic and resourceful and should so organize his office as to be free from a mass of routine, and should employ his time in a supervisory capacity over police and sanitary activities of his camp. His office is organized with the following divisions:
This important division coordinates the duties of all office divisions, checks communications coming into or leaving the office, prepares all papers for the surgeon's approval and signature, and receives, distributes, and censors all mail. The administrative division is subdivided into two sections: Detachment, dealing with the enlisted personnel on duty in the office and the records pertaining thereto; mess, dealing with conduct of the messes for Medical Department personnel, enlisted personnel and, if conditions warrant, for officers as well.
This division conducts the pharmacy (which should be well stocked), maintains a place for holding sick call, the attendance upon which will be large by reason of the large number of troops arriving and departing (and in this connection a medical officer with the necessary attendants must be on duty at all hours), and is the location for the prophylactic station, which must be adequate and open day and night.
Space should be allotted within the dispensary for dental sick calls and treatment room. Dental officers should be provided in these locations without regard to rate per thousand. All possible emergency and reparative work must be completed here prior to troops leaving for the front or for home territory.
This important division should be under an officer qualified in physical examination, the conduct of disinfestation and bathing establishments, and the detection of venereal or other communicable skin diseases. His office is subdivided into the following sections:
Examining teams.-The duties of this section are of great responsibility in that it is the point at which the separation of the fit from the unfit is inaugurated and diseases that would be a menace to the forces in the advance detected, at the same time being the proper place for examining home-bound troops, to sort out venereals and those having other diseases which would be a menace to the homeland.
Bath teams, which conduct the bathing and disinfestation establishments through which all troops bound for home must pass, and on occasion those arriving from the homeland, as vermin in wartime are found in abundance on all military routes of travel. This personnel also supervises the laundry establishment of the camp or center.
Train teams, which are concerned with meeting every train filled with the sick and wounded to be embarked, to examine all cases which give evidence of unfitness for further travel, and to render any medical assistance needed in case of sudden sickness or injury among arriving or departing troops. The personnel of these teams also accompany troop trains for the purpose of medical attendance.
Dock teams, which are primarily for detection of the unfit among arriving troops, and secondarily to render medical assistance to all at the piers, including crews of vessels if desired. In evacuations this personnel makes the last inspection of sick and wounded prior to their embarkation for home territory.
Venereal teams, which examine all incoming and outgoing troops for the detection of venereal and contagious skin diseases, and provides for the treatment of such cases as are detained, and for the immediate transfer of others to the designated hospital.
This division is concerned with the sanitation of the entire camp and its environment, policing being given special attention, since the last place observed leaves a lasting memory with those departing for home or for the front. Barracks, billets, huts, or tents must be maintained in a state of scrupulous cleanliness, marked attention being given to latrines, ventilation, and heating. Kitchens and mess halls should be inspected daily and sanitary defects corrected on the spot, under authority of the camp commander. Food handlers should be examined frequently for detection of possible "carriers." The disposal of garbage and waste should be perfect in every detail, as well as the disposal of manure, not only to prevent fly breeding but also to afford an object lesson in sanitary policing. Drinking water supplies must be well protected, and if chlorination is required, daily tests must be made for its sufficiency. Water and food containers must be perfectly cleaned daily. If the location is malarial or mosquito breeding, steps should be taken to eliminate the cause, if humanly possible.
This division of the office of the base section chief surgeon should be under the control of an officer of the Medical Corps, with the rank of lieutenant colonel. He should be assisted by two other field officers of the Medical Corps and one officer of the medical administrative service. The officer in charge of hospitalization should be a man trained in hospital work in all its details, including those of the administrative and constructive branches as well as those of a professional nature.
In large expeditionary forces (two or more armies) it will be necessary to decentralize hospital control, except that of hospital centers, to the office of section chief surgeons, thereby relieving the chief surgeon of the forces of an infinite amount of details. At the same time this decentralized control should be exercised only in carrying out the policies of the chief surgeon of the forces, which will be, for the section concerned, part of a grand scale hospitalization plan. This office must therefore remain at all times in close touch with the mother group in the office of the chief surgeon of the forces. The division is organized into the subsections of inspection, construction, and retrenchment.
The inspection section is concerned with investigation of the administration, internal economy, discipline, efficiency, and supply of the hospital units within the base section. In so far as hospital centers are concerned, their control by the base section surgeon's office is confined to the supervision of their sanitation and to fire protection. In cooperating with the evacuation division this section investigates the efficiency of the evacuation system as developed by the individual units in an effort to further standardize all such activities.
New sites for hospitals will be inspected and passed upon by the section prior to their being recommended for acceptance, and in cooperation with the construction section frequent inspections and reports thereon will be made as construction upon these sites progresses toward completion.
The construction section is directly concerned with the completion of hospitalization projects authorized for this section. Plans prepared in the office of the chief surgeon of the forces and turned over to the constructing service for completion will be followed as closely as possible, but varying conditions in localities may demand that modification be made in these accepted plans. All such approved modifications will be reported to all offices concerned, and thereafter contractors or builders will be held to the new specifications.
Authorized repairs or additions to completed projects should be carefully supervised by the construction section and retained files of plans brought up to date in conformity with the change effected.
The retrenchment section prepares, in advance of need therefor, a systematic plan for the gradual reduction of hospital facilities within the section. This is of great importance when buildings and sites have been utilized within the territory of a foreign country, for upon conclusion of hostilities demands for such shelter are sure to be made, and for reasons of international comity, at least, these must be diplomatically received and considered.
When active retrenchment begins, this section takes over the function of transferring again to civil control, foreign or otherwise and in accordance with the prearranged plan, hospitals, buildings, sites, etc., as they can be spared and vacated.
In the case of transfer of buildings, equipment, etc., from military to civil control, the process must be formal and complete and will be accomplished in cooperation with the inspection section and the rents, requisition, and claims department of the services of supply.
PROPERTY AND FINANCE
A field officer of the Medical Corps, assisted by an officer of the medical administrative service and the necessary noncommissioned officers and enlisted men of the Medical Department, controls this division of the office of the base section chief surgeon. This force receives and visas all requisitions for equipment and supplies from Medical Department units or attached organizations within the base section.
Every base section should have at least one full stock issuing medical supply depot, under control of the section chief surgeon's office and established to cover local distribution needs. Upon the 15th and last days of every month these depots should render a complete stock-balance report to the property division. It should also be required that for its information a duplicate of all similar reports made to the central control office by base storage station be made to the section chief surgeon's office. Requests for initial equipment or other requests involving carload lot shipments of the heavier or bulkier items will be, whenever this is possible, visaed and relayed to "controlled stores," chief surgeon's office.
Requisitions from issue depots of the section must be passed upon in the supply division before being forwarded to the central control office in the office of the chief surgeon of the forces. Such requests may be filled either wholly or in part by diverting the necessary matériel, in original packages, from the stream of matériel flowing into base or interior storage stations. This contingency is provided for by blanket authority for such action to base section chief surgeons.
For the information of the central control office, the supply division will carefully supervise the management and stocking of base storage stations and the activities of Medical Department dock representatives, although for administrative purposes such organizations are directly under control of the supply division of the office of the chief surgeon of the forces. All correspondence, however, from this higher control to the storage stations, should, in the interests of good coordination, pass through the office of the section chief surgeon.
Under blanket authority this office should be permitted to approve emergency purchases of medical supplies or equipment up to a definite and fixed limit (usually $250). This granting of authority presupposes due consideration being given stocks in depots, outside the section, before issuance of a request for the authority to purchase as "emergency." Such information is available by use of the ordinary means of communication.
With reference to finance, this office maintains liaison with the finance and accounting division of the office of the chief surgeon of the forces and should audit accounts referred to above under emergency purchases. Hospital fund statements should be examined, corrected and approved, and proper final disposition made thereof in this office. Should a medical disbursing officer be found necessary, he should be located and operate under the division of property and finance.
THE CORPS SURGEON
The corps surgeon is the adviser of the corps commander in all matters of sanitary interest arising within the corps, and controls under the authority of the corps commander the sanitary units assigned the corps through the commander of the sanitary train,r his duties being both administrative and tactical; he prepares the sanitary paragraph of the corps battle order based upon the army battle order when the corps is operating under army control, and independently when the corps is operating alone.
The corps surgeon supervises the location of the mobile surgical hospital (corps), these locations having been previously tentatively selected by the director of field hospitals, due regard being given safety from direct fire, roads to front and rear, relation to divisions of
r Each corps surgeon has under his immediate control 1 medical regiment belonging to the corps troops. See Tables of Organization 81-W.-Ed.
the corps in line of battle, water and fuel; he announces to the army chief surgeon and to the division surgeons the location of these mobile surgical hospitals (corps), and sees that the roads leading to them are conspicuously marked by signs both to the front and rear for the direction of ambulance drivers.
He transmits important sanitary communications from the divisions and corps troops to the army chief surgeon, or directly to the next higher medical authority in the absence of army command; he supervises the work of the division surgeons and sees that divisional units are correctly located for the most effective service; he concerns himself with the sufficiency of sanitary supplies, equipment, personnel, and transportation within both the corps and divisions; he maintains close liaison with the division surgeons operating under the corps on the one hand and with the army chief surgeon on the other.
He assumes charge of any epidemic within the corps area, under the authority of the corps commander, either among the military or civil population, and also within the divisional areas when the division surgeons fail in control, himself calling upon the army chief surgeon for assistance in the event of his resources being overtaxed; he directs the activities of the consultants assigned his office, and especially through the director of field hospitals, the activities of the mobile surgical hospital (corps) where the consultants find their greatest field of usefulness. He maintains no office of record beyond a loose-leaf file, and diary (data for his final report), and a card index of commissioned medical personnel within the corps or divisions of his corps; his office must of necessity be mobile and the furnishings so simple that all can be moved upon one 3-ton truck upon short notice.
The director of field hospitals and ambulance companies perform the same duties outlined for the divisions (q. v.), the director of field hospitals being mainly concerned with the conduct of the hospitals for nontransportable wounded in which duty he is assisted by the consultants.
The duties of the remainder of the office force are similar to those in the office of the army chief surgeon and need no comment.
MOBILE SURGICAL HOSPITAL (CORPS)s
(Numbered from 1 up)
In order to provide for the class of battle casualties known as nontransportable wounded it is necessary to provide a well-equipped, standardized surgical hospital that is easily transportable, and can be brought forward close to the division field hospital used as a triage, to provide prompt surgical care for these cases and obviate a long ambulance haul to larger hospitals placed of necessity further to the rear. The addition of a complete operating equipment to any division field hospital, besides being difficult of transport with a division, offers the further objection that once the hospital receives severely wounded it becomes immobilized. In order to properly function and to keep contact with the division the field hospitals must not lose their mobility.
There has been provided, therefore, for the nontransportable wounded, one modified field hospital, with standardized X-ray, electric lighting, sterilizing, and surgical equipment in the proportion of one of these surgical hospitals for each combat division in the corps.
Experience has effectually disposed of the fetish born of the long period of indecisive trench warfare to the effect that a wounded man must be immediately operated upon. Adherence to this idea can only result in the unnecessary death of many, since the shock of operation will be superimposed upon that of trauma. The question of how far a wounded man may be transported with safety is an open one, but if rest and shock treatment be given before the journey is begun the man will bear transportation to the mobile surgical hospital (corps) where facilities obtain for further shock treatment if necessary, and the majority of cases will arrive in condition for early operation.
To each corps there is assigned a medical officer of the rank of major as a director of the mobile surgical hospital (corps). He will be under the direct orders of the corps sanitary train commander, or, in his absence, the corps surgeon.
sSurgical hospitals are army units placed at the disposition of the corps surgeon for the purpose outlined under this heading. See Tables of Organization 284-W.-Ed.
Each mobile surgical hospital (corps) is commanded by a medical officer of the rank of major who functions under the immediate orders of the director of the mobile surgical hospital (corps) or, in his absence, under the orders of the corps surgeon.
These mobile hospitals are sent to the army area to be under the control of corps surgeons. They will be provided in the proportion of one to every combat division in the corps.
These hospitals are placed in the corps or division area according to the orders of the corps sanitary train commander to the director of corps field hospitals, to be located where they can provide immediate care for the divisional nontransportable wounded. They will be placed as close to the division triage as possible. They must not be placed too far forward when there is a possibility of a sudden retreat, and care must also be exercised that they are not placed in direct range of enemy artillery.
The evacuable operated wounded are transported to the evacuation hospitals from the mobile surgical hospital (corps) by ambulance companies under orders of the corps surgeon, assisted by the army ambulance service assigned to evacuation duty when requested.
The surgical consultant assigned to the corps is responsible for the proper performance of the surgical work in these hospitals.
If the departure of divisions from the corps area leaves an excess of mobile surgical hospitals (corps), the fact will be reported by the corps surgeon to the chief surgeon of the army, who will issue orders for the proper reassignment of the hospitals.
These hospitals, being designated in the battle order for the reception of nontransportable wounded, are expected to receive only that class of casualties. Should poor triage in the divisions result in sending transportable wounded to this hospital, report will be made at once to the corps surgeon for its correction.
A mobile surgical hospital (corps) should have the following departments: (1) Receiving, triage or sorting; (2) shock ward; (3) X-ray department; (4) operating room; (5) pharmacy, laboratory, dental; (6) mess (patients, officers, nurses, enlisted personnel); (7) evacuating; (8) office (commanding officer, adjutant, quartermaster); (9) morgue.
