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Chapter XXVI

Contents

SECTION IV

EVACUATION OF PATIENTS TO THE UNITED STATES;
DISCONTINUANCE OF HOSPITALS

CHAPTER XXVI

EVACUATION OF PATIENTS TO THE UNITED STATES

Administrative matters concerning the selection of disabled members of the American Expeditionary Forces for return therefrom to the United States, and the transfer of such men from hospitals in the Services of Supply to base ports and thence to suitable transports, were made a responsibility of the hospitalization division of the chief surgeon's officer, A. E. F. As stated in Chapter XIV, Section I, a particular section of this division, namely, the transportation and evacuation section, was devoted to such matters.1

Early Medical Department plans for the return of the disabled to the United States comprised extensive hospitalization at Savenay, in base section No. 1, in order that selected cases might be collected there and evacuated thence through the port of St. Nazaire; and at Beau Desert, near Bordeaux, for evacuation through the latter place. Owing to the fact that Brest was not considered at the time in the scheme of the return movement, hospital facilities were not provided on a relatively large scale at that place until the latter months of the war.1

During the first eight or nine months of the existence of the American Expeditionary Forces, cases believed to be suitable for transfer to the United States were relatively few in number, and comprised much the same type of cases as would, in peace time, be considered unfit for further military service.2 Such cases were selected initially in the various base hospitals of the American Expeditionary Forces and, usually, transported by hospital train to the base hospitals of the above-mentioned ports. Here the patients were surveyed by a physical disability board; and if found suitable for transfer to the United States, were prepared for the journey there.2

The conditions of actual warfare and the difficulties incident to transporting personnel to France prompted general headquarters, A. E. F., in March, 1918, to depart from our peace-time custom of determining degrees of physical disability.3 In the conduct of the war it was essential that all personnel be utilized to the utmost. Thus, many cases of presumed disability, instead of being returned to the United States, were retained thereafter in the American Expeditionary Forces. The comprehensive order which general headquarters issued on the subject, though it deals with the determination of the physically fit as well as the unfit, is given here practically in full, so far as the present subject is concerned:

The action of a disability board does not require review or approval by higher authority except upon application to the convening authority by the commander of an organization of


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which the officer or soldier examined is a member. In this latter case the action of the board will be passed upon by the convening authority, whose action will be final. Reports will be rendered on card form, in duplicate, copies of which will be distributed, one to the statistical section, adjutant general's office, general headquarters, A. E. F., and one to the organization to which the officer or soldier is transferred.

The success of the evacuation service depended in great degree upon the skill of disability boards, which the above quoted order prescribed, in selecting those cases throughout the American Expeditionary Forces which were unfit for further duty but were able to bear transportation both to the base ports and to the United States.2 Selection by these boards of cases capable of performing the land journey, but unable to withstand the difficulties incident to the sea trip, led to congestion of the facilities for nontransportable cases at hospitals near the base ports, reduced the elasticity of these hospitals, and limited their
embarkation facilities.2

As previously stated, patients in the American Expeditionary Forces in France were embarked at one of the three following ports: Brest, St. Nazaire, and Bordeaux; however, until after the armistice was signed the major portion of them sailed from Brest, due to the fact that this port had the deepest harbor, and in consequence it was to this harbor that our largest ships came with troops from the United States. Since large ships could not dock at Brest, patients had to be placed on improvised lighters and carried on them out to the vessels, frequently in very rough weather. During the period of hostilities, most patients that were embarked at Brest were prepared for transfer to the United States at the hospital center at Savenay,1 since it was desirable that there be a reservoir of patients from which a suitable number of them could be embarked, without an appreciable loss of time, following notification from shipping authorities that certain ships would be available.2

Promptly after the armistice began, the War Department notified General Pershing that every effort would be made to expedite the early return of the American Expeditionary Forces.4 No necessity now obtained for so rigidly adhering to the principles which prompted the promulgation of General Orders, No. 41, quoted above. Now, not only were all patients classed D to be returned to the United States as soon as their condition would permit, but also all officers and soldiers in hospital who in the opinion of attending surgeons could be safely transported and, in addition, required at least two months' additional treatment.5 Exemptions to this general classification included men with contagious6 and venereal diseases.7 Pertinent parts of the instructions covering the return of the disabled are as follows:

                                AMERICAN EXPEDITIONARY FORCES,
        HEADQUARTERS, SERVICES OF SUPPLY,
                                         France, November 20, 1918.

EMBARKATION INSTRUCTIONS NO. 1

(Personnel to be returned to the United States)

In order to carry out the policy outlined by general headquarters, the following regulations concerning the return of hospital patients and B and C class officers and soldiers to the United States are published.


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I

1. All officers and soldiers now in hospitals who will require at least two months' treatment who, in the opinion of the attending surgeons, can safely be transported, and all officers and soldiers who would be evacuated as of class D will, as rapidly as facilities permit, be returned to the United States for continued treatment. The transportation of this class of personnel on hospital trains to designated ports and from thence to hospital ships will be in accordance with regulations to be prescribed by the chief surgeon.

2. All officers and soldiers in hospitals who are evacuated as of class C and all those who are evacuated as of class B, who will require at least two months for restoration to class A, will be returned to the United States in accordance with regulations hereinafter prescribed.

