Evolution of the Medical Department in USA Army during the World War-I

Evolution of the Medical Department.

By Col. Charles Lynch, M. C

In order to furnish a background for the history of the Medical Department
of the United States Army as it operated during the World War, it is deemed
pertinent to trace briefly the various stages of the evolution of medical depart-
ments of armies in general, dwelling at length on the phases of this development
which have exerted a more or less definite influence upon the organization of
our own medical department and its expansion to the stage reached by April 6,
1917. It is true that old methods, because largely, if not wholly, obsolete,
might well be disregarded; on the other hand, certain ancient underlying prin-
ciples continue to obtain, and it is for this reason that the earlier steps in army
medical department progress are traced. By sketching the distant background
lightly and the foreground more heavily, it is believed that the truest picture will result.

ANCIENT HISTORY

Military medicine is practically as old as armies. While in Egypt, in the
Assyro-Babylonian civilization, and among the Hebrews, medicine and surgery
were developed earliest, the records which have come down to us from these
nations are of no importance from the present standpoint, except as they relate
to sanitation as practiced by the Hebrews, among whom the priests were hygienic
police and the physicians were a class apart.

So far as textual records go, the Hebrews were the founders of public
hygiene; they had a very definite idea of the nature of contagion, as the book
of Leviticus shows, and of the need for isolating individuals suffering from
contagious diseases. Here, then, we have a highly effective scheme of sanita-
tion for hot climates, which was never observed or recorded by the Greeks and
the Romans. In Deuteronomy a careful dietetic regimen is outlined, and the
following remarkable rules for the sanitary policing of a military camp are given:

9. When the host goeth forth against thine enemies, then keep thee from every wicked thing.
10. If there be among you any man that is not clean by reason of uncleanliness that chanceth
him by night, then shall he go abroad out of the camp, he shall not come within the camp.
11. But it shall be, when evening cometh on, he shall wash himself with water; and when the
sun is down, he shall come unto the camp again.
12. Thou shalt have a place also without the camp, whither thou shalt go forth abroad;
13. And thou shalt have a paddle upon thy weapon; and it shall be when thou wilt ease thyself
abroad, thou shalt dig therewith and shalt turn back and cover over that which cometh from thee;
14. For the Lord thy God walketh in the midst of the camp, to deliver thee and to give up thine
enemies before thee; therefore shall thy camp be holy; that he see no unclean thing in thee, and
turn away from thee.
a Indebtedness is acknowledged to Brig. Gen. Jefferson R. Kean, M. D., and to Lieut. Col. Louis C Duncan, U. S. Army,
retired, for considerable contributions to the text. Acknowledgment is also made of the utilization of historical material
rendered available by the researches of Col. James L. Bevans, M. C, and those of Lieut. Col. Fielding H. Garrison, M. C.
Military surgeons appear to.have accompanied the armies of all the ancient
civilizations. The histories of Greece and Rome arc well worth study in this
connection. Going back into the domain of legend, it is interesting to note that
Homer’s knowledge of war surgery was such that Frolich regarded the poet as
a military surgeon.2 Be this as it may, in Xenophon’s writings we enter the
realm of historical fact, for this historian mentions the medical service in
several of his books. Xenophon’s account of military medicine in the Cyropsedia
is regarded, however, by the classical scholars, as the expression of an experi-
enced general’s ideal of what such a service should be rather than as a true
picture of anything actually existing in Persia in the sixth century B. C. Cyrus.
the model king and commander, is made to say that he provided his army with
the most skillful practitioners he could find. In the Hellenica, Xenophon tells
how Jason attached his mercenaries to his service partly by the care with which
he had them tended in sickness.3 On the expedition of the Ten Thousand
(415-400 B. C), it is related that the troops suffered much from cold, hunger,
and overexertion and from constant attack by the enemy; snow-blindness
and frost gangrene were noted. At one halting place eight surgeons were
commandeered to treat the wounded. In the Anabasis we read that Ctesias
accompanied Artaxerxes to the battlefield of Kunaxa as his physician. In the
Cyropitdia, Xenophon recorded that Cyrus said to his father, Cambyses, that
even as States that wished to be healthy elected a board of health, so he
took with him, as did other generals, men eminent in the medical profession.
Cambyses, in reply, likened physicians to the menders of torn garments, and
pointed out that to prevent troops from getting sick a healthy camp site
should be chosen, and that such localities were best found by inquiry among the inhabitants and by noting their physique and complexions, whether healthy or otherwise.

Aside from the accounts found in Xenophon’s writings, one of the first
authentic records pertains to Greece, and dates from the Persian wars, about
450 B. C.4 This is an inscription discovered at Dali in Cyprus. It is shown that
certain physicians went, as volunteers, with the men of Idalion on an expedi-
tion to repel a Persian raid.

In these ancient armies disease often spread widely, practically uncon-
trolled, and many a military disaster is known to have been due to pestilence
among troops.

The Greeks by this time had developed a fine system of physical training
and cult cleanliness,5 and this, doubtless, was reflected in the physical fitness
of their troops.

Alexander was accompanied by the best known medical practitioners from
all parts of Greece. His comparatively small army seems to have been rela-
tively free from disease. The cause for this state of affairs is hidden by the
mist of antiquity. One explanation which has been offered is that the sites of
his camps were frequently changed.

Historical records are available in some detail in respect to the sanitary rules of the Romans during war. According to Vegetius,6 the Romans took great care that the men should be well supplied with good water, good pro-
visions, firewood, and a sufficient quantity of wine, vinegar, and salt. They endeavored to keep their armies in good health by due attention:

1. To situation, avoiding marshes and dry uncovered ground in summer;
having tents; frequently changing camps in summer and autumn.
2. To the water, for bad water was considered to be very productive of
diseases.
3. To the seasons, not exposing men to heat in summer; in winter, taking
particular care that the men never were in want of firewood or of clothing.
4. To food and medicine, the officers seeing that the men had their regular
meals and were well looked after by the commissariat.
5. To exercise, by keeping the troops during the daytime in constant
exercise, in dry weather in the open air, in time of rain or snow under cover;
for exercise was believed to do a great deal more for the preservation of health
than the art of physic.

Roman soldiers are said to have enjoyed excellent health, and, as compared
with other armies of the same period, it is fair to surmise that this was true,
although no figures are available for proof. Nor have we figures showing the
health of Roman soldiers as compared with that of Hebrews of approximately
the corresponding period. Modern sanitation takes into account both the resist-
ance of the individual and the limitation of spread of disease from man to man
by preventing contact of sick and well. For the former we can refer back to the
Greeks and Romans, especially Romans, and for the latter to the Hebrews. Of
course, the practice of each was empirical; and with their lack of exact scientific
knowledge their results could not have compared favorably with those of any
efficient modern army; it is of importance, however, as showing that hundreds
of years ago there were nations which appreciated the value to their armies of
good sanitation, and which put into practical effect measures to secure it.
Doubtless, as is the case to-day, this could be done only at the expense of
considerable extra work and interference with military efficiency for the time
being. They must have thought, therefore, as we do, that both were justified
by the better results which were ultimately attained.

In the Roman armies, the medical service was well developed. From Livy
we learn that the Roman armies, after a battle, took their wounded with them
when possible, often staying with them until they had recovered.7 In the Etrus-
can wars, the Romans distributed their wounded among patrician families to
be cured, the noble Fabian family having become popular by doing most in this
respect. An unpopular Roman commander, whose troops fought indifferently to
injure his reputation, could gain their favor and support by displaying unusual
solicitude for his wounded. The soldiers at Lucerina (548 B. C.) would not
fight because fatigued, and were kept awake by the groans of the near-by
wounded and dying. An epidemic in camp is said to have had the same dis-
astrous effect upon morale. Marcellus could not follow up his victory over
Hannibal on account of the great number of wounded on his hands; while
the Carthaginians in Africa drove away their own soldiers, panic stricken by
defeat and wounds, in order not to demoralize the better disciplined part of
their line in action. In the second Punic War (218-201 B. C.) velites, or lightly
armed soldiers, were employed, 1,200 to a legion, to transport the wounded from
the field.

Regular medical administration in the Roman Army had its beginning
in the reign of Augustus Caeser (31 B. C.-14 A. D.),8 who reorganized the military service and created a standing army of 300,000 selected men, with long terms of enlistment, the praetorian cohorts, who occupied and guarded Italy.
In the reign of Trajan (92-117 A. D.) the medical organization of the army was
about as follows:9 Each cohort (700-1,500 men) had four surgeons (medici
cohortis); each legion of 10 cohorts (7,000 men) had in addition medici legionis
or legionary physicians, probably 10 in all; the praetorian cohorts had appar-
ently a medicus clinicus or special internist for the sick. To the stationary
camps were attached a camp surgeon (medicus castrensis) and a valetudina-
rium or optiones valetudinarii who ranked after the centurions. The hospital
to which others were added when there were more than three legions in camp
was placed at a distance from the farriers (veterinary hospitals) and smithies.
Even before Trajan and Hadrian, every closed formation, every warship,
every cohort, had attached to it a medicus, and about 218-201 B. C. medici
vulneraii, or wound surgeons, are first mentioned as attached to certain forma-
tions. Sick and wounded soldiers became objects of great solicitude, commonly
visited by the emperors in their tents. Alexander Severus held that the emperor
should care more for his soldiers than for himself, since upon their welfare hinged
and hung the welfare of the State.

The individual soldier carried bandages which served as a first-aid packet.
Wagons are mentioned as having been in use as ambulances. Good and bad
Roman rulers alike seem to have sought to win the favor of their troops by
giving them the best medical care available at the time.

While the fall of the Western Empire (A. D. 476) carried down with it the
efficient medical service which had been carefully built up in the west, the
army medical organization was much further elaborated in the east, in the
Byzantine Empire. In every troop of 200 to 400 men, 8 or 10 stout fellows
(deputati) were deputed to ride immediately behind the fighting line to pick
up and rescue the wounded. Now, probably for the first time, male nurses
(nosocomi) were attached to military hospitals, which were numerous and of
different classes. This was before 600 A.D.

It is interesting to note that, according to the historical records, military
medical service at the beginning was not developed through dictates of humanity
but as a means of increasing military power. Human sympathy was not lacking,
however, even in those times. Xenophon related that Cyrus and his physicians
cared for the enemy wounded as well as his own, and certain Greek and Roman
matrons are said to have borne the title of Mater Castrorum.

Little is to be recorded concerning the practice of military medicine during
the long period between the fall of the Roman Empire and the time of Queen
Isabella of Spain, who first introduced into warfare a broad humanitarianism
toward ill and injured soldiers.

THE DARK AGES.

Among the Teutonic tribes, as recorded by Tacitus, care of the wounded
was in the hands of women, and such rude medicine and surgery as the chiefs
could acquire was learned from so-called “wise women” and “wild women “
the prototypes of the Valkyries, who looked after the welfare of the heroes
and bore them to Valhalla when slain in battle.10 As the feudal system devel-
oped, the wives of the nobles and other great ladies of the time took upon
themselves nursing and healing functions. At the same time, after the fashion of the Indian kings, of Alexander the Great, and of the Roman Emperors, all great personages, whether king, pope, or over-lord, began to attach to them-
selves learned and skillful physicians, who accompanied the warriors on their
campaigns. The Crusades (1096-1250) occupied Europe for nearly two cen-
turies, and the knightly spirit engendered by them led to the organization of
definite societies for the care of the sick and wounded, notably the Knights
Hospitallers of St. John, the Teutonic Knights, and the Knights of Malta. The
St. John Ambulance Association of Great Britain is a more or less direct
descendant of the Knights of St. John of Jerusalem. Its activities in supply-
ing partially trained enlisted personnel to supplement the Royal Army
Medical Corps in war are well known and of recognized value. Otherwise none
of these orders has now any medical function.

RENAISSANCE.

Queen Isabella, consort of Ferdinand, King of Spain, first established field
hospitals and ambulances on a large scale.11 Of the siege of Alora (1484), the
Spanish historian, Hernando del Pulgar, wrote: “For the care of the sick and
wounded the Queen sent always to the camp six large tents and their furniture,
together with physicians, surgeons, medicines, and attendants, and com-
manded that they should charge nothing, for she would pay all. These tents
were called the Queen’s Hospital.” On the surrender of Malaga, 1487, the
Spanish Army on its entry was followed by the Queen’s hospital in 400 wagons,
ambulancias. Nor were these the only occasions on which this hospital did
good service. The Queen herself frequently visited the wounded, and when
it was hinted that this was contrary to Castilian etiquette, she is said to have
replied: “Let me go to them, for they have no mothers here, and it will soothe
them in their pain and weakness to find that they are not uncared for.” Queen
Isabella’s plans were followed and elaborated by Maximilian the First, and
by his and her grandson, Charles the Fifth.

Maximilian the First not only organized the Landesknechte along military
lines, but wrote medical regulations of great interest to us. Frolich says that
Maximilian’s organization represents the origin and basis of medical depart-
ment principles of all later German organization to his day. Many of these
Landesknechte regulations are known to us from a treatise on imperial courts-
martial, written by Leonhard Fronsperger in 1555, which, fortunately, included sanitary rules.

At the siege of Metz, in the army of Emperor Charles the Fifth (1552),
whose medical arrangements represent the developed plans of the Landes-
knechte, it was the custom to send the sick and wounded to the trains where
they were cared for by barbers and women. The Landesknechte paid a
hospital superintendent to look after the hospital, care for the sick on the
march, and wait on the medical men. There was for each Hauffen, which
constituted 5,000 to 10,000 infantry, a field physician and there was an
assistant field physician with the chief of artillery. These men had pay and
rank assimilated to those of high officers. To each independent troop and to
each company of 200 men, as well as to each squadron, there was a field barber,
who, when not in ranks during battle, was the rear guard, and who ranked
somewhere between a quartermaster sergeant or clerk and a corporal.

The following quotation from Fronsperger is used by Ileizmann in his discussion of the siege of Metz:

The physician in chief must have been a doctor, or one who had recently charge of surgeons
or field barbers by State authority; he must be a well-known, skillful, experienced, and cautious
man, of the proper age, upon whom all barbers, cutlers, wounded, sick, and stricken could rely for
help and counsel in time of need, particularly when they are shot, cut, bruised, or broken, or are
suffering from any accidental or disabling diseases, such as scalds, fluxes, fevers, and similar
affections that occur among soldiers. His duties are even more extensive in that he should inspect,
both when the regiment is organized and later at monthly muster, the instruments and everything
pertaining thereto, and when he finds anything lacking or lost, such shall be charged to the field
barber, to make up the deficit. When this can not be done, he shall find other means to meet
emergencies. On the march he will closely attend his commanding officer. When exigency or
peril impends from the enemy, in battle array or skirmishes, and such like, he shall remain in the
neighborhood of his superior military officer, but he will also oversee as much as possible the other
physicians, surgeons, and the like, wherever wounded, etc., are to be attended, and he shall devote
his care, advice, and skill to all others, prticularly because he, above others, is ready with instruments, apothecaries, and medicines for both internal and external wounds and sickness.

He should also with diligence advise a leg, arm, or such should be amputated or preserved by
other means. Further, he should give his attention to the severely wounded, that they may not be
left too long on the lines or in the companies, but immediately carried to the surgeons and aided by
beneficial dressings. On the march, when it becomes important to have a field barber near at
hand or available, it is his business to see that one is stationed between the cavalry and infantry,
with his instruments. On other occasions, in camp and quarters, each barber remains with the
troop in which he has been assigned for duty. Whenever a question arises between barbers and
cured soldiers or others as to the payment to be made, he shall settle it, seeing that neither too much
nor too little is given.

As it is necessary that a field barber or surgeon serve with each troop, so should each captain
be careful to select a well-versed, skillful, experienced, and trained man, and not a poor beard
shaver or bath boy, as often happens by reason of favor; thus the killing or maiming of good soldiers
may be prevented. The field barber should be supplied with all necessary medicines and instru-
ments in a field wagon, and the captain should see that it is done. He should be a capable knecht,
to help in necessity. His duty is to render assistance first, when there is need, to those of his own
troop, not to exact too much from anyone, but to treat men at reasonable and like rates. He shall
have his lodging at night at the company pennant, so that he may be found in necessity, and it is
best that one barber should be accessible to each lodging house on account of the sick and wounded.
He shall serve with his troop in all else like an ordinary soldier, and he shall receive double pay.

The Due de Guise, who occupied Metz while it was under siege by Charles
the Fifth, also made many medical arrangements. In advance he furnished
money to the surgeon barbers to enable them to make preparations for the sick.
The sick and wounded were carried to hospitals. He placed the city in good
sanitary condition, according to the teachings of that day, and isolated those
sick with contagious disease. In the French Army of his time, medical men
“were attached to the persons of great captains and nobles whom they fol-
lowed and upon whom they depended. In the interval between campaigns,
surgeons went back to their civil pursuits.” Their duty was to
look after their patrons first, higher ranking officers next, and down the list
until the soldier was reached—if he was reached at all. The medical care re-
ceived by the soldier apparently depended a good deal upon the individual com-
mander and to a less extent upon the particular surgeon concerned. Indeed
most of such aid as he received from time to time came from quite different
sources—from the barber surgeons, from irregular practitioners of medicine
who were often found in the rabble of camp followers, from women who served
as nurses on occasion, and from civilians having no military connections.

The name of one military surgeon stands out far in front of all others of
this time. It is that of Ambroise Pare. He was born in 1510 and died 80 years
later. During the years of his manhood, his country, France, was almost con-
stantly at war, and in all of these wars Pare participated.13 After the siege of
Metz he served as surgeon to the King. Pare was an intense individualist and
not in any sense an organizer; yet through his wonderful professional abilities
he was a potent factor in emphasizing the importance to armies of a competent
medical service. He was so highly esteemed for his skill that his coming to a
command was regarded as equal to a large reinforcement of troops. Perhaps
this was best exemplified at the siege of Metz, in 1552, when the King, after
considerable difficulty, managed to get Pare into the besieged city.14 The next
day Pare was received with joy by all the higher ranking officers, who assured
him that now they would no longer be afraid of dying if they should happen to
be wounded. It was to this class that Pare gave the greater part of his atten-
tion; indeed, he would probably never have been sent to Metz if it had not so
happened that seven princes, a number of veteran captains and officers, and
many other gentlemen were there. Pare, however, was far too independent and
too privileged a character to brook restraint in the direction of his professional
activities, and the fact that he was as highly esteemed by the soldiers as by the
nobles indicates that the former shared his services with the latter, despite the
conditions which prevailed at the time respecting the medical care of troops.
Notwithstanding their superior organization, the besiegers, the Spaniards,
were apparently much more brutal to the common soldier than the besieged, the
French. When the Duke of Alva, in command of the besiegers, represented to
Charles the Fifth that his soldiers were dying at the rate of more than 200 a day,
and that for this and other reasons there was little hope of entering the town, the
Emperor asked what men were dying and whether they were gentlemen and
men of mark. The reply was that they were all poor soldiers. “Then,” said
the Emperor, “it is no great loss if they die.” Queen Isabella was apparently
totally forgotten, as well as certain military lessons respecting the effect of good
medical care of soldiers as insuring better military service by the whole army.
From what has already been said on this subject, it is apparent that this was
realized as far back as Xenophon’s time.

Gustavus Adolphus of Sweden carefully developed the medical service, and
his last campaign, in 1630, represents the height of his system. He strictly
regulated the rules under which he permitted his troops to plunder and to sub-
sist on the country. Civil hospitals, not used for military offensives, were ex-
empt from pillage. One-tenth of the spoil of each soldier went to the main-
tenance of sick and wounded in hospitals. It was the custom to leave the sick
and wounded, with the heavy baggage, under guard of a small garrison, in
the civil hospitals of captured towns. Wagons for carrying wounded were used
by both armies during part of the Thirty Years’ War.

The Parliamentary Army evidently had a medical service superior to any-
thing which had previously existed in England. Besides the regimental sur-
geons and their assistants, there were usually two or three medical officers
on the staff of the general to supervise medical administration.16 Each sur-
geon of Cromwell’s army was allowed £15 for the purchase of a regimental
medical chest, £10 for a horse to carry it, and 2 shillings per day for the maintenance of the horse and attendant. Medicines for internal use were supplied by the apothecary general, while the surgeon general supplied those
for external use. A certain proportion of the pay of a soldier in hospital was
stopped to defray the cost of drugs. There were no mobile hospitals during
the campaign, but it is recorded that Essex sent his wounded soldiers from
Reading to London and that many sick men were billeted in houses and towns
remote from London.17 The seriously wounded were left in villages near the
field of battle. During the First and Second Civil Wars the London hospitals
were the only permanent places for the care of sick and wounded soldiers.18
Finally, Parliament established two special military hospitals and placed them
in the hands of parliamentary commissioners. In Scotland one hospital of 30
beds was expected to care for the sick from 10,000 troops. Women nurses were
used, who, as a rule, were the wives or widows of soldiers. There were no orderlies.

The first stationary or base hospital was established by Richelieu, at Pignerol, 70 miles from the front,19 while in the same century regimental and general hospitals, camp infirmaries, and retreats for old soldiers were established
both in France and England, notably the Invalides (Paris, 1676), and Chelsea
(16S2), and a sailors’ hospital at Greenwich (1695) .20 Due to the interest of
Louis the Fourteenth, the French Army at the battle of Seneffe (1674) was pro-
vided with 230 army surgeons, nursing personnel, and adequate material.21
In 1683 an order was issued by the French Government which required that
sick and wounded be lodged before officers.

The following quotation is from the seventeenth century writings of one Diggs, a surgeon who fought in Cromwell’s time:

It were convenient to appointe certaine carriages and men of purpose to give their attendance in
every skirmishe and incounter to carry away the hurte men to such place as surgions may imme-
diately repayre unto them, whiche shall not only greatly incourage the souldior, but also cause the
skirmishe to be better maintained, when the souldiors shall not neede to leave the fielde to carry
away their hurte men. These were called among the Romans ” Deputati.” And this among other
laudable Romane orders have the Spainards at this day revived and put in practice, whereby also
they conceale from the enemie what losses in any skirmishe they have received.

EIGHTEENTH CENTURY IN EUROPE.

In the eighteenth century, armies were put on a much more definite
status;22 limited periods of enlistment, regular medical examinations of recruits,
regular salaries of officers, government quarters for troops, a common daily
ration, the military regulation of army hospitals and regular schools of military
medicine, became part of the established order of things. Medical examinations
of recruits were inaugurated in France in 1726; in England in 1790; Prussia
commenced the same system in 1788. Louis the Fourteenth had revived
regularly laid out camps of Roman model as early as 1667, but now treatises
on sanitary details began to appear. Pringle wrote one in 1752; Brocklesby, in
1764; Munro, of Scotland, published one in 1764; and Colombier, another in 1772.

Surgeons now gradually assumed a position equal to that of the physician,
and training schools became necessary.22 France established the first joint
army and navy school in 1718, but separate ones for the army and navy did not
appear until 1775. In Saxony one was opened in 1748. The first medical military school of Prussia was established in 1795 as a part of a general medical
school. The Josephinum of Austria opened in 1784. The enthusiasm of some
individual medical officer was behind nearly every one of these institutions.
The first military medical journal was published in France in 1766
One of the outstanding accomplishments in the progress of military surgery
during the eighteenth century was the establishment of the Royal Academy of
Surgery of France in 1731.22 Five of its seven original officers were military
surgeons and one-half of its members were doctors of the army. Army and
navy medical officers wrote more than two-thirds of the papers and observations
in the first volumes of the proceedings of the society from 1743 to 1768.
During the War of the Austrian Succession there was present at the battle
of Dettingen (1743) a shrewd Scotch officer, who, through the Earl of Stair,
brought about an agreement that both the French and English military hos-
pitals be regarded as neutral and immune from attack.23 This officer was Sir
John Pringle (1707-1782), who had been made surgeon general of the British
Army one year before (1742) and who served until 1758. Yet the siege of
Metz (1552), where something was done in the same direction, and the battle of
Dettingen (1743), were by no means the only instances of a temporary agree-
ment of this nature; no less than five, between 1743 and 1864. were placarded
at the Berlin Exposition of Military Medicine in 1914.

At the Battle of Fontenoy (1745) the French had 60,000 troops with 40
surgeons. Surgeons were in the front line and the “ambulances,” as the
temporary hospitals of the battle field were called, were about 2,000 yards
back from the first line. After the battle the wounded were carried on caissons
and carts to cities about 20 miles away. Bagieu, of the French medical service
at the time, wrote as follows:

In the battle there is an ambulance hospital more or less within the reach of the place where
an engagement occurs, where the surgeon major and other surgeons hold themselves in readiness.
This is the first depot where wounded are collected, whence they are carried to hospitals in the
nearest towns, and thence to cities farther removed when these become overcrowded. It is rare
that surgical operations are performed on the field proper—that is, at the place where wounds are
inflicted—and still more rare are amputations performed. The light wounded betake themselves
to the ambulance station; the dangerously wounded are carried there on litters.
His comments are otherwise notable from the fact that, besides mentioning
litters, he gave details of a wagon for carrying wounded, described a horse
litter devised by Petit, and discussed transportation by water.
Puysegur in 1749 wrote a book on the Art of War and gave a map placing
the ” ambulances ” 2,500 yards in rear of the front lines.22
In the British service in 1748, separate beds, clean linen, and trained
nurses were provided for hospitals.24 In 1793 relative rank was given to sur-
o-eons.2” Surgeons serving in general hospitals were called staff surgeons,
while army surgeons followed the fighting lines. Wounded were removed by
pioneers and bandsmen under the supervision of the quartermaster. There
was no wheel transportation for them worth mentioning.
The first garrison hospital in Prussia was a house in the Spandau suburb,
set apart for the purpose in 1709. This became known as the Charite in 1720;
and the Theatrum Anatomicum, founded in 1713, was expanded in 1724 to
include a Collegium Medico-Chirurgicum. Under the administration of General Holtzendorff, the first surgeon general of the Prussian Army, both these
institutions were designated to train surgeons better for war service.
So far as Germany is concerned, the reign of Frederick the Great includes
nearly all of the progress made in medical organization during the eighteenth
century. Field hospitals in Frederick the Great’s army were under well-
known surgeons. Those who presided over the military surgeons in the field
carried the titles of first, second, and third surgeon general.6 In 1797 Fred-
erick William the Second made a great advance by appointing a surgeon gen-
eral of the army and director of field hospitalization, thus centralizing the
authority in one officer.

