History
WORLD WAR I
THE AMBULANCE SERVICE
In April 1917 the United States entered World War I on the   side of the Allies-France, Russia, Great Britain, and Italy. The British and   French asked for immediate medical support because their medical systems were   severely taxed. Their war against the Central Powers (Austria-Hungary, Germany,   Turkey, and Bulgaria) was in its third year. While mobile war characterized the   Eastern Front, barbed wire, machine guns, and the increased accuracy and rate of   fire of weapons had created a static front in the west. "The two lines sat   opposite each other and did nothing but hammer at each other."1 Everywhere the war was bloody, and casualties were high. The combatants would   suffer over 34 million casualties, including nearly 8 million deaths from wounds   and disease.2 Though a latecomer to the   fighting, the United States mobilized over 4 million soldiers and deployed over   2 million to Europe; 106,378 would die before peace returned.3
The need for medical support was staggering. Great battles   used up manpower at an incredible rate. During the 1916 Battle of the Somme, in   seven days British artillery threw 1.5 million explosive and chlorine gas shells   at the well-dug-in Germans. Yet when the British attacked, surviving Germans   manned their machine guns and inflicted 60,000 casualties on the attackers   during the first day alone. The battle lasted five months, during which there   were some 420,000 British, 200,000 French, and 650,000 German casualties.   British artillery preparation for the Third Battle of Ypres the following summer   devoured the entire production of 55,000 British ammunition workers for a year,   and a victory of very limited value cost them 8,222 casualties per square mile.4
To meet the needs of war, the U.S. Army's surgeon general,   Maj. Gen. William M. Gorgas, presided over an enormous expansion of the Army   Medical Department. When the United States entered the war his department   consisted of less than 1,000 personnel, but it numbered over 350,000 when peace   returned in November 1918. The Surgeon General's Office mushroomed from a staff   of 153 at the beginning of the war to over 2,100 at its end. The Medical   Department was authorized 444 physicians at the beginning of World War I, but it   had 31,530 when the war ended. Nearly 24 percent of all American physicians   served in the Army.5
Increases in the other specialties were also dramatic. By   war's end the department had 4,620 dentists, 21,480 nurses, and 2,234   veterinarians. In addition, there were two new precursors of the Medical Service   Corps. The U.S. Army Ambulance Service, formed in 1917, had 209 officers, and   the Sanitary Corps,
Map of Europe, 1914
38
formed the same year, had 2,919. The department was rounded   out with 281,341 enlisted soldiers and 10,695 civilian employees.6
Military medicine benefited from medical advances, but   severe limitations remained. Sulfa drugs and antibiotics were yet to come, and   some medical problems remained intractable. Measles and influenza were the most   significant diseases for the Army in World War I because of respiratory   complications, principally the scourge of the pneumonia which followed. The   influenza epidemic of 1917-18 killed over 24,500 soldiers. Massachusetts   Institute of Technology's "Roll of Honor" lists those alumni who died in World   War I. Of the 123 listed, 41 died of pneumonia.7 However, the addition of new organizations to the Medical Department enabled it   to expand its medical team to accommodate the most advanced technology of its   time and to post the best record yet for the medical support of an American army   in the field.8
Volunteer Ambulance Officers
Put on your               old gray bonnet
With the               strap ahangin' on it,
And we'll               go thru shrapnel & thru shell-
Then on roads of desolation
We will               cure your constipation
With a wild               night ride in hell!9
As popular support for American participation in the war   increased, volunteer organizations capitalized on that spirit, enrolling many   young Americans who served as ambulance drivers in France and Italy. Until there   was an opportunity for overseas service in the Army, the volunteers provided   person-to-person proof of America's willingness to support its allies. They   received short orientation courses and wore uniforms patterned after those of   the U.S. Army. When deployed, they served under the command of the French or   Italian Army units to which they were attached. Volunteer ambulance   organizations preceded U.S. Army ambulance units in Europe, and their officers   were predecessors of Medical Department commissioned ambulance officers.