* * * * * * *

II

Officers and soldiers to be returned to the United States under this order, excluding hospital patients referred to in paragraph 1, section I, shall be sent to depots and rest camps at ports of embarkation, as follows: In the advance and intermediate sections to be sent direct to the 1st Depot Division, St. Aignan-Noyers, for organization and equipment and from thence to the rest camp, St. Nazaire, for transportation to the United States. In the Paris district to be sent direct to base depot, Blois, for organization and equipment, and from thence to rest camp, Brest, for transportation to the United States. In base sections Nos. 4 and 5 to be sent direct to rest camp, Brest, where they will be organized and equipped and returned to the United States. In base section No. 1 to be sent direct to rest camp, St. Nazaire, for organization, equipment, and shipment. In base sections 2, 6, and 7 to be sent to rest camp, Bordeaux, for organization, equipment, and shipment.
 III. ORGANIZATION AND EQUIPMENT

1. All soldiers, upon arrival at the 1st Depot Division, at the base depot, Blois, or at a rest camp at a base port, if sent directly there, shall be organized into casual companies consisting of 2 officers and 150 enlisted men per company, the necessary medical attendants (class B or C, if available), and medical supplies to accompany each company or group of companies. White and colored troops to be organized separately. Such companies to be serially numbered, with the added designation of the depot or rest camp at which the company is organized. To avoid duplication of numbers assignment is made in blocks, as follows: "Bordeaux Casual Companies Nos. 1 to 100"; "St. Nazaire Casual Companies Nos. 101 to 200"; "Brest Casual Companies Nos. 201 to 300"; "Blois Casual Companies Nos. 301 to 400"; "St. Aignan Casual Companies Nos. 401 to 500." When a block is exhausted at any camp a new series will be started by adding 500 to the initial number of the previous series; for example, Bordeaux's second series of numbers will be 501 to 600.

2. Each company will be physically examined for contagious diseases and deloused at the depot or rest camp at which it is organized, and the commanding officer of the organization will be furnished with a certificate showing its serial number and other designation and the fact that each member has been thoroughly deloused and is free from contagious disease. The proper sanitary inspection will also be made at base ports prior to embarkation.

3. When a company is organized each soldier will be provided with a neat and well-fitting uniform and serviceable equipment * * *.
 IV. DISPOSITION OF RECORDS

1. It is of the utmost importance that each soldier returned to the United States under this order shall be accompanied by his qualification card, service record, all war-risk papers pay card individual pay record book, and individual equipment record; and also that each officer takes with him his original qualification card securely wrapped and sealed, his identity card, and, if a captain or of lower rank, his officer's record book.

2. Commanding officers of hospitals will, upon the evacuation of B or C class personnel under this order, send immediate telegraphic notice, as far in advance of evacuation as possible; in the case of officers, to the statistical division, adjutant general's office, general head-


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quarters, and in the case of soldiers, to the central records office, Bourges, stating the name, rank, serial number, former organization, together with the depot or rest camp to which the records are to be sent.

3. In the case of class B or C personnel on duty in the American Expeditionary Forces affected by this order, the commanding officer forwarding such personnel will be held responsible that the proper records accompany them to the depot or rest camp to which sent.

4. Courier service will be established between the central records office and the two depots and the three rest camps at which casuals and organizations are prepared for embarkation, for the purpose of the prompt procurement of records. In the event that the central records office is unable to furnish the required records, all data available, including the statement that the records can not be obtained, will be forwarded with the organization with which the soldier sails. The commanding officer of the rest camp shall furnish the central records office with a list of enlisted men departing for the United States without their individual records, showing the organization to which they belonged. The central records office will forward such records as soon as obtained to The Adjutant General, Washington, D. C.

5. In the case of officers and soldiers sent direct to the United States as hospital cases, as provided in paragraph 1, section I, of this order, telegraphic notice shall be sent as above, stating the port at which the patients are to be embarked and directing that the records be sent there, addressed to the commanding officer of the base hospital at the port of embarkation, and plainly marked, "Records of hospital cases." The embarkation of hospital patients shall not be delayed by reason of the failure to obtain the individual records. Every effort shall be made, however, to obtain them in every case, as required by existing orders. The evacuating hospital at port of embarkation will furnish the central records office with lists of men returned to the United States without their records, by courier, accompanied by any records received too late to go with the patient.
 V. REPORTS

The commanding generals of base depot, Blois, and the 1st Depot Division will send telegraphic notification to the rest camp which they feed, immediately upon the departure of an organization, giving the following information:

    (a) Designation of organization.

    (b) Date and hour of departure.

     (c) Number of officers.

     (d) Number of soldiers.

A duplicate of this telegram will be sent to the commanding general, Services of Supply (G-1).
 VI. GENERAL INSTRUCTIONS

1. Class B and C personnel of the Marine Corps will be organized into provisional companies composed entirely of Marine Corps officers and soldiers. No attempt will be made to segregate marines with reference to the geographical area from which they were recruited in the United States.

2. Whenever casuals in sufficient numbers come from the same sections of the United States, they will be formed into companies according to localities, in order that they may be sent to the cantonment or camp nearest the place from which they entered the service. This will not apply to hospital evacuations.

3. The commanding general, base section No. 3, will make necessary arrangements for the return to the United States of hospital patients and class B and C personnel through English ports and rest camps, in accordance with special instructions issued from these headquarters.

4. The provisions of this bulletin do not apply to base section No. 8, concerning which special arrangements will be made.

By command of Major General Harbord:

                                            W. D. CONNOR, Chief of Staff.

Official:

     L. H. BASH, Adjutant General.


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Embarkation Instructions No. 4, headquarters, Services of Supply, November 25, 1918, required that commanding officers of casual companies organized for embarkation would be held responsible that the records of both officers and enlisted men were completed. If a service record was not at hand or was not procurable at the central records office, a supplementary record was to be prepared from the best available data, usually consisting of information from the soldier.

