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ACCESS TO CARE
GENERAL VIEW OF THE MEDICAL DEPARTMENT ORGANIZATION
PERSONNEL, MATÉRIEL, ORGANIZATIONa
No hard and fast boundary line between the front and the Services of Supply was, or could have been drawn, so far as medical personnel and matériel were concerned. Naturally, however, so far as might be, the needs of the front had precedence. For example, as noted elsewhere, the statement was made by the chief surgeon, A. E. F., that base hospitals were robbed of medical personnel to provide operating teams for the front, and similar action was taken in other respects, whether personnel or matériel was involved.
This being the case, it is not possible to discuss personnel and matériel solely from the standpoint of the front. This discussion must be in part of the American Expeditionary Forces as a whole. It need not be exhaustive in the latter particular, however, as the question involved pertains mainly to other volumes of the history. In short, in this volume the personnel and matériel of the front will always be kept in mind primarily, but whenever it seems advantageous to discuss these subjects in their regard to the American Expeditionary Forces as a whole this will be done if it is essential to a clear understanding of Medical Department operations at the front. Organization presents fewer difficulties, but here, too, the scope of other volumes must be invaded more or less.
Shortly after our declaration of war with Germany, an act of Congress,1 gave practically unlimited powers to the President to increase temporarily the Military Establishment of the United States. Empowered by this congressional authorization the relative strengths of the Medical Corps2 and the enlisted force of the Medical Department3 were increased to 1 and 10 per cent of the Army, respectively. As will be seen, however, this allowance was not put into effect in the American Expeditionary Forces.
ALLOWANCE OF MEDICAL PERSONNEL
Our Tables of Organization prescribed a certain allowance of medical personnel, so far as divisions were concerned, and this had been mobilized and trained with its respective divisions in the United States. The same thing was
true of smaller units, generally, and a few nondivisional hospitals were supplied. On the other hand, though the general organization project, American Expeditionary Forces, included the organization of an army and its five component corps, the organization of these was not completed in the United States, so their needs in the American Expeditionary Forces were not met in the same way as were those of divisions. Especially is this true in so far as the Medical Department was concerned. Furthermore, numerous other units which were organized in the American Expeditionary Forces were in the same situation as were the armies and corps.
In these respects it was found there was need for additional personnel for organizations, and replacements, of course, made additional demands. Practically all had to come from the United States, and for every officer and man of the Medical Department place had to be found on a priority schedule, whereon demands by other parts of the Army were equally if not more insistent. Then, too, if possible, priority had to be worked out long in advance, so long, in fact, that future needs could not always be clearly foreseen.
CHIEF SURGEONS EARLY ESTIMATES OF PERSONNEL NEEDED IN THE AMERICAN EXPEDITIONARY FORCES
In the summer of 1917, when General Pershing prepared his projects for the organization of the forces to be sent to France, the forces considered were divided into the following two groups: A general organization project,4 which included army, corps, and divisional troops; and a project of the rear5 which included the personnel for the Services of Supply.
In the general organization project, the organizations comprehended were based on Tables of Organization. These tables provided for Medical Department personnel, and no great problem connected with this personnel, confronted the chief surgeon, A. E. F., at the time. The contrary was true for the Medical Department personnel of the Services of Supply.
On August 11, 1917, the chief surgeon, A. E. F., made an estimate of the Medical Department personnel as follows:6
Memorandum for the CHIEF OF STAFF:
The attached estimate of sanitary personnel is submitted in compliance with instructions dated July 30, 1917.
This estimate includes the personnel required for all sanitary formations except those listed in the Tables of Organization as belonging to the division.
The basis of the calculation is an army of 5 corps and 30 divisions. The other fundamental factor in the preparation of this estimate is that hospital beds should be available in the ratio of 1 to each 4 men of the enlisted strength of the Army.
The sanitary formations listed below are those provided by existing regulations. It is probable that the developments of modern warfare will require the creation of sanitary formations not provided for in the attached estimate.
It will be observed that, including dental surgeons, veterinarians, chemists, and female nurses, this estimate calls for a total sanitary personnel of 118,512, or 10.5 per cent. If to this figure is added the sanitary personnel attached to each division, the percentage becomes 14 per cent.
It is believed that if this calculation is erroneous the error will be on the side of conservatism. The duration of hostilities and the difficulties of transporting the totally disabled to the United States and thereby relieving hospital congestion are factors which can only be approximated.
1Including contagious and special diseases but not
The program for the Medical Department, exclusive of Medical Department personnel attached to combat organizations, for an army of 20 combat divisions, 10 replacement and base divisions, for general headquarters, army, corps, and Services of Supply troops was as follows:5 For the forward services, 31,017 officers and men; for the Services of Supply, 65,593 (plus 10 per cent replacement). The number of officers and enlisted men of the Medical Department attached to the combat organizations of the 30 divisions then contemplated was approximately 17,910.7 Thus the allowance of personnel of the Medical Department was about 121,079b for the projected army of 1,328,448 men, or practically a percentage of 9. When compared with the estimate for Medical Department personnel made by the chief surgeon, A. E. F., on August 11, 1917, it will be seen that the total percentage allowed was less by 1˝ per cent than that considered by the chief surgeon as being necessary for the Services of Supply alone. However, the figures in the service of the rear project were considered only as a reasonable approximation of what actually would be required, both for the organization of the Medical Department, A. E. F., and for the preparation of a shipping program.5
The following tabulation outlines in detail the program for the Medical Department, A. E. F., both for the forward services and for the Services of Supply as given in the project of the rear:5
11 per 1,000.
NOTES EXPLANATORY OF TABLE 2
M-1. A. E. F. project, July 11, 1917, as corrected by cable sent No. 114, par. 18, Aug. 20, 1917; i. e. Sn. Tn. organized as per Table 36, Tables of Organization, 1917.
M-202. A. E. F. project, July 11, 1917. Organized as per par. 794, Manual for the Medical Department; i. e., 432 beds. In a crisis can be increased to at least three times as many beds as personnel; i. e., 595 beds.
M-401. Par. 793, Manual for the Medical Department, assigns two evacuation hospitals to L. of C. per division in the zone of the advance; i. e., 40. Including 8 with the army, this allots 2 per all divisions; i. e., 60, and gives the following hospitalization at the front in case of crisis:
M-402. Organized as per par. 760, Manual for the Medical Department; capacity increased to 1,000 beds and personnel to 33 officers, 200 soldiers, and 100 nurses.
M-403. Personnel for 1,000-bed venereal hospital: 20 officers, 24 NC Os, 14 cooks, 115 privates; total, 173.
M-404. Personnel for 1,000-bed convalescent camp: 10 officers, 24 NC Os, 16 cooks, 50 privates; total, 100.
M-405. Personnel for 5,000-bed convalescent depot, approximately 10 officers, 4 NC Os, 20 privates, Medical Corps, and 5 officers, 16 NC Os, 20 privates for administering duties. The purpose of this depot is to transform the convalescent into the soldier by physical exercises and drills; the convalescents being organized into companies and performing all the routine duties, the most experienced regular medical officers having supervision. Total hospitalization provided exclusive of field hospitals of 200,100 beds.
M-406. Par. 804, Manual for the Medical Department, allots 1 per division at the front. Headquarters personnel, 1 major, 1 supply officer, 2 sergeants, 2 privates, 2 cars; companies, 1 officer, 3 NC Os, 34 privates, 12 motor ambulances, 1 truck, 1 car, 1 side car.
M-407. Personnel for trains having capacity of 200 patients, as per par. 614, Manual for the Medical Department, with the addition of 4 nurses.
M-408. Personnel for hospital ships capacity of 200 beds, as per par. 621, Manual for the Medical Department, 60-70 per cent of wounded will be returned to the front.
M-409. Personnel, 8 officers, 8 NC Os, 25 privates; total, 41.
M-410. 3 ports, 1 intermediate, and 1 advance section sanitary service, each: 3 officers, 2 NC Os, 6 privates; total, 11.
M-411. Personnel, 1 medical officer, 1 chemist, 1 NC O, 2 chauffeurs; total, 5; motor laboratory, 1 car.
M-412. Personnel, 4 medical officers, 2 chemists, 4 NC Os, 8 privates; total, 18.
M-413. Personnel, 1 officer, 4 NC Os, 20 privates, 1 truck, 1 side car, 4 bicycles, and 2 chauffeurs; total, 27. Two for each division billet at the front and 12 for lines of communication, viz, 3 ports, 3 port depots, 4 intermediate, 2 advance.
M-414. Personnel, 2 officers, 6 NC Os, 40 privates, 3 port depots, 2 intermediate, 1 advance.
M-416. Personnel for 3 port receiving camps, 1 intermediate and 1 advance casual camp; corps and army school details.
To provide a proper balance between all the various elements of the American Expeditionary Forces to be shipped from the United States, a priority schedule of shipment of personnel was forwarded by General Pershing to The Adjutant General, October 7, 1917.8 The priority schedule comprised six phases. Each of the first five phases embraced a theoretical army corps and in addition certain army troops and Services of Supply troops; the six phases covered the personnel for the organization of an army (exclusive of aviation and replacements) and the Services of Supply troops (exclusive of replacements) necessary to maintain that army. The personnel called for in each of the first five phases varied from 275,200 in the first phase, to 210,000 in the fifth phase; aggregating, 1,230,781. The sixth phase called for Services of Supply troops only, numbering 16,618. The grand total of the phases of the priority schedule was, excluding aviation personnel and replacements, 1,247,399.
