UH 390 C561d 1918 NLH DSD^^D 2 NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE PROPERTY OF THE NATIONAL LIBRARY OF MEDICINE NLM050999302 national lie IDI03VV kTlONAl IIBRARY 4IDIQ3W JO-AaVi MIONAl LIBRARY NIIDI03W JO AaVI ATIONAL LIBRARY RETURN TO NATIONAL LIBRARY OF MEDICINE BEFORE LAST DATE SHOWN FEB 29 1984 \JK7~1 SAW > MOiaaw jo Aavaan ivnoiivn 3NiDia3w jo Aavaan ivnoiivn ifft 5 TV* j(fl S T*0 THE DOCTOR'S PART v n ->'>;"~t--| t . First Aid Post in a Church p. 243 THE DOCTOR'S PART WHAT HAPPENS TO THE WOUNDED IN WAR BY JAMES ROBB CHURCH, A.M., M.D. COLONEL MEDICAL CORPS, TJ. 8. ARMY WITH FOREWORD BY MAJOR-GENERAL WILLIAM C. GORGAS BURGEON-GENERAL, U. 8. ARMY D. APPLETON AND COMPANY NEW YORK LONDON 1918 an "i'bO C5fcld Copyright, 1918, by D. APPLETON AND COMPANY Printed in the United States of America FOREWORD These impressions of a Military Observer are the results of over two years spent by Colonel Church on the Western front as an Observer with our Allies and later on the Staff of the Command- ing General of the American Expeditionary Force. His service of twenty years in our army, includ- ing duty on the Mexican border and with the First United States Volunteer Cavalry (Rough Riders), in the war with Spain where he won the Medal of Honor for gallantry under fire, well qualifies him for this important duty. The author has presented in non-technical lan- guage much information which will be of value to Medical and line officers as they go abroad on active duty with troops in France. The book will also be read with interest by the laity as Colonel Church has the happy faculty of presenting the human side of his experiences in an interesting manner. He has given us a glimpse of certain side lights of the great war not heretofore available. W. C. Gorgas, Surgeon General, U. S. Army. July 1, 1918. Washington, D. C. 7 PREFACE So much has already been written in regard to the present war that any one who essays to add to the sum total cannot help but wonder if there is anything left unexpressed by those who have gone before him. The inclination to describe the many complex phases which enter into modern conflict is per- haps natural. There are two passions which are, have always been, of paramount interest to man- kind. Kipling voices this when he says, "Two things greater than all things are, the first is love, the second is war." And so I fancy that each individual who has been given the opportunity to view with his own material eyes a part of the titanic struggle which at present convulses this troubled world, believes that some of the events which he has taken a part in may be of interest to others. And yet I am sure there must always be hidden somewhere in the back of his mind the doubting conviction that the events which seem so real to him may lack, when expressed, the value which they have in his own eyes. George Moore, in his altogether charming and entirely irresponsible writings, "Memoirs of My Dead Life," says, "Think of the writer of stories! Two, three, or four more stories are required to make up the 9 PREFACE requisite number of pages. The dusk has inter- rupted his labor, and he rises from his writing- table asking who will care whether the last stories are written or left unwritten? If he writes them his ideas will flicker green for a brief springtime, they will enjoy a little summer; when his garden is fading in the autumn his leaves will be well- nigh forgotten; winter will overtake them sooner than it overtakes his garden, perhaps. The flow- ers he deemed immortal are more mortal than the rose. 'Why,' he asks, 'should any one be inter- ested in my stories any more than in the thousand and one stories published this year? Mine are among the number of trivial things that compose the tedium which we call life.' " In much the same way I am a little doubtful as to whether the things I saw, and had a part in, may have the same active interest to others that they did for me. During a busy period of more than two years in embattled France I had ample opportunity to observe the work which my French professional brothers were doing, and the conditions under which they worked from the first line trenches where the wounds are made, back to the hospitals of the inner area where the human wreckage is patched and cobbled and coaxed again to full effi- ciency, or to something which has a semblance to man as God made him in His image. The wastage in Medical personnel has been high in the present war and the Sanitary Service has paid its own red toll shoulder to shoulder with the brothers of the Line. I believe this common sacrifice in the cause has brought the two services closer together than ever before: has enabled each 10 PREFACE to become better acquainted with the fine qualities of the other and to be more tolerant with the short- comings. I saw things which I cannot write of for ob- vious Military reasons. I saw others which are best left untold as the gratuitous transcription of suffering and horror which should have no other than a morbid interest to the layman. The following pages comprise the impressions of a Medical Military Observer of matters in his 1 own province, together with notes of other current affairs. It is in no sense technical and it makes no pretense to the dignity of "literature." I hope that there may be something of interest in it for those who look with wistful eyes to the troubled East and wait with aching hearts for the return of some one, "over there." James Robb Church. Washington, D. C, July, 1918. 11 CONTENTS chapter page I. Introductory.....17 II. General Sanitary Service op the French.....34 III. Hospitals op the Interior . . 69 IV. The Zone op the Armies . . 104 V. Transportation .... 168 VI. Front Lines ..... 222 VII. Conclusion.....261 13 LIST OF ILLUSTRATIONS First Aid Post in a Church . Frontispiece PAGE Red Cross Nurses at a Railway Station Canteen Giving Coffee to the Wounded 61 Tent Wards, Showing One of the Type of Tent Used by the French ... 61 Mutilated Soldier Learning to Engrave with an Artificial Hand ... 79 Soldier with Double Amputation of the Arms, Showing How Much May Be Ac- complished with the Artificial Hands . 79 Fracture Ward in Blake's Hospital, Com- monly Known There as the Machine Shop.......85 A Fracture Ward.....85 Operating Room on a "Sanitary Train" 145 Interior of a French Dental Ambulance. This is a Rolling Dental Office, Com- pletely Fitted and Mounted on an Auto- mobile Truck......145 Transport of Wounded by Litter Through s Trench.......169 Wheel Litter Transport . . . .169 15 LIST OF ILLUSTRATIONS PAGI Ambulance Drawn by Dogs . . . 