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ACCESS TO CARE
DISCONTINUANCE OF HOSPITALS
With the signing of the armistice on November 11, 1918, retrenchment of activities in the American Expeditionary Forces was begun. On that day general headquarters, A. E. F. directed all chiefs of supply services, American Expeditionary Forces, to make immediate reports to the commanding general, Services of Supply, as to what projects and constructive activities had now become nonessential.1
As a result of these instructions, the commanding general, Services of Supply, on November 14, 1918, directed that the following action would immediately be taken:2 Cessation of further procurement, cancellation of such contracts as could be canceled, suspension of construction, stopping of further shipments from the United States of supplies or material already purchased. In addition, each chief of a supply service was directed to study the situation in so far as it pertained to his department and to make further recommendations concerning reductions. That part of this order which affected the hospital situation was as follows:
* * * * * * *
(a) Provide normal hospitalization on a basis of 7½ per cent of total strength instead of 15 per cent as hitherto.
(b) All contracts for hospital tentage will be canceled.
* * * * * * *
(d) French contracts for beds and mattresses, mobile hospitals, and mobile surgical units, in excess of the needs of 30 divisions, will be canceled.
* * * * * * *
(f) The authorization for construction of hospital centers at Evreux, Alencon, Dourdan, and Liffol-le-Grand is canceled.
(g) The authorized increase of 5,000 beds at Rimaucourt is canceled.
(h) Construction work now under way upon the following hospital centers will be stopped: Avoine, La Suze, Montoir, Reignac, and Landerneau. At Beau Desert and Savenay the projects shall be limited to 10 units.
(i) At hospital centers, not above enumerated,
all buildings which have been started will be completed.
Because of the many patients in hospital, obviously compliance with some of the above-mentioned instructions could not immediately be carried out; for example, the reduction of the percentage of hospital beds from 15 to 7½ was contingent upon the rapidity with which patients in hospital could either be returned to duty or sent to the United States.3 As a matter of fact, not only did the number of hospital beds increase after the signing of the armistice, but also the number of base hospital units.4 Thus, though on November 7 there were 118 base hospitals (or hospitals operating as such) in the American Expeditionary Forces, exclusive of Italy, providing 147,379 normal beds, these numbers were gradually increased until on December 26 there were 127 base hospitals (or hospitals operating as such) with 159,029 normal beds. On the other>
hand, emergency beds numbered 83,377 in base hospitals on November 7 (subsequently increased to 86,000), and since these beds were used for the less seriously sick or wounded, and the admission of wounded naturally ceased shortly following the armistice, such beds could be dispensed with fairly rapidly, so that by January 2, 1919, their number had fallen from 86,000 to zero. At this time the number of patients was 93,494.4
From this time on the number of base hospitals could progressively be diminished, in that more facilities were provided for transferring patients in them to the United States, and the diminution could keep pace with such transfers. In this connection it is necessary to consider two factors: General instructions for the return of units from the American Expeditionary Forces to the United States, and the selection of units whose services were no longer required.
General instructions affecting the return of organizations to the United States were issued by general headquarters, A. E. F., and by headquarters, Services of Supply; that is to say, general headquarters prescribed in general terms the manner of selecting organizations for return: Troops in the Services of Supply, which included the units of stationary hospitals, were to be returned to the United States in the order in which their services could be spared and, so far as possible, in the order of their arrival in France.5 More specific instructions were issued by general headquarters, but these pertained to such matters as embarkation instructions, the transfer and attachment to returning organizations, of excess personnel;6 the disposition of property and funds, discharge of officers and enlisted men, etc.7 To headquarters, Services of Supply, were left the details of transferring designated units and attached personnel to the United States.