The American Red Cross Ambulance Service actively recruited   through its headquarters in New York and established units in France and Italy.   By the spring of 1917 it had forty-six ambulance units supporting the Allies.10 One who joined was eighteen-year-old Ernest Hemingway, who as a Red Cross second   lieutenant became the first American wounded in Italy.11 Hemingway received over two hundred artillery fragment wounds in his legs during   a night attack in July 1918 and was further wounded by machine-gun fire when he   carried a wounded Italian soldier to safety. He likened his left leg to the hide   of an old horse that had been branded and rebranded by fifty owners.12
Another group, the Norton-Harjes Ambulance Service, was   formed in 1914 by Richard Norton, an American archaeologist who served as its   director, and A. Herman Harjes, a French banker. Norton-Harjes affiliated with   the American Red Cross, and its members incurred a six-month obligation with the   Red Cross when they joined. By July 1917 Norton-Harjes units had over six   hundred
 39
Ernest Hemingway   convalescing at a hospital in Italy, April 1919; below, Inspector General Andrew
American ambulance drivers and three hundred ambulances.13
The largest of the volunteer ambulance groups was the   American Field Service. The organization dated from the earliest days of the   war, when the American colony in Paris outfitted a rudimentary ambulance service   to support the French Army. In May of 1915 the American Field Service was   operating 60 ambulances organized in 3 sections; by late 1917 it had 1,220   ambulances in 31 sections supporting 66 French divisions. Inspector General A.   Piatt Andrew, former director of the mint and a future congressman, served as   its director. Andrew was honored by France for his contributions with the Legion   d'Honneur and by the United States with the Distinguished Service Medal.14
Although neither the Red Cross nor the American Field   Service paid the volunteers, the French government insisted on reimbursing them   at five cents a day, equivalent to the pay of a French soldier. The volunteers   paid for their own transportation, clothing, uniforms, and personal equipment.   As one put it, "the Americans not only had to be willing to risk their lives,   they also had to pay to do it."15
The volunteer ambulance units refined motorized evacuation   techniques that were later adopted by the U.S. Army when it entered the war.   They incorporated Jonathan Letterman's ambulance corps officer, a specialty that   had been lost to the U.S. Army for thirty years. Inspector General Andrew noted   the similarity of his organization's doctrine with that of the French, who also   used non-physician officers to command the evacuation system. "From the French   point of view, it was as illogical to
40
Standard Ford ambulance with storm   curtains
expect doctors and surgeons to accomplish this work   successfully as it would be to ask automobile experts to do surgical and medical   work in the dressing stations and hospitals."16
Ford, Fiat, Peugeot, and General Motors Company ambulances   were severely tested under combat conditions that demonstrated their advantages   in speed and patient comfort. The Ford Model "T" could climb narrow mountain   roads where patient movement previously was possible only on mules or in   horse-drawn carts. The Ford put new meaning in "fording." It sat high and could   get through flooded roads not accessible by lower vehicles. Indeed, French   soldiers accused the Americans of painting water lines on their vehicles as   depth gauges, and some calls for evacuation would request the ambulance "boats."   If a road was blocked, the "T" could go cross-country. It was light enough that   three or four soldiers could pick it up and move it if it stuck in a ditch or   shell hole.17
Nevertheless, the motorized ambulances were primitive   vehicles. The Ford's idiosyncrasies made mountain driving dicey. Its gravity   gasoline feed did not work on steep grades, compelling drivers to back their   vehicles up the hills. Another problem was that prolonged driving in low gear   caused excessive and uneven wear on the transmission bands. To equalize the   wear, drivers in mountainous terrain used the low-speed band during climbs, the   reverse band to assist in controlling descents, and the foot brake on corners   and the steepest parts of hills. Transmission bands would last ten to fourteen   days with this technique. Mountain driving was further complicated by brakes   that could not handle the steep grades. Drivers kept an eye peeled for   strategically placed trees that could stop them if necessary. Sometimes patients   had unforgettable rides.18
41
Unfortunately, automobile driving was not yet a universal   skill, and the inexperienced drivers were further bedeviled by problems such as   horseshoe nails in the roads. The nails raised havoc with the tires, which, in   turn, raised havoc with the drivers, since this was before demountable rims. The   crews were further tested by the hazardous conditions of the combat zone. At   Verdun they navigated roads named for the risk of artillery fire-Dip of Death,   Hell's Half Acre, and Dead Man's Turn. William Seabrook, an American Field   Service volunteer, described how it was. "Those of us who used to laugh at   danger have stopped laughing. . . . We don't come back any longer and tell each   other with excited interest how close to our car this or that shell burst-it is   sufficient that we came back."19
Medical Department Organization and   Doctrine
While volunteers toiled in Europe, the Medical Department   readied itself for war. Its doctrine for wartime medical support, built on the   lessons learned in previous wars, rested upon the work of the staff of the Field   Service School for Medical Officers at Fort Leavenworth, Kansas. Setting forth   medical doctrine in landmark field manuals, Maj. Edward L. Munson, MC, and other   officers at the school formed a vibrant group of medical planners whose   foresight during the years of peace paid dividends when the United States again   went to war.20
First to go in May 1917 were six base hospitals; some of   their personnel were the first U.S. soldiers killed in action.21 The Medical Department deployed an astonishing array of skilled personnel over   the next year and a half to support Maj. Gen. John J. Pershing's American   Expeditionary Forces (AEF). At the time of the Armistice 145,000 American   soldiers were hospitalized in 152 base hospitals and 101 camp hospitals in   France and England, backed up by 7 medical laboratories and 28 medical supply   bases, depots, and stations. In addition, the Medical Department operated   147,636 beds in 92 hospitals in the United States.22
Army hospitals in Europe also served the field medical   units of the 43 American divisions deployed to France, the 2 regiments sent to   Russia and Italy, and the 19 divisions that remained in the United States. Each   Army division contained 40,000 soldiers-28,000 combat soldiers and 12,000   support troops. General Pershing insisted on extensive training of the divisions   prior to their commitment to battle, and the first committed did not go into   combat until the latter part of April 1918, a year after the United States had   entered the war.23
The Medical Department's doctrine for combat operations was   built upon an evacuation scheme configured within three levels of medical   support (see Chart 1). The zone of the advance was the first echelon. It   extended from the front lines through the division area of operations. The   second echelon, the line of communications, was the area of the field armies   that supported divisions. The third echelon, the service of the interior,   constituted the continental United States support base for overseas operations.   Under wartime conditions Medical Department doctrine was adapted to the   exigencies of combat, and the structure and procedures employed varied with the   type of combat (trench or open warfare), the intensity of the fighting, and such   other factors as terrain and weather.
