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Chapter XXI



Movement of Patients in the United States

The movement of patients in the United States, although fairly simple early in the war when it involved only the transfer of individuals or small groups from station to general hospitals, began to assume different characteristics about the middle of 1943. A steady increase in the number of evacuees received from theaters-from about 3,000 per month early in 1943 to a peak of more than 57,000 in May 1945-focused attention on the transportation of patients from debarkation to general hospitals. Meanwhile declining troop strength in the United States, along with establishment of regional hospitals to serve in lieu of general hospitals for patients from camps in surrounding areas, reduced to a trickle the transfer of zone of interior patients to general hospitals. Growth of the Army's fleet of hospital cars from 24 early in 1943 to 380 by the end of the war, along with a shortage of commercial sleepers and diners, meant that emphasis shifted from the transportation of patients on regular passenger trains to their movement on Army hospital trains. A change in Air Force policy in the spring of 1944, permitting certain planes to be assigned primarily to evacuation operations in the United States, resulted in a transition from sporadic to regular movement of patients by air. Finally, compliance with the policy established early in 1943 of transferring patients from debarkation hospitals to hospitals designated as specialized centers and located as near as possible to patients' homes complicated the problem of planning their transportation.

Regulating the Flow of Patients

Although The Surgeon General was designated by Army directives as the chief medical "regulator," in the early part of the war he exercised only a general influence over the distribution of patients among Army hospitals. His office granted ports unlimited bed credits in general hospitals located nearest them. Port commanders then transferred patients to such hospitals, reporting later to the Surgeon General's Office the number received from theaters, the date of their arrival, and the name of the hospital to which they had been transferred.1 Station hospitals transferred patients to general hospitals in which they held bed credits. General hos-

1(1) WD Cir 120, 21 Jun 41. (2) An Rpt, 1943, NYPE. HD. (3) Ltr, SG to CG HRPE, 14 Aug 42, sub: Rpt of Pnts Arriving from Overseas. SG: 705.-1 (HRPE).


pitals normally did not hold bed credits in other general hospitals and hence had to request the Surgeon General's Office to authorize transfers and to designate receiving hospitals. In order to know which had vacant beds, The Surgeon General began in April 1943 to require all general hospitals to submit daily bed status reports to his Office.2 When general hospitals requested the transfer of patients to other such hospitals in order to free beds for subsequent arrivals from near-by ports, his Office authorized the transfer of groups, sometimes as large as 250. Decisions as to particular patients to be transferred were left to hospital commanders. Normally, then, in the first part of the war the Surgeon General's Office authorized the transfer of patients in bulk and depended upon local commanders to request individual transfers to comply with the policy of hospitalizing patients near their homes and in specialized centers.3

Later in the war, as the movement of patients in the United States increased and grew more complex, a new procedure was developed to give the Surgeon General's Office greater control over the transfer of individual patients. It involved reports to the Medical Regulating Unit of patients received at debarkation hospitals and of vacant beds in general and convalescent hospitals. In May 1944 the Medical Regulating Officer established a system for debarkation hospitals to use in requesting the transfer of patients to other hospitals. Instead of asking for authority to transfer a certain number of patients without regard to disabilities or home locations, debarkation hospitals reported in coded teletype messages the geographical destination (home), diagnosis or special disability, sex and military status, and general physical condition (litter or ambulatory) of each patient received. For example, one male enlisted neurosurgical patient whose home was in Florida was reported as "6NCY"; ten such patients, as "6NCY10." In August 1944 this system was revised, and additional medical classifications or diagnoses were listed, along with more exact definitions of each. About the same time, the system of daily bed status reports was changed. In the fall of 1943 a code had been established for hospitals to use in reporting vacant beds. In August 1944 this code was modified so that hospitals reported vacant beds not in such general categories as medicine, surgery, and neuropsychiatry but in terms of the particular diseases or injuries for which they had been designated as specialized centers. For example, hospitals with vacant beds for male neurosurgical patients reported them under code "12TVKN." Early in 1945 both debarkation and bed status reports were further revised to reflect changes in specialty designations of hospitals and thereby to permit a greater degree of accuracy in sending patients to proper hospitals. Using both reports together, the Medical Regulating Unit was able to direct debarkation hospitals to transfer patients, in small groups or as individuals if necessary, to general hospitals that specialized in the diseases or injuries with which they suf-

2(1) AR 40-600, 6 Oct 42. (2) Ltr, SG to CO Billings Gen Hosp, 26 Apr 43, sub: Daily Bed Rpt. SG: 632.2 (Billings GH). By July 1943 the Hospitalization and Evacuation Division, SGO, was receiving daily reports from 28 hospitals, giving number of patients, number of medical, surgical, and neuropsychiatric beds, and number of patients transferred to and received from other general hospitals.
3Telegrams in which the Surgeon General's Office authorized the transfer of patients are filed in SG: 704.-1 and 705.-1. See also weekly diaries of the Hospital Administration Division. HD.


fered and that were located as near as practical to their home addresses.4

At first this system applied only to patients being transferred from debarkation hospitals to general hospitals of definitive treatment, but gradually it was extended to cover even the transfer of patients from station and regional hospitals to general hospitals. Because of crowded conditions of general hospitals in the populous northeastern part of the United States, in July 1944 The Surgeon General directed that no patients should be transferred to certain hospitals in that area without prior approval of the ASF Medical Regulating Officer. In effect, this directive canceled all bed credits which station or regional hospitals held in the hospitals listed. About two months later additional hospitals were placed in this category, raising the number thus restricted from thirteen to thirty-one. Ultimately, early in 1945 the system that originated as a means of authorizing the transfer of evacuees from debarkation to general and convalescent hospitals was formally extended to include all transfers to such hospitals.5 The degree of control which the Medical Regulating Officer thus achieved over the use of beds in general and convalescent hospitals enabled him to authorize transfers of patients promptly and to use beds effectively when they were at a premium in the first half of 1945.

