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Summary and Conclusions

Contents

Summary and Conclusions

In concluding this volume with a brief review of the general subject it is pertinent to give first of all certain summary figures which indicate the Medical Department's total accomplishment in the field of hospitalization and evacuation during the war. In the period from January 1942 through August 1945, there were approximately 5,100,000 admissions to Army hospitals in theaters of operations and 8,900,000 to hospitals in the zone of interior.1 In the same period, more than 518,500 patients were debarked by the Army at ports plus 121,400 by aircraft in the United States for transportation to zone of interior hospitals. (Table 16) Meanwhile, evacuation units that were organized and trained in the United States transported many thousands of patients from front-line areas to medical stations and hospitals in theaters of operations. The number of patients on the registers of hospitals in theaters reached a peak of almost 266,500 at the end of January 1945.2 In a single month-May 1945-more than 57,000 patients were evacuated from theaters to the zone of interior. And by the end of June 1945 the number of patients on the rolls of Army hospitals in the United States rose to more than 318,000. (Table 13) The manner in which the Medical Department prepared for and discharged this unprecedented task of hospitalization and evacuation has been the subject of this volume. From the details already presented, certain generalizations can be made and certain conclusions drawn to emphasize some of the problems involved in the accomplishment of this mission.

Like the rest of the Army and the War Department, the Surgeon General's Office and the Medical Department were in the midst of preparations and therefore not ready for a global war when it overtook them in December 1941. The partial mobilization that began with the passage of the Selective Training and Service Act in the fall of 1940 had caused only a partial adjustment from peacetime to what might be expected in wartime. Tables of organization, tables of equipment, and equipment lists of medical units had been revised, but more with considerations of desirability than possibility in mind. Data on hospitalization and evacuation in World War I had been analyzed and were available as a basis for estimating requirements. They had already been used in the establishment of an authorized ratio of beds to troops for hospitals in the United States, but whether or not World War I experience would be applicable to World War II remained to be seen. Hospitalization and evacuation units had been organized and were being trained, but they were few in number. Also, there was uncertainty as to the role of these particular units-whether they would remain in the

1These figures are "preliminary pending publication of final tabulations based on the individual medical records." Memo, Eugene L. Hamilton, Chief Med Statistics Div SGO for Clarence Smith, Historical Unit AMS, 3 Mar 53, sub: Hosp Admissions during World War II. HD: 705.
2Statistical Review, World War II, App R, p. 237.


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United States as training units or be sent overseas as functional units. Plans had been made to call others into active service in the event of war, that is, reserve hospital units affiliated with civilian schools and hospitals. With regard to hospital service in the United States and its territories, experience in expanding hospital facilities had shown the undesirability of depending upon existing buildings and had revealed many unsatisfactory features in plans for cantonment-type hospitals. Blueprints were drawn, therefore, for hospitals of a new type, to be of two-story semipermanent construction. An improved general-service ambulance had been developed and put into use; but plans for motor vehicles of other types, such as multipatient ambulances, were still in the experimental stage. Two unit and four ward cars for hospital trains had been delivered, but they had not yet been used in the actual transportation of patients. Although the ships' hospitals of some transports had been enlarged and improved, it was uncertain whether the Army or Navy would operate transports, and therefore evacuate patients from overseas areas during wartime. Moreover, basic decisions as to whether hospital ships would be authorized or not, and as to whether the Army or the Navy would operate them, remained to be made. Evacuation from theaters and transportation of patients from ports to general hospitals in the United States proceeded according to peacetime procedures, with little indication of changes that would be required for a wartime load. Plans for air evacuation were in the hopeful more than the practical stage. And plans for the internal administration of hospitals and the global operation of a system of hospitalization and evacuation were in terms of expanding peacetime procedures rather than of substituting new procedures designed for the task that lay ahead. Finally, a shortage of medical supplies and equipment plagued medical officers from the highest to the lowest levels of command.