For the general functioning of the hospital see the part on the evacuation hospital, the organization and work of the surgical department there being similar. The mobile surgical hospital (corps), under canvas, will occupy 22 tents and will have a capacity of 250 patients.
THE DIVISION SANITARY SERVICE
The surgeon of the Infantry or Cavalry division must have the rank of colonel, and the officer selected for this duty must not only be energetic and zealous but possessed of tact and a broad knowledge of sanitary tactics and administrative duties.
He is the adviser of the division commander upon all questions of sanitary interest, and in his administrative capacity controls the sanitary activities of the organizations and units composing the division and the activities of the voluntary aid associations attached.
He inaugurates and maintains a schedule of training for the entire sanitary personnel of the division, and this schedule should be begun when the division is formed and continued to the time of entry into combat.
He maintains no office of record beyond a loose-leaf file, diary, and card index of the sanitary personnel of the division.
All official communications relating to the sanitary service, whether to or from the organizations and units of the division, are referred to him for action. He is responsible for the prompt and accurate preparation of casualty reports and the inspections of the divisional organizations and units to insure preparedness for combat and compliance with sanitary regulations; he systematizes and maintains the entire sanitary service for such medical and surgical care as the divisional facilities afford the sick and wounded and provides for the necessary transportation to insure the prompt evacuation of all cases in a condition to bear transportation; if suitable buildings exist, he will assign such equipment and personnel as are necessary to convert the buildings to hospital use, in this manner conserving his tentage; he makes provision for the disposition of the sick and wounded of the division on the march,
in training, and in combat, making use of all facilities to free the command of noneffectives and maintains the entire sanitary service in the highest degree of mobility; he is responsible for the timely rendition of requests for replacement of personnel and requisitions for matériel, which includes those for transportation.
To be in perfect liaison with the general staff of the division the division surgeon must have a medical officer detailed who will be attached to the administration section where he will be in a position to gain accurate information of all matters relating to the sanitary service and transmit this information promptly to the division surgeon, whose engrossing duties do not permit him to remain in an office during combat.
The sanitary paragraph of the battle order is prepared by the division surgeon and based upon the corps battle order unless the division is operating independently, and submitted to the division commander for approval and incorporation in the divisional battle order. This memorandum will show the location of the aid stations, the triage, the field hospitals, the ambulance companies, the litter bearer battalion, and the medical supply dump, the plan and routes of evacuation to the aid stations, triage and field hospitals, and the disposition of cases as sick, wounded, or gassed. If time affords, a road sketch showing the above data should be prepared and submitted to the division commander and the corps surgeon, though the latter must always be given the location of the divisional aid stations and sanitary units in either a formal or informal manner to insure coordination with the sanitary service of the corps.
During combat all changes in location of the divisional sanitary units must be promptly notified to the corps surgeon, as must also preparations for an advance or retreat, and this information must be sent by a trusted officer who is personally known to the corps surgeon and who must be prepared for this service at all times.
The division surgeon must see to the enforcement of orders to the effect that all ambulances carry a sufficient number of blankets, litters, splints, hot-water bags, etc., to replace those taken from the aid stations with the sick and wounded, and that the triage and field hospitals maintain a supply of similar articles to replace those turned over by the ambulances to the hospitals with the patients, in this manner insuring automatic replacement.
In campaign there are assigned to duty with the division by the director of professional services, medical officers of the consultant body who will be known as division consultants. The services represented are psychiatry, orthopedics, toxic gas, and urology, the first three finding their greatest field of usefulness in combat at the triage to which they are assigned by the division surgeon; the last concerning himself with the prevention and treatment of venereal and skin diseases in the entire command.
During the training period these officers give instruction to the medical personnel of the division; the psychiatrist making examinations to detect mental or neurotic cases with a view to prompt elimination, and during combat, while on duty at the triage, he differentiates the genuine war neuroses from the false, and in proportion to his ability and zeal conserves to the combatant troops many men who are malingerers, hysterical or extremely fatigued, and who may be returned to the line after a few hours of rest; the orthopedist institutes measures to prevent "trench foot," makes the examinations for the detecting of and prescribes treatment for genuine flat feet, trains the sanitary personnel in the application of splints, and during combat while on duty at the triage superintends the readjustment of application of splints; the toxic-gas officer instructs the entire personnel of the division in the effects of toxic gas, in the proper use of the mask and in the preparation of a dugout to exclude the gas, and the sanitary personnel in the means of combating the effects of gas, particular instruction being given the personnel of the field hospital set apart for the treatment of toxic-gas cases; at the triage during combat he differentiates real from false cases irrespective of previous diagnosis before reception, and recommends the disposition. The commanding officer of the field hospital, acting as a triage, must be possessed of great diagnostic ability, for upon him and the consultants assigned to the triage during combat rests a great responsibility, the triage being the sorting place where the real sick and gassed cases are separated from the false, and the wounded are classified for disposition. Faulty triage will inevitably cause overwhelming of the evacuation system and a reflex congestion at the triage and field hospitals besides greatly affecting the morale of the division.
Upon receipt of a movement order, whether by train, truck, or marching, the division surgeon prepares a schedule for submission to the division commander in which is detailed the position of the sanitary units on the march or by train or truck and the provisions for hospitalization of the sick and wounded to remain or be transported, these latter details being also transmitted to the corps surgeon or in his absence to the army surgeon.
DIVISION SANITARY INSPECTOR
To each division is assigned a medical officer of the rank of major who is concerned with the sanitation of the division, and the officer selected for this duty must possess tact, experience in field sanitation, and be well versed in epidemiology.
He makes the sanitary inspections of the entire division, whether in training area, on the march, or in combat, and also, when so directed, makes the required inspections of sanitary troops attached to regiments and smaller units and the sanitary train to determine the discipline, instruction, and sufficiency of supplies, equipment, personnel and transportation, reporting his findings upon appointed forms to the division surgeon; he instructs the entire sanitary personnel in sanitation and assists in every way to maintain sanitary perfection; he concerns himself intimately with the preparation of food, the cleanliness of kitchens and appliances, mess halls, handling food, which he has had examined by the bacteriologists for the detection of "carriers"; he investigates the quality, sufficiency, and variety of food and makes recommendations for modification or improvement; he investigates the availability of bathing and clothes-washing facilities at approved locations if none obtain in the area, making suggestions for improvisation if standard types are not available; he investigates the question of disinfection and disinfestation, and drying of clothing, recommending such number of disinfectors or disinfestors and dryers as may be required, and if unobtainable suggests improvisations; he investigates and reports to the division surgeon the incidence of any infectious or communicable diseases and the means taken to prevent their spread.
He investigates and makes report upon the venereal status of the command and makes recommendations for the prevention, care, treatment, and disposition of these diseases; he makes constant inspection of the prophylactic stations and investigates their conduct and the frequency of use in relation to the prescribed physical inspections and prevention of venereal diseases; he investigates the type, adequacy and management of methods for the disposal of liquid and solid garbage and manure, and makes recommendations for modifications or improvements; he concerns himself intimately with the disposal of liquid and solid human excreta and makes recommendations for a standard system in the training area, on the march, and in combat; if the command is to be billeted, he makes arrangements with the civil authorities for sanitation during the period of occupancy, and concerns himself with the adequacy and potability of the water supply; he has all sources of drinking water placarded as potable or unsafe as the case may be, and investigates the use of Lyster bags, the cleanliness of water containers and whether the water is chlorinated, frequently submitting samples for testing for the sufficiency or excess of chlorination; he investigates the sufficiency and adequacy of clothing and the proper fitting and preparation of shoes, the facilities for drying clothing and shoes, and the care of the feet.
The sanitary inspector investigates police adequacy, and the suitability of houses, barracks, or tents for occupancy, pays particular attention to heating and ventilation, and makes recommendations for repair or improvement; he searches for fly or mosquito breeding places and takes steps for their elimination; he precedes the command whenever possible to a new location to familiarize himself with all conditions relative to sanitation, and prepares his recommendations for any improvements indicated; in combat he concerns himself with the supply of hot food for the troops and the cleanliness of containers, policing of the battle ground, and the interment of the human and animal dead.
THE DIVISION DENTAL SURGEON
The division dental surgeon acts in a supervisory capacity over the dental surgeons of the division, all reports of dental work being consolidated by him for transmittal; he sees to the sufficiency of dental supplies and equipment; he requires that periodic dental examinations of the command be made and records kept of the necessary dental work to be performed,
and the immediate dental examination of and reparative work to be performed upon any recruit joining the division; he makes provision for dental treatment of the personnel attached to division headquarters, and, upon notification, for the personnel of the division supply train. The mobile hospital receiving the nontransportable wounded of the division will be provided with dental attendance by the division dental surgeon or one of his assistants.
THE DIVISION SANITARY TRAIN
The sanitary train of a division is composed of four motor ambulance companies (three light and one heavy), four motorized field hospitals, one litter bearer battalion, one medical supply unit, and one laboratory unit, the train being under the command of a medical officer with the rank of lieutenant colonel, who must be experienced in Medical Department administrative and tactical duties.t
The sanitary train of a division is technically an integral part of the divisional trains, which are under the control of the division commander of trains. This control, in so far as the sanitary train is concerned, extends only to march and road control while the trains are together and marching or camping as a unit. When combat is imminent or when the sanitary train is detached from the other trains, all control, either technical, tactical, or administrative, reverts to the division surgeon through the medical officer in command of the sanitary train.
All communications concerning the units of the train pass through the office of the sanitary train commander. The train commander by frequent inspection insures the preparedness of the units for combat duties; he directs the movements of the train in compliance with orders, and in combat exercises assumes direct command over the units and coordinates their functions in relation to the battle order; when possible he precedes the train to a new location and makes a reconnaissance, reporting his observations to the division surgeon, if time permits before the entrance of the division into battle, he, in company with the director of ambulance companies, makes a study of the battle terrain, and reports his recommendations to the division surgeon concerning the availability of locations for the establishment of the triage and field hospitals, due regard being given to existing houses, fuel, water, and roads both to front and rear; he consolidates the supply of the train and provides for the necessary transportation from the divisional railhead to the units; he maintains perfect liaison with the regimental surgeons and the division surgeon during combat; all requisitions for supplies, spare parts, etc., for the units are transmitted by him to the division surgeon, and all requests for replacements in personnel and transportation; he provides the transportation for the litter bearer battalion when the exigencies of service demand quick transportation to a given point.
THE TRIAGE OR SORTING STATION
It is the duty of the Medical Department to retain effectives at the front by preventing those who do not require more than slight medical or surgical care from going to the rear, and to promptly evacuate the noneffectives without interference with military operations.
Triage or sorting begins at the front and continues through the entire chain of sanitary formations. Improper triage causes a loss in effectives through permitting men with slight or no disability to leave their units, and not only causes congestion of the evacuating system, but lowers the morale of the troops.
Correct triage insures the proper and prompt disposition of the sick and wounded in the hospitals designated for their reception and treatment, and a constant uninterrupted flow of evacuables to the rear.
It is poor policy to retain in the divisional and corps areas cases requiring more than a very brief hospitalization, for this practice immobilizes the hospitals and increases the supplies and matériel which can only be transported by an unwarranted tax upon the supply train.
The triage, which is in reality the receiving ward of a field hospital, is located as near the front as conditions permit, due regard being given accessibility both to the front and rear, and to this point all the sick and wounded are transported from the aid stations by the
t Each Infantry division now has a medical regiment in lieu of the old sanitary train. See Tables of Organization, 81-W.-Ed.
litter bearer battalion or by ambulances as dictated by the military and topographical conditions. The director of field hospitals, under the orders of the sanitary train commander, is charged with the location and establishment of this important formation, which is the keystone of the divisional evacuating system, and which is conducted by the commanding officer of the field hospital assigned this duty, who with one of the medical officers of the hospital, three noncommissioned officers and six privates, and assisted by the consultants in psychiatry, orthopedics, and toxic gas, receives and sorts the cases, designating those for transfer to the division field hospitals, mobile hospital for nontransportable wounded, evacuation hospital, and those to be returned to duty.
In a command untried in battle it is well to have a sufficient number of military police assigned to assume charge of those returned to duty, to insure their reporting to their respective units.
A blanket, litter, hot-water bag, and splint exchange must be established under the charge of a noncommissioned officer whose duty is to see that for every one received one of each kind is returned to the aid station from which the sick or wounded man came, in this manner providing automatic replacement.
No attempt is made to provide medical or surgical care at this station beyond checking hemorrhage, readjusting a splint, or reenforcing a bandage, but antitetanic serum should be administered if previously omitted; the assistant of the triage officer with two privates makes the necessary additions or corrections to the diagnosis tags and prepares the field cards and envelopes of the cases examined by the triage officer and the consultants; one noncommissioned officer with two privates disposes of the cases as received in such a manner that they will not be confused with those already examined; the remaining noncommissioned officers with two privates superintends the evacuation of those examined and assigned to hospitals, and turns over those pronounced fit for duty to the military police, if doubt is entertained of their willingness to return to their units voluntarily.
Surgical cases are divided into the following classes: (a) Those able to perform duty in three days; (b) transportable requiring hospitalization longer than three days; (c) nontransportable.
The nontransportable cases are divided into four classes: (a) Sucking chest; (b) perforating abdominal; (c) severe hemorrhage; (d) shock.