42
CHART 1-WORLD WAR I ECHELONS   OF MEDICAL SUPPORT
Treatment of combat casualties was based on triage, a   French term for sorting patients in mass casualty situations into categories:   those who would die no matter what treatment was provided ("expectant"); those   who would live if treatment were immediately rendered ("immediate"); and those   whose treatment could safely be delayed ("delayed"). Initial medical attention   was concentrated on the immediate group, and the evacuation system was based on   the movement of serious cases to the rear for definitive treatment. Medical   personnel, equipment, and supplies were under Medical Department control. Army   regulations restricted ambulances to the Medical Department's use for movement   of the sick and wounded and emergency transportation of medical supplies.24
Medical support in the zone of the advance was the   responsibility of the medical elements within the divisions, including the   medical support organic to the maneuver units and the division sanitary train.   Two enlisted medical soldiers were customarily attached to each rifle company   where they established a company aid post. Wounded soldiers were brought there   for first aid treatment, carried from the front line by company bearers. Most   divisions detailed soldiers from the line companies to supplement the number of   litter bearers.
The battalion aid station was normally 250 to 500 yards to   the rear of the front line, close enough to be able to render prompt treatment.   It was staffed by
43
Officers of the 117th   Sanitary Train in Bertricamp, France, April 1918
one or two physicians, a dentist (if available), four to   six medics, plus two runners and one or more litter squads supplied by the   supporting ambulance company. Battalion aid stations with two medical officers   could split into two sections that leapfrogged to keep pace. Litter squads   consisted of four bearers. It was found that 1,000 yards marked the limit of a   squad's endurance, and distances greater than this were handled by squads in   relay. The 305th Ambulance Company, supporting the 77th Division during the   Meuse-Argonne offensive, had relays operating over routes as long as three and a   half miles.25
Each division had a sanitary train (today's medical   battalion), which consisted of an ambulance section, a field hospital section,   and a medical supply unit. This organization had been made a part of the force   structure in 1911 and formed an integrated medical support capability under   unitary medical control that was flexible enough to be task-organized to meet   changing conditions.26 It provided the division   surgeon with centralized control of the division medical assets. If needed, all   ambulance companies in a division could be consolidated. Depending on the combat   situation, the litter bearers might be under the control of the ambulance   companies or under the regimental or battalion surgeons. If a battalion surgeon   became a casualty, an ambulance company medical officer could replace him. In   all, a division's medical personnel totaled 1,331 officers and enlisted   personnel. Of that number, 991 were in the sanitary train.27
The ambulance section of the division sanitary train was   organized on the basis of four ambulance companies per division (two per cavalry   division). Each company provided twelve ambulances to evacuate casualties from   the battalion aid stations to the company's dressing stations, 3,000 to 6,000   yards from the front, and farther
44
Officers at the dressing   station of the 137th Ambulance Company in Amphersbach, Germany, August 1918
back to the field hospitals. The length of time required to   transport wounded soldiers from the front lines to the field hospitals was   affected by a variety of factors including road conditions, visibility, and   traffic. The 3d Division, for example, averaged five hours' transit time during   the Second Battle of the Marne and two and one-half hours during the Meuse-Argonne   offensive. Overall, in the AEF the time from wounding until the arrival at the   first triage point was five to six hours.28
The field hospital section of the division sanitary train   operated four field hospitals set up six to eight miles from the front, rounding   out the medical support in the zone of the advance. The field hospitals were on   the order of more sophisticated dressing stations. Patients were stabilized   there-as they were at earlier points in the evacuation chain-so that they could   either be returned to their units or evacuated farther to the rear for more   definitive care. Each hospital had a normal capacity of 108 beds, expandable to   162, thus providing a 432-bed (648-bed expanded) capability for a division in   combat. In addition, this section operated eight dispensaries for routine   medical care.29 Patients evacuated from the   field hospitals passed into the second echelon, the line of communications,   where the evacuation hospital along with smaller mobile hospitals and surgical   hospitals formed the principal early surgery capability in the theater of   operations.30 The evacuation hospital expanded   from 340 to 1,000 beds during the war, but in some cases operated at higher   capacities. Patients evacuated to the United States entered the third echelon of   medical support, the service of the interior and its network of general   hospitals and supporting facilities.
45
American doctrine was based on speed of evacuation, a basic   philosophy that differed from that of the French.31 The AEF evacuation system moved serious cases as quickly as possible to the rear   after the patients had been appropriately stabilized for further movement. AEF   evacuation hospitals essentially served as clearinghouses. Surgery was performed   only as necessary to enable further evacuation of the casualties, and patients   were held only until they could be safely moved.32 The French, on the other hand, placed a more sophisticated capability farther   forward than the Americans, and some of their hospitals had as many as 5,000   beds. The larger facilities provided definitive care for the wounded earlier in   the evacuation chain. However, their large, immobile hospitals would be at a   disadvantage if trench warfare turned into a war of movement.
Doctrinal differences between the Allies extended to the   operation of the ambulance system. The Americans, based on their lessons learned   from previous conflicts, kept ambulances under medical control and attempted to   integrate treatment and resuscitation during evacuation. The French ambulance   service was under the automobile service, divorced from medical control. Its   focus was patient transport, and its personnel were not expected to have medical   training. It depended for its success upon evacuation over shorter distances to   a definitive treatment facility.33
The U. S. Army Ambulance Service
When the United States declared war against Germany, the   status of American volunteers in Europe became uncertain because they now had a   U.S. military obligation to fulfill. France, fearing the loss of ambulance   volunteers, requested that the United States ensure the uninterrupted   continuation of the vital service. U.S. leaders thus agreed to incorporate   American volunteer ambulance units into the American Army and to continue their   service at the front with the French.