Centralized control over the transfer of patients to general and convalescent hospitals did not assure that policies on the hospitalization of patients near their homes and in specialized centers would be wholly complied with. Hospital beds in the United States were not distributed in proportion to density of population. Hence, early in 1945 when the patient load became great enough to fill general and convalescent hospitals, it was impossible for the Medical Regulating Officer to send all patients to hospitals located near their homes. Furthermore, the necessity of sending patients to specialized centers sometimes conflicted with and outweighed the desirability of sending them to hospitals near their homes. Finally, debarkation hospitals had time for little more than superficial examinations of patients before requesting their transfer to other hospitals. As a result, the medical classifications reported by debarkation hospitals were sometimes incorrect and patients were sent to general hospitals when they should have been sent to convalescent hospitals.6

Some idea of the complexity of the process of authorizing patient-transfers may be gained from the work load of the ASF Medical Regulating Unit. In the early part of 1945 it received bed status reports from 64 general, 12 convalescent, and 7 temporary debarkation hospitals. Information from these reports was posted daily to show at all times the ability of hospitals to accept patients. Each day the Unit received approximately 100 telegrams, 10 letters, and 25 telephone calls requesting the transfer of patients in small groups or as individuals. Every month it received in addition fifty to sixty coded

4(1) History . . . Medical Regulating Service. . . .(2) ASF Cirs 149, 20 May 44; 284, 30 Aug 44; 249, 4 Aug 44; and 89, 10 Mar 45. (3) Ltr, CG ASF (SG) to CO Billings Gen Hosp, 15 Oct 43, sub: Daily Bed Rpt. SG: 632.-2 (Billings GH)K. Identical letters were sent to other general hospitals. Telegrams and correspondence on bed capacities and patient transfers are filed in HD: 705 (MRO Staybacks), 705 (MRO Chart on Pnt Capacities in Hosps), and 705 (MRO Daily Diaries, Daily Bed Status).
5Telg SPMDD-DR, SG (MRO) to all SvCs, 3 Jul 44, 17 Sep 44, 21 May 45, 6 Sep 45. HD: 705 (Med Reg Unit book).
6See above, pp. 211-12, 240-41.


telegrams from debarkation hospitals requesting the transfer of patients to general hospitals; the typical request covered 500 patients who had to be transferred because of their diagnoses, home addresses, sex, and military status to an average of forty-five different hospitals.7

Procedures for Rail Evacuation

The principal method of moving patients in the United States-other than by ambulance-was by train-either regular passenger trains or hospital trains made up of Army hospital cars supplemented by commercial equipment. During most of 1942 patients were moved almost exclusively in Pullman cars of passenger trains, because the necessity of transporting large groups was practically nonexistent and the Army had only six hospital cars. For groups of patients and attendants numbering fewer than fifty, local transportation officers arranged with railroads for cars and routings. For larger groups, the Office of the Chief of Transportation made necessary arrangements, upon request of local transportation officers.8

Toward the end of the summer of 1942, SOS headquarters, the Chief of Transportation, and The Surgeon General began to plan for the operation of hospital trains. By that time the delivery of additional hospital cars-enough to serve as the nuclei of eight hospital trains-was expected, and an increase in the number of evacuees was impending. Since several agencies were involved, delineation of their responsibilities for the control and operation of hospital cars was complicated. Although hospital cars were procured by the Transportation Corps and used by the Medical Department, SOS headquarters decided with the approval of both The Surgeon General and the Chief of Transportation that they should be "attached" to (i.e., placed under the jurisdiction of) service commands. A service command hospital was being constructed near each port which lacked one, and it was anticipated that patients debarked at ports would be transported by motor vehicles to such hospitals and there turned over to service command control. Hence, ports would have no need for hospital cars. In addition, it was thought that service commands could furnish personnel and medical supplies for hospital trains more easily than could ports. Experience had already shown that service commands where ports were located would need hospital cars most, because general hospitals in such commands would receive large numbers of patients for transfer to hospitals further inland. Plans were therefore made to attach six hospital cars each to the Second, Fourth, and Ninth Service Commands, four to the Eighth, and two to the Sixth (for use in evacuating patients from areas in Canada), and service commands were directed to furnish supplies and medical attendants for hospital trains. Any of the hospital cars could be attached to or detached from service commands by the Chief of Transportation. Either one unit car and two ward cars, or one ward dressing car and two ward cars, were to form the nucleus of a hospital train. Supplemental Pullmans, diners, and other

7Memo, Dirs Hosp and Resources Anal Divs SGO for Dir HD SGO, 18 Jun 45, sub: Add Mat for An Rpt for FY 1945. HD: 319.1-2.
8(1) Memo, CofT for SG, 28 Mar 42, sub: Basic Plan for Evac of Sick and Wounded. HD: 705. (2) AR 30-925, C 2, 22 Aug 42. (3) WD Cir 192, 16 Jun 42. (4) Ltr SPOPH 322.15, CG SOS to CGs and COs of SvCs and PEs, and to SG, 15 Sep 42, sub: Mil Hosp and Evac Oprs, with incl. HD: 705.


