U.S. Army Medical Department, Office of Medical History
Skip Navigation, go to content

HISTORY OF THE OFFICE OF MEDICAL HISTORY

AMEDD BIOGRAPHIES

AMEDD CORPS HISTORY

BOOKS AND DOCUMENTS

HISTORICAL ART WORK & IMAGES

MEDICAL MEMOIRS

AMEDD MEDAL OF HONOR RECIPIENTS External Link, Opens in New Window

ORGANIZATIONAL HISTORIES

THE SURGEONS GENERAL

ANNUAL REPORTS OF THE SURGEON GENERAL

AMEDD UNIT PATCHES AND LINEAGE

THE AMEDD HISTORIAN NEWSLETTER

Chapter XVIII

Contents

CHAPTER XVIII

THE DIVISION OF HOSPITALIZATION (Continued)

THE PROFESSIONAL SERVICES

ORGANIZATION

The organization of the professional services in the American Expeditionary Forces, conformably to a plan which had been developed in the Surgeon General's office, was undertaken by the chief surgeon in the autumn of 1917. In Circular No. 2, November 9, 1917, chief surgeon's office, the organization of these services was prescribed and the scope of their activities defined. This circular provided for eight services each under a director, and for the future assignment of assistant directors, consultants for corps, administrative sections of the line of communications, larger hospital centers, and other commands. The services prescribed were general medicine; general surgery; orthopedic surgery; surgery of head; urology, skin, and genitourinary diseases; laboratories; psychiatry; Roentgenology. It emphasized the fact that professional authority did not include administrative control; directors were to be immediately responsible to the chief surgeon, and the professional services of hospitals were to be so organized that they conformed to the eight divisions prescribed above.

At about this time, a plan for the organization of the professional services in hospitals was formulated in the Surgeon General's Office,1 but no copy of this was received by the chief surgeon until several months later, and after a statement of organization of the professional services in the American Expeditionary Forces had been cabled to the War Department.2

On March 9, 1918, the Surgeon General wrote the chief surgeon as follows concerning the organization of the professional services in base hospitals:3

1. The attention of the hospital division has just been called, for the first time, to your letter of November 9, Circular No. 2, paragraph 5, in which it is noted that the commanding officer of each base hospital is directed to organize his hospital by the assignment of suitable officers to duty in charge of each of the eight sections, and that each chief of section will report direct to the commanding officer, to whom he will be responsible for the operation of his particular section.

2. Attention is invited to the fact that this is not quite in accord with the plan of organization adopted by the Surgeon General of the Army in his memorandum of November 11, which should have been sent to you at that time.

3. It will be noted that instead of having eight independent sections there are three main clinical services-surgical, medical, and laboratory-with a chief of each, and that each service is divided into sections representing the different special branches, eight in all. This was the result of many conferences and was finally adopted as a better plan of organization than to have the eight independent sections.

4. It is not contemplated that this arrangement will in any way interfere with the work of the different sections, but that the chief of each service will be the responsible coordinating officer for all of the different sections of that service and that he will be responsible directly to the commanding officer for the work of all the sections under his control.

5. It is not considered that this plan of organization of base hospitals would in any way interfere with your plan of organization, as provided for in paragraphs 1 and 2 of your Circular


352

No. 2. All base hospitals now organized and in process of organization in this country for service overseas are being organized in accordance with the Surgeon General's memorandum of November 11.

In another letter to the chief surgeon, dated March 16, 1918, the Surgeon General stated that the plan under which his office was then working provided for nine sections, instead of eight, among the professional services.4 One section concerned with food and nutrition had been added.

While the Surgeon General and the chief surgeon, A. E. F., were thus developing a continuity of policy in the provision and the orientation of the professional services, the services themselves were undergoing rapid development.

DEVELOPMENT

By General Orders, No. 58, general headquarters, A. E. F., November 10, 1917, "directors," as the chiefs of the several specialties were first designated, were appointed, respectively, for the laboratory service, general surgery, orthopedic surgery, and venereal, skin, and genitourinary diseases. In the following month a director of psychiatry was designated and directors of Roentgenology and general medicine in March of the following year.

On December 21, 1917, the following letter of instructions, which was typical of that issued to other directors, was forwarded to the director of general surgery:5

You are hereby announced as director of the division of general surgery for the American Expeditionary Forces.

You will proceed to such places in the training areas as may be necessary from time to time for consultation with medical officers serving with the American Expeditionary Forces, in matters pertaining to general surgery.

In this connection, your attention is invited to General Orders, No. 58, dated November 10, 1917, an advance copy of which is herewith furnished you.

At the end of each month you will submit, for confirmation by these headquarters, a list of the journeys performed by you under these instructions.

Commanding officers of the places visited by you are hereby directed to afford you proper facilities for carrying out this work; this letter to you is to be considered their authority for such action.

Chiefs of all services were announced and their new official designation prescribed by General Orders, No. 88, general headquarters, A. E. F., June 6, 1918, which is discussed below.

As shown by the histories of the individual services, there was great development of their activities prior to the publication of the general order last mentioned. The directors of all except the laboratory service were congregated at Neufchateau, where they were technically under the control of the hospitalization division of the chief surgeon's office, which was located from September 1, 1917, to March 18, 1918, at Chaumont, some 45 miles distant.6 Means of communication between the two offices were at first very limited, for transportation was scant, and mail and telephone facilities inadequate. The group continued to receive its orders from the chief surgeon's office even after this had been moved to Tours.6

Until April, 1918, the group of directors did not function as an organized body, therefore their activities were uncoordinated, each director seeking to solve in his own way his very different and difficult problems.6 No specific


353

instructions had been issued governing their status. The only office provided until April, 1918, which had the power to coordinate the efforts of this group was that of the chief surgeon, A. E. F., which, meanwhile, was being concerned with many other urgent responsibilities.

It is necessary to visualize the situation of the directors in the fall of 1917, and during the earlier succeeding months, in order to appreciate the difficulties of their task. Headquarters, A. E. F., including the chief surgeon's office, were undergoing rapid expansion and incessantly meeting new emergencies. The new professional directors, lacking military experience, were further handicapped though not having special regulations detailing their duties, and by lack of an agency for their effective organization and control.7 Each director believed that his appointment granted him authority to organize and direct separately his special department. Each was an enthusiast in his own specialty and the misnomer "director" seemed to imply administrative control which in fact was not conferred.6 Yet the direction and supervision of the professional services in all sanitary formations, the provision for continuity of treatment from front to rear, the modification, as need be, of accepted methods of treatment and the inauguration of new ones, were some of the duties with which they were charged.8 In the absence both of military experience and of specific instructions some confusion was inevitable, and for these reasons the zeal of the directors was at first to an appreciable degree misdirected as well as uncoordinated.6

Great embarrassments also developed in supplying members of the group with transportation, for each director was authorized to utilize an automobile for an unlimited time, though the multiplicity of their organizations and the shortage of motor vehicles rendered their supply very difficult.6

During this period many of the most able operators had been detailed as consultants in divisions and other formations, and thus removed from that service which they were peculiarly able to perform.9 The professional services were thus deprived of many of their best clinicians, for these officers were placed in positions where they, under existing conditions, could neither exercise their professional attainments nor handle properly the new situations that arose.

When junior members of the special professional services began to arrive and were assigned to combat divisions, the complications pertaining to the general operation of the professional services considerably increased.7 These officers were not recognized in the Tables of Organization, and the details of arranging for billets, mess facilities and transportation already greatly overtaxed were therefore difficult. For this reason the divisional specialists were assigned for billet and mess to field hospitals or to those facilities at division headquarters which accommodated transients and officers of junior rank.6 Assignment to divisional hospitals separated them from the division surgeon, for these units were not located at headquarters and this precluded the best performance of the specialists' duties which were divisional in scope. These complications now seem trifling, but they led to disturbed feelings which impaired the usefulness of the junior consultants.7


354

Usually division surgeons were officers of the Regular Army, and were trained along line of military administrative control. The specialist presented a new problem concerning which the division surgeon had not been sufficiently informed.7 The division surgeon had the choice of taking the specialist into his own overcrowded office, forcing him into a mess, where, usually, he was not wanted because of inadequate facilities and because he did not hold one of the positions which entitled him to membership, urging a harassed billeting officer to make room for him in an overcrowded headquarters town, or sending him to a hospital where also he was at once regarded as a person apart.7 The specialist, because of his new and unique status, was brought out in sharp contrast to the other medical officers serving with divisions.7 If he was not tactful, and he was not always so, his position was difficult. The division surgeon found it hard to make suitable arrangements for specialists even in billeting areas, and when battle conditions ensued the situation was almost impossible.7

By the spring of 1918, several divisions were in the firing line and additional divisions were arriving rapidly.10 As corps and armies were formed, the complexity of the situation for the consultants increased enormously.7 Medical officers in administrative positions, as well as the specialists, knew that a defective plan was in operation. All professional branches still lacked coordination and there was much confusion of activity; there were too many orders, too many reports, too many inspection trips; uncoordinated ideas were surging up from below, and until April, 1918, there was lack of effective administration from above.6 As the functions of the specialists were not well defined, the problems of the special branches were being handled by many different methods.

Some of the difficulties experienced by the consultants with divisions did not as a rule exist in the hospital centers.11 There the consultants usually were chiefs of services of base hospitals, who were assigned as consultants in addition to their other duties. Their living facilities were thus already provided and the geographical scope of their activities was limited. Though often harassed by demands from the directors for reports, the duties of their positions were generally well understood and systematically performed. There were some differences in the methods followed by the several services, but there were many basic similarities.

Though considerable attention is given above to the early lack of coordination, to the initial misconception of their duties on the part of directors, and to the difficult position which the specialists occupied with divisions, the fact should be stressed that despite these handicaps the initial work accomplished was of very great importance.7 After the group of chiefs of service at Neufchateau was reorganized in April, 1918, its efforts coordinated, and the duties of its members more clearly defined (in Circular No. 25, chief surgeon's office, A. E. F.), the value of the consultants' services was greatly increased.7

On April 18, a director of professional services was appointed with station at Chaumont,6 his office, for purposes of coordination, being in juxtaposition to that of the representative of the chief surgeon, A. E. F., with the general staff.12 In the letter notifying him of this assignment the chief surgeon wrote as follows:13

* * * * * * *


355

By virtue of this appointment, you are empowered to represent the chief surgeon, A. E. F., in all matters pertaining to the administration, direction, and coordination of the professional services. You are responsible for such professional matters relating to hospitalization, evacuation, laboratories, sanitation, and other activities as may pertain to the proper sorting, distribution, and evacuation of sick and wounded through the channels that will best insure efficient treatment from the front to the rear.

All requests for the movement of personnel and supplies originating in the professional services will be forwarded by or through you to the chief surgeon, A. E. F., or to some one designated by him.

The consultants in the professional divisions will be recommended by you for detail as teachers at the Army Sanitary School in such numbers and at such intervals as may be requested by the commandant of the school. In order that recent methods of treatment may be standardized, it is desired to make the instruction course at this school as thorough and intensive as circumstances will permit, and no effort will be spared in securing all instruction hours possible on the schedule of the school.

There is transmitted a tentative scheme of organization for the divisions under your control, and, after it has been given a fair trial, should any changes, in your opinion, seem warranted, you will submit appropriate recommendations to this office for recommendation.

The tentative scheme of organization to which allusion was made in this letter was published, as finally developed, in Circular No. 25, chief surgeon's office.