Reasons for the unpreparedness of the Medical Department for war-or at least some of them-are reasonably clear. Planning of the Army for many years had been in terms of defending the United States against sudden attack, and even during the period of peacetime mobilization there was uncertainty as to whether United States troops would be employed overseas. Furthermore, appropriations for preparedness were meager, and there was hesitancy even on the part of the President to appear aggressive in planning for a possible war. Finally, the Surgeon General's Office-and perhaps the entire Medical Department-found it difficult, apparently, to break peacetime habits of thought and action and to plan imaginatively for the accomplishment of its mission during a possible future war.

For the Medical Department, as for the rest of the Army, the first year and a half of the war was a time of meeting emergency needs and completing mobilization, while at the same time preparing for full scale war. Needs of the moment received first consideration. As they were met, emphasis gradually shifted to evaluating experience as it accumulated and to planning more effectively for the future. Despite many difficulties, sufficient hospitals were constructed and placed in operation to meet the Army's requirements during its rapid growth and training in the United States. The necessity of speed and economy, however, dictated abandonment of new plans for hospitals of semipermanent construction and the erection of canton-


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ment-type hospitals on unsatisfactory existing plans, with attendant alterations, additions, and repairs. Eventually, availability of materials and general dissatisfaction with the hospitals under construction resulted in the erection of buildings of a third type-one-story buildings of brick or tile-considered by the Surgeon General's Office to be the best for emergency construction. Toward the completion of the construction program, efforts were made to co-ordinate plans of the Army for hospital construction with those of other agencies and with postwar needs. Concurrently with the establishment of additional hospitals in the United States, hospitalization and evacuation units were sent overseas, and others were organized and placed in training for later service. Contrary to earlier plans, standard Army hospital units rather than affiliated reserve units constituted the primary means of meeting the first needs for hospitals overseas. Some of the latter-as well as nonaffiliated hospital units-remained in training in this country for long periods after their activation, and the question arose of whether or not they might be used-as evacuation units were-to provide medical service concurrently with and as a part of their training in the United States. The Surgeon General withstood the demands of higher headquarters to plan toward that end, and the problem of making effective use of numbered hospital units in the United States remained unsolved. By the spring of 1943, after the most urgent needs of theaters had been met, measures were taken to evaluate their existing facilities for hospitalization and evacuation and to plan more effectively to meet their future needs.

The early part of the war was also a time of establishing basic policies and procedures that were to endure throughout the conflict. An early decision of importance was that the Army would operate transports and evacuate patients aboard them. A corollary decision toward the middle of 1943 was that the Army would also operate hospital ships to supplement the space available for evacuation on transports. Procedures that required only minor adjustments later in the war were established to co-ordinate the activities of theaters, ships' surgeons, ports of embarkation, and corps areas (later called service commands) in the evacuation of patients from theaters to hospitals in the zone of interior. In addition, a procedure for evacuating patients from theaters in regularly scheduled transport airplanes was also established, but it was policy during this period to keep air evacuation to a minimum. Despite the wishes of The Surgeon General and the Air Surgeon, AAF headquarters ruled that airplanes would not normally be set aside or built for evacuation only. Hopeful plans for forward-area air evacuation were thereby shelved. Procedures were also developed-albeit directives announcing them were unclear and in some instances contradictory-for the movement of patients by hospital train in the United States. While hospitals and the hospital system in the zone of interior continued for the most part to operate under peacetime procedures, the designation of general hospitals as centers for specialized treatment and the establishment of a policy of hospitalizing patients near their homes occurred early in 1943. These actions came too late to influence the location of general hospitals, and had not had time by the middle of 1943 to affect appreciably procedures for evacuation in the zone of interior. The desirability of shortening the length of time patients stayed in


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hospitals was recognized and efforts toward that end were begun. They pertained primarily to procedures in administrative channels outside Army hospitals. Finally, attempts of the Air Surgeon to set up separate convalescent facilities for Air Forces patients, along with an awareness by the Surgeon General's Office and other Medical Department officers of the desirability of convalescent-reconditioning programs, caused the establishment early in 1943 of convalescent centers and annexes-the forerunners of convalescent hospitals of later years.