In the campaigns of Frederick the Great, his method of front and flank
attack in close formation and volley firing at close range was thought to prevent
rescue of wounded during battle. The old rule of the Brandenberg army was
that no one should approach the wounded until the battle was over and victory
had been sounded by the trumpets.

AMERICAN REVOLUTION (1775-1783.)

While from the beginning of our history as a Nation the Medical Depart-
ment of the United States Army has great traditions in the line of professional
attainments, of devoted service to sick and wounded, and of gallantry in action
—in fact, in every direction so far as the work of individual medical officers is
concerned—good medical department organization was of slow growth and did
not flower till fertilized b}^ experience in the Civil War.
The story of the Medical Department of our Army in our first war, the
Revolution, adds nothing to that of its development to the stage when we
entered the World War. Possibly one exception might be made to this state-
ment, for the lack of medical organization in the Continental Armies demon-
strated that no matter how skillful the doctors—and they were skillful for that
time—their services were largely wasted with bad organization.
From the British we had inherited an organization which distinguished
sharply between hospital surgeons and troop surgeons. Baron von Steuben,
who wrote our first Army Regulations, in 1780,28 maintained the distinction
between surgeon, physician, and apothecary. These lines of cleavage operated
seriously against a united medical department. But the jealousies of the
different colonies were even more powerful in preventing a centralized admin-
istration, with all medical officers merely parts of a whole, working for the
common good. The evils that existed from cross purposes were intensified by
constant change. It should be noted that the difficulties were increased by
shortage of medical supplies. Yet, with all its shortcomings, the medical
service, as the result of bitter experiences, improved considerably toward the
end of the Revolution. The failure of Arnold’s expedition to Canada is gen-
erally ascribed to the miserable physical condition of his troops. They were
poorly supplied in most respects, and disease had its way with them little
checked or controlled. Smallpox proved a terrible scourge. By the time of
the Revolution, inoculation with human virus against smallpox was practiced,
b The very ancient distinction between physicians and surgeons was maintained and carried down to the davs of
our Revolution.  Yet this procedure proved by no means an unmixed blessing, because the inoculated person had
smallpox and in consequence was a danger to others. The soldiers got into
the habit of inoculating themselves. This was prohibited in general orders.

NAPOLEONIC WARS.

Late in the eighteenth century, as a result of the American and French
Revolutions, it was recognized that the people had certain prescriptive rights
and, in consequence, the wounded soldier came to have the same consideration
that had been accorded him in the days of the Roman Republic and Empire.
There was no disposition to deny this to him in the American Revolution, but
ignorance of the means for doing so was fatal to performance. In the
Napoleonic Wars, on the other hand, the means of performance were supplied
through the efforts of that genius of medico-military administration in the field,
Baron Larrey, surgeon in chief of Napoleon’s Army.30 A choir boy who studied
medicine, he first served in the navy, but after meeting Napoleon at Toulon, joined
the Army of the Rhine. The admiration of the two men was mutual, and they
became fast friends. In fact, Larrey seems to have been one of the few men
for whom Napoleon had real affection. Napoleon did not like desk officers;
would promote none who had not served with troops under fire for 10 years
or who had not been wounded in action. Larrey qualified here, as he had
been thrice wounded; and in this particular, as well as in many others, he won
the esteem of his chief. Larrey devoted his whole life to military surgery
and to the welfare of the wounded soldier. He was constantly with Napoleon;
and altogether served in the French Army 53 years, in 26 campaigns. He
became professor at the School of Military Medicine at Yal de Grace, founded
in 1796, and wherever he happened to be in a quiescent period he set up a school
of military surgery. His Memoirs of Military Medicine (1812-1817) is one of
the great classics of the subject. It contains the first account of the excision
of wounds with primary suture.

In spite of advances which had been made before his time, looking to the
amelioration of the condition of the wounded in battle, Larrey found, when
he joined the army, that the sanitary personnel and supplies were kept with
the baggage train, from 1^ to 3 miles from the firing line, that high-ranking
officers were carried back by their men; and that wounded soldiers in general were
allowed to reach the train by themselves, or were transported back by comrades
who should have been in the firing line. If the battle ended in defeat the
wounded fell to the enemy; if it resulted in victory, servants, bandsmen, and
camp followers brought them to the villages, using local transportation for the
purpose. Larrey, noticing the delays which thus occurred in the transporta-
tion of the wounded to hospitals, reasoned that it would be better administra-
tion to take aid to the wounded than have them seek it. He then introduced
his system of ”flying ambulances,” which immediately achieved a great
success, and of which hundreds were eventually in action.31 Regimental aid
and fixed ambulance stations existed before that time, and the French Army,
as a whole, did not adopt Larrey’s plan. Nevertheless, it was the forerunner
of the system of handling the wounded on the field which exists to-day.

The vehicles which Larrey introduced were of two types, each strong
but light. They were drawn one by one horse and the other by two horses,
and could go over rough country and practically to the firing line. With the
necessary personnel they afforded both surgical treatment and means of evacuation for the wounded.

Baron Percy, at about the same time, organized a corps of litter bearers. 
His men were trained and equipped for collecting the wounded during battle.
He devised a wagon drawn by six horses which carried eight surgeons, orderlies,
instruments, dressings, and litters. Halting in a sheltered place, his group
gave aid to the wounded brought in by the litter bearers. By the beginning
of the nineteenth century the French medical arrangements, with the support
of Napoleon, had come to represent a combination of the ideas of Larrey and
Percy.

While the British in the Napoleonic Wars, and much later, had nothing
to correspond with the “flying ambulance” of Larrey—for the Duke of Wel-
lington refused to approve the recommendations of his medical officers that
it be adopted, on the ground that troops were hampered—they made certain
advances in field medical organization which are worthy of record here. Sir
James McGrigor, chief surgeon in the Peninsular War, established divisional
hospitals in front and convalescent hospitals in the rear where men were received
en route to the depot.33 This is shown by his narrative on “The Retreat from
Burgos,” where he is said to have saved Lord Wellington from the mortifica-
tion of abandoning his sick and wounded to the enemy.

In Napoleon’s time it was still too early for scientific army sanitation.
Indeed, nothing of value can be learned on this subject from his methods.
As a matter of fact, Napoleon’s armies suffered very severely from disease and,
as a consequence, in military efficiency. In Egypt, plague was largely respon-
sible for failure and a quietus was put on the Russian Army by typhus and
smallpox. As was inevitable, the demand for more and more men in the
later career of Napoleon resulted in very inferior recruits. As he well knew,
the efficiency of his troops as he approached Moscow and Waterloo was much
lessened by these physically unfit soldiers.

Napoleon’s Louisiana expedition, which halted in San Domingo, is often
mentioned as an example of an army that disintegrated through bad sanita-
tion and, in consequence, overwhelming sickness.34 Whatever his intentions,
in a military way, may have been toward the New World, they ceased perforce
on account of the fearful mortality in this ill-starred army; and because of
conditions at home, it was never possible for him to send another expeditionary
force from France.

It is perhaps fair to assume that while the use of the “flying ambulance”
appealed to Napoleon as a military method of distinct importance’in promoting
the morale of troops, sanitation made no such appeal to him. Perhaps the
results to be accomplished by it were, in the ignorance of the subject of that
day, far too indefinite for that master military mind.

WAR OF 1812 AND WAR WITH MEXICO.

The War of 1812 was unimportant so far as medico-military tradition is
concerned; nor did the war with Mexico, despite a reorganization of our Medical Department in 1818 on modern lines so far as peace-time administra-
tion was concerned, bring much of value for the future. Records are readily
available to show good service in that war on the part of individual medical
officers; in fact, the conduct of the Medical Department as a whole seems to
have been of a high order of merit, although its organization was scarcely better
than in Revolutionary days. Not that there was the same amount of friction
as in the earlier war. This friction seems to have been quite absent in the war
with Mexico, which affords, rather, an example of poor medical service due to
lack of medical personnel, plus inherent faults in organization. The Medical
Department field organization was wholly regimental35 and, as it proved,
regimental medical complements could not be maintained at authorized strength.
As a matter of fact, save a very small administrative force at headquarters,
there were practically no medical officers except those assigned to regiments,
and this was on a scale which to-day would be considered inadequate for even
that purpose. Whenever it became necessary to establish a hospital, even
one of the more permanent type, there was no way to staff it except to rob
the regiments of medical officers, and this was done continually, with the
result that neither regiments nor hospitals were adequately supplied.35
While the military accomplishments in the Mexican War were very great,
especially considering our means available there, this was a very disastrous
campaign, so far as sickness and deaths from disease are concerned.36 The
losses due to disease alone actually exceeded 33 per cent of General Scott’s
command. A good many reasons conspired to this unfortunate result. The
command as a whole was poor physically, it was ill supplied, service was very
hard, and, which was most important, the country was unhealthful—that is
to say, prevalence of communicable diseases was encountered by troops serving
there. Of course, just as with the French at San Domingo, it was far too early
to combat disease scientifically, for nearly half a century was yet to pass before
the cause and methods of transmission of the various infectious diseases
encountered were actually known. Even so, on one important occasion at
least, General Scott’s army does not seem to have taken advantage of the
empirical knowledge of that day of how to prevent disease. When his troops
were about to return home, the medical authorities recommended that they
march directly through Vera Cruz, without stop, to the awaiting transports,
with a view to diminishing, as far as possible, the danger of contracting yellow
fever in that plague-ridden city. This advice was not adopted, and yellow
fever was introduced into the United States at several points by the returning troops.

CRIMEAN WAR.

From the historical standpoint, the Crimean War is a most interesting
one for study. Furthermore, its medical history, through excellent con-
temporaneous accounts, is readily available to the student, which is not the case
to the same extent with earlier wars. Field hospitals by that time had been
established in the British Army in response to necessity, and an ambulance
service was now attempted.38 Unfortunately, the heavy wagons sent out
in the First Conveyance Corps failed to be useful and contributed their part
to the dreadful conditions of medical service in that frightful war. During the Crimean War medical officers of the British service were commissioned
in battalions and regiments and practiced about as did doctors in civil life.
The hospitals were regimental,39 with a colonel as governor, with a paymaster
as treasurer, with a quartermaster in charge of stores, and with soldiers as
nurses. The doctor was a visiting physician or surgeon without command,
authority, disciplinary functions, or financial responsibility, and with little or
no administrative supervision. The sick were carried from the line to the
regimental hospital and from there to general hospitals improvised at the
base.40 At the general hospital at Scutari, confusion, chaos, and malad-
ministration reigned, 2,500 patients being at one time under the care of 10
surgeons and 12 cooks.

The modern health movement, under the leadership of Sir Edwin Chad-
wick, had its origin in England just before the Crimean War. It then came
to be realized by the public at large that sickness is one of the great afflictions
and handicaps of the poor, and to lessen this became the purpose of Chadwick
and his coworkers. The public health act of 1S48 and the organization of the
general board of health were the outcome of their labors.41 At the beginning
of the war the death rate from disease in the British Army in the Crimea was
extremely high, and sanitary conditions and the state of affairs with respect to
the care of sick and wounded were deplorable. A popular uproar of condemnation
arose in England, where the public, through the recently inaugurated better-
ment work, had been educated in such matters sufficiently to expect reasonably
good care for their troops, both sick and well. The popular outburst of indig-
nation, combined with the realization on the part of the war office that existing
evils must be corrected, led to the inauguration of changes for the better.42
With these improvements the name of Florence Nightingale is firmly linked.
The remarkable energy and administrative abilities of this nurse resulted in
raising the standard of the British military hospitals until they were no longer
comparable with those of the Dark Ages, but were on a par with the better
civil institutions of their time. This bettering of hospital conditions, together
with improvements in the living conditions of the army, resulted, in the latter
part of the war, in better health conditions among British troops than among
the French and Russians.

In view of the lack of knowledge at that time of the manner of trans-
mission of infectious diseases, it is rather puzzling to determine just how a
desire for better health in troops was transmuted into actual accomplishment.
As a matter of fact, in the days of the Crimean War not much more was known
of how to prevent disease in armies than in the days of the Roman legions.
Vaccination against smallpox had come into general use, it is true, but this
was the only important advance in knowledge of sanitation. Filth was thought
to be responsible for the spread of all disease. This has been aptly called the
era of the sanitation of bad smells. The dominant role of the sufferer or of the
carrier in spreading many diseases was not recognized. Nothing was known
of the spread of other diseases through insects. By diminishing the visible
filth in the British Army, which had been living under horrible conditions
and by the necessary wider separation of man from man in order to accomplish
this, the chances of contact infection were lessened, and this alone would be
enough, perhaps, to explain the improved mortality rates. Better treatment 
of wounded and sick was probably another factor. If, in the process of hit-or-
miss sanitation, the British had also drained the swamps, doubtless unwittingly
they would have gained greatly thereby in the freedom, or comparative freedom,
of their troops from malaria.0
The only measure of the results of British sanitation in the Crimea so far
alluded to is based on comparison of their mortality rates with those of the
French and Russians. So measured, they are relatively satisfactory. With
all that was accomplished, however, the death rate in the British forces was
still very high. A large part of the army was destroyed and a fresh force of
younger men took its place. Soon after the war the great sanitary reforms
of Lord Herbert took place in the British Army.

The French, during the Crimean War, are said to have had specially good
stationary (general) hospitals in the best buildings in Constantinople. The
difficulty with these large permanent hospitals at that time, however, was that,
on account of lack of knowledge of how to prevent the dissemination of disease
in them, they proved much more dangerous than the smaller hospitals, in
which, of course, the groups were smaller, and in which, because of the smaller
number of patients, contagious diseases were not so likely to be introduced.
The harrowing experiences of the Crimean War, and the improvements in
the care of sick and wounded instituted toward the latter part of that struggle,
seem not to have served to prevent similar undesirable conditions in the years
immediately following that conflict. For the Battle of Solferino (1859), in the
war waged by the French and Piedmontese under Napoleon the Third and
Victor Emanuel of Italy against the Austrians under Francis Joseph the Sec-
ond, was so fraught with suffering and inefficient care of the wounded that the
description thereof by a Swiss eyewitness 43 resulted in the organization of the
International Red Cross Society, with the announced object of ameliorating
the sufferings of sick and wounded in war. This organization, effected at the
first Geneva Convention (1864), again brings to notice the humanitarian motive
as a potent factor in activating service to sick and wounded soldiers.

THE CIVIL WAR.

Notwithstanding the work of Larrey and Percy, and the experiences of
the Crimean War, no efficient and methodical system for handling the wounded
on the field of battle had yet been evolved on the outbreak of the war between
the States. The problem was then, as now, a most complicated one.
During the first year of the Civil War an efficient military organization
was developed which was most perfect in the Army of the Potomac, under
the inspiration of McClellan.44 The Medical Department, however, did not
share in this development, and remained much as it had been in the Mexican
War. There was a small regimental personnel providing regimental first aid
at the front.45 There were base hospitals located in old buildings well back at
the rear, but there was nothing to bridge the great gap between. Each regi-
ment had one or two surgeons, a hospital steward, and a few men. 

The extensive draining of swamps which characterized Roman occupation of a country is said to have cut down the malarial rate to a notable extent, though it was not done for this purpose and the reason for the effect on disease was not appreciated until centuries later from the regiment to act as cooks and nurses. The band was counted as a part of the regimental medical assistance in battle, but its services were of comparatively little value. Each regiment was supposed to have two or three ambulances, but these were under control of the regimental quartermaster and were driven by civilians, who seem to have been a drunken and disorderly lot who gave much trouble to the medical officers under whose direction they were temporarily placed in battle.46 After battles the wounded who could not get to the rear on their own legs were slowly gathered into buildings adjacent to the field, where they received haphazard and inadequate care from the regimental surgeons who were detailed or who volunteered for the task. These collections of wounded are often spoken of in the reports as field hospitals, but they had not the organization, equipment, and mobility which are the distinctive attributes of such units at present. So outstanding and obvious a need as ambulance companies and field hospitals could not escape the many acute and practical minds whose attention at this time was focused upon the problem of the rescue of the wounded. In General Grant’s army, in his attack on Fort Donelson in February, 1862, four ambulance companies and four field hospitals were organized by Surg. H. S. Hewitt, United States Volunteers, for the operations of the attack, the ambu- lance companies being made from the regimental ambulances, and the field hospitals from the regimental medical personnel and equipment.

These were provisional organizations, it is true, but they demonstrated that the need was appreciated and the solution understood, if only certain ancient prejudices against medical field units under the control of medical officers could be over- come and these essential units could be established as permanent, trained military organizations.

In May, 1861, Dr. J. O. Bronson, of New York, urged on Gen. Winfield Scott the organization of an ambulance corps.48 Bronson’s letter was referred to the Surgeon General, but no further action seems to have been taken. On September 19, 1861, the surgeon general of Pennsylvania wrote to Surg. C. S. Tripler, United States Army, medical director of the Army of the Potomac, recommending the formation of an ambulance corps, and stating that he had much of the facilities for transportation on hand and could do so if the plans were approved.48 At that time Tripler recommended the plan in question for the favorable consideration of the Secretary of War. No action was taken on the recommendation. In the early spring of 1862, a similar plan was submitted to the Secretary of War by a Mr. Charles Pfirsching.

Surgeon Tripler commented as follows when the matter was referred to him for an expression of his opinion: Headquarters, Army of the Potomac, Medical Director’s Office, Washington, March 6, 1862. Sir: I have the honor to report that, in obedience to your instructions, I have examined the plan of organization of an ambulance corps submitted by Charles Pfirsching. I lowever desira- ble a regularly organized ambulance corps may be for any army, it is too late now to raise drill and equip so elaborate an establishment as this for our service. There is nothing new in this plan nothing that has not been thought of and well weighed years ago in connection with our own organization, unless it be the arsenal of pistols and hatchets with which the men are to be loaded As we have no ambulance corps proper, an attempt has been made to instruct a certain number  of men in each regiment in the duties appertaining to such a corps. An order providing for the drilling of 10 men and the band of each regiment to the ambulance service was issued from these headquarters on the 3d of October, 1861. This has been faithfully done, and we now have a tol- erably well-instructed body of men for this duty. Instructions for the distribution and employ- ment of these men during an action have been prepared by me and even submitted to General Williams, Adjutant General of the Army of the Potomac, for the action of General McClellan, some 10 days ago. I hope they will soon be printed and circulated. When that is done all necessary and practicable arrangements for the transportation of our wounded will have been made. I am, therefore, of opinion that the plan of Mr. Pfirsching is neither needed nor available for our sendee at the present time. Very respectfully, your obedient servant, (Signed) Charles S. Tripler, Surgeon and Medical Director, Army of the Potomac. This report of Surgeon Tripler was returned on March 7 to the Secretary of War by the Surgeon General (Finley), who fully indorsed the views of Sur- geon Tripler. William A. Hammond, the next Surgeon General of the Army, had the better vision, as shown by a remarkable letter written on September 7, 1S62, to the Secretary of War, Mr. Stanton,46 in which he called attention to the frightful state of disorder existing in the arrangements for moving the wounded from the field of battle. This letter, after more than 50 years, retains the vibrant tone of suppressed emotion as he mentions that 600 wounded were lying on the battle field of the Second Bull Run, fought 10 days before, and that many had perished of starvation and neglect. What Surgeon General Hammond asked appears to us, at this date, to be surprisingly simple and obvious, namely, the organization of an ambulance service which should be placed under the control of the Medical Department. He mentions that such a plan had already been laid before the Secretary of War, but had been disapproved by the then general in chief, General Halleck. Fortunately, General McClellan, the commander of the Army of the Potomac, had a more open mind. On July 1, 1862, Jonathan Letterman had reported to him to be medical director of the Army of the Potomac.49 He was only 38 years of age and had just received his promotion to the rank of major. It is not known what prompted Surgeon General Hammond to select this comparatively junior officer for so heavy a task, for the Army was crowded with the sick and wounded of the Seven Days’ Fight, and in the retreat to Harrison’s Landing on the James most of the medical equipment and supplies had been lost or expended. But the selection was most happy, in that it placed in the position of opportunity the man who was destined to make an advance in medical organization which was the greatest, perhaps, in history. Letterman drew up at once a plan for an ambulance corps, simple, practicable, and immediately effective. It was organized with officers and men transferred on the spot from the depleted regiments of the line. A distinctive uniform and a simple drill were prescribed. This organization was announced in orders, apparently without reference to Washington, on August 2, 1862,44 and was soon followed by a scheme for regimental medical service and the establishment of division field hospitals. The field hospital system was established by Letterman m a circular dated October 20, 1862.50 These, taken together, made a complete, workable system which at once marked a new epoch in medical organization and placed the Army of the Potomac, in this respect, far ahead of any military establishment in the world.