This circular charged the director with the supervision and coordination of the professional activities of the American Expeditionary Forces. The chief consultant in surgery was charged with the supervision of the professional surgical subdivisions, their organization and coordinations; with timely recommendations concerning changes in personnel, the formation of surgical teams and reports of their activities; with recommendations concerning inspections of his specialty. The chief consultant of the medical services was similarly charged with supervision of the medical subdivisions in the American Expeditionary Forces, and with such recommendations as were necessary to insure a high professional standard and complete harmony among his assistants in all formations. Senior consultants were to coordinate under their respective chiefs, professional activities pertaining to their respective specialties, and to make appropriate recommendations for instruction of consultants and specialists in divisional or other formations.

One senior medical and one surgical consultant, were to be assigned to each tactical organization equivalent to an army corps, and consultants were to be appointed in such numbers as might be necessary to assist divisional consultants. Senior division consultants were to be responsible for the duties theretofore discharged by division consultants, were to make frequent and complete surveys of professional practices in the division, supervise the activities of consultants, operating teams and other professional personnel attached to the division; organize and distribute such teams, including those which would serve newly arrived troops, and promote their efficiency; render appropriate reports, returns, and recommendations to the chief surgical consultant.

You will direct the compilation of a classified roster by each chief consultant, of all professional personnel, such as specialists, consultants, or surgical teams among the various army units of our own and allied formations, so as to facilitate their proper distribution and utilization in emergencies as well as in routine. When the organization of the professional service is completed, you will direct its workings, either from general headquarters or such other places as best serves the interests of the service.


356

With the three original divisions, medicine, surgery and laboratories as a basis, you will so coordinate the activities of the subdivision thereof that scientific research and clinical proficiency may be effectually promoted.

Circular No. 2 and Circular No. 11, this office, will be revoked or modified, as will all other orders, letters and instructions heretofore issued which conflict with the instructions contained in this communication.

A circular is now being prepared in this office along these lines.

The senior divisional medical consultant was to secure medical cases the best and most advanced treatment possible and make appropriate reports and recommendations to the chief medical consultant.

The divisional surgical consultant was to exercise immediate supervision over the work of operating teams in the division, but in time of mobile or semimobile warfare and when evacuation hospitals were lacking, this supervision was to be exercised by the senior divisional consultant or his assistant, over teams working in hospital for nontransportable wounded. Direction and supervision of the purely operative work in divisional formations was a duty of the senior divisional surgical consultant or his assistants. Divisional medical consultants were to supervise the immediate medical activities in the division to which they were assigned. The division surgeon was to furnish the necessary hospital facilities, supplies, and personnel other than those forming teams.

Such consultants for base hospital groups as were thought necessary by the chief surgical and medical consultants were to be appointed from time to time. Base and other hospitals so far as possible were to be organized in three services-surgical, medical, and laboratory-each under a chief of service. Under the chief of the surgical service were grouped general, orthopedic, and head surgery, including that of the brain, nervous system, eye, ear, nose, throat, face, and mouth; urology; roentgenology; and dentistry. Under the chief of the medical service were general medicine, neurology, and psychiatry, and under the chief of the laboratory service, pathology, bacteriology, and serology.

The first copies of Circular No. 25 were received simultaneously with the notice that the corps would not function while our divisions were reenforcing the French, and it was modified to permit the appointment of consultants to the tactical equivalent of an army corps.6 One week after Circular No. 25 was issued other changes were again instituted which permitted the consultants for corps to function.6

In effecting the reorganization of the professional services, the director of these services found himself considerably embarrassed by the fact that individual organizations had been built up around each director; the harmonizing of these, their coordination and summetrical development, therefore, were very difficult.6

An effort was made to procure a copy of the card index, prepared in the office of the Surgeon General, showing the professional qualifications of all officers in the American Expeditionary Forces, but this was unsuccessful and the director was obliged, in making assignments, to rely upon his very inadequate personal6 knowledge of the ability of each officer concerned.6

The publication on June 6, 1918, of General Orders, No. 88, general headquarters, A. E. F., gave the directors, whose titles were now changed to consultants, a status in the forces generally which promoted a broader appreciation of


357

their responsibilities.6 This order directed that there be appointed for the coordination and supervision of the professional care of the sick and wounded of the American Expeditionary Forces a director of those services, and a chief consultant in medicine and in surgery, respectively; also, that there be appointed for each army chief consultants, senior consultants, and consultants in special subdivisions of surgery and medicine. It also assigned selected officers as director of professional services, as chief consultants in the surgical and medical services, and as senior consultants in the following branches: General medicine; roentgenology; surgical research; neurological surgery; orthopedic surgery; ear, nose, and throat surgery; general surgery; neuropsychiatry; venereal, skin, and genitourinary surgery; maxillofacial surgery; ophthalmology. The order further directed that other senior consultants and consultants for hospital centers and other formations be designated from time to time as the need for them arose and that specialists in neuropsychiatry, urology, and orthopedic surgery be appointed from the divisional sanitary personnel.

It will be observed that Circular No. 25, unlike Circular No. 2, chief surgeon's office, A. E. F., did not include the laboratory division among the professional services, except in so far as the organization of base and general hospitals was concerned. Nor was that division included among them by General Orders, No. 88. Nevertheless, Circular No. 25, recognized the close relationship of this specialty and that of dentistry with the other services by including them with the special services in the hospital organization which it prescribed.

By General Orders, No. 88, and by Circular No. 25 the professional services were centralized and their efficiency greatly enhanced.

On August 7, 1918, the chief surgeon, A. E. F., wrote to the director of professional services stating that it was desired to have consultants in various specialties stationed at each hospital center; he was requested to nominate the officers who would be ordered to these centers for duty.14 These consultants were to include a specialist in diseases of the heart and one specialist in orthopedics who it was planned would be attached to each convalescent camp which formed part of a hospital center.

Each of these consultants was notified of his appointment and informed that he was expected not only to act as consultant for the hospitals in his center, but also that at regular intervals he would visit others, which his letter of assignment designated.15 With respect to the hospitals visited, these visits were to be made of service in establishing standardized methods of treatment and to assist in selection of cases for evacuation to the United States or to other hospitals.

On August 13, 1918, the chief surgeon asked the director of professional services to designate certain hospital centers to which specialists arriving in France might be sent, both in order to expedite their clearance from depot divisions and to determine their capabilities.16 At that time Roentgenologists were being sent automatically to the hospital center at Bazoilles, and it was desired that officers skilled in other specialties be similarly distributed to other selected places. The distribution was not to be made to apply to surgeons and internists who had not practiced specialties. It was, therefore, recommended that psychiatrists and neurologists who arrived as casuals be sent to Base Hospital No. 117


358

at La Fauche; specialists in eye, ear, nose, and throat surgery and ophthalmology to Base Hospital No. 115, at Vichy; specialists in tuberculosis to Base Hospital No. 8, at Savenay; urologists and dermatologists to Base Hospital No. 66, at Neufchateau; orthopedic surgeons to Base Hospital No. 9, at Chateauroux, and specialists in neurosurgery to Base Hospital No. 46, at Bazoilles.7

On August 27, 1918, certain orthopedic surgeons were appointed consultants in their specialty for designated districts.17 Hospitals and other formations in those districts which needed their services were authorized to apply to the nearest consultant at the address given in Circular Letter No. 7a. This circular gave the names of these consultants, their respective addresses, and the hospitals, hospital centers, and depot divisions which each of these consultants was expected to serve.

On September 2, 1918, the chief consultant of the medical and surgical services informed the chief surgeon that in order to meet the needs for qualified medical officers, it was essential that the chief consultants be authorized to reserve such officers as might be necessary to carry out the work in their several departments.18 They requested that the chief surgeon authorize such reservation of medical officers, and that their representatives be instructed to confer with representatives of the chief surgeon in order to prepare and put in operation a method for dealing with questions relating to the personnel of the professional services. The chief surgeon considered this plan practicable within certain limitations and arranged for a conference whereby a thorough understanding might be reached of the points involved.

On the same date the chief surgeon notified the director of professional services that certain officers had been designated professional consultants and heart specialists at five of the more important hospital centers; also, that they had been informed that this designation did not necessarily relieve them from their other duties.19 It was requested that, if possible, in making future recommendations to fill other vacancies among consultants in hospital centers, some officer belonging to a unit in the center be selected.19

On September 8, at the instance of the director of the professional services the following general letter was addressed by the chief surgeon to all division surgeons concerning the service of psychiatrists, urologists, and orthopedic surgeons assigned thereto:20

There is apparently some misunderstanding among division surgeons relative to the duties and status of specialists assigned to divisional formations for duty.

During the recent activities one division surgeon assigned the psychiatrist to dressing the slightly wounded. While he was engaged at this work, several hundred cases of slight war neurosis were evacuated that would never have left their division if they had been examined by a trained psychiatrist.

The above instance is cited to show the importance of properly utilizing the services of these trained specialists with a view in this instance of avoiding a repetition of the experiences during the recent activities, when a total of nearly four thousand cases of slight war neurosis were evacuated to base hospitals that should never have left their divisions.

I. GENERAL STATUS AND DUTIES

Orthopedists, urologists and psychiatrists are attached to tactical divisions solely to aid in dealing with the medical and surgical problems of the divisions.


359

Their activities have two objects: (a) To keep the fighting strength of the division at the highest possible point and (b) to bring about the prompt elimination from the division of those who become unfit for duty.

These three branches of medicine and surgery are represented because they are concerned with those diseases and injuries which experience shows contribute most to noneffectiveness of individual soldiers and troops in general.

The function of these specialists is to help the division surgeon in the clinical work of the division in much the same way that the sanitary inspector does in sanitation and the assistant to the division surgeon in administration. They should be attached to the office of the division surgeon as additional assistants. In no other way can they render efficient service. Their permanent assignment to any subordinate sanitary formation of the division inevitably curtails their usefulness. In periods of stress, however, they should be stationed by division surgeons in the post in which they can work to the best advantage (e. g. orthopedists and psychiatrists in triages, the urologist in the surgical hospital during combat).

They should not be regarded as consultants representing an organization outside divisional control, but as integral parts of the division sanitary personnel, wholly concerned with the medical work of the division to which they are attached and directly under the supervision of the division surgeon.

II. SPECIFIC DUTIES

ORTHOPEDISTS

Division in training or rest.-(l) Instruction in application of splints and dressings to entire sanitary personnel.

(2) Instruction in proper care of the wounded during transportation.

(3) Instruction in prevention and treatment of shock and hemorrhage.

(4) Examination and reclassification of those unfit for combat due to faulty posture and foot disabilities.

(5) The inspection of shoes and instruction in proper shoeing and care of the feet.

Division in combat.-(l) Supervision of supply and distribution of splints and dressings.

(2) Continuance of instruction in application of splint dressing, treatment of shock and hemorrhage, and care of wounded during transportation.

(3) Supervision of surgical treatment of wounded from front line to hospital.

(4) Prophylaxis of foot conditions arising in trench warfare.

UROLOGISTS

Venereal diseases.-Prophylaxis of venereal diseases: (1) Lectures to medical officers and personnel of prophylactic stations.

(2) Inspection of prophylactic stations as to proper location, equipment, personnel, technique, results, and failures.

(3) Cooperation with the A. P. M. in investigation of local conditions concerning prostitution, regulated and clandestine, and alcoholism.

Treatment: (1) Supervision of physical inspections, early recognition of venereal cases and evacuation to medical labor camp.

(2) Supervision of genito-urinary treatment and operations in divisions.

Skin diseases.-Prophylaxis: (1) Cooperation with other departments and officers concerned in the bathing and disinfecting of troops and equipment.

(2) Instruction of personnel assigned to bathing establishments in the prompt recognition of skin diseases, and the importance of removing them at once from their commands.

(3) Supervision of inspections for skin diseases made simultaneously with venereal inspections.

Treatment.-Supervision of treatment of skin diseases in field hospital or other medical unit assigned for the purpose.

Cooperation with the senior consultant in venereal, skin, and genito-urinary diseases through the division surgeon in accumulation of data concerning venereal, skin, and genito-urinary surgery, by monthly reports.