In so far as the selection of hospital units for return to the United States is concerned, as mentioned above, this was contingent upon the use that had to be made of the hospitals. Naturally the movement of hospital units formed but a very small part of the return movement as a whole. Transportation difficulties which obtained during active hostilities still existed, reflecting in the following manner on hospitals in the Services of Supply: Throughout December, 1918, totally inadequate transportation could be secured for the return of men, in hospitals and fit for duty, to their proper organizations, thus leaving in hospital at the end of that month approximately 30,000 men who otherwise should not have been there.8 As this would have caused the Medical Department reports to show a relatively high and fictitious morbidity in the American Expeditionary Forces, the chief surgeon, A. E. F., on January 23, 1919, adopted the plan of showing on his daily report of relation of patients to beds, class A patients separate from bona fide patients.4
Other factors obtained which influenced the selection of hospital units for return to the United States. These were location, with relationship to lines of communication; whether or not a hospital unit occupied a French building which would be needed for military or other purposes by the French. In Chapter XVI, Section I, which concerns the hospitalization scheme of the American Expeditionary Forces, references are made to the fact that it was necessary for us to go far afield for locations for some of our hospitals; that is, some had to be placed well off our lines of communication, thus making them>
not readily accessible. In addition, though some of the places where our hospitals were located proved usable during the period of hostilities, nevertheless, since no sufficient reason existed during the armistice for continuing them, especially if physical characteristics militated against their use, such places were slated early for abandonment. Thus on December 31, 1918, the chief surgeon, A. E. F., reported to the commanding general, Services of Supply, that plans were well under way for the abandonment of the following hospitals in French buildings:8 Base Hospital No. 66, at Neufchateau; No. 23 and No. 36, at Vittel; No. 31 and No. 32, at Contrexeville; No. 20, at Chatel Guyon; No. 30, at Royat; No. 71, at Pau; No. 98, at Lourdes; No. 218, at Poitiers; No. 208, at Autun; No. 63, at Caen; No. 85, at Paris. In addition, it was his plan to abandon the hospital center at Allerey at an early date, because it had been rendered practically useless through the excessive muddiness of the locality.8
Aside from the urgent necessity for returning to the French as many as possible of their buildings we had been using as hospitals, the abandonment of hospitals had to be governed to a great extent by their positions on the line of communications; that is to say, though, on the one hand, it was possible to foresee early that certain hospitals could be abandoned, or hospital centers compressed, in the advance and intermediate sections; on the other hand, in the base sections, particularly Nos. 1, 2, and 5, hospitalization not only had to be kept at a pre-armistice status, but also increased to make possible an adequate preparation of the homeward-bound sick and wounded.4
The discontinuance of hospitalization then, involved at first principally the advance and intermediate sections.4 As to the advance section, on January 1, 1919, there were 29 base hospitals or hospitals acting as such.4 There were four principal hospital centers, namely, Toul, Bazoilles, Vittel-Contrexeville, and Rimaucourt. In the changed nature of affairs brought about by the signing of the armistice, some of these continued to be of importance, others did not. Reference was made above to the fact that the Vittel-Contrexeville center was slated for abandonment as soon as its patients could with safety be evacuated to other hospitals. On the other hand, because of the convenient location of the Toul and Bazoilles centers, in so far as the Third Army, and other organizations in the locality, were concerned, these centers remained relatively uncompressed for the first three months of 1919; however, in April, when the number of patients in these centers had materially been reduced, the major portion of their component hospitals ceased operating, and early in May the centers were discontinued.4 The Vittel-Contrexeville center was emptied of patients early in February and ceased to operate.4 Rimaucourt comprised only five base hospitals at the beginning of 1919.4 These were reduced to two by the end of January, to care for the relatively few remaining patients; then to one during the week ending April 24, when the center ceased to exist as such.4
During the period January 1 to May 31, 1918, in which the major part of the activities of hospital discontinuance occurred, the number of patients in the advance section diminished from 22,521 to 1,233.4 These 1,233 patients were being cared for in five base hospitals located as follows: Commercy, Rimaucourt, Langres, Chaumont, and Dijon.4>
On January 1 the intermediate section contained 46 base hospitals, most of which were in the following hospital centers: Beaune, Allerey, Mars, Mesves, Vichy, Clermont-Ferrand, Orleans, and Tours.4 The principal of these were the first five named. The hospitals as a whole contained 69,802 patients, more than thrice the number in any other one section.4 As stated previously, the hospital center at Allerey was not desirable for hospital purposes after the first of the year 1919, consequently by the end of the first week in February it had been reduced in size from seven operating hospitals to one; this remaining base hospital in turn was replaced by camp hospital personnel during the week ending March 6.4 A similar experience befell the hospital center at Beaune, except that here an additional week intervened between the conversion of the last base hospital to a camp hospital.4 Beaune and Allerey then were used for purposes of the American Expeditionary Forces University.9 The hospital centers at Mars and at Mesves were larger than the other centers; in fact, the center at Mesves attained proportions unequalled by any other center in the American Expeditionary Forces.4 Both were increased in the number of component base hospital units following the signing of the armistice, Mars to 8 and Mesves to 12.4
