Reference: http://history.amedd.army.mil/booksdocs/HistoryofUSArmyMSC/chapter2.html WORLD WAR I THE AMBULANCE SERVICE In April 1917 the United States entered World War I on the side of the Allies-France, Russia, Great Britain, and Italy. The British and French asked for immediate medical support because their medical systems were severely taxed. Their war against the Central Powers (Austria-Hungary, Germany, Turkey, and Bulgaria) was in its third year. While mobile war characterized the Eastern Front, barbed wire, machine guns, and the increased accuracy and rate of fire of weapons had created a static front in the west. "The two lines sat opposite each other and did nothing but hammer at each other."1 Everywhere the war was bloody, and casualties were high. The combatants would suffer over 34 million casualties, including nearly 8 million deaths from wounds and disease.2 Though a latecomer to the fighting, the United States mobilized over 4 million soldiers and deployed over 2 million to Europe; 106,378 would die before peace returned.3 The need for medical support was staggering. Great battles used up manpower at an incredible rate. During the 1916 Battle of the Somme, in seven days British artillery threw 1.5 million explosive and chlorine gas shells at the well-dug-in Germans. Yet when the British attacked, surviving Germans manned their machine guns and inflicted 60,000 casualties on the attackers during the first day alone. The battle lasted five months, during which there were some 420,000 British, 200,000 French, and 650,000 German casualties. British artillery preparation for the Third Battle of Ypres the following summer devoured the entire production of 55,000 British ammunition workers for a year, and a victory of very limited value cost them 8,222 casualties per square mile.4 To meet the needs of war, the U.S. Army's surgeon general, Maj. Gen. William M. Gorgas, presided over an enormous expansion of the Army Medical Department. When the United States entered the war his department consisted of less than 1,000 personnel, but it numbered over 350,000 when peace returned in November 1918. The Surgeon General's Office mushroomed from a staff of 153 at the beginning of the war to over 2,100 at its end. The Medical Department was authorized 444 physicians at the beginning of World War I, but it had 31,530 when the war ended. Nearly 24 percent of all American physicians served in the Army.5 Increases in the other specialties were also dramatic. By war's end the department had 4,620 dentists, 21,480 nurses, and 2,234 veterinarians. In addition, there were two new precursors of the Medical Service Corps. The U.S. Army Ambulance Service, formed in 1917, had 209 officers, and the Sanitary Corps, Map of Europe, 1914 38 formed the same year, had 2,919. The department was rounded out with 281,341 enlisted soldiers and 10,695 civilian employees.6 Military medicine benefited from medical advances, but severe limitations remained. Sulfa drugs and antibiotics were yet to come, and some medical problems remained intractable. Measles and influenza were the most significant diseases for the Army in World War I because of respiratory complications, principally the scourge of the pneumonia which followed. The influenza epidemic of 1917-18 killed over 24,500 soldiers. Massachusetts Institute of Technology's "Roll of Honor" lists those alumni who died in World War I. Of the 123 listed, 41 died of pneumonia.7 However, the addition of new organizations to the Medical Department enabled it to expand its medical team to accommodate the most advanced technology of its time and to post the best record yet for the medical support of an American army in the field.8 Volunteer Ambulance Officers Put on your old gray bonnet With the strap ahangin' on it, And we'll go thru shrapnel & thru shell- Then on roads of desolation We will cure your constipation With a wild night ride in hell!9 As popular support for American participation in the war increased, volunteer organizations capitalized on that spirit, enrolling many young Americans who served as ambulance drivers in France and Italy. Until there was an opportunity for overseas service in the Army, the volunteers provided person-to-person proof of America's willingness to support its allies. They received short orientation courses and wore uniforms patterned after those of the U.S. Army. When deployed, they served under the command of the French or Italian Army units to which they were attached. Volunteer ambulance organizations preceded U.S. Army ambulance units in Europe, and their officers were predecessors of Medical Department commissioned ambulance officers. The American Red Cross Ambulance Service actively recruited through its headquarters in New York and established units in France and Italy. By the spring of 1917 it had forty-six ambulance units supporting the Allies.10 One who joined was eighteen-year-old Ernest Hemingway, who as a Red Cross second lieutenant became the first American wounded in Italy.11 Hemingway received over two hundred artillery fragment wounds in his legs during a night attack in July 1918 and was further wounded by machine-gun fire when he carried a wounded Italian soldier to safety. He likened his left leg to the hide of an old horse that had been branded and rebranded by fifty owners.12 Another group, the Norton-Harjes Ambulance Service, was formed in 1914 by Richard Norton, an American archaeologist who served as its director, and A. Herman Harjes, a French banker. Norton-Harjes affiliated with the American Red Cross, and its members incurred a six-month obligation with the Red Cross when they joined. By July 1917 Norton-Harjes units had over six hundred 39 Ernest Hemingway convalescing at a hospital in Italy, April 1919; below, Inspector General Andrew American ambulance drivers and three hundred ambulances.13 The largest of the volunteer ambulance groups was the American Field Service. The organization dated from the earliest days of the war, when the American colony in Paris outfitted a rudimentary ambulance service to support the French Army. In May of 1915 the American Field Service was operating 60 ambulances organized in 3 sections; by late 1917 it had 1,220 ambulances in 31 sections supporting 66 French