185 Sanitary Dog . . . "Red Cross Dog". . . Dressing His Wounds . . . .185 First Aid Post in Cellar Belonging to Arab, "Spahi" Troop . . . .205 A Trench, Showing Sign Indicating Loca- tion of a First Aid Station . . .205 10 THE DOCTORS PART CHAPTER I introductory I suppose that prior to the present war few of the people who make up our ten million and odd of population had any more than a hazy idea of what the army, which they paid taxes to support, did to justify the expenditure. Ideas were hazy because, in our remoteness, it seemed that we were geographically immune from attack, and consequently the armed forces carried about the same interest as father's old revolver, loaded and tucked away in the back of the top bureau drawer: a tacit concession to the possibility of the unexpected burglar, but from any other standpoint of lit- tle interest. And so, when in 1915 I told tome of my 17 THE DOCTOR'S PART civilian friends that I had been ordered abroad for duty as Military Observer, they looked slightly puzzled and after asking, "What do you mean, Military Observer?" reverted to cur- rent topics in a language they could under- stand. A Military Observer is an authorized inter- national Village Pest: he is tolerated by bel- ligerent powers because they may some time desire themselves to be onlookers in a quarrel which does not concern them. He is treated with very perfect courtesy, but what he sees is not nearly so much a matter of consequence to the nation at war as to put something over on the enemy. He is governed and hedged about by very precise diplomatic conditions, and transgression of them is more than apt to result in his recall. From his own standpoint, he is, to begin with, a neutral: at least, he is very particular to convey that impression to those with whom he comes in contact. In the privacy of his own mind it is allowable to give rein to his indi- 18 INTRODUCTORY vidual wishes and sympathies, but aside from that he must be a perfectly impersonal and very inquisitive person. His duties are to collect and transmit in- formation : that is about the sum and substance of the instructions he gets, and the methods are a matter of his own personal resource and ingenuity. The fact that he is an accredited representative of his Government gives him a certain standing with the country to which he is sent, but aside from that it is a more or less perfunctory status. In the first place, the warring power is entirely too busy, as I have said, to give up time which may be profitably employed in that engaging pastime of "killing your neighbor" to showing a benevolent neu- tral exactly all the detail of the modus oper- andi. In addition, there is also the justifiable uncertainty as to which side the neutral might take if he decided to break into a busy private quarrel. The usual International procedure is to carefully guard the safety and welfare of the observers so that they may be returned in 19 THE DOCTOR'S PART undamaged condition eventually to the country which sent them. At stated intervals trips are arranged for all the Observers in the country and they are taken under the chaperonage of a designated officer to such points as the fight- ing host deems proper, and he shows as much as is considered advisable. You do not see more than that, either: as Ruggles of Red Gap said, "it simply isn't done." The country you rep- resent cannot make too many requests, for it would be embarrassing to refuse them and embarrassing to be refused. And there you are! Which may go to show that the job of collecting and forwarding useful information from a country at war, to your own Govern- ment is by no means a sinecure, but a job which requires patience, tact and resource. If you add to this the fact that all the interesting things that you want to know about are cam- ouflaged under a language which you thought you knew something about until you heard the rapid and careless way its inventors use it, it may readily be understood that the life of the 20 2341527. WAR DEPARTMENT THE ADJUTANT GENERAL'S OFFICE WASHINGTON November 15, 1915. From: The Adjutant General of the Army. To: Major James R. Church, Medical Corps, Fort Crockett, Texas, through the Commanding General, Eastern Depart- ment. Subject: Detail as Military Observer. 1. The Secretary of War details you as a military observer with the French armies in the field. 2. The Secretary directs, as necessary in the military ser- vice, that you repair to this city at the earliest practicable date and report in person to the Chief of Staff for temporary duty in his office for a period of fifteen days; that at the ex- piration of this period you proceed to Paris, France, and report to the American Ambassador at that capital for the purpose of carrying out the instructions of the War Depart- ment, and that upon the completion of the duty enjoined you return to your proper station. 3. The Secretary of War appoints you an acting quarter- master while on this duty. p q March Adjutant General. Rec'd Hq. Eastern Dept. Nov. 16, 1915 201 Church, James R. 1st Ind. was-mr HQ. EASTERN DEPT., Nov. 17, 1915.—Through Depart- ment Surgeon and Comdg. Officer, Ft. Crockett, Tex., to Major James R. Church, Med. Corps. WAS H.P.B. 2nd Ind. Office Dept. Surgeon, E. D., Nov. 18, 1915—Through the C. O. Ft. Crockett, to Major James R. Church, M.C. RECD HCDG AM 11/22/15 Thru Surgeon, to Maj. James R. Church, M C, 11/22/15 Author's Appointment as Military Observer in Francb 21 THE DOCTOR'S PART Military Observer is not an idle one nor alto- gether a bed of roses. I knew all this as a matter of theory before I went to France but, once there, I quickly recognized the difference between theory and practice. In November, 1915, I received an order which came in the nature of a surprise. (See page 21.) The opportunity offered was a fas- cinating one, but the novel demand which it makes on one's resources would, I think, leave the average man with some apprehension as to whether he could measure up to the standard expected of him. I left the United States on the 15th of Jan- uary, 1916, and after the usual winter cross- ing, which was at that time little disturbed by any apprehension of submarine menace, landed at Liverpool; from Liverpool to London and, after a short stay there, to