Both centers continued to operate until May, meanwhile experiencing a gradual compression; so that by April 24, each contained but one operating base hospital.4 Mesves ceased to be hospital center during the week ending May 8; Mars several weeks subsequently, due to the fact that its base hospital units, though not operating, were awaiting orders to move to a base port.4 The Vichy center comprised five base hospitals, or hospitals operating as such, on January 1, 1919.4 These were all in French buildings, principally hotels; hence, despite the fact that the center had developed into a special center for the treatment of head injuries, it was compressed to three hospitals by the middle of January; to one by February 20, and ceased to exist during the week ending March 13.4 The Clermont-Ferrand center, being a late development, comprised only four hospitals when the armistice was signed, all in separate localities.4 The hospital at Clermont-Ferrand was never operated; the hospital at Le Mont Dore was never used to more than 70 per cent capacity.4 At the beginning of the year 1919, these two last-mentioned units had ceased to exist, in so far as the center was concerned.4 During January, the patients were evacuated from the remaining two base hospitals of the center, and by the 23d of the month they had ceased to operate.4 At the end of May, only two base hospitals were in operation in the intermediate section. These comprised the Tours center, and contained 513 patients.4
In the base sections under consideration-that is, Nos. 1, 2, and 5-it was necessary to maintain hospitalization on a relatively large scale until well toward the end of the existence of the American Expeditionary Forces.4 Particularly was this true when the hospitals were adjacent to the ports. Where this was not so, as in the case of the centers at Limoges and Perigueux, the hospitals were handled in much the same way as those in the intermediate section; that is, they were compressed, when in centers, and closed when operating independently as rapidly as the evacuation of patients permitted.4>
On June 16, 1919, only 12 base hospitals remained in operation in the American Expeditionary Forces. These, with their locations, were as follows:10 Base Hospital No. 57, Paris; No. 65, Kerhuon; No. 88, Savenay; Nos. 113, 118, and 119, Savenay; No. 121, Beau Desert; No. 214, Savenay; 216, Nantes. All but the first four of these had ceased functioning by the end of June; the first four were discontinued in July.11
The gradual reduction in the number of base hospital units in the American Expeditionary Forces was not merely a question of releasing the units when they were no longer needed; on the contrary, a certain amount of shifting of the units was necessary so that those units earliest in France could be released and, at the same time, there would be no interference with the operation of a hospital. This was particularly true of hospitals operating independently. Thus, for example, in January, 1919, Base Hospital No. 6, Bordeaux, was replaced by Base Hospital No. 208; Base Hospital No. 9, at Chateauroux, was replaced by Base Hospital No. 36; Base Hospital No. 27, Angers, was replaced by Base Hospital No. 85.4 Also, evacuation hospital units were used to replace base hospital units, to permit the latter units to return early to the United States.4
In so far as camp hospitals are concerned, since these were not used for battle casualties, but rather for the temporary care of the sick of troops in their respective localities, the discontinuance of them necessarily was contingent upon the cessation of troop activities; therefore, a given camp hospital had to be kept open until the very last of such activities. There were 56 camp hospitals in the American Expeditionary Forces on January 1, 1919,4 and though, on the one hand, it was possible soon to discontinue some of them at different places, on the other hand, it was necessary to establish new ones, for example, at the American embarkation center and at the base ports.4 Also, some base hospital activities were taken over by camp hospitals.4 Thus the reduction in the total number of camp hospitals in the American Expeditionary Forces was not nearly so rapid as was the case with the base hospitals, and on April 30, 50 camp hospitals remained in operation. However, during the following month, this number was reduced to 29,4 and by the middle of June, only 11 existed.10 a
In respect to the actual closing of a hospital, there is no necessity for going into great detail as to this. Suffice it to say that when the chief surgeon, A. E. F., reached the decision that a hospital unit soon could be returned to the United States, he notified the assistant chief of staff, G-4, headquarters, Services of Supply, of that fact, and usually at the same time gave advance notice to the hospital unit concerned.12 G-4 gave final notice to the unit at the proper time, whereupon the officer commanding the unit, after having accomplished certain administrative matters referred to below, reported to G-1, Services of Supply the fact of the unit's readiness to move in order that this section of the general staff, Services of Supply, charged with the movement of troops, could make proper provisions.13 The unit then joined the general movement to the base ports and took its turn in embarking.