Sucking chest and perforating abdominal cases not requiring immediate shock treatment are transported to the near-by mobile surgical hospital. Severe hemorrhage and shock cases are removed to wards assigned to such cases within the field hospital conducting the triage. Cranial injuries bear transportation well before operating and not at all afterwards, so these cases must be voluminously dressed, and, if not in shock, transported to an evacuation hospital designated for severely wounded, for the necessary surgical interference.
Medical cases are divided into two classes: (a) Those able to perform duty after hospitalization for three days; (b) those requiring hospitalizaton longer than three days.
The battle order designates the field hospitals for the care of sick and gassed cases and the evacuation hospitals to receive the severe and slightly wounded of the division as well as the location of the mobile surgical hospital sent forward for the reception of the nontransportable wounded. The corps ambulance companies, reinforced if necessary by the ambulance companies assigned to evacuation duty, evacuate all cases of the transportable classes to the hospitals designated by the triage officer, the transportables being divided into two classes, sitting and prone.
While partially equipped for surgical work no operative procedures beyond those necessary to save life will be attempted in a field hospital. The personnel of the field hospital assigned triage duty, as well as that of the field hospital in reserve, which may be advanced and become the triage, must be especially instructed in triage duty, for the work is exhausting under battle conditions and the triage party must be relieved from time to time.
THE DIRECTOR OF FIELD HOSPITALS
To each division is assigned a medical officer of the rank of major as director of field hospitals and who is under the immediate control of the sanitary train commander.u The duties of this officer are tactical and not administrative, and he maintains no office of record.
When the division is assigned a sector in the line he must make personal reconnaissance and study of the map, become familiar with the terrain, and submit recommendations to the division surgeon covering sites selected by him for the establishment of the field hospitals; he designates the field hospital for triage duty, the one for gassed cases, the one for sick, and the one to be in reserve; this designation and the location of each being incorporated in the division battle order in the sanitary paragraph.
He supervises the inspection of the personnel of the field hospitals and observes their performance of duty, making such recommendations to the division surgeon as he deems best to improve the service; he sees that each hospital is adequately supplied with medicines, dressings, foods, and heating facilities at all times.
During combat he takes station at the triage and supervises the evacuation, informing the division surgeon from time to time of the number of cases received and hospitalized in the divisional units and the necessity for an increase in evacuation.
Should the division be compelled to change location, and the triage and gas hospital contain nontransportable cases, he designates the number of personnel and the equipment to remain for their care, and reports the facts to the division surgeon.
On the march he accompanies the field hospital designated to care for the sick or wounded en route; he sees that the sick are disposed of as directed by the division surgeon and makes arrangements for the keeping of proper records pertaining to those left behind; he makes the necessary agreement for such reception in writing and transmits the document to the division surgeon.
THE FIELD HOSPITAL
(Numbered from 1 up)
The commanding officer of a field hospital is a medical officer with the rank of major and is under the direct orders of the director of field hospitals or the division surgeon.
The function of the field hospital is to provide food and temporary shelter, medical, and surgical care for the sick or injured divisional troops in combat or on the march, and in the absence of a camp hospital in the training area. A field hospital is a standard unit, designed with a view to mobility, and additional equipment will not be permitted.
The locations of field hospitals for combat service are defined in the battle order of the division, and care must be exercised to avoid crossroads, which are targets for enemy artillery, and the vicinity of ammunition dumps or aerodromes, or the vicinity of railheads, factories, or conspicuous buildings that are on ground recently vacated by the enemy.
Should the line stabilize, advantage should be taken of existing buildings which do not offer a target. All selected sites will be conspicuously marked with a large white cross upon the ground upon a dark background to preclude damage by indirect fire following aerial observation.
The roads leading to a field hospital must be plainly marked to direct ambulance drivers, and the signs are the property of the hospital, to be recovered when the hospital moves to a new location for further use. The designation of these hospitals for the care and treatment of certain cases is detailed under the article on triage, but no hospital except the triage should be opened for the reception of sick and wounded until its use is indicated, and then only in sections, unless it is definitely known from the nature of intended combat that all will be required.
Every effort must be made to maintain one hospital in reserve for use in an advance or retreat, and a hospital once established will not be closed except by order of the director.
A field hospital is divided into the following sections for administrative convenience: Reception and triage, surgical dressing, hospitalization, evacuation, record, mess, and
u In the medical regiment organization an officer of the rank of major commands the hospital battalion. See Tables of Organization 85-W.-Ed.
mortuary. Each hospital will be provided with facilities for combating shock, and as heat is the most effective agent for this purpose, small stoves will form part of the equipment.
Only those cases requiring hospitalization for not more than three days will be retained, and this class must be kept at the minimum to insure mobility. If the military situation demands a change in location, all cases will be, upon order of the director, transferred to an evacuation hospital without delay.
Being both an administrative and tactical unit, a field hospital maintains a full record system, employing the forms prescribed from time to time. The diagnosis tags, field medical cards, and envelopes of cases admitted are prepared for those not recorded in other units, alterations and corrections are made where required, and all completed cases are reported on sick and wounded cards. The record system includes loose-leaf files, a diary, and a card index of personnel.
THE DIRECTOR OF AMBULANCE COMPANIES
To each division is assigned a medical officer with the rank of major who performs the duties of director of ambulance companies under the direction of the commander of the sanitary train.v
He maintains no office of record, but transmits all communications arising in or referred to the ambulance companies; through constant inspection he insures the adequacy of personnel, equipment, and transportation, reporting deficiencies to the sanitary train commander; he concerns himself with the instruction of the companies, such instruction commencing upon the reporting of each company for duty with the division. This instruction must be given without regard to the length of service directed, since ambulance companies assigned to front-line work must be kept in a condition for immediate and effective service at all times; on the march he accompanies one of the companies and carries out the orders of the sanitary train commander concerning the distribution and service of the units under his command during the march; in the training area he maintains the ambulance service for the evacuation of the sick and wounded from their respective camps to the camp hospital or field hospital acting as such.
If time affords before the division enters combat, he, in company with the sanitary train commander and the director of field hospitals, will make a reconnaissance of the terrain and prepare a road sketch, in rough, showing the most suitable routes for ambulances and the locations of the ambulance companies, and submit it with his reasons for the approval of the division surgeon; his tentative recommendations having been approved, he furnishes a sketch to each ambulance company commander who in turn instructs the drivers in the location of all aid stations, triage, field, and corps mobile hospitals; during combat he alternates between the aid stations and field hospitals assisting in the evacuation from the combat line in every way to insure a steady, uninterrupted flow, and when a road block occurs he invokes the aid of the military police to give the ambulances from the aid stations the right of way; when an unusual number of casualties occurs at a point of the line he arranges with the commander of the litter bearer battalion for the rapid transport of so much of his battalion as is deemed necessary to the point, employing ambulances and trucks for the purpose. Should the number of casualties overwhelm the ambulance service he requests more transportation of the commander of the sanitary train and calls upon the commander of the supply train for the authority to use trucks returning empty from the front.
In boggy terrain or densely wooded areas with soft roads he is empowered by the division commander through the division surgeon to employ the regimental combat wagons which are admirably adapted for this service over short distances. He insures the automatic replacement of litters, blankets, splints, and hot-water baths to the aid stations, and employs such empty ambulances going to the front as are necessary to transport medical supplies; he makes immediate report to the commander of the sanitary train of unauthorized use or abuse of Medical Department transportation.
v In the medical regiment organization an officer of the rank of major commands the ambulance battalion. See Tables of Organization, 84-W.-Ed.
THE AMBULANCE COMPANY
(Numbered from 1 up)
Motorized ambulance companies are provided in the proportion of four to each division and assigned from the army ambulance service. Each company is commanded by an officer of the medical service corps, as the service is one of transport only, and the company commander is under the control of the director of ambulance companies. The light and heavy companies assigned a combat division will be in the proportion of three of the former to one of the latter.w
The function of the ambulance company is the transportation of the sick and injured from the aid stations to the triage and field hospitals; to replace matériel removed from the aid stations with the sick and wounded, and transport needed medical supplies from the division supply unit to the aid stations; to transport sanitary personnel either to or from the front; and to provide ambulance service in camp, in the training area, and on the march.
The company commander is responsible for the discipline, instruction, efficiency of the personnel, and responsible for the property, transportation, and equipment of the unit. During combat he directs the work of his company in every part of the sector assigned through the director of ambulance companies by the division surgeon. He instructs his drivers by means of a road sketch or map in the location of the aid stations, the routes to be followed to the front and rear in conformity to the orders governing circulation issued by the administrative section of the division general staff, and the location of the triage and field hospitals. He establishes an ambulance relay station, as nearly as possible midway between the aid station of the sector served and the triage to provide for an ambulance returning from the front being replaced immediately; should his company become overwhelmed he advises the director and requests assistance; he maintains close liaison with the battalion and regimental surgeons and the commanding officers of the litter bearer companies.
An ambulance company, being an administrative and tactical unit, the records must conform to prescribed orders, and a loose-leaf file, a diary, and a card index of personnel and transportation will be kept, the latter containing all data necessary for the prompt furnishing of information required with reference to any vehicle. This date must include the details concerning number of individuals or wounded transported; the quantity of gasoline, oil, and grease used; the number of miles traveled; the details of the abuse of transportation; the damages sustained and the repairs or replacements indicated; and the spare parts required. This data is a basis for the report required by the director of the army ambulance service upon the completion of a service period.
THE DIVISIONAL LITTER BEARER BATTALION
To each combat Infantry division in war is assigned a litter bearer battalion which is under the control of the sanitary train commander, and companies of which or parts thereof will be applied by him to any part of the combat line to supplement the bearers of the regiments of separate battalions.x
The normal duty of the four companies of this battalion is the littering of wounded from the front line to aid stations and from the latter to the point attained by the ambulances if conditions preclude the ambulances approaching the aid stations.
In this last situation it may be necessary to direct the bearer companies to establish dressing stations, the equipment for which remains at the camp of the battalion until needed. The establishment of these stations, however, in modern warfare will be infrequent, and then only while operating on a flat terrain. The battalion is commanded by a medical officer with the rank of major, the nature of the duty requiring experience in field work and disciplinary powers beyond the ordinary. He maintains no office of record, but presents a
w Ambulance companies now form a part of the ambulance battalion of the medical regiment.-Ed.
numerical report of the cases carried upon the conclusion of combat. Close liaison with the regimental and battalion surgeons and the ambulance company commanders must be maintained.
The companies ordinarily proceed to the scene of activity by marching, and must be in a position of readiness at the front before the commencement of combat, since a sudden increase in casualties beyond the capacity of the battalion bearers in a particular sector of the line may demand their quick transport to that point. In such cases application is made to the director of ambulance to furnish the necessary transportation. Upon the conclusion of combat duties the entire battalion may be transported to the triage and field hospitals to assist the evacuation.
The equipment of the dressing station is simple and the work is confined to dressing wounds, readjusting splints, checking hemorrhages, administering liquid food, and heating the shocked, the evacuation to the triage being conducted with promptness. Should the establishment of the dressing station be decided upon after the commencement of combat, the battalion commander notifies the sanitary train commander of the location and time of opening. No records or reports are required from a dressing station. Use must be made of any shelter and if none exists application is made by the battalion or company commander to the nearest field hospital for a tent. In inactive periods the battalion camps with sanitary train headquarters and on the march follows the Infantry.
THE REGIMENTAL MEDICAL SERVICE
The regimental surgeon, as a member of the regimental staff, is the adviser of the regimental commander upon all sanitary subjects, and under his authority controls the Medical Department personnel attached to the regiment.
In his administrative capacity he inaugurates the instruction of the sanitary personnel and maintains sanitary discipline on the march, in camp and in combat. He is his own sanitary inspector and makes recommendations to the regimental commander for the installation and use of all measures indicated for the disposal of liquid and solid wastes, excreta, and manure. He has all sources of water supply investigated before permitting any to be placarded as potable, and sees that a sufficiency of water sterilizing bags are provided, and that the chlorination is efficiently performed.
The regimental surgeon cooperates with the police officer in the maintenance of thorough police of the entire environment of the command, and pays marked attention to the preparation, quality, sufficiency, and variety of food, and to the cleanliness of the kitchens and appliances and the exclusion of "carriers" from those handling food; he investigates the living quarters of the troops and determines the adequacy of floor and air space; he causes all members of the command to be inoculated against smallpox, typhoid, and the paratyphoids, and takes immediate steps for the isolation of every case of infectious and communicable disease and the segregation of contacts; he is responsible for the sufficiency of medical supply and maintains the combat equipment at its maximum at all times, forwarding requisitions as indicated from time to time; he is responsible for the inauguration and maintenance of the venereal prophylaxis stations, and personally sees that they are operated effectively, and that the stated physical inspections are made; in the training areas he gives lectures upon sanitary subjects in relation to field work to the officers of the regiment.
He maintains no office of record beyond a loose-leaf file, a diary, and a card index of the sanitary personnel, and prepares and forwards the prescribed reports; he institutes measures for the drying of clothing and shoes, the disinfestation and bathing of the command, and with his assistant makes frequent examinations of the footwear of the entire command and the care of the feet, prescribing the correct sizes of shoes and socks, and has the ailments of the feet corrected; in cold or wet weather he must see that the feet are bathed daily in cold water and dusted with foot powder containing camphor if obtainable, and that the feet and lower legs are frequently given friction with tallow, salt-free lard, or whale oil; should the regiment be ordered to change location by marching, he informs the division surgeon of the time of departure and requests the necessary ambulance service for the command.