France. The Chan- nel crossing, even at that time, was a tedious and delayed procedure, and one knew only a short time in advance as to what port he would 22 INTRODUCTORY sail from and at what he would arrive. We crossed from Folkestone to Dieppe on the after- ward ill-fated Sussex, and if she had been torpedoed that day, I think there might have been an extended casualty list, for every avail- able inch of space seemed to be occupied by human freight. The cabins were full, the din- ing saloon was jammed, all deck chairs occu- pied, and many stood on deck during the five or six bleak hours that it required to transport us from Albion to Gaul. Fortunately, the sea was smooth and there was none of the horror of seasickness. At Dieppe, in the darkness of a winter night, we proved to the Alien Officer that we were suit- able for entry into France, and I was chided for not showing the diplomatic passport which I had and thus taking precedence over my tired fellow passengers. I unwittingly slipped one over on the Cus- toms, for in my suit case I had about 500 American cigarettes on which I supposed I should either have to pay duty or claim diplo- 23 THE DOCTOR'S PART matic exemption. However, the officer with whom I was traveling put his hand baggage down next to mine and the French examiner opened two of his pieces, none of mine, assum- ing that they all belonged to my fellow traveler, and I went gayly and guiltily away. We arrived at Paris at one in the morning of the 29th of January, and at nine that night received our first intimation, from the measure of personal realization, that we were in a war- ridden country. Some three or four of us went that evening to the Gaumont Palace Theater, over in the Montmartre neighborhood, to a moving picture performance. As we came out at the end of the show we noticed that the city was darker than usual and that there were crowds of peo- ple in the streets, watching the skies. Pencils of white light streaked the heavens and there seemed to be a rapt attention in the air of all the low-voiced French speaking people whom we passed. We went down through the gloomy streets 24 INTRODUCTORY of the Montmartre district, stumbling from one curb to the other, and wondering when we might hear the crash of falling bombs and the reply of the French anti-aircraft guns. We made an uneventful trip over to the Place de la Concorde and came out there into the still dark- ness of a winter night, which was interrupted only by the flashing rays of the many search- lights, which constantly shifted from one part of the heavens to the other. After standing there for what seemed to me an indefinite length of time, we heard the Paris fire engines going through the streets sounding their horns, and in addition the "brelocque," which is the French Army "recall" and means that the danger for the time being is over. The "Brelocque" ic#=p=p: *-» • * P The French "Recall' 25 THE DOCTOR'S PART This ended my first day on French soil. Of necessity, my earlier days in the French capital were given up to adjusting myself to conditions there, to finding how I might be of the best use and familiarizing myself with conditions as they existed in relation to official life and my chances for obtaining the informa- tion for which I had been sent abroad. After about a week I was notified that I would be received at the War Department as an accredited representative of our Government, to be introduced there by our military attache^ who would present my credentials and introduce me to those who might further my aims in France. To any one who has business with the French War Department the contrast with our own methods in this western democracy must be very striking. In Washington, prior to war days, any citizen of our free republic had the privilege of walking unchallenged into the War Department and was only possibly halted at the door of the office to which he 26 INTRODUCTORY sought admission. In France things are de- cidedly different. The War Department in France, the building in which is housed the machinery which is running so large and com- plicated an organization, is unpretentious, rather out of repair and does not compare at all with our own ornate building in Washing- ton. It seems a queer setting for the cunning genius which is, and has been, directing so fine an attack and defense against the invading Hun for the period since 1914. We were challenged at the gate, a very se- cure gate, at the entrance to the War De- partment by a reservist in red "pants" (very red), with a long mustache (very long), who scrutinized very carefully the specific written pass which we had and, after his approval, ad- mitted us to the labyrinth of dusty winding stairs, which took us eventually to a courteous Major of the French service; who chatted very amiably with the Military Attache and, as I understood, promised in a general way to afford us the facilities which were usually granted to 27 THE DOCTOR'S PART representatives of a neutral country. From his office we went to another one, where we were presented to an equally charming French Staff Colonel, who renewed the assurances of good fellowship but made us no definite prom- ises. In fact, it seemed to be a recognized part of the game that, while we were to be ac- corded all courtesies and every possible op- portunity for the gleaning of information, it was probable that we could not rely to an ex- cessive extent on the overtaxed resources which had other things to do, rather than to explain to the curious bystander why they were doing them. This was my introduction to my duties as an Observer in France. Added to this, I found that it was difficult for me to understand the rapid, careless French of the Parisians and evi- dently more than difficult for them to under- stand my best attempts at their own language. Fortunately, for the sake of my mission and its fulfillment, in due course of time the rapid stream of French which at first meant so lit- 28 INTRODUCTORY tie to me, fell into a more or less orderly se- quence and I was able to mend many of the er- rors of my early days, both those of omission and commission. As an evidence of helpless- ness during my first experiences in and about Paris, I might cite my system of getting from one place to another. The American policeman is replaced in Paris by the "Agent de Police." He is sprinkled about Paris with about the same frequency as the American "copper" is in our