divisions. Inspector General A. Piatt Andrew, former director of the mint and a future congressman, served as its director. Andrew was honored by France for his contributions with the Legion d'Honneur and by the United States with the Distinguished Service Medal.14 Although neither the Red Cross nor the American Field Service paid the volunteers, the French government insisted on reimbursing them at five cents a day, equivalent to the pay of a French soldier. The volunteers paid for their own transportation, clothing, uniforms, and personal equipment. As one put it, "the Americans not only had to be willing to risk their lives, they also had to pay to do it."15 The volunteer ambulance units refined motorized evacuation techniques that were later adopted by the U.S. Army when it entered the war. They incorporated Jonathan Letterman's ambulance corps officer, a specialty that had been lost to the U.S. Army for thirty years. Inspector General Andrew noted the similarity of his organization's doctrine with that of the French, who also used non-physician officers to command the evacuation system. "From the French point of view, it was as illogical to 40 Standard Ford ambulance with storm curtains expect doctors and surgeons to accomplish this work successfully as it would be to ask automobile experts to do surgical and medical work in the dressing stations and hospitals."16 Ford, Fiat, Peugeot, and General Motors Company ambulances were severely tested under combat conditions that demonstrated their advantages in speed and patient comfort. The Ford Model "T" could climb narrow mountain roads where patient movement previously was possible only on mules or in horse-drawn carts. The Ford put new meaning in "fording." It sat high and could get through flooded roads not accessible by lower vehicles. Indeed, French soldiers accused the Americans of painting water lines on their vehicles as depth gauges, and some calls for evacuation would request the ambulance "boats." If a road was blocked, the "T" could go cross-country. It was light enough that three or four soldiers could pick it up and move it if it stuck in a ditch or shell hole.17 Nevertheless, the motorized ambulances were primitive vehicles. The Ford's idiosyncrasies made mountain driving dicey. Its gravity gasoline feed did not work on steep grades, compelling drivers to back their vehicles up the hills. Another problem was that prolonged driving in low gear caused excessive and uneven wear on the transmission bands. To equalize the wear, drivers in mountainous terrain used the low-speed band during climbs, the reverse band to assist in controlling descents, and the foot brake on corners and the steepest parts of hills. Transmission bands would last ten to fourteen days with this technique. Mountain driving was further complicated by brakes that could not handle the steep grades. Drivers kept an eye peeled for strategically placed trees that could stop them if necessary. Sometimes patients had unforgettable rides.18 41 Unfortunately, automobile driving was not yet a universal skill, and the inexperienced drivers were further bedeviled by problems such as horseshoe nails in the roads. The nails raised havoc with the tires, which, in turn, raised havoc with the drivers, since this was before demountable rims. The crews were further tested by the hazardous conditions of the combat zone. At Verdun they navigated roads named for the risk of artillery fire-Dip of Death, Hell's Half Acre, and Dead Man's Turn. William Seabrook, an American Field Service volunteer, described how it was. "Those of us who used to laugh at danger have stopped laughing. . . . We don't come back any longer and tell each other with excited interest how close to our car this or that shell burst-it is sufficient that we came back."19 Medical Department Organization and Doctrine While volunteers toiled in Europe, the Medical Department readied itself for war. Its doctrine for wartime medical support, built on the lessons learned in previous wars, rested upon the work of the staff of the Field Service School for Medical Officers at Fort Leavenworth, Kansas. Setting forth medical doctrine in landmark field manuals, Maj. Edward L. Munson, MC, and other officers at the school formed a vibrant group of medical planners whose foresight during the years of peace paid dividends when the United States again went to war.20 First to go in May 1917 were six base hospitals; some of their personnel were the first U.S. soldiers killed in action.21 The Medical Department deployed an astonishing array of skilled personnel over the next year and a half to support Maj. Gen. John J. Pershing's American Expeditionary Forces (AEF). At the time of the Armistice 145,000 American soldiers were hospitalized in 152 base hospitals and 101 camp hospitals in France and England, backed up by 7 medical laboratories and 28 medical supply bases, depots, and stations. In addition, the Medical Department operated 147,636 beds in 92 hospitals in the United States.22 Army hospitals in Europe also served the field medical units of the 43 American divisions deployed to France, the 2 regiments sent to Russia and Italy, and the 19 divisions that remained in the United States. Each Army division contained 40,000 soldiers-28,000 combat soldiers and 12,000 support troops. General Pershing insisted on extensive training of the divisions prior to their commitment to battle, and the first committed did not go into combat until the latter part of April 1918, a year after the United States had entered the war.23 The Medical Department's doctrine for combat operations was built upon an evacuation scheme configured within three levels of medical support (see Chart 1). The zone of the advance was the first echelon. It extended from the front lines through the division area of operations. The second echelon, the line of communications, was the area of the field armies that supported divisions. The third echelon, the service of the interior, constituted the continental United States support base for overseas operations. Under wartime conditions Medical Department doctrine was adapted to the exigencies of combat, and the structure and procedures employed varied with the type of combat (trench or open warfare), the