rail equipment were to be used to complete it.9

After the decision to attach hospital cars to service commands was made, SOS headquarters issued directives establishing procedures for their use. The directives conflicted with one another and with Army regulations governing the transportation of personnel in general. As already noted, War Department regulations permitted local transportation officers to arrange with railroads for the transportation of groups of persons numbering less than fifty (after June 1943 less than forty), but provided that the Chief of Transportation would arrange for the transportation of all larger groups. This meant arranging with railroads for carrier-owned equipment and for routes and schedules.10 On the other hand, SOS directives provided that local transportation officers could arrange for all routings of hospital cars within the boundaries of service commands to which they were attached. Another stated in contradiction that except in emergencies service commands would ask the Chief of Transportation for routing instructions to cover the movement of each hospital car. Two SOS directives stated that service command transportation officers would arrange with railroads for all supplemental rail equipment, while another limited them to arrangements for supplemental equipment needed when hospital cars were moved within service command boundaries. None of the SOS directives took account of Army regulations requiring the Chief of Transportation to arrange for equipment and routings for the movement of large groups.11 Such conflicting instructions caused confusion about which both the Office of the Chief of Transportation and service commands complained.12

The feasibility of attaching cars to service commands and then attempting to divide authority for controlling their use was questioned in the winter of 1942 and again in the spring of 1943. The commanding general of the Eighth Service Command believed that hospital cars would be used most in the transportation of patients arriving from theaters of operations and proposed, therefore, that they should be controlled exclusively by the Transportation Corps and operated by ports.13 The Chief of Transportation considered this possibility, but agreed with the SOS Hospitalization and Evacuation Branch to follow plans already made. Nevertheless, in preparation for the reception of casualties from the North African invasion, all hospital cars were temporarily transferred to the New York and Hampton Roads Ports and placed under their jurisdiction.14 In December 1942 both the Chief of Transportation and the Hospitalization and Evacuation Branch agreed that they should be returned to

9(l) Memos, CG SOS for CGs 2d, 4th, 6th, 8th, and 9th SvCs, CofT, and SG, 18 and 26 Aug 42, sub: Location and Control of Hosp Tns. AG: 531.4. (2) Ltr, CofT to CGs PEs and SvCs, 9 Sep 42, sub: Control of Hosp Tns. TC: 531.4. For a discussion of different types of Army-owned hospital cars, see below, pp. 372-75, 381-83.
10(1) WD Cir 192, 16 Jun 42. (2) AR 55-130, 28 Dec 42, with C 2, 4 Jun 43.
11(1) Memos cited n. 9(1). (2) Ltr cited n. 8(4).
12(1) Ltr, CG Ft Sam Houston to CG NYPE, 27 Sep 42, sub: Control of Hosp Tns, with inds. HD: Wilson files, 531.4. (2) 3d ind, CG SOS to CG SFPE thru CG 9th SvC, 3 Nov 42, on telg (n d) from CG 9th SvC. AG: 322.38. (3) Memo, Tank Car Br OCT for Col William J. Williamson, OCT, 16 Nov 42, sub: Opr of Hosp Tn Cars. TC: 531.4.
13Rpt, Conf of CGs SvCs, New Orleans, La., 17 Dec 42. HD: 337.
14(1) Ltr, CG SOS to TAG, 31 Oct 42, sub: Hosp and Evac for Special Opr. TC: 531.4. (2) Memo, CG SOS for SG and CofT, 1 Nov 42, same sub. HRS: ASF Planning Div file, "Hosp and Evac No 15."


service commands.15 In the spring of 1943, when plans were being made to receive ninety-six hospital cars ordered earlier, a representative of The Surgeon General suggested that it would be advantageous eventually, when large numbers of patients began to arrive from theaters of operations, to have service commands supply personnel for hospital trains but to place all hospital cars in pools under the exclusive control of the Chief of Transportation. Presumably such an arrangement would have promoted the more efficient use of cars, but the Transportation Corps preferred to continue the system of attaching cars to service commands in which ports were located, and The Surgeon General's representative concurred in plans for the allocations of 45 cars to the Second, 24 to the Third, and 27 to the Ninth Service Commands.16

Later in the war, when a shortage of carrier-owned equipment combined with a steadily increasing evacuation load to require the greatest possible use of Army hospital cars, centralized control was adopted, along with other measures, to achieve that goal. By the winter of 1943-44 it was widely recognized that maximum use was not being made of hospital cars. In many instances they returned empty to home stations after delivering patients to general hospitals. In others, service commands permitted hospital cars to stand idle while they arranged for carrier-owned equipment to transport patients. In February 1944 the Surgeon General's Office pointed to this situation and suggested again that better use could be achieved by centralizing control of hospital cars in the Office of the Chief of Transportation.17

Before this step was finally taken, a movement already begun to achieve closer co-operation between the Transportation Corps and the Medical Department had to be completed. Late in 1943 the Evacuation Branch of the Surgeon General's Office had agreed to supply the Office of the Chief of Transportation with copies of all messages authorizing general and debarkation hospitals to transfer patients to other hospitals, enabling the latter to anticipate requests from service commands for rail equipment. A short time later the Chief of Transportation established an evacuation unit in his Traffic Control Division. It collaborated with the Surgeon General's Office and service commands in planning rail movements, and for this purpose kept a current record of the location and use of each hospital car. In May 1944 the transfer (already mentioned) of the Surgeon General's Evacuation Branch to the Medical Regulating Unit, which was physically located in the Office of the Chief of Transportation, enabled medical officers who authorized the transfer of patients from debarkation to other hospitals to consult at all times with transportation officers as to the availability of Army hospital cars and carrier-owned equipment. Conversely, transportation officers had readily available information as to the lo-