DEPARTURES FROM THE PRIORITY SCHEDULE
The first departure of magnitude from the program laid down in the original priority schedule was in consequence of the military situation in
France in March, 1918, and was the direct result of an agreement with Great Britain following a meeting of the supreme war council in the latter part of that month.9 Under this agreement, Infantry and Machine Gun troops were to be brought to France in great numbers, by the use of British shipping, without reference to the priority schedule. This agreement made necessary an extensive readjustment of the priority schedule.
Under the Abbeville agreement, May 2, 1918, the policy of giving absolute priority to Infantry and Machine Gun units was continued.9 Based on this agreement, a further revision of the priority schedule, to apply to shipments for May and June, was prepared and cabled to War Department, May 12, 1918.9 From this time on, frequent revisions were made in the priority schedule, that had in view the increase of the initial project of 30 divisions to one of a much greater number of divisions.9 In other words, the project changed from a 1,000,000 basis to one of approximately 2,000,000 men.
EFFECTS OF THE DEPARTURES FROM THE PRIORITY SCHEDULE
Surprisingly rapid work in the summer of 1918 caused the shipments from the United States to exceed all expectations. They contained an excess of combat troops. This was partly due, as has been explained above, to our agreement to ship Infantry and Machine Gun units to France without reference to the priority schedule, and also to the fact that the War Department required from three to six months notice in order to prepare special units, such as the Medical Department units, for the Services of Supply.10 So long a notice could not be given by General Headquarters A. E. F., and as a result such troops as were already organized in the United States, principally combat troops, were shipped.10 The practical effect of this, in so far as the Medical Department was concerned, was that combat troops were being shipped to France for the 60 divisions project before the Medical Department had received its allowance for the initial project, which was based on 30 divisions, as will be seen later.
SHORTAGES OF MEDICAL DEPARTMENT PERSONNEL
Until the spring of 1918, the demands for medical personnel were not so insistent as was the case later. Our forces had not been heavily engaged and the French had provided their hospital care in part. Yet, even so, there was then and had been practically from the beginning, a shortage in Medical Department personnel.11
On April 15, 1918, and again on May 2, the chief surgeon, A. E. F., made full and comprehensive statements to the commanding general, Services of Supply, of the constantly increasing deficiency in medical personnel in the A. E. F.12 It was shown in these communications that the case was urgent, and that the deficiency was not due to recent or unexpected causes, but largely to a failure, extending over many months, to furnish the replacement and Medical Department units which were due the troops in France.
On May 2, 1918, in a cablegram to The Adjutant General, the commander in chief, A. E. F., reported that since July 1, 1917, repeated urgent cable
requests had been made for Medical Department replacements.13 Because these requests had been met only in small part, the Medical Department at this time was facing a critical shortage. There were hospitals which could not be opened for lack of personnel; and there was an inadequacy of replacement personnel for organizations with combat units.13
As a result of the investigation conducted under the direction of the general staff, General Headquarters, following the engagement at Chateau-Thierry (the Aisne operation) and the attack on Soissons (the Aisne-Marne operation), the Medical Department personnel shortage was clearly defined.14 The recommendation of the inspector general, A. E. F., based on the situation at Chateau-Thierry was that further provisions be made for emergency reserve surgical teams, and that steps be taken to secure an increase of the sanitary personnel, both commissioned and enlisted.14
The chief surgeon, A. E. F., in a memorandum dated July 30, 1918, to G-4, General Headquarters, called attention to the fact that surgical teams were being obtained by stripping base hospitals, to a considerable extent, of their surgical staffs, at the very time when their services were needed at the hospitals because of active evacuation of wounded from the front.15
At times the shortages of approved priority were much larger than in May, 1918, and a cable from the commander in chief, A. E. F., sent on August 10, called for a total Medical Department personnel of 21,700, to be given priority in so far as possible over divisional units.16 On September 30, the total shortage of approved priority was 26,497.16
The Medical Department personnel expected in October amounted to 34,868, while approximately 18,000 arrived.16 On November 11 the shortage of approved priority was: Officers, 3,604; nurses, 6,925; men, 28,023.16
The following tabulation covering Medical Department personnel shows the bimonthly totals by class of personnel from June 1 to November 30, 1918. These totals are only approximately correct, as reports of arrivals of personnel were often delayed in the mail.16
The highest numbers of officers, nurses, and men reported in the American Expeditionary Forces at any time (first week of December, 1918) are asfollows: Officers, 18,146; nurses, 10,061; men, 145,815.
The situation at times was desperate, and in the early days of November it appeared that the armistice was the only thing that could save the Medical Department from breaking under the strain.11 On November 11 the Medical Corps was short approximately 250 officers on the division requisitions alone.11
There is no doubt that the shortage in officers, and nurses particularly, contributed to the death of several patients in hospital, as it was necessary in some base hospitals for the bacteriologists, ophthalmologists, otolaryngolo-
gists, commanding officers, and adjutants to assist in performing operations, and in many cases these specialists or administrative officers, comparatively untrained in major surgery, had to perform major operations in order to do what they could to prevent loss of life.17 Instances were reported where patients died of secondary hemorrhage in base hospitals when no trained attendant was present or available.17
ASSIGNMENT OF MEDICAL PERSONNEL OF COMBAT DIVISIONS TO OTHER DUTIES
One other matter should be mentioned here which interfered seriously with the Medical Department organization of combat divisions. The growth of the American Expeditionary Forces constantly led to an increase in the number of camps and camp hospitals. The policy of General Headquarters, at first, was that no permanent personnel should be supplied camp hospitals.18 This necessitated the use of the Medical Department personnel attached to units in training or at rest camps. When the units in training or at rest changed station, their Medical Department personnel as a matter of course had to accompany them. In order to accomplish this, it was imperative that Medical Department personnel with combat units be not diverted and that a certain percentage of personnel not belonging to divisions be assigned permanently to each camp hospital. This subject was presented very forcibly by the commanding general, Services of Supply, February 8, 1918, in a letter to the commander in chief:18
I may say that no organization arrives in France without a large distribution of measles, mumps, meningitis, and scarlet fever. It requires personnel to decently care for these unfortunates, and I am sure that they are not at this moment getting the care they might have were the personnel available.
The chief surgeon, A. E. F., pertinently stated the situation in referring to the use of personnel withdrawn from combat units in training:19
This personnel has been entirely inadequate numerically and could not at the same time accompany its organizations when they left camp and remain behind with the sick. Therefore replacements have been used up and base hospitals robbed in an effort to supply the deficiency. But the basic difficulty lies in the continued failure to send over base hospitals and evacuation hospitals in accordance with the priority schedule, which calls for four base hospitals, and two evacuation hospitals for each combat division. Therefore, there should be 104 base hospitals and 52 evacuation hospitals, instead of which there is a total of 42 base hospitals and 8 evacuation hospitals with the A. E. F.
A novel feature of the World War was the very liberal utilization of medical, surgical, and other specialists, exclusively, or practically so, in their own specialities. This plan, of course, was a logical outcome of what had occurred in the ranks of the medical profession throughout the world. No longer do many men holding medical degrees carry on a general practice, the majority being internists, surgeons, orthopedists, ophthalmologists, otolaryngologists, etc. In this connection, the real problem in the American Expeditionary Forces was how best to use the special professional skill of the medical officers.
In September, 1917, special services of the Medical Department were established, with headquarters at Neufchateau.20 These special services were divided into eight branches, each under a director, and comprised surgery, medicine, X ray, neuropsychiatry, skin and genitourinary diseases, and eye, ear, nose, and throat diseases. Medical officers of known qualifications were assigned as consultants to the special services to coordinate and improve the professional activities of the Medical Department. Prior to the publication of General Orders No. 88, G. H. Q., A. E. F., 1918, a number of specialists were so assigned, but there was no adequate organization which could coordinate their activities. With the promulgation of General Orders No. 88, however, the work of these specialists was put on a much more systematic and efficient basis; a director of professional services was appointed; and the positions of chief consultant in both medicine and surgery were created.
The consultants were assigned to supervisory duty wherever their services were needed. The scope of their work included hospitals, principally, but it likewise took them to organizations at the front where their special knowledge could be utilized even before the patients were admitted to hospital.