intensity of the fighting, and such other factors as terrain and weather. Treatment of combat casualties was based on triage, a French term for sorting patients in mass casualty situations into categories: those who would die no matter what treatment was provided ("expectant"); those who would live if treatment were immediately rendered ("immediate"); and those whose treatment could safely be delayed ("delayed"). Initial medical attention was concentrated on the immediate group, and the evacuation system was based on the movement of serious cases to the rear for definitive treatment. Medical personnel, equipment, and supplies were under Medical Department control. Army regulations restricted ambulances to the Medical Department's use for movement of the sick and wounded and emergency transportation of medical supplies.24 Medical support in the zone of the advance was the responsibility of the medical elements within the divisions, including the medical support organic to the maneuver units and the division sanitary train. Two enlisted medical soldiers were customarily attached to each rifle company where they established a company aid post. Wounded soldiers were brought there for first aid treatment, carried from the front line by company bearers. Most divisions detailed soldiers from the line companies to supplement the number of litter bearers. The battalion aid station was normally 250 to 500 yards to the rear of the front line, close enough to be able to render prompt treatment. It was staffed by 43 Officers of the 117th Sanitary Train in Bertricamp, France, April 1918 one or two physicians, a dentist (if available), four to six medics, plus two runners and one or more litter squads supplied by the supporting ambulance company. Battalion aid stations with two medical officers could split into two sections that leapfrogged to keep pace. Litter squads consisted of four bearers. It was found that 1,000 yards marked the limit of a squad's endurance, and distances greater than this were handled by squads in relay. The 305th Ambulance Company, supporting the 77th Division during the Meuse-Argonne offensive, had relays operating over routes as long as three and a half miles.25 Each division had a sanitary train (today's medical battalion), which consisted of an ambulance section, a field hospital section, and a medical supply unit. This organization had been made a part of the force structure in 1911 and formed an integrated medical support capability under unitary medical control that was flexible enough to be task-organized to meet changing conditions.26 It provided the division surgeon with centralized control of the division medical assets. If needed, all ambulance companies in a division could be consolidated. Depending on the combat situation, the litter bearers might be under the control of the ambulance companies or under the regimental or battalion surgeons. If a battalion surgeon became a casualty, an ambulance company medical officer could replace him. In all, a division's medical personnel totaled 1,331 officers and enlisted personnel. Of that number, 991 were in the sanitary train.27 The ambulance section of the division sanitary train was organized on the basis of four ambulance companies per division (two per cavalry division). Each company provided twelve ambulances to evacuate casualties from the battalion aid stations to the company's dressing stations, 3,000 to 6,000 yards from the front, and farther 44 Officers at the dressing station of the 137th Ambulance Company in Amphersbach, Germany, August 1918 back to the field hospitals. The length of time required to transport wounded soldiers from the front lines to the field hospitals was affected by a variety of factors including road conditions, visibility, and traffic. The 3d Division, for example, averaged five hours' transit time during the Second Battle of the Marne and two and one-half hours during the Meuse-Argonne offensive. Overall, in the AEF the time from wounding until the arrival at the first triage point was five to six hours.28 The field hospital section of the division sanitary train operated four field hospitals set up six to eight miles from the front, rounding out the medical support in the zone of the advance. The field hospitals were on the order of more sophisticated dressing stations. Patients were stabilized there-as they were at earlier points in the evacuation chain-so that they could either be returned to their units or evacuated farther to the rear for more definitive care. Each hospital had a normal capacity of 108 beds, expandable to 162, thus providing a 432-bed (648-bed expanded) capability for a division in combat. In addition, this section operated eight dispensaries for routine medical care.29 Patients evacuated from the field hospitals passed into the second echelon, the line of communications, where the evacuation hospital along with smaller mobile hospitals and surgical hospitals formed the principal early surgery capability in the theater of operations.30 The evacuation hospital expanded from 340 to 1,000 beds during the war, but in some cases operated at higher capacities. Patients evacuated to the United States entered the third echelon of medical support, the service of the interior and its network of general hospitals and supporting facilities. 45 American doctrine was based on speed of evacuation, a basic philosophy that differed from that of the French.31 The AEF evacuation system moved serious cases as quickly as possible to the rear after the patients had been appropriately stabilized for further movement. AEF evacuation hospitals essentially served as clearinghouses. Surgery was performed only as necessary to enable further evacuation of the casualties, and patients were held only until they could be safely moved.32 The French, on the other hand, placed a more sophisticated capability farther forward than the Americans, and some of their hospitals had as many as 5,000 beds. The larger facilities provided definitive care for the wounded earlier in the evacuation chain. However, their large, immobile hospitals would be at a disadvantage if trench warfare turned into a war of movement. Doctrinal differences between the Allies extended to the operation of the ambulance