aFor details concerning the final disposition of the few remaining camp hospitals, see Sec. VI of this volume.-Ed.>
Since no medical property was to be returned to the United States,14 except combat equipment and certain articles including surgical instruments, scientific laboratory equipment, and X-ray equipment,15 it was necessary for each hospital unit to pack its supplies and equipment with a view of having them stored subsequently in one of the medical supply depots. Circular No. 72, chief surgeon's office, A. E. F., which is given in the appendix to this volume, covers the method that was to be used in preparing equipment for shipment. In view of the inadequacy of space in the medical supply depots and transportation, most supplies pertaining to Services of Supply constructed hospitals remained where they were, ultimately to be turned over to the French.16 Of course, in so far as those of our hospitals which occupied French buildings are concerned, all supplies and equipment had to be removed.
The disposition of records was as follows: Certain records accompanied the unit to the United States, there to be sent finally to The Adjutant General.17 These included the correspondence book and document file, morning reports, sick reports, general reports, local orders, war diary. Retained records, such as retained muster rolls, were to be sent to the office of the chief surgeon, A. E. F.18 In addition the chief surgeon, A. E. F., required each hospital, upon finally closing its work as an organization in the American Expeditionary Forces, to send to his office a final sick and wounded report and the retained register cards (Form 52 M. D.)18
(1) G. O. No. 202, G. H. Q., A. E. F., November 11, 1918.
(2) G. O. No. 54, headquarters, S. O. S., A. E. F., November 14, 1918.
(3) War diary, chief surgeon's office, A. E. F., November, 1918.
(4) Daily report of relation of patients to beds in base hospitals, A. E. F., made by the officer in charge, hospitalization division, chief surgeon's office, A. E. F. Copies on file, Historical Division, S. G. O.
(5) G. O. No. 35, G. H. Q., A. E. F., February 21, 1919.
(6) G. O. No. 17, G. H. Q., A. E. F., January 25, 1919.
(7) G. O. No. 20, G. H. Q., A. E. F., January 30, 1919.
(8) First indorsement from the chief surgeon, A. E. F., December 31, 1918, to the assistant chief of staff, G-4, headquarters, S. O. S. On file, A. G. O., World War Division, Chief Surgeon's Files 322.32911.
(9) Memorandum for the assistant chief of staff, G-1, headquarters, S. O. S., from the chief surgeon, A. E. F., March 17, 1919. On file, A. G. O., World War Division, Chief Surgeon's Files, A. E. F., 320.23.
(10) Memorandum for the statistical division, Central prisoners of war, Inclosure No. 1, A. E. F., from the chief surgeon, A. E. F., June 16, 1919. On file, A. G. O., World War Division, Chief Surgeon's Files, A. E. F., 322.32911.
(11) Based on the histories of the separate base-hospital units, A. E. F., prepared for the chief surgeon, A. E. F. These histories are on file in the Historical Division, S. G. O.
(12) Circular No. 66, chief surgeon's office, A. E. F., February 4, 1919.
(13) Embarkation Instructions No. 13, headquarters, S. O. S., December 31, 1918.
(14) Final report of Gen. John J. Pershing, September 1, 1919.
(15) Embarkation Instructions No. 13, headquarters, S. O. S., January 4, 1919.
(16) Letter from the commanding general, A. F. T. F.,
to The Adjutant General of the Army, January 7, 1920.
(17) Circular No. 73, W. D., November 18, 1918.
(18) Circular No. 61, chief surgeon's office, A. E. F., December 18, 1918.