The early period of the war also afforded an opportunity to review plans already made and to adjust them to the new situation. The mobility of war on land masses and the character of operations in island areas highlighted the necessity of modifying existing hospitalization and evacuation units. In some instances, new units were developed. In others, theaters were left to adapt existing units to new uses. Several conditions-shortages of personnel and shipping space, and the nature of combat operations-combined to initiate a trend that was to be carried to greater lengths later-the reduction of personnel and equipment authorized for units and installations of all types and sizes. In this connection, certain other practices began: the substitution of Medical Administrative for Medical Corps officers in administrative positions in theater of operations units and in zone of interior installations, and the replacement of general service men with limited service men, civilians, and enlisted women in hospitals in the United States. Experience with unit cars for hospital trains revealed their impracticability, and the Surgeon General's Office substituted for them a new type of car, called a ward dressing car. The Office successfully opposed a proposal to develop at this time a fourth type of car-one that would include not only a dressing room and berths for patients but also a small kitchen. The Surgeon General's recommendation for the development of a forward-area ambulance was disapproved by higher authority, but the general-service ambulance was modified to facilitate its shipment to and use in theaters of operations. Experiments with multipatient ambulances were unsuccessful, but other vehicles-such as surgical trucks-were developed for use in the evacuation system in theaters.

The task of providing hospitalization and evacuation in the first year of the war was complicated by the fact that it had to be accomplished while a major reorganization in the War Department was taking place. The creation of three major commands-Ground, Air, and Service Forces-required delineations of responsibility for hospitalization and evacuation, and raised questions concerning the extent of The Surgeon General's authority. Responsibility for units to be used in theaters of operations was readily divided between The Surgeon General and the Ground Surgeon, but the Air Surgeon's responsibility and authority, and his relationship with The Surgeon General, were not sufficiently delineated to prevent recurring instances of friction between them, particularly when the Air Surgeon attempted to set up a completely separate hospital system for the Air Forces. The establishment within ASF headquarters of a group concerned with hospitalization and evacuation and headed by a Medical Corps officer had a variety of effects. This group assumed the lead in planning and in coordinating the activities of the many agencies involved in evacuation operations, with the full concurrence, apparently, of


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the Surgeon General's Office. When it entered the field of hospital operations it encountered opposition. Whether the good it accomplished in this field counterbalanced the ill-feeling and friction which it engendered is difficult to determine accurately even now. Progress had been made by the middle of 1943 in composing differences and solving problems arising from the reorganization, but further adjustments in relations and authority remained to be made in the latter part of the war.

The last two years of the war were characterized by the necessity of providing hospitalization and evacuation for an all-out war with more limited resources than had been anticipated. The problem of estimating requirements therefore demanded continual and increasing attention. By the latter half of 1943 it began to be evident that estimates based on World War I statistical data were too high for World War II. In the fall of 1943, when evacuation policies were established and bed ratios were authorized for theaters for the first time, there occurred the first attempt to use World War II experience as a source of data for estimating requirements. Soon afterward the Surgeon General's Office completed an estimate of the patient load for 1944 for use in planning evacuation from theaters and in determining hospitalization for both theaters and the zone of interior. Facilities provided on the basis of this estimate seemed excessive during 1944 and, as the personnel situation became more restrictive, various agencies of the War Department urged retrenchment. Reductions followed in the ratio of beds (to troops) authorized for station hospitals in the United States and for fixed hospitals in most theaters of operations. Early in 1945, when requirements increased, general and convalescent hospitals in the United States had to be expanded rapidly, more hospital train cars had to be procured, and additional hospital ships had to be rushed to completion. Experience in estimating requirements during 1944 and 1945 pointed up the importance of collecting casualty and disease data early in the war for planning purposes. It also highlighted the necessity and difficulty of correlating far in advance estimates of requirements with estimates of the time when they would occur. Furthermore, it emphasized the importance of co-ordinating plans for hospitalization in theaters with plans for evacuation and for hospitalization in the zone of interior in order to avoid duplication and the uneconomical use of limited resources.