The first trial of the new system was on the bloody field of Antietani on September 17, 1862, where the wounded of the army corps from the Army of the Potomac were promptly removed from the field and cared for, 51 in marked contrast to the experience of the wounded in the army corps from Pope’s army. At Fredericksburg, where the confusion of defeat was added to heavy losses, the ambulance companies nevertheless did their work with smoothness and dispatch, and the wounded were quickly transported to the division field hos- pitals.52 The medical director of the Sixth Corps reported that it ” afforded the most pleasing contrast to what we had hitherto seen during the war.” Letterman’s organization was soon adopted by the other armies of the United States, and was established by law in the spring of 1864.53 Unfortu- nately, this legislation was only for the war army; after the war it disappeared from the statute books, from Army Regulations, and, apparently, from the memory of the Army, except among the older medical officers. The complete history of Letterman’s ambulance and hospital plan may be found in Part III, Surgical Volume, Medical and Surgical History of the War of the Rebellion, and in his ” Medical Recollections of the Army of the Potomac.” His system provided for an ambulance corps for each army corps, consisting of about 17,000 men, and a field hospital for each division, approximately one- third the size of an army corps. The number of ambulances allowed was very much greater than later, and generally averaged at least 1 to 150 men, or 200 to what would be a division (World War), instead of 48. Under this system wounded men were picked up promptly, carried back to field hos- pitals, and given such professional care as was then possible. The battle field was cleared of wounded men within 24 hours. For the first time in the history of the world the wounded were systematically collected, sheltered, and given surgical attention. The one thing lacking was an evacuation system behind the field hospitals. Wounded men were collected and carried to field hos- pitals, but between these and the great general hospitals far in the rear there was no general plan of evacuation. There was neither evacuation hospital nor a regulated system of evacuation ambulance companies, hospital trains, and boats. This was the incomplete feature of Letterman’s scheme left for future medical officers to perfect. Not entirely unrelated to the work of medical officers in the field was another unique order of that time bearing on the status of such officers. Gen- eral Orders, No. 100, War Department, April 24, 1863, providing for the govern- ment of the armies of the United States in the field, contained this paragraph (No. 53): “The enemy’s chaplains, officers of the medical staff, apothecaries, hospital nurses, and servants, if they fall into the hands of the American Army, are not to be treated as prisoners of war, unless the commander has reason to detain them.” This is believed to have been the first general official recognition of exactly this type, of the exemption of medical personnel from capture as prisoners of war, a principle later established by the first Geneva Convention, which did not meet until 1864. Scarcely of secondary importance to Letterman’s field organization was the creation of medical inspectors. This was effected by an act of Congress EVOLUTION OF MEDICAL DEPARTMENT. 41 approved April 16, 1862. At the head of the medical inspection service was a medical inspector general with the rank, pay, and emoluments of a colonel of Cavalry, who, by the act in question, under the Surgeon General was empowered to supervise “all that relates to the sanitary condition of the Army, whether in transports, quarters, or camps, and of the hygiene, police, discipline, and efficiency of field and general hospitals, unde: such regulations as may here- after be established.” It was further enacted “that there shall be eight med- ical inspectors, with the rank, pay, and emoluments each of a lieutenant colonel of Cavalry, and who shall be charged with the duty of inspecting the sanitary condition of transports, quarters and camps, of field and general hospitals, and who shall report to the medical inspector general, under such regulations as may hereafter be established, all circumstances relating to the sanitary condi- tion and wants of troops and of hospitals, and of the skill, efficiency, and good conduct of the officers and attendants connected with the Medical Department.” Another provision was “that whenever the Inspector General, or any of the medical inspectors, shall report an officer of the Medical Corps as disqualified, by age or otherwise, for promotion to a higher grade, or unfitted for the perform- ance of his professional duties, he shall be reported by the Surgeon General for examination to a medical board, as provided by the seventeenth section of the act approved August 3, 1861.” Corps medical inspectors, who took into cognizance similar questions involving the corps concerned, also were detailed. It will be noted that the medical inspectors were granted very broad powers by the act of Congress relating to the subject. These were by no means cur- tailed by the regulations published later as provided by the act. In fact, they were, if anything, somewhat extended. It is not believed to be necessary to go into further details here; all that is necessary for our present purpose is to invite attention to the fact that through these inspectors the Medical Depart- ment controlled sanitation, medical formations, and the fitness of medical personnel, with a machinery to get rid of the unfit. For improvements made in the Medical Department during the Civil War, improvements which amounted to a change -from haphazard bungling to a methodical and scientific administration, sufficient credit has never been given to Surg. Gen. William A. Hammond. The war was entered upon with a Med- ical Department conservative to the point of fossilization. Hammond put new life into it. He transferred hospitals from old hotels to new pavilions, inaugurated new and improved reports and returns, began a library, a museum, and a history of the war; he even advised the establishment of an Army med- ical school. He also placed Letterman at the head of the Medical Depart- ment of the Army of the Potomac, as we have seen, and supported him in securing the adoption of his epoch-making system for evacuating the wounded. The really magnificicnt results obtained by the Medical Department in the Civil War were due very largely to the efforts of these two men—Hammond and Letterman. Before concluding this phase of the subject, one other most important point should be mentioned. At the beginning of the Civil War and for a consider- able time thereafter, Army doctors in administrative positions apparently were quite at a loss in performing the duties incident to them. That is to say, they 42 SURGEON GENERAL S OFFICE. occupied themselves with professional services to the sick and wounded ins!cad of exerting anv control over their subordinates. Many accounts are to be found of the early days in which descriptions of amputations are given by division and corps surgeons during battle, at the sacrifice of time which should have been devoted to the running of the complicated medical machine, though of course this was not realized at the time. Larrey could do this, it is true, but he was a genius to whom the ordinary rules do not apply. However, conditions in this respect were corrected later. A very clear account of the duties of all the officers on duty with a corps medical department may be found m Part III, Surgical Volume, Medical and Surgical History of the War of the Rebellion (p. 903 et seq.). Strange to say, these duties were apparently not embodied in regulations. As a matter of fact, the definition of the duties in question was given in reply to a circular sent by the medical director to the Army of the Potomac to the medical director of the Fifth Corps, directing him to secure reports of his duties from each of the officers concerned. One curiosity, as we see it now, of Civil War medical department organiza- tion was the employment of acting assistant surgeons (contract surgeons) in large numbers, both in the field and in hospitals. Many of the great general hospitals were near large cities, and their medical and surgical professional staffs were often made up wholly of acting assistant surgeons. This was part-time work, the individual local doctor so employed maintaining his own private practice at his home and at the same time giving some hours of each day to his Army hospital duties. Many of the doctors who so served were distinguished members of the profession, whose services proved of great value from a purely professional standpoint. In fact, some of their contributions to medical litera- ture were the most brilliant published as a result of Civil War experience in treating sick and wounded. The plan, however, made no permanent impres- sion, for it has never been imitated in any army at war. This refers to the general employment in war of doctors as contract surgeons at their own homes for part-time work in great hospitals or for duty with troops in the field. Contract surgeons are still employed in our Army for certain special duties. Mention has been made of the Civil War having forestalled the Geneva Convention in one important respect—nonretention of the medical staff as prisoners of war. Two commissions, forerunners of the Red Cross, were organized early in the war, the Sanitary Commission54 and the Christian Commission.55 These were volunteer bodies animated by the same spirit as the Red Cross. Both gave play to the sympathy of the public generally toward sick and wounded soldiers, and both did a great deal of good in this direction. Yet their relations toward the Army were not what to-day would be considered well ordered. After one campaign, General Banks complained that the Sanitary Commission had stolen his whole army. On this occasion, as well as on some others, the humanitarian zeal of the members of these commissions outran all else, with consequent serious inroads on military strength. Helpful as they were to sick and wounded in numerous instances, their independent status resulted in lack of coordination of effort with the Medical Department and in consequent confusion. The subject of sanitation in Civil War history is by no means devoid of interest. By this time, in the march of events, the prevention of disease in EVOLUTION OF MEDICAL DEPARTMENT. 43 armies had assumed more importance, both in the medical and in the military mind, but its actual practice lagged far behind, for definite knowledge of how diseases are transmitted was still lacking. The results obtained, therefore, could not be other than very disappointing. Perhaps the most important point of present-day interest which was brought out is how wholly unsatisfactory immature boys are as soldiers. The youth of many soldiers on both sides in the Civil War rather surprises one not acquainted with the facts. Save very exceptionally, it was found that these boys could not physically support the rigors of campaign. Not that this observation was a new one: it had prob- ably been made centuries before. Certainly, as already stated, the demand for more men in the later career of Napoleon resulted in the calling out of youth- ful troops who were not physically in the class with his veterans, and who consequently, aside from other reasons, made far less efficient soldiers. FRANCO-PRUSSIAN WAR. (1870-1871.) The Franco-Prussian War was characterized by an excellent medical service on the German side.56 Apparently the Germans followed Letterman’s organiza- tion very closely. The medical department of the French Army, on the other hand, broke down and was compelled virtually to turn matters over to the Red Cross.57 A point well worthy of note is involved here in this connection. When the Red Cross was first organized, it was proposed that it act independ- ently of contending armies; that is to say, that care be extended by it quite irrespective of the nationality of the sick and wounded. No system was evolved at first which would fuse the Red Cross of a nation with the medical department of its own army. The original plan was found impracticable in the first great war after its organization—France against Germany in 1870. It soon became evident that Red Cross personnel could serve only with the army to which it was attached, except by giving aid to enemy prisoners of war. The status of the Red Cross respecting independence of the medical department of its own army was not settled so quickly. There was, however, a gradual change here, more rapid in well-organized armies and slower in those less well organized. The only great army in which the Red Cross worked more or less independently when the World War came was the Russian. Unquestionably, the Medical Department of our Army owes a great deal to the Franco-Prussian War in so far as its modern organization is concerned. This was not apparent at once, however, nor for quite 30 years. No serious study of military organization was carried on in this country for a long time after the Civil War. As a matter of fact, it took the Spanish-American War to awaken us. By that time, the medical organization of European armies, based on the plan suggested by Letterman, improved by the Franco-Prussian War, and still further improved after the war by the different civilized nations seriously preparing for war, had approached present-day standards. In our new organization, we adopted it as it then existed, with modifications to suit our part ieular needs. 44 SURGEON GENERAL’S OFFTCE. The Franco-Prussian War brought out another matter of great importance to the Army and to the Medical Department. The German mortality was reported to be so low that for the first time in the history of wars deaths from wounds exceeded in numbers those from disease.50 For many years their results in this particular were set as a standard to be striven for. The outcome was more remarkable in the light of the status of preventive medicine at that time. Undoubtedly flaws could be discovered in the statistics of Prussian casualties in the Franco-Prussian War, yet it is none the less noteworthy that the well-organized German medical machine added very largely to the military strength of its army by good sanitation. France failed to utilize this military asset. For example, smallpox, which could be prevented then as well as now, made very serious ravages in the ranks of the French Army, while the Germans, through efficient vaccination, were relatively free from it.57 THE DAY OF SMALL THINGS IN THE UNITED STATES ARMY. (18(io-lS98.) After the disbandment of the Federal Armies in 1865, the Regular Army was rapidly reduced to the small nucleus of 25,000 men. It went back to its former conditions of service in small and isolated posts, mainly in the Indian country of the far West. The medical service returned to its peace organiza- tion, with a Surgeon General in Washington, a medical director for each geo- graphical department, and a post surgeon, with perhaps an assistant or two, and a hospital steward, at each military post. The hospital was manned by a small enlisted detachment detailed from the companies on duty at the post. Such details were temporary in character and their duration usually depended upon the success of the surgeon in retaining the good will of the company commanders. Active military operations against the Indians were frequent and arduous, but were conducted by small commands, usually of Cavalry, the Medical Department of which was represented by a medical officer, one or two ambulances, and a few detailed soldiers. The post life of those days was usually tranquil and not unpleasant. The professional demands upon the surgeon were not large, although he had to be prepared to meet all of the medical and surgical emergencies of military and family life. During the major portion of this period there was no national interest in questions of military organization or preparedness. As a consequence, the Medical Department was too small to provide for other than routine duties, and even for these contract surgeons had to be employed to supplement the small medical staff.58 The Regular Army was self-sufficient through force of circumstances. The National Guard existed, it is true; but it was a thing apart from the Army. The organization of the Association of Military Surgeons in 1892, with a journal of its own, by the noted surgeon, Col. Nicholas Senn, M. C, National Guard of Illinois, gave a common ground for discussion of problems of mutual interest to medical officers of both Regular Army and National Guard. Years were still to pass before the medical profession of the country as a whole was to be interested in its military obligations. This quiescent period lasted almost iininterruptedly until the Spanish- American War, a period of 33 years. Yet during this time some accomplish- ments in the Regular Army were of sufficient importance to be recorded here. EVOLUTION OF MEDICAL DEPARTMENT. 45 Organization op Hospital Corps. A most important accomplishment of this period was the organization and development of a hospital corps, consisting of men enlisted solely for duty in the Medical Department, to replace the system of detailed cooks, nurses, and civilian personnel. This was done by act of Congress of March 1, 18S7. The Secretary of War was authorized to enlist men for or to transfer them to the Hospital Corps, and to fix the number. The act also provided for hospital stewards and acting stewards. An act of Congress of March 16, 1896, fixed the number of hospital stewards at 100. There were at that time about 100 acting stewards and 500 privates. The organization of a hospital corps was of basic importance, and its in- fluence on the subsequent history of our Medical Department must not be overlooked. Before this was done, it was impossible, in peace, to make any real preparation for war, as the Medical Department had had no men to train, and in the absence of them there was a consequent limitation of the training of medical officers in this respect, since instructors learn by teaching. Cer- tainly it was equally impossible to form essential Medical Department units when there were no Medical Department soldiers for them. The realization of these deficiencies in other armies had, by this time, resulted in the organization of hospital corps. Many of them had maintained service corps, it is true, which we did not. This fact has been a prolific source of mistaken statements about our relatively greater strength of Medical Department enlisted compared with Medical Departments of foreign armies. In most armies, other than our own, service corps constituted an actual part of their Medical Department at all times, thus materially augmenting their strength, without apparently doing so, this service corps personnel being carried as such and not being credited to the Medical Department. A misunderstanding of the above facts has led to the publication of figures showing our Medical Department enlisted strength to be relatively far greater than that of the armies of other nations, which is wholly misleading. In Civil War days the enlisted force of the Medical Department at both front and rear came from the line. According to modern military opinion this was a wholly unjustifiable drain on fighting troops. One who has the curiosity to look into the matter may find numerous instances of line soldiers being retained for many months in hospitals far in the rear when they were perfectly able to serve with their own organizations at the front. Conditions in this respect were somewhat improved later, when the disabled men of the Veteran Reserve Corps became available at hospitals, but they were never entirely corrected; and until the end of the war the Medical Department, having no men of its own, continued to get them from the only source available—the line— to the very great detriment of the line, because of the inroads on strength and also because of its bad influence on morale. Establishment of the Army Medical School. The Army Medical School, projected by Surgeon General Hammond in 1862, was finally established at Washington in 1893.59 The number of medical officers at the time was small (about 190); and the students, assigned to take the full course, were new officers entering the Medical Corps. The number of 46 SURGEON GENERAL’S OFFICE. student officers was correspondingly small, varying from five to eight, during this early period. The course of instruction included lectures on and practical teaching in 60 the duties of medical officers in war and peace- military surgery, the care of wounded in time of war, and hospital administration; military hygiene; military medicine; chemistry; pathology; bacteriology; Hospital Corps drill, and first aid to the wounded. For instruction in Hospital Corps drill, a small Hospital Corps company of instruction was maintained at Washington Barracks.61 This company was originally created at Fort D. A. Russell, Wyo., and was used as a school of in- struction for men enlisted in the Hospital Corps from civil life, as was a similar company at Fort Riley, Kans.61 Field service was not dignified by a special course of lectures at the Army Medical School. Sanitation was rightly emphasized, but the value of chem- istry as applied to the training of medical officers appears to have been some- what overestimated. At about the same time the Army Medical School was organized other plans were put into effect for the better professional teaching of medical officers. The Surgeon General (Sternberg) stimulated a widespread interest in bacteri- ology among the medical officers of the Army 62 and facilitated their acquisition of material for the establishment of laboratories at the different posts; oper- ating rooms were liberally provided; the equipment of post hospitals was brought up to date, and the practice of detailing certain medical officers for duty in large cities, to enable them to do postgraduate work, was instituted. In fact, every effort was made to stimulate medical officers in the exercise of their initiative for professional advancement. Military Training. In the latter years of this period some small maneuvers were held, but never by more than two or three regiments. In these the Medical Department participated in a way. Sometimes, too, the visit of an inspector to a post was characterized by a little maneuver in which the Medical Department was found, but so small in numbers that most situations had to be imagined rather than acted out. The only routine military work of the Medical Department was Hospital Corps drill. In this certain men detailed from line companies par- ticipated as company bearers. The drill consisted of marching with and with- out litters, of dressing, picking up, and carrying patients, and sometimes of loading ambulances, when the quartermaster in whose charge these were could supply animals to bring them to the hospital. Ambulances are spoken of in the plural, but, as a matter of fact, not more than one ambulance was ever found except at the largest posts. From what has just been said it might be thought that the medical officer of the Regular Army of that day had no opportunity for military training as such, except for some elementary Hospital Corps drill. Incident to his life with troops, he acquired some valuable information here and there. He found out that being an Army doctor necessitated having knowledge of many things not concerned directly with caring for patients. He learned how to command men and became familiar with Army business methods. Primary knowledge of medical organization in war was required of him, and was enforced by exam- EVOLUTION OF MEDICAL DEPARTMENT. 47 inations for promotion. He became a good, practical sanitarian for posts and small commands in the field. In these respects at least he had become a specialist. Effect of the Birth of Scientific Preventive Medicine. This period, though one of comparative inactivity in the United States Army, is notable, on the other hand, for being the most active one in all history in the progress of medical science. During this time the germ theory of disease was developed. Before Pasteur’s discoveries practice in the prevention of dis- ease, save for smallpox, was as wholly empirical as it had been with the ancient Hebrews and Romans.63 Much had now been learned about the prevention of intestinal diseases in civil communities,64 but that knowledge was insufficient when applied to armies in the field. We were on the threshold of insect-borne disease prevention, but that field of medicine was actually not opened up until just after the Spanish-American War. During the period under discussion the discoveries in regard to pathogenic microorganisms had been utilized most extensively in surgery, with the result that the technique of clean surgery had been perfected. In military surgery, though the first-aid packet had been developed,65 improvement in the tech- nique of preventing infection in extensive lesions had not progressed far. This was equally true of similar surgical lesions occurring in civil life. Many years were yet to pass before wounds attended with great destruction of tissue were to fall under surgical control. This did not prove a matter of very great impor- tance in the Spanish-American War, for few such wounds then came to treat- ment. While the treatment of infectious diseases, unfortunately, did not ad- vance markedly with the discovery of pathogenic microorganisms, there was some progress in this direction; and diagnosis changed, between Civil War and Spanish-American War days, from a status of uncertainty to one of scientific precision. THE SPANISH-AMERICAN WAR. (1898.) The experiences of the Spanish-American War were of great importance in the development of the Medical Department of our Army. Not because this war taught what to do; on the contrary, it taught most emphatically what not to do. But its lessons were taken to heart; and, based on them, plans were adopted later looking to avoiding for the future the mistakes then made. The Report of the Surgeon General for 1898 affords a fair picture of the medical service in this difficult year. It is a record of unpreparedness, of vague aims, of hasty improvisations of all kinds, of little support from those higher in authority, of partial accomplishment, and of generally unsatisfactory results. This outcome was due to no lack of individual effort, zeal, activity, or energy. On the contrary, on reading the report in question, one can not but be impressed with the fact that, having such meager personnel and equip- ment, the Medical Department was able to accomplish what it did. The Medical Department entered the war without adequate personnel, without sufficient equipment, and without even clear-cut plans on its own part and on that of the War Department. The war ended before these deficiencies had been remedied. Had it lasted longer order would have replaced confusion, 48 SURGEON GENERAL’S OFFICE. as was true in the Civil War, but the end came before this was accomplished. Hence the many criticisms and strictures which followed. Thirty-three years without serious warfare or serious study of warfare had operated to the great disadvantage of the Army so far as organization for war was concerned. The Medical Department, in common with the rest of the Army, had been going on well enough in peace times, and that it could not do so under the greatly in- creased demands of war without greatly increased means did not seem to occur to those responsible for providing such means. There was lack of early appro- priations for the Medical Department, lack of machinery for its war expansion, and lack of cooperation of the component parts of the Army itself. The following information regarding the medical aspects of the .Spanish- American War is taken from the Report of the Surgeon General for the year 1898. This report is the only printed authority in existence for most of the facts. When the war began in April, 1898, medical plans of all kinds—had they existed would have been hampered by lack of personnel and of money, and by an almost total absence of supplies for the field. The number of medical officers, 192, allowed by law to the Army was inadequate in time of peace. This number included the additional 15 assistant surgeons authorized by the act approved May 12, 1898; and this, by the way, was all the regular Medical Department was increased in officer personnel. Later in May there were 13 vacancies. When the various other details had been provided for, but 100 regular medical officers were left for duty with troops. All volunteer regiments had three medical officers appointed by governors of States, or, in the case of United States Volunteers, by the President. Volunteer surgeons to fill the vacancies created by the act approved April 22, 1898, were appointed by the President; eight corps surgeons, with the rank of lieutenant colonel, and 110 division and brigade surgeons, with the rank of major, 5 of the former and 36 of the latter positions being filled by appoint- ment from the Army Medical Department. Under provision of the act of Con- gress approved May 12, 1898, the services of over 650 contract surgeons were engaged. By present-day standards approximately 2,500 medical officers would have been required for an army of the strength of that organized for the Spanish- American War. The actual number was far short of this at all times, and the shortage was apparent everywhere, especially in the field. This alone was fatal to efficiency. In by far the greater number of instances newly appointed medical officers and contract surgeons were wholly lacking in military experi- ence. Nor was the anomalous position and small remuneration of contract surgeons one to attract the highest class of medical men, though it is but fair to say that among them were found many doctors who had given no thought to this and who, in entering the service, had been animated solely by a patriotic desire to serve. On April 25, 1898, in connection with the call of President McKinley for 125,000 volunteers, the Surgeon General (Sternberg) asked for legislation to provide for the enlistment of 1 hospital steward and 25 privates for each regi- ment (about 1,000 men), 1 hospital steward and 5 privates for each battery of Artillery, and 1 hospital steward and 50 privates to serve under the direction of EVOLUTION OF MEDICAL DEPARTMENT. 49 a chief surgeon of each division (about 10,000 men). Congress, however, merely suspended, during the war, the law which restricted the number of hospital stewards at any one time to 100, but limited them to 200. The act of Congress, approved April 22, 1898, authorized one hospital steward for each battalion of each volunteer organization received into the service. These were in addition to the 200 mentioned above. Reliance was placed on the original law of March 1, 1897, and General Orders, No. 58, Adjutant General’s Office, May 31, 1898, for the enlistment in or transfer to Regular and Volunteer regiments of the desired quota of Hospital Corps men. Finally, about 6,000 Hospital Corps men were secured for the Army of 28,000 Regulars and 223,000 Volunteers, a propor- tion of less than 3 per cent. According to present-day standards there should have been approximately 22,500 Hospital Corps men. Similar shortage was everywhere apparent, It resulted in a number of instances in the detail of enlisted men other than those of the Hospital Corps to Medical Department work, thus taking them from their legitimate duties, to the detriment of the rest of the Army. In a report of Col. Charles R. Greenleaf, chief surgeon of the Army in the field, the statement is made that the Surgeon General, in order to get 5 per cent Hospital Corps, the proportion he estimated as needed, was relying in part on the line of the Army, line soldiers having received instruction in first-aid and litter-bearer work. It should be noted that regiments had a larger medical personnel (3 officers and 25 enlisted men for a regiment of from 1,000 to 2,000 men) than did the regiments of 1917 (7 officers and 48 enlisted men to a regiment of about 3,700 men). They were needed, however, for from these detachments worn taken almost the entire personnel for ambulance companies, field hospitals, and other field units, creating a condition of universal shortage, reminding one of the Mexican War. Over 1,700 women nurses were employed on contract; first, only in general hospitals, afterwards at division field hospitals which, of necessity, had been immobilized for the definitive treatment of sick, and thus, by the way. diverted from their proper function of being ready to move with troops. This was due, of course, to the overwhelming number of sick to be cared for and lack of other provisions for them. While these nurses helped notably, it is now conceded that with a better organization their services could have been made of even more value. Medical supplies had been provided for the then peace strength of the Army—28,000 men—and were particularly adapted to post service. Prior to the war no funds had been available to collect a reserve. For months after the war began shortages were apparent, especially in field supplies. Certain of these shortages, notably tentage and ambulances, were in articles provided by the Quartermaster and not by the Medical Department, it is true, but it was equally true that, in common with the rest of the articles needed by sick and wounded, there was a lamentable lack here. Colonel Greenleaf, in speaking of the conditions when the forces were mobilized and when an attempt was being made to organize medical field units, said: “There was lack of material with which to work—tents, ambulances, litters, medical and surgical chests, and a 50 SURGEON GENERAL’S OFFICE. variety of materials absolutely necessary to the establishment of hospitals was not manufactured.” One hospital train was put into service and did good work up to the limit of its capacity. Three hospital ships were finally provided, but only one, the Olivette, extemporized for hospital purposes from a water boat by the equipment of a division field hospital, was available at the Battle of Santiago. A hospital ship was asked for on April 15; this request was complied with by the purchase of the John Engl is. Renamed the Relief after being refitted by the Quarter- master Department, she sailed from New York on July 2, arriving at Siboney on July 7. The third hospital ship, the Missouri, after refitting, sailed from her home port on August 23. The Volunteer Army was organized with the corps as the principal admin- istrative unit. An Infantry corps consisted of not more than 3 divisions, 9 brigades, 27 regiments. Usually it was composed of 2 divisions of 9 regiments each. In numbers it was never larger than the typical 1917 division. The general plan for field medical organization was approved by the major general commanding the Army and was put into operation on May 20, 1898. As con- ditions varied greatly, it was provided that the corps commanders could vary the plan to suit special circumstances. The result of this was a lack of uni- formity in the ambulance corps and field hospitals. Each corps surgeon fol- lowed his own ideas, possibly patterning, in a very general way, after the plans of Letterman. As a rule, in each corps, three or four division hospitals were organized. A circular from the Surgeon General’s Office, dated May 18, 1898, gave some meager directions to medical officers placed in charge of hospital and ambulance units. As no table of organization existed, each corps surgeon was left to his own devices and secured his personnel by transfer or enlistment, got what equipment he could beg, borrow, or take by main force, and improvised a field hospital for each division. General Orders, No. 58, 1898, provided for transfer of enlisted men to the Hospital Corps, and General Orders, No. 76, laid down some rules as to equipment, such as ambulances and tents. Regimental commanders made the Medical Department a dumping ground for undesirable men of whom they wished to be rid; in addition, regimental surgeons generally were opposed to division hospitals and resented the transfer of their men. The organization of field hospitals, therefore, was slow and difficult. Shortages in equipment were responsible for further delay and further difficulties. While the Surgeon General’s Office seems to have appreciated the disadvantages of regimental hospitals, popular sentiment, based on ignorance, made it almost impossible to do away with this archaic organization. As stated elsewhere, division field hospitals were so largely lost to their proper purpose that few were available for such service. The general hospitals were rather better than the division hospitals, but their lack early in the war resulted in the retention of patients in the division hospitals, other hospital facilities not existing. Lack of equipment made it almost impossible to organize ambulance companies. Few were organized and few of these were complete. The allowance of equipment for the field, as embodied in General Orders, No. 76, of June 22, 1898, seems to hark back to the days of 1861. Ambulances were authorized in the proportion of one to each 400 men; wagons, one to each 600 men. The allowance of hospital tents was one for each six patients EVOLUTION OF MEDICAL DEPARTMENT. 51 When 25 enlisted Hospital Corps men per regiment were authorized in May. General Greenleaf planned for each division (about 10,000 men to a divi- sion) a division hospital of 200 beds, with six officers and 99 enlisted men. He also planned an ambulance company for each division, with an allowance of six officers and 114 men to a company. A reserve hospital and ambulance company were also planned for each infantry corps of three divisions. When officers and men were transferred from regimental detachments to form these units, the detachments often approached the vanishing point in size. In a number of corps, the allowance for retention with the regiment was one surgeon, one hos- pital steward, and one private. Progress in carrying the plans for medical field organization into effect was noted by Colonel Greenleaf as early as May, but, as has been previously explained, even at the best was very slow. Col. A. C. Girard, chief surgeon of the Second Corps at Camp Alger, Va., recounted the great difficulty he had met in securing and equipping the hospitals under his command. He did not mention ambulance companies, as he had none. In common with most of the chief surgeons, he organized a hospital company, or reserve hospital company, which was actually a sort of recruit or casual company, to be drawn on generally for hospital or ambulance personnel needs. Col. R. S. Huidekoper, chief surgeon of the First Army Corps at Chicka- mauga Parkj, organized three field hospitals in June and July, 1898. Only the reserve ambulance company was organized. The departure of regiments, thus drawing hospital personnel, interfered greatly with efficiency, while division hospitals tended to become fixed and immovable. When, in July, 1898, the First Division moved to Porto Rico, Colonel Huidekoper wrote: “It was accom- panied by the reserve hospital and ambulance company completely organized with 12 officers, 213 enlisted men, 24 ambulances, 20 Army wagons, and tentage and supplies for a hospital of 200 beds.” Space will not permit a description of the hospitals of the other corps, except the Fifth, which were similar to those of the First and Second Corps. Generally the division hospitals, when organized, became camp hospitals on account of the great number of sick not otherwise provided for, leaving only the reserve units free to move with departing divisions. The Santiago Campaign. The military student naturally turns to the Fifth, or Regular Corps, which carried out the brief operations at Santiago, Cuba. Lieut. Col. B. F. Pope, chief surgeon of the corps, in his report, gives sufficient information for an intelligent understanding of its medical activities. A provisional corps, made up chiefly of Regular regiments, was assembled at Tampa, Fla., in April, 1898. The troops had brought regimental hospitals with them, and these were expanded into improvised divisional hospitals. There were four of these, under command of Maj. M. W. Wood, surgeon; Maj. Louis A. La Garde, surgeon; Maj. A. H. Appel, surgeon; and Maj. George McCreery, surgeon, respectively. The organization of these hospitals was directed, but for lack of time was barely completed at Tampa. To provide personnel for them the regiments were stripped of their Hospital Corps men, only one steward and one private being left to a regiment. But with all this shortage created in regiments field hospitals had not more than five medical 52 SURGEON GENERAl/s OFFICE. officers and 35 to 40 enlisted men each. Tentage was obtained in part from the commands at Tampa, but much of this was old and nearly useless. Badly off as were the hospitals, the ambulance trains were in still worse condition. Two small trains were organized—one of 10 ambulances, secured from the regiments, and one of seven ambulances, obtained no one states how. When the expedition sailed it carried all four divisional hospitals, or a part of each. The sick left behind required some provision, which, in the absence of other hospitals, had to come from those accompanying the combat division overseas. All tentage except flies, all ambulances except three knocked down, all wagons, all mounts except one per officer, and much of the supplies, were left behind at Tampa. When the hospitals were landed in Cuba, not all their supplies could be removed from the transports, and there was no transportation with which to carry them from the beach. Only three ambulances had been landed on July 1; these were the only ones available on the days of the fights at San Juan and El Caney; 10 other ambulances arrived a day or so later. With such inadequate equipment as was at hand Major Wood set up his hospital well to the front, and this was the only real field hospital during the Bat- tle of Santiago. Major La Garde’s hospital was set up at Siboney and did excellent work, but was more in the nature of an evacuation or rather base hospital. There is no report of Major McCreery’s hospital having acted as such. Major Appel’s hospital remained on the hospital ship Olivette. The medical personnel in Cuba was pitifully small. The number of Hospi- tal Corps men proved so inadequate during the engagements near Santiago that the troops had to be depleted to secure litter bearers. In fact, no Hospital Corps men at all were available for such duty. Most of the wounded were car- ried to Siboney in springless wagons, in which straw was used as long as it held out. Their further journey home had to be in troopships, in the main, as hos- pital ships were available for only a limited number. Medical officers were found right up with the troops, however, and to their care and devotion may be ascribed the generally favorable outcome of wounds. Most of these, fortu- nately, were caused by the small bullet of the Mauser, so the first-aid packet was at its very best. Notwithstanding the many difficulties, the wounded, as a whole, did very well. As a matter of fact, it was the sick and not the wounded that proved the more serious problem. Malaria and yellow fever in severe form attacked the troops as soon as they landed in Cuba. On August 3, the corps commander summoned all the general officers and chief surgeons of divisions to a conference. The unanimous opinion was expressed that the Army was in a deplorable condition on account of illness, and that to prevent its ultimate destruction its immediate removal from Cuba must be effected. The Army was withdrawn and the expedition thus came to an end. Fortunately, its main object had been accomplished. In the Spanish-American War, notwithstanding the fact that good models of medical department organization were available to us, among them that of Letterman, which was the basis of all modern methods, we failed to avail’our- selves of them in so far as the prevention of disease in troops was concerned. That is to say, by taking advantage of what was already well known, we could have created, in the Spanish-American War, a medical organization capable of repeating in this direction our triumphs in the Civil War. Regarding sani- EVOLUTION OF MEDICAL DEPARTMENT. 53 tat ion in the field in such a country as Cuba, the situation was far different from anything to which the Army was accustomed. Malarial and yellow fever were endemic there in 1898. Scientific knowledge of how to present them was lack- ing at that time, so they must have spread widely, irrespective of anything we could do. It was the same with typhoid fever in the camps in the United States. Previous to the Spanish-American War it was believed that typhoid was mainly a water-borne disease, and the natural presumption was that if good water could be supplied at camps they would be free from typhoid fever. Typhoid was widely introduced into the camps, however, for it was a much com- moner disease throughout the country then than it is to-day. Within the camps it spread like wildfire, not generally through the water supply, but, as shown by the Reed-Yaughan-Shakespeare Board, by contact from sick to well, through the medium of the fly.66 While the important part played by man-to-man transmission and by the fly as an agent in the spread of typhoid were established by these investigators, the role of the human chronic carrier was not appre- ciated at that time. The discoveries made by this board were of great mo- ment, though their practical importance was minimized later through the devel- opment of the method of preventing typhoid fever by vaccination. Then, as now, the problem of respiratory diseases was a sealed book, but, fortunately, so far as these were concerned, the war was in summer. One other point is noteworthy here. Between Civil War days and those of the Spanish-American War a considerable change seems to have taken place in military circles with regard to the need for physical fitness in officers and soldiers. Physical standards were apparently not considered a matter of very great importance in Civil War days. At least we know that many hundreds of unfit men were taken into the Army then. Complaints were very general of men who not only were unfit to fight but who served only to encumber the roadsides, and ultimately to fill badly needed space in hospitals. Nor, appar- ently, was any physical examination required on separation from the service. Conditions in both respects were much better during the Spanish-American War. While numbers of physically unfit men did slip into the Army then, this did not occur to nearly the extent that it did in the earlier war. For the first time in our service a physical examination was conducted on discharge.67 Through this, evidence was provided for the adjudication of any future claims by ex-soldiers against the Government. This was not a matter having to do with military efficiency, to be sure, but it was of great importance from the standpoints of equity and economy. Voluntary aid in the Spanish-American War played a not inconsiderable part in Cuba and at Montauk Point, to which the crippled Army in Santiago was brought. At these places it was almost lavish; elsewhere, its role was rather a minor one. Even when most generous, organization and cooperation with the Medical Department were lacking. SOUTH AFRICAN WAR. (1899-1901.) The South African War apparently found the British almost as inade- quately prepared for serious warfare as the Spanish-American War found us. Just as was the case with our Medical Department in 1898, their medical 54 SURGEON GENElLVL’s OFFICE. department was organized and administered for peace and for minor expedi- tions,68 and when the strain of war came was not able to cope with it. Just as with us in the Spanish-American War, many medical officers did fine work individually, and a great deal was accomplished with what they had; but, as with us, they had far too little. Then, too, in South Africa, just as in our home camps in 1898, a frightful epidemic of typhoid fever occurred.69 It was in the South African War that typhoid vaccination was first tried out.70 While it was not a proved success then, its later development was based in part on this pioneer work. The reorganization of the Royal Army Medical Corps on modern lines dates from the South African War. That it was very successfully accom- plished is manifest by its readiness for the World War. This reorganization involved no startling changes, but was based on the provision of adequate personnel, both officers and men, adequate supplies, sound education and training, and such additional authority for their medical department as would enable it to perform duties devolving on it by law and regulations. The South African War also had an important effect, to be noted later, on field medical organization. In the British service the first bearer company was improvised in 1879, and the first regularly organized company was seen in 1880. When the South African War began in 1899, the only field units were the bearer company and field hospital.71 Of these, there was one of each to a brigade, with additional reserve hospitals for divisions and corps. There were also stationary hospitals with no evacuation (or clearing) hospitals.71 Organized field service, with transportation plans, therefore, may be said at this time to have practically ended at the field hospitals. Back of them the wounded were handled by no definite organizations, though hospitals were established in the rear of field hospitals and on the lines of communication. Often these hospitals were improvised; usually they were fixed. From them the wounded were taken to the bases by hospital trains or other means. Subsequent to the Boer War the British studied their Army medical service in the light of observations made and some important changes were effected.72 Two of the most important of these were: The combination of bearer company and field hospital to form the “field ambulance” and the formation of an entirely new unit, the ” clearing hospitals.” The field ambu- lance was created by Army order of March, 1905, and the clearing hospital by Army Order No. 174 of 1907. One clearing hospital, with 102 officers and men and 200 beds, was authorized for each Infantry division of about 12,000 men. The clearmg hospital was made the most advanced formation of the lines of communication; not an Army unit. Its functions were governed by Field Service Regulations, Part II.

