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Chapter XVII

Contents

CHAPTER XVII

THE DIVISION OF HOSPITALIZATION (Continued)

MEDICAL DEPARTMENT TRANSPORTATION

HOSPITAL TRAINS

Hospital trains of the American Expeditionary Forces, being Medical Department organizations,1 that department administered the personnel as signed to them and was responsible for the maintenance of train supplies and equipment.2 As railway units, hospital trains were operated under the direction of the officer to whom they were assigned, and were repaired by the transportation service, A. E. F.2

Assignments of hospital trains were made by the fourth section, general staff, general headquarters, A. E. F., to regulating officers and to the troop movement bureau, headquarters, Services of Supply.2

An officer of the Medical Department was assigned to each regulating station as a part of the staff of the regulating officer and as a representative of the chief surgeon, A. E. F., to whom commanding officers of hospital trains assigned to that regulating station, were directly answerable in matters pertaining to Medical Department administration.2 The medical assistant to the regulating officer was charged with the duty of seeing that trains were at all times ready to answer calls, and, to this end, that they were kept properly stocked and provisioned.

Briefly, evacuation of sick and wounded from the zone of the armies by means of hospital trains was effected by trains assigned to regulating officers. On the other hand, evacuation from hospitals in the rear of the zone of the armies was provided for by the troop movement bureau at headquarters, Services of Supply, in accordance with requests made upon the bureau for this purpose by the chief surgeon, A. E. F.2

Prior to the signing of the armistice, most of the hospital trains were assigned to the control of the chief surgeon's representative at general headquarters.3 The remainder, which were engaged in secondary evacuations-i. e., removal of patients from one base hospital to another in the Services of Supply-were under the immediate control of the transportation section of the hospitalization division, chief surgeon's office, A. E. F., except that certain of these secondary evacuations, the purpose of which was to clear base hospitals in the advance section, A. E. F., were conducted for a brief period by the regulating station at Is-sur-Tille.3

Since the operation of regulating stations, and primary evacuations from the zone of the armies are discussed in Volume VIII of this history, no further reference will be made to these subjects herein.

The transport and hospitalization of sick and wounded in the American Expeditionary Forces after they had left the zone of the armies, presented


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difficulties which differed in many respects from those which had confronted the French Army during three and a half years of warfare, and also from those of the British whose system of evacuation was similar to that of French though modified by geographic conditions.3 The French and British systems involved no long lines of communication to home ports. France was hospitalized intensively in each of her military regions, so that her disabled could be distributed among the many military hospitals scattered throughout the country, and, when hospital bed space was lacking, in private homes.3 The shortness of the journey to England made it possible for British wounded to reach home bases rapidly and in large numbers.

The American Army, on the other hand, was compelled to hospitalize in France and in England almost all its sick and wounded, during the period of active warfare, since it was impracticable to return to the United States any except a relatively small number who were permanently disabled.3 To meet the needs imposed by this situation and to economize personnel and matériel, we had recourse to the use of large hospitals and hospital groups into which patients could be received by the trainload. These organizations necessarily were situated on supply lines of the American Expeditionary Forces. The plan involved long hauls when patients were moved from the front into hospital centers in the intermediate or base sections, and early in the organization of the American Expeditionary Forces it was appreciated that ample hospital train service was one of the prime elements of a successful evacuation service. The procurement of such trains was one of the first subjects taken up by the chief surgeon, A. E. F.3

PROCUREMENT

Pending later arrangements, two hospital trains were rented from the French Government, the order for them being placed in July, 1917,4 delivery for one being effected in December of that year and for the other in February, 1918.5 Since it was known the French could not furnish more trains, and as a tentative estimate had been made that 10 trains would be needed for every 500,000 troops, contracts for others were let in England.6 By August 12, 1917, arrangements had been completed for the procurement of 12 hospital trains from England and the 2 (above mentioned) from France. As the situation developed, an increasing number of these trains was contracted for to a total of 48 hospital trains and 20 corridor trains for sitting patients only.5 Fifteen of the former had been ordered prior to December 31, 1917, and by the end of August, 1918, 17 hospital trains were in use, and orders had been placed in England for 23 others.5 The order for the corridor trains was placed on November 7, 1918.5 Delivery of trains of both kinds was stopped when the armistice was signed.5 At that time 19 hospital trains had been received from the British and 4 more were ready for shipment.5 The cost of each train was approximately $200,000.3 In addition to these trains others, not especially built for the conveyance of casualties but adapted as well as might be to that purpose, were rented from the French to meet emergencies.3


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BRITISH-MADE AMERICAN HOSPITAL TRAINS

Each of the British-made trains consisted of 16 coaches. With a few minor exceptions they were standardized and afforded the following accommodations:7 1 car for infectious cases, 24 beds (one end used for caboose); 1 staff car, 8 beds; 1 kitchen and sick officers' (sitting) car, 3 beds for cooks, 20 seats; 9 ordinary ward cars, 36 beds each; 1 pharmacy car, 12 beds; 1 personnel car, 33 beds; 1 train crew and store car, 3 beds; 1 kitchen, men's mess car, caboose, 2 beds for noncommissioned officers.

The average weight of an empty train, without engine, was about 450 tons, and the average length, less the engine, 920 feet.7 Long coaches, 54 to 56 feet from end to end, were used instead of the short, continental type, in order to insure more comfortable journeys. These trains were so attractive in appearance that they were frequently placed on exhibition in England before being shipped to the Continent.

Each train was provided with 360 beds for patients.7 Not infrequently, however, in emergencies, the train personnel gave their beds to patients, thus increasing train capacity to 396 beds. Fittings in all trains (except the one first rented from the French, which accommodated 306 recumbent patients) could be so adjusted by folding up the middle tier of beds that the relative number of recumbent and sitting patients could be varied from 120 of the former and 480 of the latter-the normal arrangement-to 360 of the former and no sitting patients. The crisis load was 120 beds and 488 sitting patients.6

Special provisions were made for the badly wounded, the slightly wounded, infectious and mental cases, respectively, including arrangements for their medical care and for supplying them with proper food.7 Special cooking facilities were afforded in the two kitchen cars which formed part of these trains.

The forward kitchen car was divided into three sections-kitchens, sitting room for disabled officers, and a bedroom for cooks.7 In the first section was installed an Army range with equipment, together with an apparatus providing an adequate supply of water for cooking purposes. This kitchen was used only when there were patients on board and was supplementary to the kitchen at the rear of the train. The latter served duty personnel, whether there were patients on board or not.

The staff car, for medical officers and nurses, was provided with sleeping compartments and a separate dining room for nurses and officers.7 Also it was equipped with a shower bath and was made as comfortable as possible.

Each of the 9 ordinary coaches for recumbent patients was fitted with 36 beds, arranged in tiers of 3. Beds were specially designed, were removable, and in case of necessity could be used as stretchers.7 When the car required cleaning these beds could be folded against the sides, and by lowering the middle one flush against the sides of the car the bed nearest the floor was converted into a comfortable seat or couch, the top one being still available for a recumbent patient. By thus converting beds into seats the less seriously wounded could sit up or lie down as desired.


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These coaches were considered models of simplicity and efficiency.7 To expedite loading and unloading double doors were provided on each side of each ward coach, as near the center as possible. In cases of serious injury where it was not advisable to remove a patient from the litter, this could be rested directly on the bed supports, without complicated adjustments. Ash trays and small racks for holding patients' toilet and other personal articles were provided in convenient places.

The pharmacy car was placed near the center of the nine ward coaches. It was well equipped with drugs, linen, medical and surgical necessities, and had an office where records were kept. It also had a room containing a collapsible operating table for minor operations or for changing dressings, a 12-bed ward, and a morgue.7

The car for infectious cases was divided into four compartments for patients and one for attendants.7 Each compartment for patients (used also for mental cases, as required) accommodated six patients.

The personnel car, provided for the enlisted force, was designed on the same lines as an ordinary ward coach, so that in emergencies it could be utilized as a patients' car.7 Accommodation for patients was also increased at such times by the insertion of litters wherever these could be placed.

The second kitchen car had dining-room accommodations for noncommissioned officers and enlisted men and was equipped with facilities for cooking and for heating water similar to those installed in the forward kitchen car.7

The last coach on the train furnished ample storage space for general supplies such as food and drugs for seven days and, in a section partitioned off from the rest of the car, afforded additional accommodations for the train crew.7

Trains were electrically lighted throughout and were capable of generating current when running at any speed.7 Storage batteries were placed under the bodies of the cars to furnish current when the train was not in motion, but orders were enforced that current be economized. Hurricane oil lamps and an ample supply of candle holders were provided for emergency use in case the electrical connections became disordered. Material for gas lighting was supplied at some stations, but in times of battle pressure trains were not held to have this supply.7 If this material was refused at any of these stations, the fact was reported to the transportation section of the chief surgeon's office.

Our British-made hospital trains were steam heated throughout, the ratio of heat-radiating surface being higher in them than in any other railway coaches on the Continent.7 Staff and personnel coaches were provided with a special self-heating equipment for use when detached from the engine. As the personnel lived on board, this was a necessary provision. When trains carrying patients were garaged on sidings and their engines detached, the train commander was authorized to request French authorities or the railway transportation officer to have an engine attached if weather conditions were severe.

An ample supply of water for drinking and other purposes was provided on all coaches, the amount per train being about 2,500 gallons.7 Drinking water was supplied in 6-gallon tanks throughout the train, and it was ordered that these tanks be filled as opportunity offered, due notice being given the railway transportation officer, who was charged with making necessary arrange-


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ments. All drinking water was sterilized. Water for washing trains was obtained from the station supply.

Special attention was given to ventilation of ward and other cars and of lavatories.7 Trains were equipped with large electric fans, and small portable ones were used in the treatment of gassed cases. Lavatory accommodations were ample.