His tactical duties are concerned with terrain exercises and combat, and being furnished a map of the regimental area he selects the locations of the battalion aid stations and submits a report to the regimental commander for approval and incorporation in the battle order for the information of all, a copy being furnished the division surgeon. The map used must be of the same date and scale as those used by the regimental and battalion commanders.
If time affords he makes a reconnaissance of the terrain and instructs his subordinates, who will conduct the battalion-aid stations, as to the proper location and designates the routes of evacuation from the front to these stations, and the water points, and informs the division surgeon of his action. The regimental and battalion medical combat wagons, when not a part of the divisional train, are under his control. The division surgeon coordinates the regimental medical activities with other branches of the sanitary service of the division.
Combat may be suddenly entered upon before selection of aid stations can be made by the regimental surgeon and in this event each battalion surgeon locates his station and informs the regimental surgeon, by means of a runner, of the exact location and the roads to be used for evacuation, and this information is transmitted to the division surgeon and regimental commander.
In modern combat every available cellar, dugout, or cave affording protection from shell fire must be made use of, and if the terrain does not afford such shelter first aid must be rendered in the open and the evacuation to a sheltered location by litter made as quickly as possible. Wheeled litters should be used at every possible opportunity as their use obviates the exhaustion of the litter bearers and quickens the evacuation. When facilities offer for the establishment of an aid station under proper conditions, every wounded man must receive a prophylactic dose of antitetanic serum before he is evacuated.
Facilities will be provided for combating shock and splinting fractures in aid stations. Shock cases must be heated and surrounded with hot-water bags and blankets, and all compound fracture cases must be correctly and securely splinted, both classes being given an opiate before they are evacuated. All fracture cases should be splinted as near the scene of injury as possible, and the trench or snowshoe combination splint and litter is especially indicated for all fractures of the lower extremity.
Cases of toxic gas will not be treated in a dugout, cave or room with the sick or wounded, since the latter may be gassed, and the equipment so penetrated that others will be gassed from it.
All gassed cases must be evacuated in ambulances carrying only that class of cases. Should the command occupy trenches, the sanitation must of necessity be as perfect as human ingenuity can devise. This subject has been considered under the article on sanitation. Upon relief from a trench sector the surgeon of the command to be relieved must conduct his successor over the entire area giving him full information on all points necessary for conduct of an efficient sanitary service.
DIVISIONAL MEDICAL SUPPLY UNIT
The divisional medical supply unit is an integral part of the sanitary train.y This unit is the medium for the procurement and distribution of all Medical Department supplies and equipment required for the sanitary service of the division. The function, personnel, organization, and equipment of this unit are fully covered upon graphic charts and in text under the separate heading "Supply Service." Attention, in this connection, is invited to the table of organization, "Sanitary train-Infantry division." For march and road control this organization is under the control of the commander of the sanitary train. In all other respects the commanding officer of this unit is an assistant to the division surgeon, and as the divisional medical supply officer advises him upon all questions relating to medical matériel.
y The medical supply section is now part of the service company of the medical regiment. See Tables of Organization, 82-W.-Ed.
DIVISIONAL LABORATORY UNIT
To each division, whether combat or replacement, is assigned a mobile laboratory, the equipment of which is packed in chests and transported upon one truck, the unit being part of the sanitary train.z
In the training area the unit is located at the point of greatest use, and when the division enters combat, at the camp of the sanitary train in conjunction with the medical supply unit.
The equipment is sufficient for the routine bacteriological work of the front hospitals and the testing of the sufficiency of chlorination in the water for drinking purposes. The greatest use of the unit is in the training area, where time affords for the bacteriological work; but during combat its use is of necessity curtailed, as the field hospitals do not retain cases sufficiently long to warrant bacteriological technic, though upon occasion it may be called upon to exercise bacterial control of cases in the mobile surgical hospitals, or to make pathologic examinations and prepare specimens of interest for transportation to the central laboratory.
THE REGULATING STATION
MEDICAL DEPARTMENT ACTIVITIES
Regulating stations for the military control of railway traffic are established in large railroad centers within the zone of the armies. The number and distribution of those groups will depend upon the size of the forces and upon the topographical distribution of the transportation lines.
Each regulating station group will be under the command of a regulating officer who will be a member of the general staff corps, and the coordination section thereof. Regulating stations will ordinarily serve an army or group of armies but may be established for the service of a detached army corps. The regulating officer will require a capable administrative and technical staff to assist him in the many responsible duties associated with his position of a military general manager of a railway center.
Regulating stations and regulating officers are under the direct control of general headquarters through the agency of the chief regulating officer, who is a member of the coordination section of the general staff at general headquarters. Regulating officers remain at all times in close liaison with this control, this section of the general staff being responsible for troop and train movements and supply within the theater of operations. General headquarters will keep regulating officers constantly advised upon actual or anticipated changes in the military situation with reference to their front. Regulating officers will therefore be in a position to decide all questions involving train movements upon their immediate sector.
All trains coming from the zone of supply are controlled by the troop movement bureaus, which are under the control of the coordination sections of the general staff at the headquarters concerned. This control continues until trains enter the zone of the armies, when they come under the direction of regulating officers. Conversely, all trains leaving the zone over which the regulating officers exercise control are taken over by the troop movement bureau of the coordination section concerned.
This system, wherein regulating officers and troop movement bureaus have been endowed with powers beyond those delegated to the general managers of civil railway systems, makes for efficiency, but requires the services of experts in railway technique, excellent liaison and coordination, and the most perfect telephone and telegraph facilities obtainable.
The regulating officer is the commanding officer of the regulating station group. He is in every sense a post commander. A medical officer therefore of experience and ability in administrative and sanitary affairs must be detailed as an assistant to regulating officers. This medical officer will bear the same relation to the commanding officer of the station group as does a post surgeon to the commanding officer of a garrison, and as a member of the staff of the regulating officer will be his adviser upon all questions relating to the conduct of the sanitary service within the domain of the regulating station group.
z The medical laboratory section is now part of the service company of the medical regiment. See Tables of Organization, 82-W.-Ed.
Such additional officers of the medical department as may be required will be assigned to regulating stations. Inasmuch as those groups are large and entail the handling of large numbers of men, it will usually be necessary to station at such places a camp hospital. This unit will, however, remain under the orders of the chief surgeon, army service area.
Should the actual management of hospital train dispatching require additional commissioned assistants, these may be detailed from among officers of the Medical Corps. These officers will be concerned with the multitudinous duties attendant upon the dispatching, supply, inspection, etc., of Medical Department trains.
The senior medical officer present, who as stated will be known as the surgeon, is responsible for the sanitation of the area occupied by the station group. In this respect only he is responsible to the chief surgeon, army service areas. Medical and dental attendants will be furnished the command by the personnel of the camp hospital, where permanent hospitalization will be provided for the sick of the group.
The medical officer on the staff of the regulating officer not only controls the movements of the hospital trains in the domain of the regulating station, but is responsible for the conduct and efficiency of the personnel, and for the equipment and supplies carried by the trains.
Commanding officers of hospital trains assigned to regulating stations will be under orders of the surgeon of the regulating station group in matters pertaining to Medical Department administration. This staff officer is responsible to the regulating officer that trains are at all times ready to answer calls and kept properly stocked and provisioned.
He maintains a small storehouse for the medical supplies required by hospital trains. This issue point will be under an officer who is thoroughly conversant with the requirements of these units in medical supplies and equipment. The necessary rations for trains will be drawn from the common source of such supplies.
Tables of organization of personnel will be kept on record for each train in service. Should the chief surgeon, expeditionary forces, order changes in personnel of trains, the regulating officer will see that such directions are carried out, and the personnel will be regulated through the regulating station office. All changes in personnel of trains will be kept on record at the regulating station concerned.
The number and composition of hospital trains, assigned to regulating officers by the coordination section, general staff, general headquarters, will be kept on a classified list, copies of which will be furnished the chief surgeon of the army, and the chief surgeon of the forces.
This list, giving carrying capacity (in litter and sitting) of each train, is particularly important in case foreign or other than regular hospital trains are placed at the disposal of the regulating officer, since such trains will vary greatly in capacity. The list will be valuable for the use of officers in charge of evacuations in preparing loads when trains are announced. Changes in lists will be reported at once and all retained copies modified in consonance therewith.
The surgeon of a regulating station group maintains an accurate record of all hospital trains in all particulars, together with lists of modifications of schedules for trains going to any part of the zone, and a list of evacuating points supplemented with maps giving the length of sidings and loading facilities in the entire zone, and the number of trains permitted to load at each siding during a period of 24 hours, and the length of stay allowed upon each siding; he informs the chief surgeon, army group, army corps, or division, as the case may be, of this data when it is desired to establish an evacuation hospital or loading point at any siding; he receives a report from each train commander of the number of cases carried, by classes, and keeps a correct record based upon these reports which he reconciles with daily phone or wire reports from the evacuating officers. (For the procedure to be followed in the use of hospital trains at the front, see text of evacuation hospital.)
Hospital trains are Medical Department organizations and, as sanitary formations, are under the direction of the chief surgeon, expeditionary forces. As railway units, and in systems of evacuation within the zone of the armies, they are operated under the direction of the regulating officer to whom they are assigned. They are repaired by the transportation service.
Assignments of hospital trains will be made by the coordinating section, general staff, general headquarters, to regulating officers, and to the troop movement bureau at headquarters, S. O. S. When the coordination section, general staff, directs a change in assignment of a hospital train by telegram or otherwise from one regulating officer to another, the former regulating officer notifies the following by telegram as soon as the train is ordered to move: The commanding officer of train; troop movement bureau of area to which train moves; regulating officer to whom train is assigned; coordination section, general staff, general headquarters; chief surgeon, expeditionary forces.
Through the surgeon of the group there must be a constant liaison between the regulating officer and the train commanders. The regulating officer being informed as to the general and special situation at the front, is usually in a position to say when the next journey by any particular train will be made. When trains are in one garage, journeys will be assigned consecutively and the first train in will be the first train out. All trains, however, must be fully stocked and prepared at all times and held in a state of readiness for calls upon short notice.
For the purpose for simplifying evacuation, hospitalization facilities will be districted into zones. This is accomplished by the coordination section, general staff, in consultation with the chief surgeon of the forces. Regulating officers will be advised of the zone into which the chief surgeon will make his evacuations. After this division into zones becomes effective, the commanding officers of hospital centers and base hospitals will telegraph daily to their respective regulating officer the number of beds available for use of the army which the regulating officer is serving. These messages will be sent direct and will state the beds available as of 8 p. m. and that this number will be available for 24 hours. In these figures, trains routed to the hospital in question, but not yet arrived, must have been considered. For centers in base sections these telegrams will be relayed by the office of the chief surgeon. In these reports beds will be classified as surgical, medical, contagious, and convalescent. The arrival of a train at a center or detached hospital is announced by telegram from the regulating officer, and the commanding officer of the train.
After all trains have been dispatched, regulating officers will daily inform the coordinating section, general headquarters, and the office of the chief surgeon of the forces of the number of hospital beds available. The evacuation officer, army chief surgeon's office, and representing the coordination section of the army general staff, or the commanding officer of each evacuation hospital group will advise the regulating officer of his area or army as of 8 a. m. and 6 p. m., each day as to the number of evacuable cases classified as follows: Wounded preoperative, litter and sitting; wounded, post-operative, litter and sitting; medical cases, litter and sitting; gassed cases, litter and sitting; officers, allies, and prisoners, litter and sitting; contagious, litter and sitting.
The regulating officer with this data available will arrange for a sufficient number of hospital trains to evacuate completely the evacuable cases reported; he will determine the destination of each train according to the cases to be evacuated; i. e., medical cases to medical hospitals, and surgical cases to surgical hospitals, etc. The evacuation officers do not request trains; they merely give the regulating officer the number of evacuable cases.
As soon as destination and schedule for trains are arranged with the railway technician, the regulating officer will telephone to the evacuation officer concerned giving the exact load of each train, the number and type of cases, and the time of arrival and departure of train at loading point, and will direct the number of rations to be placed on the trains when rations are necessary; in case other evacuations by same train are to be made further along the route, each evacuation point or collecting station will be notified in the same manner.
The regulating officer will confirm telephone calls to the evacuation officer by telegram, and in addition will send copies to the following: Coordinating section, hospital evacuation, army; commanding officer of base hospital at destination; regulating officers through whose areas train moves; troop movement bureau of area in which train moves; statistical department, adjutant general's office, general headquarters; chief surgeon, expeditionary forces. In each telegram to the evacuation officer he is instructed to give copy of telegram to the commanding officer of train.
The evacuation hospital will see that necessary steps are taken to load the train in the allotted time, and only with the number and type of cases designated by the regulating officer. If the loading of the train is delayed the train will lose its schedule and will be subjected to delays en route. Should the train be loaded with other than class of patients designated, the base hospitals at destination may not be equipped to take care of them.
In time of calm, collecting of patients from two or more evacuation groups is possible, but the total loading time from different evacuation centers should not exceed four hours, including the time spent en route from one loading point to another. In intensive operations full train loads only are sent from each evacuation group. Before loading a hospital train evacuables must be most carefully classified into seriously and slightly wounded, and ordinary and special sick. Such classification will permit of loading the patients by classes into different parts of train and will greatly facilitate their ultimate distribution at unloading points. Further grouping according to destination will be resorted to whenever possible. The evacuation officer will give the commanding officer of train the evacuation sheet, on which appears nominal lists of all cases (classified) to be evacuated; the commanding officer of the train in turn will prepare his train for this load.