RUSSO-JAPANESE WAR.” (1904-1905.)

From the medical department standpoint the Russo-Japanese War was much greater and more important than the South African War. The Japanese medical department was well organized on German lines. It is curious that Letterman’s organization went around the world to come back to us through a nation which, in Civil War days, had no army from the modern standpoint. From front to rear the Japanese had a well-organized medical department, EVOLUTION OF MEDICAL DEPARTMENT. 0 0 superior to Letterman’s in that the line of communications was well provided for. Evacuation from field hospitals was attended to hy reserve medical personnel, as the Japanese term has been translated, but which actually con- stituted evacuation hospitals. Their organization and administrative details were carefully studied and were made use of in our subsequent regulations, but even more important was the lesson learned from their experience of what a great increase of numbers in medical personnel is needed for modern warfare. When the statement was first made in this country that 10 per cent of medical personnel would be required in serious warfare, few could be found who believed that this percentage was not excessive. At the same time, it was calculated that 1 per cent of the total personnel must be medical department officers. These estimates, established by Japanese experience, have certainly been borne out, and were regarded as essentially correct when we entered the World War. The Japanese, too, had a very clear idea of the value of the medical department in sustaining the morale of troops at the front, and carried it out by always providing surgical service at the front line, even at the considerable sacrifice of medical personnel due to the bullets of the enemy. While the exact methods are of less importance now, through discoveries made in the meantime, the Japanese, it should never be forgotten, set a very high standard of sanitation for troops. The importance of good sanitation was announced in military orders in somewhat the following words: “It is realized that the Russians have more men than we have. On the other hand, it is believed that we can save a great many men to the ranks through more effective sanitation than the Russians practice; therefore, in this way matters can be evened up.” The actual sani- tary accomplishments of the Japanese were of a very high order, save for one disease alone—beriberi—from which their Army suffered very severely. At that time the cause of beriberi was unknown, another proof that sanitation to be effective must be based on specific knowledge of how preventable diseases are to be combated and not on omnibus measures. Very possibly no army even yet has paid more attention to the instruction of the individual soldier in personal hygiene than the Japanese. In the Japanese Army the Red Cross in war disappeared into the medical department, where it rendered very efficient service as a part of that department. Practically nothing was learned from Russia’s part in this war. Well equipped professionally as many of its physicians were, their services were largely frittered away through bad organization. Their army was probably th(T last, except the Austrian, to retain nonmedical officers in command of medical units, though regulations to put all such units under the command of medical officers had been published shortly before the war. It was then too late, for it was not to be expected that doctors could at once assume wholly foreign duties of a complicated nature without special training or experience. The independent status of the Red Cross resulted in a good deal of confusion.d A unique opportunity was presented by this war to compare the influence on morale of a well-organized medical department at the front with an ill- organized one. The Japanese had a complete organization for each division, consisting of a regimental service, a large sanitary company, and four field /Reference has been made to the fact that the only great army in which the Red Cross worked more or less independently was the Russian  hospitals (normal); the Russians had nothing of the kind.

That is to say, in theory they had an organization which, while not exactly like the Japanese, should have been capable of giving a good account of itself. None of the links in the chain was missing in theory, but actually they lacked here and there in the majority, if not in all, of their corps and divisions in combat. At Mukden, while the Japanese medical department could be depended on to take care of wounded, this was not the case with the Russians. This resulted, notwith- standing the fine fighting qualities of the Russian soldier, in enormous losses in fighting effectives. In the sanguinary combat at Li-Kwan-Pou, for example, the Russians lost hundreds of unwounded men who escorted their wounded comrades to the rear, no medical department agency being on hand for this purpose. The Japanese losses in fighting effectives due to this cause were negligible.

THE DAY OF LARGER THINGS IN THE UNITED STATES ARMY.

The period from the Spanish-American War to the World War was char- acterized by more serious military study and greater accomplishments in definite organization, with closer coordination of the various branches making up the Army, than any other like length of time in our history as a nation. Progress was as notable for the Medical Department as for the Army as a whole. In fact, with the former so much was crowded into these comparatively few years, many activities going on simultaneously, that it is impossible in this account wholly to separate these progressive activities one from another, at the same time preserving chronological sequence. Organization of the General Staff. The effect on the Medical Department of a revolutionary change made in the organization of the Army shortly after the Spanish-American War must be explained in so far as is pertinent to the present discussion. This change involved the creation of the General Staff,74 whose paramount duty by law was preparation for war and the coordination, to this end, of the various ele- ments making up the Army. Our previous history shows how revolutionary this change was. Formerly, in peace, there was absolutely no intelligent prepa- ration for war, nor could there well be. In fact, despite a very high class of personnel, before the Spanish-American War the true objective of the Army had been lost sight of. Each branch of the Army independently did good routine peace work, it is true, but from the modern standpoint we had no army at all, neither did we have any plans for an army. Moreover, with the independent status of the various elements making up our land forces, even if one of them had worked out the best possible plans for war, this would have led nowhere because effective organization of any army is de- pendent on cooperation and not independence. Therefore, the departments concerned would have been quite at a loss as to what other branches would and could do—even if they were vitally affected—and there was no ma- chinery for finding out. The General Staff coordinated the various branches of the service and prepared Field Service Regulations which governed the entire Army. This does not mean that the General Staff was responsible for all the improvements effected in the Medical Department between 1898 EVOLUTION OF MEDICAL DEPARTMENT. 57 and 1917. However, it greatly stimulated the preparation by the Medical Department of plans for war. After these plans had been submitted to and possibly modified by the General Staff to meet the general plans, they were finally approved by it for embodiment, as far as possible, in regulations, thus giving certainty instead of uncertainty. The Medical Department still remained very largely dependent on its own exertions for everything affecting its interior organization and operation, including appropriations for its support, though, as always had been the case, all larger plans required the approvar of the Secretary of War. As time went on, the successive Secretaries doubtless sought more and more the advice of the General Staff on such matters. For the great part of this time a medical officer was detailed on the General Staff, and usually had an opportunity to express an opinion on matters affecting the Medical Department. The character of service as a whole for all medical officers differed totally in the period between 1899 and 1917 as compared with that before the Spanish- American War, for in the earlier time instruction for war was almost totally wanting, due to small posts, lack of opportunities, and even the realization of what modern warfare involved in the way of medical preparation. The very circumscribed field of medical officers then, as a matter of fact, is hardly realiza- ble to-day. After the Spanish-American War and the acquisition of foreign territory, the field immediately changed to almost a limitless one so far as opportunities were concerned. These opportunities, it is true, did not con- stitute war experience, but the constant dealing with large affairs proved no mean preparation for war. Dodge Commission. At the close of the Spanish-American War, President McKinley appointed a body, commonly known as the Dodge Commission, to investigate the conduct of the war.7″‘ During their investigation this commission made a careful study of the operations of the Medical Department and embodied their conclusions in seven recommendations, as follows: 76 What is needed by the Medical Department in the future is: 1. A larger force of commissioned medical officers. 2. Authority to establish in time of war a proper volunteer hospital corps. 3. A reserve corps of selected trained women nurses, ready to serve when necessity shall arise, but, under ordinary circumstances, owing no duty to the War Department, except to report resi- dence at determined intervals. 4 A year’s supply for an army of at least four times the actual strength of all such medicines, hospital furniture, and stores as are not materially damaged by keeping, to be held constantly on hand in the medical supply depots. 5. The charge of transportation to such extent as will secure prompt shipment and ready delivery of all medical supplies. 6. The simplification of administrative “paper work,” so that medical officers may be able to more thoroughly discharge their sanitary and strictly medical duties. 7 The securing of such legislation as will authorize all surgeons in medical charge of troops, hospitals, transports, trains, and independent commands to draw from the subsistence department funds for the purchase of such articles of diet as may be necessary to the proper treatment of soldiers too sick to use the Army ration. This to take the place of all commutation of rations of the sick now authorized. . Convalescent soldiers traveling on furlough should be furnished transportation, sleeping berths or staterooms, and $1.50 per diem for subsistence in Ueu of rations, the soldier not to be held accountable1 or chargeable for this amount. 58 SURGEON GENERAL’S OFFICE. Attention was also called to the need of a special corps of medical inspectors (such as had been found necessary during the Civil War).78 When Gen. R. M. O’Reilly became Surgeon General in September, 1902, he adopted these recom- mendations as the policy of his administration. How earnestly and successfully General O’Reilly devoted himself to the carrying out of this program is shown in the last annual report signed by him, that of 1908,77 in which he took up these recommendations one by one and showed that practically all had been carried out. As a matter of fact, as will be seen later, the Medical Department in these eventful years did not stop with these recommendations. Progress was far more notable than it would have been by slavish adherence to their text. Not only was advantage taken of our own recent experience, as outlined in these recommendations, but a serious study was made of the organization of the medical departments of armies, including our own in the Civil War. Then plans, so far as they would help us, were finally adopted. The steps taken to carry into effect recommendations Nos. 1, 3, and 4 will now be discussed in detail. Such simple treatment of what was done relative to the other recommendations is not possible; but, as has just been ex- plained, and as will be more apparent later in the course of the narrative, similar, though not so direct, action was taken to put them into effect. One need not search, however, for an account of any great simplification of paper work. Yet it will be seen that forms were changed to meet conditions, which was not the case at the time of the Spanish-American War. A Large Force of Commissioned Medical Officers. After the Spanish-American War the Army experienced a reorganization which was supposed to embody the lessons of the war. In accordance with act of Congress approved February 2, 1901, the Army was increased in size to a pos- sible maximum of 77,287, and was modernized in many ways. The Medical Department was increased in numbers. The Army Nurse Corps was authorized. But, aside from this increase in strength, the Medical Department really benefited not at all by this reorganization. Surgeon General Sternberg had made carefully prepared recommendations, which were disapproved by the War Department, and for them was substituted an organization which not only failed to provide for the peace needs of the Army, but destroyed any hope of future development of the Medical Department for war. Apparently the act of 1901 expressed the opinion of neither the Secretary of War nor the President. This was shown by Secretary of War Root’s recognition of its defects and by a fine indorsement of the bill prepared by Surgeon General O’Reilly, in 1904, to rectify its provisions relating to the Medical Department. The attitude of the President, Theodore Roosevelt, was expressed in a special message sent to Congress recommending amendment of this act, as follows: 78 To the Senate and House of Representatives: I have, in a former message, stated to the Congress my belief that our Army need not be lar^e, but that it should in every part be brought to the highest point of efficiency. The Secretary of War has called to my attention the fact that the act approved February 2,1901, which accomplished so much to promote this result, failed to meet the needs of one staff department in which all of our people are peculiarly interested and of which they have a right to demand a high degree of ex- cellence. I refer to the Medical Department. Not only does a competent medical service by safeguarding the health of the Army, contribute tTeatly to its power, but it gives to the sons who are wounded in battle or sicken in the camp not only skilled medical aid, but also that prompt and well-ordered attention to all their wants which can come only by an adequate and trained personnel. I am satisfied that the Medical Corps is too small for the needs of the present Army, and there- fore very much too small for its successful expansion in time of war to meet the needs of an enlarged Army and in addition to furnish the volunteer service a certain number of officers trained in medical administration. A bill which, in the opinion of the Secretary of War, of the late Secretary of War, and of the General Staff of the Army, supplies these deficiences was introduced at the last session of (Vin^ress, and is now before you. I am also advised that it meets with the cordial approval of the medical profession of the country. It provides an organization which, when compared with that of other nations, does not seem to err on the side of excessive liberality, but which is believed to be sufficient. I earnestly recommend its passage by the present Congress. If the Medical Department is left as it is, no amount of wisdom or efficiency in its administration would prevent a complete breakdown in the event of a serious war. I transmit herewith a memorandum which has been prepared for me by the Surgeon General of the Army, and also the remarks of the former and of the present Secretary of War with reference to this bill. ******* Theodore Roosevelt. White House, January 9, 1905. Medical Department Reorganization of 1908. It was not until 1908 that a law was passed 7!) which restored the number of medical officers to the same proportion of army strength which had existed approximately for 40 years, and also the long-established proportion in each grade, both of which had been seriously diminished by the act of 1901. These proportions, however, where not made automatic, and in consequence the Medical Department failed to grow with the various increases of the Army, until, by 1916, it had again become inadequate for the performance of its duties. By the national defense act of June 3, 1916,80 which will be discussed at length later, the number of medical officers and enlisted men of the Medical Department, for the first time, was placed on a percentage basis, so as to increase or diminish automatically with the authorized strength of the Army, i. e., seven medical officers per thousand, and 5 per cent enlisted men, of the authorized enlisted strength of the Army, exclusive of the Medical Depart- ment. By the creation of a workable and efficient system of examinations for promotion, with the elimination of dead wood, the law of 1908 added greatly to the efficiency of the Medical Department and to its readiness for the great task which it was to undertake in the World War. The deplorable condition which existed in the Medical Department in securing candidates for commissions (1901-1908), when the applicants finally approached the zero mark, was the subject of a good deal of comment in medical circles. The medical profession of the country had been pretty well stirred up, too, bv the unfortunate occurrences in Spanish-American War days. On the other hand, the 1901-1908 period was characterized by epoch-making sanitary work by Army medical officers. This, of course, attracted wide attention from their brothers in civil life. So, as a very important result of the struggle to rectify conditions, due to the act of 1901, a strong bond of union was created between civilian and military doctors. Never since then has the medical profession of the Army been regarded as a thing apart, but rather as representing one of the specialties which constitute American medicine as it 60 SURGEON GENKRAL’S OFFICK. is practiced to-day. The civilian medical profession of our country also recog- nized then, perhaps for the first time in peace, that they had a special obliga- tion as doctors, by virtue of their special knowledge of medical requirements, to use all legitimate means to insure that their representatives in the Army should be of such a strength, of such professional capacity, and so organized as to constitute a reasonable preparation in this particular for future war. That their interest in these subjects was a proper one is indicated by President Roosevelt’s letter, quoted above. The Medical Reserve Corps. The law of 1908, however, went further than merely the improvement of the regular corps. By the creation of the Medical Reserve Corps, it brought the Medical Corps of the Army into still closer touch with the medical profession in civil life and prepared the way for the vast expansion which it was called upon to undergo nine years later, by which it grew from 445 to 30,591 medical officers, and the total personnel of the Medical Department to 281,341,81 almost three times the strength of the entire Army a few years before the beginning of the World War. This was pioneer legislation, being the first integral volun- teer reserve for war ever organized in our Army. Its advantages were soon appreciated and imitated, first by the Medical Corps of the Navy, and later by the Army through the national defense act of 1916, which adopted this principle for the line and all the staff departments. It is impossible to overestimate the importance of the creation of the Medical Reserve Corps, and only those who witnessed the confusion and inefficiency of the small Spanish-American War mobilization can visualize what would have happened without it in 1917. An early effect of this law, of great importance to the Medical Department, was brought about by a considerable number of the best-known doctors in the United States who, being commissioned in the Reserve Corps, exerted their influence in obtaining a very high class of candidates for the Regular Medical Corps. Reserve Nurses. Much difficulty and little success attended the first attempts to organize a reserve for the Army Nurse Corps. A way was found through the ability and patriotic devotion of the superintendent of nurses, Miss Jane A. Delano, who conceived the idea that a common reserve for the Army and Navy might be organized through the agency of the American Red Cross.82 She resigned her position in the War Department and devoted herself to this great work as a volunteer, without salary, until her death in France in March, 1919. Having the support and confidence of the nursing organizations and the nursing pro- fession, she built up an admirable organization which had enrolled, when the United States entered the World War, over 7,000 nurses, and which supplied to the Army during the war nearly 18,000,Si the character and qualifications of each being carefully investigated before appointment. Medical Supplies. One of the first questions studied after General O’Reilly became Surgeon General (1902) was that of medical supplies.84 After a careful study of the evidence as to what was lacking during the Spanish-American War, it became  evident that the majority of articles of medical supply could usually be obtained in the markets of the United States in sufficient quantity and that the shortage at the time of the Spanish-American War was due largely to lack of foresight and boldness in making purchases and to defects in the methods of distribution. Every article in the supply table was looked up to determine the available supply procurable within 30 days, and an estimate was made of the amount needed for armies of various sizes. The sources of supply were also investigated. Medical and hospital supplies were thus divided into two classes, of which the first and larger could always be obtained in the United States in sufficient amount, being the drugs and supplies habitually used by the medical profession. The second list comprised chiefly articles intended to meet the special require- ments of the military service not kept in stock by commercial houses and requiring manufacture on order. These included, of course, field chests, field equipment, and the drugs and dressings specially prepared for field use. Of these a reserve supply for war was evidently needed, it having been found that the field chests ordered at the beginning of the Spanish-American War were not delivered by the contractors until after its close. These conditions of supply, although generally true, did not apply altogether to the quite abnormal com- mercial conditions which obtained in 1917, when the United States entered the World War. Available stocks in the world’s market had been exhausted by the war demands of Europe, and prompt deliveries of even standard articles were difficult to obtain. Yet by the plans made it was possible to surmount even these difficulties. In the year 1908 Congress made an appropriation of $200,000 for the purchase of field equipment.85 Similar appropriations were made in the follow- ing years, so that in 1916 the Surgeon General’s report showed the following units of equipment on hand: 