The effect of Embarkation Instructions No. 4 was to delay the evacuation of patients, even more so from England than from France, since those of our men who had been serving with the British, as in the American Second Corps, and were evacuated through British hospitals after injury, often had their records lost or delayed in transit. After the order above mentioned was published, the commanding general of our troops in England estimated that only 4 per cent of the records pertaining to our sick and wounded there were obtainable, that many of these patients were selected and ready for embarkation, and that ships were at the docks, with adequate space for the patients.2

It was now necessary to decide whether the best interests of the patients would be served by prompt embarkation or their retention until service records became available.2 If looked at solely from the standpoint of evacuation, it mattered relatively little whether or not the incapacitated were accompanied by service records; however, the difficulties of properly disposing of patients in the United States after their arrival there precluded the possibility of disregarding the necessity for service records accompanying the patients. Therefore, subsequent promulgations dealing with the evacuation of sick and wounded from France took into consideration not only the necessity for facilitating the embarkation of patients, but also the great need for having service records accompany patients so embarked.

In the early part of January, 1919, revised instructions concerning the evacuation of sick and wounded from the American Expeditionary Forces were issued by headquarters, Services of Supply.8 These instructions contained not only much that former embarkation instructions included, but also details that would further insure the ready and accurate identification of each patient so evacuated. That part which has present pertinence is as follows:

II. (1) All officers and soldiers in hospitals who will require at least two months' treatment and who, in the opinion of the attendant surgeons, can safely be transported, and all officers and soldiers who would be evacuated as of class D, will, as rapidly as facilities permit, be returned to the United States for continued treatment. The transportation of this class of personnel on hospital trains to designated ports and from thence to hospital ships will be in accordance with regulations to be prescribed by the chief surgeon.

(2) In accordance with detailed instructions to be issued by the chief surgeon, convalescent or ambulant patients who require no special accommodations evacuated on any transport will be organized into one or more detachments, each not exceeding 150 men, and under command of an officer, to be selected wherever practicable from casual medical officers, convalescents, or B or C class personnel. These detachments will be numbered serially, beginning with No. 1 at each port of embarkation, as follows: (Convalescent Detachment No. -, Bordeaux). The destination of the detachments to which these men are assigned will be entered on the passenger lists, hospital records, and on the service record that is forwarded with the soldier. The officer in command of each detachment is charged with the duties outlined in Section I, paragraph 7.


796

On each transport carrying sick and wounded not organized into casual detachments, as above indicated, a medical officer will be put in charge of the sick and wounded, and such officer will be charged with the duties outlined in Section I, paragraph 7. On naval transports the duties of this officer will be discharged after consultation and in full accord with the naval authorities.

To insure accurate identification, in addition to proper notations on the passenger lists and hospital records, the sailing number of the transport will be entered, in each case, on the service records of all sick and wounded not organized into casual detachments.

(3) Commanding officers of hospitals will, upon evacuation of officers, send immediate telegraphic notice, as far in advance of evacuation as possible, to the statistical division, adjutant general's office, at general headquarters, stating their name, rank, and organization, together with the hospital, depot, or embarkation camp to which their records are to be sent.

(4) Daily courier service will be maintained by the postal express service between the central records office and the evacuation hospitals at base sections Nos. 1, 2, and 5, for the purpose of the prompt procurement of records of enlisted men received at these hospitals without them. Requests submitted by this courier system (and those submitted as outlined in Section III, par. 4) will be given preference by the central records office. In the event that the central records office is unable to furnish the required records, all data available, including statement from the central records office that the records can not be furnished by that office, will be forwarded with the organization with which the soldier sails. When records can not be obtained, steps should be taken to provide supplementary records and payments as outlined in Section I, paragraph 10. The commanding officers of such hospitals are charged with arranging for the payment of all patients prior to evacuation. The evacuation hospitals at ports of embarkation will furnish the central records office, by courier, with a list of names of men returned to the United States without their records, showing the organizations to which the men belong. (Notation in red ink under man's name on passenger list furnished central records office may be used in lieu of list.) The central records office will forward such records, as soon as obtained, to The Adjutant General, Washington, D. C. Records received too late to accompany hospital patients will be forwarded by base port personnel adjutant to The Adjutant General's office, Washington, D. C., with a letter of transmittal, giving the organization to which the men belong and the name of the boat on which they sailed; a copy of this letter will be sent by courier to the central records office.

On January 5, 1919, general orders were promulgated by general headquarters, A. E. F., prescribing that all soldiers in hospitals, classified for return to the United States under the provisions outlined above, with the exception of class D patients, were to be transferred to specified overseas casual camps.9 Patients classed D were to be transferred to hospitals at Savenay, Bordeaux, or Brest, and carried on casual rolls. Prior to embarkation all soldiers were to be transferred from casual camp or hospital to a properly numbered casual company, convalescent detachment, or sailing convoy for transportation to the United States.9 Soldiers selected for transfer to the United States were to be dropped from the rolls of their organizations, and the service records of these soldiers were required, when obtainable, to be completed by the hospital commander, and to accompany the men upon transfer.

On February 2, 1919, further instructions were issued by general headquarters, A. E. F.,10 to the effect that officers and soldiers admitted to hospital would not be dropped from the rolls of their organizations, except when the hospital to which the officers or soldiers were admitted was not in the vicinity of the organization, thus precluding the organization from carrying the patients concerned as present sick. In the event it was necessary to drop patients in hospital from the rolls of their organizations (for example, when the hospital


797

was not in the vicinity of the organization or when patients carried present sick by organizations were selected for transfer to some other hospital), commanding officers of organizations, upon proper notification, furnished commanding officers of hospitals with the service records of the men concerned. Commanding officers of hospitals were directed to make proper notations on the service records of men evacuated. Service records were to accompany men when evacuated.