own cities; his duties are those of our own police officers, and his manners are tinged with the true po- liteness of the French, and if he does not ex- pect it, at least he appreciates a military sa- lute, whether one be in uniform or not. When hopelessly lost, I found that my best way was to approach one of these dignified Agents de Police and, in the best French I could command, ask him for directions in regard to the place I wanted to go. If he understood me (which he did about half the time), he imme- diately launched into a voluble explanation. I 29 THE DOCTOR'S PART paid no attention whatever to this and let my mind wander to any extraneous topic: Ty Cobb's batting average, who would win the Yale-Princeton game that fall, or anything else that came into my mind. When he reached the end of his explanation, however, I became instantly intent, for at the conclusion of his directions he was always sure to point in some direction, and, following the lead of his out- stretched hand, I thanked him courteously in French and started off in the direction which he indicated. After having gone as far as I considered safe, I hunted up another Agent de Police and worked the same game on him. In this way, by what I suppose one might call a semaphore system, I was enabled always in broad daylight eventually to work myself from one place to another. If the condition had occurred in the night when I could not have seen my policeman friend, all my knowledge of spoken language would have availed me little or nothing. Realizing my shortcomings in the French 30 INTRODUCTORY language, a knowledge of which I had foolishly supposed I possessed when leaving the United States, I sought quarters at once with a French family, none of whom had any acquaintance with English and who were will- ing to attempt to instruct me in the intricacies of French as it is spoken in Paris. The ac- quisition of French under such circumstances is not entirely a bed of roses. Sanitary im- provements in France are not on an equal plane with those to which the average American is accustomed. The French find no difficulty in keeping their houses at least as warm as the temperature outdoors; beyond that, they seem to have no particular interest. The house in which I lived during a severe winter had no heat in it with the exception of a gas fire in the kitchen to cook with and was guiltless of any bathing facilities. When one felt the ne- cessity of a bath, there was always the French public bath establishment available for a cer- tain, not excessive, fee. I know many people who cheerfully state 31 THE DOCTOR'S PART that if they went abroad they would imme- diately seek quarters of this kind in a French family and learn French. I doubt very much if they understand what the whole thing means. To be a guest with people, who, although kindly, considerate, interested and thoroughly sympathetic, have a different viewpoint in re- gard to almost everything, makes the situation a little trying. In addition to this, to be in an atmosphere which is murky with an unknown language which is constantly dinned into your ears, leaves one's brain tired and fagged be- yond expression at the end of the day. My good landlady used to come in and talk French and read French to me in the morning while I had my early coffee. She captured me at noontime and talked French to me all through my midday meal. On any of my free days she appropriated me to go with her to points of interest in Paris and to listen in the meantime to the rapid flow of very perfect but badly understood Parisian French. I went to the theater with her on my free evenings. I 32 INTRODUCTORY met all her friends who came to call on her. I was taken to call on all her French friends and by them, in turn, upon all their friends. None of them spoke any English. I lived in a be- fuddled atmosphere of a language in which I was constantly groping and never sure of mj meanings. I made mistakes, they misunder- stood what I wished to say, and, all in all, it seemed a most discouraging proposition. I remember one or two despairing occasions when I had been all day battling to keep my chin before this French flood, when on my re- turn from some French excursion of this sort I made a plea that I had collars to buy or a friend to see and my last ray of hope was choked off by the cheerful assurance of madame that she was not at all tired and would go with me. The above is not a complaint, but merely a suggestion that the acquisition of a practical working linguistic knowledge which one as- sumes that he has, may not always measure up to the standards which he has set for it. 33 CHAPTER II GENERAL SANITARY SERVICE OF THE FRENCH I suppose at the present time there is no doubt in the mind of any one in the civilized world that the Germans in 1914 were the most perfectly prepared of any of the nations for a state of invasive warfare. The French were prepared, but still in the midst of many im- provements in the perfecting of their war ma- chine which had not been brought up to date. Along with other things, the Sanitary Service of the French was still in a condition of transition. By "Sanitary Service" I mean the whole measure of the French for caring for their sick and wounded, the same thing which is covered in our own service here in America under the direction of our Medical Depart- ment. In 1910 a decree had been issued by the French making decided changes in their Sani- 34 GENERAL SANITARY SERVICE tary Service, and when the war broke out in 1914 these changes had not been thoroughly incorporated into their system of army organ- ization. Of necessity on this account there was a certain amount of initial disorganization in the care of those wounded or sick amongst the army forces in the early period of the war. To give some idea of what the French Sani- tary Service, the organization that cared for their wounded, covered, it might be well to un- derstand some of the arrangements the French made for this purpose during times of peace. Of course every one knows that all French subjects are liable to military duty, obligatory military service. All France in times of peace is divided into "regions"—there are 21 of these, all told, in the Republic—19 in continental France proper and 2 in Morocco and Algiers. During peace times each of these regions is oc- cupied by a French Army and military com- mand is vested in the commander of that army. During times of peace certain