Evacuation hospitals…………………………………………………………. Base hospitals……………………………………………. Field hospitals……………………………………………………………… Ambulance companies……………………………………………………. Regimental infirmaries………………………………………………………. These units were complete except that they were without transportation of any kind. Vnother preparation for war which falls well under the present headmg, •is it hid to do with supplies in respect to the shelter of the sick and wounded, was the preparation of building plans for temporary hospitals. These were published in detail by the Surgeon General’s Office in 1906.86 Field Medical Supply Depots. With the beginning of General O’Reilly’s administration a study was made of the field equipment on hand with reference to its storage and readiness for issue. That which was obsolete and unserviceable was e hminated. It was found that in the medical supply depots in New York and St Louis which were those especially depended on for current medical supplies m time of peace the war supplies and field equipment were so mixed up with routine hospital supplies that promptness of issue was impossible. To separate the.two classes at the New York medical supply depot, it was necessary to close the depot for 62 SURGEON GENERAL’S OFFICE. several months to permit the employment of its personnel exclusively on segre- gation. It was soon determined, therefore, that efficiency demanded the establishment, for the field supplies, of depots separate from those for current issue in time of peace. A beginning had already been made under Surgeon General Sternberg by the organization of a field medical supply depot in Wash- ington.87 This principle was adopted, and was greatly extended during the first four years of General O’Reilly’s administration; and a systematic plan was adopted for the assembling of regimental and field hospitals complete, with ordnance and all quartermaster supplies, including tentage, but excepting transportation.87 Field medical supply depots were established at Washington, St. Louis, San Francisco, Manila, and, later, at San Antonio. These depots were prepared to issue, on telegraphic order, all equipment and supplies neces- sary for an expeditionary force of several divisions. Under succeeding admin- istrations, the Supply Division of the Surgeon General’s Office steadily advanced and developed in efficiency, until it was able to meet, with remarkable success, the vast demands and difficulties of the World War. Prompt Shipments. An amusing and unexpected result of this preparedness occurred when an expeditionary force was sent to Cuba in the fall of 1906. The medical equipment and supplies shipped by express arrived at the port of embarkation far in advance of any other supplies and naturally were stored in the farthest extrem- ity of the warehouses at Newport News. The more slowly arriving supplies for the Quartermaster and Commissary Departments were piled up in front of them, with the result that when the transports were loaded those which last arrived, being nearest the doors, were shipped first and the medical supplies, which arrived first, were shipped last of all. In the World War, however, this same readiness of shipment stood the Medical Department in good stead, for its supplies, arriving at ports first, were shipped first, and found abundant cargo space in the transports, because the more bulky supplies of the Quartermaster Department were slower to arrive. Furthermore, at first the demand on cargo space was not so great as it was later, when troops with their equipment were shipped in great numbers. Field Regulations and Tables of Organization. At the time of the Spanish-American War no Field Service Regulations existed. With their publication and with that of other official publications based on them the recommendations of the Dodge Commission, so fai as they were pertinent, were put into effect in a better manner than was or could be contemplated at the time these recommendations were made. Field Service Regulations for our Army were first issued in 1904. They had been preceded much earlier by a small booklet, entitled “In Campaign.” This was of little value for any purpose, and in it the Medical Department, to all intents and purposes, was totally neglected. In the first Field Service Regulations, however, the medical service was adequately treated. Besides the regimental allowances, four field hospitals and four ambulance companies were provided for each infantry division. Editions of the Field Service Regula- tions were issued from time to time. The last before the World War was pub- EVOLUTION OF MEDICAL DEPARTMENT. 63 lished in 1914, and later corrected to April 15, 1917. Tables of Organization, first published in 1916, prescribed the organization for the Army. Before and during the war these tables were changed and amended as proved necessary. At first the Field Service Regulations included organization data, but later these were placed in the Tables of Organization, which were held confidential. With the succeeding issues of the Field Service Regulations and the Tables of Organi- zation, some changes naturally were made in the text relating to the duties of the Medical Department and in its allowances. The subject is too large a one for discussion at length here. Yet it should be understood that the plan followed was to include in Field Service Regulations only such material relating to the Medical Department as was of importance to the Army as a whole. Matters of interest to the Medical Department only were found in the Manual for the Medical Department. The student is referred to these various publications for detailed information. Of course, it was not permissible to allow the medical manuals to differ from the Field Service Regulations or from the Tables of Organization. In fact, in the later manuals the greatest care was taken to make sure that the medical officer in reading the manual would not be confused by even the slightest diversion from Field Service Regulations; however, as the latter were devoted to the division at the front, and as a great part of medical service in campaign has to do with the line of communications, in point of fact the medical manuals had to cover ground barely stirred by Field Service Regulations. For those who have the curiosity and industry to study in detail the prog- ress of medical organization in our Army in the 20 years before the World War, it may be of interest to look over the successive manuals of the Medical De- partment that were issued during that period. The thin volumes bearing dates prior to the Spanish-American War were written from the viewpoint of post administration solely; war was a contingency for which no provision was made beyond a few vague phrases and the provision for field chests for field service. In the manual published in 1898, the duties of medical officers in the field are given in one paragraph, and three are given to the duties of the Hospital Corps in war. The manual for 1900 gives two paragraphs to the regimental hospital in field service. That of 1902 shows a great step forward in giving the sanitary organization, personnel, and transportation for a division of 18,000 men, three field hospitals and three ambulance companies being allowed to it. By 1906 the manual had grown to larger size, and its treatment of field medical and sanitary service occupies 36 pages, exclusive of field supply tables. It covers fairly well the main principles of field organization and administration, and gives in detail the personnel, transportation, and tentage for sanitary units. Another very long step in advance was taken by the edition of 1911. Part II of this book’is an admirable treatise on medical service in campaign, covering SI pages, and bringing the whole subject well up to the date of publication. The duties of medical officers of all grades, the details of organization of medical units, the general scheme of operation of the Medical Department m war, and the lists of field supplies are all given in great fullness and detail. In the prepa- ration of this edition of the manual, for the first time great pains were taken to reconcile all differences with Army Regulations and Field Service Regulations which had crept in from time to time. 4.~i270°—23—–.” 64 SURGEON GENERAL’S OFFICE. The manual used during the World War was placed in the hands of medical officers just one year before we entered it. The Medical Department field service is little changed from the 1911 manual, but in this edition appears, for the first time, provision for the use both of organized and individual voluntary aid and a full discussion of the assistance which the American National Red Cross would be expected to give the Army, in accordance with the act of April 24, 1912. That the Red Cross did not create the exact units or function in exactly the way prescribed in the manual was due to its organization while the manual was in press, and to the rapid development of its military side during the year 1916, all of which is explained in detail subsequently. Although the Army underwent a reorganization during that eventful year, and many changes of administrative method were made in France, the 1911 manual, so far as it went, supplemented, as noted, by the 1916 edition, was prepared with such care and precision that it proved to be applicable with amazing completeness to the conditions of medical administration in the World War. Hand in hand with the work on the various editions of the Manual for the Medical Department, modifications and changes were effected in the blank forms used in medical administration. Little need be said on this particular subject here except in regard to one most important form. Save for that one it may be dismissed with the statement that these changes finally produced results which proved of practical value when a great war came and that the enormous expansion which followed showed little need for modifications. In Civil War days, and long subsequently thereto, a great book was used for the register of all individual records of disease or injury. The report on the subject was at first numerical, and subsequently nominal, then being made on detached sheets of similar size to the pages of the register. Each register or report, as the case might be, of course, carried many different names on each page, which subse- quently had to be carded in order to get together the sick record of officer or or man concerned. After the Civil War, with its enormous number of patients, a truly tremendous work had to be done in straightening out these records for pension purposes. Years were consumed in preparing the statistics for the Medi- cal and Surgical History of the War of the Rebellion because of the need to extract the required information from numerical reports. In 1905 the Medical Department substituted individual cards for the old register and report of sick and wounded sheets.88 No copying of sheets to cards was therefore required in the World War. This actually proved a saving of much time in compiling statistics as well as the saving of tens of thousands of dollars. The thought underlying the recommendation of the Dodge Commission regarding the simplification of “paper work” is apparent, and doubtless a great deal of time which was badly needed for the performance of other duties more nearly connected with the sanitation of camps and the professional care of ill and injured was employed in preparing the various reports required of Spanish- American War medical officers. Yet rather voluminous records are regarded as essential to any great business; nor has the medical department of the army of any nation been able to escape the burdensome task of preparing them— our own, rather less than that of any other nation, on account of our liberal pension laws, which involve losses of millions of dollars if careless work is done here. Better forms, however, were adopted for this purpose, and simpler EVOLUTION OF MEDICAL DEPARTMENT. 65 methods of accounting were put into vogue, as well as simplification in some other directions. PROGRESS IX ORGANIZATION FOR WAR. While perhaps the most important service performed by the Field Service Regulations, the Tables of Organization, and the newer editions of the Manual for the Medical Department was bringing real order out of just as real chaos, of course their successive editions recorded developments made from time to time in military practice. These will be discussed here only in so far as the Medical Department is concerned. To do this it is necessary to recall the experience of the other nations which were then engaged in war, as given briefly in the accounts of the South African War and the Russo-Japanese War, for, as already indi- cated, the development in our Medical Department organization was partially based on their experience—very largely so in certain particulars. Completion of Our Evacuation System. As previously indicated, the chief detail in medical organization that was brought home to us by the South African and Russo-Japanese Wars affected the lines of communication and primarily the most advanced unit there, which was ultimately named in our service the evacuation hospital. By us two evacuation hospitals, of 324 beds each, were provided for each division of about IS,000 officers and men.89 It was planned to have them moved by rail, but the invention of the motor truck made it possible to move them across country, away from the railroad. An evacuation ambulance company was also provided to bridge the transport gap between field and evacuation hospitals at the railhead.

These units belonged to the line of communications. By 1910 our evacuation system was complete in plan, from battalion aid station at the front to base hospital at the rear.91 There was for the first time a complete relay of definite and permanent units (in theory and plans) so manned and equipped as successfully to handle the wounded man from the time when his injury was received until he could be placed in a permanent hospital in the area of distribution. Plans preceded organization, however, as further study of the text will show. Actual Organization of Medical Field Units. The idea that an army in time of peace, when there were no wounded to be rescued, should have organized and equipped ambulance companies and field hospitals was difficult of acceptance in our service in the early years of this century. While it was clearly apparent that companies of infantry and bat- teries of artillery should be trained in peace time, when there was no enemy to fight, no like necessity could be seen for medical units. Consequently, it took many years to get such units organized and trained in advance of war. The need for them was demonstrated in the maneuvers which took place from time to time, and it is interesting to see how, in the earlier ones, the medical service was represented by weak detachments, intended solely for the care of the cases 66 SURGEON GENERAL S OFFICE. of sickness that might develop in the command. Later, it began to be recog- nized that the Medical Department had its own tactical questions which had to be taken into consideration for the satisfactory solution of military problems, and additional medical personnel was allowed for use in making up provisional medical units to participate in the maneuvers. Finally, it became clear to everyone that units which were necessary as soon as troops took the field should have a permanent organization and place in the Military Establishment. In the National Guard.—Subsequent to 1365, the first Medical Department field unit to be organized and mustered into service appears to have been a field hospital of the New York National Guard. A State law of 1905 authorized such a unit.92 The record of the adjutant general’s office, State of New York, shows that the first field hospital was mustered into service on March 14, 1906. It was attached to division headquarters at 56 West Sixty-sixth Street, New York City. The first ambulance company, authorized on December 10, 1910, was reorganized as a field hospital on November 29, 1911. The first permanent ambulance company was authorized November 29, 1911, and was organized at Binghamton on the same date. The first field hospital went into camp at Peekskill, N. Y., with equipment and transportation, during July and August, 1906. This was on field duty each year until 1916; then on the Mexican border; and in 1917 was drafted into Federal service for the World War. To the State of New York, then, belongs the credit for organizing the first modern field hospital unit in this country. It was not, therefore, in the Regular Army but in the National Guard that medical field units were first provided. The organization of field medical units in the National Guard was much stimulated by the detail of a medical officer for duty with the Militia Division. This detail was obtained by the Surgeon General in July, 1910.93 Records show the status of the sanitary units of the militia to have been as follows: Field hospitals……… Ambulance companies. 

Most of these, so far as organized by 1916, served on the Mexican border.
Immediately thereafter discharges were generally taken so freely that many
of these organizations became meager skeletons. With the beginning of the
World War they were quickly recruited up to strength, often, to a considerable
extent, from their old officers and men. While ready in a sense, when we
entered the World War, very few of these organizations were ready for instant
service, as were similar organizations of the Regular Army.
In the Regular Army.—In the year 1911 Hospital Corps companies (see
Hospital Corps Companies of Instruction, infra), as such, disappeared, and the
field hospitals and ambulance companies, so long planned, at last materialized.98
The change was authorized by The Adjutant General on April 17 1911. There
had been up to this time four Hospital Corps companies of instruction desig-
nated Company A, B, C, and D, respectively.98 By the reorganization,
effected in 1911, they became, first, Field Hospital and Ambulance Companies

The ambulance companies were formed from the respective parent organiza-
tions by a division of personnel, that portion remaining being designated a
field hospital and continuing the records of the parent organization.

These were all in the United States In 1916 Ambulance Company No. 9 was organized in the Hawaiian Islands.101
These complete the lists of units organized before April 6, 1917, on which date
there were six field hospitals and seven ambulance companies (Regular Army)
in the United States proper. These 11 organizations had reasonably complete
equipment and transportation. They formed the divisional evacuation service
which was ready at once to take the field when war came and when the first
important General Staff decision called for 40 combat divisions.

Instruction.

After the Spanish-American War it was well appreciated that both officers
and men of the Medical Department should receive more thorough military
instruction than was previously required. The Army Medical School at Wash-
ington continued to serve a useful purpose, it is true, but its course was intended
primarily to supplement the professional knowledge of newly entered medical
officers of the Regular Establishment in order to fit them for Army practice
and to give them some idea of routine duties at posts.

It may also be well to point out here that by this time all the larger nations
had established special schools for army medical officers. As a matter of fact,
some of these schools had now been in operation for more than a century.
The character of instruction varied considerably, but it is not necessary here
to go into this further than to state that in all cases it was supposed to be
of such a character and sufficient in amount to qualify the students as army
medical officers. Usually, advanced as well as primary courses were conducted
in these schools. Military as well as strictly medical duties were always
taught, and as time went on the tendency was to give practical field instruction
in one way or another. With countries which maintained a tactical organiza-
tion with medical units in being as parts of divisions, instruction in the operation
of these medical units was practically continuous. This, of course, was in
addition to the instruction given at the schools. In some countries practical
instruction was very largely given in divisions. Without going into the sub-
ject further, the point which it is desired to emphasize is that all important
nations by this time realized the necessity for special instruction of army
medical officers, and took steps to give it.

Hospital Corps companies of instruction.—Two Hospital Corps companies
of instruction were established in 1861,61 one at Fort Riley, Kans., and one at
Fort D. A. Russell, Wyo. The object of the organization was twofold: To
have at hand a trained body of sanitary soldiers, and to have a training school
through which could be passed all enlisted men of the Hospital Corps. Neces-
sity for economy in transportation limited the use of the companies largely to
the training of enlisted men from civil life. In 1893, the company at Fort
D. A. Russell was moved to Washington Barracks to make it available for the instruction of the class of medical officers at the newly created Army Medical
School. In 1896 the company of instruction at Fort Riley was disbanded and
its personnel distributed to selected posts throughout the West where instruc-
tion was continued in detachments.102 During the Spanish-Ameiiean War,
systematic teaching in the company of instruction at Washington Barracks
was practically suspended, but the company was used as a depot for detach-
ments of men who were collected for service in the camps in the United States,
the West Indies, and the Philippines.103 A similar school was oiganized at
Angel Island, Calif., where men destined for the Philippines were collected
and given some instruction prior to leaving the United States.104 In March,
1901, the company at Washington Barracks was leorganized, 105 later becoming
Company of Instruction No. 1; and in 1902 a reorganization of the company
at Angel Island was effected, when it became Company of Instruction No. 2.108
These companies were the germs of both ambulance companies and field
hospitals which have already been described. They had some equipment but
no transportation. Drills and training were carried on with the hope that
some day they would be completed and prepared to serve in the field.
An act of Congress of March, 1903,107 provided that “the Secretary of
War is authorized to organize companies of instruction, ambulance companies,
field hospitals, and other detachments of the Hospital Corps, as the necessities
of the service may require.” This act gave authority for creating the units
named in the 1904 Field Service Regulations, but the units were not created
until 1911.98 In 1904, Company of Instruction No. 2, at Fort McDowell,
Angel Island, was converted into Company B, Hospital Corps; and the Company
of Instruction at Washington Barracks was transformed into Company A,
Hospital Corps.108 These, however, were changed in little else than in name;
the companies had hospital equipment but no ambulance transport.
In 1904 a pamphlet on the “Regulations and Program of Instruction in
Hospital Corps Companies of Instruction, United States Army,” was issued.
This shows the company to have been essentially one of instruction. Instruc-
tion was given in handling both field hospitals and ambulance companies as
well as regimental hospitals. Because of lack of both barracks and transporta-
tion, the original company and others were retained in the same form for years.
Companies A and B were ordered to Cuba in 1906, and a new company, C,
was organized at Washington Barracks.109 In 1907 and 1908 the two companies
were returned from Cuba. This company organization of the field service
continued until 1911, when the three hospital companies formed the total
of our Army evacuation service in the United States for 100,000 men. More-
over, these companies had no transportation, and, except for its plans, accumu-
lated supplies, and the general training of its officers and men, the Medical
Department, so far as field organizations were concerned, was little better pre-
pared for war than it was in 1898 or in 1861.
Medical camps of instruction.—ha. 1909 Surgeon General Torney obtained
permission from the War Department to establish medical camps of in-
struction at Antietam, Md., at Sparta, Wis., and at San Francisco, Calif, at
each of which courses of instruction were given to medical officers of the
Organized Militia (National Guard).110 Regular medical officers, as well as
organized companies of the Hospital Corps, were ordered to these camps. Both of these participated as practical instructors. These camps served a useful
purpose in stimulating interest as well as by demonstrating how sanitary units
should be conducted. They were prototypes of the “Plattsburg idea,” origi-
nated at the citizens’ training camp, Plattsburg, N. Y.. 1915, but tliev suffered
the usual fate of ideas which are ahead of their time. Their value was not
sufficiently appreciated by the War Department to secure funds for their
continuance in future years.
The purpose of these camps, of course, was to give instruction in the
internal administration of Medical Department field units and in the details
of field sanitation. They were not intended to teach the duties of the Medical
Department as part of an army in campaign, though they furnished a most
valuable preliminary course therefor by giving primary instruction which
would enable the Medical Department to participate to better effect in general maneuvers.

Field service school for medical officers.—A definite step forward was the
establishment (at Fort Leavenworth, Kans.) of a correspondence school for
medical officers. This school was planned and instituted in 1910.m Prior
to this a series of lectures to line officers had been delivered, by a specially de-
tailed medical officer, as part of the course at the Army Service Schools.112
A ruling was secured from the service schools to the effect that no solution of a
tactical problem would be considered complete without plans for handling the
wounded. This was an important step and gave the whole subject new con-
sequence. The Leavenworth problems and solutions were distributed and
became widely known. In 1910 a scries of problems and solutions was pub-
lished under the title, “A Study in Troop Leading and Management of the
Sanitary Service in War.” 113 In 1911 “The Principles of Sanitary Tactics”
was also published.114 Both these volumes were widely used throughout the
service and also in the British Army.
The Army Field Service School for Medical Officers was established at
Fort Leavenworth in the summer of 1910,115 with 12 students; a correspondence
course was given to 30 additional medical officers. This was an entirely
original institution, not modeled after any other school at home or abroad.
It has been continued in peace times and is still doing excellent work.
Maneuvers.—Through lack of any primary school of instruction except the
Hospital Corps companies, which provided for the teaching of only a very
limited number of medical officers in a limited way, general maneuvers for a
long time constituted the only course of military instruction for medical officers
generally. This plan was not unlike attempting to give a college course to
students who had not been through a high school; nevertheless it was far better
than no military instruction at all.
Col. J. Van Rensselaer Hoff, M. C, in his report as chief surgeon of the
provisional division assembled at Fort Riley, Kans., in October, 1903, for maneu-
ver purposes, made the following retrospective statement with regard to the
progress of the Medical Department at early maneuvers: 116
It may be interesting to glance at the development of the Medical Department at maneuvers,
he-inning with the first in this region, when in 1S88 the Fifth Cavalry assembled near Guthrie,
Okla., followed the next year by much more extensive operations at Chiloeco under General Mer-
ritt; then the maneuvers of 1902, and finally those of 1903, at all of which the undersigned acted
as chief surgeon.