15(1) Ltr, CofT to CGs NYPE and HRPE, 10 Dec 42, sub: Hosp Cars. TC: 531.4. (2) Diary, Hosp and Evac Br SOS, 22-23 Dec 42. HD: Wilson files, "Diary." (3) Memo, ACofT for CofT, 22 Dec 42, sub: Asgmt of Hosp Tn Cars. TC: 531.4.
16(1) Memos, Mtg, Off Chief Rail Div OCT, 22 Apr and 18 May 43. SG: 453.-1. (2) Ltr, CG ASF to CGs 2d, 3d, and 9th SvCs, 22 May 43, sub: Location of Add Hosp Cars. TC: 531.4. (3) Memo, Mvmt Div OCT for ACofT, 2 Jul 43, sub: Mtg of SvC Comdrs. Same file.
17(1) Memo for Record, on 3d ind, CG ASF to CofT, 10 Sep 43, on unknown basic ltr. HD: Wilson files, "Day File." (2) Ltr, Dir Hosp Admin Div SGO to Surg 9th SvC, 4 Dec 43. SG: 705.-1 (9th SvC)AA. (3) Hosp and Evac: Re-estimate of Pnt Load and Facs, pp. 25-26. HD: 705-1. (4) Rpt, Conf CGs of SvCs, Dallas, Tex, 17-19 Feb 44. HD: 337.


cation, destination, number, and types of patients to be moved by rail.18

As the offices of The Surgeon General and the Chief of Transportation developed closer co-operation in planning the movement of patients by rail, measures were adopted to centralize the control of hospital cars. At the end of 1943, SOS directives that had caused confusion by attempting to divide responsibility for their use between service commands and the Office of the Chief of Transportation were superseded by a War Department circular which agreed in its provisions with general transportation regulations. The routing, including scheduling for train connections, of all hospital cars-whether empty or loaded and whether moving within or beyond service command boundaries-was centralized in the Office of the Chief of Transportation. Moreover, local transportation officers were specifically limited in the arrangements which they could make for supplemental rail equipment to instances when fewer than forty persons were to be carried on hospital trains. When larger groups were moved the Office of the Chief of Transportation alone could make all arrangements. For several months this Office was indulgent, accepting generally the recommendations of service commands as to dates of hospital train movements and the make-up (that is, the combination of Army-owned with carrier-owned cars) of hospital trains. Later, in the spring of 1944, it began to exercise its authority to arrange without consultation with service commands for the rail transportation of groups of patients numbering forty or more. Informed by the Medical Regulating Unit of the patients to be moved and of their destinations, the Traffic Control Division determined the make-up of hospital trains and set the dates of their departure. Upon the recommendation of the Medical Regulating Officer it diverted hospital cars to places where they were needed, informing service commands to which they were attached only if this action delayed their return to home stations for more than ten (later five) days. This meant, for example, that a car attached to the Second Service Command, carrying patients to a hospital in the Fifth Service Command, might be loaded with other patients at the latter place and diverted to a destination in the Fourth Service Command before being returned to its home station.19

Further centralization in rail evacuation operations and more extensive use of hospital cars was achieved during 1945 when the size of groups for which service commands might independently arrange commercial transportation was reduced from a maximum of thirty-nine to fourteen. As long as service commands could arrange for the movement of groups of patients that were large enough to warrant the addition of a special tourist or sleeping car to a regularly scheduled train (that is, any group of fifteen or more persons), it was possible for such a car to be procured to move patients along a route

18(1) Memo, CofT for SG, 23 Oct 43, sub: Opr of Hosp Tn Cars. SG: 453.-1. (2) Memo, Maj Samuel N. Farley, TC, for Lt Col I. Sewell Morris, TC, 27 Oct 43, sub: Conf in SGO re Better Util of Govt-Owned Hosp Cars. Off file, Hosp Evac Unit, OCT. (3) Memo, Same for Same, 17 Jan 44, sub: Functions of the Hosp Evac Unit. Same file.
19(1) Interv, MD Historian with Samuel N. Farley, 9 Oct 52. HD: 000.71. (2) WD Cir 316, 6 Dec 43. (3) ASF Cir 147, 19 May 44. (4) Memo, Lt Col John C. Fitzpatrick for Gen [Raymond W.] Bliss, 23 May 44, sub: Util of Hosp Tns. HD: 705 (MRO, Fitzpatrick Stayback, 1334). (5) Memo, SG for Fiscal Dir ASF, 26 Jul 44. SG: 322 (Hosp Tns). (6) ASF Cir 328, 30 Sep 44. (7) Transcript of Proceedings, Hosp Tn Conf, 15-16 Feb 45. HD: 531.4.


over which an Army hospital car-under orders of the Office of the Chief of Transportation-was traveling empty at approximately the same time. The Chief of Transportation therefore recommended in May 1945 that arrangements for the movement of all groups of patients and attendants numbering fifteen or more persons should be centralized in his Office. This recommendation was approved and in June 1945 local transportation officers were limited to making arrangements for the movement of individuals and of groups of patients and attendants numbering fourteen or less. Knowing the locations and routes of all Army hospital cars, the Chief of Transportation could then arrange to use them in moving some of the groups which service commands had formerly dispatched in extra sleeping and tourist cars of regularly scheduled passenger trains.20