In order to supplement the facilities for emergency surgical work in evacuation hospitals, surgical teams, consisting usually of one surgeon, an assistant, one anesthetist, two nurses and two orderlies, were organized early in 1918.21 Subsequently, splint teams and shock teams were developed.21
Specialization obtained also within the divisions, specialists being assigned to the sanitary train for such duties within their respective specialties as might be required by the division concerned. The specialists in question usually comprised a surgeon, an orthopedist, a psychiatrist and a urologist, but this varied somewhat. A medical gas officer was also assigned to each division.22
MEDICAL PERSONNEL FROM AN UNEXPECTED SOURCE
There was a provision in the Abbeville agreement which proved of inestimable advantage to the Medical Department, A. E. F., namely, the request of the British that we limit sanitary train personnel of the Second Corps, attached to the British Expeditionary Forces, to one-half the complement authorized in our Tables of Organizations. This was necessitated through shortage of British equipment and the fact that a well-organized overhead in British hospitalization and evacuation resources was always locally available for use of these divisions. Consequently, the personnel of approximately 2 field hospitals and 2 ambulance companies of each of our 10 divisions brigaded with the British when sent to France, were concentrated in the seventeenth training area. As there was little likelihood that this sanitary personnel would ever be called for while the divisions continued to operate with the British Expeditionary Forces, they were assigned to service with American forces; and despite their total lack of equipment, they practically saved the day for our medical service during operations in the summer of 1918. In consultation with G-3 of G. H. Q., A. E. F., an arrangement was made whereby this personnel could be utilized wherever their services were
most needed.23 They were then thrown in behind the line to augment depleted Medical Department establishments, except that some of the ambulance companies were utilized to good advantage at base ports, in rapidly assembling and forwarding incoming ambulances so urgently needed at the front. This reserve, which so fortunately came to hand in this manner in the hour of need, was one of the most important factors enabling the Medical Department to discharge the weighty obligations imposed at that time.23
MEDICAL DEPARTMENT CASUALSREPLACEMENTS
It was not until September 30, 1917, that any fairly large number of Medical Department casuals arrived in France. On September 30, 1917, about 650 men landed.24 This was just prior to the establishment of a medical replacement camp at Blois, and it was necessary to assign these 650 soldiers in groups to various base hospitals, which had already arrived and had barrack space to accommodate the additional men. Another casual detachment of 250 men arrived in November, 1917.24 This was the last detachment of any size to arrive for several months, and it was only after urgent appeals had been sent to The Adjutant General that Medical Department casuals again began to be received. This occurred in the latter part of February and in March, 1918.24
Replacements were handled entirely through the Services of Supply. In the fall of 1917, a Medical Department replacement camp was planned at Blois. Its organization was practically completed when its site was given over to a casual officers depot.11 The depot, however, continued to handle Medical Department casuals, until July, 1918, when a depot for these officers was made a part of the First Depot Division at St. Aignan.11 This transfer was made with a view to establishing a short course of training in field work at the First Depot Division, but it was never possible to carry out this plan because of the constant shortage of Medical Department enlisted personnel which necessitated using all available men at all times, the longest stay in the depot being not more than two weeks. The transfer was a disadvantage in that it caused some delay in getting officers and men shipped to points where they were needed at once. The delay was mainly due to lack of transportation.11
The greatest difficulty was experienced, in January and February, 1918, in tracing Medical Department men who arrived in France. It was estimated that fully 1,000 men, who were sorely needed by the Medical Department, succeeded in transferring to the line of the Army while they were passing through the First Depot Division, St. Aignan.24
MEDICAL DEPARTMENT CONCENTRATION AREA
Establishment of a concentration area for the Medical Department proved an important factor in meeting hospitilization and evacuation demands incident to combat activities. Under conditions first existing in France the Medical Department mobile formations were landed at base ports and dispersed individually to various localities in the area of the Services Supply for the purpose of securing necessary equipment. After this was obtained they were
transported to the combat area and there located. To expedite and
facilitate this work there was urgent need that the Medical Department be assigned an area
properly located in the zone of the armies to which incoming sanitary formations,
particularly evacuation and mobile hospitals, ambulance companies, surgical teams, and
other auxiliary personnel for front-line work, could be sent for mobilization, equipment,
training, and assignment. Accordingly, upon recommendation of the medical section of G-4,
G. H. Q., and with the approval of the French, a Medical Department concentration area was
designated and set aside in October, 1918, at Joinville, Department of Haute Marne, for
the exclusive use of sanitary formations.25 This area comprised approximately 25 square miles and contained nine
villages, affording a billeting capacity for about 500 officers and nurses and 10,000
enlisted men. Good roads led from it to all parts of the American front, and its location
was such that any sector could be reached by motor transport within a few hours.
Furthermore, it was located on several railroads, which served admirably to assemble units
arriving from base ports and to distribute them by rail to the more remote parts of the
fronts should need arise.25
Prior to the establishment of this concentration area the Medical Department had lacked means of providing reserve units and of keeping them in close liaison with troops.25
In order that the trained units held in reserve might be thrown in behind any part of the line, as the military situation dictated, geographic proximity, good roads and adequate railroad facilities, were factors of prime importance in the selection of this area.
Upon arrival at a base port, the personnel of all army and corps mobile sanitary formations was sent to this concentration area.25 A supply depot was established in the Joinville area, with sufficient material always on hand to equip these corps and army units as they arrived. After having been equipped, the personnel was given an intensive course of training in a demonstration unit of the same character as that to which they belonged, which was established there. They were thus given a working knowledge of the equipment and functions of the organization which they were to operate in the field.25
This concentration area was also used as a rest area for the personnel of mobile formations when not engaged in active operations, and afforded facilities for overhauling and repairing equipment. Where overworked personnel was sent there for much needed rest, it was replaced by fresh personnel from the area without any change being made in transportation or equipment of the units concerned.25
The value of this expedient was demonstrated even during the very brief period when the Joinville area was operated.
PERSONNEL SUPPLEMENTING THE MEDICAL DEPARTMENT
The personnel of the Medical Department, American Expeditionary Forces, was supplemented extensively by personnel from other branches of the Army as well as from sources without the Army. The practice was tem-
porary in some instances, and in others it was continuous. There were occasions when the Medical Department was confronted with tasks which were infinitely greater than it could accomplish in the time available. It was then that other forces were used temporarily to supplement the Medical Department.
The assistance rendered us by our allies involved a personnel reenforcement as well as help in other directions. When American organizations served with the British and the French, the plan was to hospitalize the American wounded in hospitals (save in field hospitals which we provided ourselves) of the particular ally with which the American organizations were serving. Prior to the organization of the First Army, the French had charged themselves with the care of American wounded back of divisional areas.26 The French were forced to give up this plan. The reasons for this are discussed in Chapter XII. There were occasions, however, when large numbers of American wounded were cared for in French hospitals; for example, when the French general hospital at Bar-le-Duc, provided 2,200 beds for a prospective overflow of American casualties during the St. Mihiel operation.27
During the same operation, because of the acute shortage in Medical Department personnel and to help out in the emergency, it was necessary to secure authority for the assignment of 1,200 men of the line from the orthopedic training battalion to our mobile sanitary formations.28
That the personnel of the Medical Department might be used for more pressing duties connected with the care of the sick and wounded, labor troops were utilized, when their services were available, to dig graves for those who died in hospitals at the front.29
Sections of the United States Army Ambulance Service, on duty with the French, frequently supplemented divisional Medical Department organizations,30 to clear our aid stations. Less frequently they were used to clear our dressing stations; rarely to clear evacuation hospitals not located near a railhead; and very rarely to serve troops in training areas and other localities. During the preparations made for the St. Mihiel operation the situation seemed so acute that 15 ambulance sections, sent to Italy from the United States for duty directly under the jurisdiction of the Italian Government, through its prompt cooperation, were detailed to our service and brought up for use in the engagement.30 It is true that the transport of the sections was the principal consideration, but the personnel of the sections were also acquired and in consequence played their part in increasing the strength of the Medical Department, A. E. F.
To the troops of the Marine Corps and other naval units that served in France there were attached naval Medical Department personnel. This personnel never exceeded 500 in number for any one month (except the month of September, 1918, when it was 561),31 but as a supplemental force it was constant.
As will be noted elsewhere, good use was also made to a considerable extent of certain Red Cross personnel.
RESULT OF SHORTAGE IN MEDICAL DEPARTMENT PERSONNEL
There is ample testimony from the highest military authorities to the effect that our Medical Department performed good service in France, and there is certainly no disposition here to controvert such testimony, if this were possible, which is not the case. On the other hand, no subject concerning the Medical Department is of so much importance as the strength of the personnel, which experience shows to be necessary for an army in campaign. The actual fact is that all evidence is to the effect that our Medical Department in France proved too small. If possible, it would be highly desirable, from the historical standpoint, to record what resulted. As the possible results of inadequate medical personnel in an army in campaign are well known, no difficulty presents in a study of the situation as it applies to our Army in France. Inadequacy in Medical Department strength generally results in (1) details from the line to the Medical Department to a considerable extent, thus taking trained line soldiers from combatant duties. In France such detail ran in many companies in battle, from 10 to 12 men.32 Thus the loss in combatant strength (Infantry) in battle ran from 4 to 4.8 per cent. (2) Loss of combatants from the battle line to give aid to wounded comrades and to accompany them to the rear in the absence of Medical Department personnel to do this. (3) Neglect of sick and wounded. This question has, of course, a military, a moral, and a humanitarian aspect. Our Medical Department seems to have succeeded well here, though the chief surgeon mentions loss of life due to shortage in medical personnel.17
This summary should not be concluded without pointing out the danger of basing future Medical Department strength on the strength in France. Everybody concerned seems to have agreed there was serious shortage. That we got through as well as we did was obviously due to much assistance from outside agencies which was available, fortunately, though to an extent that is not likely to be the case again; to the greatest devotion to duty of the medical personnel generally, which it is hoped can always be counted on, and to a comparatively short war for us. As is pointed out in the chief surgeons report, the armistice was the only thing that saved us from a disastrous situation resulting from personnel shortage.11
The full discussion of this subject will be given in a special volume on supplies. What is said here is confined, so far as possible, to the front, though in order to explain the supply situation there it has been found necessary to discuss supplies in part from the standpoint of the American Expeditionary Forces as a whole.