In 188S-89 one looked in vain for any regulation prescribing the medical equipment and
personnel for any command beyond the mere allowance of medicines * * *. What we had
at both these maneuvers was absolutely improvised. The contingency was met, but had it not
been no one on the ground could properly have been blamed.
An excellent regimental medical field equipment was devised in 1891 and used until the be-
ginning of the Spanish-American War, when another was substituted, which in turn gave place
to that of 1900 and 1901, but even yet the field hospital, as such, was without form and void.
The regulations of 1902 (Manual for the Medical Department) set forth for the first time a de-
tailed statement of the complete equipment of the field hospital and ambulance company, showing
exactly the material to be supplied by each department. This was done advisely, so that there < ould be no misunderstanding on the part of anyone as to exactly what these organizations consisted of, what was to be supplied by the Quartermaster’s Department as well as the Medical Department, what the possibilities of the organizations should be, and how they were to be conducted. The new field hospital equipment referred to was tried out at the 1903 maneuvers, and a beginning was made in forming provisional units out of casual personnel. In the maneuvers at Manassas in 1904, in which the National Guard of most of the Eastern States cooperated with the Army, provisional ambulance companies, field hospitals, and base hospitals were assembled and took part in the program. Thereafter this was almost the universal prac- tice at maneuvers. In 1908, companies of instruction were ordered to maneu- ver camps,117 where they were temporarily divided into field hospitals and ambulance companies, and this continued to be the practice thereafter until the companies were replaced by permanent field hospitals and ambulance com- panies. The medical units which participated at first were of necessity wholly provisional, for permanent units did not exist. Later, with the organization of permanent units, both Regular Army and National Guard, it was no longer necessary to organize them in each case on the maneuver ground. At the maneuvers at American Lake, WTash., in 1910,118 field problems were for the first time worked out for the Medical Department. In 1912 sani- tary units took part in the maneuvers at Fort Benjamin Harrison and in Connecticut.119 Mobilizations—In 1911 a division of troops, the first mobilized since 1898, was assembled at San Antonio, Tex.,120 ostensibly for purposes of training, but really on account of disturbed conditions in Mexico. For this division a com- plete sanitary train of four field hospitals and ambulance companies was organ- ized and functioned. This was the first complete sanitary train since Civil War days. The instruction was evidently good, for the discipline, military appearance, and efficiency of the medical units excited much favorable com- ment. The necessity of these units as an integral part of the divisional organi- zation was becoming recognized by this time, and the next step was an increase of the number of permanent organizations from two ambulance companies and two field hospitals to four each.” This camp at San Antonio was a noteworthy one from the Medical Department standpoint, not only for the completeness of its medical organization, but because it set a new standard in camp sanitation as will be seen later. It was still in existence in 1912 and the sanitary units took part in its maneuvers of that year. Again, in 1913, a division was assembled in Texas and spent the spring and summer in camp at Texas City,121 one of its brigades having gone on to Vera Cruz and occupied that city.122 This expeditionary brigade was accompanied by a field hospital but no ambulance company; an ambulance company was EVOLUTION OF MEDICAL DEPARTMENT. 71 improvised from regimental ambulances taken along.122 These mobilizations (dearly demonstrated the numerical deficiency of the Hospital Corps when it came to supplying sanitary trains for mobilized divisions, and brought forth the following straightforward statement from Surgeon General Torney in his annual report for 1913: I can not, in transmitting this my last annual report, fail to call your attention to one particular in which the Medical Department is unprepared to fulfill its responsibilities to the Army and the Nation. It is one which has been the subject of frequent communications from this office in the last few years and has been pointed out for several years in the annual reports—that is, the great deficiency in number of the Hospital Corps; so that when the tactical divisions of the Regular Army take the field they can have not more than one-fourth of the sanitary units required for the medical service and called for by the Field Service Regulations. In fact, the first division sta- tioned in the Eastern Department has not a single sanitary unit. This matter is discussed quite fully on page 165 et seq. of this report. No action by Congress is necessary to remedy this defect, since Congress, in order that such a deficiency might be avoided, has placed in the hands of the President the responsibility for providing a sufficiently numerous Hospital Corps to care for the rick and wounded, and has specifically stated that they shall not be counted as a part of the strength of the Army. It is believed that Congress has thus shown the intention that our Army shall have an adequate medical service proportioned to its strength, and this is what I have repeatedly urged. It is also believed that if the Secretary would recommend to Congress the reorganization of the Hospital Corps, which is asked for in this report, it will be easily obtained and will much facilitate the recruitment of suitable men for this relatively unattractive service. The next year, 1914, saw no improvement in the Mexican situation, and preparations were made for the mobilization of a field army, in view of which a few additional medical units were authorized, including two evacuation hospi- tals and two field supply depots. The year 1915, for the Army, was one of watchful waiting, as the phrase then was, but the mental attitude was rather one of weary waiting in the lonely camps on the southern border. The year 1916 was much more eventful, beginning with Villa’s unprovoked night attack on our troops at Columbus, N. Mex. This was followed by the punitive expedition of about 12,000 123 men of all arms, which remained in Mexico nearly a year. The killing or capture of a detachment of our men by Mexican troops resulted in the dispatch of practically the entire Regular Army and National Guard to the Mexican border,123 where they remained on field duty from July to the end of the year. The expedition into Mexico was accompanied by two ambulance companies (motorized) and two field hospitals (one motorized). The field hospitals served as camp hospitals, while the ambulance companies carried on the evacuation service.124 It was at this time that the value of motor ambulances was first (dearly demonstrated in our service. A complete sanitary train was also organized at San Antonio,125 Tex.; where special schools were conducted for officers and men, constituting a more extensive course of training with troops than had ever been practical before. The war cloud which had burst over Europe two years before was begin- ning to cast its shadow over America, and although measures of preparedness were not officially encouraged, the attention of the people was drawn in this direction by the current of events and by the advocacy of farseeing men. This mobilization of the armed forces of the Nation was most fortunate and oppor- tune, therefore, as a training maneuver alike in military and sanitary matters.  One result was a large increase in the number of sanitary units both of the Regular Army and the National Guard. Furthermore, nothing could have been more fortunate for the medical supply service from every standpoint. Not only was the experience of itself of value in obtaining and issuing supplies, but certain supplies were ready at hand when the World War came, which would not likely have been the case if the Army had not been mobilized immediately prior thereto. PROFESSIONAL PROGRESS IX MEDICINE AND SURGERY. Throughout the history of armies army medical and surgical practice, gen- erally speaking, has been on a par with civilian practice of the same epoch. The development of specialization in American medicine since the Spanish- American War has had a most important effect on Medical Department or- ganization, for even as late as that war it was assured that any doctor, with a little military instruction, would be able to fill almost any place in the Army medical establishment. On the other hand, possibly specialization has been carried too far of late years; no good purpose would be served by entering here into a controversy on this subject. The fact remains that, as has just been stated, such general specialization as obtained among the civil medical profes- sion greatly complicated the fitting of erstwhile practitioners into positions where their knowledge could be made of most value. It is also the fact that since the Spanish-American War great advances have been made in the prac- tice of medicine, surgery, and the specialties. This resulted, by the time the World War came on, in greatly enhanced possibilities of contributing to the military strength of the Army through efficient professional practice. Thou- sands of patients could now be restored to military usefulness who even as late as the Spanish-American War would have been physically incapacitated for the whole course of the war. ADVANCES IN FIELD SANITATION. The lamentable sanitary conditions and the great amount of sickness which prevailed in the Spanish-American War made a profound impression upon the Army and upon the country at large, and the causes and practicable methods of prevention of diseases in campaign were subjects of diligent study by the Medical Department during the succeeding years. Methods for the disposal of garbage and excreta, for the purification of water, for the preven- tion of the breeding of flies and mosquitoes, and all the other details for the prevention of intestinal and insect-borne diseases that might prevail, were studied, tried out, and if not found practically efficient were rejected. For the camp latrines the sanitary trough devised by Walter Reed was first adopted, and later abandoned because of practical difficulties in the way of operation./ It was succeeded by the McCall incinerator, but this was costly and lacked portability. Finally, where sewers could not be had, the old pit system was restored but with its objectionable features removed by the Havard box and a daily burning out with oil. In the same way the ingenious Forbes sterilizer for drinking water was replaced by chlorination, and finally with the Lyster / One of the most serious was that in wet weather, where there were not paved roads, the weight of the it almost impossible to haul.  bag as the field method of application of chlorination. By 1917 the methods of fly and mosquito prevention had reached a high degree of efficiency. Another no less important step forward in the prevention oAntestinal diseases was taken by the issue of general instructions that the hands be washed after a visit to the latrine and before meals.126 Unfortunately, it was found difficult to enforce this order under field conditions. The camp of the maneuver division at San Antonio in the summer of 1911 reached a degree of sanitary perfection which had rarely, if ever, been equaled in our Army. This command of over 10,000 men lived under canvas for more than four months, with better general conditions of health than in the regi- ments which remained in barracks at their posts. Only two cases of typhoid fever developed there.127 However, such remarkable and, at that time, unprec- edented immunity from this former plague of camps is to be explained by a fact which makes this camp notable in the annals of preventive medicine. Here, for the first time, compulsory universal immunization of a large body of men against typhoid fever was tried out by the practical and efficient method with which the name of Russell will be always associated. This tri- umphant demonstration caused the prompt adoption of typhoid immunization as a prescribed routine procedure in our Army 128 and its acceptance by the French two years later. Without this beneficent preventive measure there is good reason to believe that typhoid incidence would have been very much higher in the World War than it actually was. Such an incidence as that of the Spanish-American War would have given us, for each million of men, 140,000 cases and 14,000 deaths. Instead of these terrible figures, we had,, in our great armies in France and America, during the years 1918 and 1919, a total of 1,897 cases with 227 deaths.129 While the lesser amount of typhoid throughout the United States in 1917, as compared with 1898, doubtless had its influence, this should not be held to minimize the importance of this mag- nificent sanitary achievement. Paratyphoid was also found subject to this method of control during the Mexican border mobilization in 1916. As a result a triple vaccine was made available to troops and its universal use was enforced.130 That equally favorable results were not secured in the World War for sputum-borne diseases as for intestinal and insect-borne diseases is not due to lack of recognition beforehand of the importance of the former. The border mobilization of 1916 was attended by a high incidence of pneumonia, with many deaths;131 and on our entry into the World War prophets were not lacking in the Medical Corps of the Army who announced that pneumonia would prove to be the scourge of our troops in that war. This being the case, preparations to combat pneumonia were made, based on the scientific knowledge of the time, reinforced by what was supposed to have been learned during the border mobilization. Possibly the results would have been far worse without the sanitary measures which were taken. On the other hand, it is possible that in the years to come our efforts, due to lack of exact scientific knowledge, will go down into the limbo of hit-or-miss sanitation. Before the World War much progress had been made in the prevention of venereal diseases, which, while not fatal to the personnel of armies like the diseases which have just been discussed, are likely to prove no less, if not  more, fatal to military efficiency. Our methods, in brief, contemplated the compulsory use of a prophylactic, with punishment for failure to take the same, and loss of pay for disability due to misconduct.132 Prior to the World War little or no control could be exercised over civilian sources of infection at home, but something had been done in this direction at various places occupied by our troops abroad. At all events, the importance of this form of control was well appreciated by the Medical Corps. Any account of advances made in military sanitation in our Army during the period between the Spanish-American War and the World War would be very incomplete if no reference were made to the development of the sanitary conscience of the Army in the meantime. With the American public as a whole, from which, of course, our World War Army came—and this also doubtless proved of considerable assistance in protecting the health of troops—the same process had been going on. It is not too much to say that in the great advances made in scientific sanitation between 1898 and 1917 the Army of the United States had been garrisoned in small and isolated posts where there was not much sickness. When the Spanish-American War began, while the Army as a whole did not regard sanitation as a medical fad, as has sometimes been asserted, yet the rank and file in no sense appreciated the danger incident to large camps with personnel hastily raised from all parts of the country. Nor did they realize the risks of service in a tropical climate, where it was inevitable that much disease would be introduced, or of service in places where sources of infection would be much multiplied while at the same time sanitary conveniences were lacking. The awakening was rude but thoroughly effective, and since then the subject of sanitation has been one of acute practical interest to the Army. Typhoid in the camps of the United States, and malaria and yellow fever in Cuba, proved far more deadly than the bullets of the enemy in the Spanish-American War. Then came some epoch-making sanitary work by medical officers of the Army in every new territory opened up to the United States by that war. It could not but be apparent, therefore, to the Army as a whole that the possibilities in the prevention of disease were very great. Between the Spanish-American War and the World War the Army served very generally in tropical countries or in camps where disregard of sanitary laws was likely to be followed by condign punishment. Still further, before we entered the World War the experience of the earlier combatants in pre- venting disease, and the great importance this had assumed from the stand- point of military efficiency, was well known throughout our Army by April 6, 1917. All in all, then, it is very possible that no army had its sanitary con- science so well developed as our own when we entered the World War. Cer- tainly no American Army ever before realized to nearly an equal extent that its good health was very largely in its own hands. Nor was its attitude a passive one; on the contrary, it was most active, and no trouble was too great to take if it promised to be repaid by keeping troops free from disease.

WORLD WAR PERIOD PRECEDING ENTRY OF UNITED STATES.

As the subjects which would naturally fall under this heading, being so intimately and nearly concerned therewith, are largely a part of the story of our actual participation in the World War, and will therefore be discussed  at length in the various volumes of this history, it is deemed unnecessarv to go into them so fully here as would otherwise be desirable Yet our early arrangements, as a matter of fact, were influenced to a considerable extent by what we had learned before we entered the war, from the experience of our future allies and enemies. So it is believed that while details should be left to the body of the history, certain lessons learned from that experience may appropriately be summed up here. The reorganization of our own Army by the national defense act of 1916 is also pertinent to the present sub- ject, and will be considered first, as it was very important and represents a concrete accomplishment. Moreover, during the war, Medical Department as well as Army organization as a whole was based primarily on the organiza- tion of 1916. As little as it made for preparation in the light of subsequent events, it went further in the way of legislation for a war army than any previous act of Congress passed in peace times. This, probably everyone will grant now, was due solely to the World War, which, when the act in question was passed, was drawing measurably near to us. National Defense Act. The act of Congress in question, commonly known as the national defense act, is very long and should really be read in its entirety. Lack of space pre- vents quoting other than extracts closely relating to the Medical Department. ACT REORGANIZING ARMY, 1916. Bulletin) WAR DEPARTMENT, No. 16. J Washington, June. 22, 1916. The following act of Congress is published to the Army for the information and guidance of all concerned: AN ACT For making further and more effectual provision for the national defense, and for other purposes. Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That the Army of the United States shall consist of the Regular Army, the Volunteer Army, the Officers’ Reserve Corps, the Enlisted Reserve Corps, the National Guard while in the Bervice of the United States, and such other land forces as are now or may hereafter be authorized by law. ******* Provided further, That the total enlisted force of the line of the Regular Army, excluding the Philippine Scouts and the enlisted men of the Quartermaster Corps, of the Medical Department, and of the Signal Corps, and the unassigned recruits, shall not at any one time, except in the event of actual or threatened war or similar emergency in which the public safety demands it, exceed one hundred and seventy-five thousand men: Provided further, That the unassigned recruits at depots or elsewhere shall at no time, except in time of war, exceed by more than seven per centum the total authorized enlisted strength. m ******* Sec 3. Composition of brigades, divisions, and so forth.— * * * The typical Infantry division shall consist of * * * and one sanitary train. The typical Cavalry division shall con- sist of * * * and one sanitary train. The typical Army corps shall consist of * * * and such sanitary trains as the President may deem necessary. * * * Each sanitary train shall consist of such officers and enlisted men and shall be organized as the President may prescribe. Nothing herein contained, however, shall prevent the President from increasing or decreasing the number of organizations prescribed for the typical brigades, divisions, and Army corps, or from prescribing new and different organizations and personnel as the efficiency of the service may require.  Sec 10. The Medical Department.—The Medical Department shall consist of one Surgeon General, with the rank of major general during the active service of the present incumbent of that office, and thereafter with the rank of brigadier general,* who shall be chief of said department, a Medical Corps, a Medical Reserve Corps within the limit of time fixed by this act, a 1 )ental Corps, a Veterinary Corps, an enlisted force, the Nurse Corps, and contract surgeons as now authorized by law, the commissioned officers of which shall be citizens of the United Stales. The Medical Corps shall consist of commissioned officers below the grade of brigadier general, proportionately distributed among the several grades as in the Medical Corps now established by law. The total number of such officers shall approximately be equal to, but not exceed, except as hereinafter provided, seven for every one thousand of the total enlisted strength of the Regular Army authorized from time to time by law: Provided, That if by reason of a reduction by law in the authorized enlisted strength of the Army aforesaid the total number of officers in the Medical Corps commissioned previously to such reduction shall for the time being exceed the equivalent of seven to one thousand of such reduced enlisted strength no original appointment to commissioned rank in said corps shall be made until the total number of commissioned officers thereof shall have been reduced below the equivalent of seven to the thousand of the said reduced enlisted strength, nor thereafter so as to make the total number of commissioned officers thereof in excess of the equivalent of seven to the thousand of said reduced enlisted strength, and no promotion shall be made above the grade of captain in said corps until the number of officers in the grade above that of captain to which the promotion is due shall have been reduced below the proportional number authorized for such grade on the basis of the reduced enlisted strength, nor thereafter so as to make the number of officers in such grade in excess of the proportional number authorized on the basis of said reduced enlisted strength: Provided further, That when in time of war the Regular Army shall have been increased by virtue of the provisions of this or any other act, the medical officers appointed to meet such increase shall be honorably discharged from the service of the United States when the reduction of the enlisted strength of the Army shall take place. Provided further, That persons hereafter commissioned in the Medical Corps shall be citizens of the United States between the ages of twenty-two and thirty years and shall be promoted to the grade of captain upon the completion of five years’ service in the Medical Corps and upon passing the examinations prescribed by the President for promotion to the grade of captain in the Medical Corps: Provided, further, That relative rank among captains in the Medical Corps, who have or shall have attained that rank by operation of law after a period of service fixed thereby, shall be determined by counting all the service rendered by them as officers in said corps and as assistant surgeons in the Regular Army, subject, however, to loss of files by reason of sentence of court-martial or by reason of failure to pass examination for promotion: Provided further, That hereafter the President shall be author- ized to detail not to exceed five officers of the Medical Department of the Army for duty with the military relief division of the American National Red Cross. The enlisted force of the Medical Department shall consist of the following personnel, who shall not be included in the effective strength of the Army nor counted as a part of the enlisted force provided by law: Master hospital sergeant, hospital sergeants, sergeants (first class), sergeants, cor- porals, cooks, horseshoers, saddlers, farriers, mechanics, privates (first class), and privates: Provided, That master hospital sergeants shall be appointed by the Secretary of War, but no person shall be appointed master hospital sergeant until he shall have passed a satisfactory examination under such regulations as the Sectetary of War may prescribe before a board of one or more medical officers as to his qualifications for the position, including knowledge of pharmacy, and demonstrated his fitness therefor by service of not less than twelve months as hospital sergeant, or sergeant, first class, Medical Department, or as sergeant, first class, in the Hospital Corps now established by law; and no person shall be designated for such examination except by written authority of the Surgeon General: Provided further, That original enlistments for the Medical Department shall be made in the grade of private, and reenlistments and promotions of enlisted men therein, except as hereinbefore prescribed, and transfers thereto from the enlisted force of the line or other staff departments and corps of the Army shall be governed by such regulations as the Secretary of War may prescribe: Provided further, That the enlisted men of the Hospital Corps who are in active service at the time of the approval of this act are hereby transferred to the corresponding grades of the Medical Department, established by this act: Provided further, That the total number of enlisted men in the Medical Department shall be approximately equal to, but not exceed * This law was changed at a later date.  77 except as hereinafter provided, the equivalent of five per centum of the total enlisted strength of the Army authorized from time to time by law: Provided further, That in time of actual^or threatened hostilities, the Secretary of War is hereby authorized to enlist or cause to be enlisted in the Medical Department such additional number of men as the service may require: Provided further, That the number of enlisted men in each of the several grades designated below shall not exceed, except as hereinafter provided, the following percentages of the total authorized enlisted strength of the Medical Department, to wit: Master hospital sergeants, one-half of one per centum; hospital sergeants, one-half of one per centum; sergeants, first class, seven per centum; sergeants, eleven per centum; corporals, five per centum; and cooks, six per centum: Provided further, That the number of horseshoers, saddlers, farriers, and mechanics in the Medical Depart- ment shall not exceed one each to each authorized ambulance company or like organization: Provided further, That in said department the number of privates, first-class, shall not exceed twenty-five per centum of the number of privates: Provided further, That if by reason of a re- duction by operation of law in the authorized enlisted strength of the Army aforesaid the number of noncommissioned officers of any grade in the Medical Department whose warrants were issued previously to such reduction shall for the time being exceed the percentage hereinabove specified for such grade, no promotion to such grade shall be made until the percentage of non- commissioned officers therein shall have been reduced below that authorized for such grade on the basis of the said reduced enlisted strength, nor thereafter so as to make the percentage of noncommissioned officers therein in excess of the percentage authorized on the basis of the said reduced enlisted strength; but noncommissioned officers maybe reenlisted in the grades held by them previously to such reduction regardless of the percentages aforesaid; and when under this provision the number of noncommissioned officers of any grade exceeds the percentage specified any noncommissioned officer thereof, not under charges, may be discharged on his own application. Provided further, That privates, first class, of the Medical Department shall be eligible for ratings for additional pay as follows: As dispensary assistant, Sl> a month; as nurse, S3 a month; as surgical
assistant, $5 a month: Provided further, That no enlisted man shall receive more than one rating
for additional pay under the provisions of this section, nor shall any enlisted man receive any
additional pay under such rating unless he shall have actually performed the duties for which
he shall be rated.
The President is hereby authorized to appoint and commission, Dy and with the advice and
consent of the Senate, dental surgeons, who are citizens of the United States between the ages of
twenty-one and twenty-seven years, at the rate of one for each one thousand enlisted men of the
line of the Army. Dental surgeons shall have the rank, pay, and allowances of first lieutenant3
until they have completed eight years’ service. Dental surgeons of more than eight but less than
twenty-four years’ service shall, subject to such examination as the President may prescribe, have
the rank, pay, and allowances of captains. Dental surgeons of more than twenty-four years’ serv-
ice shall, subject to such examination as the President may prescribe, have the rank, pay, and
allowances of major: Provided, That the total number of dental surgeons with rank, pay, and
allowances of major shall not at anytime exceed fifteen: And provided further, That all laws relat-
ing to the examination of-officers of the Medical Corps for promotion shall be applicable to dental
surgeons.
Authority is hereby given to the Secretary of War to grant permission, by revocable license, to
the American National Red Cross to erect and maintain on any military reservations within the
jurisdiction of the United States buildings suitable for the storage of supplies, or to occupy for that
purpose buildings erected by the United States, under such regulations as the Secretary of War may
prescribe, such supplies to be available for the aid of the civilian population in case of serious
national disaster.
*******
Sec. 16. Veterinarians.—The President is hereby authorized, by and with the advice and
consent of the Senate, to appoint veterinarians and assistant veterinarians in the Army, not to
exceed, including veterinarians now in service, two such officers for each regiment of Cavalry, one
for everv three batteries of Field Artillery, one for each mounted battalion of Engineers, seventeen
as inspectors of horses and mules and as veterinarians in the Quartermaster Corps, and seven as
inspectors of meats for the Quartermaster Corps; and said veterinarians and assistant veterinarians
shall be citizens of the United States and shall constitute the Veterinary Corps and shall be a part
of the Medical Department of the Army.

Hereafter a candidate for appointment as assistant veterinarian must be a citizen of the United
States, between the ages of twenty-one and twenty-seven years, a graduate of a recognized veteri-
nary college or university, and shall not be appointed until he shall have passed a satisfactory
examination as to character, physical condition, general education, and professional qualifications.

An assistant veterinarian appointed under this act shall, for the first five years of service as
such, have the rank, pay, and allowances of second lieutenant: that after five years of service lie
shall have the rank, pay. and allowances of first lieutenant: that after fifteen years of service he
shall be promoted to be a veterinarian with the rank, pay, and allowances of captain; and that
after twenty years’ service he shall have the rank, pay, and allowances of a major: Provided, That
any assistant veterinarian, in order to be promoted as hereinbefore provided, must first pass a satis-
factory examination, under such rules as the President may prescribe, as to professional qualifica-
tions and adaptability for the military service; and if such assistant veterinarian shall be found
deficient at such examination he shall be discharged from the Army with one year’s pay.
The veterinarians of Cavalry and Field Artillery now in the Army, together with such veteri-
narians of the Quartermaster Corps as are now employed in said corps, who at the date of the approval
of this act shall have had less than five years’ governmental service, may be appointed in the Vet-
erinary Corps as assistant veterinarians with the rank, pay, and allowances of second lieutenant;
those who shall have1 had over five years of such service may be appointed in said corps as assistant
veterinarians with the rank, pay, and allowances of first lieutenant: and those who shall have had
over fifteen years such service may be appointed in said corps as veterinarians with the rank,
pay, and allowances of captain: Provided, That no such appointment of any veterinarian shall be
made unless he shall first pass satisfactorily a practical professional and physical examination aa
to his fitness for the military service: Provided further, That veterinarians now in the Army or in the
employ of the Quartermaster Corps who shall fail to pass the prescribed physical examination be-
cause of disability incident to the service and sufficient to prevent them from the performance of
duty valuable to the Government shall be placed upon the retired list of the Army with seventy-
five per centum of the pay to which they would have been entitled if appointed in the Veterinary
Corps as hereinbefore prescribed.

The Secretary of War, upon recommendation of the Surgeon General of the Army, may appoint
in the Veterinary Corps, for such time as their services may be required, such number of reserve
veterinarians as may be necessary to attend public animals pertaining to the Quartermaster Corps.
Reserve veterinarians so employed shall have the pay and allowances of second lieutenant during
such employment and no longer: Provided, That such reserve veterinarians shall be graduates of a
recognized veterinary college or university and shall pass a satisfactory examination as to charac-
ter, physical condition, general education, and professional qualifications in like manner as here-
inbefore required of assistant veterinarians; such reserve veterinarians shall constitute a list of
eligibles for appointment as assistant veterinarians, subject to all the conditions hereinbefore pre-
scribed for the appointment of assistant veterinarians.
Within a limit of time to be fixed by the Secretary of War, candidates for appointment as assist-
ant veterinarians who shall have passed satisfactorily the examinations prescribed for that grade
by this act shall be appointed, in the order of merit in which they shall have passed such exami-
nation, to vacancies as they occur, such appointments to be for a probationary period of two years,
after which time, if the services of the probationers shall have been satisfactory, they shall l>e
permanently appointed with rank to date from the dates of rank of their probationary appointments.
Probationary veterinarians whose services are found unsatisfactory shall be discharged at any time
during the probationary period, or at the end thereof, and shall have no further claims against the
Government on account of their probationary service.
The Secretary of WTar shall from time to time appoint boards of examiners to conduct the vet-
erinary examinations hereinbefore prescribed, each of said boards to consist of three medical offi-
cers and two veterinarians.
*******
Sec 30. Composition of the Regular Army Reserve.—The Regular Army Reserve shall consist
of, first, all enlisted men now in the Army Reserve or who shall hereafter become members of the
Army Reserve under the provisions of existing law; second, all enlisted men furloughed to or en-
listed in the Regular Army Reserve under the provisions of this act; and, third, any person holding
an honorable discharge from the Regular Army with character reported at least good who is physically qualified for the duties of a soldier and not over forty-five years of age who enlists in the
Regular Army Reserve for a period of four years.

Sec 37. The Officers1 Reserve Corps.—For the purpose of securing a reserve of officers available
for service as temporary officers in the Regular Army, as provided for in this act and in section eight
of the act approved April twenty-fifth, nineteen hundred and fourteen, as officers of the Quarter-
master Corps and other staff corps and departments, as officers for recruit rendezvous and depots,
and as officers of volunteers, there shall be organized, under such rules and regulations as the Presi-
dent may prescribe not inconsistent with the provisions of this act, an Officers’ Reserve Corps of
the Regular Army. Said corps shall consist of sections corresponding to the various arms, staff
corps, and departments of the Regular Army. Except as otherwise herein provided, a member of
the Officers’ Reserve Corps shall not be subject to call for service in time of peace, and when-
ever called upon for service shall not, without his consent, be so called in a lower grade than that
held by him in said reserve corps.
The President alone shall be authorized to appoint and commission as reserve officers in the va-
rious sections of the Officers’ Reserve Corps, in all grades up to and including that of major, such
citizens as, upon examination prescribed by the President, shall be found physically, mentally,
and morally qualified to hold such commissions: Provided, That the proportion of officers in any
section of the Officers’ Reserve Corps shall not exceed the proportion for the same grade in the cor-
responding arm, corps, or department of the Regular Army, except that the number coinmissioned
in the lowest authorized grade in any section of the Officers’ Reserve Corps shall not be limited.
***** * *
One year after the passage of this act the Medical Reserve Corps, as now constituted by law,
shall cease to exist. Members thereof may be commissioned in the Officers’ Reserve Corps, subject
to the provisions of this act, or may be honorably discharged from the service.
*******
Sec 38. The Officers’ Reserve Corps in war.—In time of actual or threatened hostilities the
President may order officers of the Officers’ Reserve Corps, subject to such subsequent physical
examinations as he may prescribe, to temporary duty with the Regular Army in grades thereof
which cannot, for the time being, be filled by promotion, or as officers in volunteer or other organiza-
tions that may be authorized by law, or as officers at recruit rendezvous and depots, or on such other
duty as the President may prescribe. While such reserve officers are on such service they shall,
by virtue of their commissions as reserve officers, exercise command appropriate to their grade and
rank in the organizations to which they may be assigned, and shall be entitled to the pay and
allowances of the corresponding grades in the Regular Army, with increase of pay for length of
active service, as allowed by law for officers of the Regular Army, from the date upon which they
shall be required by the terms of their orders to obey the same.
*******
Sec. 60. Organization of National Guard units.—Except as otherwise specifically provided
herein, the organization of the National Guard, including the composition of all units thereof,
shall be the same as that which is or may hereafter be prescribed for the Regular Arm}-, subject
in time of peace to such general exceptions as may be authorized by the Secretary of War. And
the President may prescribe the particular unit or units, as to branch or arm of service, to be main-
tained in each State, Territory, or the District of Columbia in order to secure a force which, when
combined, shall form complete higher tactical units.
*******
Sec 7S. The National Guard Reserve.—Subject to such rules and regulations as the President
may prescribe, a National Guard Reserve shall be organized in each State, Territory, and the Dis-
trict of Columbia, and shall consist of such organizations, officers, and enlisted men as the President
may prescribe, or members thereof may be assigned as reserve to an active organization of the Na-
tional Guard.
* * * * * * *
Sec 111. National Guard when drafted into Federal seroice.—When Congress shall have author-
ized the use of the armed land forces of the United States, for any purpose requiring the use of troops
in excess of those of the Regular Army, the President may, under such regulations, including such
physical examination as he may prescribe, draft into the military service of the United States, to
serve therein for the period of the war unless sooner discharged, any or all members of the National
Guard and of the National Guard Reserve.
*******

Sec 115. Physical examination.—Every officer and enlisted man of the National Guard who
shall be called into the service of the United States as such shall be examined as to his physical
fitness under such regulations as the President may prescribe without further commission or enlist-
ment: Provided, That immediately preceding the muster out of an officer or enlisted man called
into the active service of the United States he shall be physically examined under rules prescribed
by the President of the United States, and the record thereof shall be filed and kept in the War
Department.
*******
Sec 120. Purchase, or procurement of military supplies in time of actual or imminent war.—The
President, in time of war or when war is imminent, is empowered, through the head of any depart-
ment of the Government, in addition to the present authorized methods of purchase or procure-
ment, to place an order with any individual, firm, association, company, corporation, or organized
manufacturing industry for such product or material as may be required, and which is of the nature
and kind usually produced or capable of being produced by such individual, firm, company, asso-
ciation, corporation, or organized manufacturing industry.