precautionary measures are taken through the Sanitary de- 35 THE DOCTOR'S PART partment in each of these regions. That is to say, the French have looked forward to a pos- sible invasion of their country ever since the war of 1870 and have been shaping their af- fairs by the light of that occurrence. The sanitary matters in each of these regions were organized partly under the strict supervision of the regular medical department of the army and partly through the intermediary assistance of the French Red Cross. At the time of mobilization the command of these regions passed from the commander of the mobile army, who went with his forces, and was delegated to an officer of the reserve or one who was beyond active military age, and upon his shoulders fell the responsibility for the putting into operation of the measures in- stituted in times of peace for the care and reception of wounded which might result from the war. This meant, in fact, the selection in each region of a certain number of buildings, schools, where available, and large public buildings, or 36 GENERAL SANITARY SERVICE anything of that sort which would be readily adapted to the care of the sick, and the draw- ing up of plans leading to their rapid trans- formation for the purpose intended. In addi- tion to this, the Red Cross undertook to fur- nish a certain amount of supplies for the main- tenance of these hospitals, and they were stored in each district, although not necessarily in the hospitals themselves. In regard to personnel, the medical person- nel from the standpoint of the Red Cross was practically nil. This can be readily under- stood when we consider that France was living under a system of compulsory military serv- ice. All men of military age, whether medical men or otherwise, were subject to draft on the mobilization orders issued at the commence- ment of hostilities, and this left no opportu- nity for any surplus personnel of a non-military type to be used to man these hospitals. On the other hand, the Red Cross Societies trained and educated a certain number of women who were competent, to a limited degree at least, 37 THE DOCTOR'S PART for the duties of nurses. All this was France's reserve in event of just such an occurrence as the invasion by Germany in August, 1914. As I have stated before, this organization was not completed at that time in accordance with the decree of May, 1910, and in the early days of the war there was undoubtedly much hardship due to this fact. As time went on, the French realized that the conflict was not a matter of months but one of a considerable length of time, the various defects were reme- died, the sanitary machine and personnel ham- mered into shape and brought to work with the most excellent efficiency which characterizes it to-day. For instance, after the battle of the Marne in September, 1914, there was lacking trans- port by train, by horse-drawn vehicles, and most notably by automobile transport. There were not nearly sufficient hospitals to receive and care for the large number of wounded which came from the battle of the Marne and the French retreat preceding this. As a natural 38 GENERAL SANITARY SERVICE consequence, there was much improvisation and, as would naturally be expected, this makeshift method did not stand the test and gave very evident proof, not only to the Medical Depart- ment itself, but to the generality of France, that rapid improvement in the whole system of caring for the sick and wounded was a very imperative necessity. France took this matter very seriously, as was indicated in the report of a High Com- mission authorized by the Chamber of Deputies and commonly known as the "Reinach" report, which, by the way, forms very interesting read- ing in regard to this subject. Dating from this period, conditions in re- gard to the care of sick and wounded fell into more orderly lines, and errors in the assignment of personnel and the utilization of various vol- unteer organizations were more clearly classi- fied, and the whole system was put upon a more orderly basis. The French had at this time, that is to say, after the battle of the Marne, found the ne- 39 THE DOCTOR'S PART cessity of sending a great number of their wounded far into the interior to be taken care of by the volunteer organizations already re- ferred to. They found from actual experience that in this practice one of two conditions ex- isted. Either the men did not receive the pre- cise and careful treatment that they needed, or, through an excess of sympathy, they were over-treated and were held at the rear for a longer time than was necessary, so that the fighting forces at the front were unnecessarily deprived of the services of men who should have been returned long before the period of their actual arrival. A French medical officer, in commenting on this situation to me, remarked: "The armies melted like snow and many who were furloughed to the interior disappeared like rabbits in the underbrush." It is unnecessary to say that, after a short experience of this kind, the French realized that some more practical method had to be evolved, and this was the beginning of 40 GENERAL SANITARY SERVICE the present workman-like system which leaves very few able-bodied men unaccounted for. With the present system I think it is safe to say that the most important thing in the sani- tary scheme is that comprised in the French word "triage," which means "sorting." You hear it everywhere in connection with the oper- ation of the service, and in addition to being a method of classification, it is a careful and con- tinual check on the movement of the wounded and disabled. After the experience gained by sending the non-effective back into the Zone of the Interior, the French cast about for a more logical method of caring for them. It was decided that the best thing for both the State and the individual was to shorten as much as possible the time between the receipt of the in- jury and the curative means employed. The percentage of recoveries was higher when wounds were treated within some hours after their infliction than if days intervened, and in this way lives were conserved not only for the benefit of the individual, but to the advantage 41 THE DOCTOR'S PART of the army as a further addition to the fight- ing force. In the second place, it minimized very much the evil of absenteeism which I re- ferred to and which at one time was a serious problem for the