Despite the fact that centralized control of hospital cars and hospital train movements was not wholly approved by service commands, the Surgeon General's Office considered such control essential. One service command surgeon felt that his lack of control over the personnel on hospital cars from other commands jeopardized the loading and care en route of patients whom he was transferring. A local transportation officer in another service command believed that he could expedite the movement of patients from the debarkation hospital which he served if he were permitted to arrange rail movements independently. Still another service command complained of the use elsewhere of personnel which it supplied to care for patients being transported from its own debarkation hospital. Other objections arose from the difficulty service commands encountered in property and mess management on hospital cars attached to them but diverted elsewhere for use. In reply to such complaints, The Surgeon General repeatedly explained that centralized control of the movement of hospital cars and hospital trains was necessary to insure the maximum use of all available rail equipment, both Army- and carrier-owned, in the orderly transportation of large numbers of patients.21

Measures other than centralization of control were adopted to achieve better use of hospital cars, conserve medical personnel, and relieve railroads of furnishing more sleeping cars. In June 1944 the Transportation Corps requested carriers to return hospital cars in passenger rather than in freight service. In this way hospital cars that had to be moved without patients spent less time idle than they might have otherwise.22 By the early part of 1945 the Transportation Corps itself began to arrange hospital-car routes and schedules, without reference to railroad representatives. Though this procedure was a departure from the Army's agreement with the railroads, the latter apparently inter-

20(1) Memo, CofT for ACofS G-4 WDGS, 16 May 45, sub: Routing Control and Carriers' Equip for Mvmt of Pnts and/or Med Attendants in Groups of 15 or More. . . .TC: 511 (AR 55-130). (2) WD Cir 177, 15 Jun 45.
21(1) Ltr, Surg 2d SvC to Brig Gen Raymond W. Bliss, SGO, 3 Feb 44. SG: 531.2 (2d SvC)AA. (2) Diary, Evac Br MRU Oprs Serv SGO, 20 Jun 44. HD: 024.7-3. (3) Ltr, CG Letterman Gen Hosp to Lt Col John C. Fitzpatrick, MRO, 14 Nov 44. HD: 705 (MRO, Maloney Stayback, 127). (4) Memo cited n. 19(4). (5) Ltr, MRO to CG Letterman Gen Hosp, 21 Nov 44. SG: 705.1 (Letterman GH). (6) Ltr, Dep Chief for Hosp and Domestic Oprs, Oprs Serv SGO to Surg 2d SvC, ca. 28 Dec 44. SG: 531.2 (2d SvC)AA. (7) Memo, Maj Frederick H. Gibbs, MAC, for Surg 4th SvC, 29 Jan 45, sub: Hosp Tn Serv, Stark Gen Hosp, with 2 inds. SG: 453 (Stark GH)K.
22Ltr, Lt Col I. Sewell Morris, TC, to A. H. Gass, Mil Trans Sec AAR, 6 Jun 44, with reply dated 8 Jun 44. TC: 531.4.


posed no objection. Its chief advantage was that hospital cars could be sent along unauthorized routes (those not normally used by railroad companies) to reduce mileage and to deliver groups of patients at different hospitals. The higher cost which railroads charged for such movements was considered by the Surgeon General's Office to be fully justified by the ends achieved.23

In addition to the larger problem of using hospital cars to the best advantage, others were encountered in the operation of hospital trains. One of them, feeding patients on hospital trains, was partially solved by the procurement of Army hospital kitchen cars and the installation of buffet-kitchens in other hospital cars.24 To govern the procurement of food for these cars, along with the bookkeeping procedures involved, the ASF Control Division, the Surgeon General's Office, and the Office of The Quartermaster General collaborated in the preparation of a standard subsistence procedure for hospital trains in the last part of 1944.25 Other problems arose in accounting for hospital cars and their equipment, and in their maintenance. In September 1944 a circular governing accounting procedures was published by ASF headquarters, while some months earlier the Transportation Corps prepared technical bulletins on the maintenance of hospital cars.26 Another problem involved the position of hospital cars in trains. In the winter of 1943-44 the Transportation Corps requested carriers to place hospital cars on regular passenger trains in such a position that the public would not have to use them as passageways. Carriers agreed to place them either directly ahead of or directly behind other passenger cars in the same train. Furthermore the carriers agreed, upon the request of the Chief of Transportation and the recommendation of The Surgeon General, to place "buffer" cars (cars in which no patients were carried) between hospital cars and locomotives when special hospital trains were made up.27 The carriers also co-operated in observing a request of The Surgeon General that patients be transported only in air-conditioned cars. By Army regulations and an agreement with railroads, patients were authorized "sleeping car accommodations in tourist sleeping cars if available, otherwise standard sleeping cars." Of the entire fleet of Pullman tourist cars, only four hundred were air-conditioned, and it was therefore impossible for carriers always to supply air-conditioned tourist cars when they were requested. For a time during 1944 they supplied higher-priced air-conditioned standard sleeping cars without any increase in cost, but in December of that year they revised an earlier agreement