TRAINS OBTAINED FROM THE FRENCH

The acute need for hospital trains arose first in May, 1918, at Cantigny, and was intensified during the operations in the Marne area.3 It continued throughout July and late into August in the last-mentioned sector and in that of the Champagne. A large number of American wounded were evacuated by trains procured from the French during operations in front of Paris in July and August, though we then had 9 trains, from Pantin, in service.3 From 4 to 6 of these were sent daily to entraining points and were routed into Paris or through it to other destinations. Arrangements had also been made with the French to furnish us other hospital trains and trains for patients. In the same way 45 French trains were borrowed for use during the St. Mihiel and Meuse-Argonne operations.3 These were additional to the 2 specially prepared trains rented from the French in July and the 19 built in England.

FIG. 82.-Hospital train obtained from the French, at Base Hospital No. 9, Chateauroux

French trains obtained for the Meuse-Argonne operation were of three main types:9 (1) Permanent trains made up of corridor cars. (2) Permanent sanitary trains made up of cars specially constructed for the transportation of bed patients. These were comparable to our hospital trains except that they were smaller, carrying 120 recumbent patients. Heating, as a rule, was central. Patients were unloaded through side doors. (3) Improvised hospital trains


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made up of ordinary passenger cars fitted with racks for holding stretchers. Only recumbent patients were carried in these, 12 to a car. Cars were heated by a small stove in each, and there was no communication between them. One enlisted man of the French Medical Department traveled in each car.

In addition to these hospital trains there were the mixed or semipermanent types, made up of the ordinary French day coaches (second and third class) with lateral corridors. Certain of them were equipped for carrying recumbent cases.9 Some of these trains were made up of corridor cars only; others only partially so. Two stretchers, one above the other, were placed in one-half of each compartment, leaving room for 3 sitting cases on the opposite seat; that is, each compartment carried 5 patients, 2 lying and 3 sitting. According to the number of compartments (6, 7, or 8), cars carried 12, 14, or 16 recumbent cases each, and 18, 21, or 24 seated; a total of 30, 35, or 40.

FIG. 83.-French hospital train, with continental type of carriage

The method of supporting stretchers varied somewhat, according to the type of train and also whether it belonged to the Midi or Paris-Lyons-Mediterranean Co.9 In cars of both these lines the interior handle of the stretcher rested against an iron frame fixed to the side of the compartment. In the Paris-Lyons-Mediterranean type of train the external handle of the stretcher rested on the end of the same frame, while in the Midi type of train it was suspended by a chain from the roof of the car.


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Carrying capacities of these French trains varied considerably.9 Some accommodated an average of 70 recumbent and 300 sitting patients; others from 70 to 280 recumbent and no sitting patients. Some carried 108 recumbent and from 230 to 250 sitting patients, and so on.

Toward the end of the Meuse-Argonne operation a few trains of large capacity, carrying from 1,000 to 1,500 were utilized for the exclusive use of sitting cases.9 It was thought that box-car trains would be used only during periods of intensive evacuation. In point of fact we employed them frequently during the Meuse-Argonne operation, because the whole front line from the sea to the Vosges was continually evacuating, and every available kind of transportation was needed.

Except the two trains obtained at first, those leased from the French were operated as arranged for by them, but their destination was controlled by the American Army.3 They were not used exclusively, however, for American wounded. French wounded carried on these trains were cared for and taken to American hospitals just as were American patients. Disabled German prisoners, too, were carried in the same way, no difference being made with them in accommodations, treatment, or disposition. During the St. Mihiel and Meuse-Argonne operations, approximately 2,000 wounded German prisoners were carried on trains belonging to the American evacuation service.3

It had been contemplated that box cars would be fitted up in such a way that they could be used for transporting patients from the front, and, by the readjustment of fittings, for transporting supplies from the rear.5 These fittings, consisting of metal posts supporting tiers of litters, could be screwed in to the floors and tops of cars and easily removed. Though these fittings arrived in France, they were never used, for while the idea appeared sound there was delay in cleaning trains and adjusting fittings. Moreover, cars were not always available when needed for this purpose. The French and the British Governments both had attempted to use the plan but soon abandoned it.

SUPPLIES

Initial supplies and equipment for hospital trains were procured from the American Expeditionary Forces medical supply depot, Cosne, upon which requisition was made direct.10 After being placed in operation these trains obtained their supplies from the hospital train store established at the central depot for hospital trains and from supplementary depots established as necessity arose. In times of pressure, hospital trains disembarking casualties at base hospitals where there were not hospital train depots, sometimes had to return direct to railhead areas without stopping for any prolonged period. Under such circumstances the commanding officers of these trains obtained supplies, if possible, from these base hospitals or from the quartermaster depots located there. Notice of stores drawn under such circumstances was sent to the central depot against which these supplies were charged, so that this depot could check the issue.

It was intended that property accountability should be taken care of by these depots and that hospital trains were to obtain their supplies from them on memorandum receipt, but until such depots were established it was neces-


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sary for the trains to keep a property account.10 As soon as depots were established, orders were issued for hospital trains to invoice the property to depots but to retain the same on memorandum receipt. When emergency issues were necessary, a telegram was sent to the base hospital or quartermaster storehouse, giving train number, time of arrival, and name and quantity of articles wanted so that these would be available on arrival. When absolutely necessary for supplies to be drawn at the railhead, notice of what had been drawn was sent to the central depot for hospital trains.10

A list of the standard equipment for each train was furnished the regulating officer and was kept for his reference.7 He was authorized to check this equipment whenever he deemed this necessary, and the commanding officer of the train was ordered to check it frequently, verify its condition, and make suitable provision for its care. Hospital trains were supplied with adequate material to effect exchange of all property brought by patients from evacuation hospitals, such as pajamas, splints, crutches, litters, air pillows, and dakinization tubing; when such matériel was delivered with patients at base hospitals it was similarly replaced. Also, a sufficient supply of litters and blankets was kept at the hospital centers to permit an exchange, thus avoiding transfer of patients from one litter to another. When reserve supplies were not sufficient for the exchange of item for item, either the commanding officer or the supply officer of the train was given a receipt for matériel not replaced.

Red Cross comforts for patients were obtained at any train depot.3 Blankets were checked frequently, were obtained from depots when needed, and were disinfected at the central sterilizing plant.3 Reserve blankets were turned over to the railhead depot when required, and other medical supplies carried as reserve when asked for. When the train returned to a depot these reserve blankets and supplies were replaced. Similarly clothing and shoe repairs for personnel were obtained at the hospital train depots. Splints and suspension bars were carried in reserve to replace those brought with patients from the zone of the advance. Arrangements for dental service of train personnel were made at the depots.

PERSONNEL

Each American train carried, at first, a personnel of 3 medical officers, 3 nurses, 1 sergeant, first class, or hospital sergeant, 2 sergeants, 2 cooks, and 31 other enlisted men of the Medical Department, including 1 engineer-mechanic.3 Later it was found that two medical officers were sufficient, the third being replaced by an additional nurse. Train personnel was housed and fed on board whether in transit or in garage.3

ADMINISTRATION

The commanding officer of a train was charged with several correlated duties, exercising military jurisdiction and professional control.10 He was responsible for discipline, exercising control over personnel and patients, for which reason he appointed a summary court officer. He was also charged with the thorough instruction of his personnel. When patients were being entrained or detrained, the entire train personnel was on duty, and only the


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officer in charge of the movement and the necessary enlisted help were allowed off the train.11 Furloughs were granted only on approval of the regulating officer or of the transportation section of the chief surgeon's office if the train was under the latter's immediate control. Passes to leave a train were granted with discretion. No such passes were granted in the advance zone, and nurses were not permitted to be away from a train longer than two hours. Such of the train personnel as became incapacitated were left at the nearest base hospital. If anyone on duty missed his train he reported at once to the railway transportation officer of the station it, being forbidden to travel without orders on any train; all absences were reported to higher authorities. Ward orderlies were not sent out of the train for any purpose whatever. At night at least one medical officer, one trained nurse, and one orderly for each ward remained on duty. Precautions against fire were enjoined, and appropriate orders, including assignments in case of such emergency, were issued. The train commander permitted no one to travel on his train except its authorized personnel, men whose names appeared on the evacuation lists, and those authorized by the chief surgeon, A. E. F., or by the regulating officer to whom the train was assigned.10, 11 Armed guards who had accompanied such a train from the zone of the advance were forbidden to return on it except as so authorized.10, 11

The train commander kept a war diary in which he made note of all matters of importance to its service.11 He reported to the regulating officer or to the chief of the transportation section, chief surgeon's office, all cases of slight sickness and of the wounded who should have been retained in the advance area, and all cases of death, giving full particulars. (The regulating officer, in turn, transmitted this information to G-4, general headquarters, and to the Army surgeon.)12 He supervised the treatment of patients and made provision for their care, kept up the records of sick and wounded, and sent to the chief surgeon A. E. F., to the commanding officer of the base hospital to which he was taking patients, and to the regulating officer, telegrams stating the number of recumbent and sitting patients in his total trainload, and the same information covering each class of patients on board: Wounded, sick, and gassed.11 His telegram to the regulating officer, confirmed by mail, gave complete detailed information concerning the trip. To the chief surgeon, A. E. F., and to the regulating officer he sent copies of his train report and of his "detraining state." A telegraphic report of any accidents, confirmed by letter giving full particulars, was sent to the regulating officer, who was charged with the responsibility of sending immediate relief, with a wrecking crew, and with report of the facts in the case to the chief surgeon's office.11, 12

Accidents causing damage to coaches, or derailments, were reported by telegraph to the transportation section, chief surgeon's office, A. E. F., and repeated to the Railway Transport Service, general headquarters.10 Demand for repairs, was handed to railway transport office representatives at bases where such repairs were possible and were authorized, but except in cases of great emergency no such demands were made at a railhead or other unauthorized station.