French to face. The outcome was that the majority of the cases were held in the Zone of the Armies and there, under direct Military authority, they were not lost nor delayed in their return to their organizations. With this idea the various units of the Zone of the Armies were developed and built up. The Evacuation Hospitals came to be, in part at least, true hospitals and not merely forwarding points. The Ambulances of the First Line took more formal care of the wounded than before, and throughout the Zone of the Armies the Surgical centers were de- veloped and in them patients were grouped who would have been scattered under the old system throughout the Zone of the Interior. I spoke a few pages back of the part which the French Red Cross plays in the care of the sick and wounded. It seems to me that there is 42 GENERAL SANITARY SERVICE here, in the United States, a good deal of mis- understanding as to the real function of this society during time of war. With the French it is almost exclusively employed in regions other than of actual conflict. The Red Cross nurse in the poster, she of the winsome face and spotless uniform liberally adorned with the insignia of the society, caring for a wounded man amid a hail of shot and shell, is, as a matter of fact, replaced by some hairy and probably dirty- faced Brancardier whose military duty it is to get himself killed if need be while he brings in his wounded brother of the line. Common sense would seem to indicate that the fringe of a battlefield is no place for a woman. I have no desire to impugn their courage, but it just is not a woman's job any more than it would be for them to take rifle and grenade and go charging forth to attack the opposing lines. There are some instances where women have maintained aid posts and rest and comfort sta- tions close to the lines and they have done the work well, but the greater part of the duties 43 THE DOCTOR'S PART which must be performed on or near the front lines fall to the hand of man rather than to those of the gentler sex. As it has been with the French, so will it be with our own forces, and the adventuresome and plucky girl who goes abroad with the idea of work of this character will probably be dis- appointed. This does not mean that those who nurse with the army are free from risk, for the Boche, in the persistent idea of undermining the allied morale, still sticks, and probably will continue to stick, to the plan of bombarding and bombing buildings protected by the Red Cross with the same indifference that he dis- plays in regard to any question involving right and wrong. Nurses and medical officers have been killed in a number of hospitals under these circumstances and there is no probability that any of the Sanitary Units which work within gun range or easy flying distance of the Ger- man lines will have any immunity from attack. The determination of the personnel which is available for the Sanitary Service of the French 44 GENERAL SANITARY SERVICE is not a difficult matter. No more so than the determination of the personnel of the Army, since both are dependent on the law of universal service. The Regular—standing—Army of France is fixed by law at a certain number both as to the commissioned and enlisted personnel, and in the event of the outbreak of war this does not in- crease as such, but remains the same. The increase is made in the personnel which is called to the colors from the citizens of the land who have been trained for this duty by the period of compulsory service and the yearly maneu- vers. The medical profession has no exemption (neither has the clergy) from this duty, and if a doctor is not needed in his own character he goes to make up part of the combatant force. As a matter of fact, with the high wast- age in the Sanitary Service there has been oc- casion not only for all the graduates in medi- cine, but the French have made use also of cer- tain of the medical students who have completed enough of their work to be of actual service 45 THE DOCTOR'S PART with certain units in the field. These are termed the "Medecins Auxiliares," and are of very real value in the work of the corps. In time of peace each man who has com- pleted his training knows to what provisional regiment he is assigned and each officer, medi- cal as well as combatant, has his sealed orders which he is to open if war is declared and which will give him directions as to where to report and to whom. General mobilization orders are prepared also and are stored in the barracks of the "Gendarmerie National," or State Po- lice. When the State decides to call forth the forces, the necessary data, date and place, etc., are filled in at the barracks of the Gendarmes and the proclamations, or orders of mobiliza- tion, are all posted throughout the country at the same time. Care is taken so that these re- serve regiments are made up of the inhabitants of the region, and the consequence is that all who are called are supposed to be at the depot or place of assembly within twenty-four hours after the mobilization order has been posted 46 GENERAL SANITARY SERVICE As to the medical personnel of a regiment, gen- erally the senior officer is one selected from the regular establishment to give balance to the or- ganization and the others supplied from the re- serve who come under the mobilization. In addition to those Medical Officers who are needed for the care of the Regiments, there are of course a number who are required for other organizations. To meet this requirement there is kept in the office of the Chief of the Sani- tary Service a list of the Medical personnel which is available and from it is drawn the num- ber required for extra-regimental requirements. In this reserve army there is no limit; those who are needed are called and on the cessation of hostilities they revert again to an inactive status. The effect is that every able-bodied man in France is a potential defender of the State and that he must stand ready to drop all else and give his services to the common need. The education of these Reserve Medical Offi- cers is that which is acquired by any prac- ticioner of medicine plus the term of required 47 THE DOCTOR'S PART ■errioe, three years with the colors. Under these conditions any man called from civil life has the advantage that he does not go from the paths of peace to the ways of war with only a hazy idea as to what the duties of a soldier are. He has