system. The Americans, based on their lessons learned from previous conflicts, kept ambulances under medical control and attempted to integrate treatment and resuscitation during evacuation. The French ambulance service was under the automobile service, divorced from medical control. Its focus was patient transport, and its personnel were not expected to have medical training. It depended for its success upon evacuation over shorter distances to a definitive treatment facility.33 The U. S. Army Ambulance Service When the United States declared war against Germany, the status of American volunteers in Europe became uncertain because they now had a U.S. military obligation to fulfill. France, fearing the loss of ambulance volunteers, requested that the United States ensure the uninterrupted continuation of the vital service. U.S. leaders thus agreed to incorporate American volunteer ambulance units into the American Army and to continue their service at the front with the French. The Army organized a new ambulance corps for that purpose. War Department General Orders No. 75, which established the U.S. Army Ambulance Service (USAAS), was issued on 23 June 1917-an important date in the evolution of the Medical Service Corps. Like the Sanitary Corps, which followed it by a week, it was a temporary expedient made possible through the special wartime powers given President Woodrow Wilson in the Act of 18 May 1917. The USAAS also afforded the Medical Department an expanded opportunity to commission individuals in specialties it needed. Its officer authorization was set at 203, and it was organized into 160 sections known as sanitary squad units. It soon increased to 214 officers in 169 sections. Sanitary squad units supported divisions on the basis of 1 per 10,000 combat soldiers.34 When the AEF deployed to France for its lengthy period of organization and training, General Pershing found that the volunteer organizations had set up a good ambulance system. The AEF worked to bring that system wholesale into the USAAS, and the volunteers were offered the opportunity to join the U.S. Army. The American Field Service was operating forty-seven sections in France at that point, and many of its 1,200 members enlisted in the USAAS or volunteered for other combat duties. Eighty-one volunteers were commissioned in the Army 46 Main gate to Camp Crane, Pennsylvania Medical Department: sixty-nine in the USAAS and twelve in the Sanitary Corps, the other new Medical Department corps.35 Inspector General Andrew was commissioned a major in the USAAS and assigned as head of its Motor Transport Department. Andrew delivered to the AEF a valuable asset in his American Field Service, a mature organization with its own vehicle assembly and repair facility, supply depot, training camp, recreation facilities, and hospital. Perhaps most important, the American Field Service had three years' experience in combined operations with the French Army. Enough volunteers joined the USAAS to form an immediate nucleus of 28 sections, including 25 sections from the American Field Service and 3 sections from Red Cross units. These sections, when deployed with the Allied forces, were detached from the AEF and came under the direct command of the French or Italian units to which they were attached.36 Initially, USAAS officers were active duty Medical Corps physicians. Col. Percy L. Jones, MC, headed the USAAS, and Col. Elbert E. Persons, MC, assumed command of the training base. Eventually physicians were replaced by nonphysician USAAS commissioned officers. In August 1917, as Medical Corps officers were being ordered into clinical duties, Colonel Persons submitted to the surgeon general a list of noncommissioned officers he recommended for commissions in the USAAS. By the end of the war there were very few Medical Corps officers left in the Ambulance Service. One who commanded an ambulance company said that physicians viewed being posted to an ambulance company with "almost as much distaste as assignment as a battalion surgeon."37 The twentieth century ambulance corps officers performed well. General Gorgas said they made "an excellent record"38 and "in every way justified their 47 "USAAC March" sheet music appointment."39 By 30 June 1918, the USAAS had 173 officers, including 1 colonel, 2 lieutenant colonels, 3 majors, 30 captains, and 137 lieutenants. In all, 224 officers and 11,750 enlisted personnel served in the USAAS during the war. Three of its officers received the Distinguished Service Cross and sixty-six were awarded the French Croix de Guerre. Seventeen sections were cited in French Army orders. No officers were killed or wounded, but 182 enlisted soldiers were killed in action or died of wounds and another 320 were wounded or gassed.40 In the United States, USAAS recruits received their military training at Camp Crane, Allentown, Pennsylvania. Named for Brig. Gen. Charles H. Crane, surgeon general from 1882 to 1883, the camp occupied the Allentown fairgrounds, which also became the site of the USAAS headquarters. Recruits were billeted in available buildings, including horse barns, pig pens, and horse cooling sheds. Despite such makeshift quarters, the USAAS attracted the adventurous by offering the promise of quick and certain action in Europe. By 19 June 1917, over thirteen hundred volunteers were in training at Camp Crane; a week later, the number stood at thirty-three hundred. In all, 20,310 volunteers (2,085 officers and 18,225 enlisted) trained at Camp Crane between 1 June 1917 and 10 April 1919.41 Volunteers came from Army recruiting stations, predecessor volunteer ambulance units, and a variety of institutions and industrial organizations. Sponsors of USAAS sections included over forty universities and colleges. Harvard, which had led in the number of volunteers for the American Field Service, set another record by providing three USAAS sections. Other sponsors included corporations, cities, and sports groups. The trainees were an exceptional group. Fifteen All-American football players among them became the nucleus of a team that played a winning season against a lineup that included Georgetown, Penn State, and Fordham. The camp band also attracted premier talent, and John Philip Sousa was among the guest