Compliance with all such orders for products or material shall be obligatory on any individual,
firm, association, company, corporation, or organized manufacturing industry or the responsible
head or heads thereof and shall take precedence over all other orders and contracts theretofore
placed with such individual, firm, company, association, corporation, or organized manufacturing
industry, and any individual, firm, association, company, corporation, or organized manufacturing
industry or the responsible head or heads thereof owning or operating any plant equipped for the
manufacture of arms or ammunition, or parts of ammunition, or any necessary supplies or equip-
ment for the Army, and any individual, firm, association, company, corporation, or organized
manufacturing industry or the responsible head or heads thereof owning or operating any manu-
facturing plant, which, in the opinion of the Secretary of War, shall be capable of being readily
transformed into a plant for the manufacture of arms or ammunition, or parts thereof or other
necessary supplies or equipment, who shall refuse to give to the United States such preference
in the matter of the execution of orders, or who shall refuse to manufacture the kind, quantity
or quality of arms or ammunition, or the parts thereof, or any necessary supplies or equipment as
ordered by the Secretary of War, or who shall refuse to furnish such arms, ammunitions, or parts of
ammunition, or other supplies or equipment at a reasonable price as determined by the Secretary
of War, then, and in either such case, the President, through the head of any department of the Gov-
ernment, in addition to the present authorized methods of purchase or procurement herein pro-
vided for, is hereby authorized to take immediate possession of any such plant or plants, and through
the Ordnance Department of the United States Army,.to manufacture therein in time of war or
when war shall be imminent, such product or material as may be required, and any individual,
firm, company, association, or corporation, or organized manufacturing industry, or the responsible
head or heads thereof, failing to comply with the provisions of this section shall be deemed guilty
of a felony, and upon conviction shall be punished by imprisonment for not more than three years
and by a fine not exceeding §50,000.

The compensation to be paid to any individual, firm, company, association, corporation or
organized manufacturing industry for its products or material, or as rental for use of any manufac-
turing plant while used by the United States, shall be fair and just.

The President is hereby authorized, in his discretion, to appoint a Board on Mobilization of
Industries Essential for Military Preparedness, nonpartisan in character, and to take all necessary
steps to provide for such clerical assistance as he may deem necessary to organize and coordinate
the work hereinbefore described.
* * * * *
* * *

Medical Preparedness.

On April 14, 1916, probably prompted by pending legislation on national
preparedness, a group of eminent surgeons met in the Union League Club in
Chicago and organized a Committee on Medical Preparedness. At this meet-
ing it was voted to place before the President of the United States the desire
and willingness of the medical profession to make a comprehensive survey of
the medical resources of the country, and to prepare a complete invoice of
these resources, setting forth not only the names of men trained in the special- 
tics of medicine, surgery, and sanitation, but to include the extensive equip-
ment under their control, such as hospital facilities and nurses.
The offer was actually made under date of April 26, 1916.133 The letter
containing it set forth the facts as to the membership of the medical bodies
represented (the American Medical Association, the American Surgical Asso-
ciation, the Congress< of American Physicians and Surgeons, the Clinical Con- gress of Surgeons of North America, and the American College of Surgeons, representing approximately 70,000 medical men); the attitude of the medical profession toward preparedness, and the need for such preparedness along medical and surgical lines. It offered, on behalf of the committee, to make a survey of the medical resources of the country and to make an inventory thereof, including the availability of hospital facilities, buildings available for use as hospitals, facilities for transportation of sick and wounded, food supply and drug supply available, lists of trained nurses and other persons essential for hospital work. This offer was referred to the Secretary of War, who con- sulted with the Surgeon General. It was soon accepted, and steps were taken to carry it into effect. Various members of the Committee on Medical Preparedness wired the Surgeon General, in the latter part of May, 1916, urging that a medical repre- sentative be placed on the contemplated council of executive information on preparedness then receiving legislative consideration. The designation of the advisory body, as finally created by act of Con- gress approved August 29, 1916,m was Council of National Defense. The Council of National Defense, as created, consisted of the Secretary of War, the Secretary of the Navy, the Secretary of Agriculture, the Secretary of Commerce, and the Secretary of Labor, with an advisory commission of seven. It was created for the purpose of coordinating “industries and resources for the national security and welfare.” This advisory commission, as specified in the act in question, was to consist of persons having special knowledge of some industry, public utility, the development of some natural resource, or being otherwise specially quali- fied in the opinion of the council for the performance of the duties required of such an advisory body by the act. On October 11, President Wilson appointed the civilian advisory members of the council, among whom was a physician, Dr. Franklin H. Martin, of Chicago, 111. The organization of the advisory council provided that each member of the commission gather about himself, for the most effective coordination of the activities he represented, a committee or board of representatives of the Government departments and of eminent civilian mmbers. The medical committee consisted of Dr. Franklin H. Martin, chairman; William C. Gorgas, Surgeon General of the Army; William C. Braisted, Sur- geon General of the Navy; Rupert Blue, Surgeon General of the Public Health Service; Col. Jefferson R. Kean, director general, military relief, American Red Cross; Dr. William H. Welch, member of the National Research Council; Dr. William ,1. Mayo, chairman of the Committee of American Physicians for Medical Preparedness; Dr. Frank F. Simpson, chief of Medical Section, Council  of National Defense, and secretary of the Committee of American Physicians for Medical Preparedness. The effect of having a doctor on the Advisory Commission of the Council of National Defense insured that the importance of medicine to any war army we might create would not be overlooked, as was the case in the Spanish- American War. Perhaps this was the greatest service which the council ren- dered to the Medical Department. It was far from the only service, however. Before the war opened for us it is probable that the principal work accom- plished by the Medical Committee of the Council of National Defense was that of lining up the medical profession. A large body of medical men, fairly well classified according to their special qualifications, was thus actually avail- able for immediate service when war came.135 A committee on dentistry, consisting of seven members, was formed early. This was divided into five sections: Mobilizing dental educational activities, base hospitals, dental sup- plies, dental research, and the Preparedness League of American Dentists. The principal work of the medical committee, so far as supplies were concerned, consisted in the appointment of a “Committee for the Standardization of Medical and Surgical Supplies and Equipment.” A committee on hospitals, known as the hospital committee, was organized in the early part of April, 1917. Just as soon as the United States entered the war, all these committees became very active, and their preliminary work then proved the saving of months of time. For a fuller account of their activities, the chapter devoted to the Council of National Defense, in the body of the history, or the official reports of the council, should be consulted. But the effect on our Medical Department of the World War period preced- ing American participation really went much further than the more or less tangible results which have just been mentioned. The immensity of the conflict was, of course, well known to practically everybody in the United States, and the vastness of the problems involved in caring for the enormous number of sick and wounded was hardly less well known. This led, when war came, to vast estimates of what would be needed by the Medical Department, prompt approval of such estimates by the War Department, and liberal ap- propriations by Congress. This change in a state of mind must be mentioned here both on account of its intrinsic importance and because of the great contrast with Spanish-American War days, when penuriousness at the start so handicapped the Medical Department that it was never able to recover. Very possibly in the World War, with an army representing nearly every home in the land, ample means would have been available in any event; on the other hand, without the earlier history of the World War to guide us, it is by no means certain that such wise liberality would have been manifested at the beginning, when it counted most. Before we entered the war, preparation, except in the ways mentioned, lagged very considerably. There was certainly no rush to join the Medical Reserve Corps at this time, and on account of the Mexican border experience the National Guard Medical Department actually decreased very considerably in strength for the time being. Matters in these respects changed very notably, however, as soon as we actually entered the war, when medical officers and men  poured into the service in a veritable flood. As both the Medical Reserve Corps and the Medical Department of the National Guard had existed long before the World War began, however, their organization can not be set down as affecting the creation of organizations which doctors could join. Having such organizations in advance was of first importance, however, for when war came no delay was occasioned, as the machinery existed for tak- ing care of all applicants for commissions. This point should be noted because the situation was so different from that which existed at the time of the Spanish- American War, when the places for doctors were so limited, being political or largely confined to contract surgeons, a status not generally considered com- mensurate with the dignity of the medical profession. The lack of places for enlisted men at the outbreak of the Spanish-American War has already been discussed; no similar difficulty existed in the World War. Familiarity with the experiences of the combatants before the United States entered the World War caused the medical profession of this country to realize in how great num- bers they would be needed should we enter the conflict. Doubtless this realiza- tion would not have been the case, or at least not to the same extent, if we had gone into an unheralded war. The Mexican border mobilization and not the World War was really responsible for a considerable increase in supplies, and was perhaps even more important in establishing a war supply system so that the machinery existed for setting about the actual purchase of supplies when war came. Before we entered the war instruction of the medical profession in mil- itary matters as it affected members of that profession was carried out on a considerable scale so far as didactic teaching was concerned. Courses of lec- tures were given at many medical colleges and in various medical societies. This was perhaps of more value in stimulating interest than from what was actually learned, and yet its importance from the latter standpoint can not be disregarded. While this instruction was extended to a much greater num- ber of doctors, the practical knowledge gained from having Medical Depart- ment field units and actual observation of their operation by the limited few of course carried field instruction much further. This was an incidental result of the Mexican mobilization and not of the World War. It will be noted that the time given between the passage of the national defense act and the entry of the United States into the World War was short. For this reason not a great deal could be done in the interval in increasing the Medical Department of the Regular Establishment. From the beginning in the war our medical officers were found with a num- ber of the combatants in the role of observers, and their reports proved of a great deal of value.136 Furthermore, study by our Regular and National Guard medical officers of what the medical departments of the various armies at war had accomplished was very general, and this resulted in the publica- tion of numerous articles of particular importance. During the years preceding our entrance into the World War, many American civilian practitioners, imbued with the spirit to serve in their profes- sional capacities, allied themselves with the medical departments of one or another of the combatant armies in Europe. The valuable experiences they gained, largely surgical, were in many instances the subjects of articles in 84 SURGEON GENERAL’S OFFICE. medical journals, published and widely read in America. Other interesting fields were opened, notably the psychiatric. American doctors who practiced abroad with the foreign armies also made notable contributions to our knowledge of what should be done in respect to certain medical organizations, with particular reference to the great desirability for cohesiveness in operating and hospital units, organized for immediate active service. As these latter contributions bore fruit in the pre-war arrangements of the Red Cross, they are discussed later under the subject of Red Cross Medical Department units. The World War showed far more clearly than any previous war the neces- sity for specialists in the medical departments of armies. The observations of our civilian doctors before we entered the war was a potent factor here. This point was emphasized by them and led, when war came, to an actual contest among the various specialties to secure personnel and supplies for their particular needs. These civilian doctors became convinced that no matter how well qualified a doctor was, from the civilian standpoint, he needed additional instruction to qualify him for Army practice. This was partly responsible for the establishment of professional schools as soon as we entered the war. These not only provided review work but taught a great deal which was new and which had been brought out by the war. The military importance of correct professional practice, by the way, had never been as clearly shown as it was in the World War. While the assistance of good sanitation in adding to military strength had been appreciated for centuries, never before had the possibility of restoring wounded men to the ranks been so great. This was due of course to the advance in surgical practice. Before we entered the war literally thou- sands of men were fighting who, in pre-antiseptic days, would have been dis- abled for its entire period, if not forever. American volunteer ambulance corps operated with the French long before we entered the war. Their ambulance sections served as a model for us later, and from their ranks came some of our experienced personnel. Some changes in our Medical Department field organization were made, it is true, but these were put into effect rather from what was seen to be the need after we had entered the war than from anything we had learned previous to that time. Long before the World War it was fully realized that the success of a medical department in combat was dependent more on adequate and rapid means of transportation for patients than on any other one factor. This was by no means a novel conclusion, therefore, from observation of the medical service of the combatants in the war prior to April 6, 1917; on the other hand, their successful utilization of rapid motor transport helped us materially to a realization of what we must provide in the way of motor evacuation facilities.

SUMMARY.

Having traced the various stages in the evolution of medical departments of armies in general, and their influence on the development of our own Medical Department to the point reached by the time we entered the World War, by way of summary, attention is directed to certain basic influences which have operated on nations throughout the ages, and which have culminated in the development of military medical departments, including our own. While at the beginning of military history, medical departments of armies were very small and simply organized, by the time of the World War they had become most complicated, involving the expenditure of vast sums of money and requiring for their operation an enormous personnel. One naturally demands the reasons. It is obvious that no nation at war can afford to spend money needlessly and it can still less well afford to burden its already compli- cated military machine by personnel unless such personnel serves some very valuable purpose. The influences which have resulted in the very elaborate army medical departments of to-day may be summed up under politic, obliga- tion, humanitarian, economic, and military efficiency. Seldom, if ever, in history has one of these operated to the exclusion of all the others and to-dav all combine to make medical departments of armies what they are. 1. Politic.—For an example of this, and a very good one, we can go back as far as ancient Rome. It was then recognized as essential that the interests of the soldier in the medical way be carefully safeguarded in order to secure his loyal support. This is as true to-day as it was then, and has been so through the ages. The only exception that has been cited was under Charles the Fifth. This, it should be noted, was at the time when the common man was to all intents and purposes a serf, whose opinion amounted to little one way or another. To-day such practice would be absolutely inconceivable. It should be noted that even at that time important personages were well provided for in the way of medical service. 2. Obligation.—As early as ancient Rome, if not earlier, it was recognized that the state as a matter of right and justice had medical obligations to the soldier. Only in the Middle Ages was this feeling absent. Of course, it obtains to-day. 3. Humanitarian.—The humanitarian sense of the world has greatly increased since ancient days. As has been noted in the text, the spirit of human- ity was first given large practical effect by Queen Isabella in the fifteenth century. The organization of the Red Cross some four centuries later was a much wider application of the same spirit. As noted in President Roosevelt’s message quoted on page 5S, the American public demands a high degree of excel- lence from the Medical Department of its Army. Nobody doubts that this is due to the high spirit of humanity inherent in our people which finds personal expression mainly in the Red Cross but which, at the same time, expects a high order of accomplishment from the official agency in charge of sick and wounded—the Medical Department of the Arnry. It is sometimes overlooked that this agency, no less than volunteers, is influenced by dictates of humanity. 4. Economic.—The human wastage of war, of course, has to be paid for, whether disabled men and the families of the dead are liberally provided for by legislation or not. With us, with the very large burden that we willingly put upon ourselves to take care of soldiers, the economic question assumes the largest importance. A medical department of sufficient size, and well organized, it is universally admitted, will actually save many lives, first, by good sanita- 86 SURGEON GENERAL’S OFFICE. tion, and second, by minimizing bad results in many cases of illness and injury, thus minimizing ultimate cost to the state. Furthermore, by excluding physi- cally unfit men and by a final examination of all officers and soldiers on dis- charge, claims are reduced while at the same time justice can be done both to Government and soldier. 5. Military efficiency.—By the time of the World War, from the stand- points of policy, obligation, humanity, and economy, it would seem to have been inevitable that no civilized nation could have afforded not to have had an army medical department of such strength and so organized as to take full advantage of what has been demonstrated would be gained from the standpoint of policy, obligation, humanity, and economy. So far as these went, this was doubtless the case, yet in war in the last analysis everything must give way to military efficiency. Therefore, it is specially important here to trace what history has to offer on the influence of medical departments on military effi- ciency. A good deal might be said on this subject so far as home territory is concerned; in fact, as late as the Spanish-American War our Army was wrecked in the home camp through diseases which, whatever may have been the case then, it is certain an efficient medical department could prevent to-day. Yet at home it is so well recognized by all military students that all the influences which have been previously mentioned, as well as military efficiency, demand a large enough medical department to attain maximum results, that it would be superfluous to discuss what is really a self-evident fact. In order to form an opinion on the subject at issue it is necessary, there- fore, to turn to the army operating in the field. Realization of the importance of the Medical Department from the stand- point of military efficiency in the field is comparatively a new thing. The general military opinion on this subject as late as the early days of the Civil War is believed to be well expressed in a letter written by General Halleck, then general in chief of the Armies of the United States: War Department, Washington City, D. C, August 29, 1862. Sir: The Secretary of War desires me to acknowledge the receipt of your communication of the 21st instant, submitting a project for a Hospital Corps, and to inform you that the subject was referred to the general in chief, whose views, adverse to the project, are expressed in the following words: ” Our army trains are already much too large and very seriously impede the move- ment of our troops in the field. The enemy have great advantages over us in this respect. To organize such a medical force as is here proposed would, besides involving enormous expenses, greatly increase this evil. Moreover, the presence of noncombatants on or near the field of battle is always detrimental, as most panics and stampedes originate with them. Medical soldiers would not obviate the necessity of sending fighting soldiers from their ranks with their wounded, for the former would seldom be near enough to the enemy to perform that duty. The soldier can be very much relieved by hiring cooks, nurses, and attendants in hospitals, whenever the circumstances will permit; but I can see no advantage in having them enlisted for that special purpose. All persons so employed, are, by law, subject to Army Regulations. I regard this project as one calculated to increase the expenses and immobility of our Army by adding to it a large corps of noncombatants, without any corresponding advantages. I therefore report against its adoption.” Very respectfully, your obedient servant, P. H. Watson, Assistant Secretary of War, EVOLUTION OF MEDICAL DEPARTMENT. 87 Later, Letterman’s demonstration of what could actually be done by an efficient field medical department in battle caused a reversal of opinion; and the orders which resulted in the organization of the ambulance and field hospital service in the Army of the Potomac, were finally extended to all the Federal Armies by a confirmatory act of Congress. Yet the question was by no means finally settled so far as our Army was concerned, for with the end of the Civil War this organization disappeared and we went into the Spanish-American War no better off in respect to field medical organization than we were in the Mexican War. Nor is the question an easy one to settle. The object of an army, of course, is the defeat of the enemy, and to this everything else must give way. In the older day it was the well-established military belief that the medical department at the front was solely a source of weakness because of the additional mouths to feed and bodies to supply, plus interference with the movement of troops without at the same time any additional hands to destroy the enemy. Latterly, it has been more clearly realized by military students that all of war does not consist of destroying the enemy at a blow, but partially in preserving one’s own strength, so that ultimately the same result will be obtained in fuller measure. The medical department, as history shows, con- duces to this result by: Good sanitation; prompt and efficient treatment, so that the effects of wounds are minimized, with earlier recovery; and by sus- taining morale. Both the Franco-Prussian War and the Russo-Japanese War show how one army profited over its enemy by better sanitation, and our own experience in many fields since the Spanish-American War demonstrates even more fully what wonderful results can be obtained through good modern sanitary practice. Even before our entry into the World War modern surgery had resulted in restoring wounded to the ranks in vast numbers. The modern soldier is believed to fight better if he knows that in case of being wounded he will receive prompt attention (from history it is apparent this was no less true in ancient days). If one agency (the medical department) is appointed to care for wounded, no excuse is presented for leaving the line of battle; if there is no such agency, leaving the line to attend wounded comrades becomes a matter of very serious moment, more especially so as this will occur to the maximum extent when the loss can be least well sustained—heavy combat and heavy losses. On the other hand, it is realized that the medical department at the front can be of only such strength as to carry out these objects reasonably well under ordinary battle field conditions. With extraordinary demands it must prove too small, though, even so, temporarily supplementing it after a battle, if it is of the proper size and properly organized, should provide efficient medical service with the military benefits therefrom. By the time of the World War our Medical Department strength at the front was a compromise; in other words, a medical department strength capable of carrying out the objects recited above, at the same time not so great as to interfere seriously with the needs of the rest of the Army. This was exemplified in the Tables of Organization for our own Medical Department at the front as well as in those of the other large nations.

SURGEON GENERAL’S OFFICE. REFERENCES.