Suggestions concerning minor alterations in structure which appeared to be desirable, or notes on general conditions of trains, were sent by mail to the transportation section in the chief surgeon's office, A. E. F.11


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Trains were loaded as nearly as possible according to the instructions of the regulating officer and were routed as he directed, no trips being made except upon his authorization.2 Upon completion of evacuation the train was sent back to the regulating area and garaged there.11

If coaches were removed from or added to a train, notification with time, place, and cause, was telegraphed to the chief surgeon, A. E. F., or to the regulating officer concerned, who altered his record of the carrying capacity of such train and arranged his load for it accordingly.11 Changes in the composition of hospital trains were authorized only by the chief surgeon. If the regulating officer found that conditions required such changes, he consulted the chief surgeon's office. If through accident or emergency cars were detached, the regulating officer endeavored to have them returned as soon as possible if in his area; if outside it, he made appropriate request upon the transportation section, chief surgeon's office. Use of cars except for their designated purposes was forbidden.11

Careful classification of evacuable patients before loading was of vital importance, for the following reasons:11 The rate of distribution among hospitals in the rear was proportionately as rapid as classification at loading points was correct. Retention of patients of the same classification in the same part of the train expedited their removal.

Evacuation officers of hospitals where patients were received gave especial attention to the classification of outgoing patients into such groups as "Seriously wounded," "Gassed," "Ordinary sick," "Infectious cases," "Mental cases."11 The commanding officer of the train verified this grouping of cases according to classification. If several places were scheduled for detrainment, the patients were grouped according to their destination as far as this was possible.11

The evacuation officer gave the train commanding officer his evacuation sheet, on which appeared nominal lists of all cases-classified-to be evacuated, and the latter prepared his train for the load.11

When it was possible to do so the evacuation officer inspected each man as he was placed on board, noting the condition of clothing and dressings, the patient's field card, record of antitetanic injections given, and saw to it that no helmets, arms, or packets were carried. Only personal belongings were allowed to be retained by the patient.11

The following reports were rendered for each journey:10, 11

Detraining state: 2 (1 to detraining medical officer at destination; 1 to transportation section, chief surgeon's office, A. E. F.)

Report of train journey: 1 to transportation section, chief surgeon's office, A. E. F.

List of documents received: 1 to detraining medical officer at destination.

Nominal roll of officer patients: 2 (1 to detraining medical officer at destination; 1 to transportation section, chief surgeon's office, A. E. F.)

Death reports: 2 (1 to adjutant general's office, general headquarters; 1 to transportation section, chief surgeon's office, A. E. F.)

Nominal list of patients detrained en route: 1 to detraining medical officer at detraining station.

Telegram of French sick and wounded on train: 1 to commandant des Armees Francaises at destination.

Diet accounts: 1 to transportation division, chief surgeon's office, A. E. F.

War diary: 1 monthly to adjutant general's office, through transportation section, chief surgeon's office, A. E. F.

Return of journeys: 1 monthly to transportation section, chief surgeon's office, A. E. F.


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A correspondence book was kept on each train, and a reserve supply of official labels in the office of each train, as follows:11 (1) Casualty; (2) description; (3) patient's kit; (4) red labels (affixed to patients too sick to be transported farther and therefore put off at intermediate hospitals); (5) white or ship labels; (6) specification labels. These were supplied to trains as soon as obtainable by the depots.

The "detraining state" was a report given by the commanding officer of a hospital train to the detraining medical officer, and contained the following items:11 (1) Train number; (2) army from which entrained; (3) time and place of departure; (4) destination; (5) gross number of patients on board; (6) numbers classified as "lying" and "sitting" in accordance with the following category: Infectious cases (disease to be specified); mental cases; Carrel cases; venereal cases; any other special cases; civilian patients (including Y. M. C. A. and Red Cross men); labor contingents; French, Belgian, Portuguese, etc.; German.

When patients were entrained at base hospitals for ports of evacuation, the entraining medical officer sent this information by telegram to the detraining medical officer of the port. When trains were loaded with patients for hospitals located at seaports and not intended for ships, the word "Hospital" was noted on the telegram to specify destination. Patients carried only between stations-as, for instance, for dental treatment-were not included in the telegram to detraining station, as this telegram was intended to notify base hospital authorities concerning the amount of bed space which would be needed for patients then en route.10, 11

The commanding officer of the train and the evacuation officer checked the loading of patients and verified the number evacuated.11 When loading was completed the commanding officer of the train advised the railway transportation officer, who furnished him with an order of transport, showing destination, stops and load. The commanding officer advised the former of his readiness to leave, and verified the transmission of his several telegrams.

It was important that advance notice be sent of the expected arrival of a train, so that the receiving officer could arrange for prompt unloading and for sufficient transportation for the removal of sick and wounded to hospitals.11 In order to expedite matters, announcement of prospective arrival of the train was made to the commanding officer of the receiving hospital by telegram from the regulating officer. It was also made by telegram from the commanding officer of a train as soon as loading was completed.

As promptly as possible after a train was loaded its commanding officer made inspection, again examining field cards and clinical records, verifying information regarding the administration of antitetanic serum and, when necessary, ordering it to be given.11 He instructed ward car orderlies how to care for patients, and the orderlies prepared for him a list of the patients in their care. These lists formed the basis of the commanding officer's reports and of his telegrams to the chief surgeon and to the regulating officer making final records for the train trip.

In so far as the British-built American hospital trains were concerned the following scheme was adopted for a balanced load when it was desired to carry


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600 or more patients:11 Top berths were used for litter cases, the middle berths being folded, and lower berths for sitting patients, so that each car provided accommodations for 12 recumbent and 48 sitting patients. Serious cases requiring much attention were placed in the pharmacy car in order that their wounds might be redressed if necessary or the patients be otherwise cared for on the operating table installed in this car. Unless it was necessary to do so, wounded men were not removed from one car to another or from one litter to another. In times of stress the capacity of ward cars was increased by placing litters, in tiers of three each, across the car doors. These were secured by hooks attached to the end rods of the bunks, and by straps.

FIG. 84.-Interior of one of our hospital trains (British built)

Bodies of patients who died en route were left at the larger stations where stops were made, and full details regarding each body were given in an envelope to the officer taking charge of it, with notice that the commanding officer of the train had signed the official telegram notifying the central records office, A. E. F., of the patient's death.10, 11 Personal effects of such casualties were disposed of in accordance with Army Regulations. The transportation section of the chief surgeon's office, A. E. F., was notified by letter of all deaths occurring on trains, with full particulars, and a telegram was sent thereto at the same time as that sent to the adjutant general's office, A. E. F. Very serious cases were sometimes detrained en route, at the larger places, but only when this was absolutely necessary.11


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PROFESSIONAL ACTIVITIES

Serious cases were cared for at once. Orthopedic cases and those that would require dressing en route, if not placed in the pharmacy car, were placed in the middle and lower bunks, with injured parts next the aisle.11 Slightly wounded, recumbent patients were put in top berths and injured parts immobilized before the train started.11 Mental cases were searched before being placed on board (all patients were disarmed before being entrained) and were taken to a separate compartment the windows and doors of which were closed, ventilation being provided by electric fans and roof ventilators. These patients were kept under constant surveillance. Contagious cases also were carried in special compartments.

Chest cases bore transportation badly. Empyema cases usually drained freely. When there was danger of secondary hemorrhage, new amputations were dressed while a stop was being made. A few operations, including ligations of arteries, were performed on trains, but professional activity was limited usually to redressings-generally performed in the pharmacy car-and symptomatic treatment.11 Conditions causing the greatest concern were injuries of head and abdomen, and pneumonia cases. Cases of the first two classes were prone to secondary hemorrhage; pneumonia patients did not endure well any movement before convalescents. Gassed cases were carried recumbent when this was possible, and they were not allowed to smoke. If their eyes were injured and sensitive to the light, they were placed on the lowest berths if these were not needed for seriously wounded patients. If a patient's splint was so adjusted that it obstructed the car aisle, he was placed at the end farthest from the toilet and a chair put under his splint to remind passers to make a detour around him. Headboards of berths, especially on train No. 55, were placed at the end farthest from the car door, and patients were entrained head first and placed in berths without being turned around.13 This arrangement facilitated supervision by the ward master stationed at the center of the car. Upon completion of loading, this attendant examined all his patients and their medical cards, making appropriate entries in a notebook, noting the need of Carrel-Dakin solution, the administration or nonadministration of tetanus antitoxin and morphia, the presence of contagious or venereal diseases, abdominal wounds necessitating liquid diet only, and other items of professional importance.

SUBSISTENCE

Hospital trains drew rations and supplies at base hospitals if this plan was found to be more convenient.11 Drawing of commuted rations was found difficult. Sales commissaries in advance zones were not in convenient locations for the 30 or 40 stations at which trains were garaged, and even when available they had not sufficient stock on hand to supply organizations in addition to those to which they had been assigned.11 Nor were these sales commissaries open at all hours of the day and night.