By no means were all supplies used by the Medical Department furnished by that department. For the present purpose, however, this offers no particular difficulty, as the Medical Department actually supplied a large percentage of the articles involved in the care of sick and wounded at the front
including motor ambulances for a greater part of the war. For convenience, the motor ambulances will be considered under the head of transportation.
The amounts and kinds of medical supplies were prescribed in certain tables which appeared in the Manual for the Medical Department. Basic allowances brought to France by divisional and other Medical Department organizations were in conformity with these tables, but, as will be seen, great independence was manifested in supplementing this official allowance. This was more especially true in trench warfare. On one occasion the Medical Department of the 1st Division, when that division turned over its sector to another division, is reported to have transferred seven carloads of supplies.33 Nor was this great increase of supplies wholly confined to trench warfare. In numerous places in the text will be found mention of additional supplies in open warfare. These consisted mainly of blankets, splints, and gas and shock apparatus. Besides these, shell-wound dressings and antitetanic serum were found to be especially demanded by the Medical Department at the front during the World War.
Generally speaking, medical supplies were furnished in ample quantity. Mention was made of this fact by the surgeon of the 26th Division, who regarded it as remarkable that in all situations supplies were adequate and were obtainable without delay.34 This does not mean, however, that there were not some shortages in particular articles.
One of these shortages that was keenly felt was that of splints of the latest approved pattern. The American Red Cross established a factory in Paris where these splints were made and supplied to the American Expeditionary Forces in quantities adequate to meet the needs of battle casualties occuring in June and July, 1918.35 Some time later plans were made for the establishment of a plant for the production of nitrous oxide and oxygen for use in anesthesia. This plant also was established in Paris by the American Red Cross.35
RESERVE SUPPLIES IN FRANCE
On August 20, 1917, when there were about 25,000 troops in France, General Pershing announced his policy of supply to the chiefs of the various services, American Expeditionary Forces.36 In this memorandum, with its subsequent additions, there was outlined a definite method of supply procurement, both from the United States by shipment overseas and by purchase in foreign markets. In this it was furthermore specifically set forth by what policy, under procurement, the increment of reserve supplies was to be accumulated. The supplies were divided into the following three classes: Automatic supply for articles regularly conserved so as to permit of automatic supply; replenishment supply for articles of which specified stocks had to be maintained; and exceptional supply for articles of which no specific stocks had to be established.
On September 7, 1917, General Pershing, in a cablegram to The Adjutant General, announced his decision to establish in France reserves of all classes of supplies for 90 days.37 This reserve was based on authorized issues, where
such issues were regular, and on actual periodic consumption of other articles based on French and British experiences during the War. General Pershing directed the chiefs of the various services in France to prepare estimates for cabling, first, a list of four months supplies to accompany each movement of troops from the United States. This provided a 90 days reserve and, in addition, one months automatic supply for consumption and emergency. Second, a list showing the amounts which would have to be shipped monthly for each 25,000 men of the American Expeditionary Forces. In terms of days, the 90-day reserve plan provided for 15 days of the reserve to be in the advance section, 30 days in the intermediate section, and 45 days in the base ports.
In January, 1918, the problem of automatic replacement of supplies of the Medical Department, A. E. F., was taken up by that department on receipt of a letter on this subject from the Office of the Surgeon General.38 The study of the problem was completed by the latter part of March following. In a letter on the subject to the Surgeon General dated April 2, 1918,39 the chief surgeon, A. E. F., explained that it was highly desirable to have a single list of articles used in common by the various branches of the Medical Department, and for that reason a consolidated list of field and post supplies had been made.
ESTABLISHMENT OF MEDICAL SUPPLY DEPOTS
In accordance with the plan to have 90 days reserve medical supplies in France, supply depots were established as follows: Base depots at each of the ports utilized by American troops; an intermediate depot at Cosne; and an advance depot at Is-sur-Tille.40
At an early date (July 15, 1917), a depot was established at Cosne, which later grew into Intermediate Medical Supply Depot No. 3.41This depot was the Medical Departments main, full-stock distribution point, and from this establishment the entire medical supply distribution system was largely elaborated. For a considerable period of time practically all supplies were concentrated at and likewise distributed from Cosne.
The original plan was to develop the supply depot at Cosne and plans were submitted for its expansion. Since Cosne was off the railroad lines operated by the Americans, and the French railroads were unable to handle increased shipments therefrom, the original plans for its development were abandoned.42
As a substitution, Intermediate Medical Supply Depot No. 2, which had been established at Gievres, October 20, 1917,43 was to replace the depot at Cosne as the main issuing depot, the Cosne depot being retained as an auxiliary. As the depot at Gievres developed, this plan was being made effective.
Advance Medical Supply Depot No. 1, at Is-sur-Tille, was put into operation November 18, 1917.43 This depot, an extremely important unit, largely took over the distribution of medical supplies to troops and units in the advance section. It was not, however, until considerably later that this depot was made a full-stock unit. Prior to its being made a full-stock depot its activities were confined largely to the supply of medical units on duty with combatant organizations. The problem of supplying the numerous fixed
Medical Department organizations in the advance, intermediate, and base sections continued to be a responsibility of the main depot at Cosne. As the situation developed the depot at Gievres was increased in capacity and utilized largely for shipments of carload lots. Small issuing depots were gradually established at the main base ports and gradually larger base storage stations were installed at these places.44
ESTABLISHMENT OF "ARMY DUMPS" (MEDICAL)
With the organization of the Paris group and later of the First Army, the establishment of army dumps became essential. In connection with the Medical Department purchasing business in Paris, there had been established previously in Paris a small medical receiving warehouse; and although this was utilized somewhat in the manner of an army dump, it was not essentially that type of depot. The first army dump established was at Lieusaint,45 and this was organized and administered for the purpose of supplying combat units in the Paris group and, later, the First Army.
The supply table authorized for an army dump, which in common parlance later became known as the "Lieusaint list," grew out of the establishment of this army dump.45 The original basis of the "Lieusaint list" was the replacements necessary for one combat division for eight days, and the officer in charge of this distribution point was authorized to maintain in storage as many times this amount as there were combatant divisions in his area.45 This practically constituted a stock maximum for his depot. Practically this same system, although with a modified list, was adopted for use in planning the distribution of medical supplies when the offensive operations, directed toward the reduction of the St. Mihiel salient, and later against the Meuse-Argonne area, were in preparation. Gradually, however, a policy was developed of establishing army dumps for which there was authorized a definite fixed stock maximum without reference to the number of combat units to be supplied, but based more upon the number of such dumps established in relationship to the known number of divisions to be employed in the operation. Such dumps, for instance, were established at Toul, Souilly, Vaubecourt, Fleury, and Les Islettes, and in the order named.45
Toward the end of hostilities the manner of distribution from the supply echelons at the base to those in the most forward areas had been worked out with exceeding care. The plan of distribution, as evolved, was an elaboration of the policies under which the units previously had been functioning, but it was better balanced, and all echelons were much more clearly defined. This was also true as regards the important technique of filling the requests for supplies of forward units from the unit next in the rear.45
MEDICAL SUPPLY ECHELONS AND SYSTEMS OFREPLENISHMENT
Essentially this scheme of distribution involved the use of several echelons. They were as follows:45 Divisional medical supply unit; army park medical supply dump (for each corps); army medical supply depots (for each army); Services of Supply depots (advance and base).