conductors. Lt. Col. Clarence P. Franklin, MC, who succeeded Colonel Persons as the camp commander, convinced Sousa to write a march for the Army Ambulance "Corps," and the famous composer copyrighted the "USAAC March" in 1919.42 Not all the trainees had a grand time. To begin with, they found much to complain about with the food. Their arrival at Allentown "brought home to us for 48 the first time the disturbing realization that we were in the army," with the moment of truth coming when they sat down to "one of the vilest suppers ever set before man since God made the world." The hungry soldiers were served a melange "on the same greasy tin pan, of salty corned beef and forlorn little prunes, mournfully swimming in their juice."43 Their transition into the life of a soldier was recorded in letters, diaries, and literature. In 1917 John Dos Passos returned from service in France with NortonHarjes to find a draft notice awaiting him. Deciding to volunteer for the USAAS, he reported to Camp Crane. He later wrote of his "captivity" at "Syphilis Valley" where he said he had washed over a million windows.44 His novel Three Soldiers was based on his experiences there and featured characters he encountered in training and later during his service in France. Those who had volunteered to go "over there" were frustrated when the Army did not quickly ship them to Europe and became bored with repetitive tasks, such as marching day after day. Guth Station, a field training site complete with mud and trenches, was particularly vexsome. The grousing was reflected in the words to a marching ditty: Of course to drive an ambulance, you've got to learn to drill So every morning, afternoon they put us thru the mill, And when this war is over, you will find us at it still, For we never saw an ambulance and never, never will!45 Over There In time Camp Crane graduates did make it "over there." The first contingent arrived in France on 21 August 1917, commanded by Colonel Jones, who left Camp Crane to head up the USAAS in France from headquarters in Paris. There he had a strong deputy in A. Piatt Andrew, now a lieutenant colonel whose position as head of the Motor Transport Department placed him at the heart of the evacuation system. This, coupled with Andrew's experience in running the American Field Service organization, made him a central figure, and he served as the acting chief in Colonel Jones' absence. By July 1918 the USAAS had 77 sanitary squad units serving with the French Army; 49 units had been organized and trained at Camp Crane and added to the 28 units formed in Europe from the earlier volunteer organizations.46 The call of action in Europe also attracted Colonel Persons, who left Camp Crane to head up the USAAS units with the Italian Army. In June 1918 Persons took thirty units comprising 76 officers and 1,641 enlisted personnel to Italy where their arrival in Genoa was heralded by a parade with five marching bands. Colonel Franklin later left Camp Crane to join Persons as his deputy.47 Not long after Persons' arrival in Italy, the AEF reassigned fifteen of his sections to American units in France as AEF losses mounted. Hard fighting during the St. Mihiel offensive had underscored the inadequacy of the AEF evacuation capability, which had less than 50 percent of its authorized ambulances, partly the result of shipping delays.48 USAAS officers and enlisted members continued in Europe the heritage of selfless dedication begun at Antietam. In France, Sanitary Squad Unit (SSU) 49 525, commanded by Lt. H. L. Biby, USAAS, received the French Croix de Guerre with Palm. Biby's unit had three soldiers killed and nineteen wounded or gassed in actions that included Verdun. SSU 503, commanded by Lt. Lars Potter, USAAS, received the Croix de Guerre with Silver Star for Bravery. SSU 585, an ambulance unit formed by Yale University, was commanded by Lt. John R. Abbot, USAAS, in its support of the French 128th Division. Abbot, praised by the members of his unit for "inspiring leadership"49 and "guts,"50 was wounded and decorated along with the other members of SSU 585 with the Croix de Guerre. One of the units that moved from Italy to France was the 649th Ambulance Section, which was attached to the U.S. 35th Division. Beginning 25 September 1918, the members of the 649th saw continuous action in the MeuseArgonne where their twenty Ford ambulances evacuated over eight thousand wounded soldiers from the Argonne forest during a sixteen-day period, suffering eleven casualties in this action. Colonel Jones said the 649th reflected the USAAS spirit by "overcoming all obstacles in reaching the destination where the wounded are collected."51 The USAAS established a proud record. Pvt. George E. Shively, a member of SSU 585 who received the Distinguished Service Cross, said that their most fundamental principle was "the wounded must come in: difficulties and even impossibilities in the way form no excuse for failure. The impossible can be accomplished when men's lives are at stake." Their mission tested the courage of each ambulance driver. "If he chooses to shirk, there is no one to hinder; and if he himself falls, there is no one to help."52 In Italy, USAAS crews were "often kept busy during day and night for long periods of time."53 An example was SSU 526, whose commander, Capt. William A. Lackey, USAAS, was awarded the Italian Cross. Lackey's unit evacuated 29,852 patients during the Piave advance in June 1918.54 Other USAAS crews met the challenges of combat in the rugged terrain of the Austrian front. The men would get three or four hours of sleep when we became completely exhausted and then would be right at it again. Driving the roads in wet or dry weather was a challenge in itself, with hairpin turns; but with a load of wounded and guns going off at their backs and in front of them, exhaustion would come upon them suddenly.55 As one participant put it: "An ambulance driver is nearly always in mortal danger."56 Units operating on Mount Grappa would evacuate casualties to cable cars in which the patients were strapped and moved down the mountainside. The USAAS benefited from lessons learned by the earlier volunteer organizations. For example, the ambulance bodies used by the American Field Service on