The Army organized a new ambulance corps for that purpose.   War Department General Orders No. 75, which established the U.S. Army Ambulance   Service (USAAS), was issued on 23 June 1917-an important date in the evolution   of the Medical Service Corps. Like the Sanitary Corps, which followed it by a   week, it was a temporary expedient made possible through the special wartime   powers given President Woodrow Wilson in the Act of 18 May 1917. The USAAS also   afforded the Medical Department an expanded opportunity to commission   individuals in specialties it needed. Its officer authorization was set at 203,   and it was organized into 160 sections known as sanitary squad units. It soon   increased to 214 officers in 169 sections. Sanitary squad units supported   divisions on the basis of 1 per 10,000 combat soldiers.34
When the AEF deployed to France for its lengthy period of   organization and training, General Pershing found that the volunteer   organizations had set up a good ambulance system. The AEF worked to bring that   system wholesale into the USAAS, and the volunteers were offered the opportunity   to join the U.S. Army. The American Field Service was operating forty-seven   sections in France at that point, and many of its 1,200 members enlisted in the   USAAS or volunteered for other combat duties. Eighty-one volunteers were   commissioned in the Army
46
Main gate to Camp Crane,   Pennsylvania
Medical Department: sixty-nine in the USAAS and twelve in   the Sanitary Corps, the other new Medical Department corps.35
Inspector General Andrew was commissioned a major in the   USAAS and assigned as head of its Motor Transport Department. Andrew delivered   to the AEF a valuable asset in his American Field Service, a mature organization   with its own vehicle assembly and repair facility, supply depot, training camp,   recreation facilities, and hospital. Perhaps most important, the American Field   Service had three years' experience in combined operations with the French Army.   Enough volunteers joined the USAAS to form an immediate nucleus of 28 sections,   including 25 sections from the American Field Service and 3 sections from Red   Cross units. These sections, when deployed with the Allied forces, were detached   from the AEF and came under the direct command of the French or Italian units to   which they were attached.36
Initially, USAAS officers were active duty Medical Corps   physicians. Col. Percy L. Jones, MC, headed the USAAS, and Col. Elbert E.   Persons, MC, assumed command of the training base. Eventually physicians were   replaced by nonphysician USAAS commissioned officers. In August 1917, as Medical   Corps officers were being ordered into clinical duties, Colonel Persons   submitted to the surgeon general a list of noncommissioned officers he   recommended for commissions in the USAAS. By the end of the war there were very   few Medical Corps officers left in the Ambulance Service. One who commanded an   ambulance company said that physicians viewed being posted to an ambulance   company with "almost as much distaste as assignment as a battalion surgeon."37
The twentieth century ambulance corps officers performed   well. General Gorgas said they made "an excellent record"38 and "in every way justified their
47
"USAAC March" sheet music
appointment."39 By 30 June   1918, the USAAS had 173 officers, including 1 colonel, 2 lieutenant colonels, 3   majors, 30 captains, and 137 lieutenants. In all, 224 officers and 11,750   enlisted personnel served in the USAAS during the war. Three of its officers   received the Distinguished Service Cross and sixty-six were awarded the French   Croix de Guerre. Seventeen sections were cited in French Army orders. No   officers were killed or wounded, but 182 enlisted soldiers were killed in action   or died of wounds and another 320 were wounded or gassed.40
In the United States, USAAS recruits received their   military training at Camp Crane, Allentown, Pennsylvania. Named for Brig. Gen.   Charles H. Crane, surgeon general from 1882 to 1883, the camp occupied the   Allentown fairgrounds, which also became the site of the USAAS headquarters.   Recruits were billeted in available buildings, including horse barns, pig pens,   and horse cooling sheds. Despite such makeshift quarters, the USAAS attracted   the adventurous by offering the promise of quick and certain action in Europe.   By 19 June 1917, over thirteen hundred volunteers were in training at Camp   Crane; a week later, the number stood at thirty-three hundred. In all, 20,310   volunteers (2,085 officers and 18,225 enlisted) trained at Camp Crane between 1   June 1917 and 10 April 1919.41
Volunteers came from Army recruiting stations, predecessor   volunteer ambulance units, and a variety of institutions and industrial   organizations. Sponsors of USAAS sections included over forty universities and   colleges. Harvard, which had led in the number of volunteers for the American   Field Service, set another record by providing three USAAS sections. Other   sponsors included corporations, cities, and sports groups.
The trainees were an exceptional group. Fifteen   All-American football players among them became the nucleus of a team that   played a winning season against a lineup that included Georgetown, Penn State,   and Fordham. The camp band also attracted premier talent, and John Philip Sousa   was among the guest conductors. Lt. Col. Clarence P. Franklin, MC, who succeeded   Colonel Persons as the camp commander, convinced Sousa to write a march for the   Army Ambulance "Corps," and the famous composer copyrighted the "USAAC March" in   1919.42
Not all the trainees had a grand time. To begin with, they   found much to complain about with the food. Their arrival at Allentown "brought   home to us for
48
the first time the disturbing realization that we were in   the army," with the moment of truth coming when they sat down to "one of the   vilest suppers ever set before man since God made the world." The hungry   soldiers were served a melange "on the same greasy tin pan, of salty corned beef   and forlorn little prunes, mournfully swimming in their juice."43
Their transition into the life of a soldier was recorded in   letters, diaries, and literature. In 1917 John Dos Passos returned from service   in France with Nortonï¿½Harjes to find a draft notice awaiting him. Deciding to   volunteer for the USAAS, he reported to Camp Crane. He later wrote of his   "captivity" at "Syphilis Valley" where he said he had washed over a million   windows.44 His novel Three Soldiers was based   on his experiences there and featured characters he encountered in training and   later during his service in France.