Schedules given to hospital trains will depend upon the zone in which they may be operating. Within the zone of the armies military schedules only will be obtainable and these are usually slow. While traversing the zone of supply schedules will be faster. In cases of emergency trains may be dispatched on fast schedules for entire length of journey, provided it does not interfere with the schedules of military trains which have priority. All fast intercommunicating schedules will be arranged by the coordination section, general staff. Such arrangements are immediately made known to the regulating officer interested, to permit train dispatching and the notification of proper railway authorities.
As armies advance or retreat the regulating officer will select new loading stations at points most conveniently located to the proposed evacuation centers decided upon by the army chief surgeon. Army chief surgeon will consult regulating officer on the location of these evacuation points for loading hospital trains. Reconnaissance of loading points will be made by the regulating officer, in conjunction with the evacuating officer of the army and the railway technician, should an important movement of the army be contemplated.
Regulating officers must arrange with the railway technician to route hospital trains so as to allow patients to reach their destination in shortest possible time. Long stops at stations will be permitted only where there are tracks which will permit loading or unloading without blocking main tracks. In small stations where there are no such conveniences, the unloading must be done in the short time allowed and such unloading points will be avoided whenever possible. On branch lines a night service is not always organized, and advance notice will be given should train be due to arrive during the night. Trains will not be split except in certain large stations and then only when absolutely necessary.
MEDICAL DEPARTMENT HOSPITAL TRAINS
For the railway evacuation service of an expeditionary force hospital trains will be provided. Each train will be capable of transporting 360 prone patients. The number of trains required will depend upon the size of force, length of land lines of communications, and the nature of the combat problem. In general terms it may be stated that with forces of 20 combat divisions (one army) or less, two Medical Department hospital trains will be required per division and with forces greater than one army (two or more armies) one train per division will suffice.
Hospital trains must be constructed in time of peace in conformity to standard specifications and garaged at convenient locations under the charge of caretakers, for when war is declared the rolling stock of railways is too much in demand to permit the assignment of a sufficient number of Pullman, tourist sleepers, or first-class passenger cars to the Medical Department, and the alterations for the conversion of American cars of any type is time consuming and expensive. Should it become necessary to convert coaches to hospital train use the cardinal defect to be overcome in American cars is the absence of side doors on both sides of every car to be used for ward purposes, as without side doors for loading it will be next to impossible to introduce a loaded litter without intervals between the cars to permit a litter being passed into the vestibule.
As locomotives are not always available in war for permanent attachment to a hospital train to furnish steam for heating, a steam boiler of adequate capacity will be installed in the brake van or baggage car to supply steam at all times, and a gas motor-driven dynamo to supply the electric lighting power, both plants being under the charge of two mechanicians, one relieving the other at stated periods. When the train is under traction the locomotive will supply steam for the radiators, and the dynamos attached to the running gear of each car the electric current, the excess going to accumulators; but as hospital trains often stand idle for long periods it is in the interest of economy and utility to maintain separate heating and lighting units, especially in cold weather when if in motion the locomotive requires its steam for traction use with these heavy trains.
A field officer of the Medical Corps will be assigned to each hospital train as commanding officer. He will be assisted by medical officers, nurses, and enlisted men as indicated below. The duties of a hospital train commander may be conveniently classified as administrative, and professional or technical.
As an administrative officer he controls his personnel and patients, being responsible for their discipline, rationing, and comfort at all times. He is responsible that none are evacuated except those appearing upon lists furnished him prior to the movement. The question of triage, which is of the utmost importance in an evacuation system, is carefully considered by the commanding officers of all trains, cases which should properly have remained in the zone of the armies being reported by name and organization to the regulating officer.
Cases of death occurring en route will be reported with full particulars to the regulating officer, who will transmit this information to the proper office. The commanding officer of trains has authority to refuse cases which he deems unfit to travel. He will report his action on such instances to the regulating officer. He maintains an office of records for the sick and wounded under his care and for his detachment of Medical Department enlisted and members of the Army Nurse Corps (female).
When the commanding officer of the train had carefully checked the data given him upon an evacuation and verified same with patients on board the train, he will send a telegram to the following:
The chief surgeon of the forces (or his
deputy at headquarters, Services of Supply).
This telegram will contain data covering the following, classified further into officers, nurses, allies, and enemy prisoners:
litter and sitting.
All cases for evacuation will be carefully inspected by the evacuation officer prior to loading upon train. No patient will be evacuated unless properly clothed. All cases requiring antitetanic serum must have received the proper injections. Equipment carried will be limited to the personal belongings of the patient, all arms, accoutrements, etc., having been turned in for salvage at the hospital.
Before loading the commanding officer of the train and evacuation officer will verify the number to be evacuated. When loading is completed the commanding officer of train advises the railway transportation officer who furnishes him with an order of transport showing destination, stops, and load; the commanding officer advises him of his readiness to leave and dispatches the several telegrams previously mentioned. It is important that the arrival of the train at the destination be announced in advance, in order that the receiving officer of the hospital or hospital center may arrange for the prompt and efficient transportation of the patients to the various hospitals.
Trains may be stopped en route at hospitalization points to unload patients when the commanding officer considers them unfit to complete the journey. To arrange for such stops and to assure quick action and preparation, the commanding officer will telegraph ahead to the railway authorities and the regulating officer concerned, as well as to the commanding officer
of the hospital to receive the patients; the commanding officer of the train will report such cases to the regulating officer and will request a receipt for all patients removed from his train at other than designated points.
Accidents or derailments should be reported immediately, by telegram, to the regulating officer, and should be confirmed by letter giving full particulars. The regulating officer will do everything in his power to expedite the sending of relief and wrecking crews to the place where an accident has occurred.
Unauthorized individuals will not be transported upon hospital trains. Authority to travel upon a hospital train, for other than train crew, personnel, and patients being evacuated, will be obtained in writing from the office of the chief surgeon of the forces.
Frequent inspection of trains will be made by the surgeons of the regulating station groups, who will note carefully the conduct of the command and personnel, reporting any unfavorable conditions to the chief surgeon of the forces, recommending changes in personnel when they are for the best interest of the service.
Requests for leave of absence or furlough will be forwarded through the proper channels to the regulating officer by commanding officers of trains. Such absences will be granted only when not interfering with the efficiency of train service, and not at all during periods when extensive combat operations are contemplated or in progress.
The hospital train consists of 16 specially constructed communicating cars, in assembly about 960 feet in length. The exteriors of the cars are the color of Army khaki, with the Red Cross of the Medical Department imposed upon the sides, roof, and at each end of the cars. The upper structure is almost entirely of wood, the lower structure consisting of a steel-beam frame riding upon two sets of double trucks. There are 9 regular ward coaches, 1 coach for contagious and infectious diseases, another for the staff officers and the nursing personnel, 2 coaches for kitchens, 1 coach devoted to a pharmacy and an emergency operating room, another for the sleeping quarters of the personnel, while the last coach is utilized for stores and provisions.
Each ward coach, with the exception of the infectious and contagious car, contains 36 superimposed bunks, arranged in tiers of 3; 18 placed on either side, permitting a generous central passage. These bunks are attached to the walls of the car by collapsible bunk standards, making it possible to remove individual bunks for the purpose of cleaning and disinfection or for transporting cases from car to car without transferring patients to litters. It is possible, by allowing the middle bunk of the tier to drop upon its standard and thereby forming a back, to produce a seat formed from the lower bunk. By this arrangement it is possible to transport 48 sitting and still utilize the 12 upper bunks for lying cases, thus making the total capacity of the car 60 patients, should suitable cases be available. With the proper combination of lying and sitting cases 600 may be carried, 480 sitting and 120 lying, or 718 sitting.
The infectious and contagious ward car contains 24 bunks. This car is divided into four distinct compartments, thereby permitting the transportation of four different infectious or contagious diseases. In case of these individual compartments there are six bunks.
At the lower end of each ward car is a small lavatory. Here are also cupboards for the eating utensils, racks for drinking and sputum cups, tanks for drinking water, etc. Opposite the lavatory is a small compartment containing the racks for bedpans and urinals, cupboards for cleansing materials and disinfectants for use in that particular ward car. The toilet for the car is also placed in this compartment, consisting of a galvanized-iron latrine bucket with ordinary toilet seat.
Ward cars are well lighted by spacious windows. Artificial light, furnished by electric current, generated by individual dynamos attached to each coach and stored in individual accumulators, two sets of the latter in each car. The power for the dynamo is received by bolt transmission from a pulley on the axle of one of the trucks, while the train is in motion.
Ventilation is brought about by upper ventilating windows in some trains and by special roof ventilators in others. In addition to this means, three large electric fans are placed, one at either end of the car, and one in the center. These are kept constantly in motion when the train is loaded, this combined system effectively maintaining circulation of fresh air. In addition to the larger fans referred to, small portable fans, five to each coach, are available,
which can be readily placed upon receptive standards, attached to the car wall opposite individual bunks carrying serious respiratory cases, for the purpose of affording them more and better air. The heating of ward coaches is effected by means of cylindrical iron steam radiators, placed one under each lower bunk, and two upright in the central portion of the car, steam being obtained from the engine.
The pharmacy and emergency operating car is placed in the center of the train assembly. The numerous cupboards on the walls of this car contain the necessary drugs, dressings, and appliances for use in emergency. Water and the ordinary field surgical instruments and instrument sterilizers are carried. A complete and compact train office is situated in the lower end of this car.
The forward kitchen car is divided into compartments; one of these is utilized as the officers' pantry; another for sleeping quarters for the cooks of the train, still another for patient officers' lounging and mess room, while the main and central portion of the car is devoted to a well-equipped kitchen. The rear kitchen car is also divided into compartments, one for a personnel mess, another for noncommissioned officers' sleeping quarters, pantry, and kitchen. The quarters of the personnel are similar in arrangement to that of one of the ward cars.
The stores and provisions car is divided into five compartments; the lower one being fitted up for use as a refrigerator, in which can be placed about five quarters of beef, plenty of space remaining for other perishable articles. Another compartment is utilized for the storing of canned rations; another for the transportation of officers' baggage, and workroom for the mechanics of the train; while still another is for storing extra blankets, linen, repair parts, etc.
Each train carries approximately 2,000 rations aboard at all times. The water supply is obtained from reservoirs placed in the structure of the roof of each car. The reservoirs of the kitchen cars contain about 800 gallons of water apiece; while those of the ward cars carry about 150 gallons. Hospital trains, although carrying a stock of 2,000 rations, when garaged at distant points may require replenishment of this stock by the transfer of rations overland upon motor transportation. Rations may be drawn at any time from railhead officers who are under the regulating officer should shortages occur when the train can not replenish from its own depot.
The staff car is divided as follows: One compartment fitted up for combined sitting room and dining room for the staff officers; three compartments for use as sleeping quarters for the officers of the personnel; two compartments as sleeping quarters for the nurses and one for the dining room of the nurses.
The personnel of each hospital train consists of three medical officers, three nurses, three noncommissioned officers, of which two are sergeants and one a sergeant first class, two cooks, one mechanic, twenty ward orderlies, privates or privates first class, and ten men for general duties. The senior medical officer present is the train commander. One assistant is designated as summary court officer, and performs, in addition, any other duties that may arise. The second assistant acts as supply and mess officer. The senior noncommissioned officer carries on the work pertaining to records, reports, returns, and other office work of the organization. Another sergeant is detailed as general duty sergeant, and the third is the mess and supply sergeant.
After the trains have been unloaded at a hospital center or base port, the mattresses, bedding, etc., must be subjected to disinfection to free the articles of vermin as well as contagion, and the interior of every car must be gone over with a 5 per cent solution of lysol, after which the doors and windows are kept open for at least six hours.
The general plan followed after a train has been loaded, to ascertain the type of treatment, diet, and orders for patients being transported is as follows: One officer, accompanied by a nurse, commences an examination of the cases in the lower half of the train, while another officer and nurse take up the same work in the upper half. The field medical card of each case is examined by the attending officer, and a general survey of the case is made. He then determines any treatment necessary for the case en route, in the way of medical prescriptions, changing of dressings, surgical appliances, special diets, etc., while the nurse accompanying him makes notation in the train order book of the bunk number, name of
patient, and treatment prescribed. When this has been accomplished throughout the train, this data is compiled, and the professional work is apportioned among the officers and nurses for completion.
Ward attendants in each ward coach will prepare a complete list of their cases. This list will be prepared after the medical officer has made his rounds. The consolidation of these lists will be the basis of the train commander 's report to the regulating officer and the chief surgeon with reference to the trip, and will become a part of the final records of the train. Upon the completion of an evacuating trip, the commanding officer of the train will prepare a brief report for submission to the regulating officer under whose command he is assigned. This report will cover the gross details of the evacuation and any incidents occurring during the period thereof.
A supply of such Medical Department blank forms as are required by trains will be kept on board each train at all times. These will be replenished from stock at replenishment depots.
A list of standard equipment and composition of each train will be kept in the office of the surgeon at regulating stations for reference. Should coaches be removed from or added to a train, the regulating officer will be notified of the time, place, and cause of the change, in order that he may properly alter his retained data relative to the carrying capacity of the train.