The officer in charge of the divisional medical supply unit normally indicated the need of all organizations in his particular division upon a consolidated requisition, which, after passing through the office of the division surgeon and that of G-1, was forwarded for filling to an army park.46 Often the division medical supply officer was far removed from the division surgeon and the division staff generally, and as a result numerous requisitions had to be sent to the nearest army park in a most informal manner and without any visé or approval. This was recognized as a necessity, and such contingencies were provided for by authorizing the park personnel to honor such emergency calls. It was found in practice that such authorizations increased the confidence of those in the forward areas and that the end result was a better and closer cooperation of all concerned.46
The logical medical stock for army parks included only articles of combat equipment and supplies and trench stores, and divisional units would naturally requisition only such articles, but in the early developmental days of the corps echelon it was found necessary to carry limited replacements at these parks, for such units as mobile and evacuation hospitals. It was very soon learned, however, that this produced a useless dispersion of equipment which it was difficult to obtain, and quickly rendered immobile the army park medical supply dumpsunits, which of necessity, must remain mobile. It therefore became the policy to confine articles on the fixed stock maximum of such parks to those of combat material and trench stores. Just as soon as this decision was made it necessitated the establishment of a new echelon, inasmuch as large hospitals in the advance zone would now be required to replenish their stock from a new advance supply unit.46
It was therefore contemplated immediately to establish (and sites were actually selected) full-stock army advance medical supply depots on a basis of one per army.46 This unit, although carrying a complete stock, carried its articles, in so far as quantity was concerned, upon a very limited time basis. The functions, then, of this larger unit would be primarily to fill the calls of the army parks and secondarily to fill requisitions from medical units in the advance zone. The latter was obviated as far as possible by distribution from the rear through "controlled stores" in other depots.46
It will be recalled that it was not until well into the spring of 1918 that medical supplies began to be shipped automatically to France. Prior to this time procurement was by American Expeditionary Forces requisition, which led to a real shortage about December 1, 1917. Toward the end of that month there were approximately 175,00031 troops in the American Expeditionary Forces, and, although the troops had been coming over slowly, more had arrived than had been anticipated. This inevitably reduced the reserve supplies, which on January 2, 1918, were reported by the chief surgeon, line of communications, to be 25 per cent short.47
On March 11, 1918, General Pershing cabled to The Adjutant General that the reserve stock in the medical supply depots in France had been reduced
to the unsafe level of approximately 30 days supply.48 General Pershing also stated in this cablegram that he was convinced that the automatic medical supplies were not being placed on ships in quantities determined as necessary and sufficient to meet the needs of troops then in France. He requested that immediate steps be taken to ship these supplies.
In the latter part of March, 1918, when the Germans began their first spring offensive, call after call was sent to America to ship combat troops and combat supplies. Nothing else was given priority; the Medical Department priority shipment schedule was set aside.49 Though there were but 320,000 troops in France on April 1,31 and 300,000 now due to arrive each month, base hospital after base hospital arrived without its equipment. Camp hospitals were being rapidly expanded to meet the local needs of incoming troops.
At this time (April, May, and June, 1918), the dispersion of the American Expeditionary Forces became progressively greater. With each extension the supply problems of the various services became more complex.
In the case of the Medical Department the reserve had never been great. As a result of the extremely active period between June 1 and August 1, 1918, this reserve became considerably depleted. There were several reasons for this depletion, but the principal one was the inability of the authorities in home territory to ship supplies equal to the needs of the Medical Department, A. E. F.
By August 1, 1918, there were approximately 1,184,000 men in the American Expeditionary Forces,31 including 29 divisions. Great quantities of material had to be shipped them for replacement as well as initial equipment.
Shortages of strictly technical Medical Department equipment and supplies were consistently distributed among all classes of such material during the period prior to the large offensive of the autumn, 1918. It appeared, however, that the more highly technical articles were most lacking and shortages were particularly apparent in dental, veterinary, and X-ray supplies, and in surgical instruments.50 Fortunately, a repair unit for surgical instruments and typewriters reached the American Expeditionary Forces from the United States at about this time.51 This unit proved of the greatest value in connection with the conservation of surgical instruments and typewriters.
Just before the armistice, the major part of the combat troops of the American Expeditionary Forces was concentrated behind a front approximately 50 miles in extent. Advance, intermediate, and base depots existed and their storage contained a reasonable amount of supplies. Maintenance problems had been worked out in actual combat. Our troops had overcome every German division which had been thrown against them, and throughout it all there had been no essential shortage in medical supplies.
It has been necessary in discussing personnel to mention certain shortages in hospitals. This description of the situation is pertinent here also, but what has been said need not be repeated.
The division medical units, including field hospitals, had been organized in the United States, and accompanied their respective divisions overseas. The situation was far different, however, in respect to the hospital establishments immediately to the rear of divisions.
In providing for early care of battle casualties behind the divisions, reliance was placed, by our pre-war organization, chiefly on evacuation hospitals. For each division sent to France the shipping schedule called for the coincident dispatch of two of these units; but in spite of repeated cable appeals to the War Department this automatic supply was never furnished, and shortage of evacuation hospitals was a source of continual anxiety to the Medical Department.52 Not until after the armistice was there ever more than 25 per cent of the authorized quota of these units in France; though as indicated elsewhere in the early period of our activities there, this shortage did not cause any great concern.52 Then, with fixed hospitalization in the rear fairly well established, the hospital needs of our troops engaged in training for trench warfare were easily met. Static conditions then prevailed. A state of immobilization of troops, too, had obtained long enough to permit the French to construct well-organized and well-equipped hut evacuation hospitals behind their trenches, or, in lieu of construction, to take over and alter existing buildings for hospital purposes.53 These French hospitals afforded every facility for carrying on treatment of the wounded along modern lines. Coincident with the arrival of one of our divisions in the trenches, it was arranged that the French should turn over to our use one or more of these hospitals, either temporarily or permanently, and hospitals thus taken over were transferred to us with full equipment.53 Then merely the installation of our own medical personnel was required before the formation concerned could function as an American hospital and care for American patients. This very desirable arrangement from our point of view obtained, however, only in fairly restricted areas, notably in Toul, Luneville, and Baccarat. These were the areas in which the greater part of the training of American troops in trench warfare was conducted.53 In remoter regions to which it sometimes was necessary that our troops be sent, either for training or to relieve French troops in quiet sectors of the line, our casualties were sent to near-by French hospitals administered by French personnel. Then, frequent changes in the designation of training sectors for American troops made strictly American hospitalization impracticable at times. While this was our policy from the first, changes were made so rapidly that rarely was it advisable to be very insistent in requests for such facilities. The situation then was that while American troops still possessed and operated to a maximum degree their own division field hospitals, when sick and wounded were admitted to French hospitals it was seldom that American personnel was authorized to care for them. This unsatisfactory condition soon made it necessary for the Medical Department, A. E. F., to use every effort to obtain control over the treatment of American patients. Quite naturally the Americans preferred to be cared for by their own countrymen, if for no other reason than that they could thus easily make known their wants.53
The German offensive of March 21, 1918, created an entirely new hospital situation on all ports of the allied front.54 Until that time, hospitalization for the allies had been a comparatively simple matter. This German offensive caused a reversion from static, or trench, warfare to mobile, or open warfare. Incident to the changes daily taking place in the surging battle lines, the stationary, hutted evacuation hospitals, which previously had answered well, became relatively useless and, for purposes of immediate combat hospitalization, a thing of the past.54
To maintain hospitalization near the front, the utilization of tentage, and such existing buildings as could be found and were habitable, became necessary. As the Medical Department did not have at hand the mobile hospitalization provided for in the shipping schedule, this shortage seriously increased our operating handicaps.54
The pioneer experience in our divorce from the conditions of static warfare to more or less constant movements of open warfare devolved upon the 1st Division.55 As mentioned elsewhere, this division was hurriedly withdrawn from the Toul sector and placed at the disposition of the French, in reserve behind the Montdidier salient.55 The American Expeditionary Forces possessed no hospitalization in that region, at the time, short of Paris.55 As the division was placed under the French, the responsibility for hospitalizing the sick and wounded devolved upon and was assumed by the French.56 This obligation was in keeping with the ruling previously adopted during our period of trench warfare instruction. In orders prepared by the French and directing the dispatch of the 1st Division to the new front, it was specified that all hospitalization (except that furnished by divisional field hospitals) and evacuation of our troops would be provided by them.55 These orders also prescribed the liaison to be established between our field hospitals and the French hospitals farther to the rear.
Despite a most serious shortage in personnel and equipment for our army sanitary units, and the frankly stated objection of the French to the establishment of American Expeditionary Forces evacuation hospitals in the rear of divisions operating with them, it was very early recognized that we should make every effort to provide for the evacuation and hospitalization of our own wounded.
Repeated efforts were made to secure permission from the French to establish at Beauvais at least one American evacuation hospital in the rear of the 1st Division, during the operations of that division at Cantigny, the latter part of May, 1918.55 These requests were disapproved by the French on the ground that a dual hospitalization and evacuation service in that region, in view of existing traffic conditions, would result only in confusion.55 As will be mentioned later, the permission of the French was obtained to establish an American Red Cross hospital there.
With the beginning of the German Aisne offensive, the latter part of May, 1918, it became necessary hurriedly to place additional American divisions on the enemy front before Paris.55 This created a new hospitalization
problem. Since the French had lost all their evacuation hospitals in that region, in their retreat, they were not in a position to assume the additional burden of caring for American casualties.57
For the first time, the French not only permitted but assisted the American Expeditionary Forces in every way to begin the establishment of its own chain of hospitalization behind its engaged divisions, and the evacuation of our casualties from the hospitals, by means of American hospital trains, to our fixed hospitals in the rear.57 Obstacles, however, were almost insuperable, for the rapid German advance had so demoralized railway service that it was impossible to operate hospital trains, and for a short time evacuation by ambulance and truck was necessary for a distance of from 40 to 100 kilometers, (25 to 62 miles) in order to clear our field hospitals. This situation was immeasurably aggravated by our great lack of ambulances.57 The difficulties thus encountered and the manner in which they were met are discussed later.