had, so to speak, a magnified Plattsburg and comes to the ways of the serv- ice with less timidity and more confidence than if it were altogether terra incognita. For the Medical Officer of the Regular Army admis< sion is by way of the schools at Lyons, or else- where. The young man who decides to make Military Medicine his career matriculates at the Medical School at Lyons and takes the same courses there as do his civilian brothers, but in addition to this he has extra work given by the Military Faculty in the same place and he lives during the time of his study under Military control. This school is organized to train five hundred or more students and the proportion of ac- cepted candidates is generally about 10 per cent. The applicant for admission must be un- 48 GENERAL SANITARY SERVICE der twenty-four years of age, the possessor of a Baccalaureate Degree and have had one year in a recognized Medical School. If accepted after physical and mental examination the stu- dent receives the grade of "Aspirant," which is equivalent to a warrant grade. After admis- sion to the school he is assigned to a Regiment, usually Cavalry, as a private, and serves there with no medical function for one year, after which he returns to the school and takes up his professional work. The course is three years in duration and the work is intensive. Those who pass the examinations are commissioned as second-lieutenants after they receive the Medi- cal Degree and are then sent to the Military Hospital, Val de Grace, in Paris, where they receive practical instruction for eight months and are then assigned to regiments and ranked in accordance with their standing. Promotion to the grade of first-lieutenant is automatic after one year, or four months after the course at Val de Grace, and relative standing is de- pendent on the grading in the final examination 49 THE DOCTOR'S PART in this hospital. Promotion thereafter is by selection rather than by seniority, but no one can skip a grade and, unless an officer has shown some unusual aptitude or brilliance, it is not usual that he be advanced over the heads of many above him. There are authorized one thousand Dentists, who are not commissioned, and the Army Nurse Corps is fixed at one thou- sand also. There is agitation to increase the number of Dentists and naturally the number of nurses is entirely insufficient to meet the de- mands of war-time conditions. The direction of this service lies in the hands of a civilian who is a member of the French Cabinet. He is titled the "Under Secretary of State for Sanitation," and in spite of the "Un- der" in his designation he is practically autony- mous in his position and his decisions in his own Department carry authority. Prior to the war one of the General Officers of the regular Medi- cal Service held this position, and at present two of them act as aids to the Director. I think it is doubtful as to whether the change in direc- 50 GENERAL SANITARY SERVICE tion has been a gain and that it i3 problematic as to whether the system does not sooner or later revert to its first status. The head of all the service centers with the Director in Paris and branches throughout the different armies and regions which are affected. The Service of Supply, as well as that of replacement of personnel, is based on the plan of echelon and a marked feature is the numerous re- serves of both men and material which are main* tained at various points in the chain which stretches from the Interior to the ultimate limits of the fighting line. It simplifies the system of supply, for all that is required of any supply depot under this system is to see that the supply in the depot is kept at the normal level, and each one calls on the one behind it to replenish what has gone on to the unit in front. Thus, the Brigade supplies the Regiment and draws on the Division for replacement; the Division, after supplying the Brigade, depends on the Army to refill its stores and so back to the Central supply Depots in the larger cities of the Zone 51 THE DOCTOR'S PART of the Interior. This obviates the necessity for the repeated transfer of requisitions and the chance of delay due to congestion in traffic or delay in approval or other usual causes. It is simple and effective. It is difficult to give in so brief a space any adequate idea of the complexity of the ma- chinery which is evoked in the care of an army under field conditions. We must understand that it is not only the question of caring for the wounded man. That is the apex of the pyramid, the object of the entire procedure, but as we multiply the one man by "X" the pyramid descends to its base with a wide angle and we find that many questions which do not at first occur to us have to be considered. Transpor- tation, supply, records, construction, feeding, preventive medicine and many other things fall in line to make up the perplexing whole. And, withal, everything must function with a certain degree of smoothness and be fairly automatic, for unless the wastage is promptly and care- fully made good there will not be fighting men 52 GENERAL SANITARY SERVICE enough to carry on and the State will have to divert too much of its energy to the care of its non-effectives. As an evidence of the magnitude of the task which falls to the lot of the Sanitary Service in war, I may state that in one operation wluch lasted for three days the casualties were esti- mated at 90,000. A proportion of these were killed, to be sure, but even that involved duty in burial and in completion of the records, and the remaining fraction leaves us with the im- pression that although it is a tremendous task to maneuver in battle large masses of troops, it is by no means easy to collect and put in shape again those who have fallen in the at- tack. The accompanying diagram shows graphi- cally, and in a general manner, the path fol- lowed by the wounded man from the first line to whatever point he be destined. The work of the front line trench is carried out by the Regi- mental personnel, both Commissioned and en- listed, and this personnel is augmented by the 53 THE DOCTOR'S PART band, provided there be one in the Regiment. The duty of the Regimental personnel is fin- ished when the wounded are delivered to the First Aid Post, which has its own personnel for the care of the cases which come to it. The route of the wounded soldier from this point may be by several means of transportation. If he is