Those who had volunteered to go "over there" were   frustrated when the Army did not quickly ship them to Europe and became bored   with repetitive tasks, such as marching day after day. Guth Station, a field   training site complete with mud and trenches, was particularly vexsome. The   grousing was reflected in the words to a marching ditty:
Of course to drive an            ambulance, you've got to learn to drill
So every morning,            afternoon they put us thru the mill,
And when this war is            over, you will find us at it still,
For we never saw an            ambulance and never, never will!45
 Over There
In time Camp Crane graduates did make it "over there." The   first contingent arrived in France on 21 August 1917, commanded by Colonel   Jones, who left Camp Crane to head up the USAAS in France from headquarters in   Paris. There he had a strong deputy in A. Piatt Andrew, now a lieutenant colonel   whose position as head of the Motor Transport Department placed him at the heart   of the evacuation system. This, coupled with Andrew's experience in running the   American Field Service organization, made him a central figure, and he served as   the acting chief in Colonel Jones' absence. By July 1918 the USAAS had 77   sanitary squad units serving with the French Army; 49 units had been organized   and trained at Camp Crane and added to the 28 units formed in Europe from the   earlier volunteer organizations.46
The call of action in Europe also attracted Colonel   Persons, who left Camp Crane to head up the USAAS units with the Italian Army.   In June 1918 Persons took thirty units comprising 76 officers and 1,641 enlisted   personnel to Italy where their arrival in Genoa was heralded by a parade with   five marching bands. Colonel Franklin later left Camp Crane to join Persons as   his deputy.47 Not long after Persons' arrival   in Italy, the AEF reassigned fifteen of his sections to American units in France   as AEF losses mounted. Hard fighting during the St. Mihiel offensive had   underscored the inadequacy of the AEF evacuation capability, which had less than   50 percent of its authorized ambulances, partly the result of shipping delays.48
USAAS officers and enlisted members continued in Europe the   heritage of selfless dedication begun at Antietam. In France, Sanitary Squad   Unit (SSU)
49
525, commanded by Lt. H. L. Biby, USAAS, received the   French Croix de Guerre with Palm. Biby's unit had three soldiers killed and   nineteen wounded or gassed in actions that included Verdun. SSU 503, commanded   by Lt. Lars Potter, USAAS, received the Croix de Guerre with Silver Star for   Bravery. SSU 585, an ambulance unit formed by Yale University, was commanded by   Lt. John R. Abbot, USAAS, in its support of the French 128th Division. Abbot,   praised by the members of his unit for "inspiring leadership"49 and "guts,"50 was wounded and decorated along   with the other members of SSU 585 with the Croix de Guerre. One of the units   that moved from Italy to France was the 649th Ambulance Section, which was   attached to the U.S. 35th Division. Beginning 25 September 1918, the members of   the 649th saw continuous action in the Meuseï¿½Argonne where their twenty Ford   ambulances evacuated over eight thousand wounded soldiers from the Argonne   forest during a sixteen-day period, suffering eleven casualties in this action.   Colonel Jones said the 649th reflected the USAAS spirit by "overcoming all   obstacles in reaching the destination where the wounded are collected."51
The USAAS established a proud record. Pvt. George E.   Shively, a member of SSU 585 who received the Distinguished Service Cross, said   that their most fundamental principle was "the wounded must come in:   difficulties and even impossibilities in the way form no excuse for failure. The   impossible can be accomplished when men's lives are at stake." Their mission   tested the courage of each ambulance driver. "If he chooses to shirk, there is   no one to hinder; and if he himself falls, there is no one to help."52 In Italy, USAAS crews were "often kept busy during day and night for long   periods of time."53 An example was SSU 526,   whose commander, Capt. William A. Lackey, USAAS, was awarded the Italian Cross.   Lackey's unit evacuated 29,852 patients during the Piave advance in June 1918.54 Other USAAS crews met the challenges of combat in the rugged terrain of the   Austrian front.
The men would get three or four hours of   sleep when we became completely exhausted and then would be right at it again.   Driving the roads in wet or dry weather was a challenge in itself, with hairpin   turns; but with a load of wounded and guns going off at their backs and in front   of them, exhaustion would come upon them suddenly.55
As one participant put it: "An ambulance driver is nearly   always in mortal danger."56 Units operating on   Mount Grappa would evacuate casualties to cable cars in which the patients were   strapped and moved down the mountainside.