ASSISTANCE RENDERED BY AMERICAN RED CROSS HOSPITALS
At this point it should be stated that especially during the early part of the development of the American Expeditionary Forces, American Red Cross hospitals played a very important part in the care of our sick and wounded. Among other institutions which the Red Cross had established for service of the French, was the "American Ambulance" in Paris. This was turned over to the American Expeditionary Forces on July 20, 1917, and was designated American Red Cross Military Hospital, No. 1, though it continued at first to receive only French casualties.58 As General Pershing would not permit American military hospitals in Paris at that time,59 and hospital facilities proved to be needed there, the American National Red Cross then established a number of hospitals whose collective capacity was rapidly increased to 10,000 beds.57 The association also established other hospitals in the field, where they operated as evacuation hospitals in rear of the various divisions. These Red Cross hospitals were used in the zone of the armies only through urgent necessity. They were organized at the request of the chief surgeon. Personnel for them came largely from the army, but their equipment was supplied by the Red Cross. The Medical Department was at all times so short of resources that it was necessary to call upon the Red Cross to furnish hospital tentage, equipment, and some personnel to meet our needs. Its hospitals functioned in the same manner as did the army evacuation hospitals, each being under the command of an officer of the Medical Corps, save one under a French medical officer, located at Beauvais during the Cantigny operations. Two were utilized during the Chateau-Thierry operation, and two during the St. Mihiel and Meuse-Argonne operations.58
MEDICAL DEPARTMENT TRANSPORTATION
Transportation facilities of the Medical Department, A. E. F., comprised ambulances, trucks, trains (including those on light railways), and canal barges.
Ambulances comprised two kinds of vehicles: Animal-drawn and motor. The Medical Department made use of both kinds of ambulances for the transportation of patients, in the American Expeditionary Forces. Transportation of patients was a responsibility with which that department was charged throughout.
PROCUREMENT OF AMBULANCES
In the American Expeditionary Forces, the use of animal-drawn ambulances was very restricted. These ambulances were assigned only to Medical Department units serving with combat troops; that is, one ambulance company of each divisional ambulance section was animal-drawn.60 Both animal-drawn ambulances and animals for them were supplied by the Quartermaster Corps;60 their procurement was not a responsibility of the Medical Department.
The procurement of motor ambulances, on the other hand, was a direct responsibility of the Medical Department for the greater part of the war.61 In discussing this question it must be considered from both sides of the Atlantic. This is because motor ambulances, though classed as Medical Department matériel when we entered the World War, became Motor Transport Corps matériel some months prior to the armistice. Since this change was effected considerably earlier in the American Expeditionary Forces than it was in the United States, there was a period when, as will be explained, the Medical Department in the United States was purchasing motor ambulances and shipping them abroad on Motor Transport Corps tonnage.
In December, 1917, what was then the Motor Transportation Service was created a part of the American Expeditionary Forces.62 Its purpose, in part, was the technical supervision of all motor-driven vehicles; their reception, organization, and assignment (except vehicles belonging to organized units); and the organization and operation of repair and supply depots for motor vehicles. Until May, 1918, motor ambulances in the American Expeditionary Forces were not included in the classes of vehicles controlled by the Motor Transport Service, A. E. F.;63 however, they were maintained in a state of repair by that service. From May, however, all motor ambulances arriving in the American Expeditionary Forces were turned over to what had now become the Motor Transport Corps, A. E. F.; but being classed as special vehicles, motor ambulances were held by that corps subject to the orders of the chief surgeon, A. E. F.63 Between this time and the following August, though the Medical Department procured motor ambulances in the United States, they were shipped overseas on Motor Transport Corps tonnage.64 Subsequent to August, when the Motor Transport Corps, in the United States, took over the procurement of motor ambulances from the Medical Department,65 their shipment overseas became a responsibility of the Motor Transport Corps. Thereafter shipments were based on estimates furnished by the Medical Department, A. E. F.
METHODS OF SHIPPING AMBULANCES FROM THE UNITED STATES
Tables of Organization and Equipment prescribed the number of ambulances for Medical Department units serving with combat troops. For a while (until October, 1917) ambulances belonging to these organizations were shipped from the United States with the organizations. This was not a practical method, and it was discontinued in October, 1917.66 Thereafter all ambulances were sent to France in a knocked-down condition.66 This was done not only to conserve tonnage but to preserve the ambulances in good condition.
Shipping ambulances knocked down necessitated having a skilled force of men in France to assemble them on their arrival. It was intended that all ambulances should reach the American Expeditionary Forces through the base port at St. Nazaire. Accordingly, a group of skilled mechanics was established at that port by the Medical Department soon after (November, 1917) it was determined to ship unassembled ambulances. However, as it happened, ambulances were subsequently received not only at St. Nazaire but also at Brest, Le Havre, La Pallice, Bordeaux, and sometimes at Marseille. There never was any way of determining in advance how many ambulances would arrive at any of these places, nor when they might be expected.66 It was a common occurrence for chassis to arrive at one port and bodies of ambulances at another, necessitating driving the chassis overland to where the bodies had been received.
The distribution of ambulances in the American Expeditionary Forces was influenced by two factors: Ambulances for Medical Department units with the forward services, and those for the services of the rear. In the forward services, Tables of Organization governed the question of the number of ambulances that each Medical Department unit should have. The actual assignment of ambulances to units serving in the zone of the advance, however, was controlled by General Headquarters on a priority basis and in accordance with Tables of Organization.67
Since no allowances of ambulances were specified by Tables of Organization for the Services of Supply, except for combat organizations serving therein, the distribution of ambulances in that area was based on local needs, and was, in turn, contingent upon the amubulances available. As the supply of ambulances in the American Expeditionary Forces was always short, as will be shown later, it was necessary to effect some measure which would stretch the smallest number over the greatest territory. This was done by establishing a system of pooling the ambulances.
The principle of supplying individual units in the Services of Supply, such as regiments, service battalions, and signal companies, with ambulances
was found to be uneconomical as regards both supplies for and upkeep of these vehicles.67 Therefore, in order that our resources might be conserved and the greatest use of the limited number of ambulances on hand might be made, pools of ambulances were established at all hospital centers, base hospitals and in each base section. These pools were under the direct control of the transportation section of the chief surgeons office, A. E. F. As frequently happened, ambulances were detached from these pools for purposes of temporary duty elsewhere, being returned to the pool when the unit, to which the ambulances had been assigned temporarily, moved out of the Services of Supply, or when there was no longer a need for the temporary use of the ambulances. As might be seen, this allowed a very elastic use of ambulances located in the Services of Supply.
Owing to the great shortage of ambulances in the American Expeditionary Forces, it was frequently necessary for all of the ambulances in one pool to be sent to such places as base hospitals so as to facilitate unloading hospital trains, or for like emergencies. Upon the completion of such duties the ambulances concerned would be returned to the pool to which they belonged.67
SHORTAGES OF AMBULANCES
Before December, 1917, there had already developed an acute shortage of ambulances, and shipments from the United States, because of procurement and tonnage difficulties, were under our estimated need.68 Although cable after cable was dispatched setting forth our emergency needs along this line, the shortage continued to increase. The problem of estimating our requirements was made more difficult by the lack of tables of organization in Services of Supply, corps, and army units;68 existing tables indicated transportation for divisions only. In the late spring of 1918, however, an estimate of the situation was made, which resulted in the Medical Department assuming that from front to rear a minimum of 120 motor ambulances per division in France would be required.68 The number of ambulances required for the American Expeditionary Forces to cover past shortages and future needs was estimated, and on July 3, 1918, the results of these estimates were included in a cable.64 Only during the months of September, October, and November, 1918, was it apparent that the number of motor ambulances which the authorities in the United States stated they would float would have any influence upon reducing the accumulated shortage.68 Shipments had heretofore not even covered current needs.
Shortages were the subject of constant reports. To cover them in part, large numbers of ambulances were borrowed from the French and from the Red Cross.69 Sections of the United States Army Ambulance Service proved of particular value. The need for ambulances was so acute that we actually had to borrow 15 of these sections we had sent to Italy for service with the Italian army.69
In all there were shipped to France (and Italy) approximately 3,070 G. M. C. ambulances and 3,805 Ford ambulances.70
The primary purpose of motor trucks assigned to mobile Medical Department units was, of course, to convey the equipment of such units from one point to another within the theater of operations, as well as to transport their replenishment supplies when the units had been established and were operating. The number of trucks for each motorized field hospital and each ambulance company was prescribed by Tables of Organization and Equipment.71 For other mobile Medical Department organizations, such as the evacuation hospital, there was no prescribed number of trucks.
In most divisions in the American Expeditionary Forces truck transportation was pooled as a matter of conservancy. Consequently, when it became necessary to change the location of a field hospital, trucks were assigned for this purpose. Likewise, trucks were assigned to evacuation hospitals whenever it was necessary to move the mobile parts of such hospitals.
There were frequent occasions, during active operations, when motor trucks were put to other uses by the Medical Department, than for cargo-carrying purposes. This was the case when great numbers of casualties had occurred, from time to time, and the number of ambulances available was inadequate to effect prompt evacuation.