23(1) Memo, CofT for SG (MRO), 14 Feb 45, sub: Routing of Hosp Tn Travel, with inds. SG: 531.4. (2) Ltr, Lt Col E. B. White, TC, to Interterritorial Mil Cmtee, 9 Mar 45. TC: 531.4. After the war ended, in November and December 1945, the Army and Navy agreed upon a procedure for the joint use of Army hospital cars in the United States. This agreement contributed to the conservation of carrier-owned equipment and still greater use of Army-owned hospital cars. ASF Cir 441, 11 Dec 45.
24See below, pp. 381-86.
25WD Cir 480, 22 Dec 44. Also see WD Cir 184, 21 Jun 45.
26(1) ASF Cirs 286, 1 Sep 44; 401, 9 Dec 44. (2) TB 55-285-1, 24 Jul 44; TB 55-285-2, 24 Aug 44, on Echelon Maintenance for Hosp and Kitchen Cars. A complete manual for operation of the new unit cars (TM 55-1254, 15 Dec 45, Car, Railway, Hospital Unit) was issued after the end of the war.
27(1) Ltr, Hosp Tn Comdr to CG 2d SvC, 21 Oct 43, sub: Trans Rpt of Hosp Tn Mvmt HT-69, Main 57616, 14-19 Oct 43, with inds. SG: 453.-1. (2) Ltr, CofT (Tfc Control Div) to AAR, 24 Jan 44. TC: 531.4 (Placement of Hosp Cars on Regular Tn). (3) Ltr, SG to SvCs, 2 Dec 44, sub: Use of Buffer Cars in Connection with Mvmt of Pnts by Rail. SG: 453 (SvCs).


with the Army to provide special rates for standard sleeping car equipment.28

The problems just reviewed are representative only, in no way intended to be an exhaustive listing, of those encountered by authorities on a higher level than hospital train commanders. These commanders were faced with other problems which were perhaps even more varied and complex. Solutions for most of them had to be found locally, for there was no War Department manual on hospital train operations. During 1945 a series of conferences of hospital train commanders, attended by representatives of The Surgeon General and the Chief of Transportation, were held to discuss such common questions as linen exchange procedures, feeding difficulties, the handling of baggage, entraining and detraining plans, personnel and equipment requirements, means of providing recreation aboard trains, and problems of hospital car maintenance and operation.29

Some idea of the scope of hospital train operations may be gained from the following figures. During 1944, 172 hospital trains carrying 37,371 patients were dispatched from the Second Service Command to general and convalescent hospitals scattered throughout the United States. During the period from 26 June 1944 to 15 October 1945, 205 hospital trains evacuated 35,697 ambulatory patients and 17,320 litter patients from Stark General Hospital. From January to August 1945, inclusive, the hospital train detachment of the First Service Command made 232 trips to 1,334 destinations, covering 48,888 miles and moving 67,608 patients. Between July 1944 and December 1945, the Ninth Service Command moved 56,061 patients in hospital cars and 29,439 in Pullmans.30

Despite the widespread use of centrally controlled hospital trains, service commands retained throughout the war the authority to arrange with common carriers for the movement of patients as individuals or in small groups. The main difficulty they encountered was in securing accommodations for them in sleeping or parlor cars occupied also by civilians. In November 1943 the ASF Control Division investigated complaints of hospitals about delays in getting reservations for patients and found that they were justified. The average period that elapsed between the time transportation was requested and was made available for 27,265 patients was 3.8 days. In some instances it ranged as high as 15.3 days. Continuation of this situation would mean not only that the treatment of patients would be delayed but also that some hospitals in time would become hopelessly overcrowded. In February 1944, therefore, ASF headquarters directed The Surgeon General, with the assistance of the Chief of Transportation and service commands, to arrange with railroads for securing promptly rail accommodations for Army patients.31

28(1) AR 55-125, 9 Jan 43; C 1, 4 Jun 43; C 2, 4 Aug 43. (2) Memo, CofT for SG, 22 Aug 44, sub: Accommodations in Air-Conditioned Sleeping Cars, with inds. SG: 531.2. (3) WD Cir 240, 7 Aug 45. (4) Ltr, CofT (Tfc Control Div) to GAO (Claims Div), 1 Oct 45. TC: 531.4.
29(1) Mins, Hosp Tn Conf, 15-16 Feb 45, Miller Fld, NY; Hosp Tn Unit Comdrs Conf, 10-13 Jul 45, Presidio of San Francisco. HD: 531.4 (Conf). (2) An Rpts, 1st, 2d, 4th, and 9th SvCs, 1944 and 45. HD. (3) Ltr, 9956 TSU Letterman Gen Hosp to SG, 22 Mar 50, sub: Ref Mat for Util of Hosp Tns. HD: 453.1.
30An Rpts, 1st, 2d, 4th, and 9th SvCs, 1944 and 45. HD.
31(1) AR 55-130, 28 Dec 42, with C 2, 4 Jun 43. (2) WD Cirs 229, 24 Sep 43; 316, 6 Dec 43. (3) History of Control Division, ASF, 1942-45, App, Project 95-2. HD.


In conferences held in Chicago and Washington during April and May 1944, representatives of The Surgeon General, the Chief of Transportation, and the Railroad Interterritorial Military Committee agreed upon procedures for obtaining reservations for individuals and for groups of fewer than fifteen persons. For this purpose, patients were divided into five classes. Class I patients were those who were acutely sick or injured and whose immediate movement to hospitals staffed and equipped to care for them was "a matter of extreme urgency." Class II patients were similar cases whose movement might be delayed safely for forty-eight hours. Class III patients were those who needed to be moved for medical reasons but whose transfer could be delayed approximately seventy-two hours; this group included patients received from theaters of operations at debarkation hospitals. Class IV patients were those being moved, not for medical reasons, but for their own convenience; their transfer might be delayed for approximately six days. Class V patients were those being discharged from the service, being returned to duty, or being sent on sick leave; their movement could be delayed about ninety-six hours. The carriers agreed to appoint special representatives for each individual railroad to assist hospital commanders in obtaining accommodations for patients of all classes within the time limits established for each. Hospital commanders were enjoined to co-operate with such representatives and, when requesting transportation for patients in either of the first two classes, were required to submit certificates attesting that transportation for Class I patients was necessary immediately and for Class II patients within forty-eight hours.32