EVACUATION OF SICK AND WOUNDED FROM THE PORT OF ST. NAZAIRE, BASE
SECTION NO. 1

DURING THE PERIOD OF HOSTILITIES

In the evacuation of sick and wounded from the port of St. Nazaire the factors always to be considered were comfort to the patients, and at the same time as much speed as possible.11 The element of speed was made necessary by the fact that the arrival of vessels invariably was kept secret until the last few hours before arrival. Then, as a rule, only tentative arrangements could be made, for a great deal depended on the size and the number of the transports.

At this port there were adequate docking facilities, so that each ship usually found a berth alongside a dock.11 Thus little trouble was experienced in loading of the disabled.

As soon as the base surgeon's office received news of the expected arrival of a convoy the hospital center at Savenay, the main center of evacuation of class D patients, was notified, and the names of the ships were given if known.11 In this way tentative plans could be made, for by referring to a list provided by the Navy Medical Department the number of patients of each type capable of being loaded aboard each of the ships could be calculated. It now remained to find out from the Transport Service the most convenient time for loading the transports and the docks to which they were to be moored.

The passenger lists were made out at Base Hospital No. 8 under the following headings:11

Litter

Walking

Surgical

Medical

Mental

Total

Litter

Walking

T. B.

Others

Restraint

Others

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A medium-sized transport could carry 50 bed cases, 500 walking cases, and 30 to 40 officers of either type.11 If mental cases were to be sent, the number was usually about 35, 1 attendant being required for every 8 mental cases. In order to further facilitate matters, a naval representative proceeded to Base Hospital No. 8 for the purpose of tagging each patient, designating the compartment of the ship, if possible, and showing a serial number corresponding to that on the passenger list.

Choosing patients fit to travel and whose records were complete was a duty of the base hospital.11 The passenger lists were
made out there also,


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and, based on the total number of patients, blankets (three per man) and mess kits were drawn and placed aboard the hospital train. If the patients were destined to return home on a hospital ship, no mess gear or blankets were required, the ship being amply supplied with these essentials.

The loading of the hospital train was in charge of the evacuation officer.11 In addition to seeing that the proper patients were placed aboard, it was his duty to see that each man was tagged, had his medical envelope attached to his clothing, and had his blankets and mess kit, and that the lists of patients and the records were delivered to the commanding officer of the train. On occasions it became necessary for the evacuation officer to accompany the patients to the base port. In this event he in person turned over to the detraining officer the records of the patients and the passenger lists. If the evacuation officer did not board the train, the above-mentioned records and equipment were turned over to the commanding officer of the train.

When the loading of the train was well under way, the evacuating officer notified the railway transport officer, who arranged a schedule for the train over the French railroad.11 On this particular division a schedule was usually possible every 20 minutes. Thus the time of the departure of the train could be anticipated almost to the minute. The train having left the sidetrack running up to the hospital, the commanding officer of the hospital or his adjutant notified the base surgeon, whose office was in the city (St. Nazaire) in which the detraining and embarkation occurred.

From the base surgeon's office the various auxiliary departments were called on the telephone.11 The naval liaison officer was notified; also, the officer in charge of the ambulance battalion was notified of the probable time of arrival of the train, and was instructed as to what kind and how much equipment to bring with him. The detraining officer was notified. In this way all was in readiness when the train backed into the railroad yards, the ambulances were lined up beside the track, the detraining officer was on hand, and the necessary arrangements were made aboard the ship to be loaded. It may be well to state here that it was customary to load but one boat at a time.11 This avoided confusion and misplacing patients and records.

The detraining officer boarded the staff car, procured the passenger lists and records, and signed receipt for mess kits and blankets.11 He then ascertained the position in the trains of the cars containing the various types of patients. As a rule, the walking cases were kept in cars by themselves, the bedridden in other cars, and the officers and nurses, if any, in still another section. Having obtained this information, he planned the method of unloading accordingly and gave instructions to the commanding officer of the ambulance convoy. These instructions varied with each evacuation, for there were several factors to be considered. Among these factors were: (a) The type of train (if American, the bunks and beddings were fixtures on the train; if French, the men were lying on litters in racks of three tiers, covered with blankets, the property of the train); (b) the relative proportion of the litter and walking cases; (c) the position in the train of patients of each group; (d) the time of day and the weather.

In the case of an American hospital train it proved best to have on hand a large extra supply of blankets and litters, for none of the train's equipment


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could very readily be used.11 The extra supplies, carried in small motor trucks, kept up with the ambulances as they unloaded first one car and then another. By keeping the two types of machines abreast, patients with extension apparatus too long or too awkward for the small Ford machine could be placed in a G. M. C. Furthermore, when things were running smoothly the detail easily could load two ambulances at once at each of the several train doors. Seldom more than two cars could be worked at one and the same time, for to do this 13 men were required at each car, 4 to handle the litters in the car, 8 outside, and a noncommissioned officer to direct in case of the temporary absence of one of the officers. Then, too, too much speed at the train congested loading at the ship, since the checking required some time, and the litter bearers could progress with only moderate rapidity in the narrow passageways and up the steep stairways. They might further be detained by having to wait some time for the patients to be transferred from litter to bunk. In order not to lose property, it was the rule for each pair of men to return with the litter on which they carried their patient aboard. In order not to lose time, sitting or walking patients were transferred in G. M. C.'s Fords, and even in motor lorries, during the time the litter cases were being handled. Therefore there were no idle vehicles. The detraining officer proceeded by first ambulance to the transports, carrying records and passenger lists, so that checking might begin the moment the first patient arrived.

 PROCEDURE DURING THE ARMISTICE

The signature of the armistice, on the 11th of November, marked the turning point with respect to the policy of evacuation of the sick and wounded of the American Expeditionary Forces. The secrecy surrounding arrivals and departures of ships and the haste required in loading them no longer obtained. Every effort was made to keep the proper authorities advised of the expected arrival of transports, and once they arrived, due consideration could be paid to the comfort of the patients-speed was not the important factor that it had been.11

On November 25, 1918, the work of the evacuation of patients to the United States from base section No. 1 was officially placed under the base commander by the following letter from the commanding general, Services of Supply:

                                            AMERICAN EXPEDITIONARY FORCES,
                                                    HEADQUARTERS SERVICES OF SUPPLY,
    FIRST SECTION, GENERAL STAFF,
                                         November 25, 1918.