The USAAS benefited from lessons learned by the earlier   volunteer organizations. For example, the ambulance bodies used by the American   Field Service on the Ford chassis had evolved through trial and error. The USAAS   eventually adopted that ambulance, but only after several thousand vehicles of   inferior design were shipped to the AEF. One minor item that created a lot of   difficulty for AEF units was the failure to adopt the American Field Service   practice of adding oak tracks to the floor of the ambulances. Although standard   U.S. Army litters had wooden legs, ambulance crews frequently encountered   litters with iron legs, which tore up the vehicle floors unless they had been   protected with the special tracks.57
50
Standard General Motors   ambulance chassis; below, ambulance disassembled and boxed for shipment
51
The requirement for a great number of vehicles caused the   Medical Department to establish the Motor Ambulance Supply Depot in June 1917 at   Louisville, Kentucky, to provide ambulance supply, repair, and salvage as well   as a school for mechanics. Its staff included six Sanitary Corps officers. The   department procured and shipped to Europe 3,070 GMC and 3,805 Ford ambulances.   The vehicles were sent unassembled in two sections, the chassis and the body,   because assembled vehicles were often damaged in transit. A motor ambulance   assembly detachment of three Sanitary Corps officers and sixty technicians at   St. Nazaire, France, prepared the ambulances for combat service. The detachment   began assembling the vehicles at the rate of four per day in January 1918, a   rate which later increased to fifteen per day.58 In September 1918 the assembly functions and the Sanitary Corps officers   involved with this mission were transferred to the Army's newly formed Motor   Transportation Corps.59
The USAAS ambulance system settled into a mature operating   capability that was fully integrated within the AEF organization. Its level of   standardization as an operating system is reflected in guidelines used by the   AEF inspector general for medical support operations in the combat zone. The   condition of a medical unit's ambulances, the map-reading ability of enlisted   and officer personnel, and the division surgeon's positioning of ambulance   companies and field hospitals were all fair game for General Pershing's   inspectors.60
Summary
American soldiers wounded in World War I enjoyed a much   greater chance of surviving than had their predecessors in any previous war.   Much of that was due to an improved evacuation system. By the time of the   Armistice the Medical Department had evacuated 214,467 casualties in Europe and   transported 14,000 sick and wounded to the United States.61 It evacuated another 103,028 patients to the United States following the   Armistice. This record was achieved through major Medical Department   improvements, beginning with its doctrine for support of an army in the field.   The medical support apparatus fielded by the American Expeditionary Forces was   enormously improved in kind and amount from anything previously attempted in   wartime.
The formation of the USAAS from predecessor volunteer   ambulance organizations was a principal part of that improvement and was a   significant step in the evolution of the Medical Service Corps. More important,   it was a significant advance in the Medical Department's ability to perform its   wartime mission through a functional adaptation to changing technology and   warfare.
52
Notes
1Quoted words: Giulio Douhet, Command of the   Air, trans. Dino Ferrari (New York: Cowardï¿½McCann, 1942), p. 157. C. S.   Forester paints an indelible scene of the British commanding general at Verdun   lighting his cigar at the moment the attack began: "As the tobacco flared a   hundred and twenty thousand Englishmen were rising up from the shelter of their   trenches and exposing their bodies to the lash of the German machine guns."   Forester, The General (Boston: Little, Brown, 1936), p. 249.
2Statistics: Fielding H. Garrison, Notes on the   History of Military Medicine (Washington, D.C.: Association of Military Surgeons   of the United States, 1922), p. 199.
3Army figures: 50,510 battle deaths, 55,863   other deaths. Armed Forces Information Service, Almanac, Defense 83 (Washington,   D.C.: Government Printing Office, September 1983), p. 46. Casualty figures vary   by source. For example, Col. Leonard P. Ayres, head of the Statistics Branch of   the War Department General Staff; put Army and Marine deaths at 115,660: 57,460   disease; 50,280 battle; 7,920 other. The War with Germany (1919; reprint,   New York: Arno Press, 1979), pp. 13, 123.
4Statistics: Theodore Ropp, War in the Modern   World (New York: Collier Books, 1979), pp. 248, 250; John Keegan, The   Face of Battle (New York: Penguin Books, 1978), pp. 235, 285. Keegan   estimates one-third of the British soldiers killed or missing in action in the   Battle of the Somme could possibly have survived if they had been evacuated   within a few hours of wounding (ibid., p. 274).
5Gorgas: Gorgas had been appointed as the   surgeon general and promoted to brigadier general in January 1914. In March 1915   he became the first chief of the Medical Department promoted to major general.   George A. Scheirer, "Army Medical Department Chronology, 1775-1947," p. 45.   Numbers: SG Report, 1919, 2: 1117. In 1918 there were 30,591 MC officers   and 939 contract surgeons. SGO: Lynch, The Surgeon General's Office, p.   126; Bulletin of the U. S. Army Medical Department (October 1934): 4, a   departmental journal known by various titles beginning in 1919 (see   bibliographical note), hereafter cited as Medical Bulletin with date but   without a volume number due to the number changes and restarts. The SGO numbered   2,103 at the peak: 265 officers, 30 nurses, 191 enlisted, and 1,617 civilian.   U.S. physicians: "Medical Service in the World War," Medical Bulletin (31   May 1932): 2.
6Numbers: SG Report, 1919, 2: 1117.
7Disease: SG Report, 1918, pp. 172, 175;   John H. Ruckman, ed., Technology's War Record (Cambridge: War Records   Committee of the Alumni Association of the Massachusetts Institute of Technology, 1920), pp. 88-129; Garrison, Notes on the   History of Military Medicine, p. 203; James S. Simmons, "The Division of   Preventive Medicine, Office of the Surgeon General," Medical Bulletin (July 1941): 63-68; Military Medical Manual, 6th   ed., rev. 1944 (Harrisburg, Pa.: Military Service Publishing Company, 1945), p.   346.
8Capability: Neuropsychiatry also posted   advances. During the war the department developed a standard approach to shell   shock-later called war neurosis-new names for the "depressed feeling" that   Letterman had noted afflicted some soldiers. This consisted of treatment up   front with a quick return to the soldier's unit after a brief period of rest,   food, encouragement, and reassurance. Lynch, The Surgeon General's Office, p. 65; SG Report, 1917, p. 369; Letterman, Medical Recollections, p. 101. The World War I treatment would be relearned in subsequent wars as the   best way of handling combat exhaustion, combat fatigue, combat stress reaction,   or whatever term was in vogue at the moment.