The question of priorities for patients over civilians came up when this agreement was reached. Army authorities agreed with railroad representatives that establishment of such priorities would carry the unintentional implication that railroads were not "doing the job." Therefore they decided against it. In the following June, representatives of The Surgeon General, the Chief of Transportation, and railroad companies maintained a like position when the Office of Defense Transportation proposed a system of priorities. Soon afterward, however, the Interstate Commerce Commission, on the recommendation of the Office of Defense Transportation, issued an order which provided for the dispossession of passengers to obtain accommodations for patients. While this action protected railroads against unwarranted lawsuits by civilians who were displaced, the Surgeon General's Office feared that it might create unjustified hysteria on the part of the public instead of dissuading it from unnecessary travel and, at the same time, might endanger the Army's good relations with the railroads. To avoid the latter contingency, and particularly the unwarranted use of priorities by general hospitals, the Army in October 1944 revised the circular describing the voluntary agreement worked out in May. Restating that agreement, the revised version of the circular required hospital commanders to submit to railroads, along with each request for reservations, certificates attesting the classifica-

32(1) Memo, SG for CG ASF thru CofT, 20 Mar 44, sub: Delays in Trans of Pnts to Hosps, with inds. SG: 531.2. (2) Memo, CofT (Mvmt Br) for SG, 16 May 44, sub: Delays in Trans of Pnts to Hosps. Same file. (3) Ltr, CofT to SG, 29 Apr 44, sub: Apmt of RR Rep at US Army Gen Hosps in Arranging Accommodations for Litter and Ambulatory Cases. SG: 705. (4) Ltr, Western Mil Bu to Member RR Assn, 9 May 44, sub: Accommodations for Litter and Ambulatory Cases. SG: 531.2. (5) WD Cir 234, 12 Jun 44.


tion of each patient, those in Classes III, IV, and V as well as in Classes I and II, and indicating the period of time within which accommodations should be provided. In addition it provided that the Interstate Commerce Commission order should be invoked only in accordance with the provisions of this circular. It also forbade the use of priorities to dispossess passengers to secure accommodations for medical attendants returning to home stations.33 Presumably, so long as railroads lived up to terms of the May agreement, the Army would not dispossess passengers to secure accommodations for patients.

Procedures for Air Evacuation

Air evacuation in the United States in the early part of the war was limited to the movement of individuals or groups of three to four patients from scenes of crashes to hospitals or from one hospital to another. In 1942, for instance, Maxwell Field transported a few patients by plane to Lawson General Hospital, and MacDill Field sent others to both Lawson and Walter Reed General Hospitals. At the time of the North African invasion, the Hampton Roads Port arranged for the flight of a patient suffering from a brain injury to Walter Reed General Hospital.34 Such flights were exceptional and the first sizable air evacuation of patients in the United States did not occur until the beginning of 1944. For sporadic flights prior to that time, the Air Forces normally set aside no single group of planes, and it was therefore imperative that air evacuation be carried out normally in administrative, training, or transport planes.35 Moreover, until the latter part of 1942, no personnel was trained especially for air evacuation operations. Air station surgeons either arranged with local operations officers for the transportation of patients by planes belonging to their stations or called upon the surgeons of training centers to supply the necessary accommodations. They either accompanied patients themselves or sent nurses or doctors from air station hospitals as attendants. AAF headquarters authorized SOS installations to submit requests for the air transportation of patients to near-by Air Forces installations, the Air Transport Command, troop carrier commands, and the Air Surgeon's Office.36

During the winter of 1943-44 there were widespread demands, for a variety of reasons, for air transportation of patients in the United States. On 16 November 1943, for example, the commander of Ashford General Hospital requested air evacuation to relieve congestion on railroads in that area. A few weeks later the commandant of the School of Air Evacuation suggested it to provide training for air evacuation personnel and to increase the comfort of patients.37 Early the next Janu-

33(1) ICC, Order 213, Title 49, Transportation and Railroads, 27 Jun 44. HD: 531.4. (2) Memo, Col A[lbert] H. Schwichtenberg for SG, 26 Jun 44, sub: Rail Trans of Pnts. SG: 531.2. (3) WD Cir 405, 14 Oct 44. See also WD Cirs 61, 26 Feb 45, and 471, 15 Dec 44.
34(1) Ltr, Base Surg AAB MacDill Fld to CG AAF (Air Surg), 17 Nov 42. AAF: 370.05 (Evac Book No 1). (2) Ltr, Surg HRPE to CO Langley Fld, 16 Dec 42, sub: Air Trans for Overseas Sick and Wounded Arriving at HRPE. AAF: 452.1 (Amb Plane).
35See below, pp. 429-33.
36(1) 3d ind, Hq AAF to Port Surg HRPE, 5 Jan 43, on Ltr, HRPE to CO Langley Fld, 16 Dec 42, sub: Air Trans for Overseas Sick and Wounded Arriving at HRPE. AAF: 452.1 (Amb Planes). (2) Ltr, 6th SvC to AAF (Air Surg), 16 Apr 43, sub: SOP, with ind. AAF: 370.05 (Evac).
37Ltrs, CO Ashford Gen Hosp to CO AAB, Richmond, Va., 16 Nov 43; AAF School of Air Evac, Bowman Fld, Ky., 6 Dec 43, sub: Trans of Pnts by Air. AAF: 370.05 (Evac, Book 1).