French hospital trains in American service were furnished with rations by railhead officers upon request of the evacuation officer.12 Patients on these French trains were fed at station infirmaries at regular feeding points and stops were arranged for in the schedule.12


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MESSING OF PATIENTS ON REGULAR HOSPITAL TRAINS

Immediately upon entrainment patients were given hot drinks, soups, or other light nourishment. As the patients were to be on board only a relatively short time, meals were standardized on a number of trains-e. g., train No. 53, with the result that waste was minimized, the accumulation of unsuitable food prevented.11

On train No. 58 patients were served a thick soup containing ingredients that otherwise would have been served as separate dishes-such as beef, potatoes, beans, hominy, and the like-and were given sandwiches.14 This method expedited service and facilitated the feeding of bed patients and at the same time conserved stove space needed for special diets. On other trains-e. g., No. 59-patients received the garrison ration, except that special cases were given light, soft, or liquid diets.15

MESSING OF PATIENTS ON EXTEMPORIZED HOSPITAL TRAINS

As previously stated, patients on most of the trains rented from the French were fed by station infirmaries while en route, at regular subsistence points, and stops were arranged for in the schedule.12 When there was intercommunication between ward cars these stops were unnecessary. Certain of these trains were equipped with kitchen cars where patient's meals were prepared en route and served at certain stops specified in the schedule, and these trains were rationed accordingly. All French trains which the United States employed were rationed at railheads by local evacuation officers.12

DETRAINING PATIENTS

Each of our large hospitals or hospital groups had a railway transportation officer, one of whose duties was the arrangement of priorities for the stopping of hospital trains at proper detraining points.3 At each such detraining point detraining parties were organized, charged with the proper unloading of trains and with the duty of assisting train crews in the work of cleaning and disinfecting the cars, as well as in the proper exchange of blankets, litters and other supplies which might be unloaded with patients. This exchange was made through the train commander.

On arrival at a base hospital the commanding officer of a train had in readiness his "detraining state," which he turned over to the detraining officer of the hospital, together with all documents pertaining to patients, including any X-ray plates.11 These were duly receipted for. The detraining medical officer informed the train commander of the order in which his patients were to be removed; whereupon an officer of the train supervised the unloading, taking care that patients' kits went with them. Officer patients' baggage was turned over to a noncommissioned officer detailed by the detraining medical officer to receive and receipt for it. Any articles whose ownership could not be traced were turned over to the central hospital train depot, with full particulars regarding them.11

The train commander informed the railway transport officer of any gas, repairs, or water required and also gave the time when his trains would be ready to proceed.11 Unnecessary delays were carefully avoided, as even a few minutes' delay might mean the loss of a schedule, resulting often in a halt of three or four hours before a new schedule could be obtained.


331

SANITARY SUPERVISION OF TRAINS

The sanitary condition of these trains required constant supervision, as patients were often received at the front with badly soiled clothing.3 Many of them harbored vermin, and many suffered from infectious diseases. One of the greatest difficulties experienced in train service was the provision of any adequate supply of water under sufficient pressure for flushing out all cars, though trains carried many lengths of garden hose to make distant water connections.3 The French offered the use of their disinfecting apparatus employed on their own trains, but their process did not utilize the methods and agents which American authorities preferred.3 It was the American practice to flush out trains from end to end as they returned to the front, walls being washed with formaldehyde solution and floors scrubbed with strong cresol. Blankets were shaken, mattresses turned, and latrine buckets cleansed and deodorized with chloride of lime. French trains placed at the disposal of the American Army invariably had been disinfected with formaldehyde, though this measure consumed time which the American service employed in returning trains to the front.3 One reason for our method was the shortage of trains. When ours were held in garages or on sidings for any length of time, galvanized-iron cans were placed under all waste and toilet discharges and were emptied by train personnel into proper places before the train started. This was always a troublesome process, especially in large freight yards such as at Pantin, near Paris, where many trains of all kinds were placed on tracks so close together that passage between them with these iron cans was almost impossible.3

FIG. 85.-Hospital train at Base Hospital No. 27, Angers


332

LAUNDRY

Laundry was exchanged either at replenishment depots, including that of the regulating station, or at hospitals to which patients were taken.11

TRAIN MOVEMENTS

As stated above, train movements were determined by the Railway Transport Service, which made the necessary traffic arrangements.7 American trains were not allotted to any particular line but were interchangeable and were operated according to Medical Department needs and traffic facilities.

Immediately upon requisition of the first train, arrangements were made for garage points and for routing and rates of speed on French railways.3 Through areas in advance of regulating stations it was never possible to route hospital trains any faster than freight.3 This corresponded to the slow freight train of America, but the disadvantage was not so great as might be supposed, the distance between entraining points and regulating stations usually being short. In routing trains from the latter stations, however, to points far in the interior, and even to base ports, the transportation of patients at such low speed was inadvisable, though the French used it for their hospital trains.3

Our need for a faster schedule arose from the fact that hospital trains had to travel long distances to reach our base hospitals.3 After several conferences on this subject, held in Paris with the fourth French bureau, the French Government gave orders to the French director general of transportation that American hospital trains traveling from regulating stations toward the interior be given the advantage of passenger-train schedules.3 In point of fact the speed was that of military trains, but on lines in the interior a faster schedule was followed whenever technical conditions permitted. In cases of emergency trains were dispatched on fast schedules for the entire journey, provided this did not interfere with the schedule of military trains having priority. All express schedules were authorized by the fourth bureau, general staff, which arranged the intercommunicating schedules with the railway management. These authorizations for rapid movement were transmitted immediately to the regulating officers concerned, showing the advanced notice required for dispatching trains and the proper railway authorities to be notified in each case.11

Constant liaison was necessary between the regulating officer and train commanders, as the former could usually give the latter information concerning the approximate time of the next trip.12 Especially was this true when trains were in one garage and where train trips followed consecutively; that is, where the last train in was also the last train to go out. Trains were often moved up to the loading points as trains already loaded pulled out. In such cases it was difficult to determine the time of movement. It was important, therefore, under such circumstances that trains always be fully prepared to be called on to move at a moment's notice.

Trains were routed so as to reach their destinations in the shortest possible time.11, 12 They did not make stops en route even on sidings, if this could be avoided, and only after previous consultations with the railway authorities,


333

if this was possible. Long stops at railway stations were permitted only where tracks allowed loading or unloading without blocking the main line. Trains were ordered not to halt on main lines for more than the briefest possible time. At small stations unloading had to be done within a specified time, and so far as possible these places were avoided. Trains were split only in case of absolute necessity.

Night service was not often organized on branch lines, and notice had to be given in advance when trains were due to arrive at night.l2

The regulating officer selected new loading stations in the army zone at points most convenient to the evacuation centers designated by the army surgeon.12

When a hospital train garaged at a regulating station was asked for by the army, the regulating officer proceeded to route the empty train, fully equipped, to an entraining point farther toward the front, where sick and wounded were received from evacuation or mobile hospitals.3 The regulating station then routed the train back, generally through the regulating station and then farther on into the interior to base hospitals in the advance, intermediate, or base sections designated to receive the patients.

The train made this journey under more difficulties than are at first apparent.3 In all forward areas, railways were constantly congested by traffic, and all rolling stock was routed on a priority schedule from which no deviation could be made without causing great confusion. For example, bread trains, passing forward daily through the regulating station, had priority over everything except moving troops, and empty hospital trains going forward from regulating stations had to take their chances for priority with all other railway transportation loaded with army necessities. If one train at an entraining point fell behind its schedule for starting on the return journey this might for the next 24 hours throw out the schedules of other trains carrying all kinds of supplies, for after loading, the hospital train proceeded back toward the regulating station and it became one of a stream of empty trains passing to supply bases over the same route. After arrival at the regulating station, another schedule had to be arranged for it by the regulating officer to get it through to its destination or detraining point in the interior. Little outside assistance could be given train commanders along this entire route, for which reason full equipment had to be issued before the train could begin its journey. In addition to this, excess equipment, rations, and supplies had to be carried, to provide for the numerous emergencies and delays which might occur before it could reach its destination.

PROVISIONS FOR REPAIRS

It early became apparent that provision must be made for minor repairs first, and major repairs later, which could not be made by the mechanic on duty with each train unit; consequently, immediately upon acquisition of the first trains, arrangements were made with the French fourth bureau for garage and repair at the American car shops at Nevers.3 Necessary repairs always began within an hour after the arrival of hospital trains at the shops, whether by day


334

or by night. Facilities were also provided at regulating stations in the army zone for garage of hospital trains, minor repairs, reception of water, rations, medical supplies, and the distribution of mail.3, 12

SECONDARY EVACUATIONS

For secondary evacuations the 2 trains constructed by and leased from the French at the outset of our activities and the 19 trains built by the British were those chiefly employed, for they were in effect rolling hospitals, self-sustaining, and much better equipped for the care of patients during long hauls than were the smaller trains rented from the French.3 The latter were therefore used for primary evacuations.16 Secondary evacuation effected by the chief surgeon's office pertained chiefly to the movement of patients from base hospitals to ports of embarkation and the collection of certain types of cases-e. g., maxillofacial-at hospitals designated for their special treatment. Patients sent to ports of embarkation where those whom disability boards in the various hospitals had reported unfit for further military service in France (class D) and those who would require at least six months' hospital treatment before they could become members of class A; that is, fit for any military duty. Because of their serious wounds or their chronic illness, these class D patients required the most careful attention during transport, and, being widely scattered throughout France, their systematic collection and treatment en route presented a very serious problem to the transportation service. While many such patients made the necessary journey on ordinary passenger trains to hospitals at base ports, whence they were to be transferred to the United States, most of these were collected on hospital trains so routed as to impose the least hardship through unnecessary handling and delay in transit. The success of this secondary evacuation depended largely upon the cars used by disability boards at hospitals in the advance and intermediate sections in selecting such cases as were plainly able to bear both the journey on hospital trains and the subsequent transfer to ships at the base ports. If cases were selected at base hospitals for transfer to the United States which upon arrival at base ports were found unable to continue the journey to the United States, they had to be retained at port hospitals until such time as their condition warranted their embarkation and the long sea voyage. If such retention was protracted, there was danger of overcrowding hospitals at base ports.3

Prior to the armistice the collection of class D patients (i. e., those to be returned to the United States) for evacuation to the ports was a difficult problem, for these were cases of chronic illness or mutilating wounds, many of which required great care while in transit.3

As already stated, certain of these cases which were not in need of extraordinary care made the journey to base port hospitals by ordinary passenger train.3 Among such categories were cases of incipient tuberculosis and mental defectives of certain types; also some of those suffering from healing wounds or other injuries of the upper extremities could properly be sent in small parties accompanied by the necessary attendants. Larger groups of such cases were sent in special coaches furnished by the local railway transportation officer at hospital entraining points. Very often this method imposed hardship on certain types of cases sent, for many times it happened that changes of cars not anticipated by the


335

railway transportation officer were ordered by the French en route, accommodations sometimes being substituted which were inferior to the standard which the American service strove to maintain. But, whenever possible, patients were carried to the ports on hospital trains, for on the whole the system described above did not work well. It was resorted to only when hospital trains could not be spared for the purpose and hospitals had to be emptied to make room for fresh increments of the sick and wounded.