From: Commanding general.

To: C. O., base section No. 1; C. G., base section No. 2; C. G., base section No. 5.

Subject: Evacuation service.
 * * * * * * *

2. The responsibility for the evacuation of personnel to transports is vested in base section commanders, and the details will normally be executed through their staffs. Naval medical liaison officers have been detailed to duty at ports of embarkation, and the utilization of the services of these officers along the lines indicated in this correspondence should materially assist these staff officers in handling this important work.

By order of the C. G.

                                                         J. B. CAVANAUGH,
                            Assistant Chief of Staff, G-1.


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On December 2, 1918, additional instructions were given by the chief surgeon, A. E. F., in the following letter, and three hospital trains were assigned permanently to the section for the transportation of sick and wounded between hospitals of the section and from hospitals to transports:

    AMERICAN EXPEDITIONARY FORCES,
                                                            OFFICE OF THE CHIEF SURGEON, A. P. O. No. 717,
                                                         December 2, 1918.

From: Chief surgeon.

To: Surgeon base section No. 1

Subject: Evacuation of patients to the United States.

1. The chief surgeon desires that you assume charge of the evacuation of all patients selected for transfer to the United States from the hospital centers, Angers, Nantes, Savenay, and St. Nazaire. When such patients are selected at these hospitals, use the hospital trains 50 and 51, now assigned to you, to collect them at Savenay for final scrutiny, assembly of records and equipment, with clothing, blankets, mess kit, and toilet articles.

2. It is very essential that improper cases for transfer to the United States be not all assembled at Savenay, resulting in congestion of nontransportable cases there, so that you are advised to have the cases which are moved from Angers and Nantes selected from those able to bear the journey to the United States. Also, take advantage of the fact that men discharged from hospitals of classes B and C who are able to join casual companies may be sent to the casual concentration camp at St. Nazaire.

3. Keep this office informed of your needs in the way of personnel, transportation, supplies, and equipment, in order that the deficiencies may be promptly met. A copy of this letter has been sent to the commanding officer, hospital centers, Angers, Nantes, Savenay, and Base Hospital No. 101, St. Nazaire.

By direction:

        R. M. CULLER, Colonel, Medical Corps.

When this port was designated as one of the three principal ports of embarkation, plans immediately were made to cope with the situation, and in the medical, as well as in all the other departments, an evacuation branch was inaugurated. "The general system used previously was not materially changed. However, instead of relying upon casual organizations at the rest camp to furnish details of litter bearers and ambulance drivers, an ambulance company was assigned to the duty. Soon it was found that in addition an evacuation ambulance company and a field hospital unit could be used, the three organizations working as a battalion."

Furthermore, the regulating branch in the office of the base surgeon took on added responsibilities, and in order to systematize and standardize the reports required by the different departments several mimeographed forms were promulgated.

The following circular letter was sent to all base hospitals and camp hospitals, hospital centers and convalescent camps in Base Section No. 1:

                    SERVICES OF SUPPLY,
                                                        OFFICE OF THE SURGEON, BASE SECTION NO. 1,
                                 France, November 21, 1918.

Circular Letter A-16.

From: The surgeon.

To: The commanding officer.

Subject: Report of patients to be evacuated to the United States.

1. In order to facilitate the evacuation of patients to the United States, it is requested that you submit daily telegraphic or telephonic report to this office giving the following information by numbers of patients in your hospital ready to be evacuated to the United States:


801

    (1) Stretcher cases in sick bay.

    (2) Requiring dressings, in standees.

    (3) Requiring no dressings:

            (a) Requiring help.

            (b) Not requiring help.

    (4) Tuberculosis.

    (5) Mental.

2. The report should reach this office by 10 a.m., daily.

3. Report should be made as given in the form below:

BASE SURGEON, St. Nazaire:

Base Hospital twenty seven November twenty second re circular letter A sixteen one 133 two 145 three A231 B 452 four 99 five 63.

                            SMITH.
                            CHAS. L. FOSTER,
                                                            Colonel, Medical Corps, United States Army.

This report enabled the base surgeon to keep constantly on hand such data as the total number of class D patients in the base section, the total number of litter patients, tuberculosis, mental, and other groups.11 As soon as these data were received they were tabulated, so that at the end of each day it was possible to tell in a moment how many class D patients were in the section, how many at a particular hospital, which hospital was overcrowded, and which one needed first consideration when an opportunity to evacuate presented.

A "Capacity and adaptability report" was made up as follows:11

Name of transport

Litter cases

Ambulatory surgical requiring dressings

Medical and surgical in standees

Attendants

Officers in rooms

Tuberculous patients

Medical or surgical not requiring attention

Mental patients

Total number of patients

Number of bunks to be reserved

Patients

Attendants

Bed

Walking

Restraint

Others

Attendants

Officers

Enlisted men

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This report was a great help also in that it covered all the essential points with respect to a transport's fitness to receive patients.11 It was designed with the concurrence of the naval medical representative, and was used by him, and by the Army medical officer assigned to the duty of passing judgment upon arriving transports. Upon receipt of this form the data were transcribed to permanent records in the office of the surgeon, where they were available for ready reference when the ship returned to this port. A copy of the report was sent to the hospital center at Savenay, where it was used in preparing the passenger lists. In order not to delay matters, however, the data usually were read over the telephone to the commanding officer of the hospital center, and the report sent as confirmation.