Changes in the composition of hospital trains are authorized only by the chief surgeon of the forces; when a regulating officer finds that conditions require such changes, he will consult the chief surgeon's office; when cars are detached through emergency or accident, the regulating officer will endeavor, through the proper channels, to have them returned.
Mental cases requiring special care will be put in separate compartments; if a guard is necessary, attendants from the evacuation hospital will be detailed for the voyage in such numbers as are deemed necessary. Contagious cases will be transported in the special car provided for them, and when unloaded must be so designated; it is imperative that cars carrying contagious cases be thoroughly disinfected as directed in orders issued by the chief surgeon of the forces.
At each regulating station and embarkation point there will be established depots known as hospital train replenishment depots, which carry on the following functions in reference to hospital trains: Administration and regulation within sections of the services of supply, under direction of the transportation division of the chief surgeon's office; the replenishment of supplies for hospital trains; the replacement of personnel; general and sanitary inspection; arrangements for minor repairs; central mail office for hospital trains; and the furnishing of motor transportation for use in connection with the hospital train service.
Prompt delivery of mail to mobile organizations of this type will always present a difficult problem. Every effort must be made, however, to accomplish this result. Mail should be forwarded to the chief surgeon of the section in which a train operates or to the regulating officer in command of the regulating station to which the train is assigned.
Personnel, food, fuel, mail, and accessories intended for hospital trains will be sent to the main depots located at the regulating station. Telephone communication between these depots and headquarters of the regulating stations must be established. These depots will be kept stocked with special diets and such other medical supplies conducive to the comfort of the patients as may be available in regular depots or those of the auxiliary aid societies. Branches of the hospital train replenishment depot may be required upon long stretches at some convenient junction where trains stop en route.
In loading and unloading patients, prone cases will not be moved from one litter to another except when absolutely necessary. At all hospitals and centers an adequate stock of litters, blankets, etc., will be maintained so that the prompt exchange of these articles can be effected without disturbing patients. Supply officers of hospitals will receipt to the commanding officer of hospital trains for all such nonexpendable matériel for which an exchange could not be accomplished.
Train commanders will personally arrange the exchange of linen, blankets, etc., with the supply officers of hospital centers or hospitals to which the evacuation is made. It will frequently be necessary for train commanders to replenish the stock of rations of their trains
during the stop at unloading points, and this will be accomplished by making requisition upon the hospital center or unit quartermaster.
The meals of patients are served by transporting the food from the kitchens in heat-retaining utensils to the several ward cars, from whence it is distributed by the wardmaster. Hospital trains will have the same hospital fund privileges that may be authorized for other Medical Department organizations, and every effort must be made to furnish patients being transported a varied diet of light nourishing hot food. In practice it will be found better, as a rule, to avoid the heavier items of the ration in meals served patients upon trains where opportunities for exercise of even those able to move about are so limited. Use of the sales commissary will be taken advantage of at every opportunity. When trains have no kitchen-car facilities, arrangements for feeding patients and personnel en route must be made. These stops and messing arrangements must be provided for in the schedule for the journey. Kitchen cars will be requested in the assembly of the train whenever it is known that they are procurable. Even if the coaches are not intercommunicating, the inclusion of kitchen cars will make the train independent as regards messing, since meals may be prepared en route and served to cars during stops.
There will be maintained at the embarkation depots a unit known as the casual hospital train unit, from which replacements are furnished to meet the deficiencies in the hospital-train personnel, arising through transference of personnel to other organizations as the result of sickness, misconduct, etc. A certain percentage of this personnel is placed upon hospital trains for tours of instruction in that particular service, so that when replacements are made, experienced men can be utilized to fill the vacancies.
A hospital train repair service must be maintained for making minor repairs to the trains. At the time of inspection the general condition of the train is noted, and if breakages have occurred during the voyage, the train is ordered to garage at a designated place, where broken parts are repaired or replaced by the transportation repair service.
The movements of hospital trains in the Services of Supply are arranged for by the transportation section, chief surgeon's office, with the troop movement bureau, the latter relinquishing the trains to the regulating officers upon entrance into the Army service zone.
From a regulating standpoint, the commanding officer of the hospital train is in command of the evacuation as far as relations with the transportation service are concerned, and acts as a troop commander of the evacuees, as defined in the rules governing ordinary transportation. He receives his instructions from the regulating officer as to destination of his train, and, based thereon, he makes out his orders of transport as directed by the regulating officer, who will be consulted upon all movements of trains not previously authorized. Upon completion of the evacuation, train commanders are authorized to order their trains back to the regulating station group.
HOSPITAL CENTER HEADQUARTERS, EXPEDITIONARY FORCES
A hospital center of 15,000 beds or more should be commanded by a brigadier general of the Medical Corps, and the officer selected for this important duty must be active in mind and body, as the duties are onerous and require high administrative and professional attainments, for he should direct all policies and activities of the center peculiar to location and not covered by precedent or current regulations and orders.
When the hospital center is organized the commanding officer should not be expected to supervise personally routine matters, but as far as possible he should be left free to observe daily the operations of the various organizations, in their professional and administrative activities, with a view to correcting defects or to originate new policies that such observation suggests for the improvement of the service. He should have as assistant one who is qualified to assume his duties and who enjoys his complete confidence.
His office is divided into two main groups, technical and administrative. The technical group is composed in the main of consultants, each having general supervision over the clinical activities in the entire center in the particular service represented, and holding weekly conferences with the chiefs of the service he represents. In this manner the services are kept informed of recognized efficient methods of treatment in other organizations.
At the conclusion of a conference each center consultant should make report and recommendations to the commanding officer relative to personnel and methods of treatment employed in any unit of the center within his sphere in which improvement is indicated. Center consultant should visit such special cases from time to time as requested by the chiefs of services.
Each consultant should render a monthly report to the center commander upon all commissioned personnel engaged in clinical work under their supervision, with recommendations which are pertinent for more efficient and harmonious service in the various hospitals comprising the center. The main divisions of the technical group are: Surgery, Roentgenology, and medicine. These sections are either apportioned among the component hospitals of the center, or certain hospitals are designated for the care and treatment of certain classes of cases as military operations demand.
Surgery.-This grand division is subdivided into sections as follows: Maxillofacial; eye, ear, nose, and throat; neurological; orthopedic; general.
Roentgenology.-This division is supervised by an officer of the consultant body who should be thoroughly familiar with the technic of his service and should also be qualified to direct the necessary repairs in a defective machine.
Medicine.-This grand division is subdivided as follows: General medicine; neuropsychiatry; ophthalmology; tuberculosis; toxic gas.
Like those of the surgical division, these sections are either apportioned among the component hospitals of the center, or certain hospitals are designated for the care and treatment of certain classes of cases as the military operations demand.
In addition to the foregoing, divisions of the technical group are:
Dental.-The officer in charge of this division acts in a supervisory capacity over the dental surgeons of the center, and this duty, not being an engrossing one, he maintains an office for the professional treatment of members of the headquarters personnel.
Nursing.-This division is under the chief nurse of the center, and she has general supervision, under the center commander, of all policies and instructions relating to the nursing service, that uniform application may be made to all component hospitals. She should hold frequent conferences with the chief nurses of component units, for the purpose of advising them of current instructions and for originating new policies for the approval of the commanding officer toward improving the nursing service. She examines all reports and returns relating to the nursing service and prepares them for the action of the commanding officer.
Graves registration service--One officer of this service is assigned prior to the opening of the center, and he is concerned with the selection and lease of a cemetery site, subject to the approval of the commanding officer, and with the correct registration of all interred therein, particular attention being given to the names, organizations, and grave numbers.
The administrative group, whose activities are coordinated through the adjutant, is composed of the following divisions:
Adjutant.-This important division should be in charge of a member of the medical administrative service whose previous experience qualifies him to handle the routine correspondence and maintain the record files of a large organization. His duties are similar to those provided for in regulations, but being of an entirely administrative character, if he is a member of the Medical Corps he should be relieved of all professional service as contemplated in the Manual for the Medical Department, United States Army, 1916. He should institute means for correlating the activities of officers attached to the center headquarters in an administrative capacity, and should publish to the center such orders or instructions received from higher authority and provide for the execution of policies decided upon by the commanding officer peculiar to location. He should act as summary court officer for the hospital center headquarters only, each base hospital maintaining its own summary court.
Records.-Under supervision of the adjutant, this division is responsible for the correct filing and care of all official correspondence under prescribed methods originating in or received by any office of the command requiring reference or records; he prepares all official correspondence emanating from the center headquarters; is responsible for proper acknowledgment of all mail received or dispatched, keeping accurate record of the same. He
should assume responsibility for telegram numbers and their proper sequence, maintaining a telegraph file; preserve all records of public property chargeable to center headquarters. This division has three sections-postal, mailing, and distribution.
Postal.-Conducts center post office, which should be in charge of a noncommissioned officer having general supervision of all mail orderlies of separate units and responsible for their receiving and properly distributing all mail of the center. Improperly addressed mail will be corrected by reference to index of patients kept in evacuation office. Receipts for registered mail will be taken from all individuals concerned.
Mailing.-This section prepares both official and private mail for shipment, noting compliance or lack of it with existing censor regulations.
Distributing office.-This office will be responsible for the prompt and accurate distribution of all instructions, orders or official communications relating to the command under methods prescribed by center headquarters. An index should be kept of all instructions or orders issued from headquarters and should provide that all orders, memoranda, etc., requiring numbers are used in proper sequence. Numbers should be issued and charged to the various departments requiring them. This office indexes orders for use at headquarters, and all blank forms for use of the center should be requisitioned by and distributed from this office.
Statistics.-In so far as is pertinent, the duties and responsibilities of this office should conform to those indicated for personnel office (q. v.) relating entirely to patients in the center. Index of all deaths occurring in the center will be compiled and correctly kept from records available in the center, cause of death being shown under separate classification.
Personnel.-This division is charged with the instruction of subordinate officers in separate units for correct and punctual rendering of all reports relating to personnel of command required by regulations or current orders; the keeping of the records of all organizations, showing strength present and authorized; the issuing of orders pursuant to competent authority for the change of status of all organizations or individuals of the command, making the same when applicable a part of the personnel record of personnel as is hereafter provided, and providing for the notification to proper offices of such changes; the keeping of separate card files of all personnel, classified as officers, Army Nurse Corps, enlisted men and civilian employees, showing those present or absent or transferred, who are carried on rosters of various organizations of command. In addition, to be a part of the above records, should be kept a record of duties performed, qualifications military, professional and technical, and such other information as may be of value; consolidation of the morning reports of various organizations, and the check against records of office; the correctness of ration returns of separate organizations; the keeping of separate files of special and professional services of center.
The office is divided into sections, as follows: Detachment, dealing with center detachment; orders and leaves, dealing with entire subject in center; assignments, dealing with assignments based upon qualifications.
Fire marshal.-The center fire marshal is responsible for the proper distribution of his assistants, of the orders governing this division, and the instruction of the entire command in fire duties. He will divide the personnel of the center and each component unit into fire-fighting squads, and drill each in its duties to insure efficiency and uniformity, this being done daily until proficiency is attained; after that, weekly. He will make weekly inspection of fire-fighting apparatus to insure its readiness for prompt use, and make to the commanding officer such recommendations for improvement in facilities as are needed. He will also make a weekly report to the commanding officer of the activities of his division.
Sanitation.-The duties of this division are under supervision of the commanding officer of the sanitary squad, who functions as center sanitary officer. He should make daily inspections of the center, paying particular attention to grounds, drainage, wastes, water supply, and internal sanitary conditions of units. The daily inspections should include messes and all that pertains to them, including prevention of waste and the carrying out of the directions of the commanding officer relating to messes. Upon the appearance of epidemic or contagious disease he should make exhaustive effort to determine the source and should make provision for its suppression, through the cooperation of other divisions
necessary to that end. He prepares the monthly sanitary report for the approval of the center commander. The sanitary squad, whose duties are given in another chapter, is under his control. These assistants are trained in inspections and in the repair of all sanitary apparatus, particular attention being paid to its conservation and proper working. If latrines or pits or tubs are used, the cleanliness thereof is insisted upon, care of them being given either to civilian employees or to enemy prisoners. Destruction of all waste which can not be used is carefully supervised, as is also the care of the incinerator. Careful inspection is made for prevention of fly breeding, by maintaining perfect police of garbage cans and horse standings or stables. Adequate measures are taken to prevent mosquito breeding. Ventilation and heating of wards are inspected and report made to the center commander if defects and deficiencies are found. In conjunction with the officer in charge of laboratories, search is made for "carriers" among those who have to do with the preparation and handling of food. If drinking water is not above suspicion, daily tests are made in cooperation with the laboratory section for the use and sufficiency of chlorination.
Evacuation.-In so far as it is applicable, this division bears the same relation to the center as the receiving and discharging officers of a general hospital, with such additional duties as the exigencies of the service may require. Through consultation with the proper authorities, the officer in charge keeps an up-to-the-minute list of available beds by classes. He is charged with responsibility for classified evacuations and the correct issuance of competent orders governing them. He keeps a record of all patients present and disposed of in the center each day. One study should be instructed in each unit in train, boat, and ambulance evacuation, both from the receiving and discharging side, and enlisted men detailed in each unit as litter bearers should be trained by him in their duties relating to boats, trains, and ambulances. When notified of the arrival of a train of boat, he must see that litter bearers and ambulances are on hand and that adequate supplies of blankets and hot-water bags are assembled at the platform. Having a list of vacant beds and receiving the list of patients from the train or boat commander, he is in a position to make prompt distribution of those received. Upon evacuation of the center, knowing the capacity of the boat or train, and having a list of evacuables by classes, he is in a position to embark or entrain them promptly. He turns over to the boat or train commander the list of patients evacuated, by classes. Before assuming his duties, he should, if possible, gain experience in evacuation work at an active evacuation hospital.