360

PSYCHIATRISTS

Division in training or rest.-(l) Elimination of insane, feeble-minded and epileptic (especially among replacements).

(2) Mental examination of general prisoners in accordance with section 11, General Orders, No. 56, current series.

(3) Instruction of medical officers regarding diagnosis, early management, and prevention of war neurosis (shell shock).

Division in combat.-(l) Examination and sorting of officers and men returned to advanced sanitary posts for exhaustion, concussion by shell explosion, and war neurosis in order to control their evacuation.

(2) Treatment of light cases of exhaustion, concussion, and war neuroses in divisional sanitary formations so as to preserve the greatest number possible for duty.

(3) Mental examination of general prisoners and men suspected of having self-inflicted injuries.

Concerning the withdrawal of consultants from the army corps, the chief surgeon of the First Army Corps, on November 4,
1918, forwarded the following record of his analysis of the situation:21

The chief surgeon, First Army Corps, desires to call attention to certain features connected with the organization of the Medical Department of a corps.

There appears to be a tendency to withdraw corps consultants. The undersigned believes this would be a vital mistake.

The corps surgeon should have on his staff the following: (a) Internist; (b) psychiatrist; (c) urologist work during active operations is concerned largely with bathing, delousing, and skin diseases; (d) orthopedist; (e) medical gas officer; (f) sanitary inspector.

Evacuation of sick and wounded should be supervised by the commanding officer, corps sanitary train.

All the above men should be carefully selected in order that each fits perfectly into his place. Each must have the undivided support of the corps surgeon.

Concentration of these specialists in an army and attempting to control the work of divisions without working through the corps will result in inefficiency. The army is too far removed from the front line. Personal contact with conditions in the front line is absolutely essential in order to properly appreciate the difficulties connected with divisional work and to formulate means for their correction.

The only consultant whose services can be dispensed with in a corps under present conditions is the surgical consultant. The chief surgeon, First Army Corps, however, feels that mobile hospitals should be under the control of the corps surgeon, and in that event a corps consultant in surgery would be indispensable. Mobile hospitals should work so far forward that only the corps surgeon is sufficiently familiar with conditions to determine promptly when and where they should be moved. The present system has not been satisfactory.

Divisions need constant supervision in all phases of their medical, surgical, sanitary and evacuation work. Obviously, the corps surgeon would be helpless in attempting such supervision alone. His staff of consultants furnishes him with an invaluable means for keeping in touch with every phase of the work in the various divisions, and if properly selected, supervised and supported, they are absolutely indispensable in enabling the corps surgeon promptly to detect defects and to correct them.

This can not be done from an army largely because of the lack of personal contact.

In this plan, each division consultant would be under the direct supervision of the corresponding corps consultant; each corps consultant under the supervision of the corresponding army consultant; each army consultant under the supervision of the corresponding chief consultant, G. H. Q., A. E. F. The chief consultant, general headquarters, A. E. F., would formulate policies-the army, corps, and division consultants would be responsible that these policies are enforced. Without supervision, they will not be carried out; with proper organization and supervision, they will be carried out.


361

The above plan gives a logical, balanced organization that will bring results. If corps supervision is not included, there will be a missing link that will mean inefficiency.

Transportation is of course vital. Without it, consultants in either army, corps or division are helpless.

It may be possible at some latter date that divisions may become so experienced and well trained that this supervision may not be necessary. This is certainly not true at present and we do not believe it will be true during the continuance of this war.

The chief surgeon, First Army Corps, feels so strongly in this matter that, in case the corps consultants are not included as the general policy, he requests that the First Army Corps be permitted to retain the staff as outlined above.

In commenting upon the above-outlined plan the chief surgeon, First Army, stated:22

It was thought at first the duties could be performed by assigning consultants to the army with assistants to work with the corps, but this plan has not proven effective due to the great distance the combatant troops are from the army headquarters, rendering it impossible to keep in touch with them with the paucity of transportation.

The paucity of truck transportation has precluded the further use of complementary groups with divisions, and it has been necessary to move the mobile hospitals far to the front to act as nontransportable hospitals, using the corps field hospitals for reservoirs.

The attitude of the chief consultant in surgery, concerning the plan of the chief surgeon, First Army Corps, was expressed by him as follows:23

The plan as outlined by Colonel Grissinger with reference to corps consultants is most heartily approved.

His suggestion with regard to the disposition of mobile hospitals and their control by the corps surgeon has been fully justified by recent experiences in the Argonne and is also concurred in.

* * * * * * *

On November 16, 1918, the chief surgeon instructed the director of professional services to confer with the chief consultants in medicine and surgery at the earliest possible date, with a view of compiling a report on the activities of the different subdivisions of medicine and surgery.24 He felt that by utilizing the services of the officers in the professional services during the then inactive period, every phase of the subject, from front to rear, could be covered without difficulty.

Unfortunately the early dissolution of the consultants' staff and the return of many of them to the United States prevented a full realization of the chief surgeon's project.

ACTIVITIES OF THE SURGICAL SERVICES

GENERAL SURGERYa

The section of general surgery, the parent stem from which the subsection of the surgical services, A. E. F., were subsequent offshoots, came into existence upon the appointment of a director of general surgery, November 10, 1917. On December 22, 1917, two assistants to the director were appointed, and on January 28, 1918, a joint office for administrative purposes was opened in Neufchateau, with the directors of the "divisions" of orthopedic surgery, psychiatry, and genitourinary surgery.

aThe statements of fact appearing herein are based on "Report of the activities of the division of general surgery, A. E. F.," by Brig. Gen. J. M. T. Finney, M. C., chief consultant, surgical services, A. E. F. The report is on file in the Historical Division, Surgeon General's Office, Washington, D. C.-Ed.


362

The section of general surgery, being independent at the time in question, as was true of the other professional services, reported directly to the chief surgeon, A. E. F. Pursuant to General Orders, No. 88, general headquarters, A. E. F., June 8, 1918, the various professional services were coordinated under a director of professional services, and the director of the surgical services now became the chief consultant thereof, with the following subdivisions, each in charge of a senior consultant, directly under him: roentgenology; surgical research; neurological surgery; orthopedic surgery; ear, nose, and throat surgery; general surgery; venereal and skin diseases and genitourinary surgery; maxillofacial surgery; ophthalmology.

SURGICAL CONSULTANTS WITH TACTICAL UNITS

The first step taken was the recommendation that a surgical consultant be appointed by the director of surgical services, following his appointment in November, 1917, for each of the tactical divisions then in France. After their appointment, these officers met the medical officers of the divisions and advised with and instructed them. When the tactical divisions went into the front line the services of the divisional surgical consultants proved to be more valuable in the hospitals, and thereafter their time was chiefly spent in the evacuation hospitals. Consultants to our divisions operating in French armies occupied their time chiefly in observing the methods and treatment in French hospitals.

There was in the beginning (in each division) a decided tendency to do surgery in the field hospitals. The chief consultant in surgery received an order from the chief surgeon, A. E. F., forbidding operations in a field hospital when an evacuation hospital was available. This made it possible to place consultants with mobile and evacuation hospitals only.

As the surgery was now all done in hospitals, other than divisional, save in unusual circumstances, it soon became apparent that consultants were not needed with divisions; therefore a consultant and assistant were then designated for each corps. This new arrangement was satisfactory until the First Army was formed, when the same objections obtained as to consultants with corps as proved true of divisions. A consultant for each army was then appointed, with a sufficient number of assistants, to supervise the surgical work in all the evacuation and mobile hospitals. This policy was put in operation in both the First and Second Armies and proved fairly satisfactory. Corps surgeons were almost unanimous in the opinion that no consultants were needed with divisions or corps.

SURGICAL TEAMS


 Another important step, after securing the assignment of consultants to tactical units, was the organization of surgical teams from the personnel of all base hospitals. This was initiated on January 7, 1918. Each team consisted of 1 operator and assistant anesthetist, 2 nurses, and 2 orderlies. A dozen teams were quickly organized, and others as more hospital units arrived, so that by the end of October some three hundred teams had been organized and two hundred were operating with the First and Second Armies.


363

THE PREOPERATIVE TRAIN

Another improvement instituted by the chief consultant, surgical services, was the "preoperative train"-a train filled with certain (unoperated) cases, which would not suffer from transportation and a delay of 29 to 36 hours. During the St. Mihiel operation the chief surgeon, First Army, was furnished a list of the type of cases suitable and the plan was put in practice, thus relieving the forward hospitals of many cases. No bad results followed except in a few instances where trains were sent to more distant hospitals.

SURGICAL CONSULTANTS, HOSPITAL CENTERS

The necessity for surgical consultants in the large hospital centers was apparent to the chief consultant for a long time; however, through lack of personnel, they could not be supplied until toward the end of active hostilities. At the end of 1918, 16 hospital centers had surgical consultants.

EXPERIMENTAL WORK

Early in January, 1918, a committee was appointed by the chief consultant in surgery to study the best methods of blood transfusion for use in the forward area. An excellent report was prepared and distributed to the medical officers. Instruction in the treatment of shock was given at the central laboratory, Dijon. Experimental work in connection with the problems of wounds of the thorax also was done. The chief consultant suggested an interchange of personnel between base and mobile hospitals and this plan was partly carried out.

LECTURES

In addition to the activities directly connected with the treatment of the wounded, the senior consultants of the subsections and the consultants with troops and hospital centers gave lectures at the Army sanitary school, Langres, on surgical subjects connected with their various departments.

NEUROLOGICAL SURGERYb

A senior consultant in neurological surgery was appointed on June 7, 1918, and directed to organize a subsection. His problem was unique since no precedent existed in any army. A rough estimate by him made it seem probable that 25 per cent of all casualties would present neurological problems; unofficial figures from British and French sources gave the following percentage of nerve injuries: Wounds of the head, 16 per cent of all wounds; wounds of the spine, 2 per cent of all wounds; wounds of major peripheral nerves, 20 per cent of all serious wounds of the extremities.

The problem presented two aspects: The immediate care, in forward hospitals, of the more serious cranial and spinal cases; later care at base hospitals of residual paralysis of peripheral nerves. The results at that time in both cases were not encouraging; over 50 per cent of penetrating skull wounds

bThe statements of fact appearing herein are based on "Report to the chief surgeon, A. E. F., from the senior consultant in neurological surgery, dated Neufchateau, Dec. 2, 1918, on summary of the activities of the department." Copy on file, Historical Division, S. G. O.-Ed.


364

and 80 per cent of the spine were fatal. The wounds of peripheral nerves were simply accumulating and awaiting treatment later.

The plan of organization provided for teams for hospitals in the zone of the advance; representatives in the base hospitals; neurological centers.

For each team, one surgeon from each evacuation hospital was selected, given special instructions and assigned to this work in his hospital; also proper equipment was supplied. A difficulty was that in "centers" devoted exclusively to diseases and injuries of the nervous system, as in the French Service, on emergency these surgeons were often impressed for general work. Another difficulty, in a rush period, was the slowness of head operations. Often the tedious head cases were passed on to base hospitals that more cases might be handled. Through June, 1918, there were teams only at Mobile Hospitals Nos. 1 and 2; by July most of the evacuation and mobile hospitals had such teams. Following this, more specialists arrived from the United States and more instruments were available; so that, before the St. Mihiel operation in September, each hospital in the forward area had an experienced team. Although this operation was relatively short, it was seen that one team in each hospital was not sufficient to screen out the cases; in some hospitals the teams were off duty or doing general surgery, and the results were not satisfactory. Fifty per cent of head cases died, exclusive of those dying later in base hospitals.