Limited resources affected hospitalization and evacuation in more ways than in demanding repeated estimates of requirements. Shortages of personnel led to widespread application in the latter half of the war of practices already begun on a small scale. Further reductions occurred in the relative amounts of personnel authorized for hospitalization and evacuation units as well as for named hospitals in the United States. Medical Administrative Corps officers were used more extensively to replace Medical Corps officers in administrative and semiprofessional positions; and limited service enlisted men, civilians, and enlisted women replaced the major portion of able-bodied enlisted men in zone of interior installations. The extent to which reductions and substitutions of personnel were made supports the belief that hospitalization and evacuation organizations were overgenerous in their use of personnel at the beginning of the war. It also suggests that the Medical Department might have avoided many difficulties in adjusting to changes eventually required


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by circumstances and higher authorities if it had been more realistic in the first place, reducing amounts of personnel authorized for various units and installations to that actually required and using from the start greater proportions of Medical Administrative Corps officers, limited service enlisted men, civilians, and enlisted women. Personnel shortages also required the adoption of new practices in the latter half of the war, such as the use of provisional platoons to care for patients on transports, the employment of enemy protected-personnel in the medical service of theaters and the zone of interior, and the substitution of small units that could be used in flexible combinations for larger rigid table-of-organization units, such as regiments and battalions, in combat areas.

Restrictions on new construction in the latter part of the war led to the practice of expanding existing hospitals by using medical-detachment barracks for hospital patients, theater-of-operations-type barracks for detachments, and post barracks for convalescent patients. While several station hospital plants were converted into general hospitals, earlier plans and proposals to meet in the same manner a growing need for general hospital beds in the latter part of the war proved impractical because of a shortage of specialists to man additional general hospitals. Toward the end of the war, the removal of restrictions on the use of certain materials formerly in short supply permitted a program of hospital improvement to correct some of the deficiencies in cantonment-type buildings erected earlier. Although hospital construction was curtailed about the middle of 1943, the major portion of the program of constructing hospital cars and ships occurred after that time-primarily because the need for them was either not fully comprehended or not recognized in the form of authorizations earlier. Demands from theaters in the Pacific in the latter part of the war focused attention upon the need for prefabricated hospital buildings for use in overseas areas. The war ended before this need could be satisfactorily met.

Important changes were made in the zone of interior hospital system in the latter part of the war-partly because of limitations upon available resources but also for other reasons, such as competition between the Air Surgeon and The Surgeon General for the control of segments of hospitalization, the desirability of providing a helpful psychological atmosphere for convalescent patients, and the emergence of new needs. The existing program of specialization in general hospitals was extended to promote the effective use of scarce specialists. The development of regional hospitals represented an attempt to eliminate duplication inherent in the operation of dual sets of hospitals (Air and Service Forces) by providing hospitalization on a regional or geographic instead of a command basis. The establishment of convalescent hospitals not only provided a better psychological environment for convalescent patients but also permitted their care in less expensive facilities than general hospitals. The operation of specific general hospitals solely for prisoner-of-war patients reduced administrative and security problems and contributed eventually to personnel economy. Although there were no significant changes in the system of hospitalization and evacuation in overseas areas, efforts were made to provide theaters with additional types of units, such as medical holding battalions, mobile army surgical hospitals, and convalescent camps, in order to meet existing and emerging needs effectively. Changes


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did occur in the system of evacuation from theaters to the United States. Aside from improvements in procedures already established, the most important modification was the creation of a Medical Regulating Unit in Washington to centralize control over the use of hospital beds and over the flow of patients and to co-ordinate the movement of patients by sea, rail, and air. This step reflected a growing use of hospital ships, airplanes, and government-owned hospital cars in the evacuation process, contributed to stricter observance of the policies of caring for patients in specialized centers and in hospitals near their homes, and revealed the desirability of locating general and convalescent hospitals in relation to population density rather than troop concentrations.