The movement of insane patients and mental defectives, including psychoneurotics popularly known as "shell-shocked," was always attended by difficulty and embarrassment.3 The laws of France prohibited the transport on French trains of men declared insane, but as a matter of fact this regulation was sometimes disregarded, for mental cases developed in regular, small increments, making it impracticable to hold these patients for the accumulation at hospitals of a sufficient number to warrant the routing of hospital trains to collect them.3 Unless mental cases needed the closest supervision, or unless they were such as to excite comment en route, many of these were sent, accompanied by proper attendants, on ordinary passenger trains as "observation cases."3 We never had cause to regret dispatching these cases in this manner, since they were chosen carefully for this method of transportation, and the procedure prevented the accumulation of mental cases at hospitals which could not maintain specially trained personnel for their care, observation, and classification.3

FIG. 86.-Entraining class D patients at Base Hospital No. 30, Royat


336

When occasion demanded, hospital trains made periodic visits to collecting points such as the hospital center at Bazoilles on call of the psychiatric service to transport cases accumulating there.3 Some complaints arose from various causes concerning the transportation of mental cases, but these were invariably investigated by the evacuation service of the chief surgeon's office and no instances were found in which such patients were subjected to conditions which jeopardized their safety or ultimate recovery.3

Similarly, difficulties confronted the assembling of maxillofacial cases at Vichy, where special apparatus and personnel were provided to care for them.3 These cases were received at base hospitals all over France, but their number never warranted the use of hospital trains for their collection at one point.3 Though it is true that many of these cases were ambulant and were able to make journeys on ordinary passenger trains, the French were very insistent that mutilated patients be not routed on such trains, where the sensibilities of the traveling public would be distressed.3 Aside from this issue, it was very difficult for attendants to feed such cases en route from one hospital to another. Transport of selected cases to the maxillofacial center at Vichy was therefore a matter of exceptional difficulty, for their wide dispersion in hospitals throughout France, and the paucity of cases in a given hospital did not warrant the frequent use of a hospital train for their collection and conveyance.3 To a degree the same difficulty applied to the assembly and evacuation of the blind.3

After the beginning of the armistice, and after battle casualties had been cleared from field units, most of the hospital trains were engaged in evacuations from hospitals in the advance or intermediate section to others near base parts, but a few continued to serve the Third Army, making primary evacuations from the area of occupation, until arrangements were made for shipment of casualties down the Rhine.3

SUITABILITY OF HOSPITAL TRAINS

During our active military operations of 1918 American hospital trains proved excellently suited to our needs, except as noted below.3 When once a patient was started on the journey on one of these trains, food, warmth, and necessary treatment en route were assured. Patients sent on trains rented from the French (other than the two first obtained) were not so conveniently served, for these trains had limited kitchen facilities, or none at all, and routes taken to American base hospitals were not provided with the rest and refreshment stations found all along French evacuation lines. The American Expeditionary Forces had no personnel for the operation of such stations. This was one reason why French trains were used preferably for short hauls from the front hospitals in the advance section and American trains on longer trips to hospitals farther to the rear. Though excellent in other respects, American trains were so long and so heavy that French railway officials found difficulty in laying them on sidings and in providing space for them at garages and entraining points. In about 50 per cent of instances where trains were placed on sidings it became necessary to divide them into two or sometimes even three sections. In cold weather this was a great disadvantage, for the reason that it disconnected part of a train from its circulating steam line.


337

AMBULANCES

Ambulances comprised two kinds of vehicles: Animal-drawn and motor. The Medical Department made use of both kinds of ambulances for the transportation of patients in the American Expeditionary Forces; transportation of patients was a responsibility with which that department was charged throughout.

PROCUREMENT

In the American Expeditionary Forces, the use of animal-drawn ambulances was very restricted. These ambulances were assigned only to Medical Department units serving with combat troops; that is, one ambulance company of each divisional ambulance section was animal-drawn.17 Both animal-drawn ambulances and animals for them were supplied by the Quartermaster Corps;17 their procurement was not a responsibility of the Medical Department.

The procurement of motor ambulances, on the other hand, was a direct responsibility of the Medical Department for the greater part of the war.5 In discussing this question it must be considered from both sides of the Atlantic, motor ambulances, though classed as Medical Department matériel when we entered the World War, became Motor Transport Corps matériel some months prior to the armistice. Since this change was effected considerably earlier in the American Expeditionary Forces than it was in the United States, there was a period when, as will be explained, the Medical Department in the United States was purchasing motor ambulances and shipping them abroad on Motor Transport Corps tonnage.

In December, 1917, what was then the Motor Transportation Service was created a part of the American Expeditionary Forces.18 Its purpose, in part, was the technical supervision of all motor-drawn vehicles; their reception, organization, and assignment (except vehicles belonging to organized units); and the organization and operation of repair and supply depots for motor vehicles. Until May, 1918, motor ambulances in the American Expeditionary Forces were not included in the classes of vehicles controlled by the Motor Transport Service, A. E. F.;19 however, they were maintained in a state of repair by that service. From May, however, all motor ambulances arriving in the American Expeditionary Forces were turned over to what had now become the Motor Transport Corps, A. E. F., but being classed as special vehicles, motor ambulances were held by that corps subject to the orders of the chief surgeon, A. E. F.19 Between this time and the following August, though the Medical Department procured motor ambulances in the United States, they were shipped overseas on Motor Transport Corps tonnage.20 Subsequent to August, when the Motor Transport Corps, in the United States, took over the procurement of motor ambulances from the Medical Department,21 their shipment overseas became a responsibility of the Motor Transport Corps. Thereafter shipments were based on estimates furnished by the Medical Department, A. E. F.


338-339

ESTIMATES AS TO NUMBER

On September 22, 1917, the following memorandum was submitted by the chief surgeon, A. E. F., to the chief of staff:

1. The following motor vehicles of all classes will be needed by the Medical Department to meet the demands of the forces which it is estimated will be here on July 1, 1918: Motor ambulances, 1,446; motor trucks, 905; motor cars, 338; motor cycles, 557.

2. The motor vehicles should arrive per month as follows, based upon the contemplated program of the arrival of troops:

Motor ambulances

Motor trucks

Motor cars

Motor cycles

October

145

91

34

56

November

145

91

34

56

December

73

46

17

28

January

290

181

68

112

February

145

91

34

56

March

73

46

17

28

April

217

136

51

84

May

217

136

51

84

June

141

87

32

53

Total

1,446

905

338

557

On November 27, 1917, the following more explicit estimate of the needs of the Medical Department in motor transport was submitted:23

Re reply to memorandum from chief of staff, dated September 18, 1917 (corrected to November 27, 1917).

The following motor vehicles of all classes will be needed by the Medical Department to meet the needs of the forces which are estimated will be here by the 1st of July, 1918:

1. For the Army:

(a) Chief surgeon's office-

Motor cars

2

Motor cycles

2

(b) Central laboratory.

(c) Army laboratories (3 laboratories), each laboratory-

Motor car

1

Motor cycle

1

Motor truck

1

(d) One sanitary train (combat division)-

Motor cars

7

Motor cycles

17

Motor ambulances

36

Motor trucks

42

Total for the Army-

Motor cars

14

Motor cycles

24

Motor ambulances

38

Motor trucks

48

Special bacteriological cars

6

2. For each corps (5 corps):

(a) Office of each corps surgeon-

Motor cars

2

Motor cycles

2

(b) Corps laboratories, each-

Motor car

1

Motor cycle

1

Total for 5 corps-

Motor cars

15

Motor cycles

15

3. For each division (30 divisions, including 10 replacement divisions):

(a) Each division surgeon's office-

Motor car

1

Motor cycle

1

(b) Division laboratories (1 each)-Motor cycle

1

(c) Evacuation hospitals (2 per division)-

Motor car

1

Motor cycle

1

Motor trucks

3

(d) Evacuation ambulance companies (1 per division)-

Motor car

1

Motor cycle

1

Motor ambulances

20

Motor trucks

2

(e) Motor ambulance companies and field hospitals (3 per division)-

Motor cars

7

Motor cycles

17

Motor ambulances

36

Motor trucks

42

Total for the division (30)-

Motor cars

330

Motor cycles

660

Motor ambulances

1,680

Motor trucks

1,500

4. Line of communications:

(a) Chief surgeon's office-

Motor cars

2

Motor cycles

2

(d) Surgeons at base ports (3 bases)-

Motor cars

3

Motor cycles

3

(e) Base port transportation (3 bases; 1 motor ambulance company at each base)-

Motor cars

3

Motor cycles

9

Motor ambulances

36

Motor trucks

9

(f) Medical supply depot (2 at ports, 1 in intermediate section, 3 in advance section; total, 6 depots), for each depot-

Motor cycle

1

Motor trucks

2

Motor car

1

(g) Base hospitals; to July 1, 1918, 130 will be needed and each hospital must have-

Motor car

1

Motor cycle

1

Motor ambulances

3

Motor trucks

3

Total for line of communications (exclusive of 10 replacement divisions)-

Motor cars

148

Motor cycles

182

Motor ambulances

426

Motor trucks

411

Special bacteriological cars

4

* * * * * * *

Grand total:

Motor cars

507

Motor cycles

881

Motor ambulances

2,144

Motor trucks

1,959

Special bacteriological cars

10


340-342

Before December, 1917, there had already developed an acute shortage of ambulances, and shipments from the United States, because of procurement and tonnage difficulties, were under our estimated need.5 Although cable after cable was dispatched setting forth our emergency needs along this line, the shortage continued to increase. The problem of estimating our requirements was made more difficult by the lack of tables of organization in Services of Supply, corps, and army units;5 existing tables indicated transportation for divisions only. By April 24, 1918, the following further-developed estimate, concerning the motor transportation required by the various elements of the Medical Department, A. E. F., was formulated:23

1. For the Army:

(a) Chief surgeon's office-

Motor cars

2

Motor cycles (side cars)

2

(b) Central laboratory (1 laboratory)-

Motor cars

2

Motor cycles (side cars)

4

Motor ambulances

2

Motor trucks

3

Special bacteriological cars

6

(c) Army laboratories (3 laboratories), each laboratory-

Motor car

1

Motor cycles (side cars)

3

Motor truck

1

(d) One sanitary train (combat division) complete motor equipment-

Motor cars

10

Motor cycles (side cars)

22

Motor ambulances

48

Motor trucks

53

Trailmobiles, kitchen, and water carts

16

Repair trucks

4

(e) Dental service-special dental cars

2

(f) Evacuation ambulance companies (1 per division)-

Motor car

1

Motor cycle (side car)

1

Motor ambulances

20

Motor trucks

2

(g) Evacuation hospitals (2 per division), each hospital-

Motor car

1

Motor cycle (side car)

1

Motor trucks

3

(h) Mobile hospitals (20 units), each unit-

Motor cars

2

Motor cycle (side car)

1

X-ray truck

1

Motor trucks

2

Motor trucks (cargo, for moving only)

18

(i) Mobile surgical unit (20 units) each unit-

Motor car

1

Motor cycle (side car)

1

Motor trucks (cargo)

3

(j) X-ray service, motor-X-ray trucks.

2. For each corps (5 corps):

(a) Office of each corps surgeon-

Motor cars

2

Motor cycles (side cars)

2

(b) Corps laboratories, each-

Motor car

1

Motor cycle (side car)

1

(c) Dental service-dental car

1

3. For each division (30 divisions, including 10 replacement divisions):

(a) Each chief surgeon's office-

Motor cars

3

Motor cycles (side cars)

2

(b) Divisiona laboratories (1 each)-Motor cycle (side car)

1

(c) Field hospitals (4 per division)-

Motor cars

4

Motor cycles (side cars)

10

Repair trucks

4

Motor trucks

44

Trailmobiles

8

(d) Motor ambulance companies (4 per division)-

Motor cars

6

Motor cycles (side cars)

12

Motor ambulances

48

Motor trucks

9

Trailmobiles

8

(e) Field signal battalion-motor cycles (side cars)

2

(f) Dental service-Dental car

1

Services of Supply:

(a) Chief surgeon's office-

Motor cars

6

Motor cycles

4

Motor cycles (side cars)

3

Bicycles

5

(b) Divisions of specialists (laboratory service excepted)-

The administration office-

Motor car

1

Motor cycle (side car)

1

Chief of groups (2 main groups), each-

Motor car

1

Sectionsb (9), each section-Motor car

1

One section-Motor cars

3

(c) Advance section-

Surgeon's office

2

Motor cycles (side cars)

2

(d) Intermediate section, surgeon's office-

Motor cars

2

Motor cycles (side cars)

2

(e) Base laboratories, (4 laboratories), each laboratory-

Motor car

1

Motor cycle (side car)

1

Special bacteriological car

1

(f) Base laboratories, central for hospital groups (28 laboratories), each laboratory-Motor cycle (side car)

1

(g) Surgeons at base ports (5 bases)-

Motor cars

5

Motor cycles (side cars)

5

(h) Base port transportation (3 bases), 1 motor ambulance company at each base-

Motor cars

3

Motor cycles (side cars)

9

Motor ambulances

36

Motor trucks

9

Trailmobiles

6

(i) Medical supply depot (3 at ports; 2 in intermediate section; 1 in advance section; total, 6 depots), for each depot-

Motor car

1

Motor cycle (side car)

1

Motor trucks

6

(j) Hospital centers (10 centers) each center-

Motor cars

2

Motor cycles (side cars)

2

(k) Base hospitals (130), each-

Motor cars

2

Motor cycles (side cars)

2

Motor ambulances

10

Motor trucks

3

aMedical supply unit (attached to divisional headquarters), each unit, 1 motor car, 4 motor cycles (side cars), 2 motor trucks.
bRecommended that G. U. section later have 3 cars and other 8 sections 2 each.


342

EVACUATION AMBULANCE COMPANIES

The Manual for the Medical Department, United States Army, 1916, contained provisions for the organization of evacuation ambulance companies. Since these were to be organized only in time of war, it is needless to state that no such companies existed when we entered the World War.

They were to be in the proportion of one for each division at the front, and their primary function was to be the evacuation of division hospitals, and the care and transportation of patients therefrom to evacuation, base, or other hospitals on the line of communications, or to points with train or boat connections for rail or water transport to such hospitals. They were to be field army organizations, and their personnel and equipment were to be that provided for a division ambulance company with such modifications as might seem warranted.

On November 12, 1917, the Surgeon General notified the chief surgeon, A. E. F., that the organization of three evacuation ambulance companies had been begun and that the personnel of each would be two officers and 60 enlisted men, and that its equipment would be that of a motor ambulance company less dressing station equipment.24 To this the chief surgeon replied requesting that vehicles for these units be increased from 12 to 20.25

Independently, the chief surgeon, line of communications, on November 27, 1917, recommended that ambulance personnel and transport within his jurisdiction be organized into evacuation ambulance companies, each consisting of 5 sections with 20 ambulances each.26 He also urged that if it were possible 30 sections of the United States Army Ambulance Service then in the United States but ready for shipment should be secured for the American Expeditionary Forces in order to avoid the complete breakdown which he considered immi-


343

nent.26 He remarked that the need of evacuation ambulance companies was becoming more and more apparent.26 The need for motor ambulance companies, conveniently located to meet current needs, instead of ambulances distributed among many combat and other organizations and the special need for such an organization (under the control of the advance section, Services of Supply) in the vicinity of the training areas was emphasized.26 Others as needed were to be located at other places on the line of communications. It was anticipated that personnel and matériel might ultimately be supplied from the sections of the United States Army Ambulance Service but until that service's resources were more than enough to meet its own needs, our evacuation ambulance companies might be developed quickly though temporarily by drawing in from various base and other hospitals all available transport and personnel.26 Even though such an organization might lack symmetry it would meet the situation temporarily until units of the United States Army Ambulance Service could be made available.26 The memorandum further remarked that 88 sections of that service in the United States not yet assigned, might be considered available for requisition for service on the line of communications. The necessity of a maintenance department with ample spare parts and other equipment was noted and the necessity for the immediate establishment of an ambulance park in the vicinity of the training areas was emphasized.26

The same date (November 27, 1917) the chief surgeon, A. E. F., initiated a cablegram to the Surgeon General to the effect that evacuation ambulance companies should be organized from the equipment and personnel of sections of the United States Ambulance Service, which had not yet been sent to France.27

Under date of December 8, 1917, a memorandum for the chief surgeon, A. E. F., emphasized the need for organizing on a large scale transportation for casualties, noted the limited amount of transport and inadequate spare parts available at camp and base hospitals, and requested that the chief of United States Army Ambulance Service loan to the United States Army one ambulance company section.28 It was further recommended that a cable be sent to the War Department requesting shipment of the necessary transport.28 A few days later (December 13) the chief surgeon, A. E. F., received a report, from one of his subordinates who had been ordered to investigate transportation requirements, in which emphasis was laid upon the need for evacuation ambulance companies; the wasteful results of assigning ambulances to small scattered commands; the difficulty of making evacuations in training areas, and suggesting number and locations of companies, sources of personnel and matériel, facilities for repairs, etc.29

On January 14, 1918, the chief surgeon, line of communications, reported that it was imperatively necessary to make provision for more motor ambulance transport in the advance section in order to evacuate the field hospitals, and recommended that a provisional motor ambulance company be organized from the resources of the 41st (the first depot) Division.30 This recommendation was approved and the organization of this provisional company ordered January 17, 1918.31 This unit, first designated the 116th Evacuation Ambulance Company and later Provisional Evacuation Ambulance Company No. 1 was the first evacuation ambulance company of the American Expeditionary Forces. It was located at Toul.32


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In converting sections which had been organized in the United States for the United States Army Ambulance Service (to serve with the French Army) to evacuation ambulance companies, A. E. F., some complexities arose, shown best in the following correspondence.

In a letter which the Surgeon General wrote The Adjutant General of the Army on January 30, 1918, he stated:33

1. In cable from the commanding general, American Expeditionary Forces, No. 322, paragraph 3, subparagraph A, it was stated that it was the unanimous opinion that evacuation ambulance companies be organized with the equipment and personnel of the sections of the United States Army Ambulance Service. This request was referred to again in a letter from the chief surgeon, A. E. F., written December 24.

2. In cable No. 486, paragraph 8, from the commanding general, A. E. F., the recommendation was made that the remaining 73 sections United States Army Ambulance Service be used in organizing the ambulance companies of the army sanitary train, item M201, and evacuation ambulance companies, M406, and that the remainder be drawn on for all ambulance personnel for replacement draft according to paragraph 4, cablegram 318.

3. The sections of the American Ambulance Service referred to are those now mobilized at Allentown, Pa.

4. It is the understanding in this office that when these sections were organized they were intended for service with the French Army, and they have heretofore been used for that purpose.