A "space" report was used in connection with all transports, and was sent by courier to the evacuation officer at the evacuation camp, base section No. 1, and to the superintendent, Army Transport Service.11 Thus, if for any reason any part of a ship could not be utilized by the Medical Department, it could be utilized in returning to the United States such casual and class B and C officers and men as might be awaiting transportation.


802

The following "Evacuation report" was rendered to the chief surgeon, A. E. F., for each ship loaded with patients for transportation to the United States:11

1. The following is list of patients evacuated from this port, above date, aboard

-----------------------------------------------
        (Name of transport.)

 MEDICAL

Tuberculosis --------------------------------------------------------------------------------------------------------

Mental:

    Restraint ----------------------------------------------------------------------------------------------------------------------------------
    Others -----------------------------------------------------------------------------------------------------------------------------------

All other sick ------------------------------------------------------------------------------------------------------------------------------------

Total sick -------------------------------------------------------------------------------------------------------------------------------------

Sitting cases ------------------------------------------------------------------------------------------------------------------------------------

Litter cases ------------------------------------------------------------------------------------------------------------------------------------
 SURGICAL

General surgical --------------------------------------------------------------------------------------------------------------

Fractures, upper extremities -----------------------------------------------------------------------------------------------------------------------------------

Fractures, femurs ------------------------------------------------------------------------------------------------------------------------------------------------

Other fractures ----------------------------------------------------------------------------------------------------------------------------------------------------

Total fractures ----------------------------------------------------------------------------------------------------------------------------------------------------

Sitting --------------------------------------------------------------------------------------------------------------------------------------------------------------

Litter ----------------------------------------------------------------------------------------------------------------------------------------------------------------
                                  _____

        Grand total -------------------------------------------------------------------------------------------------------------------------------------------------

This report was made instead of the lengthy one required by paragraph 4-F, Circular No. 38, chief surgeon's office, July 1, 1918, and was rendered in the case of all sailings subsequent to December 1, 1918, to comply with letter, chief surgeon's office, dated November 22, 1918, quoted above.11 One copy of this report was sent to the commanding officer, base section No. 1, and one copy was held for file, the essential data being tabulated upon a permanent form in the office of the base surgeon, for ready reference.11

Other reports, occasionally required, were readily compiled from the data obtained in the manner outlined above.11 Thus a memorandum to the chief surgeon's office was sent from the office of the base surgeon each week end, of the total number of class D patients remaining in the section.11 At the end of the month, a letter covering the total number of patients of each class evacuated to the United States was forwarded to the chief surgeon, A. E. F., and copies were sent to the commanding officer, base section No. 1, and to the naval liaison officer.11

The following extract from the Annual Report of Surgeon General, United States Navy, 1919, concerns the part played by the Navy in the return of sick and wounded from the American Expeditionary Forces:

At a very early stage of the war arose the problem of how to return the sick and wounded to America. The ideal solution would have been for the Army to return its casualties in ambulance ships owned, manned, and equipped by its Medical Department and convoyed by the Navy. This was impossible, and the next measure considered was the use of the Navy hospital ship Solace, with its capacity for returning 200 casualties a month, and the use later of two other hospital ships in process of equipment able to bring back 300 sick apiece per month. The Army's estimate of a minimum of 5,000 returnable casualties per month showed


803

these resources to be utterly inadequate even had these three vessels not been required for their original and legitimate purpose of caring for the Navy sick. Out of this situation developed the arrangement by which all Navy transports would, on the westward passage, serve to the limit of capacity for the return of Army sick and wounded, and a schedule of each ship's carrying capacity was forthwith gotten up and generally promulgated for the guidance of all concerned. This proved the best arrangement possible under the circumstances and was entirely satisfactory whenever the limit of a given ship's capacity was not exceeded. Unfortunately it was not always sufficiently clear that the complement of a troop ship bound east by no means corresponded to its capacity for adequate care of returning sick and wounded. The pressure at evacuation centers in France was, of course, enormous and it extended to ports of embarkation, but the Navy took the position from the start that what was good enough for healthy men being rushed to the front was by no means sufficient for the maimed and sick who had done their bit and were entitled to the best possible care and professional attention the moment their retrograde movement began. To subject the sick to the overcrowding of troop compartments for a 10-day voyage was to jeopardize their chances of recovery. The troop quarters, with their three and four tiers of standee bunks, on iron decks remote from mess room, toilet, and open-air recreation were absolutely out of the question for the lame and disabled, the bedridden, the surgical cases requiring one or many daily dressings and, of course, during the period of the submarine menace common humanity demanded that the number of totally disabled and helpless passengers be not out of proportion to the facilities for carrying them to and caring for them in rafts and lifeboats should "abandon ship" be necessary. The captain of the ship and the senior naval medical officer were judged by the Navy Department to have sufficient appreciation of the need for rapid evacuation, combined with a practical knowledge of conditions at sea, to determine not the maximum carrying power but the maximum of facilities approximating the required hospital service for sick and wounded on each ship. The much talked of "hommes 40, chevaux 8" car was not esteemed an appropriate means of transfer rearward for the disabled ashore, and it was not proposed to give them an analogous service on a 1-day voyage on the water.

Had it been only a question of attendant personnel, the whole matter would have been much simplified, but the humane treatment of the returning casualties included a variety of other considerations. There was a limit to the number of attendants that could work in confined ship spaces without falling over each other, especially when the ship was darkened in the submarine zone. The proper handling of contagious cases, the tuberculous, the insane, involved nice adaptation of numbers and special requirements to available space and facilities.

Conferences of the bureaus concerned, beginning November, 1917, led to the drawing up of a formal agreement by which the Navy undertook to handle all sick and wounded for which it could provide adequate space, the prime basis of adequate treatment, on troopships manned by the Navy, and to furnish the services of its three hospital ships in excess of its own needs only.