the Ford chassis had evolved through trial and error. The USAAS eventually adopted that ambulance, but only after several thousand vehicles of inferior design were shipped to the AEF. One minor item that created a lot of difficulty for AEF units was the failure to adopt the American Field Service practice of adding oak tracks to the floor of the ambulances. Although standard U.S. Army litters had wooden legs, ambulance crews frequently encountered litters with iron legs, which tore up the vehicle floors unless they had been protected with the special tracks.57 50 Standard General Motors ambulance chassis; below, ambulance disassembled and boxed for shipment 51 The requirement for a great number of vehicles caused the Medical Department to establish the Motor Ambulance Supply Depot in June 1917 at Louisville, Kentucky, to provide ambulance supply, repair, and salvage as well as a school for mechanics. Its staff included six Sanitary Corps officers. The department procured and shipped to Europe 3,070 GMC and 3,805 Ford ambulances. The vehicles were sent unassembled in two sections, the chassis and the body, because assembled vehicles were often damaged in transit. A motor ambulance assembly detachment of three Sanitary Corps officers and sixty technicians at St. Nazaire, France, prepared the ambulances for combat service. The detachment began assembling the vehicles at the rate of four per day in January 1918, a rate which later increased to fifteen per day.58 In September 1918 the assembly functions and the Sanitary Corps officers involved with this mission were transferred to the Army's newly formed Motor Transportation Corps.59 The USAAS ambulance system settled into a mature operating capability that was fully integrated within the AEF organization. Its level of standardization as an operating system is reflected in guidelines used by the AEF inspector general for medical support operations in the combat zone. The condition of a medical unit's ambulances, the map-reading ability of enlisted and officer personnel, and the division surgeon's positioning of ambulance companies and field hospitals were all fair game for General Pershing's inspectors.60 Summary American soldiers wounded in World War I enjoyed a much greater chance of surviving than had their predecessors in any previous war. Much of that was due to an improved evacuation system. By the time of the Armistice the Medical Department had evacuated 214,467 casualties in Europe and transported 14,000 sick and wounded to the United States.61 It evacuated another 103,028 patients to the United States following the Armistice. This record was achieved through major Medical Department improvements, beginning with its doctrine for support of an army in the field. The medical support apparatus fielded by the American Expeditionary Forces was enormously improved in kind and amount from anything previously attempted in wartime. The formation of the USAAS from predecessor volunteer ambulance organizations was a principal part of that improvement and was a significant step in the evolution of the Medical Service Corps. More important, it was a significant advance in the Medical Department's ability to perform its wartime mission through a functional adaptation to changing technology and warfare. 52 Notes 1Quoted words: Giulio Douhet, Command of the Air, trans. Dino Ferrari (New York: CowardMcCann, 1942), p. 157. C. S. Forester paints an indelible scene of the British commanding general at Verdun lighting his cigar at the moment the attack began: "As the tobacco flared a hundred and twenty thousand Englishmen were rising up from the shelter of their trenches and exposing their bodies to the lash of the German machine guns." Forester, The General (Boston: Little, Brown, 1936), p. 249. 2Statistics: Fielding H. Garrison, Notes on the History of Military Medicine (Washington, D.C.: Association of Military Surgeons of the United States, 1922), p. 199. 3Army figures: 50,510 battle deaths, 55,863 other deaths. Armed Forces Information Service, Almanac, Defense 83 (Washington, D.C.: Government Printing Office, September 1983), p. 46. Casualty figures vary by source. For example, Col. Leonard P. Ayres, head of the Statistics Branch of the War Department General Staff; put Army and Marine deaths at 115,660: 57,460 disease; 50,280 battle; 7,920 other. The War with Germany (1919; reprint, New York: Arno Press, 1979), pp. 13, 123. 4Statistics: Theodore Ropp, War in the Modern World (New York: Collier Books, 1979), pp. 248, 250; John Keegan, The Face of Battle (New York: Penguin Books, 1978), pp. 235, 285. Keegan estimates one-third of the British soldiers killed or missing in action in the Battle of the Somme could possibly have survived if they had been evacuated within a few hours of wounding (ibid., p. 274). 5Gorgas: Gorgas had been appointed as the surgeon general and promoted to brigadier general in January 1914. In March 1915 he became the first chief of the Medical Department promoted to major general. George A. Scheirer, "Army Medical Department Chronology, 1775-1947," p. 45. Numbers: SG Report, 1919, 2: 1117. In 1918 there were 30,591 MC officers and 939 contract surgeons. SGO: Lynch, The Surgeon General's Office, p. 126; Bulletin of the U. S. Army Medical Department (October 1934): 4, a departmental journal known by various titles beginning in 1919 (see bibliographical note), hereafter cited as Medical Bulletin with date but without a volume number due to the number changes and restarts. The SGO numbered 2,103 at the peak: 265 officers, 30 nurses, 191 enlisted, and 1,617 civilian. U.S. physicians: "Medical Service in the World War," Medical Bulletin (31 May 1932): 2. 6Numbers: SG Report, 1919, 2: 1117. 7Disease: SG Report, 1918, pp. 172, 175; John H. Ruckman, ed., Technology's War Record (Cambridge: War Records Committee of the Alumni Association of the Massachusetts Institute of Technology, 1920), pp. 88-129; Garrison, Notes on the History of Military Medicine, p. 203; James S. Simmons, "The Division of Preventive Medicine, Office of the Surgeon General," Medical Bulletin (July 1941): 63-68; Military Medical Manual, 6th ed., rev. 1944 (Harrisburg, Pa.: Military Service Publishing Company, 1945), p. 346. 