In connection with changes in the hospitalization and evacuation system came changes in the internal organization and procedures of zone of interior hospitals. They occurred near the end of the war and came largely as a result of emphasis by ASF headquarters on the achievement of efficiency and economy through management engineering. Attempts to standardize hospital organization-a prerequisite to the simplification of administrative procedures-amounted to conformance with the standard organization of ASF posts more than improvements and innovations in hospital organization as such. The introduction of management engineering led to work-load studies, work-simplification measures, and the streamlining of certain administrative procedures, especially those affecting the length of time patients remained in hospitals and, consequently, the number of beds required. Another factor affecting bed requirements-the performance of adequate diagnostic procedures to permit the admission to hospitals of only those patients needing hospital care-was not touched, and the work of dispensaries in this respect remained "one of the weakest links in the whole medical program."3

Growth of the patient load in the later war years, coupled with changing policies, procedures, and circumstances, led to the development of new transportation facilities for evacuation. Despite its earlier objection to a proposal for a hospital car with a dressing room, berths for patients, and a small kitchen, the Surgeon General's Office adopted the idea when its necessity became obvious. That Office also promoted the procurement of kitchen cars for hospital trains when it became apparent that railroad companies would be unable to supply the Army with sufficient dining cars. To assist in the movement of patients from ports to near-by hospitals, The Surgeon General proposed, and higher authority approved, the development of a multipatient ambulance. A front-line ambulance was developed experimentally, but it was not authorized for procurement because ASF headquarters and the War Department General Staff insisted upon the use of standard Army vehicles only. Toward the end of the war litter racks that could be attached to jeeps to enable them to evacuate patients from forward areas were standardized for issuance to evacuation units. While airplane ambulances were never authorized or developed, improvements in litter supports permitted increases in the capacities of transport planes for evacuation. Eventually, an increase in the availability of planes led to a modification of existing policy and the as-

3Comment by Dr. Eli Ginzberg, formerly Dir, Resources Anal Div SGO, incl to Ltr to Col Calvin H. Goddard, 5 Nov 51. HD: 314 (Correspondence on MS) V.


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signment to several commands of planes for use primarily in the movement of patients.

Further adjustments to the new organization of the War Department occurred in the latter half of the war. The Surgeon General expanded and strengthened his Office, particularly the divisions concerned most immediately with hospitalization and evacuation. Concurrently, ASF headquarters abolished its Hospitalization and Evacuation Branch and transferred many of its functions and some of its personnel to the enlarged and strengthened Surgeon General's Office. Eventually, The Surgeon General was restored to his former position of having direct contact with the War Department General Staff. Meanwhile, though still under ASF headquarters, his Office developed means of exercising closer supervision over service command hospital activities, and limits of the respective jurisdictions of the Air Surgeon and The Surgeon General gradually evolved. The Surgeon General was never in a position, though, to exercise a controlling influence over the entire hospitalization and evacuation system of the Army. Perhaps an important reason for this was that, as a result of the dual position he held, he seemed at times to be bidding against himself. As The Surgeon General of the entire Army, he was responsible-to some extent, at least-for apportioning medical resources among major commands (Air, Ground, and Service Forces) and between the zone of interior and theaters of operations. On the other hand, as surgeon on the staff of the commanding general, Army Service Forces, he was responsible for providing as good a medical service in the zone of interior as possible. This required him to act in a disinterested manner on matters involving him as an interested party. Nevertheless, despite difficulties caused by its organizational structure, the War Department and its agencies, including the Surgeon General's Office, managed successfully with limited resources to provide adequate hospitalization and evacuation for an Army of over 8,000,000 men engaged in a global war.

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