In their joint report of February 7, 1918, to you, the Surgeon Generals of the two services agreed that the Navy hospital ships were entirely unavailable for Army purposes as sick transports, their capacity being small and their services completely utilized with mobile units of the fleet. The Navy transports were agreed upon as the best available means of returning Army sick and wounded, the number to be carried being limited to available space after the Navy sick and the sick of the troops in transit had been provided for. There was also a joint recommendation for the purvey of six ambulance ships, of 500 or more capacity, for Army use.

Your letter of January 22, 1918, to the honorable Secretary of War definitely assigned to Army use the facilities for handling Army sick and wounded returning to the United States available on Navy transports then in service and of others that might be subsequently obtained, and the two Navy hospital ships Comfort and Mercy were also offered when the services of these vessels could be spared from naval use. It was stated that no increase in facilities for this purpose were contemplated by the Navy, but that, should the Army find these repatriation provisions insufficient, naval personnel would be provided to man and operate such vessels as the Army might procure. The substance of this letter was reiterated in your letter of January 29. Again, in your letter of February 15 to the honorable Secretary of War, it was clearly pointed out that the Navy would man and operate any number of hospital ships provided by the Army, said ships to be ready in all respects for occupation.


804

The following was the agreement approved by yourself and the honorable Secretary of War, March 28, 1918:

(a) That the sick and wounded being brought from France or England to the United States will be brought in naval hospital ships or transports, whichever may be most suitable and available, except in special cases where transportation by commercial liners may be authorized.

(b) The Army will be in charge of the embarkation and disembarkation of all Army patients.

(c) The Navy will be charged with the care of these patients while on board ships of the Navy acting as transports or otherwise.

(d) At the request of the Navy, the Army will render such assistance in personnel and matériel as may be necessary.

The following schedule shows the classified sick-carrying capacity of the great majority of the transports in service on December 1, 1918. The figures fluctuated more or less with alterations in internal structural details made for better ventilation or other sanitary considerations. On some transports increased passenger service went hand in hand with improved disposition of living spaces; in others, it was reduced. In every case, the numbers of different types that could be treated with gratifying results depended absolutely on the type and general structure of the ship, which, in the main, was fixed and not susceptible of modification.
 Revised table for rated capacity for troops invalided home September 5, 1918, on principal naval transports 

Total bedridden in sickbay bunks

Able to walk, requiring surgical dressings; in troop standees

Mental cases

Tuberculosis, in isolation or on open decks

Able to walk, requiring no attention; in rooms for officers

Convalescent, requiring
no special attention;
in troop standees

Aeolus

24

100

10

30

145

2,580

Agamemmon

38

130

20

60

230

3,000

America

59

140

12

25

215

3,600

Antigone

40

110

5

25

100

1,660

Calamares

42

100

5

20

80

1,100

DeKalb

12

150

---

20

50

1,000

Finland

40

200

6

30

150

3,350

George Washington

60

500

8

50

500

4,600

Great Northern

40

400

45

38

116

2,200

Hancock

20

550

3

---

40

a750

Harrisburg

38

200

5

25

100

2,200

Henderson

50

350

8

16

64

1,164

Huron

38

110

5

25

140

2,250

Konigen der Nederlanden

24

300

2

30

80

1,500

Kroonland

40

200

16

20

150

2,600

Leviathan

100

1,000

360

55

400

1,000

Lenape

20

100

---

10

44

1,000

Louisville

45

300

5

30

100

1,800

Madawaska

40

100

5

25

105

1,750

Mallory

20

100

---

10

40

1,200

Manchuria

38

300

22

40

175

2,850

Martha Washington

50

150

25

30

100

2,250

Matsonia

16

100

5

10

90

2,000

Maui

30

100

5

10

100

2,000

Mercury

44

110

20

25

120

2,300

Mongolia

33

300

5

25

170

2,850

Mount Vernon

40

130

25

25

140

1,800

Northern Pacific

44

510

45

90

120

1,700

Orizaba

40

500

---

25

90

2,000

Pastores

25

100

---

15

50

1,000

Plattsburg

38

200

10

45

100

2,000

Pocahontas

39

120

5

25

130

2,180

Powhatan

40

300

10

25-150

57

1,400

President Grant

55

110

5

25

200

4,400

Princess Matoika

35

150

5

16

150

3,000

Rijndam

50

1,000

10

40

155

1,800

Siboney

50

500

---

25

90

2,000

Sierra

30

200

5

25

100

1,300

Susquehanna

45

130

5

25

105

1,850

Tenadores

40

100

3

20

42

1,150

Von Steuben

---

b200

---

60

103

a650

Wilhelmina

20

100

5

10

100

1,500

Zeelandia

27

500

5

30

76

1,100

                       

aHammock.        bCot.                      


805

DETAILS OF EVACUATION

In July and August the demand for return of sick and wounded to the United States at the hands of embarkation officials in France increased, and pressure was constantly exerted on commanding officers to exceed their allotted complement of sick, notably in the case of the Kroonland, Finland, and Calamares. But whenever sympathy for the congested embarkation areas and for the sufferers in them got the better of the judgment of ships' officers and induced them to exceed the allotted complements the resulting overcrowding led later to complaint about overcrowding in transit. The suggestion was received from various quarters that a ship be modified in structure so as to bring back in same only in large numbers. These suggestions had in view only the evacuation from France of this unfortunate class. They did not extend to a practical consideration of how they would be cared for en masse amid the discomforts and inconveniences of life at sea and the extremely small chance they would have of surviving in the event of attack or disaster to such a ship. Neither was it appreciated by those unfamiliar with the sea that in moments of danger from enemy or stress of weather the presence on board of hundreds of insane would jeopardize the safety of a ship and its complement.