to be carried by hand, this duty is taken up here by the Divisional Group of Litter Bearers, which is distributed in accordance with need by the Division Surgeon. He may go di- rect to the Automobile Surgical Ambulance if he is a bad case, or he may be taken to one of the Ambulances of the first line to be shifted possibly from there to the unit just referred to. If able to walk, his problem is simplified and he makes his way on foot. In certain instances it is possible to evacuate the first aid posts by automobile direct, and sometimes when it is not possible for the automobiles to approach the Post, a Collecting Station (not shown in the Diagram) is established in a sheltered position in the rear of it and the wounded evacuated to 54 ^ lifLinc T-reneh (l*eg t'nt* nM Sirvite) ^^^^ N - » JXutomobt7e ti 4r_i /»i M'sp. Hcif CUlx. Hozp. Q.u.x. Hosp.. Diagram Illustrating the Routes of Evacuation of the Wounded from the Front Lines to the Zones of the Interior. 55 THE DOCTOR'S PART it by hand litter and there picked up by the automobiles. It is not unusual in a busy sector to keep an automobile constantly stationed at such a point to take care of those who need immediate transfer. It must be remembered also that all the units of the trench line system are intimately connected by telephone, and that it is not a difficult matter therefore to call for transportation when required. The automobiles which are charged with this duty of evacuation are furnished by one or more sections which are ordered to certain sectors for duty in accordance with the intensity of the action. A Section consists of twenty cars and the capacity of the cars runs from three lying cases for the Ford type to five in the latest type of the French ambulance with the Kelner type body. With the capacity known and the mile- age to be covered in the run and the average speed possible, a pretty accurate estimate can be made as to the time necessary for the evac- uation of any number of wounded. The Firs* Line Ambulances may retain their mobile func- 56 GENERAL SANITARY SERVICE tion and serve merely to care for the wounded until they are taken to units further in the rear, or they may become fixed, the "Ambulance Imobilizee" in French terminology. To accom- plish this latter end a supplementary section, known as the section of hospitalization, is sent up from the Divisional reserve and added to the mobile ambulance. It comprises both addi- tional personnel and materiel and serves to transform the mobile unit, with its compara- tively meager equipment, into the equivalent of one of our Field Hospitals. When the necessity has passed, this reinforc- ing personnel and materiel is returned to the Division reserve and the Ambulance reverts to a mobile status again. The Automobile Sur- gical Ambulance and the first line ambulances send cases to the Evacuation Hospital, which may be at a Railhead and must of necessity be o« a railroad. These Evacuation Hospitals are made up of two sections, either one of which may function independently, or both combine to make up a more formal organization. If they 57 THE DOCTOR'S PART function separately, their province is more that of a collecting and sorting point than of a Hospital proper. I have spoken of this in preceding pages, and of the important part which these hospitals now play in the Sanitary scheme. At the Evacuation Hospital, of whichever type it be, the wounded are disposed of in one of several ways. If there is a hospital section attached to the Hospital, they may be trans- ferred to it for treatment until they are in condition to be sent back to their units again. There may be a Hospital Center in the neigh- borhood, and in that event they may be trans- ferred by automobile to one of the hospitals which compose it. There are usually one or two Ambulances in the neighborhood also which can care for a certain proportion of cases. In con- nection with this hospital there is also a Depot of Convalescents and "Ecloppes," as the French call those who have not much the matter with them. This Depot serves to relieve the hospital of those who are well enough to dispense with 58 GENERAL SANITARY SERVICE formal care but not yet strong enough to go back to active service. In addition to this there is at each Evacuation Hospital the materiel and personnel to make up two Sanitary trains. At this Hospital the Sanitary trains are load- ed and routed to their destinations. There is usually s» daily train, and in times of activity the number increases. These trains are made up so that there is the minimum amount of transfer of the wounded carried by them. So far as possible trainloads are made up to go entire to some definite point and thus it is not necessary to break out cars for different points nor to disturb the wounded until they have reached the point of final debarkation. This simplifies matters considerably, and makes for the comfort and well-being of the wounded. Be- fore a train is started word is sent to the point to which it is routed and arrangements are made there to meet it at the hour specified and to dispose of its load in accordance with the number of vacant beds in the hospitals of the Region. The Director of the Line of Com- 59 THE DOCTOR'S PART munication is kept constantly informed by the Surgeons in charge of the different hospitals and Regions of the number of available beds in each one so that in routing his trainloads of wounded he knows exactly what he can count on in the way of resources in any one place. This system has grown up with the experience in the transfer of wounded and is a long step ahead of the rather crude and somewhat hap- hazard method which prevailed at the outbreak of hostilities. The wounded shipped by train to the interior are inspected at various points. Particularly at the "Gare Regulatrice," or Reg- ulating Station, which usually is at the junc- tion of the Zone of the Armies and the Zone of the Interior. It is the duty of the Medical Officer in charge at this point to see that no case goes beyond it which should be retained in the Zone of the Armies and that those who are forwarded are in proper shape for the journey. Now that the Sanitary Trains are more formal in character and manned by an ex- perienced personnel this duty is less exacting 60 r~**S£. Red Cross Nurses at a Railway Station Canteen Giv- ing Coffee to the Wounded. • * M?. ■iLi. |Sr t "RfH jfcj i f >W ill f; K mil \ . «*k . - >... v-^r . , ' ^r '