9Quoted words: Edward E. Harding, "Norton-Harjes   Section 60," in Virginia Spencer Carr, Dos Passos: A Life (New York:   Doubleday, 1947), p. 133.
10Red Cross units: Lynch, The Surgeon   General's Office, p. 546. Other American support included 1,100 American   physicians called up for Army duty who were assigned to the British   Expeditionary Force. See Bernard J. Gallagher, "A Yank in the B.E.F.," American Heritage 16 (June 1965): 18-26, 101-08.
11Hemingway: Carlos Baker, Ernest Hemingway: A   Life Story (New York: Charles Scribner's Sons, 1919), pp. 36-50; Bernice Kert, The Hemingway Women (New York: W.W. Norton and Company, 1983), pp. 47-55,   218-19. Also see Michael S. Reynolds, Hemingway's First War
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(Princeton, N.J.: Princeton University Press, 1976),    pp. 147-49; and Reynolds, The Young Hemingway (London: Basil    Blackwell, 1986), pp. 16-24, 55-57. Reynolds casts doubt upon Hemingway's    commission.
12Hemingway: Hospitalized in Milan, he fell    in love with Agnes Kurowsky, an American nurse who spurned his affections.    In November he was promoted to first lieutenant; he returned to Chicago in    January 1919 for recuperation. Hemingway's experience was the genesis of A Farewell to Arms. Ernest Hemingway, A Farewell to Arms (New    York: Charles Scribner's Sons, 1929).
13Norton-Harjes: Carr, Dos Passos, pp. 117, 127, 138-39.
14American Field Service: Charles Lynch,    Joseph H. Ford, and Frank W. Weed, Field Operations, vol. 8 of The    Medical Department of the United States Army in the World War (Washington,
D.C.: Government Printing Office, 1925), pp. 223-59,    hereafter cited as Lynch, Field Operations; George Rock, The    History of the American Field Service, 1920-1955 (New York: American    Field
Service, 1956), pp. 7, 15, 24, hereafter cited as Rock, History of the AFS; Carr, Dos Passos, p. 127; American Field    Service, History of the American Field Service in France, 3 vols.    (New York: Houghton Mifflin, 1920), 1: 16, 23, hereafter cited as AFS, AFS in France; Edgar E. Hume, The Medical Department Book of Merit (Washington, D.C.: Association of Military Surgeons of the United
States, 1925), p. 18.
15Quoted words: George C. Brown, ed., "With    the Ambulance Service in France: The Wartime Letters of William Gorham Rice,    Jr.," Wisconsin Magazine of History (Summer 1981): 279. Rice was an    AFS volunteer whose father had been Grover Cleveland's private secretary    when Cleveland was governor of New York. He wrote that Andrew "runs the    service well," but never missed the chance to criticize the other volunteer    ambulance units (p. 293).
16Quoted words: Andrew quoted in AFS, AFS    in France, 1: 28-29.
17Vehicles: AFS, AFS in France, 1:    36, 391.
18Driving: Carr, Dos Passos, p. 132;    AFS, AFS in France, 1: 511-12; John R. Smucker, Jr., The History    of the United States Army Ambulance Service with the French and Italian    Armies, 1917, 1918, 1919 (Allentown, Pa.: USAAS Association, 1967), p.    ix, hereafter cited as Smucker, USAAS.
19Escapades: Smucker, USAAS, p. xiv;    Carr, Dos Passos, p. 132. Quoted words: AFS, AFS in France, 1:    449. They also learned from the courage of the French litter bearers, the "brancardiers."    See Edward Weeks, In Friendly Candor (1946; reprint, Boston: Little,    Brown, and Company, 1959), p.6.
20Doctrine: The discussion of World War I    doctrine is drawn from Lynch, Field Operations, pp. 105-259, 1021-67; FS    School, Sanitary Field Service; Munson, Sanitary Tactics; and    Frederick Paul
Straub, Medical Service in Campaign: A Handbook for    Medical Officers in the Field (Philadelphia: P. Blakiston's Sons, 1912).
21First killed in action: 1st Lt. William T.    Fitzsimons, MC, and Pfcs. Rudolph Rubino, Jr., Oscar C. Tugo, and Leslie G.    Woods were killed by aerial bombing at Base Hospital 5, 4 September 1917.
SG Report, 1918, p. 261; American Battlefield    Monuments Commission, American Armies and Battlefields in Europe (Washington, D.C.: Government Printing Office, 1938), p. 503.
22Medical capability: Lynch, The Surgeon    General's Office, pp. 101, 327, 332; Frank Freidel, Over There (Boston: Little, Brown, 1964), p. 258; AEF Surg Gen to Commanding General    (CG), Base Section #2, AEF, sub: Hospitalization Index of Medical Department    Activities, 8th ed., 1 Dec 18, RG 120, Entry 588, File 321.6, NARA-NA.
23Training of AEF: Weigley, History of    the United States Army, pp. 360, 385-86; John J. Pershing, Final    Report of Gen. John J. Pershing (Washington, D.C.: Government Printing    Office, 1919), pp. 5, 55, hereafter cited as Pershing, Final Report,    Ayres, War with Germany, pp. 33-34.
24Ambulances: "All persons are prohibited    from using them, or requiring or permitting them to be used for any other    purpose." WD Reg 1437, WD, War Department Regulations for the Army of the    United States, 1913 (Washington, D.C.: Government Printing    Office, 1913), with changes through 15 Apr 17, p. 289, PL.
25305th Ambulance Company: Lynch, Field    Operations, p. 563.