The medical officers and hospital corpsmen of the Navy Transport Service deserve the greatest credit for their faithfulness and skill in the repeated ocean crossings with their sanitary work on the outward, their hospital work on the homeward bound voyage-and the cleaning up, alterations, improvements, constantly going on during brief stays in home ports. This credit has been accorded them by the vast majority of the men to whom they ministered, and the only criticism of the medical aspect of the Navy transport service has arisen when more patients were assigned them than regulations warranted or when men were put aboard unfit or unprepared for the voyage or with misleading diagnoses.

As late as September, 1918, it was necessary to specify, and in December to repeat the request, that at least three hours before sick for return to the United States were sent alongside the transport, its officers should be furnished with quadruplicate lists separate from that of passengers, showing sources of patients, their rank, company, regiment, organization, and diagnosis. Our internal arrangements had long been so perfected that when once this advance information was regularly supplied, the walking patients would be assigned to compartments, the sick to wards, the bedridden carried to beds without a moment's delay, and by the time the ship was well out of the harbor litters were beside each bedridden case, with men detailed as bearers, and provision had been made or instructions given for any exigency that might arise requiring "abandon ship."

Gradually as system and order in the evacuation of the sick and wounded developed all along the line, some of the overwhelming burdens were lightened and at the same time a better service was given. Before the armistice was signed liaison between the two branches of the service was so perfected that some of the early and radical mistakes of evacuation from shore to ship have since been avoided, and it was no longer possible to find one transport returning overloaded while a vastly larger one sailed practically empty from a near-by port. Much of the dissatisfaction with the carrying (adequate caring) capacity of our transports was felt ashore and grew out of methods of coastward routing and distribution of invalid cases in France. This waned as an orderly distribution was evolved based on proper advance information of ships' arrival and the accommodations they afforded.

In transporting the insane our medical officers had to follow the rule of holding to the diagnosis furnished by the medical attendants who had had the cases under observation and study in camps and hospitals ashore prior to embarkation. Every medical man knows the plausible speech and the docile behavior which the most dangerous maniac may assume for even long periods, only to break out in his true light when suspicion has been allayed. The overworked transport surgeon was not in a position to undertake the cure of the insane on an ocean voyage, nor had he the time, even if he pretended to the special skill required, to go into the niceties of differential diagnosis. When patients were no longer sent aboard indiscriminately an hour before sailing, without papers, descriptive lists, or diagnosis, but carefully tagged and sorted as surgical, medical, ambulant, or bedridden, contagious, nervous, and insane, etc., it was his duty to see that the insane were humanely treated, and humanity here


806

consisted in preventing their jumping overboard or falling down the engine-room hatch, running amuck about the ship, incommoding other patients-in a word, in restraining them and delivering them alive in America. The bulk of the transports were provided with areas inclosed by metal screens, having access to air and light on deck, with a sentry to keep away the thoughtless or inquisitive, and attendants on watch day and night, every sanitary detail being observed in regard to these unfortunates. Passengers who saw unkindness in this restraint or declined to accept the diagnosis made by the Army surgeons conversant with the cases before embarkation were not prepared to accept the responsibility for a different procedure nor could they relieve the ship's surgeon of his. In some cases groups of insane were put aboard our transports under the care of medical officers and attendants detailed for the voyage from the service to which they belonged, and under these circumstances those officers and attendants quartered and handled their charges as they saw fit without the advice or interference of the ship's authorities.

During the most active period of our military campaign the heaviest work of our medical officers on transports flowed from the requirement of surgical cases, many of whom required three or four changes of dressing daily. The most trying work was that of ministering to men sent home to die, a certain proportion of whom, of course, expired within a day or two of sailing.

 * * * * * * *

As our battleships and cruisers are normally provided with facilities for caring for the sick of their crews, estimated at not over 3 per cent for a force of from 600 to 1,000 men on each of these vessels, they were manifestly not adapted in any way nor used for the repatriation of sick and wounded.

Upon the signing of the armistice and with the initial movement for the return of our troops from abroad, steps were taken to utilize certain German ships which had been unable to go to sea owing to the preponderance of allied naval power and were still in German harbors. One of the best of this class was the Imperator, which was rapidly converted for transport purposes and, like the rest, was manned by a Navy crew composed in the main of officers and men already abroad and no longer required for campaigning. Other vessels of this category were the Graf Waldersee, Cap Finisterre, Kaiserine Augusta Victoria, Mobile, Patricia, Philippines, Pretoria, Prince Frederick Wilhelm, Zeppelin.

 REFERENCES

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

(2) Report on the evacuation of sick and wounded, A. E. F., to the United States, undated, made to the Surgeon General by Col. R. M. Culler, M. C. On file, Historical Division, S. G. O.

(3) G. O. No. 41, G. H. Q., A. E. F., March 14, 1918.

(4) G. O. No. 206, G. H. Q., A. E. F., November 15, 1918.

(5) Embarkation Instruction No. 1, Hq. S. O. S., A. E. F., November 20, 1918.

(6) Embarkation Instruction No. 6, Hq. S. O. S., A. E. F., November 26, 1918.

(7) G. O. No. 215, G. H. Q., A. E. F., November 25, 1918.

(8) Embarkation Instruction No. 13, Hq. S. O. S., A. E. F., January 4, 1919.

(9) G. O. No. 5, G. H. Q., A. E. F., January 5, 1919.

(10) G. O. No. 23, G. H. Q., A. E. F., February 2, 1919.

(11) Report on the evacuation of sick and wounded from the port of St. Nazaire, undated, made to the surgeon, base section No. 1, by First Lieut. Edward P. Heller, M. C. On file, Historical Division, S. G. O.

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