8Capability: Neuropsychiatry also posted advances. During the war the department developed a standard approach to shell shock-later called war neurosis-new names for the "depressed feeling" that Letterman had noted afflicted some soldiers. This consisted of treatment up front with a quick return to the soldier's unit after a brief period of rest, food, encouragement, and reassurance. Lynch, The Surgeon General's Office, p. 65; SG Report, 1917, p. 369; Letterman, Medical Recollections, p. 101. The World War I treatment would be relearned in subsequent wars as the best way of handling combat exhaustion, combat fatigue, combat stress reaction, or whatever term was in vogue at the moment. 9Quoted words: Edward E. Harding, "Norton-Harjes Section 60," in Virginia Spencer Carr, Dos Passos: A Life (New York: Doubleday, 1947), p. 133. 10Red Cross units: Lynch, The Surgeon General's Office, p. 546. Other American support included 1,100 American physicians called up for Army duty who were assigned to the British Expeditionary Force. See Bernard J. Gallagher, "A Yank in the B.E.F.," American Heritage 16 (June 1965): 18-26, 101-08. 11Hemingway: Carlos Baker, Ernest Hemingway: A Life Story (New York: Charles Scribner's Sons, 1919), pp. 36-50; Bernice Kert, The Hemingway Women (New York: W.W. Norton and Company, 1983), pp. 47-55, 218-19. Also see Michael S. Reynolds, Hemingway's First War 53 (Princeton, N.J.: Princeton University Press, 1976), pp. 147-49; and Reynolds, The Young Hemingway (London: Basil Blackwell, 1986), pp. 16-24, 55-57. Reynolds casts doubt upon Hemingway's commission. 12Hemingway: Hospitalized in Milan, he fell in love with Agnes Kurowsky, an American nurse who spurned his affections. In November he was promoted to first lieutenant; he returned to Chicago in January 1919 for recuperation. Hemingway's experience was the genesis of A Farewell to Arms. Ernest Hemingway, A Farewell to Arms (New York: Charles Scribner's Sons, 1929). 13Norton-Harjes: Carr, Dos Passos, pp. 117, 127, 138-39. 14American Field Service: Charles Lynch, Joseph H. Ford, and Frank W. Weed, Field Operations, vol. 8 of The Medical Department of the United States Army in the World War (Washington, D.C.: Government Printing Office, 1925), pp. 223-59, hereafter cited as Lynch, Field Operations; George Rock, The History of the American Field Service, 1920-1955 (New York: American Field Service, 1956), pp. 7, 15, 24, hereafter cited as Rock, History of the AFS; Carr, Dos Passos, p. 127; American Field Service, History of the American Field Service in France, 3 vols. (New York: Houghton Mifflin, 1920), 1: 16, 23, hereafter cited as AFS, AFS in France; Edgar E. Hume, The Medical Department Book of Merit (Washington, D.C.: Association of Military Surgeons of the United States, 1925), p. 18. 15Quoted words: George C. Brown, ed., "With the Ambulance Service in France: The Wartime Letters of William Gorham Rice, Jr.," Wisconsin Magazine of History (Summer 1981): 279. Rice was an AFS volunteer whose father had been Grover Cleveland's private secretary when Cleveland was governor of New York. He wrote that Andrew "runs the service well," but never missed the chance to criticize the other volunteer ambulance units (p. 293). 16Quoted words: Andrew quoted in AFS, AFS in France, 1: 28-29. 17Vehicles: AFS, AFS in France, 1: 36, 391. 18Driving: Carr, Dos Passos, p. 132; AFS, AFS in France, 1: 511-12; John R. Smucker, Jr., The History of the United States Army Ambulance Service with the French and Italian Armies, 1917, 1918, 1919 (Allentown, Pa.: USAAS Association, 1967), p. ix, hereafter cited as Smucker, USAAS. 19Escapades: Smucker, USAAS, p. xiv; Carr, Dos Passos, p. 132. Quoted words: AFS, AFS in France, 1: 449. They also learned from the courage of the French litter bearers, the "brancardiers." See Edward Weeks, In Friendly Candor (1946; reprint, Boston: Little, Brown, and Company, 1959), p.6. 20Doctrine: The discussion of World War I doctrine is drawn from Lynch, Field Operations, pp. 105-259, 1021-67; FS School, Sanitary Field Service; Munson, Sanitary Tactics; and Frederick Paul Straub, Medical Service in Campaign: A Handbook for Medical Officers in the Field (Philadelphia: P. Blakiston's Sons, 1912). 21First killed in action: 1st Lt. William T. Fitzsimons, MC, and Pfcs. Rudolph Rubino, Jr., Oscar C. Tugo, and Leslie G. Woods were killed by aerial bombing at Base Hospital 5, 4 September 1917. SG Report, 1918, p. 261; American Battlefield Monuments Commission, American Armies and Battlefields in Europe (Washington, D.C.: Government Printing Office, 1938), p. 503. 22Medical capability: Lynch, The Surgeon General's Office, pp. 101, 327, 332; Frank Freidel, Over There (Boston: Little, Brown, 1964), p. 258; AEF Surg Gen to Commanding General (CG), Base Section #2, AEF, sub: Hospitalization Index of Medical Department Activities, 8th ed., 1 Dec 18, RG 120, Entry 588, File 321.6, NARA-NA. 23Training of AEF: Weigley, History of the United States Army, pp. 360, 385-86; John J. Pershing, Final Report of Gen. John J. Pershing (Washington, D.C.: Government Printing Office, 1919), pp. 5, 55, hereafter cited as Pershing, Final Report, Ayres, War with Germany, pp. 33-34. 24Ambulances: "All persons are prohibited from using them, or requiring or permitting them to be used for any other purpose." WD Reg 1437, WD, War Department Regulations for the Army of the United States, 1913 (Washington, D.C.: Government Printing Office, 1913), with changes through 15 Apr 17, p. 289, PL. 25305th Ambulance Company: Lynch, Field Operations, p. 563. 261911: Fisch and Wright, Noncommissioned Officer Corps, p. 78. 27Sanitary train: Pershing, Final Report, plate 15. 28Ambulance section: SG Report, 1917, p. 158;James L. Bevans, "The Ambulance Company," in FS School, Sanitary Field Service, pp. 4-9, 34. Advanced dressing stations were sometimes situated 54 1,500-2,000 yards from the front. 3d Division rate: Lynch, Field Operations, p. 109. Overall rate: Rpt, Maj Gen A. W. Brewster, AEF Inspector General (IG), sub: Report of Inspector General, American Expeditionary Forces, RG 120, E588, Box 115, File 525, Report of Inspector General, NARA-NA. 29Field hospital section: William N. Bispham, "The Field Hospital," in FS School, Sanitary Field Service, pp. 7-10; Lynch, Field Operations, p. 1034. 