Motor transport.-The duties of the motor transportation officer are primarily the maintenance and repair of all motorized vehicles under his control. He instructs the personnel of the service in the duties required for proper operation of this service. He renders all reports required by this branch of the service, submitting to the commanding officer such requisitions for supplies currently needed to maintain the service.
Messes.-The mess officer, under direction of the commanding officer, exercises general supervision over all mess officers of the center and should hold such conferences with mess officers of separate units as may be necessary. He should make frequent inspections of organization messes as to operation and personnel, making such recommendations to the commanding officer as will provide for increased efficiency. He maintains a school for the instruction of cooks, helpers, mess sergeant, and others engaged in this class of work. He should keep informed upon the availability of local markets and the prices. He makes purchases for the separate hospitals and distributes the supplies purchased. He prepares the menus for the entire center and submits them to the commanding officer for approval two days prior to date effective.
Quartermaster.-The officer in charge of this important division is the group or depot quartermaster. He has general supervision over all the various quartermasters of the center. He makes daily inspections of all storehouses to see that stores are properly cared for, ample fire protection afforded, and precautions taken against loss. He supervises the preparation of requisitions before submission to the commanding officer for approval. He superintends the construction and repair of buildings, roads, walks, sewers, power plant, ice plant, laundry, etc. He inspects the supply officers of the center from time to time to see that they understand and perform their duties properly. He sees that troops are promptly paid and rationed,
that requisitions are promptly filled, and that ample stock is on hand at all times to provide for the needs of the center. He keeps a record of all reports that are required in his various sections, and sees that they are forwarded. He should cooperate in every way with the commanding officer and the heads of other departments. His office is divided into the following sections:
Rail transportation.-This furnishes transportation and travel allowance to troops, casuals, and men on leave status and routes them by the most practical routes; arranges for the movement of units from the center and notifies all concerned when the movement will take place. He receives and ships supplies and baggage, reporting daily by wire to the regulating officer the number of cars and kinds of supplies received and shipped; traces cars, express shipments, and baggage delayed and lost in transit; cares for all railway transportation department property at station; reports monthly to the chief quartermaster the amount and kind of transportation issued to the troops at the center; and reports to the central baggage office the data upon unclaimed baggage at the center.
Laundry.-Beyond having an expert personnel and civilian employees on hand, ironing and mending, this section needs no comment.
Subsistence.-The office force of this section makes requisition from class A-1 supplies upon a designated depot. He sees to the unloading, checking, and storage of supplies for sale or issue; issues rations on ration returns approved by the commanding officer; issues travel rations on travel orders issued by the commanding officer; sells commissary supplies to all who are authorized to make purchases. He supplies, on charge accounts to hospitals, subsistence stores required or which are authorized for sale; turns over daily the amount of cash received from cash and charge sales; abstracts the following day the articles sold for cash; abstracts during the month in which sold the articles sold on charge sales; makes the monthly abstract of subsistence stores sold, both charge and cash; abstracts at end of accounting month articles issued on ration returns or on special issue, etc. (See Manual for the Quartermaster Corps, and orders and circulars).
Property.-The officer in charge of this section is accountable and responsible for all property in his section. He prepares all requisitions for clothing, miscellaneous quartermaster supplies, fuel, forage, and ordnance, and supervises the issue of the same; sees that all salvage is collected and shipped; checks the property and ordnance accounts and returns; keeps informed by personal examination of the quantity and condition of property on hand and is responsible that it is reported upon his return; makes all reports called for.
Finance.-This section provides for all payments, handles the cash, keeps the cash books, examines all vouchers before payment, and renders all prescribed reports. The officer in charge is required to be bonded.
Maintenance.-This detachment is concerned with repairs and maintenance and is composed of carpenters, plumbers, electricians, and helpers, with a sufficient personnel to handle accounts, prepare food, and provide for police.
Salvage.-This division is under a small detachment of the Salvage Corps, which collects the miscellaneous articles deemed worthy of salvage and prepares them for shipment, turning the bundles over to the quartermaster for shipment to the designated depot.
Laboratory.-This division is under the charge of an officer responsible to the commanding officer for all the laboratory work of the center. He is in charge of the center and all subsidiary laboratories. He provides for distribution of all laboratory matériel of the center; makes recommendations to commanding officer to promote efficiency; indicates for commanding officer's approval the class of work to be done in the center laboratories; makes monthly consolidated report of all activities of laboratories in the center, with positive findings listed under proper headings.
The medical supply depot, base hospital, convalescent camp, evacuation ambulance company (ambulance company) and the sanitary squad are considered separately under appropriate headings in other portions of this manuscript.
THE BASE HOSPITAL
(Numbered from 1 up)
Base hospitals of 1,000-bed capacity should be provided in the proportion of four to each division of an expeditionary force. These should be services of supply organizations, and in order to facilitate their supply and simplify the evacuation problem, should be grouped, as far as it is possible to do so, in centers of from 5 to 20 units.a Hospital centers should be under the direct control of the chief surgeon of the forces, but detached base hospitals should be administered by the chief surgeons of the service of supply sections or army service area. Hospital centers and base hospitals should be located in army service areas, intermediate, and base sections at points offering the greatest rail and water facilities, advantage being taken of suitable existing buildings. The equipment of these units has been standardized to avoid the confusion inevitably created by personal predilection.
Base hospital projects approved for construction should be turned over to the construction service for completion. This construction should include proper sidings for hospital trains if rail facilities are available, water, lighting and disposal systems and adequate roads and streets. These hospitals should be prepared to give definitive treatment and so organized and equipped as to be in conformity with that idea.
It is essential that the operating surgeons be afforded opportunity to acquire a knowledge of battle casualty surgery, and to that end they should be assigned for periods to operating and attached to evacuation hospitals. Officers of the medical service, too, should be given similar assignments in order that they may become familiar with the care and treatment of toxic gas cases.
The commanding officer should insist that ward surgeons and chiefs of service realize the importance of correct and prompt preparation of case histories.
The officer in command of a base hospital should possess administrative as well as professional qualifications, and his office should have the following divisions. (It will be noted in this plan of organization that the office of director, having been considered superfluous, has been eliminated.)
Adjutant.-An officer of the medical administrative service should be detailed to this division to coordinate the work of the other divisions and their sections, to maintain the record files of the unit, prepare all communications arriving at or leaving the unit, to supervise the distribution of mail, and to conduct censorship of outgoing mail.
Guard.-This is exterior and is maintained by selected noncommissioned officers and enlisted men of the detachment according to roster, or from detachments from near-by line troops. The officer in charge of guard is charged also with policing of the unit area.
Records.-Concerned with maintenance of the miscellaneous records of the unit and statistical reports of the personnel.
Nurse Corps.-In charge of the chief nurse of the unit who controls the nursing service, making assignments to duty under authority of the commanding officer, and prepares all reports and returns relative to the nurses for approval and forwarding by the commanding officer.
Detachment.-Concerned with the orders relating to and assignments to duty of the enlisted personnel, and maintains the individual records of the detachment, and prepares the pay roll and muster roll.
Medical supply.-Under an officer of the medical administrative
service, and concerned with the preparations of requisitions for replenishment
for approval of the commanding officer, the receipt, storage, preservation and
issue of medical supplies to the unit, and the maintenance of records
pertaining to medical property as required by orders issued by higher
a These units are now designated as general hospitals. When not less than three general hospitals are operating in a group, the hospital center organization is authorized. See Tables of Organization, 683-W and 688-W.-Ed.
Religious and recreational.-Under control of the unit chaplain who, in addition to his spiritual welfare work, makes provision for the maintenance of reading and writing rooms, entertainments, games, both indoor and outdoor, assistance of the voluntary aid associations being solicited to this end.
Registrar.-In charge of an officer of the medical administrative service, who maintains the records of the sick and wounded, making the necessary alterations and additions, preparing them to accompany all evacuable cases or for forwarding to the chief surgeon's office in case of death, keeps the file of completed cases, and prepared sick and wounded cards of such cases for forwarding, prepares the daily statistical reports of the sick and wounded, and keeps a diary of the unit in which is entered from day to day all that transpires of interest, including orders involving movement of the unit.
Pharmacy, in which is maintained, under lock and key, the stock of those drugs and medicines capable of inducing drug addiction, and the nonhabit-forming medicines to be issued upon prescription, a file of prescriptions being kept for all issues and frequently scrutinized to preclude the unauthorized use of habit-forming drugs or intoxicants, check being made against the issues from the medical supply storeroom and the amount on hand in the dispensary.
Laboratory.-Equipped to perform the routine duties required in a large hospital, and divided into subsections for dealing with pathology-which includes the morgue-bacteriology, and serology, the latter being equipped for Wassermann and spinal-fluid tests.
Quartermaster, under an officer of the Quartermaster Corps, who is concerned with the supply of all articles and matériel not comprised in the medical supply, maintenance of the records and requisitions pertaining thereto. The office is divided into the following sections:
Disbursements, dealing with the pay, travel allowances, etc., of personnel and patients, and the pay of civilian employees. This officer is bonded, keeps the hospital fund, and prepares statements.
Supply and issues, dealing with the requisition for, the receipt of, issue of, and record of all property and supplies furnished by the Quartermaster Corps, including clothing.
Salvage, dealing with the collection of all equipment and matériel of every kind for sacking and turning over to the salvage officer of the center.
Laundry, heat and light.-Conducts these plants, with the assistance of civilian help, the laundry maintaining a linen exchange.
Transport, which cares for all transportation assigned the unit, and conducts this service under orders of the commanding officer.
Rations and messes, which draws and distributes the rations required, maintains supervision over the various messes, sees to the supply of fuel for them, and keeps the accounts.
Surgical service.-Under control of a medical officer of surgical ability who supervises the services. Subdivided into the following sections: Eye, ear, nose, and throat; genitourinary; dental, including amxillofacial; general, with its subsection of Roentgenology; orthopedic; head.
These services are dealt with under the heading "Hospital center."
Medical service, under control of a medical officer, who supervises the service. This is divided into the following sections: Neurological; general; contagious.
Convalescents.-In hospital centers
convalescents are concentrated in a unit provided for their care.b
In detached base hospitals these patients are formed into a detachment under an
officer of the medical administrative service who is known as the patients'
detachment commander. He is responsible for their pay, clothing, discipline,
nursing and amusement and recreation, all of which should be conducted through
the proper agencies of the hospital.
b A convalescent camp is authorized for each hospital center and normally should provide a capacity for 20 per cent of the normal capacity of the hospital center to which it pertains. See Tables of Organization, 685-W.-Ed.
SANITATION IN CAMPAIGN
From his induction into the service, through the vicissitudes of training camp, transport, and battle to his discharge, a soldier must be subject to the rules of sanitation if the force to which he is attached is to be effective. It behooves all officers, line and staff alike, to possess a knowledge of practical sanitation as applied to military life in contradistinction to the complex sanitation surrounding one in well-ordered civil life.
All must accept as axiomatic the statement that the sanitary apparatus found in profusion in civil communities and mobilization camps, for very obvious reasons may not be part of the sanitary equipment of a force in campaign, and that the successful field sanitarian must draw upon his fund of common sense and employ the simplest resources at hand which he must personally apply to the requirements, and not content himself with the issue of an order that often contemplates the use of matériel which is not obtainable.
Most literature upon sanitation of the Great War is based upon the trench system, which many deemed the normal, and as a result the literature is replete with descriptions of appliances in the trenches of all contending forces, leaving upon the reader an impression that war may not be prosecuted successfully without this mass of impediments to the transportation and use of which in open warfare he gives no thought. Successful warfare resolves itself into a question of mobility, and mobility signifies transportation. Therefore a military sanitarian must be gifted with vision broad enough to differentiate the essential from the nonessential, and must apply the well-known principles of sanitation to any form of warfare in a manner that will be productive of good, without laying himself open to the charge of being a nuisance through insistence upon the application of measures which a little thought would show to be impossible of performance.
The one and only object of field sanitation is to maintain a command in the most perfect condition of health compatible with military conditions, through reducing to a minimum the incidence of infectious diseases, by attention on the one hand to the individual and on the other hand to his environment.
Preparation of a soldier for his military service commences at the depot, where, if not previously immunized against smallpox, he is vaccinated and also inoculated against typhoid and paratyphoid, the efficiency of these measures having been proven beyond question. At the depot he is inculcated thoroughly with the necessity for personal cleanliness, involving attention to his teeth through use of the toothbrush, frequent ablutions of the body, washing of the hands after defecation and before going to meals, and the necessity for the prompt application of prophylactic measures after exposure.
Attempt is made to imbue him with the value of neatness in dress and care of clothes, with the double intent of improving his appearance and of creating a pride in the uniform, both reflexly arousing a desire for cleanliness of body and equipment. He is furnished with sufficient clothing, footgear, and personal equipment to make him fairly comfortable in the field, barrack, or billet except under the most extreme conditions, and is taught the care and use of his equipment in every phase of his new career.
