The pilots African American Officers doughboys with mules Riveters pilots in dress uniforms African American Soldiers 1 gas masks Mule Rearing

Delivery of Medical Care off the battlefield

Introduction

MedSupportMeuseArgonneVerdunSurMeuse

 Casualties on the battlefield are moved to medical care one by one. Within the battle area, the combat zone, patients are moved individually, or a few at a time. True, a field hospital might have to deal with 10 or 20 at a time, or even more. The focus is still on the individual soldier who is injured. But back in the rear area, in what is now called the communications zone, casualties begin to take on an aspect of mass movement. A major battle might generate several thousand casualties within a division, tens of thousands within an entire army. Over a campaign, hundreds of thousands of men will have to be moved from collecting areas near the front lines back to specialty hospitals and hospital centers capable of dealing with patients arriving literally by the trainload. The American Expeditionary Force sustained 200,000 casualties during the six to eight months in which it saw heavy combat. How was it organized to transport and care for 20,000 to 40,000 patients each month?

Delivery of Medical Care off of the battlefield

Hospital Trains

OFF BritishTrainThere were automobiles in WWI, but railroads were still the way to move large quantities of people. That was true even when the people were patients, and it made far more sense to use hospital trains (which should have been termed ambulance trains) to carry hundreds of patients instead of using scores of motor ambulances each carrying 4-6 patients.

Rather than ship rail cars to France, the US planned to purchase (or rent) hospital trains from the British and French. A limited number could be bought, but when major battles loomed more had to be borrowed. The standard train was supposed to be 16 cars:
1 car for infectious cases, 24 beds (one end used for caboose);
1 staff car, 8 beds;
1 kitchen and sick officers' (sitting) car, 3 beds for cooks, 20 seats;
9 ordinary ward cars, 36 beds each;
1 pharmacy car, 12 beds;
1 personnel car, 33 beds;
1 train crew and store car, 3 beds;
1 kitchen, men's mess car, caboose, 2 beds for noncommissioned officers

The normal capacity was 360 beds, but if the train staff gave up their beds another 36 patients could be accommodated. The exact mix of sitting and recumbent patients could be changed by fastening various middle beds so more or fewer men would be sitting, and in crises up to 600 patients could be moved by a single train. The pharmacy car had a small operating room with limited equipment, but while it was a capability, the space was more often used to change bandages than perform even minor operations. Purpose-built hospital trains had double-doors so litters could easily be carried on.OFF hospital train

Hospital trains drove some of the decisions about hospitals. In the combat zone, evacuation hospitals were usually located near rail lines: it was very inefficient to use motor ambulances to shuttle patients any distance to a hospital train. In the communications zone (rear area), hospital trains carrying hundreds of patients made it efficient to group base hospitals into hospital centers.  No one base hospital could handle the arrival of a trainload of patients with varied needs, while a 20,000-bed hospital center could readily take a train or two per day. And it made more sense to locate the hospital centers in the countryside, where rail lines could be hastily constructed, than in cities where patients would have to be moved about by motor ambulance to the various buildings converted into hospitals.OFF HospitalTrain2

Delivery of Medical Care off of the battlefield

Base Hospitals

OFF BH 9 diagram NLMLayout Diagram, Base Hospital 9

Base hospitals were the key facilities for patient treatment and recovery. Camp hospitals were for short-term problems in the rear areas, and the casualty treatment system was designed to move patients to the rear. But there were inevitably long-term patients from the rear areas, and those casualties had to have somewhere to recover. Some base hospitals were in the Advanced Section, and occasionally were used as evacuation hospitals (especially during the Meuse-Argonne fighting) but the majority of units were well in the rear.

 As the build-up in France continued, base hospitals expanded in size from 500 beds up to 1000 beds or more.  Before the war the base hospitals were planned to be 500 beds, but that turned out to be inefficient.  With a few more nurses and enlisted men, and more equipment, the capacity could be doubled to 1,000 beds. In crises they were expanded up to 2,500 beds, although most of the extra space was for recovering patients who would be moved to convalescent camps when those were organized.

OFF surgical ward BH 26 NLMSurgical Ward, Base Hospital 26, Allery, Saône-et-LoireBase hospitals were designed to have a substantial medical staff, with a balanced surgical staff able to treat all kinds of patients. The first fifty were organized from civilian institutions (medical schools, large hospitals, or consortia of small civil hospitals), but the rest were organized from the ‘Army at large’. In practice, this meant recruiting new physicians and nurses into the Army, and selecting enlisted draftees to serve in the medical units.  Surgical personnel, and some other clinical teams such as shock/resuscitation teams or splinting teams, were rotated from the base hospitals to forward hospitals to increase the treatment capacity forward.OFF officers BH117 NLMOfficers, Base Hospital 117, Montpon-Menesterol, Haute-Marne

At first, most base hospitals occupied hotels, schools, and other large civilian buildings. Later temporary buildings were built.  These were prefabricated frame buildings with tarpaper roofs.  Often, the green wood warped or shrank, and the wind came in through the gaps. Hospital construction was given a low priority until late in the war. Then, the 100,000 American casualties from the Meuse-Argonne were arriving in base hospitals and influenza was spreading through the AEF.  In general, the AEF built facilities as cheaply as possible, both because that would be less expensive, and because the war was expected to be short.  