261911: Fisch and Wright, Noncommissioned    Officer Corps, p. 78.
27Sanitary train: Pershing, Final Report, plate 15.
28Ambulance section: SG Report, 1917,    p. 158;James L. Bevans, "The Ambulance Company," in FS School, Sanitary    Field Service, pp. 4-9, 34. Advanced dressing stations were sometimes    situated
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1,500-2,000  yards from the front. 3d Division rate:    Lynch, Field Operations, p. 109. Overall rate: Rpt, Maj Gen A. W.    Brewster, AEF Inspector General (IG), sub: Report of Inspector General,
American Expeditionary Forces, RG 120, E588, Box 115,    File 525, Report of Inspector General, NARA-NA.
29Field hospital section: William N. Bispham,    "The Field Hospital," in FS School, Sanitary Field Service, pp. 7-10;    Lynch, Field Operations, p. 1034.
30Second echelon: Robert U. Patterson, "The    Line of Communication Organization, Personnel, Materiel, Function and    Administration," in FS School, Sanitary Field Service, p. 27; SG    Report, 1919, 2: 1907.
31Doctrinal issue: There is fundamental    doctrinal conflict between quickly clearing the battlefield versus    conserving the fighting strength. The French gave primacy to the latter (and    perhaps to a humanitarian impulse) by fielding a sophisticated surgical    capability early in the evacuation chain. That option assumed greater    survivability and faster return to duty through the earlier use of    sophisticated treatment. However, it was elected at the expense of providing    combat commanders a faster tempo of combat operations through a more quickly    cleared battlefield and a smaller logistical tail in the forward area. The    U.S. doctrine struck a good balance in World War I, handling the question    with good sense and within the limits of the technology available at that    time. The question remains an important one for the Army. For post-Vietnam    discussion see Ronald F. Bellamy, "Contrasts in Combat Casualty Care," Military Medicine 150 (August 1985): 409-10, and Ltr, Bellamy to the    ed., Military Medicine 151 (January 1986): 63-64; Karl D. Bzik and    Bellamy, "A Note on Combat Casualty Statistics," Military Medicine 149 (April 1984): 229-31; Eran Dolev and Craig H. Llewellyn, "The Chain of    Medical Responsibility in Battlefield Medicine," Military Medicine 150 (September 1985): 471-75. Bzik and Bellamy argue that "there are limits    to what rapid evacuation can accomplish." Exceeding those limits in order to    give first priority to clearing the battlefield leads to a policy of "scoop    and run."
32Evacuation hospitals: Also see Gorgas,    confidential report to Secretary of War (Sec War), Inspection of Medical    Services with American Expeditionary Forces (Washington, D.C.:    Government Printing Office, 1919), pp. 18-19, 46, hereafter cited as Gorgas, Inspection of AEF Medical Services.
33Evacuation: AFS, AFS in France, 1:    28-29.
34USAAS: AFS, AFS in France, 1: 10;    Lynch, The Surgeon General's Office, p. 152; WDGOs 75 and 124, 23 Jun    17 and 20 Sep 17, PL; SG Report, 1918, pp. 268, 394; SG Report,    1919, 2: 1412.
35Integration into USAAS: AFS, AFS in    France, pp. 1: 10, 30; Rock, History of the AFS, p. 22; SG    Report, 1918, p. 268; Lynch, Field Operations, p. 238. A total of    784 were commissioned in various Army branches, including 578 in Infantry,    Armor, Artillery, and Air Corps.
36Forming up: SG Report, 1918, p.    268; AFS, AFS in France, 3: 442.
37Substitution: Smucker, USAAS, pp.    12-20. Quoted words: Harry L. Smith, Memoirs of an Ambulance Company    Officer (Rochester, Minn.: privately printed by Doomsday Press, 1940),    p. 7.
38Quoted words: Gorgas, Inspection of    Medical Services, p. 20. Gorgas inspected medical services in the AEF 8    September-16 October 1918.
39Quoted words: SG Report, 1919, 2:    1411-12.
40Numbers: SG Report, 1918, p. 394; SG Report, 1919, 2: 1111; Smucker, USAAS, p. 77.
41Camp Crane: Smucker, USAAS, pp.    xiv, 12, 33, 51, 79-148.
42Activities: Smucker, USAAS, pp.    25-27, 30-32. Some trainees formed an acting company, directed by Lt.    Adolphe Menjou, and successfully toured the East Coast. Menjou became a    movie star after the war. He costarred with Marlene Dietrich and Gary    Cooper, among others, and appeared in such films as A Star Is Born and A Farewell to Arms. Sousa: Paul E. Bierley, Columbus, Ohio, to    John Franklin, 12 Jun and 24 Jun 65; John R. Smucker, Wynnewood, Pa., to    John Franklin, Philadelphia, Pa., 27 May 65 and 25 Jun 74; Mahlon H.    Hellerich, Archivist, Lehigh County Historical Society, Allentown, Pa., to    Smucker, 30 Aug 78, all in DASG-MS; John Philip Sousa, "USAAC March"    (London: Chappell and Co., Ltd., 1919), photograph in Smucker, USAAS,    p.22.
43Quoted words: George J. Shively, ed., Record of S.S.U.    585; Yale Ambulance Unit with the French Army, 1917-1919 (New York: E. L. Hildreth, 1920), p.2, hereafter cited as Shively, Record of S.S.U 585.
44Quoted words: Dos Passos to Arthur McComb, American    Academy and Institute of Arts and Letters, 7 Oct 18, in Carr, Dos Passos, p.    156.
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