In preparation for the Meuse-Argonne operation, the senior consultant, neurological surgery, urged the chief surgeon to supply two teams to each hospital on the main line of evacuation-Fleury, Souilly, and Villers-Dancourt; and to direct that field hospitals route suitable cases to one of these points. Instead, the British plan was followed; one hospital at Deuxnouds, was selected, and several teams concentrated there. Some 813 cases were secondarily routed to this hospital, whose location and general arrangements were poor. Because of these conditions and the changing personnel results were not entirely satisfactory, resulting in the adoption of the former plan, that is having special hospitals, farther forward, as named above. From 50 to 100 beds were set aside for these cases at each of the three hospitals.

As to wounds of peripheral nerves little more could be done in the advance hospitals than to prevent the destruction of nerves by extensive débridement, and to have some divided nerves sutured. This latter procedure was necessarily rare. These cases were generally handled in the base hospitals, where provision was made as far as possible, for a specialist at each.

As a rule each hospital group, a center, had one selected hospital to which proper cases were to be sent, either on arrival or later.

It was the intention to have a group of well-trained neurologists and neurosurgeons for each of the large centers and this plan was put in operation at some centers, as, Bazoilles, and Contrexeville. Military Hospital No. 1 served for the Paris group. Owing to lack of suitable personnel and to the difficulties of secondary routing, the project of a district neurological center had to be abandoned; though Base Hospital No. 115, at Vichy, made a very successful start in that direction.


365

ORTHOPEDIC SURGERYc

The orthopedic service began with the dispatch to England of an orthopedic surgeon and 20 assistants in May, 1917. These officers were assigned to duty at different orthopedic centers there pending the organization of the American Expeditionary Forces.

The subject of splinting was taken up in July, 1917, and a committee was appointed by the chief surgeon, A. E. F., for the purpose of formulating regulations for the standardization of splints. This committee recommended a set of splints, which were adopted, and described in the Manual of Splints and Appliances for the Medical Department of the United States Army, 1917.

More orthopedic personnel was now arranged for, and in October, 1917, 45 orthopedic surgeons, with 3 Sanitary Corps officers trained for splint shop work and 12 special nurses, sailed from the United States for England. All this personnel was assigned (temporarily) to the British Service, partly for instruction and partly to assist the British Medical Service.

In November, 1917, a director of orthopedic surgery and two assistants were appointed. The director and one assistant were stationed at Neufchateau, the other assistant was stationed in London as liaison officer with the British Medical Service.

Shortly after this time, our troops occupying training areas, the orthopedic problems were chiefly static defects, such as flat feet, weak back and knees, among line troops. To correct these static defects, a special training battalion was established in the 26th Division, then at Harechamp, where the men were trained to correct faulty habits of posture while on a duty status. This battalion was successful and was later transferred to the First Depot Division at St. Aignan-Noyers. By July, 1918, the need for class C men-that is, men unfit for front line duty-was so great and the number of the men mentioned so great and instead of attempting to make them fit for class A they were given short periods of training and assigned directly to class C duty. In this manner, at one time, 1,200 men were assigned to the Hospital Corps, 1,000 at another time, 1,000 for prison guard duty, 100 for military police, and others in smaller groups.

In November, 1918, a number of our orthopedic surgeons were withdrawn from service in England and assigned to combat divisions in the American Expeditionary Forces for the purpose of training Medical Department officers and men in the proper application of splints. At first three such orthopedists were assigned to each division for this purpose. In addition they made a survey of the entire personnel, and as far as possible, corrected defects of this. Later, when the divisions entered combat, training in the application of splints became a principal feature of the orthopedic section. Divisional arrangements for the transportation, storage, and handling of splints were also in the hands of the orthopedic surgeon.

Supervision of bone and joint cases was given to the orthopedic section. To accomplish this, one of the assistants to the chief consultant was assigned to

cThe statements of fact appearing herein are based on "Report of the senior consultant, orthopedic surgery, on the activities of the department of orthopedic surgery, made to the chief surgeon, A. E. F." On file, Historical Division, S. G. O.-Ed.


366

the zone of the advance and another to the hospitals in the rear; supervision of the work in the combat divisions was given to a third. In addition to these, special consultants were assigned to various groups, to centers, and hospitals.

In order to care properly for the bone and joint cases, standardized methods were announced and taught: First, splinting; second, transportation; third, posture of limb injured. This standardization did away with the unnecessary changing of splints and the possible harmful changes of methods of treatment. "Splint teams" were organized, each consisting of one orthopedic surgeon and two enlisted men. These teams took charge of the wounded man as soon as his operation was completed, applied the necessary splints, and cared for him (if retained in hospital at the front) or supervised his transport to the rear.

Groups of reconstruction aids were also employed for giving physical therapy to the men in base hospitals; curative workshops were established.

The work of the orthopedic service demonstrated, first, that a large number of physically unfit men can be restored to duty by proper training, and that many such conditions as flat-foot and weak back should not be carried on the sick report as sickness, but should be considered simply as weakness, to be corrected by training; second, the use of standard methods of splinting, transportation, and after treatment, reduced the mortality rate among combat casualties and greatly reduced the amount of their later impaired functions.

ROENTGENOLOGYd

The personnel of this department consisted of medical officers expert in X-ray work; officers of the Sanitary Corps, called technicians; enlisted men of the Medical Department. They arrived in France as members of hospital units or as casuals. Though some of the officers proved to have had little or no actual experience in this line of work, a large percentage of them had received an intensive course of training in the United States, and so arrived in France with a general knowledge of the physics underlying X-ray work and with the construction and operation of the various types of X-ray machines being used. Additional instruction was given in France, at first, at the X-ray repair shop in Paris, and later at a school established at the hospital center, Bazoilles. Several groups were instructed at Tours by a medical officer of the French Army.

The installation and repair of apparatus was done by 12 officers of the Sanitary Corps. The care and routine work was done by enlisted men, known as manipulators. As a rule, these enlisted men were trained in the United States, though some were trained in France.

The X-ray apparatus used in the hospitals in the American Expeditionary Forces was similar to that used in military hospitals of the United States. The large interrupterless type of machine was not suited to French conditions on account of the current supplied; only bedside units and modified bedside transformers were found suitable. At some places no current was available, requiring the use of a gas engine. One bedside unit was found to be needed for each 500 beds. This apparatus could be operated on practically any type

dThe statements of fact appearing herein are based on "Report of the activities of the Roentgenological service. A. E. F., by the senior consultant, roentgenology." On file, Historical Division, S. G. O.-Ed.


367

of current and used so little current that it could be attached to an electric light plug. The Army portable outfit was found very satisfactory for base hospital use.

Mobile hospitals were supplied with an X-ray motor truck of French manufacture, which had a number of faults and disadvantages. A camion devised in America was much superior, but did not arrive in the American Expeditionary Forces until toward the end of hostilities.

X-ray work was done in all the army zones and sections. At the front practically all battle casualties were examined in evacuation, mobile, and fixed field hospitals; fractures were briefly described, foreign bodies located, and evidence in chest wounds was recorded. X-ray work during an operation was but seldom necessary. The combat divisions did not need X-ray apparatus. The proportion of patients X-rayed was 80 per cent in the field hospitals for nontransferable cases and 90 to 95 per cent in evacuation and mobile hospitals. To keep up with the work in times of emergency it was necessary to employ two shifts and work continuously.

The base hospitals also employed the X ray extensively, especially in care of wounded coming directly from the front.

MAXILLOFACIAL SURGERYe

On April 18, there arrived at Brest a party consisting of 19 medical officers, expert in oral and plastic surgery, and 15 special dental surgeons. Pending active operations by the American troops, these officers were scheduled for assignment, some to a French hospital at Lyons and the remainder to British hospitals at Croydon and Sidcup, England. The officers intended for Lyons, however, were delayed and were assigned to a British hospital instead. Other officers were assigned to Evacuation Hospital No. 1, Base Hospital No. 15, and American Red Cross Hospital No. 1. Those who had been sent to allied hospitals were gradually withdrawn for general surgical and dental work, to be reassigned to their own specialty when needed.

In authorizing the establishment of the maxillofacial service the chief surgeon, A. E. F., directed that it be conducted as a part of the general surgical service, but in such a manner as to receive the cooperation of the dental service in the most efficient manner. The chief consultant, surgical service, the chief dental surgeon, and the senior consultant of the maxillofacial service were in accord as to the advisability of this plan. The general plan outlined specified that the maxillary and facial cases should be in charge of a surgeon working in cooperation with a dental surgeon. It was believed that if these cases could receive proper treatment in the advanced hospitals, and this treatment continued in the base hospitals, they could be saved (except in a few cases with great loss of time) from the reconstruction class and made fit for duty within the time cases were allowed retained in the American Expeditionary Forces. Further, that with proper care reconstruction would be simpler and more successful. Experience proved this view to be correct.

eThe statements of fact appearing herein are based on "Report of the senior consultant, maxillofacial surgery, on the activities of the maxillofacial service, A. E. F., made to the chief surgeon, A. E. F." On file, Historical Division, S. G. O.-Ed.


368

As planned in the office of the Surgeon General, each evacuation hospital was to have one surgeon and one dental surgeon for this special work. No provision was made for mobile and American Red Cross hospitals.

It was soon learned that it was best not to designate these specialists for the various hospitals by specific orders, but rather by individual understanding with the various commanding officers, who were requested to assign the most desirable officers of their personnel. The lack of special surgeons was later compensated for by the appointment of local consultants.

In each base and evacuation hospital a specially qualified dental surgeon was assigned to care for prosthetic and splint work. Unfortunately, not all the mobile hospitals were so equipped, even at the signing of the armistice, and, in a number of cases these dental surgeons were handicapped by having other duties assigned them, such as those of evacuation officers and mess officers.

On June 11, 1918, the senior consultant, maxillofacial surgery, made recommendation as to a definite plan of early treatment. This plan was authorized by the chief surgeon, A. E. F., in a memorandum issued in October. Instructions were also issued by him covering the evacuation and transportation of maxillofacial cases. It was directed that such cases, evacuated to the Paris district, be treated in American Red Cross Hospital No. 1; other cases that could be were to be transferred to any hospital having this special service, or to Base Hospital No. 115. Base Hospital No. 115 had been designated as a special hospital for surgery of the head. While there was much general surgery done there, there were more special facilities for maxillofacial surgery, such as expert modelers in wax reproductions, expert surgeons and dentists, and special supplies. With all the above facilities, however, the contemplated plan of making the repair of the soft parts in extensive injuries before return to the States was practicable in but few instances.

In September, a number of local consultants were appointed. One was assigned as local consultant, advance section, and also as assistant to the senior consultant. Local consultants were assigned as follows: Base sections Nos. 1 and 5, station at Savenay; base section No. 2, station at Beau Desert hospital center; area 3 (Toul, Bazoilles, Vittel, Chaumont, Rimaucourt, and Langres), station at Toul; area 4 (Dijon, Allerey, Beaune, Mars, and Mesves), station at Beaune; area 5 (Vichy group), station at Vichy; area 6 (Tours and Orleans), station at Tours; Paris area.

Though the senior consultant remained in America until the special equipment needed was ready for shipment, with the exception of one intratracheal vaporizor, a few sets of oral and plastic instruments, and 500 emergency jaw splints, none of this equipment had been received when the armistice was signed. This shortage was partly compensated for by the collection and having made of special jaw splinting material and by ingenuity in extemporizing material.

To sum up, the work done by the service included: (1) The training of a number of surgeons and dental surgeons in the work to be done, both in special schools and in French and British hospitals; (2) the organization of the work in the American Expeditionary Forces. This included the general organization, the appointment of local consultants, and the development of centers.

In so far as the American Expeditionary Forces are concerned the results obtained in maxillofacial surgery were not as great in quantity as had been


369

anticipated, owing to the lack of both personnel and equipment, the utilization of some of the personnel for other work, and the relative brevity of the period of active hostilities.