For the purpose of this history, hospital trains are considered more in the light of hospitals than as a means of transportation, because they were for the most part truly mobile hospitals. Their general make-up, their direct administrative control, and the details of what they effected in the way of evacuation will be found in Volume II of this history, which has to do with the administration of the Medical Department, A. E. F. For present purposes the question of their procurement and their subsequent operative control at the front will be discussed.
The first plan of the chief surgeon, A. E. F., was to use ordinary box cars adapted to hospital train purposes by introducing fittings into them for supporting tiers of litters.71 These fittings were metal posts to be screwed to the floor of the box cars in such a way that they would occupy little space and could be cleared away, when not wanted, thus permitting the box cars to serve the double purpose of evacuating wounded from the front and, when empty of wounded, of carrying supplies back to the troops at the front. Because both the British and French had found this arrangement inexpedient, the plan was not carried out in the American Expeditionary Forces.71
Limited ship tonnage space precluded procuring railroad coaches for hospital trains from the United States; consequently, two converted hospital trains were leased from the French, and 19 specially constructed, were purchased from the British.71 As these 21 trains were entirely inadequate during the St. Mihiel and the Meuse-Argonne operations, 45 additional
trains were rented from the French for use of the Medical Department during the former operation, and 46 during the latter.72
Because the office of the chief surgeon, A. E. F., was in the Services of Supply, far removed from the front, it was necessary to divide the control of the movements of hospital trains. This was accomplished by giving the control of the trains, operating at the front, to the representative of the chief surgeon in the fourth section of the general staff at General Headquarters. This control normally covered primary evacuation from the front. All other hospital train movements, however, were controlled from the office of the chief surgeon at Tours.
Hospital train movements from the front were effected directly by regulating officers, who had on their staffs officers of the Medical Department representing the chief surgeon, A. E. F. Regulating stations were established and administered by the assistant chief of staff G-4. Movements of hospital trains in the rear of the zone of armies were provided for by the train movement bureau, headquarters, Services of Supply, in accordance with requests made upon it for this purpose by the chief surgeon, A. E. F.73
During the St. Mihiel and Meuse-Argonne operations, some use was made of narrow-guage (60 cm.) railway lines, to evacuate casualties.74 Hospital
trains were formed from the returning cars, and appliances that were readily removable were attached to the flat gondolas of this system, so that it was possible with a train composed of an engine and 10 cars to transport some 80 "lying cases." This method of transportation would have been very saving of ambulances, and it is believed had the war continued for even a few months more a great deal of use would have been made of it by the Medical Department.74
At the time of the signing of the armistice, some 500 cars were available for purposes of evacuation, and it was practicable to manufacture others as fast as need for them developed. The cars, however, which were used in the St. Mihiel and Meuse-Argonne operations were built with the center of mass too high for the rough construction of the light railways in these sectors, and derailments were so numerous as to cause their abandonment.74
During the activities of the American Expeditionary Forces at Chateau-Thierry, many patients were evacuated to Paris by means of barges. The barges were operated in flotillas of six, motive power being furnished by tugboats.75
In August, 1918, the chief surgeon, A. E. F., proposed that barges be regularly used as an additional means of transporting sick and wounded, more especially seriously wounded and gassed soldiers who could not be
otherwise transported. His plan was adopted. At about the time of the signing of the armistice there were 60 barges being converted to hospital purposes.75
When we entered the World War, the organization of the Medical Department in the theater of operations was as follows:76
It will be noted that this plan contemplated a field army made up of divisions, which was in conformity with our Army organization at that time. To meet the new conditions of warfare, however, an entirely new army organization was adopted by the commander in chief, A. E. F., and proposed by him to the War Department July 11, 1917.77 This organization project of General Pershing, as adopted by the War Department, replaced the field army by corps, each consisting of six divisions, 4 of which were designated for combat, 1 for replacement and school, and 1 for replacement and training.78 Armies were also provided for, to consist normally of five corps.79
Certain Services of Supply troops were provided for in this general organization project. There was not included, however, all of the organization of the lines of communications, which was not projected until September 18, 1917, when plans for a complete service of the rear, which listed item by item the troops considered necessary for the Services of Supply, were cabled to the War Department and then approved.80 For purposes of local administration the lines of communications in France, now Services of Supply, was subdivided into districts or sections.81 The territorial sections corresponding to and immediately surrounding the principal ports were called base sections;
there was an intermediate section embracing the region of the great storage depots; and an advance section extending to the zone of operations, within which the billeting and training areas for the earlier divisions were located.
Following these changes, a change in administrative and technical supervision of troops was evolved by General Pershing.82 The general staff of General Headquarters, A. E. F., was expanded to comprise two additional sections. It should be noted that Field Service Regulations, United States Army, contemplated three sections of the general staff for an army operating in the field, as follows:83 First, combat; second, administrative; third, intelligence. The composition of the general staff at G. H. Q., A. E. F., however, was organized as follows:84 First, administrative; second, intelligence; third, operations; fourth, coordination of supply services (including Construction, Transportation, and Medical Departments); and fifth, training. These sections were referred to as G-1, G-2, etc.
lt was with the fourth section of the general staff, General Headquarters, that the Medical Department was particularly concerned, for it was this section that was charged with the supervision of hospitalization and the evacuation of sick and wounded.84 To enable it to function with the greatest degree of effectiveness, it was essential that expert technical advice be immediately and constantly available to its chief. This was possible so long as the chief surgeons office remained at General Headquarters, but the order which established the general staff at General Headquarters on its new, expanded basis, also provided for the removal of the offices of certain chiefs of staff services to headquarters, Services of Supply. Among these was included the office of the chief surgeon, A. E. F. Consequently, to provide representation of the chief surgeon at General Headquarters, authority was given him, as was given to all chiefs of staff services, to designate an officer of the Medical Department for service in connection with each section of the general staff at General Headquarters.84
How the chief surgeon continued to coordinate the activities of the Medical Department attached to organizations in active operation is separately considered in the next chapter. At this time the intention is briefly to indicate only the more important changes of the organization of the American Expeditionary Forces as a whole, in order that an interpretation of the following outline of the organizations of the Medical Department, American Expeditionary Forces, might be facilitated. For details connected with this organization table see Appendix, p. 1054.
1Sections of the U. S. A. A. S. were also used
for the evacuation of the sick and wounded.
(1) Bull. No. 32, W. D., May 24, 1917.
(2) Memorandum from the Surgeon General of the Army to Senator Chamberlain, September 20, 1917. Subject: Preparation for war of the Medical Department of the Army. On file, Record Room, S. G. O., 321.6 (Medical Department).
(3) Letter from the Surgeon General of the Army to The Adjutant General of the Army, May 21, 1917. Subject: Increase of the enlisted personnel, Medical Department. First indorsement thereon, The Adjutant Generals Office, June 15, 1917. On file, Record Room, S. G. O., 128732-T (Old Files).
(4) General organization project, A. E. F., July 10, 1917. On file, General Headquarters, A. E. F., Washington, D. C.
(5) Services of the rear project, American Expeditionary Forces, September 6, 1917. On file, General Headquarters, A. E. F., Washington, D. C.
(6) Memorandum from the chief surgeon, A. E. F., for the chief of staff, A. E. F., August 11, 1917. On file, Historical Division, S. G. O.
(7) Tables of Organization and Equipment, U. S. Army, Series A, Table I, August, 1917.
(8) Letter from the commander in chief, A. E. F., to The Adjutant General of the Army, October 7, 1917. Subject: Priority of shipment (personnel). On file, General Headquarters, A. E. F., Washington, D. C.
(9) Report of activities of G-1, G. H. Q., volume 2, 3.
(10) Ibid., 7.
(11) Report of the activities of the chief surgeons office, A. E. F., from the arrival of the American Expeditionary Forces in Europe to the armistice, by the chief surgeon, A. E. F., March 20, 1919, 47. On file, Historical Division, S. G. O.
(12) Letter from the chief surgeon, A. E. F., to the commanding general, S. O. S., May 2, 1918. Subject: Deficiency of medical personnel. On file, Historical Division, S. G. O.
(13) Cable No. 1037-S, from General Headquarters, American Expeditionary Forces, to The Adjutant General of the Army, May 2, 1918.
(14) Exhibit "K" to report on activities of G-4-B, medical group, fourth section, general staff, G. H. Q., A. E. F.: Report of investigation concerning charges of inefficiency on part of the Medical Department, from the inspector general, A. E. F., to the commander in chief, July 17, 1918, 6. On file, Historical Division, S. G. O.
(15) Report of activities, chief surgeons office, A. E. F., to the commanding general, S. O. S., March 20, 1919, 47. On file, Historical Division, S. G. O.
(16) Report of the activities of the chief surgeons office, A. E. F., from the arrival of the American Expeditionary Forces in Europe to the armistice, by the chief surgeon, A. E. F., March 20, 1919, 49. On file, Historical Division, S. G. O.
(17) Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1291.
(18) Report of the activities of the chief surgeons office, A. E. F., from the arrival of the American Expeditionary Forces in Europe to the armistice, by the chief surgeon, A. E. F., March 20, 1919, 52. On file, Historical Division, S. G. O.