Having acquired protection from the scourges that formerly decimated troops-smallpox, typhoid, and paratyphoid-and been taught the dangers of venereal infections and the surest means of precluding them, and through setting-up exercises and drills been made an up-standing, self-respecting man, the recruit is assigned to a command and enters upon his military career.
It is incumbent upon the medical officers at the depot to keep constant watch upon recruits, and particularly upon those from the rural districts, to detect the first symptoms of infectious diseases that most city-bred men acquire in childhood, and the methods of dealing with those infectious need no comment in a book of this nature.
The medical officers of the command to which the recruit is assigned must not be less vigilant in the detection of infectious disease than those at the depot, and frequent inspections must be made to weed out the infected or suspected, special attention being given cooks and those concerned in the handling of food to promptly detect and eliminate ''carriers."
When the command to which the recruit has been assigned is designated for service, either at home or abroad, just before entraining the medical officers should thoroughly comb the command for detection and elimination of infectious disease, including, of course, venereal diseases. En route to another station, either by train or by boat, daily inspection of the command should be made to detect infectious disease and also to insure the proper preparation of food and provision for pure drinking water.
Arriving at a camp or port of embarkation, constant inspection is to be made with a view to prompt elimination of the infected, and just prior to embarkation, all the medical officers obtainable should make a most thorough inspection of officers and men to exclude the unfit or diseased from the transport; for it should be constantly in the mind of every medical officer that the worst nuisance on shipboard is a case of infectious disease and that the value of a command may be nullified absolutely by its presence.
Daily inspection of the men, the living quarters, lavatories and toilets, and kitchens and pantries of the transport must be thorough to insure the highest degree of physical cleanliness. Ventilation must not be overlooked, and suitable provision must be made for the thorough washing and rinsing in hot water of all mess kits.
Upon arrival at the port of debarkation the command should be placed in barracks for adjustment and further weeding out of the unfit, but the military exigencies usually demand prompt transit to the zone of activity, and in this case the medical officers need to redouble their vigilance for the detection and elimination of infectious disease. The men must be instructed to report at once the appearance of body lice, these pests always being encountered at this stage of the journey regardless of personal cleanliness of the command, for this species of vermin is always found on military routes. Medical officers need to bear in mind that from this time on the louse will be the constant companion of troops until facilities for its elimination are provided.
The command may be en route to a training area, where the men are usually billeted in villages, and in this situation the efficiency of the medical personnel has its severest test. Eternal vigilance over every factor in the soldier's life is necessary to maintain a command at the highest physical standard. Latrines have to be prepared and maintained in perfect sanitary condition, being made fly-proof as well, and for the first time the medical officer realizes that such aids as crude oil, lampblack, or lysol are unobtainable, by reason of the difficulty in transport, and that his sole recourse is perfect mechanical cleanliness and constant instruction and supervision for its maintenance.
Of equal importance is the supply of water for drinking, and instead of waiting for the usual pronouncement of the bacteriologist upon the purity of the water, he should at once assume that it is impure and should see to the prompt installation of Lyster bags and the correct process of chlorination, at the same time placarding all other sources as dangerous, and he should see that guards are stationed to enforce his orders.
Billets should be examined for their capacity, 40 square feet per man being the minimum, and if ventilation is inadequate steps should be taken at once to provide the necessary amount.
Kitchens are to be maintained in scrupulous cleanliness and facilities for the washing and rinsing of mess kits installed, two galvanized-iron cans, one with hot, soapy water and the other with plain water, being sufficient for each company. Provision has to be made for the drying of clothes and shoes in each company, and if no room is obtainable for this purpose construction must be instituted. A small stove, with wires or lines strung across the space for suspending wet or damp clothing, being sufficient for the purpose.
Bathing facilities should be installed, and if a portable shower bath is not obtainable, recourse can be made to perforated tin boxes suspended in a convenient place, with simple facilities for heating water.
Kitchen and stable waste must be disposed of without creating a nuisance or permitting flies to breed.
Should the command be under canvas-which would be unusual in a foreign country-the requirements outlined herein would obtain, tents being substituted for billets.
The venereal rate always reaches its highest point in rest and training areas, and prophylaxis stations conspicuously marked must be provided in sufficient number, and records should be inspected daily. As sexual intercourse is a habit and not a necessity for soldiers,
advice in regard to abstention from it is seldom heeded and all known houses of prostitution should be placed off limits, with a guard to enforce the order, and prompt and adequate punishment instituted for failure to observe orders concerning prophylaxis and the reporting of venereal disease, for it should be borne in mind that all venereal disease can nullify the military value of a command as quickly as an epidemic of infectious disease.
In every training area is located a camp hospital of about 300-bed capacity, and all cases of disability should be promptly transferred to it.c Uncomplicated venereal cases, however, should be formed into a venereal battalion segregated from the remainder of the command. This battalion should not only receive intensive training under supervision of a competent urologist but should also be subjected to disciplinary control and given approximate police duties. In this way perfect control is exercised and the diseased isolated from the well with a view to the sudden transference of the command to another sphere of activity and the avoidance of confusion in segregation at the last moment. This system of segregation should be enforced during the entire period of the life of the command, whether in the front line or back areas. When the command is assigned to the front line its location is usually reached by marching, and medical officers must exercise constant vigilance for elimination of the unfit, must see to it that straddle trenches are provided, food and water surrounded by adequate precautions, and resting places properly policed upon departure.
As the command approaches the front line, facilities for personal cleanliness and waste-disposal become fewer; so care must be observed to dispose of waste in a manner that will not prove a menace or a nuisance to succeeding commands or to the civil population, and recourse must be had to prevent as much as possible the infestation of the command with lice, for these insects, feeding twice daily and multiplying with astonishing rapidity, may soon reduce the stamina of the command through the loss of sleep consequent upon irritation from the bites, which become infected and invite disaster should the victim be wounded. Literature on the subject is full of suggestions for the easy freeing of a command from these pests, but what is possible in trench or stable warfare is impossible in a marching column or in open combat, and it needs but little thought to understand the absurdity of attempting to use the heavy, clumsy and slow disinfestors which are the pièce de résistance of most writers upon sanitation in war under the latter conditions. The reader should firmly fix in his mind the fact that trench warfare is an unfortunate incident which is an open confession of the lost power of offense and is the last objective that any military commander desires or would permit if he had the power to make other choice.
The question for medical officers to decide when a command en route to or entering the line of combat is infested is what simple measures can be employed to reduce if not to entirely destroy these vermin, and the solution is found in the employment of hot flatirons over damp clothes, pressed upon the seams of clothing and underwear, and the use of certain drugs which are repellant to lice. With the knowledge that the command will be deprived of steam disinfectors in forward areas, each company should have on hand two flatirons and cloths and a quantity of naphthalin, creosote and iodoform for dusting upon the inside of clothing with happy effect. The hot iron pressed over damp cloth immediately destroys both adult and egg, while the N. C. I. [naphthalin, creosote, and iodoform] powder applied biweekly will act as a deterrent to further visitation. But the most efficacious and least unpleasant deterrent is ordinary tar soap, which wet and rubbed on the seams of clothing repels not only lice but also fleas; and as a cake of this soap used in this way will last a long time and is inexpensive, every soldier should have one in his kit and provision be made for replenishment. This use of tar soap was most successful in preventing infestation of the China contingent during the typhus season in 1912, 1913, and 1914, when the disease was rampant among the natives, and lice were omnipresent.
Having arrived at the front line, the command may enter either trench or open warfare, and if the latter, the conditions obtaining during the march must continue until the command is withdrawn to a rest area well behind the line, where facilities should be available for thorough bathing, delousing, and reclothing, and where a more or less quiet military life may be enjoyed.
c Hospitals of this type are now designated station hospitals and have a normal capacity for 250 patients. They are communications zone units. See Table of Organizations, 684-W.-Ed.
Trench or stable warfare imposes conditions upon a command in which it lives and fights in a very restricted area, in which death or injury is always imminent, and where, for obvious reasons the most perfect sanitary conditions must be maintained. As even in the quietest sectors, life in the trenches is none too enjoyable, it behooves the units occupying them to observe strictly the common-sense principles of mechanical cleanliness for their own sake as well as for the sake of units which succeed them, for otherwise conditions would speedily become intolerable. To that end provision must be made for the disposal of human waste, and such provision must naturally be placed so as to be readily accessible and yet offer protection from injury by the enemy.
With the knowledge that a command is to occupy trenches, the medical officers and quartermasters should prepare the simple equipment beforehand, and upon relief this equipment should be turned over as sector property. Latrines being out of the question in firing and support trenches, either oil drums, cracker boxes, or buckets should be provided, to fit snugly against the top of a box with a hole and a lid, the whole made fly-proof and placed for accessibility in an outshoot on the communicating trench and behind the support trench. If obtainable, a 5 per cent solution of cresol in water should be placed in each receptacle; otherwise, wood ashes should be provided in a box for a covering layer for each increment. Two of these receptacles are sufficient for each company, first firing and support trench, a similar receptacle being placed opposite in an outshoot, for officers.
In an outshoot from the communicating trench between the first firing and support trench should be dug a urine-soakage pit 4 inches in depth and width, the hole filled with small stones, broken bottles, or flattened tin cans, over which is thrown a thin layer of porous earth or sand, this being covered with gunnysacking, if handy, the surface being kept moistened with 5 per cent cresol if obtainable. Another of these pits should be placed between the feces receptacles for the men behind the support trenches, but none should be used if the soil is not porous. Latrines of the usual type may be dug farther back of the communicating trenches for use of the reserve, and these should be in dugouts, for protection.
Care of these receptacles should be exquisite, and men detailed for this duty should not be selected for punitive reasons but for their intelligence and zeal, and the fact should be impressed upon the command that this duty is just as necessary as a detail in the firing trench, for buckets or boxes must be emptied frequently and their contents carried the entire length of the communicating trench for disposal in one of the dugout trenches, and sometimes for a long distance behind that point.
Cooking in the front firing trenches is out of the question, as smoke and light immediately draw enemy fire. Food and water must therefore be brought from a distance, heat being maintained by the use of marmites. These are merely one receptacle within another, enough space being left between for an insulating layer of felt or hay. Too much care can not be expended upon marmites, for unless kept scrupulously clean they cause food fermentation. With this fact in view it is far better to provide them ready-made, with smooth inner container and a complete juncture between the inner and outer shell to preclude soiling of the insulating material; an accident invariably occurring in improvised marmites.
The usual period of trench service is four days, this being the longest period that the enervating duty may be performed without detriment to a command, though in times of stress the period is prolonged; and as the men may not leave the trenches for any purpose while able to perform duty, facilities for washing hands and face must be provided (as much for the sake of appearances as for the stimulating effect of the water) and a few basins provided as part of the equipment, water being brought to the trenches by a detail assigned that duty.
Drinking water must be chlorinated carefully, and a Lyster bag is necessary for each company. Depending upon the length of its occupancy, the trench may be a simple ditch or one provided with small dugouts containing bunks, stoves, lanterns, stools, tables and whatnot, and provided also with gas curtains. But whatever the nature of construction, if occupancy has been long the whole system is sure to be infested with vermin and with rats, and as men may not remove their clothing with impunity, the value of vermin repellants is enormous. Rats may not only constitute a menace by their presence but a menace as well through their bites and their fleas; and while the latter may be remedied by the use
of tar soap on the clothing, energetic measures are necessary to reduce rodents, large numbers of traps and the extensive use of phosphorus pastes being given preference. The use of lice and flea repellants is not only indicated for the comfort of the men, but it should be remembered, too, that the enemy may be afflicted by typhus and plague, and prisoners taken in trench raids may be the means of starting an epidemic spelling disaster.
Great care must be observed in trench life to detect and remove promptly any case of infectious disease, for the close contact of the men makes dissemination rapid, particularly in those diseases communicated through the medium of the mouth and nose secretions. All such cases should be promptly masked before their removal to a hospital, and contacts similarly made innocuous to others.
As trenches are open, both rain and ground water enter, and in spite of duck boards the men's feet are always wet and if the temperature is not very warm the constant maceration of the skin, with compression from shoes, socks, and puttees, gives rise to "trench foot," which, after the various theories have been discarded, still remains the old-fashioned chilblains and adds immeasurably to the victim's discomfort. To prevent this condition, the men's feet should be kept as clean as possible and whale oil or any other grease rubbed in with prolonged friction. Above all, means must be provided for the drying of shoes the minute a man is relieved from his post, and every man should have an extra pair of shoes and socks, so that he will always have one pair dry.
Having survived the ordeal of trench life, the command is relieved-for obvious reasons always at night-and is marched back to a rest area, where it should be afforded facilities for bathing, delousing, and reclothing.
Should the fortunes of war permit the command to give over trench warfare and take up offensive in the open, or even to pursue the enemy, exhausted nature requires its relief by a fresh command, and upon relief it goes into rest.
Whatever the situation, medical officers should not relax their vigilance for a moment, for a fatigued command is more susceptible to infection than is a fresh one, and as during rest periods replacements may impart all manner of infections, the greatest care devolves upon medical officers at this time. Upon appearance of the first case of infectious disease the victim and his contacts must be segregated and dealt with according to the nature of the disease. Diseases which are disseminated by nasal and mouth secretions demand that those who have them and all who have been exposed to them be masked at once and before anything else is done.
Upon completion of a campaign a command reverses the steps outlined herein, ever under the watchful eyes of the medical officers, and before being demobilized and returned to civil life it must be held in detention sufficiently long to free it from any disease which would be a menace to those in the homeland.