VENEREAL AND SKIN DISEASES AND GENITOURINARY SURGERYf

Four members of the Medical Corps reported to the British Army in England on June 8, 1917, for the purpose of studying the British methods of treating venereal diseases. A month was devoted to this study in England and in the British Expeditionary Forces, France. Numerous hospitals in England and in France were visited, and the routing of venereal cases from organization to hospital was studied. A second month was then spent in the study of methods employed in French military hospitals, two of the medical officers referred to making, in addition, an extended tour, accompanied by a senior French medical officer, of several French armies with the view of observing the sanitary organizations.

As regards the British Army, it was found that, during the year 1916, 112,249 cases of venereal disease were treated in hospital. Of these cases, 52,495 were treated in 14 hospitals in England and 59,754 in 5 British Expeditionary Force hospitals in France. The capacity of the hospitals in England varied from 100 to 1,500 beds, and of the British Expeditionary Force hospitals from 500 to 3,500. The largest hospital-that is, 3,500-bed capacity-had treated 55,634 patients with venereal disease, including 12,000 syphilitics. During the years 1915-16 the hospital referred to had treated 22,596 cases of gonorrhea, representing 1,082,621 days lost in hospital, or an average of 48 days each. Sixty per cent of the gonorrhea cases had complications, usually prostatitis or epididymitis; 17 per cent were readmissions for relapses of the disease after supposedly having been cured. In addition to the days lost in hospital, the patients lost from one to two weeks in traveling to and from hospital.

In respect to the French Army no statistics were obtainable by the medical officers studying the venereal situation therein, as to the prevalence of venereal disease, partly owing to the fact that uncomplicated gonorrhea had been treated habitually by the French in regimental organizations. It had been estimated by the French, however, that up to the end of the year 1916 there had been 200,000 cases of syphilis in the French Army. These syphilitics were treated in approximately 20 hospitals, the bed capacity of which varied from 100 to 800, each patient remaining in hospital from 4 to 7 weeks. The French practice was to establish throughout the country centers for the treatment of skin and venereal diseases, where both civil and military patients received dispensary and bed treatment, as the case might call for.

As a result of this investigation, the officer who was subsequently to become the senior consultant in skin and venereal diseases, as well as in genitourinary surgery, concluded that the established system of transferring venereal patients from their organizations to hospitals situated from 50 to 100 miles removed was not the best method, and that such venereal diseases as might arise in the American Expeditionary Forces could be treated fully as efficiently in the

fThe statements of fact appearing herein are based on "Report of the division of urology, A. E. F.," by Col. Hugh H. Young, M. C., senior consultant in venereal and skin diseases and genitourinary surgery, Dec. 20, 1918. On file, Historical Division, S. G. O.-Ed.


370

organizations to which the patients concerned belonged. This latter method had the following advantages: (a) Saving of time lost in the transfer of patient to and from hospital. (b) More efficient treatment. Treatment of venereal patients in their organizations permitted better control and continuity, especially as regards syphilis. (c) Saving in personnel and material by eliminating large base hospitals for the treatment of venereal diseases.

The treatment of venereal diseases in the organizations to which they belonged, then, became the established procedure in the American Expeditionary Forces. To facilitate this, a regimental infirmary urological set was adopted and a supply of them was ordered for the American Expeditionary Forces, delivery being made to the forces in January, 1918, and subsequently. Also, a proper stock of drugs for the treatment of venereal diseases was ordered; the injection treatment of syphilis was standardized; a condensed, one-page syphilitic register was devised and placed in use; special ampoule syringes containing gray oil, and ampoules of novarsenobenzol, of sterilized distilled water, and of cyanide of mercury were designed and supplied for the treatment of syphilis. Diagnostic facilities in the examination of blood smears, for the Wassermann reaction, the examination of urethral smears, were established through collaboration with the director of laboratories, A. E. F. Owing to the lack of suitable equipment in the field, the Fontana and Hollande stains were adopted for the detection of spirocheta in the field, the dark field illumination being reserved for employment in laboratories established at central points and at base hospitals. Individual prophylactic tubes for the prevention of venereal disease were devised and supplied for the use of those who did not have ready access to prophylactic stations, such as small detachments at remote stations.

A beginning was made, at the instance of the senior consultant in urology, to minimize the venereal infectiousness of the civil population of France. A hospital was established by the American Red Cross at Neufchateau, with a subsidiary hospital at Doulaincourt. From these places teams, each consisting of a medical officer and a nurse, would make daily visits to surrounding towns to establish clinics for the treatment of venereal diseases among the civil population. Six routes were established covering 50 clinics in an area radiating fully 50 miles in all directions from Neufchateau. The hospital, constructed for the purpose at Neufchateau, was completed on March 15, 1918. It contained 50 beds and had operating room and laboratory facilities.

To insure the systematic treatment of venereal diseases in the American Expeditionary Forces, urologists at base hospitals were instructed as to the methods to be employed, and specially qualified urologists were, after a preliminary course of training, appointed as urologists in each tactical division and in each base port.

In so far as the tactical divisions were concerned, the established system of treating all venereal cases in their organizations operated satisfactorily until these divisions began to take their places in the front line. Because many commands then became so broken up with working parties as to make it practically impossible for regimental medical officers to keep constantly in touch with venereal cases, who, in many instances were at work at distances varying from 5 to 10 miles from the nearest medical officer, it was necessary


371

to modify the organization for treatment. Accordingly, working camps now were established in connection with divisions at the front, wherein were collected all venereal disease cases in the division concerned. It proved that approximately three-fourths of such venereal disease cases thus could be kept on a duty status and supplied for working parties, under the direction of the divisional quartermaster or engineer officer.

As to the location of the working camps for venereal cases, a tryout of several schemes proved that such a camp could functionate best if established in one of the divisional field hospitals. Therefore, the accepted practice was to establish such a camp in conjunction with a divisional field hospital given over to the treatment of venereal and skin diseases.

Venereal camps were established not only in connection with tactical divisions but also at depot divisions, and on the same principles as obtained in the combat divisions. In the depot divisions the venereal camps were used for venereal cases sifted out from the replacement troops, thus preventing them from becoming a burden to the tactical organizations at the front.

One of the final uses to which venereal camps were put was in connection with home-going troops following the signing of the armistice. In this connection, it was required that all members of the American Expeditionary Forces returning to the United States were to be examined for venereal disease prior to embarkation, and that those found venereally infectious were to be detained and placed in segregation camps.

A manual of military urology was prepared under the direction of the senior consultant in urology and was distributed to medical officers of the American Expeditionary Forces. This manual comprised sections on venereal diseases, dermatology, and surgery of urinary and male genitalia. Also, it contained appendices giving in full all promulgations concerning the subject of venereal diseases and alcoholism both in the United States and in the American Expeditionary Forces, and the French regulations on prostitution and alcoholism.

Concerning the problems connected with dermatology in the American Expeditionary Forces, after an extensive study of the conditions in reference to scabies and lousiness in both the American Expeditionary Forces and those of our Allies, the plan of action decided upon was as follows: (a) Instructions were prepared which appeared from time to time either as general orders, headquarters, A. E. F., or as circulars from the chief surgeon's office, A. E. F. (b) Divisional and other urologists were especially instructed in the measures for the prevention, diagnosis, and treatment of these diseases. (c) Specially qualified dermatologists were constantly in the field inspecting pertinent conditions and in giving instructions on these topics. (d) Scabies hospitals were established in connection with the divisional venereal camps. (e) Regional disinfestation, rather than divisional. (f) Observance of the principles of the prevention and treatment of skin diseases as outlined in the Manual of Military Urology.

Though it was planned having special hospitals wherein cases requiring genitourinary surgery could be given special treatment, this was found to be impracticable in view of the fact that such injuries or conditions were so relatively scattered and few in number.


372

SURGICAL RESEARCHg

The section of surgical research of the surgical services, A. E. F., comprised a senior consultant and three consultants, with the necessary assistants. The work of the senior consultant was done at Base Hospital No. 4, which operated with the British Expeditionary Force at Rouen, and in collaboration with several officers in his laboratories in Cleveland; one of the consultants carried on his investigations at Base Hospital No. 10, also operating with the British Expeditionary Force at Treport; the remaining two consultants established a surgical research laboratory in connection with the central Medical Department laboratory, Dijon.

It was under the broad interpretation of research as including anything that would offer promise of yielding useful information that the work, much of which was done in the British service before our forces became actively engaged at the front, was made possible.

A program of work was planned by the senior consultant and in hand on November 11, 1917, which was contemplated for the following winter months of anticipated light military activity. It was during this relatively inactive surgical period that the researches included not only general surgical subjects but also subjects of interest to both the combatant and the medical arms. The latter researches were made in collaboration with the British Royal Engineers' training school, Rouen; however, during periods of active warfare these studies were dropped and subjects of immediate surgical bearing were taken up. The following list will indicate the wide range of subjects thus investigated: (1) Phosgene poisoning, clinical and experimental; (2) biologic test of safe and danger points in gas defense works; (3) research into carbon monoxide poisoning; (4) research into psychic effect of minor explosives; (5) further research into the effects of high explosives; (6) research into the effects of various infusions; (7) the inceptive stage of shock; (8) research into the effects of hypertonic salines.

The following researches into practical surgical problems were made: (1) Organization of resuscitation teams with the British Expeditionary Force, France; (2) slightly wounded; (3) delayed infected wounds; (4) on blood transfusion; (5) shock and hemorrhage; (6) treatment of infections; (7) chemical antiseptics; (8) delayed closure of wounds; (9) surgery of the chest; (10) study of types of wound that bear transportation.

Apparatus was secured from the United States, and the central Medical Department laboratory cooperated in every way; the American Red Cross gave grants of money freely for supplies and sundry expenses. The Research Society of the American Red Cross provided excellent opportunity for cooperation with similar services in the British, French, and Italian Armies.

The plan for the laboratory which was necessary for the various researches projected was perfected in January, 1918, and in April the laboratory was established at Dijon. Here investigations were begun in May. The principal work of this laboratory was along two lines: First, treatment of wounds of the chest, and, second, shock and hemorrhage. The results accomplished appear in Vol-

gThe statements of fact appearing herein are based on "Report of the activities of the division of surgical research, A. E. F.," made Dec. 18, 1918, by Col. G. W. Crile, M. C., senior consultant in surgical research, A. E. F. On file, Historical Division, S. G. O.-Ed.


373

ume XI, Part I. At this time it is only necessary to say that the treatment of chest wounds was largely standardized, and by the organization of transfusion and shock teams undoubtedly many lives were saved. The use of Bayliss' solution of gum acacia as a substitute for transfusion was an important demonstration; another was that of a measure of the degree of anemia requiring transfusion.

OTOLARYNGOLOGYh

When the senior consultant of otolaryngology was designated in June, 1918, there were 17 base hospitals actively functionating, with one otolaryngologist on duty in each. There were already 50 camp hospitals established, 50 per cent of which were not functionating. Of those which were active less than one-third had an otolaryngologist assigned to them. The total roster of otolaryngologists at that time was 32.

One-third of the base hospitals operating at the time were lacking in otolaryngological instruments and equipment to care adequately for the patients they were receiving. The senior consultant visited each hospital, inspected the instruments and equipment, and assisted in compiling a list for requisition from the medical supply depot. Plans for an examination and treatment room for ambulatory patients were formed in those hospitals where no provision had been made previously for them and suitable construction was at once begun. Special wards were obtained for this department and where possible specially trained nurses assigned to duty in these wards.

Of the camp hospitals operating only two had sufficient instruments and equipment properly to care for otolaryngological cases.

In only one was an otolaryngologist on duty, with practically no instruments or equipment with which to work. Otolaryngologists subsequently were assigned to all camp hospitals in the order of their needs. Instruments and equipment were obtained and examination and treatment rooms constructed.