Delivery of Medical Care off of the battlefield

Specialized Hospitals

Thomas Splint 2Applying a Thomas Splint

Having a large medical system allowed the concentration of categories of patients.  This provides better care by bringing patients to facilities with the best equipment and building expertise among staff. In essence, specialized hospitals were an extension of the ward system used in the Great War period.  A ward might be designated for, say, fracture cases.  Much the same thing is seen today in specialty units within general hospitals, or specialty hospitals for cardiac, orthopedic, or cancer treatment. 

In a military environment, skilled personnel are always scarce.  The British army, for example, never had enough orthopedic surgeons.  The first American surgeons to go overseas after our declaration of war was a group of orthopedic surgeons who went to fill gaps in British hospitals.  Even today, such specialists as neurosurgeons, plastic surgeons, orthopedists, and eye surgeons are often grouped in specialty units where their skills can be used most efficiently.  

Base Hosp 20 OR 2
Operating Room, Base Hospital 20 (University of Pennsylvania)
The AEF organized a substantial number of specialized hospitals
. A few were designated from the very top, by the Chief Surgeon of the AEF; showing the high level of concern for shell-shock patients, two of the designated hospitals were for “war neuroses” what today would likely be diagnosed as traumatic brain injury and/or post-traumatic stress disorder but were not then differentiated. Base Hospital 117 was “established, and an ambulance service has been provided in connection with this hospital by which cases can be received directly from tactical divisions at the front. At this hospital the resources found most useful in the British and French special hospitals for these cases are employed.”

Other specialized hospitals were organized within the AEF hospital centers. Hospital centers were first an administrative convenience, a way to group a few base hospitals who would share support services – for instance a central laundry or delousing facilities. That easily expanded so that clinical areas were shared, for instance X-ray equipment (and personnel) centrally located, the compounding pharmacy shared, or a central dental clinic created. Eventually hospital centers commanding officers were given full authority in many matters. They were authorized to transfer and assign commissioned and enlisted personnel within their center without reference to higher authority, to promote or demote enlisted men up to and including the grade of sergeant first class, to assign all supplies received, to request American Red Cross support, to employ civilian labor, to spend Medical Department funds, convene special courts-martial, and issue necessary travel orders for patients transferred.

Practically, that meant they could move staff and equipment from one hospital to another, building specialized hospitals. They would consult with the commanders of the various hospitals to learn what special skills there were, consult with the AEF medical staff to see what treatment types were likely to be needed (perhaps orthopedic injuries or venereal diseases), and with the eighteen specialized AEF “consultants”. These were senior physicians with deep knowledge in their specialty who supervised the professional work of the doctors serving in their respective specialties and recommended assignments. Beyond surgery and medicine, there were consultants in: surgical research; Roentgenology; neurological surgery; orthopedic surgery; ear, nose, and throat surgery; general surgery; venereal and skin diseases and genitourinary surgery; maxillofacial surgery; ophthalmology; general medicine; infectious diseases; neuropsychiatry; poisoning by deleterious gases; cardiovascular diseases; and tuberculosis.

OFF HarveyCushingHarvey Cushing, Neurosurgeon, in the ORTwenty-one hospital centers were planned, although some were still getting organized when the Armistice was signed.  Most included specialized hospitals. The most common were surgical, orthopedic, eye, ear, nose, and throat, maxillofacial, and neuropsychiatric.  Some centers had contagious disease hospitals. The center at Savenay had a special hospital for the treatment of tuberculosis patients.  That at Vichy had special facilities for maxillofacial cases, to which other specialized hospitals referred their most complicated cases. Hospital center plans provided for a separate hospital, located at a quiet point on its outskirts, where psychiatric cases would be cared for, although in a number of centers this was never completed. As resources allowed, rehabilitation facilities, such as those afforded by shop and art work for the rehabilitation of the neuropsychiatric cases, were rapidly developed, especially in the centers at Beau Desert and Kerhuon. Occupational work shops were established in some hospital centers, most commonly brace shops for orthopedic patients. Centralization was not universal.  At Allerey, orthopedic appliances were made in several shops so that doctors would not lose time travelling to a central workshop.

Specialized hospitals improved care for patients in many categories: orthopedic, maxillofacial, psychiatric, neuropsychiatric, contagious diseases, eye-ear-nose-throat, ophthalmological, venereal and dermatology, gas injury, influenza and pneumonia, tuberculosis, and neurosurgery. Some centers grouped their seriously wounded (as a general category) and some grouped the lightly wounded; that was presumably an administrative convenience, since those wards could have fewer staff assigned.Base Hosp 20 U PennBase Hospital 20, Univ of Pennsylvania

Centers usually also organized a convalescent camp so that the hospitals did not have to waste beds and staff time taking care of patients who were largely recuperated. They could also offer graduated exercise programs – more strenuous as men recovered – that sped up a soldier’s return to duty, but also offered extra time to men who needed it, and identified men who could not return to front line service before they arrived back in an infantry division. 