5. A decision is requested as to whether these sections could be used for the purpose indicated in General Pershing's cables.

6. It is to be noted that in some cases the officers attached to these sections are not medical officers. Also that they are equipped and have been trained with Ford ambulances, and that the ambulances provided for the ambulance companies of the Army are G. M. C.'s. Should the use of these sections be allowed, the personnel will differ from that as authorized for evacuation ambulance companies in the second indorsement of The Adjutant General's office, dated December 28, paragraph 3, subparagraph 8.

On March 12 The Adjutant General replied:34

There is no objection to the use of the enlisted personnel of the American Ambulance Service now at Allentown, Pa., organized under section 2, General Orders, No. 75, War Department, June 23, 1917, as amended by section 1, General Orders, No. 124, War Department, September 20, 1917, for any purpose for which the enlisted personnel of the Medical Department may be used. The commissioned personnel may be used in a like manner except that those officers who are not doctors of medicine will be assigned to such duties as their technical training permits. It is, however, to be understood that this authorization in so far as it relates to these officers is not to be construed as in any way modifying the provisions of paragraph 3, Manual for the Medical Department, 1916, which prescribes that:

"An applicant for appointment in the Medical Corps of the Army * * * must be a graduate of a reputable medical school legally authorized to confer the degree of doctor of medicine, etc."

and as fast as these officers are separated from the service their places will be filled by the appointment of medical officers.

In connection with the personnel of evacuation ambulance companies, the Surgeon General on March 22, 1918, wrote The Adjutant General, United States Army, as follows:35

1. Subparagraph H, paragraph 3, of second indorsement, Adjutant General's Office, December 28, 1917 (322.3 Medical Department, Misc. Div.), gives the personnel of evacuation ambulance companies as: 1 lieutenant, Medical Corps; 3 noncommissioned officers; 34 privates.

2. It is requested that this be amended to read as follows: 1 captain or lieutenant, Medical Corps; 3 noncommissioned officers; 3 mechanics; 2 cooks; 24 wagoners; 5 privates, first class, and privates.


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3. In General Pershing's organization project for evacuation ambulance companies, all transportation is motorized and consists of 20 motor ambulances, 1 touring car, 1 motor cycle with side car, 2 motor trucks.

4. The unit is liable to expansion by the addition of other ambulances.

5. The 2 cooks for the organization are necessary, the 3 mechanics are required to keep the motor transportation in proper order, and the 24 wagoners are the chauffeurs.

This request was granted in the following terms:

The following personnel for evacuation ambulance companies has been approved: 1 captain or lieutenant, Medical Corps; 3 noncommissioned officers; 3 mechanics; 2 cooks; 23 wagoners; 6 privates, first class, and privates.

This authorization must not be construed to change the numbers or grades of medical officers provided for the Medical Department in War Plans Division 9199-25, approved February 4, 1918.

Unfortunately, as may be seen from the following references to correspondence between War Department and the American Expeditionary Forces, these sections were not made available until the end of hostilities. On August 26, 1918, the chief surgeon, A. E. F., initiated a cablegram to the Surgeon General, in which he requested that the personnel of 48 ambulance sections, under process of organization for service with the French Army, be sent to France as casuals and without officers, since it was his desire to appoint officers in the American Expeditionary Forces selected from experienced men, graduates of the French motor service school.36 To these recommendations War Department replied that only 31 sections of the American Ambulance Company were available and that these would be shipped in September.37 On September 14 the Surgeon General notified the chief surgeon, A. E. F., that the 31 sections would be formed and sent to the American Expeditionary Forces, and that the personnel of these sections would be available for shipment in October instead of September, as formerly stated.38 On October 17 the Surgeon General notified the commander in chief, A. E. F., that Ford ambulances were being sent for the equipment of these sections.39

As some difference of opinion had arisen between the Surgeon General and the chief surgeon, A. E. F., concerning the number of ambulance company sections which had been organized and the number of sections yet remaining available under the Executive order authorizing them, the chief surgeon, A. E. F., on September 21, 1918, reported to the Surgeon General as follows:40

Commander in chief requested 48 ambulance sections as part of exceptional Medical Department replacements. The Adjutant General replied that only 31 sections were available. From the 169 sections had been already subtracted the number already organized, giving credit in the latter for 49 organized in France, whereas only 30 were organized there, and also they failed to consider 7 sections which had been disbanded and the enlisted personnel sent to France to fill up numerical shortages in the sections organized from the American Ambulance Service. It is a fact that there are 48 sections available and 9 others which; however, it is not deemed desirable to organize at the present time because the officers of these will be needed as supernumeraries for purposes of administration. It is requested therefore that the 48 sections asked for by paragraph 12, cable P 1591 be sent without officers in the manner requested by that cable. It is also requested that the shipment of Motor Transport Corps tonnage and allotment be made as called for, for October. Request every effort be made to ship material and personnel in October, and material remaining unshipped will be covered in November Motor Transport Corps priority.


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On October 30 the Surgeon General cabled that 31 ambulance sections were formed and available and that the remaining sections, to complete the 48 asked for, would be ready to sail in a few days.41

Meanwhile, on September 26, 1918, the chief surgeon, A. E. F., recommended to the chief of staff, A. E. F., the issuance of a general order, whose terms he proposed, concerning the operation of ambulances in the Services of Supply.42 In brief this was to provide that all ambulances in that territory be assigned to 18 definite evacuation ambulance companies, with the enlisted personnel then assigned to duty with these vehicles. The personnel of each unit, as recommended, should be 2 officers (captains or first lieutenants, M. D.), 2 sergeants, first class, 4 sergeants, 23 wagoners, 1 cook, 1 mechanic, 20 privates, first class, and 5 privates.42 The units were to be equipped with 20 ambulances or more, 1 motor cycle with side car, and such temporary additional machines and personnel as might be necessary, and vehicles so far as possible were to be garaged at hospital centers, base hospitals, camp hospitals, and other camps where they were thus used, but would at all times be under the orders of the commanding officer of the respective companies.42 A list showed that from 9 to 22 ambulances were garaged at the more important localities in the Services of Supply. In support of this proposed arrangement the chief surgeon urged that this organization would promote service by the pooling of ambulances and would provide units which in emergency could be sent to the zone of the advance.42 To these recommendations the chief of staff replied that as the assignment of ambulances was under the jurisdiction of the chief surgeon it was believed that they could be distributed by him as required for the purpose mentioned.43 The formation of provisional evacuation ambulance companies of varying strength, as outlined by the chief surgeon, was not favorably considered.43

On November 2 the chief surgeon, A. E. F., requested orders concerning pooling of ambulances at base ports, hospital centers, and other localities in the intermediate and base sections of the Services of Supply,44 but the general staff, general headquarters A. E. F., ruled that such orders were unnecessary, ambulances being under the jurisdiction of the chief surgeon and he enjoying authority to pool them if he so desired;45 accordingly, the chief surgeon, on November 6, 1918, issued orders that this be done.46

A total of 82 evacuation ambulance companies (including Provisional Ambulance Company No. 1) saw service in the American Expeditionary Forces.32 Of these, 12 which arrived after the armistice was signed were disbanded and their personnel reassigned in base section No. 2.32

Those which served overseas before the armistice, November 11, 1918, are discussed individually in Volume VIII.

ASSEMBLY, SALVAGE, AND REPAIR

Assembly, salvage, and repair of ambulances were important activities pertaining to their provision and adequacy within the American Expeditionary Forces.

On May 4, 1918, the chief surgeon informed the Surgeon General47 that motorized Medical Department organizations under orders for France should


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leave the vehicles they used while training at their respective training areas, receiving new and standard motor equipment in France.

This procedure was to obviate transporting used machines, which in most cases could not reach France until after the organization had been supplied there with other standard vehicles, another unit later receiving the used cars, which were apt to be minus part of their equipment and tools.

In the early days of the war the General Motors Corporation type of ambulance was adopted, because of its capacity.16 The ambulances were shipped to France, unassembled, the constituent parts of the bodies being placed in crates, and a series of envelopes were made up containing the number of screws, bolts, and nuts necessary for assembling the ambulances.16 Each operation was numbered and the corresponding number was placed on the envelope containing the hardware used.16 This ambulance body was not what is regularly known as a knocked-down body, and it was appreciated that considerable difficulty would be encountered in its assembly, unless trained men fully familiar with body construction were available in France.16 The Surgeon General's Office accordingly organized a unit known as the motor ambulance assembly detachment, consisting of 3 officers in the Sanitary Corps and 60 body builders and motor experts.16 After arrival in France this ambulance assembly unit began operations on January 2, 1918, at St. Nazaire.16 Within two weeks the necessary shelters had been constructed, power lines had been run, and the ambulance assembly commenced.16 A number of chassis and bodies had accumulated on the beach at St. Nazaire, and there was an urgent call from various organizations and divisions then in France for ambulances. The shop soon took on the appearance of a modern American factory and ambulances were turned out at the rate of 4 a day. This number was gradually increased until a daily output of 15 was reached.16

It was expected that all motor transportation would be delivered at the port of St. Nazaire.16 This, however, proved to be impracticable, and before long ambulances were being received at Le Havre, Brest, Bordeaux, Marseille, and La Pallice.16 Certain numbers of the original motor ambulance assembly detachment were sent to the parks at these ports and soon built up assembly organizations composed of Medical Department personnel and Motor Transport Corps personnel and the same efficiency was obtained as at St. Nazaire.16

In general orders, general headquarters, A. E. F., and headquarters, Services of Supply, ambulances were classed as "special vehicles."16 While orders covering assignments had been prepared by the Motor Transport Corps, all requisitions had been submitted to the chief surgeon's office, A. E. F., and that office had submitted requests to the Motor Transport Corps to assign ambulances to the points where they were most needed.16 Many organizations to which ambulances were assigned in the United States delivered them to the ports of embarkation there and they were shipped to France whenever practicable. However, no notice of prior assignment was taken in France and all motor transportation received was pooled.16

About one month before the armistice was signed a new type of knocked-down body was shipped to France. Inasmuch as it was assembled and painted in the factory and was then taken down in sections and shipped in crates, con-


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siderable time was saved in the final assembly at base ports in France and very much less personnel was required to operate the body shops. Four men could assemble two bodies in a day.16

The total number of ambulances shipped to France and Italy was 6,875; 3,805 were of the Ford type and 3,070 General Motors Corporation type.16 The former were used especially for primary evacuations in rear of the fighting line and the latter in other services farther to the rear and throughout the Services of Supply. There was never sufficient transport for the sick and wounded.48 Shortage of ambulances was placed at 40 per cent in April, 1918, at 50 per cent in September, and at 20 per cent in October of that year. Only by borrowing front the French and Italian Governments 30 of the ambulance sections loaned by the United States to those countries could our needs be met in the St. Mihiel and Meuse-Argonne offensives.48

REFERENCES

1. Manual for the Medical Department, U. S. Army, 1916, par. 613.

2. Circular letter from the commander in chief, A. E. F., to the assistant chief of staff, G-4, First Army and Paris Group and to regulating officers, August 29, 1918. Subject: Evacuation of sick and wounded.