None of the mobile hospitals established early had an ear, nose, and throat surgeon connection with them. Officers were assigned to these hospitals as needed and assistance was given to procure instruments and equipment sufficient for the needs of the department.

In none of the field hospitals functionating was there an otolaryngologist or any instruments or equipment for use in this department. Officers were assigned as needed and instruments and equipment procured.

There were eight otolaryngologists on duty with various combat divisions. Later the number was increased as requests were made, but at no time during active military operations were there sufficient officers from this department to meet the demands made upon it.

At hospital centers a set of buildings was assigned to this department so that all the work in the center could be accomplished at the one place. Special wards and operating rooms were arranged and large examination and treatment rooms for ambulatory patients fitted up, and a staff composed of officers from the base hospital units of the center was formed. This obviated redupli-

hThe statements of fact appearing herein are based on "Report of the activities of the ear, nose, and throat service, A. E. F.,"  made by Col. James T. McKernon, M. C., senior consultant, ear, nose, and throat surgery, A. E. F. On file, Historical Division, S. G. O.-Ed.


374

cation of instruments and equipment and resulted in a better care for the patients, besides allowing the excess officers in the department to be made available for duty elsewhere.

At all the large hospital centers a consultant in otolaryngology was appointed whose duty was to supervise generally the work in the center and to act as consultant when called upon by the center otolaryngologist or the individual units. This arrangement proved most satisfactory, resulting in a better care for the patients as well as maintaining a more rigid discipline for the staffs of the center.

The senior consultant visited all the hospitals, many times seeing cases in consultation, operating when necessary, and consulted as to the needs of the service with both the local otolaryngologist and the commanding officer of the hospital. Many visits were made to evacuation, mobile, and field hospitals in consultation during which advice was given as to the care and routing of the otolaryngological cases; and later following up such cases as had been routed to base hospitals in the rear, consulting as to the nature and amount of reparative work to be done on them.

In December, 1918, there were 238 officers on active duty in this department, and 12 others being held in reserve for future duty with the Third Army, when needed.

OPHTHALMOLOGYi

The senior consultant in ophthalmology was appointed in June, 1918. As the service developed, an assistant was added to the office, Neufchateau, and in September, 1918, another.

Each base hospital unit arriving in France had one or more expert ophthalmologists. To visit, advise with, and supervise these officers was one of the principal functions of the chief consultant. Some of the clinics were well equipped (for example, that of Base Hospital No. 36 of the Vittel-Contrexeville hospital center); others were not. Base Hospital No. 36 served as a special ophthalmological hospital for the Vittel-Contrexeville center. Camp hospitals, as a rule, sent all important cases to the nearest base hospital.

Gradually local consultants were supplied to the principal hospital centers and base areas.

One of the striking features of the subsection was the base optical unit, which arrived in France May 4, 1918. This unit had a strength of 1 officer and 69 men. The equipment, stock, and machinery (amounting to nearly 19 tons in weight) was delayed, but part of it reached Paris in July. Shortly after the arrival of the unit, eight auxiliary units were organized and assigned to various base hospitals; later, seven other units were made up and likewise assigned.

The shop was located first at Neuilly, but later it was removed to Port St. Cloud. It began operating July 27, 1918, and was in full operation by October 1. The equipment was sufficient for the production of 100 pairs of glasses per day. From July 27 to December 1, 1918, the production was as follows: 21,828 prescription jobs; 3,091 smoked spectacles; 1,620 repair jobs.

iThe statements of fact appearing herein are based on "Report of the activities of the ophthalmological services, A. E. F.," by Lieut. Col. Allen Greenwood, M. C., senior consultant, ophthalmology, A. E. F. On file, Historical Division, S. G. O.-Ed.


375

On account of the unusual amount of work to be done, a full day and night force was in operation in the shop. A special attachment was devised to supply the demand for prescription lenses in gas masks. The unit had men and machinery sufficient to handle all work received, but could never get sufficient supplies or material.

Artificial eyes were also supplied as needed; 1,000 were taken to France with the unit and 700 were received later. Large stocks were kept at a few places and at the base ports.

The totally blind were given preliminary training at Paris, Savenay, and Vichy, before being returned to the United States.

An important feature of ophthalmic surgery was the giant magnet. A supply of magnets, shipped to France early in 1918, was lost for a long time. When finally found, magnets were placed in two of the forward evacuation hospitals and in base hospitals at Chaumont, Bazoilles, and Vittel. American Red Cross Hospital No. 1, at Paris, was also supplied. As no more magnets arrived, work was begun on the building of giant magnets at the Medical Department repair shop in Paris, and five were turned out. Somewhat later some medium-sized and small magnets arrived from the United States, and with them it was possible to equip all hospitals necessary.

A trachoma survey was made of the labor organizations, A. E. F.; 12,461 laborers were examined and 261 cases found. Means were suggested for handling this problem.

Circulars of instruction were issued on such subjects as gassed eyes, injuries, refraction, pterygia, strabismus, wounds of the eyelids and orbits, artificial eyes, trachoma, and plastic work.

MEDICAL SERVICESj

The chief consultant, medical services, A. E. F., entered upon his duties November 9, 1917. The fact that, at the time, the chief consultant was designated "director," has been explained above, and need not be gone into further here.

With the sudden and great expansion of the Army in 1917-18, the greater part of the Regular Medical Corps was required for administrative work, leaving the professional practice of medicine and surgery almost entirely to temporary medical officers. Of this great body of new officers, generally unknown to their commanders, lay the responsibility of the actual care of the sick and wounded in the American Expeditionary Forces. On the proper selection and supervision of this ever-increasing class of officers depended very largely the cure and restoration to duty of the many thousands of sick and wounded of the Army. The efficiency of the professional services depended to a marked degree on this factor.

The chief consultant, medical services, understood that he had been selected, in part at least, on account of his general acquaintance with the character and qualifications of the medical profession of the United States, and that his duty was not only to supervise the practice of medicine in the American

jThe statements of fact appearing herein are based on "Report of the activities of the office of the chief consultant, medical services," made December, 1918, by Brig. Gen. W. S. Thayer, M. C., chief consultant, medical services, A. E. F. On file, Historical Division, S. G. O.-Ed.


376

Expeditionary Forces, but also to furnish the chief surgeon, A. E. F., with such information as to the special qualifications of various new medical officers as might facilitate proper selection and assignments.

On March 12, 1918, a principal assistant to the chief consultant was designated.

A study of medical conditions revealed considerable variations in professional personnel and practices in the various base hospitals, tactical divisions, and formations at the bases along the lines of communication. The need for supervision was clearly seen; but with the multiplicity of organization, widespread territory, and difficulties of transportation, this supervision could not be exercised by one or two officers. Special consultant officers were necessary for special localities, but few were available in France; internists who were suitable could not be spared from their stations. Accordingly, officers were sought in the United States. During April, May, and June, 1918, efforts were made to obtain from America a number of clinicians of recognized ability, who could be utilized as consultants, chiefs of service, or for special research.

The great and increasing need for officers especially qualified in internal medicine led to a cabled request on June 10, 1918, for 50 such officers of the grade of lieutenant or captain; and again, on September 26, for a request for an additional 150.

In April, a consultant, general medicine, was assigned to the advance section and zone of the army; consultants in tuberculosis and in cardiovascular diseases were designated. In June, a consultant in gas poisoning was designated. In July, senior consultants, Air Service, and general medicine were assigned. In the following month, consultants, general medicine, were assigned to base sections Nos. 1, 2, and 115, and to the hospital centers at Bazoilles and Vittel-Contrexeville.

The greater part of the medical officers requested in May did not arrive in France until October, and despite the pressing need for consultants no more designations could be made until their arrival. Beginning with October the following assignments of medical consultants were made: To the hospitals at Rimaucourt and Chaumont; Dijon, Beaune, and Allerey; Mesves; Vichy and Clermont-Ferrand; Paris section; Mars; Orleans and Tours; Justice group, Toul; and to base section No. 5; parts of the intermediate section; base section No. 2.

At the end of October, a consultant for base section No. 3 was designated. After the armistice was signed the consultant, gas poisoning, became consultant to the camp hospitals in the advance section.

With the formation of army corps, consultants were assigned to each. Likewise, when armies were organized consultants were assigned to each.

One of the earliest organizational procedures of the chief consultant, medical services, was the institution of certain medical teams. The need for the preparation of medical officers in the care of surgical shock and in the treatment of men suffering from poisoning by suffocative gases was early apparent, and, in view of the lack of such special training among the medical officers of organizations at the front, special gas and shock teams were organized. The officers of each shock team were habitually required to take the course in treat-


377

ment of surgical shock given weekly at the central Medical Department laboratory, Dijon. With the onset of open warfare the shock teams, subsequently called emergency medical teams, were in great demand for the treatment of surgical shock.

The emergency medical teams did effective service; however, the employment of them at the front resulted in great hardship in base hospitals at times because of the shortage of medical officers there, and inability to obtain replacements during the absence of these teams.

TUBERCULOSISk

The efforts of the senior consultant in tuberculosis were directed toward the education of the medical personnel of the various hospitals, more particularly base hospitals, of the American Expeditionary Forces, in the early recognition of pulmonary tuberculosis, the investigation of the pervalence of tuberculosis in the American Expeditionary Forces, and methods for its control.

Following the careful examination of the troops of the Army in the United States and the exclusion of the manifest cases of pulmonary tuberculosis there, the incidence of such cases in the American Expeditionary Forces was expected to be low. However, despite this care in elimination, approximately 2,000 cases diagnosed pulmonary tuberculosis were transferred from the American Expeditionary Forces to the United States prior to December 31, 1918. Of these over 80 per cent had sputum positive for tubercle bacilli. For the same period-that is, up to the end of 1918-there were 250 deaths from pulmonary tuberculosis among our troops in France. Unofficial reports from the French Army, subsequently proving erroneous, had led to a fear in our Medical Department, A. E. F., that there would be a greater development of tuberculosis among the American Expeditionary Forces. The causes which underlay the mistakes in the French Army also were found to obtain in the American Expeditionary Forces; that is, delayed convalescence from pneumonia, bronchopneumonia, the bronchitides-especially those combined with nasal sinus conditions.

In January and February, 1918, it was noted in the Surgeon General's Office that of the men being returned to the United States from France over 50 per cent failed to show positive evidence of the tuberculosis for which they had been sent home. This situation was very easily and effectively remedied by the senior consultant for tuberculosis as follows: (a) A change in nomenclature; that is to say, only cases showing tubercle bacilli in the sputum were now to be diagnosed frankly as pulmonary tuberculosis; all others were to be diagnosed "tuberculosis, observative," (b) The establishment of three centers where these cases could be more expertly studied, namely, Base Hospital No. 8, Savenay; Base Hospital No. 20, Chatel Guyon; Base Hospital No. 3, Vauclaire. (c) Visiting frequently the base hospitals to standardize the diagnosis of the disease from the clinical, roentgenological, and laboratory viewpoints. (d) Promulgating data, concerning these matters, to chiefs of medical services and to medical officers who were registered as preferring tuberculosis work.

kThe statements of fact appearing herein are based on "Report of the activities of the senior consultant for tuberculosis," made Dec. 18, 1918, by Lieut. Col. Gerald B. Webb, M. C., senior consultant for tuberculosis, A. E. F. On file, Historical Division, S. G. O.-Ed.


378

As regards treatment, all patients suspected of having, or actually having, tuberculosis and sent to any of the three hospitals mentioned above received excellent care. Those with fever were kept at rest, the temperature and pulse being carefully studied. Sputa were examined frequently, from 10 to 15 times before a given case would be declared negative; when time permitted, concentration methods were practiced in laboratories.