ary the director of the Surgeon General's Hospital Administration Division conferred with the Deputy Chief of Air Staff on the "feasibility of moving patients by air from port hospitals."38 The following month, at a conference of service commanders, the commanding general of the Second Service Command stated that air transportation for patients was "most desirable," and suggested its use particularly for small groups who needed to be moved without delay.39 In April the flight surgeon assigned to Brooke General Hospital propounded still another reason: the evacuation of patients by air would be economical, saving the Government, according to his estimate, at least fifty dollars per patient.40 A combination of such reasons, along with increases in aircraft production, a shortage of Pullman cars, and the absolute necessity of moving large numbers of patients who arrived in the United States from theaters of operations, were responsible for the extensive use of air evacuation in this country during the latter half of the war.

The first large-scale movement of patients by air in the United States was made in January 1944. At that time three troop carrier command planes, with personnel from the School of Air Evacuation, were sent to Stark General Hospital to move patients being debarked from two hospital ships. In a period of ten flying days, between 7 and 19 January, these planes flew 661 patients in 29 loads to 5 general hospitals. No cases of air sickness occurred and only twelve patients required medication, such as the administration of aspirin or morphine, during flight. The success of this mission prompted the commanding general of the Service Forces to congratulate the Air Forces and to express the hope that patients might be evacuated by air from ports of debarkation "repeatedly in the future."41

During the spring of 1944 plans were made to convert that hope into a reality. In April the Air Transport Command was made responsible for the movement of patients by air in the United States (as it had been made responsible earlier for air evacuation from theaters of operations). Soon afterward it assigned to its Ferrying Division as a special mission the movement of about 700 patients from coastal medical installations to various hospitals throughout the United States. The next month the Transport Command delegated its responsibility for domestic air evacuation to the Ferrying Division, and began to earmark transport planes for evacuation only.42 In June representatives of AAF and ATC headquarters, the Ferrying Division, the Air Surgeon, and The Surgeon General agreed upon procedures for domestic air evacuation operations. When the ASF Medical Regulating Officer desired to move patients by air, he informed the AAF Medical Regulating Officer, requesting necessary arrangements. The latter telephoned the Ferrying Division in Cincinnati, Ohio, to determine availability

38Diary, Hosp Admin Div (SGO), 8 Jan 44. SG: 314.8.
39Rpt, Conf CGs of SvCs. Dallas, Tex., 17-19 Feb 44. HD: 337.
40Ltr, Off Flt Surg Brooke Gen Hosp to CG AAF thru Central Flying Tng Comd, 28 Apr 44, sub: Trf by Air of AAF Pnts from Brooke Gen Hosp to AAF Conv Ctr. AAF: 370.05 (Evac, Book 2).
41(1) Ltr, CG ASF to CG AAF, 4 Feb 44. AAF: 370.05 (Evac). (2) Ltr, AAF Sch of Air Evac to CG AAF, 16 Feb 44, sub: Air Evac, with incl. Same file. (3) The Air Surgeon's Bulletin, Vol. I, No. 4 (1944), pp. 12-13.
42(1) Initial Medical History (11 February 1943 to 30 June 1944), Headquarters Ferrying Division, Air Transport Command. HD: TAS. (2) Memo, Lt Col Richard L. Meiling for Air Surg, 27 Apr 44, sub: Air Evac 19-25 Apr 44. AAF: 370.05. (3) See below, pp. 436-37.


and location of planes and then informed the ASF Medical Regulating Officer if the mission could be accomplished within the time limits desired. If so, the ASF Medical Regulating Officer directed hospitals to prepare patients for the movement planned and the AAF Medical Regulating Officer informed the Ferrying Division of the mission to be accomplished.43

The Ferrying Division co-ordinated plans for each flight with the hospital from which patients were being transferred at least 24 hours in advance of the plane's departure. Flight attendants supplied by this Division to care for patients en route also arranged to have them properly tagged for identification and to have their records and valuables carried along with them. To permit hospitals receiving patients to prepare for their reception, flight attendants notified them in advance by telephone of the expected time of arrival.44

During the period from April 1944 to August 1945 the Ferrying Division transported about 100,000 patients from debarkation hospitals to general and convalescent hospitals throughout the United States. Each patient was flown an average of 1,388 miles.45 The procedure by which this was accomplished made it possible, after control of hospital train movements was also centralized in Washington, for the ASF Medical Regulating Officer to co-ordinate the use of planes and trains in domestic evacuation, thereby relieving railroads of a tremendous burden. It also enabled the Regulating Officer to observe more closely than might have been otherwise possible the policy of transferring patients promptly and directly from debarkation hospitals to installations where they would receive final treatment.

43(1) Rpt, Conf on Air Evac, 7 Jun 44. SG: 580. (2) Memo, SG for CG AAF attn Reg Off, 7 Jul 44. SG: 580.-1.
44(1) Organizational History of the Ferrying Division, June 20, 1942 to August 1, 1944. ATC: Hist Div. (2) 1st ind, CG Ferrying Div ATC (Surg) to CG ATC attn Surg, 24 Sep 44, on Ltr, CG 2d SvC to CG ASF attn SG, 29 Aug 44, sub: Air Evac. SG: 580.
45Andres G. Oliver and Hampton C. Robinson, Jr., "Domestic Air Transportation of Patients," The Air Surgeon's Bulletin, Vol. II, No. 11 (1945), p. 400.