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(54) Stiles, Charles J.: History of the Umted States Sanitary Commission. Philadelphia, 1866.
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(56) Duncan, L. C: The Comparative Mortality of Disease and Battle Casualties in the Historic
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(57) Prinzing, Friedrich: Epidemics Resulting from Wars. Oxford, The Clarendon Press, 1916,
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(58) Brown: Op. cit., 256.
(59) G. 0., No. 51, Headquarters of the Army, Adjutant General’s Office, Washington, June 24,
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(60) G. 0., No. 78, Headquarters of the Army, Adjutant General’s Office, Washington, September,
22, 1893.
(61) Annual Report of the Surgeon General, United States Army, 1894, 36.
(62) Sternberg, Martha L.: George M. Sternberg. A Biography. Chicago, American Medical
Association, 1920, 131.
(63) Osier, Sir William: The Evolution of Modern Medicine. Yale LTniversity Press, 1921, 208.
(64) Osier: Op. cit., 214.
(65) Stevenson, W. F.: Wounds in War. The Mechanism of Their Production and Their Treat-
ment. Longmans, Green & Co., London, New York and Bombay, 1904,128.
(66) Reed, Vaughan, and Shakespeare: Report on the Origin and Spread of Typhoid Fever in
United States Military Camps During the Spanish War of 1898. Washington, Government
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(67) G. O., No. 124., W. D., Washington, A. G. ()., August 20, 1898.
(68) McPherson, Maj. Gen. Sir W. (J.: History of the Great War, Based on Officer’s Documents.
Vol. I. London, 1921, 1.
(69) Prinzing: Op. cit., 291.
(70) Osier and MoRae: Modern Medicine. Its Theory and Practice. Philadelphia, Lea Brothers &
Co., 1907, Vol. II.
(71) Makius, G. II.: Surgical Experiences in South Africa, 1899-1900. Philadelphia. P. Blakis-
ton’s Son & Co., 1904, 31
(72) Brereton, Lieut. Col. F. S.: The Great War and the R. A. M. C. London. Constable & Co.,
1919, 6.
(73) Reports of Military Observers Attached to Armies in Manchuria During the Russo-Japanese
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(74) G. O., No. 15, Headquarters of the Army, Adjutant GeneraLs Office, Washington, February
18, 1903.
(75) Commission to Investigate Conduct of War Department in War with Spain. Washington,
Government Printing Office, 1900. Vol. I, 237.
176) Ibid., Vol. I, 1S8, 189.
(77) Annual Report of the Surgeon General, United States Army, 1908, 122 et seq.
(78) Annual Report of the Surgeon General, United States Army, 1905, 130,
179) G. O., Xo. 67, W. D., May 2, 1908.
ISO i Bull. Xo. 16, W. D., June 22, 1916.
90
SURGEON GENERAL’S OFFICE.
(81) Weekly Report from the Personnel Division, S. G. ()., for week ending Nov. 15, 1918. On
file, Record Room, S. G. 0., Weekly Report File (Personnel).
(82) First indorsement from the Surgeon General to The Adjutant General, March 11, 1912. Sub-
ject: Miss Delano’s Resignation. On file, Record Room, S. G. O., 128452-28.
(83) Weekly Report from the Superintendent Army Nurse Corps to the Surgeon General for the
week ending November 15, 1918. On file, Record Room, S. (i. O., Weekly Report File
(Army Nurse Corps).
(84) Annual Report of the Surgeon General, United States Army, 1902, 42.
(85) G. 0., No. 80, W. D., May 15, 1908.
(86) Plans and Specifications for Base and Stationary Hospitals. Surgeon General’s Oflicc,
October 30, 1906.
(87) Annual Report of the Surgeon General United States Army, 1908, 124.
(88) Letter from the Surgeon General to the Secretary of War, July 11, 1904. Subject: Change
in Method of Making Reports of Sick and Wounded. On file, Record Room, S. G. O.,
40719-10 (Old Files).
(89) Tables of Organization, United States Army, 1916.
(90) Manual for the Medical Department, 1916, par. 804.
(91) Ibid., 1911, Part II.
(92) Act of Legislature, State of New York, 1905.
(93) S. O., No. 64, W. D., March 18, 1910.
(94) Annual Report of the Surgeon General, United States Army, 1912, 188.
(95) Ibid., 1914, 173.
(96) Ibid., 1916, 205.
(97) Ibid., 1917, 316.
(98) Letter from the Surgeon General to The Adjutant General, April 7, 1911. Subject: Ambu-
lance Companies and Field Hospitals. On file, Record Room, S. G. O., 135334-A (Old
Files).
(99) Indorsement from The Adjutant General to the Commanding General, Central Division,
October 3, 1911. On file, Record Room, S. G. O., 136991-P (Old Files).
(100) Letter from the Acting Surgeon General to The Adjutant General, April 28, 1914. Subject:
Additional Ambulance Companies and Field Hospital Companies. On file, Record Room,
S. G. O., 128732-1-3 (Old Files). Letter from the Surgeon General to The Adjutant
General, May 6, 1914. Field Hospital No. 7 and Ambulance Co. No. 7. On file, Record
Room, S. G. O., 148945 (Old Files). Letter from the Surgeon General to The Adjutant
General, May 8, 1914. Subject: Ambulance Co. No. 8, On file, Record Room, S. G. O.,
148988 (Old Files).
(101) Letter from the Surgeon General, to The Adjutant General, August 17, 1916. Subject:
Ambulance Company, Hawaiian Department. On file, Record Room, S. G. O., 159957
(Old Files).
(102) Letter from the Surgeon General to The Adjutant General, June 22, 1896. Subject: Dis-
continuance of Company of Instruction at Fort Riley, Kans. On file, Record Room,
S. G. O., 19944 (Old Files).
(103) Annual Report of the Surgeon General, United States Army, 1899, 21.
(104) Letter from the Surgeon General to Chief Surgeon, Department of California, August 23,
1899. Subject: School of Instruction for Hospital Corps at Angel Island. On file, Record
Room, S. G. O., 62633 (Old Files).
(105) Annual Report of the Surgeon General, United States Army, 1901, 40.
(106) Letter from the Surgeon General to The Adjutant General, October 30, 1902. Subject: Des-
ignation of Companies of Instruction, Hospital Corps, as No. 1 and No. 2. On file. Mail
and Record Division, A. G. O., 458315 (Old Files).
(107) G. O., No. 24, Headquarters of the Army, Adjutant General’s Office, Washington, March 7,
1903.
(108) Letter from the Military Secretary’s Office, War Department, to the Surgeon General, Septem-
ber 29, 1904. Subject: Companies of Instruction, Hospital Corps. On file, Record Room,
S. G. O., 65168-138 A.
(109) Annual Report of the Surgeon General, United States Army, 1907, 125.
(110) Letter from the Surgeon General to The Adjutant General, May 12, 1909. Subject: Camps of
Instruction for Militia Medical Officers. On file, Record Room, S. G. O., 127733 (Old Filesj.
(111) G. 0., No. 100, W. D., June 1, 1910.
(112) S. 0., No. 161, W. D., July 10, 1908.
(113) A Study in Troop Leading and Management of the Sanitary Service in War. J. F. Morrison
and F. L. Munson. Ketcheson Printing Co., Leavenworth, Kans., 1910.
(114) Munson, E. L.: The Principles of Sanitary Tactics. Banta Publishing Co., Menasha, Wis.,
1911.
(115) G. O., No. 132, W. D., July 11, 1910.
(116) Report from Division Surgeon, Provisional Division, Fort Riley, Kans., to the Adjutant
General, Provisional Division, Fort Riley, Kans., March 1, 1903. Subject: Operation of
the Medical Department of the Division. On file, Record Room, S. G. O., 91156-33 (Old
Files).
(117) Annual Report of the Surgeon General, United States Army, 1909, 130.
(lisi Report of Chief Surgeon, Camp of Instruction, American Lake, Washington, September 6,
1910. On file, Record Room, S. G. O., 132205-P (Old Files).
1119i Report from Chief Surgeon, Camp of Field Instruction, Fort Benjamin Harrison, Ind., to
the Surgeon General, September 15, 1912. On file, Record Room, S. G. O., 140605-M.
Report of Chief Surgeon, Connecticut Maneuver Camp, to the Adjutant General, Eastern
Department, August 31, 1912. On file, Record Room, S. G. O., 140632-N.
1120) Memo, from the Chief of Staff to The Adjutant General, March 7, 1911. Subject: Mobiliza-
tion of Division, Department of Texas. On file, Record Room, S. G. O., 1361861 (Old
Files).
(121) Report from Division Surgeon, Second Division, to the Surgeon General, July 1, 1913. On
file, Record Room, S. G. O., 144955-K-6-A (Old Files).
(122) Birmingham, H. P.: Sanitary Work of the Army at Vera Cruz. The Military Surgeon,
1915, xl, No. 4, 20.5-221.
(123) Letter from the department surgeon, Southern Department, to the Surgeon General, March
15, 1916. Subject: Expeditionary Forces. On file, Record Room, S. G. O., 156351 (Old
Files).
(124) Report from the division surgeon, punitive expedition, to the Commanding General, Punitive
Expedition, February 15, 1917. On file, Record Room, S. G. O., 156351-H (Old Files).
(125) Report from the division surgeon, Twelfth Provisional Division, to the department surgeon,
Southern Department, December 31, 1916. On file, Record Room, S. G. O., 1054-2310
(Old Files).
(126) Circular No. 62, Headquarters of the Army, Adjutant General’s Office, Washington, December
24, 1902.
(127) Report from the sanitary inspector, Maneuver Division, to the Surgeon General, September
11, 1911. On file, Record Room, S. G. O., 136186-230 (Old Files).
(128) G. O., No. 76, W. D., June 9, 1911.
(129) Compiled from Sick and Wounded Cards. On file, Surgeon General’s Office.
(130) G. O., No. 68, W. D., June 1, 1917.
(131) Shown on Consolidated Statistical Sheets, Mexican Border, 1916. On file, Statistical
Division, S. G. O.
(132). G. O., No. 31, W. D., September 12, 1912, and G. O., No. 45, W. D., June 9, 1914.
(133) Report of the chairman of the committee on medicine and sanitation of the advisory commis-
sion of the Council of National Defense, Washington, D. C, Government Printing Office,
April 1, 1918.
(,134) Bull. No. 33, W. D., September 9, 1916.
(135) Second Annual Report of the Council of National Defense for the Fiscal Year Ended June 30,
1918, 103.
(136) Annual Report of the Surgeon General, United States Army, 1916, 18, 19.

II. DEVELOPMENT OF RED CROSS MEDICAL DEPARTMENT UNITS.

During the two years and eight months that the United States occupied
the difficult role of a neutral, many of our distinguished medical men went
abroad to render service to humanity by assisting in the care of the wounded.
They learned, at close range, some of the complexities of medical organization,
the difficulties attending the operation of improvised medical units, and the
enormous delays in the procurement of adequate equipment under war condi-
tions. The necessity for preparedness in the matter of the more complex
medical units in the same way as for batteries of artillery and regiments of
infantry began thus to be recognized by individuals in the medical profession
outside of the Army medical staff. A number of small surgical groups from
American medical schools in 1916 had served in succession at the American
Ambulance at Neuilly, a suburb of Paris; and the British war office, at the
suggestion of Sir William Osier and Hon. Robert Bacon, had invited various
American university medical schools to send similar units to serve in British
hosptials. A considerable number of leading men in the medical profession in
the United States in this way gained a knowledge of medical conditions in war
and of the new problems of military surgery which were later of much value in
the building up of the medical service of our Army.

BASE HOSPITALS RECOMMENDED.

Maj. Karl Connell, M. C, of the New York National Guard, returned with
the lesson that the organization and equipment of base hospitals could not,
without disaster, be postoned until war was upon us. Dr. George W. Crile,
who had taken to France a surgical group from the Lakeside Hospital at Cleve-
land, made the valuable suggestion * that base hospitals should be organized
from the staff of large, well-organized hospitals. “These units will be most
efficient if they are exclusively made up of men who have had similar training
and who know each other well, and if they have associated with them a nursing
staff familiar with their methods.” Doctor Crile brought these ideas to the
attention of the Surgeon General, who was impressed by them, but, it seemed,
attached more importance to the idea of personal leadership than of a parent
institution as the organizing agency. He authorized, accordingly, three
members of the Medical Reserve Corps, Dr. G. W. Crile, Dr. Harvey Cushing
and Dr. J. M. Swan, to proceed to organize base hospitals. Doctor Crile was
professor of surgery in the Western Reserve University; Doctor Cushing held
a like position in the Harvard Medical School; and Doctor Swan was a prom-
inent internist of Rochester, N. Y., not connected with any medical school or
medical group.

This new departure on the part of the Surgeon General caused a protest
from the headquarters of the American Red Cross in Washington based on the
provision of their charter, by which they were charged with the furnishing of 
volunteer aid to the sick and wounded of the armed forces in war, and also on
the understanding which had previously subsisted between the Red Cross and
the Surgeon General’s Office, that the Red Cross should undertake the organ-
ization of medical units from civil life. As evidence of such an understanding,
they called attention to Circular No. 8 of the Surgeon General’s Office, dated
September 10, 1912, in which the details of organization, as approved at that
time, were laid down.

ORGANIZATION OF 1915.

In the annual meeting of the National Red Cross at Washington, in
December, 1915, the by-laws were amended so as to divide the entire field of Red
Cross activities into two great departments of civil and military relief. The
latter included the bureaus of medical service, nursing service, and supplies, and
furnished the machinery by which the Red Cross could operate effectively as
the auxiliary of military medical services. After much discussion as to whether
the first director general, upon whom should fall the responsibility of organizing
the Department of Military Relief, should be a general of the line or a medical
officer, it was recognized that the problems to be solved were predominantly
medical and a medical officer of the Army, Col. Jefferson R. Kean, was selected.
The question between the Surgeon General and the Red Cross as to who
should organize the base hospitals was decided by a compromise. It was
determined that the Red Cross should organize them, but that it should be on
strictly military basis, and that the personnel should be commissioned and
enlisted men of the Reserve Corps, so that, when called into active service by
the President, they should pass actually and completely into the Army, the
authority of the Red Cross ceasing as completely as does the parental control in
the case of the young recruit when he enlists and marches away with his company.

ORGANIZATION OF BASE HOSPITALS.

Colonel Kean reported at Washington on January 15, 1916, and in Feb-
ruary had the organization of the new Department of Military Relief sufficiently
advanced to be able to leave Washington for a visit to several medical schools
which had been selected as desirable “parent institutions” for future base
hospitals.

In the Spanish-American War, and all of our previous wars, base hospitals
were built up slowly and painfully, as personnel and equipment could be got
together. Members of the professional staff were strangers to each other and
to their commanding officers, and many of them were appointed for political
rather than professional reasons. The solving of their personal equations and
the fitting of each to the duties for which he was best qualified presented, there-
fore, a slow and difficult problem, which apparently it was impossible to solve
by any preparatory steps in time of peace, since these large units had no peace
existence. It was determined to shorten and facilitate this slow process of
integration by adopting the suggestion of Crile, above mentioned, to utilize the
cohesion and training of the staffs of the great hospitals by using these as the
nuclei of the base hospitals. In this way could be obtained units in which the
medical officers and nurses were picked groups, known to each other and
accustomed to work together, and, so far as professsional work was concerned,
always in training.

Equipment.

Equipment for base hospitals had never been provided by the War Depart-
ment in time of peace, though Surgeon General O’Reilly, who took to heart the
lessons of unpreparedness of the Spanish-American War, had established
separate depots for medical field supplies, and had set to work to accumulate
the complete equipment of field hospitals and other medical units of the service
of the front. This had been carried on by his successors, and the Medical
Department found itself, at the beginning of 1917, prepared to equip all such
units prescribed by the Tables of Organization for the maximum army then
contemplated, about 300,000 men. But equipment of base hospitals with the
beds, mattresses, bedding, furniture, and utensils was not only very costly but
exceedingly bulky, requiring for a 500-bed hospital about 10,000 cubic feet.
Storage space was a difficult question in the Army and was not to be had on
such a scale. In fact, it had been a matter of much difficulty and patient
insistence through years to get storage for the field units above mentioned.
The limitations of both the annual appropriations and of available storage thus
stood in the way of such provision. Yet it was recognized that when war
comes, base hospitals are needed long before it is possible to purchase this
elaborate equipment. The conversion of appropriations into hospital equip-
ment is an even slower process than the conversion of casual medical personnel
into trained and disciplined units, being, under the disordered trade conditions
of war, a matter of many months. Therefore, it was evident that as personnel
without equipment is useless, the Red Cross would have to provide the equip-
ment also. It was determined that the local Red Cross chapters in the cities
where base hospitals were to be organized should be asked to furnish the money
for the equipment in the same way that the medical schools or great hospitals
were to furnish the personnel. It fell to the new director general to persuade
the parent institutions to harbor and cherish within themselves a military
organization which, when called into activity, would deplete their professional
staff nearly to the point of paralysis, and also to induce the chapters to raise
large sums of money for these new medical units.

First Base Hospitals.

On February 1, 1916, two weeks after he had reported in Washington for
duty with the Red Cross, Colonel Kean started visiting different cities with the
view to making arrangements, with prominent representatives of the medical
profession, for the organization of the following base hospital units:
New York City: The Presbyterian Hospital Unit (Base Hospital No. 2),
under Dr. George E. Brewer; The Bellevue Hospital Unit (Base Hospital No.
1), under Dr. George David Stewart; The New York Hospital Unit (Base
Hospital No. 9), under Dr. Charles L. Gibson.
Boston, Mass.: The Harvard University Unit (Base Hospital No. 5),
under Dr. Harvey Cushing; The Massachusetts General Hospital (Base Hospital
No. 6), under Dr. Frederick A. Washburn, superintendent of the hospital;
The City Hospital Unit (Base Hospital No. 7), under Dr. J. J. Dowling,
superintendent of the hospital.
Rochester, N. Y.: The Rochester General Hospital Unit (Base Hospital
No. 19), under Dr. John M. Swan.
Cleveland, Ohio: The Lakeside Hospital Unit (Base Hospital No. 4),
under Dr. George W. Crile.

It will be observed that the numbers designating these units do not
correspond with the order in which their creation was initiated, the reason
being that a hospital was not given a number and its existence officially
recognized until satisfactory arrangements had been made with the local
chapter, or otherwise, for its equipment.

Funds for Equipment.

The difficult question of the donation of equipment was first taken up
with a chapter on February 17, 1916, when the director general appeared
before the New York chapter, which met at the house of Mrs. Whitelaw Reid,
the venerable Joseph H. Choate presiding. The whole question of the relation
between the Red Cross and the medical services of the armed forces was fully
discussed, and the natural and obvious question was asked, why the Govern-
ment did not furnish the equipment for these units which, in time of war,
would become incorporated into the Army and Navy. In reply it was pointed
out that it was idle to criticize. Congress or the War Department for this lack.
Congress did not prepare the military estimates, and those who did were deeply
interested in what they believed to be more important needs. The Army was
in need of a vast number of costly things for the arming and equipment of
troops for war, and until these were provided it was most unlikely that the
military authorities would be willing to see large sums expended and precious
storage space absorbed for these bulky base hospitals. It was also pointed
out that, granting in theory the obligation of the War Department to furnish
this equipment, yet the most logical theories did not equip hospitals or relieve
the sufferings of wounded men; and so, in order that they might be promptly
cared for, the Red Cross or some similar agency must provide, in advance, the
necessary means. The matter was finally decided favorably by an earnest
speech of the Hon. Robert Bacon, lately Ambassador to France. He had
personally assisted in the rescue of the wounded in the Battle of the Marne and
had seen the pitiful results of medical unpreparedness. To his view the matter
was not only obvious, but urgent, and he called upon those present to accept
the responsibility for the equipment of the proposed hospitals and to begin
immediately to meet it. When the meeting adjourned it was found that nearly
$30,000 had already been pledged. So prompt and hearty a response not
only placed the project on its feet, but set an example which could not but
exert a potent influence upon other chapters.
This, in truth, was a fair beginning, but many difficulties remained to be
surmounted.

The cost of the equipment was estimated by the Surgeon General’s Office,
with peace-time markets and the rather Spartan standards of the Regular
Service, at 825.000, but this made no allowance for the fads and fancies of
surgical experts, or even for such valuable luxuries as portable laundries and
ice plants, so this figure was soon found inadequate. Some of the units ulti-
mately expended from three to five times this amount. These large sums
were contributed mostly by men of affairs who were accustomed, when they
put money into any undertaking, to acquire a voice in its organization and control. They naturally expected, therefore, to have a voice in the selection of
directors and chiefs of service, and, of course, in the purchase of equipment.
It seemed, however, not the part of wisdom to admit such influence, and so it
was announced that these units, being military, should be immediately under
a military authority, and being, at the same time, medical, their medical and
nursing staffs would desire and expect that the direct control over them would
be of a professional character. Their organization, therefore, was managed
directly from the office of the director general in Washington, who was con-
stantly in touch with the wishes of the Surgeon General. The chapters accepted,
with good grace, the relation of “Big Sister” to the medical units, which carried
the obligation to help without any parental authority.
The feeling that purchases should be made locally, as far as possible, was
natural and strong, and was deferred to, but any efforts to standardize, espe-
cially in surgical instruments and appliances, caused trouble. Among distin-
guished surgeons in civil life individual taste in the patterns and designs of
surgical instruments had as wide and unquestioned a latitude as in the designs
of ladies’ bonnets, and they were agreed in the belief that all Army equipment
was antiquated and all Army methods of administration were “red tape.”
This conflict of opinions was finally solved by the Medical Advisory Board
of the War Council, which appointed a board of surgeons of national reputation
to select standard types of instruments and appliances, and then forbade the
manufacture of any other.

Storage of Equipment.

Storage was another difficult question which pressed for a solution as soon
as deliveries of equipment began to be made, and it was claimed, with insistence,
that the War Department, for whose use this material had been purchased,
should at least be willing to store and care for it. This was readily admitted
in principle by the Secretary of War, who authorized it wherever it could be
done without detriment to the interests of the military service, but it brought
practically no relief, because there was no storage room to spare and there
were apparently no funds available for renting storage. Permission to use the
buildings at one or more unoccupied posts was finally obtained, and the equip-
ment of four New York base hospitals was stored at Fort Schuyler. Most of
the chapters, however, had to obtain and pay for their own storage until the
entrance of the United States into war brought a solution of the difficulty by
its employment of the equipment in active service and its ultimate donation
to the United States.

The many difficult and vexatious questions connected with the purchase
of the base hospital equipment for both Army and Navy were worked out with
admirable patience and intelligence by Medical Director T. W. Richards, U.
S. N., who was detailed July 1, 1916, to report to the director general of military
relief, as his assistant for the purpose of taking charge of naval Red Cross
activities, and particularly for the organization of naval base hospitals. The
necessities of our Navy in this matter were definite and important, and are
stated by Commander Richards in a report3 which should be read by those
having special interest in the development of Red Cross medical units for that
service.

RED CROSS MEDICAL DEPARTMENT UNITS.

NATIONAL GUARD ON THE BORDER.

Popular interest in the Red Cross was much stimulated during the summer
of 1916 by our disturbed relations with Mexico, which resulted in the calling
into active service of the National Guard and in its being stationed, together
with the bulk of the Regular Army, along the Mexican border. No Red Cross
units were called into active service at this time, as the Medical Department
believed that its resources were adequate for the expansion necessitated by
this mobilization, and also because of an opinion given by the Judge Advocate
General of the Army that under the law the President of the United States is
not authorized to call into active service the Red Cross units except in case of
war or when war is imminent. A number of nurses, 117 in all, however, were
furnished by the Red Cross nursing service acting in its role as a reserve for
the Army Nurse Corps, and these did excellent service in the temporary hospitals
on the Mexican border.

COMMITTEE OF MEDICAL ASSOCIATIONS.

The by-laws of the Red Cross, in the amendments which provided for the
department of military relief, provided also for a National Committee on Red
Cross Medical Service. This committee, composed of distinguished members
of the medical profession in all parts of the country, was intended to be the
principal agent through which the department of military relief would act in
the enrollment and organization of the medical profession for service with the
lied Cross in time of war. This was recognized as a very difficult and delicate
undertaking. A new and powerful agency, however, which at first appeared
to thwart the efforts of the Red Cross for such organization, resulted in making
it possible. The presidents of the five great medical associations of the United
States—The American Medical Association, the American Surgical Association,
the Congress of American Physicians and Surgeons, the Clinical Congress of
Surgeons of North America, and the American College of Surgeons—jointly
appointed a committee to make a comprehensive survey of the medical resources
of the country, including all data required for mobilization of the medical pro-
fession, and this committee, as stated elsewhere, on April 26, 1916, made an
offer of its services and of those of the 70,000 medical men which it represented
to the President to assist the medical development of the Army and Navy.4
The director general of military relief, who was invited to be present at the meet-
ing of this committee, pointed out that the work proposed by it covered ground
which was assigned to the American Red Cross by its charter and by the presi-
dential proclamation of August 22, 1911, and proposed that this committee
should work either through the Red Cross or in conjunction with it. This
suggestion, after due deliberation on the part of the committee, was accepted
to the extent that an agreement was entered into that they should cooperate
with the American Red Cross through its National Committee on Red Cross
Medical Service, which committee should be made an interlocking one with the
committee of the associated medical societies by having as members all the
members of the committee of the associated societies. At a meeting of the
Xational Committee on Red Cross Medical Service, held at Detroit at the time
of the meeting of the American Medical Association, in June, 1916, various 
questions connected with the organization of base hospitals were discussed.
It was pointed out that there was in the public mind a fixed conception of a
hospital as a building occupied for the treatment of the sick rather than a vital
unit which could be transported wherever the Government might need it, and
the medical profession, as well as the public at large, found it difficult to visualize
these organizations or to appreciate them at their true value and importance
until one should be demonstrated to them by an actual mobilization. The
national committee, therefore, requested the Red Cross authorities to mobilize
one of its newly organized units in Philadelphia on October 28, 1916, at which
time and place the committee would have a called meeting.

FIRST MOBILIZATION OF A BASE HOSPITAL.

The purposes of this mobilization were primarily to demonstrate that the
organization existing on paper was a practical and serviceable one; secondly, to
ascertain what difficulties would stand in the way of such a mobilization, in
order that they might be met and removed; and thirdly, for the instruction in
medical preparedness of the great body of surgeons who would be in Philadelphia
at that time in attendance upon the Clinical Congress of Surgeons and the Ameri-
can College of Surgeons.

The Lakeside Hospital Unit from Cleveland, Ohio, Base Hospital No. 4,
was selected for the purpose of this mobilization. It was asked to furnish a
staff of 16 medical officers (including specialists), 25 nurses, and the necessary
administrative personnel. The equipment was brought from the Red Cross
depot at the Bush Terminal, Brooklyn, and was complete in all respects, so that
every necessity of the wounded man could be promptly and efficiently met.
The housing was furnished by tentage supplied by the United States Govern-
ment from its Philadelphia depot; and the camp was erected by a detachment
of the United States Medical Department sent over from Washington. The
location of the camp on the Belmont Plateau, in Fairmount Park, Philadelphia,
was an ideal one in all respects. The tentage, in as compact arrangement as
the convenience and administration permitted, covered an area 1,000 feet long
and 500 feet broad, being about 12 acres in extent. The mobilization of this
hospital marked an important step in Red Cross development as concerned the
obligations of the Red Cross to assist the medical service of the armed forces in
time of war. It was the first practical and concrete demonstration of the abil-
ity of the Red Cross to do so. It took the scheme of Red Cross military units
out of the domain of theory into that of accomplished fact.

FURTHER ORGANIZATION.

The five months intervening between the mobilization of Base Hospital
No. 4 at Philadelphia and the declaration of war against Germany constituted
a period of great activity and development in all branches of Red Cross organi-
zation relating to the military establishment. There was active correspondence
with the various medical centers, many of which were anxious to organize units
but had very vague notions as to what was required, in spite of the fact that
the organization of Red Cross base hospitals had been quite fully explained in
an article published in The Military Surgeon for May, 1916, reprints of which
had been liberally distributed to correspondents.

Before athorization was given for the creation of a base hospital at an institution, it was necessary to
ascertain whether it had a staff large enough to furnish the 23 medical officers
needed, and whether it was sufficiently representative to insure a capable and
efficient staff. Then, too, the very delicate question had to be decided as to
the selection of the director to whom the task of organization should be in-
trusted, as the success of the unit would depend upon his possession of sufficient
professional reputation and leadership to insure that his premiership would be
recognized by his professional associates. The question, too, of financial backing
of the proposed unit by the local Red Cross chapter had to be taken up in order
to furnish funds for the purchase of equipment. If no local Red Cross chapter
was in existence, steps were taken in some cases to organize one with this
special object in view.

The question of equipment caused great delay before authorization was
given a number of excellent units. After the declaration of war, however, this
difficulty disappeared, because funds were much more readily obtainable and
because later, as soon as war appropriations for the Medical Department became
available, the furnishing of equipment by the Red Cross was no longer required.
Much embarrassment was caused by the desire of prominent or ambitious
medical men to receive authority to organize a unit without the support of a
parent institution. Such offers, although frequently backed by strong political
and social influences and the offer of funds for equipment, were always refused.

SMALLER UNITS.

The reasonable and patriotic offers of medical institutions too small to be
the parents of base hospitals were met by authorizing those who fulfilled all
requirements to organize hospital units. These units were only one-half the
size of base hospitals, but were intended for a service of 250 beds, with a staff
of 12 medical officers and 20 nurses. They were intended either for the estab-
lishment of small hospitals, such as camp hospitals, or for the rapid expansion
of base hospitals. They were found to be very valuable for both purposes in
the service of the American Expeditionary Forces. They were designated by
letters of the alphabet to prevent confusion with base hospitals. A less elabo-
rate equipment was required for these small units than for the base hospitals.

AMBULANCE COMPANIES.

During this period the organization, training, and equipment of ambulance
companies were rapidly and successfully pushed, this work being in the hands
of an officer of the Medical Corps, who had been for several years on duty with
the Red Cross and who had organized the Bureau of Medical Service. This
service, besides organizing ambulance companies, was in charge of a great
system of first-aid instruction, not only in connection with chapters, but with
railroads, mines, and the large industrial concerns. Forty-five ambulance
companies were organized,5 which passed into the service of the United States,
most of them being assigned to sanitary trains of the various divisions. A
number of those earliest organized joined the camp established by the Surgeon
Ceneral at Allen town, Pa., for the organization of ambulance sections for
service with the French Army, and later saw service in France with the United
States Ambulance Service with the French Army.