Patients found to be tuberculous were returned to the United States, their physical conditions permitting; others were given graded exercises, first in hospital and later in a convalescent camp, and restored to duty.

PSYCHIATRYl

Psychiatry was established as a professional division in the American Expeditionary Forces in November, 1917, with a director. Subsequently, however, it was subordinated to the medical portion of the professional services, the director then becoming senior consultant. On his nomination, a specially qualified body of officers was assigned as division, army, hospital group, and section psychiatrists. These officers, under the guidance of the senior consultant, did valuable work in detecting early and treating wisely the psychoses common to armies in the field.

A neurological hospital, Base Hospital No. 117, was established at La Fauche, where patients with war neuroses were sent from army neurological hospitals and all base hospitals in the American Expeditionary Forces. The psychiatric department of Base Hospital No. 116, Bazoilles, was made to serve as a collecting station for mental cases from the tactical divisions and from hospitals in the advance section. Neuropsychiatric departments were established in base hospitals at both the Mars and Allerey hospital centers, at the base ports, and in Paris section.

The problems arising in the front areas in relation to the provisions for the care and disposition of patients suffering from disorders of the mind and nervous system can best be considered under two general heads: Conditions which occurred during periods of relative military quiet, and those occurring during active military operations.

Cases originating in front areas during times of relative quiet comprised men who could be classified in groups exhibiting defective mental development, constitutional psychopathic states, psychoneuroses-independent of combat experiences-war neuroses, and, finally, psychoses. These cases were cared for adequately in the divisional hospitals by the divisional neuropsychiatrists in the following manner: All except those with war neuroses were kept under observation sufficiently long to permit making proper diagnoses, whereupon they were transferred to base hospitals especially provided to care for the types of cases under consideration. Patients with war neuroses, which had developed in quiet areas, and when the number of such patients was comparatively small, were successfully treated for the most part in the divisional field hospitals; few required transfer to Base Hospital No. 117, at La Fauche,

lThe statements of fact appearing herein are based on, (1) "Report of the activities of the section of neuropsychiatry," made by Col. Thomas W. Salmon, M. C., senior consultant, neuropsychiatry; (2) "History of advance neurological formations," made by Lieut. Col. John H. W. Rhein, M. C., consultant in neuropsychiatry, First Army. On file, Historical Division, S. G. O.-Ed.


379

which, as stated above, was the special hospital for such cases. Those that were transferred to Base Hospital No. 117 were readily transported in motor ambulances, since this hospital was situated sufficiently near to make this possible.

Because war neuroses developed in much larger numbers during periods of active military operations, their management at the front became much more complicated. Our first relatively large experience with such cases occurred during the Aisne defensive. At this time, the plan proposed by the senior consultant, neuropsychiatry, was to have the cases of war neuroses which developed during combat retained in divisional hospitals under the care of divisional neuropsychiatrists for as long a period as possible (not to exceed 10 days or 2 weeks), especially such cases promising that degree of improvement during the period in question as to make it seem possible they could be returned to their organizations on a duty status. On the other hand, cases holding out no such promise were to be evacuated to Base Hospital No. 117, at La Fauche.

In so far as it was possible to do so, division surgeons were consulted with by the consultants in neuropsychiatry who outlined the above plan for dealing with cases of war neuroses incident to combat experiences. Unfortunately, facilities for caring for such cases in divisional hospitals at the time were inadequate; consequently, the results were on the whole disappointing. Many cases were not retained at all in the divisional hospitals but were evacuated immediately through evacuation hospitals to base hospitals with the general run of sick and wounded. This evacuation naturally tended toward Paris where cases of war neuroses were received in base and camp hospitals in relatively large numbers. Hence they had to be distributed to hospitals farther rearward or to Base Hospital No. 117. Needless to say, the capacity of Base Hospital No. 117 was taxed.

Though the plans went awry, the ultimate results in these cases were satisfactory, for under the care of the neuropsychiatrists attached to the base hospitals and after a short period of rest, patients, in a satisfactorily large percentage, were discharged from hospital to duty.

Of the approximately 200,000 men engaged in the military operations referred to above, the incidence of war neuroses was about 2 per cent of the number engaged and 10 per cent of all casualties. Not only was this number believed to be unnecessarily large but it was also thought by the senior consultant in neuropsychiatry that at least 65 per cent of the men admitted to divisional hospitals for war neuroses could have been returned to duty therefrom within a period of 10 days had suitable equipment for their local care been on hand.

Based upon the above experiences, the senior consultant in neurospychiatry initiated the establishment of neurological hospitals in the front areas a short distance to the rear of field hospitals. The purpose of these hospitals was to care for men with war neuroses who in all probabilities would be fit for duty within two or three weeks.

For the St. Mihiel operation the plan was as follows: In addition to the divisional neuropsychiatrist, each division was supplied with an assistant neuropsychiatrist. Thus one of these officers could sort cases coming through


380

the divisional sorting station; the other could treat them in the field hospital. For the cases of war neuroses, which appeared ton require more time then the specified time they should be kept in divisional hospitals, neurological hospitals were established, one at Benoit Vaux and another at Toul. These units functioned in an entirely satisfactory manner, thus retaining at the front, after a few days' treatment, many men who otherwise would have been evacuated to the rear.

During the Meuse-Argonne operation, a third such neurological hospital was established at Neubicourt. Over 60 per cent admitted to the neurological hospital at Benoit Vaux were returned to duty within a period averaging 10 to 14 days; approximately 73 per cent of the patients admitted to the neurological hospital at Neubicourt were returned to duty in an average of 10.4 days.

Neuropsychiatrists proved so necessary for expert examination of defectives and of men about to be brought to trail by court-martial, as witnesses during trial, and as experts in the examination of men with alleged self-inflicted wounds, that they were retained throughout the war in the combat divisions. So far as the combat divisions were concerned, this was true of only two other specialties, urology and orthopedic surgery.

COMMUNICABLE DISEASESm

Since the section dealing with the communicable diseases was in operation only for three months prior to the end of 1918, many of the plans that were contemplated could not be brought to completion and much of the work of the section necessarily remained fragmentary and unfinished.

A large part of the time was devoted to the hospitalization and professional care of the cases of communicable disease. A considerable number of visits were made, either by special request or by order, to various parts of the American Expeditionary Forces to consult upon diagnosis or the disposition of patients with epidemic diseases or upon individual patients suffering with unusual infections.

Since the hospitalization of the communicable disease cases seemed of immediate and prime importance, visits were paid to many base hospitals and to hospital centers to determine what conditions actually existed and to consult with the commanding officers upon plans for the future hospitalization of these cases. During these visits it seemed obvious, when some sort of segregation of these patients had not been made, that such a method for their care would have to be adopted, and as a rule one of the following methods of segregation was put into operation: (1) The establishment of infectious disease hospitals; (2) the segregation of different classes of cases in different hospitals or in different wards of a single hospital.

For hospital groups the former method seemed preferable for several reasons: It would minimize the danger of spreading infection through the hospital group; it would allow of the proper admission through observation wards of the undiagnosed infections and therefore reduce cross infections;

mThe statements of fact appearing herein are based on "Report of the activities of the section of communicable diseases," made Dec. 21, 1918, by Col. Warfield T. Longcope, M. C., senior consultant in infections diseases. On file, Historical Division, S. G. O.-Ed.


381

it would allow of a concentration of the personnel especially qualified to care for these particular diseases and therefore would assure better professional treatment; hospital epidemics, such as occurred in the late fall of 1918 in a minor degree with diphtheria, could thereby be immediately recognized; it would simplify administration and save hospital space and beds.

At one hospital center the first plan mentioned above was immediately put into operation. One hospital of the center was selected to care for all the communicable diseases, including influenza and pneumonia. According to the center commander, this method as he developed it proved to be the most efficient one for the center from the administrative standpoint; and from visits made by the senior consultant, infectious diseases, it was evident to him that the patients were most excellently cared for from a professional point of view. From practical application, therefore, the plan proved not only feasible but also highly successful, even though it was not possible to develop it in an ideal manner. In a few other centers similar organizations, though not quite so complete, were instituted.

In several other centers where the second plan was put into effect it proved not quite as satisfactory from a professional standpoint. As the plan was worked out practically it was as follows: Cases of pneumonia and influenza were sent to one hospital, mumps and measles to another, meningitis, typhoid fever, and dysentery to a third, and so on. The objections that arose to this plan in the hospitals where it was adopted were that the establishment of observation wards was not practicable and that occasionally cross infections occurred, probably from admitting to a ward suspicious cases of measles or scarlet fever. It also resulted in a rather uneven grade of professional care of the infectious diseases, for though some wards were most admirably cared for, others were not so well conducted. After a trial of this method in several centers, it was the consensus of opinion that the first method would be far preferable.

During the epidemic of influenza and pneumonia in the fall of 1918, considerable time was spent both at the front and in base hospitals in consultation with army and corps surgeons, and with commanding officers upon the proper hospitalization and care of these cases. Hospitals were established at Revigny and at Brizeaux in the First Army area for the exclusive care of these patients, while the many patients that could not be accommodated in these hospitals were adequately treated in other evacuation hospitals. When it was possible to hold all these cases in hospital and not evacuate them the disease ceased to overwhelm the forward hospital centers.

At this time a circular was prepared on the hospitalization and treatment of influenza and pneumonia which was published as Circular No. 51, chief surgeon's office, A. E. F.

During visits to hospitals the senior consultant gave advice regarding the handling of infectious diseases and the proper forms of cubicling and masking and when these methods were not in use they were insisted upon, or where they were improperly devised the methods were corrected. During these visits professional consultations were frequently held with chiefs of medical services upon many patients.


382

An attempt to furnish personnel for these infectious-disease hospitals and wards was impossible. Plans had previously been made to do so, and a group of clinicians had been trained in the United States for this purpose, but the exigencies of the situation rendered it impossible to obtain the services of these officers.

GAS POISONINGn

The activities of the gas poisoning section of general medicine may be classified as follows: (a) Instruction; (b) hospitalization and treatment; (c) actual supervision of the care of the gassed.

INSTRUCTION

Instruction was carried out either by means of circulars of information or by lectures. Circular No. 34, chief surgeon's office, which had to do with the treatment of gassed patients, was prepared in this section. Other circulars in regard to the treatment of gas poisoning were prepared from time to time in this section. Either the consultant in general medicine in charge of gas poisoning, or other representatives of his office, gave lectures on the subject of the care and hospitalization of the gassed. These lectures were given to medical officers either in tactical divisions or at the Army sanitary school, Langres.

HOSPITALIZATION AND TREATMENT

The question of the hospitalization and treatment of gassed patients, especially in division and army areas, was given much study. An endeavor was made, by advice and conference with those in authority, to emphasize the important but simple principles involved, and to achieve their acceptance throughout the American Expeditionary Forces. After comparatively little study it became obvious that the question of the care of the gassed was largely an administrative one. From the clinical point of view the question was simple. The question of the hospitalization of the gassed was a more complicated one. Like the wounded soldier, the gassed soldier needed early examination and treatment and it soon became obvious that each tactical division in active warfare must have a mobile gas hospital as a part of its sanitary train. This need was met by utilizing one field hospital per division which was supplied with the necessary extra equipment to care for the gassed. Much correspondence and conference with those in authority finally led to a simple and standard equipment which could be used in divisional gas hospitals. The matter of the secondary hospitalization of gassed cases was complicated by the promulgation of the principle that gassed cases were not to be cared for in evacuation hospitals, although it was recognized that the gassed needed special care in a hospital at the level of the evacuation hospital, quite to the same extent as did the wounded.