30Second echelon: Robert U. Patterson, "The Line of Communication Organization, Personnel, Materiel, Function and Administration," in FS School, Sanitary Field Service, p. 27; SG Report, 1919, 2: 1907. 31Doctrinal issue: There is fundamental doctrinal conflict between quickly clearing the battlefield versus conserving the fighting strength. The French gave primacy to the latter (and perhaps to a humanitarian impulse) by fielding a sophisticated surgical capability early in the evacuation chain. That option assumed greater survivability and faster return to duty through the earlier use of sophisticated treatment. However, it was elected at the expense of providing combat commanders a faster tempo of combat operations through a more quickly cleared battlefield and a smaller logistical tail in the forward area. The U.S. doctrine struck a good balance in World War I, handling the question with good sense and within the limits of the technology available at that time. The question remains an important one for the Army. For post-Vietnam discussion see Ronald F. Bellamy, "Contrasts in Combat Casualty Care," Military Medicine 150 (August 1985): 409-10, and Ltr, Bellamy to the ed., Military Medicine 151 (January 1986): 63-64; Karl D. Bzik and Bellamy, "A Note on Combat Casualty Statistics," Military Medicine 149 (April 1984): 229-31; Eran Dolev and Craig H. Llewellyn, "The Chain of Medical Responsibility in Battlefield Medicine," Military Medicine 150 (September 1985): 471-75. Bzik and Bellamy argue that "there are limits to what rapid evacuation can accomplish." Exceeding those limits in order to give first priority to clearing the battlefield leads to a policy of "scoop and run." 32Evacuation hospitals: Also see Gorgas, confidential report to Secretary of War (Sec War), Inspection of Medical Services with American Expeditionary Forces (Washington, D.C.: Government Printing Office, 1919), pp. 18-19, 46, hereafter cited as Gorgas, Inspection of AEF Medical Services. 33Evacuation: AFS, AFS in France, 1: 28-29. 34USAAS: AFS, AFS in France, 1: 10; Lynch, The Surgeon General's Office, p. 152; WDGOs 75 and 124, 23 Jun 17 and 20 Sep 17, PL; SG Report, 1918, pp. 268, 394; SG Report, 1919, 2: 1412. 35Integration into USAAS: AFS, AFS in France, pp. 1: 10, 30; Rock, History of the AFS, p. 22; SG Report, 1918, p. 268; Lynch, Field Operations, p. 238. A total of 784 were commissioned in various Army branches, including 578 in Infantry, Armor, Artillery, and Air Corps. 36Forming up: SG Report, 1918, p. 268; AFS, AFS in France, 3: 442. 37Substitution: Smucker, USAAS, pp. 12-20. Quoted words: Harry L. Smith, Memoirs of an Ambulance Company Officer (Rochester, Minn.: privately printed by Doomsday Press, 1940), p. 7. 38Quoted words: Gorgas, Inspection of Medical Services, p. 20. Gorgas inspected medical services in the AEF 8 September-16 October 1918. 39Quoted words: SG Report, 1919, 2: 1411-12. 40Numbers: SG Report, 1918, p. 394; SG Report, 1919, 2: 1111; Smucker, USAAS, p. 77. 41Camp Crane: Smucker, USAAS, pp. xiv, 12, 33, 51, 79-148. 42Activities: Smucker, USAAS, pp. 25-27, 30-32. Some trainees formed an acting company, directed by Lt. Adolphe Menjou, and successfully toured the East Coast. Menjou became a movie star after the war. He costarred with Marlene Dietrich and Gary Cooper, among others, and appeared in such films as A Star Is Born and A Farewell to Arms. Sousa: Paul E. Bierley, Columbus, Ohio, to John Franklin, 12 Jun and 24 Jun 65; John R. Smucker, Wynnewood, Pa., to John Franklin, Philadelphia, Pa., 27 May 65 and 25 Jun 74; Mahlon H. Hellerich, Archivist, Lehigh County Historical Society, Allentown, Pa., to Smucker, 30 Aug 78, all in DASG-MS; John Philip Sousa, "USAAC March" (London: Chappell and Co., Ltd., 1919), photograph in Smucker, USAAS, p.22. 43Quoted words: George J. Shively, ed., Record of S.S.U. 585; Yale Ambulance Unit with the French Army, 1917-1919 (New York: E. L. Hildreth, 1920), p.2, hereafter cited as Shively, Record of S.S.U 585. 44Quoted words: Dos Passos to Arthur McComb, American Academy and Institute of Arts and Letters, 7 Oct 18, in Carr, Dos Passos, p. 156. 55 45Verse: Smucker, USAAS, p. 54. 46France: Lynch, Field Operations, p. 238; Smucker, USAAS, pp. 34-36, 44, 70, 112; SG Report, 1918, p. 268; SG Report, 1919, 2: 1419-23, 1485. 47Italy: Mrs. John Franklin, King of Prussia, Pa. (daughter-in-law of Clarence Franklin), to Ginn, 17 Jul 88, with end, DASG-MS; Smucker, USAAS, pp. 57, 70-71. 48Redeployment: SG Report, 1919, 2: 1485; Smucker, USAAS, pp. 30-31, 50-51, 55-56; Inspector General (IG), Services of Supply (SOS), AEF, to IG, AEF, sub: Conditions in SOS, 26 Jul 18, DASG-MS. The units moved to France on 24 August 1918. 49Lt. Biby: Smucker, USAAS, p. 89; Lt. Potter, ibid., p. 81. Quoted words: Shively, Record of S.S.U. 585, p. 15. Abbot reported to the division surgeon ("médecin divisionnaire"), Lt. Col. Lejonne. Abbot's account of that relationship provides insight into the motivation of the American volunteers, as he complimented Lejonne for "dauntless energy," "unflinching devotion to duty," and for being a fearless officer whose "first thought was always for the comfort of his wounded." Ibid., p. 90. 50Quoted words: Guy Emerson Bowerman, Jr., The Compensation of War: The Diary of an Ambulance Driver During the Great War, ed. Mark C. Carnes (Austin: University of Texas Press, 1983), p. 122. SSU 585 was particularly well documented in having two accounts, Shively's and Bowerman's. 51Quoted words: SG Report, 1919, 2: 1419. 52Quoted words: Shively, Record of S.S.U. 585, p. 33. 53Quoted words: Smucker, USAAS, p. 56. 54Sanitary Squad Unit 526: Smucker, USAAS, p. 118. 55Quoted words: Smucker, USAAS, pp. 56-57. 56Quoted words: Smith, Memoirs of an Ambulance Company Officer, p. 47. 57Lessons learned: AFS, AFS in France, 1: 35-36. 58Ambulance depot: SG Report, 1918, p. 325. Assembly detachment: SG Report, 1919, 2: 1360-62. "Probably no organization ever arrived in France better equipped" (ibid., p. 1361). 59Transfer to Transportation Corps: SG Report, 1918, p. 325. 60IG: AEF IG to Inspectors, sub: Points for Consideration of Inspectors Concerning Operations of 4th Section, General Staff (checklist), 22 Jul 18, DASG-MS. 61Numbers: Pershing, Final Report, p. 77.