Delivery of Medical Care off of the battlefield

Red Cross Hospitals

OFF WilsonPosterAmericanRedCross

The American Red Cross (ARC) ran many hospitals in France and England, beginning early in the war.  Its hospitals became the backbone of the initial efforts in the AEF.  In France, 24 hospitals treated 91,356 AEF patients – one-third of American wounded – as well as military and civilian patients from other countries. ARC hospitals used special nomenclature: Red Cross Military Hospitals were under AEF control.  Red Cross Hospitals treated Allied military and civilian wounded. The ARC hospitals in Paris were especially important from May to July, 1918.  The AEF had not established hospitals there because US troops were not supposed to be fighting nearby.  But then American troops were thrown into battle on the Marne.  The ARC provided over 1,000 beds in that emergency, some ARC hospitals being moved forward as evacuation hospitals. A report at the time said “The Red Cross is considered a part of the Medical Department.” There were also 12 convalescent homes that helped 2700 American military patients for an average of three weeks each.

Beyond hospitals, the ARC operated 8 infirmaries and 13 dispensaries, two different levels of out-patient clinics, which were dedicated to the AEF.  Dozens of other clinic facilities assisted French civilians and some Allied military personnel. The clinics were useful for a lower-profile medical OFF unloading wndd ARC hosp Toul NLM
purpose: the fight against venereal disease. They were widespread in the rear areas, allowing access for soldiers on leave.  ARC clinics could and did treat French prostitutes that military hospitals could not treat. One ARC hospital was used solely for soldier VD patients.

 Most of the AEF was in France, but thousands of troops transited through Britain, where the ARC operated over 20 medical facilities (hospitals, convalescent homes, infirmaries, and dispensaries)..  Since some of the ARC hospitals had been established for years, their staff had considerable expertise and the AEF often used them for training.OFF RedCrossWomenRed Cross Women

Delivery of Medical Care off of the battlefield

Camp Hospitals

OFF Cp Bragg CH plan NLMCamp hospitals were found all over the US, wherever a training camp was located.  Many of these hospitals were fairly basic, but all had to care for training injuries as well as diseases.  When the influenza epidemic struck, both the first wave in early 1918 and the second, lethal, wave in fall, 1918, the training camp hospitals were inundated with sick soldiers.  

Just as a camp in the US had a hospital for the sick and injured, camps overseas would need the same thing.  However, there had never been overseas camps before, so camp hospitals had to be improvised. The function was quickly described, and plans were drawn up for standardized facilities so that no commander could waste construction materials on an over-fancy facility. Each camp hospital would be 10 wards, totaling 300 beds, around clinical and storage buildings and with space for tents if there were more patients. Where a camp had a much larger population, a larger camp hospital was built.  But no personnel were allotted. At first the units at the camp was supposed to provide the hospital staff, but that broke down when units moved around.  Further, installations like the debarkation ports needed a hospital but had no units stationed there. The first response was to pull personnel out of the base hospitals, and eventually enough medical replacement units (‘casuals’) arrived for those personnel to be assigned. A camp hospital might have 10 physicians, 10 nurses, and 25 enlisted men, with extra support either from convalescents or men borrowed for a few days from their units..OFF CH 2 Bordeaux NLMCamp Hospital 2, Bordeaux

Camp hospitals were not tasked to keep seriously sick or injured soldiers, rather to make initial diagnosis and treatment, and care only for those who could return to duty in a few days.  However, they did provide good care, within their limits. They had laboratories, X-rays, and operating rooms, dental clinics, and de-lousing facilities. Camp hospitals helped train medical personnel from the infantry divisions, and their staff also helped track down disease outbreaks.  

Delivery of Medical Care off of the battlefield

Hospital Centers

While each base hospital could operate independently, that was relatively inefficient and the AEF quickly began planning hospital centers. These were envisioned for 2-20 base hospitals, and would allow more specialization within a center (providing better treatment to patients), and use fewer specialists such as radiologists and plumbers or electricians. They would also allow a hospital train to make one stop instead of dropping off a few patients at a number of hospitals, thus speeding the whole system. While 20 hospitals never operated together, centers also facilitated another economy step, the convalescent camp (or hospital), where mostly-recovered men were moved out of the hospitals, got therapeutic exercise to speed their recovery, but also were not sent back to their units too soon.OFF HC Mars looking NE NLMHospital Center at Mars-sur-Allier

The largest of these ‘hospital cities’ had close to 20,000 beds in 1918-19, and several thousand hospital staff as well.  Hospital Center Mars-sur-Allier, located in Nièvre, France, even had its own "town" newspaper, The Martian.  The construction was temporary, as can be seen above.  Today, there is virtually nothing left on the ground.

WW1 Medicine

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