The application of this principle led to the establishment of special hospitals for the gassed. During the actions which preceded the St. Mihiel and Meuse-Argonne operations there were no special hospitals for the care of the gassed. Gassed cases were passed through the evacuation hospitals rapidly and often

nThe statements of fact appearing herein are based on "Report of activities of section of gas poisoning," made Dec. 17, 1918, by Lieut. Col. Richard Dexter, M. C., consultant in general medicine for gas poisoning. This report is on file in the Historical Division, Surgeon General's Office, Washington, D. C.-Ed.


383

received their first hospital treatment at the bases, a system which was unsatisfactory at best. In the St. Mihiel operation one gas hospital was established at the Justice hospital center, Toul, and one in the French gas hospital at Rambluzin. The personnel of these hospitals consisted of casuals or of officers and men loaned from base or evacuation hospitals, ambulance companies, etc. In each hospital one officer thoroughly conversant with the principles of the care of the gassed was stationed. The consultant in general medicine for gas poisoning had general supervision of the clinical work in both hospitals.

During the Meuse-Argonne operation, five hospitals were designated by the chief surgeon, First Army, to receive gassed cases. These were: Rambluzin, capacity, 250 beds; La Morlette, capacity, 550 beds; Julvecourt, capacity, 400 beds; Rarecourt, capacity, 250 beds; Villers Daucourt, capacity, 200 beds. These hospitals were enlarged by the addition of tentage and became the most important gas hospitals in the area.

The officers and personnel of these hospitals, as was the case in the St. Mihiel operation, were largely casual officers and men from ambulance companies, evacuation hospitals, etc.

After the first rush was over the five gas hospitals mentioned above carried on the care and treatment of the gassed in an eminently satisfactory manner. It was unfortunate that, owing to a shortage of nurses, only two nurses were available for use in these gas hospitals during the period from September 26 to November 11.

These hospitals received upward of 20,000 patients from September 26, 1918, to November 11, 1918. The cases were about equally divided between those who had been actually exposed to gas and those who, though they entered the hospital with a diagnosis of "gassed," had in all probability never been exposed to toxic warfare gases. The large number of cases that could not be classified as "gassed" were due principally to exhaustion, neuroses, light respiratory infections, or other unimportant conditions. The great proportion of these men could have been returned to duty without having left the army area had the proper machinery for this existed. In order that these light cases be returned to duty, rest camps must exist. Only one of the three corps in the First Army established a rest camp where men presumably fit for duty could be returned from the gas hospital and be further observed and tested before returning to the replacement battalion and the line. One corps had a replacement battalion and no rest camp, while the third had neither replacement battalion nor rest camp. With this imperfect machinery it was natural that large numbers of men who could have been returned to duty perforce were evacuated to the base.

The effect of the treatment received in the Army gas hospitals during this period on the condition of the men sent to the bases was apparent. There were found in the base fewer serious eye conditions than ever before, burns of the skin were in better condition, and cases of lung involvement were received in better general condition. Each case of definite pulmonary irritation was considered as a possible pneumonia and was held at the gas hospital for observation and treatment until it was deemed safe for the case to be evacuated.


384

The lessons learned during this period lead to the following conclusions:

(a) At least 1,000 beds for gas cases should be provided for each corps during active mobile warfare such as that of September and October, 1918.

(b) To facilitate evacuation and to economize personnel, not more than one hospital to a corps area is considered advisable. Experience has shown that the principle of having gassed cases cared for in special isolated hospitals is not a wise one. These hospitals were usually far from a railhead and off the main traffic routes. This necessitated much extra ambulance carriage, and increased the length of time that patients were in the ambulances. As no provision for gas hospitals was found in the Tables of Organization, these scattered units had to be operated as annexes to evacuation hospitals. This arrangement complicated the administration of these hospitals, and required duplication of administrative personnel. Experience showed that the recommendation to the effect that gassed cases be cared for in evacuation hospitals with augmented equipment and
personnel, made in the letter of May 7, 1918, from the senior consultant in general medicine to the chief consultant, medical services, was sound, and should be accepted as a guiding principle in the matter.

(c) The personnel of gas hospitals should be proportionately the same as that of an evacuation hospital. The staff of medical officers need not be large; no surgeons are necessary. A chief of medical service expert in the problems of the diagnosis and treatment of the gassed and in the sorting of those presumably fit for duty is essential. The rest of the officers may be young men of ordinary capacity. Nurses are absolutely necessary for the proper care of the gassed.

(d) In order that men may be returned to duty, rest camps, where the men may be observed for a time and tested by simple exercises to determine their fitness for duty, are necessary. Whether the rest camp shall be under the immediate management of the corps or of the army is open to discussion. It is noteworthy, however, that while divisions change rapidly and frequently from one corps to another, they do not as frequently or as rapidly leave an army area. For this reason it would appear that the army would be able to return the men to their proper organizations better than could the corps.

SUPERVISION

In July, 1918, after conference between the medical director of the Chemical Warfare Service, A. E. F., the chief consultant, medical services, A. E. F., and the consultant in general medicine for gas poisoning, it was recommended that each division have one officer whose special duty it would be to take charge of the organization of the treatment, care, and evacuation of the gassed within the divisional areas. The officer was to be known as the divisional medical gas officer. This recommendation was accepted and authorized by General Orders, No. 144, G. H. Q., A. E. F., August 29, 1918. Owing to the late date at which the divisional medical gas officers were authorized, many divisions never received the full benefit of the services of such an officer. In those divisions where an officer functioned as medical gas officer, the care of the gassed
immeasurably improved.


385

PERSONNELo

(July 28, 1917, to July 15, 1919)

Col. William L. Keller, M. C., director of professional services.

SURGICAL SERVICES

Brig. Gen. John M. T. Finney, M. C., chief consultant.
Col. George W. Crile, M. C., senior consultant in surgical research.
Col. Arthur C. Christie, M. C., senior consultant in Roentgenology.
Col. Harvey Cushing, M. C., senior consultant in neurological surgery.
Col. Joel E. Goldthwait, M. C., senior consultant in orthopedic surgery.
Col. James F. McKernon, M. C., senior consultant in ear, nose, and throat surgery.
Col. Charles H. Peck, M. C., senior consultant in general surgery.
Col. Hugh H. Young, M. C., senior consultant in venereal and skin diseases and genitourinary surgery.
Lieut. Col. Vilray P. Blair, M. C., senior consultant in maxillofacial surgery.
Lieut. Col. James T. Case, M. C., senior consultant in Roentgenology.
Lieut. Col. Allen Greenwood, M. C., senior consultant in ophthalmology.

MEDICAL SERVICES
Brig. Gen. William S. Thayer, M. C., chief consultant.
Col. Thomas R. Boggs, M. C., senior consultant in general medicine.
Col. Warfield T. Longcope, M. C., senior consultant in infectious diseases.
Col. Thomas W. Salmon, M. C., senior consultant in neuropsychiatry.
Lieut. Col. Richard Dexter, M. C., senior consultant in general medicine for poisoning by deleterious gases.
Lieut. Col. Alfred E. Cohn, M. C., senior consultant in cardiovascular diseases.
Lieut. Col. Gerald B. Webb, M. C., senior consultant in tuberculosis.
Maj. Franklin C. McLean, M. C., senior consultant in general medicine.
 REFERENCES

(1) Circular letter from the Surgeon General to commanding officers of hospitals, November 11, 1917. Subject: Specialists. Copy on file, Historical Division, S. G. O.

(2) Cable No. 427-S from General Pershing to The Adjutant General, Washington, December 30, 1917. On file, A. G. O., World War Division, chief surgeon's files, 321.62.

(3) Letter from the Surgeon General to the chief surgeon, A. E. F., March 9, 1918. Subject: Professional services. On file, A. G. O., World War Division, chief surgeon's files, 321.62.

(4) Letter from the Surgeon General to the chief surgeon, A. E. F., March 16, 1918. Subject: Organization of general and base hospitals. On file, A. G. O., World War Division, chief surgeon's files, 321.62.

(5) Letter from the adjutant general, A. E. F., to Maj. J. M. T. Finney, M. C., December 21, 1917. Subject: General instructions. Copy on file, A. G. O., World War Division, chief surgeon's files, 201 (Finney, J. M. T.).

oIn this list have been included the names of those who at one time or another were assigned to the division during the period, July 28, 1917, to July 15, 1919.

There are two primary groups-the heads of the division or the section and the assistants. In each group names have been arranged alphabetically, by grades, irrespective of chronological sequence of service.-Ed.


386

(6) Report of the activities of the professional services, A. E. F., between April, 1918, and December, 1918, made December 31, 1918, by Col. W. L. Keller, M. C., director of professional services. On file, Historical Division, S. G. O.

(7) Bevans, M. L., Col., M. C.: The function of medical and surgical consulting staffs determined by the late war. The Military Surgeon, xlvi, No. 5, Washington, 1920.

(8) Circular No. 2, H. A. E. F., office of the chief surgeon, November 9, 1917.

(9) Report on the activities of the chief surgeon's office, A. E. F., to May 1, 1919, made by the chief surgeon, A. E. F., to the Surgeon General. Copy on file, Historical Division, S. G. O.

(10) Final report of Gen. John J. Pershing, September 1, 1919.

(11) Based on reports of the activities of hospital centers, A. E. F. On file, Historical Division, S. G. O.

(12) Report of the activities of G-4-B, G. H. Q., A. E. F., to December 31, 1918, by Col. S. H. Wadhams, M. C. Copy on file, Historical Division, S. G. O.

(13) Letter from the chief surgeon, A. E. F., to Lieut. Col. W. L. Keller, M. C., April 18, 1918. Subject: Detail as director of professional division, A. E. F. Copy on file, A. G. O., World War Division, chief surgeon's files, 321.60.

(14) Letter from the chief surgeon, A. E. F., to the director of professional services, A. E. F., August 7, 1918. Subject: Consultants in the different specialties for hospital centers. On file, A. G. O., World War Division, chief surgeon's files, 211.52.

(15) Letter from the chief surgeon, A. E. F., to Capt. De Forest F. Willard, M. R. C., August 23, 1918. Subject: General instructions. Copy on file, A. G. O., World War Division, chief surgeon's files, 321.62.

(16) Memorandum from the chief surgeon, A. E. F., to the director of professional services, A. E. F., August 13, 1918. Subject: Designation of hospital centers for specialists. Copy on file, A. G. O., World War Division, chief surgeon's files, 321.62.

(17) Circular Letter No. 7-a, chief surgeon's office, A. E. F., August 27, 1918.

(18) Letter from the chiefs of medical and surgical services, A. E. F., to the chief surgeon, A. E. F., September 2, 1918. Subject: Personnel of professional services. On file, A. G. O., World War Division, chief surgeon's files, 321.62.

(19) Letter from the chief surgeon, A. E. F., to the director of professional services, A. E. F., September 2, 1918. Subject: Designation of professional consultants and heart specialists at hospital centers. On file, A. G. O., World War Division, chief surgeon's files, 321.62.

(20) Letter from the chief surgeon, A. E. F., to all division surgeons, September 8, 1918. Subject: Psychiatrists, urologists, and ophthalmologists in tactical divisions. On file, A. G. O., World War Division, chief surgeon's files, 321.62.

(21) Letter from the chief surgeon, First Army Corps, to the chief surgeon, A. E. F., November 4, 1918. Subject: Corps consultants. On file, A. G. O., World War Division, chief surgeon's files, 211.52.

(22) First indorsement from the chief surgeon, First Army, to the chief surgeon, A. E. F., November 5, 1918. On file, A. G. O., World War Division, chief surgeon's files, 211.52.

(23) Third indorsement from the chief consultant, surgical services, A. E. F., to the chief surgeon, A. E. F., November 30, 1918. On file, A. G. O., World War Division, chief surgeon's files, 211.52.

(24) Memorandum from the chief surgeon, A. E. F., to the chief of staff, S. O. S., January 3, 1919. Copy on file, Historical Division, S. G. O.

RETURN TO TABLE OF CONTENTS