3. Report of evacuation of the wounded into fixed formations, by Col. R. M. Culler, M. C. On file, Historical Division, S. G. O.

4. Memorandum from the chief surgeon, A. E. F., to the chief of staff, A. E. F., July 14, 1917. Subject: Weekly War Diary. Copy on file, Historical Division, S. G. O.

5. Report from the activities of the medical group, fourth section, general staff, G. H. Q., A. E. F., by Col. S. H. Wadhams, M. C., December 31, 1918. On file, Historical Division, S. G. O.

6. Report of the evacuation system of a field army (undated), by Col. C. R. Reynolds, M. C. On file, Historical Division, S. G. O.

7. Report of American hospital trains in France, by Maj. Howard Clark, M. C. On file, Historical Division,
S. G. O.

8. Report of Medical Activities in the zone of the armies, by Col. A. N. Stark, M. C. On file, Historical Division, S. G. O.

9. Report of the evacuation of the wounded in the Meuse-Argonne operation, by Col. H. H. M. Lyle, M. C. On file, Historical Division, S. G. O.

10. Instructions from the chief surgeon, A. E. F., to commanding officers of hospital trains, December 18, 1917. On file, Historical Division, S. G. O.

11. Reports of Medical Department activities of hospital trains, prepared under the direction of the respective commanding officers. On file, Historical Division, S. G. O.

12. Report of the hospital evacuating section, regulating station B, St. Dizier, made by Maj. L. C. Doyle, San. Corps. Copy on file, Historical Division, S. G. O.

13. Report of the Medical Department activities of Hospital Train No. 55, prepared under the direction of the commanding officer. On file, Historical Division, S. G. O.

14. Report of the Medical Department activities of Hospital Train No. 58, prepared under the direction of the commanding officer. On file, Historical Division, S. G. O.

15. Report of the Medical Department activities of Hospital Train No. 59, prepared under the direction of the commanding officer. On file, Historical Division, S. G. O.

16. Report from the chief surgeon, A. E. F., to the Surgeon General, U. S. Army, May 1, 1919. Subject: Activities of the chief surgeon's office to May 1, 1919. On file, Historical Division, S. G. O.

17. Tables of Organization and Equipment, U. S. Army, series A, Table 28, W. D., April 17, 1918.

18. G. O. No. 70, G. H. Q., A. E. F., December 8, 1917.

19. G. O. No. 77, G. H. Q., A. E. F., May 11, 1918.


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20. Cable No. 1407, from General Pershing to The Adjutant General, July 3, 1918.

21. G. O. No. 75, W. D., August 15, 1918.

22. Memorandum from the chief surgeon, A. E. F., to the chief of staff, A. E. F., September 22, 1917. Subject: Motor vehicles needed by the Medical Department by July 1, 1918. On file, A. G. O., World War Division, chief surgeon's files (451 Miscellaneous).

23. Letter from the Surgeon General to the surgeon, medical base group, A. E. F., October 27, 1917. Subject: Automatic replacement of supplies. On file, Historical Division, S. G. O.

24. Letter from the Surgeon General, U. S. Army, to the chief surgeon, A. E. F., November 12, 1917. Subject: Evacuation hospitals and evacuation ambulance companies. On file, S. G. O., Record Room (322.3).

25. Letter from the chief surgeon, A. E. F., to the Surgeon General, U. S. Army, December 24, 1917. Subject: Evacuation hospitals and evacuation ambulance companies. On file, S. G. O., Record Room (322.3).

26. Letter from the chief surgeon, line of communications, to the chief surgeon, A. E. F., November 27, 1917. Subject: Evacuation ambulance companies. On file, A. G. O., World War Division, chief surgeon's files (322.321).

27. Cable No. 322S. from General Pershing to The Adjutant General, November 27, 1917. On file, A. G. O., World War Division, chief surgeon's files (322.3212).

28. Memorandum from Maj. A. P. Clark, M. C., to chief surgeon, A. E. F., December 8, 1917. Subject: Transportation for evacuation of sick and wounded. On file, A. G. O., World War Division, chief surgeon's files (322.3211).

29. Memorandum from Maj. A. P. Clark, M. C., to the chief surgeon, A. E. F., December 13, 1917. Subject: Need of evacuation ambulance companies. On file, A. G. O., World War Division, chief surgeon's files (322.3211).

30. Letter from the chief surgeon, A. E. F., to the commander in chief, A. E. F., January 14, 1918. Subject: Provision of evacuation ambulance companies. On file, A. G. O., World War Division, chief surgeon's files (322.3212).

31. Telegram from the adjutant general, A. E. F., to the commanding general, line of communications, January 17, 1918. On file, A. G. O., World War Division, chief surgeon's files (322.3212).

32. Report on evacuation ambulance companies (undated) made to the chief surgeon, A. E. F., by the officer in charge of transportation, chief surgeon's office, A. E. F. On file, Historical Division, S. G. O.

33. Letter from the Surgeon General to The Adjutant General of the Army, January 30, 1918. Subject: Use of sections U. S. Army Ambulance Service as evacuation ambulance companies. On file, A. G. O., 322.3 (Ambulance companies, E. E., Miscellaneous Division).

34. Second indorsement from The Adjutant General to the Surgeon General, March 12, 1918; on letter from the Surgeon General to The Adjutant General, January 30, 1918. Subject: Use of U. S. Army Ambulance Service as evacuation ambulance companies. On file, A. G. O., 322.3 (Ambulance companies, E. E., Miscellaneous Division).

35. Letter from the Surgeon General to The Adjutant General of the Army, March 22, 1918. Subject: Personnel evacuation ambulance companies. On file, S. G. O., Record Room, 322.3212 (Evacuation ambulance companies).

36. Proposed cable from the chief surgeon, A. E. F., to the Surgeon General, U. S. Army, August 26, 1918. On file, A. G. O., World War Division, chief surgeon's files (322.3211).

37. Cable No. 1881-R, par. 6, from The Adjutant General to General Pershing, August 28, 1918. Copy on file, A. G. O., World War Division, chief surgeon's files (322.3211).

38. Letter from the Surgeon General, U. S. Army to the chief surgeon, A. E. F., September 14, 1918. Subject: Army Ambulance Service. On file, A. G. O., World War Division, chief surgeon's files (322.3211).

39. Cable No. 2035 R., par. 3, from The Adjutant General, to General Pershing, October 17, 1918. Copy on file, A. G. O., World War Division, chief surgeon's files (322.3211).

40. Courier cable from the chief surgeon, A. E. F., to the Surgeon General, U. S. Army, September 21, 1918. On file, A. G. O., World War Division, chief surgeon's files (322.3211).


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41. Cable No. 45, from The Adjutant General, to the commanding general, A. E. F., October 30, 1918. Copy on file, A. G. O., World War Division, chief surgeon's files (322.3211).

42. Letter from the chief surgeon, A. E. F., to the chief of staff, A. E. F., September 26, 1918. Subject: Proposed general order for evacuation ambulance companies. Copy on file, A. G. O., World War Division, chief surgeon's files (322.3211).

43. Memorandum from the assistant chief of staff, G-1, general headquarters, A. E. F., to the chief surgeon, A. E. F., October 18, 1918. Subject: Proposed general order for evacuation ambulance companies. On file, A. G. O., World War Division, chief surgeon's files (322.3211).

44. Memorandum from the chief surgeon, A. E. F., to the assistant chief of staff, G-4, general headquarters, A. E. F., November 2, 1918. Subject: General order for operation of ambulance service in S. O. S. On file, A. G. O., World War Division, chief surgeon's files (322.3211).

45. Memorandum from the assistant chief of staff, G-4, general headquarters, A. E. F., to the chief surgeon, A. E. F., November 5, 1918. Subject: General order for operation of ambulance service in S. O. S. On file, A. G. O., World War Division, chief surgeon's files (322.3211).

46. Circular letter (not numbered) from the chief surgeon, A. E. F., to base surgeons, November 6, 1918. Subject: Pooling of ambulances. On file, A. G. O., World War Division, chief surgeon's files (322.3211).

47. Letter from the chief surgeon, A. E. F., to the Surgeon General, May 4, 1918. Subject: Overseas motor transportation. On file, A. G. O., World War Division, chief surgeon's files (451).

48. Report from Brig. Gen. J. R. Kean, M. C., to the chief surgeon, A. E. F., April 24, 1919. Subject: Data to be used by the Military Board of Allied Supply. On file. Historical Division, S. G. O.

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