(19) The Medical Department, A. E. F., to November 11, 1918, compiled by Capt. E. O. Foster, S. C., from the chief surgeons records, A. E. F., under the direction of the chief surgeon, undated, 56. On file, Historical Division, S. G. O.
(20) Report of the activities of the chief surgeons office, A. E. F., from the arrival of the American Expeditionary Forces in Europe to the armistice, by the chief surgeon, A. E. F., March 20, 1919, 53. On file, Historical Division, S. G. O.
(21) The Medical Department, A. E. F., to November 11, 1918, compiled by Capt. E. O. Foster, S. C., from the chief surgeons records, A. E. F., under the direction of the chief surgeon, undated, 64. On file, Historical Division, S. G. O.
(22) G. O. No. 144, G. H. Q., A. E. F., 1918.
(23) Report on activities of G-4-B, medical group, fourth section, general staff, G. H. Q., A. E. F., by Col. S. H. Wadhams, M. C., December 31, 1918, 58. On file, Historical Division, S. G. O.
(24) Report of the activities of the chief surgeons office, A. E. F., from the arrival of the American Expeditionary Forces in Europe to the armistice, by the chief surgeon, A. E. F., March 20, 1919, 51. On file, Historical Division, S. G. O.
(25) Report on the activities of G-4-B, medical group, fourth section, general staff, G. H. Q., A. E. F., by Col. S. H. Wadhams, M. C., December 31, 1918, 46. On file, Historical Division, S. G. O.
(26) Ibid., 53.
(27) Medical activities in the Zone of the Armies, by Col. A. N. Stark, M. C., undated, 8. On file, Historical Division, S. G. O.
(28) Report on activities of G-4-B, medical group, fourth section, general staff, G. H. Q., A. E. F., by Col. S. H. Wadhams, M. C., December 31, 1918, 56. On file, Historical Division, S. G. O.
(29) Report of Medical Department Board, G. H. Q.,A. E. F., 1919. On file, Historical Division, S. G. O.
(30) Report on activities of G-4-B, medical group, fourth section, general staff, G. H. Q., A. E. F., by Col. S. H. Wadhams, M. C., December 31, 1918, 66. On file, Historical Division, S. G. O.
(31) Monthly returns of the American Expeditionary Forces, made to The Adjutant General of the Army.
(32) Report of Medical Department activities, Fifth Army Corps, by Col. W. R. Eastman, M. C., corps surgeon, November 18, 1918, 32. On file, Historical Division, S. G. O. Memorandum, Headquarters, First Army Corps, A. E. F., July 30, 1918. On file, Historical Division, S. G. O.
(33) Report of Medical Department activities, 1st Division, A. E. F., prepared under the direction of the division surgeon, undated, 18. On file, Historical Division, S. G. O.
(34) Report of Medical Department activities, 26th Division, A. E. F., prepared under the direction of the division surgeon, undated, 4. On file, Historical Division, S. G. O.
(35) Letter from the American Red Cross, Paris, to the chief surgeon, A. E. F., August 25, 1918. Subject: Nitrous oxide plant, splints, research society, nurses home, farms, laundries, ice plant, recuperation camps, diet kitchens, rest stations, and infirmaries. On file, A. G. O., World War Division, Medical Records Section (Chief Surgeons files).
(36) Memorandum, G. H. Q., A. E. F., August 20, 1917. Subject: Automatic supply. On
file, Historical Division,
(37) Cable No. 145-S from General Pershing to The Adjutant General, September 7, 1917.
(38) Letter from the Surgeon General to the surgeon, Medical Base Group, A. E. F., October 27, 1917. Subject: Automatic replacement of supplies. On file, Historical Division, S. G. O.
(39) Letter from the chief surgeon, A. E. F., to the Surgeon General, U. S. Army, April 2, 1918. Subject: Automatic supply. On file, Historical Division, S. G. O.
(40) The Medical Department, American Expeditionary Forces, to November 11, 1918, compiled by Capt. E. O. Foster, S. C., from the chief surgeons records, A. E. F., under the direction of the chief surgeon, undated, 75. On file, Historical Division, S. G. O.
(41) Report of the activities of the chief surgeons office, A. E. F., from the arrival of the American Expeditionary Forces in Europe to the armistice, by the chief surgeon, A. E. F., March 20, 1919, 70. On file, Historical Division, S. G. O.
(42) The Medical Department, American Expeditionary Forces, to November 11, 1918, compiled by Capt. E. O. Foster, S. C., from the chief surgeons records, A. E. F., under the direction of the chief surgeon, undated, 72. On file, Historical Division, S. G. O.
(43) Report of Medical activities, Line of Communications, A. E. F., during the War Period, by Brig. Gen. F. A. Winter, M. D., undated. On file, Historical Division, S. G. O.
(44) Report on activities of G-4-B, medical group, fourth section, general staff, G. H. Q., A. E. F., by Col. S. H. Wadhams, M. C., December 31, 1918, 79. On file, Historical Division, S. G. O.
(45) Ibid., 80.
(46) Ibid., 81.
(47) Telegram from the chief surgeon, Line of Communications, to the chief surgeon, A. E. F., January 2, 1918. On file, A. G. O., World War Division, Medical Records Section (chief surgeons files).
(48) Cable No. 706-S, from General Pershing to The Adjutant General.
(49) Memorandum from Col. A. P. Clark, M. C., to the assistant chief of staff, G-1, G. H. Q., September 12, 1918. On file, Historical Division, S. G. O.
(50) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1346.
(51) The Medical Department in the American Expeditionary Forces to May 31, 1918, compiled under the direction of the chief surgeon, A. E. F., undated, 83. Circulars Nos. 12, 23, and 43. Office of the chief surgeon, A. E. F., 1918. On file, Historical Division, S. G. O.
(52) Report on activities of G-4-B, medical group, fourth section, general staff, G. H. Q., A. E. F., by Col. S. H. Wadhams, M. C., December 31, 1918, 48. On file, Historical Division, S. G. O.
(53) Ibid., 49.
(54) Ibid., 50.
(55) Ibid., 51.
(56) Letter from the undersecretary of state of the Service de Santé (French) to the chief surgeon, A. E. F., February 12, 1918. Subject: Hospitalization of American soldiers in French hospitals and French soldiers in American hospitals. On file, Historical Division, S. G. O.
(57) Report on activities of G-4-B, medical group, fourth section, general staff, G. H. Q., A. E. F., by Col. S. H. Wadhams, M. C., December 31, 1918, 53. On file, Historical Division, S. G. O.
(58) Ibid., 34.
(59) Ibid., 35.
(60) Tables of Organization and Equipment, U. S. Army, Series A, Table 28, W. D., April 17, 1918.
(61) Report on activities of G-4-B, medical group, fourth section, general staff, G. H. Q., A. E. F., by Col. S. H. Wadhams, M. C., December 31, 1918, 84. On file, Historical Division, S. G. O.
(62) G. O. No. 70, G. H. Q., A. E. F., December 8, 1917.
(63) G. O. No. 77, G. H. Q., A. E. F., May 11, 1918.
(64) Cable No. 1407, from General Pershing to The Adjutant General, July 3, 1918.
(65) G. O. No. 75, W. D., August 15, 1918.
(66) Report of activities on G-4-B, medical group, fourth section, general staff, G. H. Q., A. E. F., by Col. S. H. Wadhams, December 31, 1918, 85. On file, Historical Division, S. G. O.
(67) Ibid., 88.
(68) Ibid., 86.
(69) Ibid., 66.
(70) Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1362.
(71) Report of the activities of the chief surgeons office, A. E. F., from the arrival of the American Expeditionary Forces in Europe to the armistice, by the chief surgeon, A. E. F., March 20, 1919, 11. On file, Historical Division, S. G. O.
(72) Final Report of the chief surgeon, First Army, upon St. Mihiel, and Meuse-Argonne operations, by Col. A. N. Stark, M. C., chief surgeon, First Army, undated, 4. On file, Historical Division, S. G. O.
(73) Letter of instruction from Section 4, general staff, G. H. Q., A. E. F., August 29, 1918. Subject: Evacuation of sick and wounded. On file, Historical Division, S. G. O.
(74) Report on activities of G-4-B, medical group, fourth section, general staff, G. H. Q., A. E. F., by Col. S. H. Wadhams, M. C., December 31, 1918, 93. On file, Historical Division, S. G. O.
(75) Report of the activities of the chief surgeons office, American Expeditionary Forces in Europe to the armistice, by the chief surgeon, A. E. F., March 20, 1919, 13. On file, Historical Division, S. G. O.
(76) Manual for the Medical Department, U. S. Army, 1916, par. 586.
(77) Final Report of General Pershing, September 1, 1919, 8.
(78) Tables of Organization and Equipment, U. S. Army, Series B, Table 101, W. D., March 5, 1918.
(79) Tables of Organization and Equipment, U. S. Army, Series C, Table 201, W. D., November 7, 1918.
(80) Final Report of Gen. John J. Pershing, September 1, 1919, 9.
(81) Ibid., 11.
(82) Ibid., 13.
(83) Field Service Regulations, U. S. Army, 1914.
(84) G. O. No. 31, G. H. Q., A. E. F., February 16, 1918.