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From The Archives

First World War Catalyzes Forward Surgical Care

Thomas S. Helling, MD, FACS

December 6, 2023


The Gosset-Marcille auto-chir—assembled in 3 hours, making it possible to establish up to 14 operating rooms in Verdun—allowed surgeons to operate on the wounded as close as possible to the battlefield. (Credit: Archives of Dr. E. Chassaing)

During the Great War, the French revolutionized forward surgical care through the introduction of Antoine Gosset’s modification of the mobile surgical unit, the ambulance chirurgicale automobile, informally referred to as “auto-chirs.”

Originally envisioned by a young French medical officer, Maurice Marcille, Gosset’s version resulted in a highly effective portable surgical platform with expanded resources to not only tend to surgical injuries, but also provide a means of short-term recovery.

Skilled surgeons and technicians with radiological capabilities could rapidly redeploy a limited number of vehicles near the front lines to care for “nontransportable” (critically injured) casualties (see photo).

The mobile equipment was distributed among several trucks for transportation to the front lines, including a separate truck for each of the following: operating tables and surgical instruments, radiology, sterilization, tentage and bedding, and basic supplies of sustenance. Of necessity, its bed capacity required “elasticity” to accommodate flow of critically wounded casualties, which proved remarkably effective in the prolonged Battle of Verdun (1916–1917).

With the US entry into the war in April 1917, there was an immediate concern regarding the treatment of the wounded among the American Expeditionary Forces (AEF). In August 1917, medical officer Captain Percy R. Turnure sent a letter to the Surgeon General of the Army, stating that:

[T]here be provided a mobile operating unit mounted on automobile trucks and provided with a well-lighted and heated operating room, electric lighting, steam and sterilizing plants, these to be fully equipped in such a manner as to insure the best hospital conditions and at the same time capable of being erected and in action in less than an hour.1

The Surgeon General agreed to this request. A mobile unit, designated “mobile operating unit,” was assembled, and it consisted of five sections that were fully independent and easily transportable. Each section could care for up to 40 casualties. However, by the time these units reached France and were properly outfitted, the armistice was signed, and they never saw service.

Nevertheless, the principle of early treatment of war wounded, as demonstrated by the French, prompted the organization of mobile field hospitals capable of surgical procedures (essentially prototypes of the “mobile operating unit” suggested by Turnure) staffed by personnel from base or evacuation hospitals.

AEF General Order No. 70, issued May 6, 1918, provided two types of these mobile surgical capabilities. First was a mobile hospital consisting of necessary surgical and radiographic equipment, fashioned much like the French auto-chirs and able to house up to 120 patients. “The operating features are designed to provide all modern facilities for six surgical teams. Mobile hospitals may function independently, or they may be attached to other advanced sanitary formations.”2

Second, to augment surgical resources in times of heavy casualties, General Order No. 70 provided for a mobile surgical unit (modeled after the French groupes complémentaires to augment divisional hospitals) that consisted of portable sterilizing, x-ray and electric lighting plants, a light-frame operating room, and surgical material mounted on two motor trucks.2

These units specifically could not operate independently and therefore, must be attached to existing forward field hospitals, which housed more than 100 beds—usually located in the divisional rear area. They were specifically designed for “immediate surgical aid to the non-transportable [critically] wounded.”2

During the all-American Meuse-Argonne offensive in September and October 1918 by the newly formed First Army, five mobile hospitals—with their surgical units (as provided by General Order No. 70 and similar to auto-chirs)—were employed, leapfrogging forward as this now rapid war of maneuvering saw sudden shifts in battlefield tactics (see photo).


The operating room at AEF Mobile Hospital No. 39 at Aulnois-sur-Vertuzy, France, awaits patients. (Credit: National Library of Medicine)

Each mobile hospital was designed to promote forward flow of patients from admissions to undressing stations to bathing and cleansing areas to the operating area itself. Shock victims were first diverted to special areas for warming and resuscitation.

For the most part, non-transportable casualties arrived, many of whom needed surgery immediately. “The condition of the wounded received at this point was deplorable. Some wounds had not been dressed...some were exposed on the field for two or three days before arrival.”3 Delays were attributed to a quagmire of traffic on congested roads.

Two additional mobile hospitals were used for neurosurgical trauma. Seriousness of injuries was exemplified by reports from Mobile Hospital No. 5 which, during the month of October 1918, admitted 839 patients, 119 of whom died (14% mortality).1

Treated casualties were then transported by truck back to evacuation hospitals located much farther in the rear. Comparable figures for the French Hôpitaux d’Origine d’Étapes (evacuation hospitals) with their attached auto-chirs around Verdun demonstrated a hospital mortality of 8.6%, but this was at an evacuation hospital where the injured already had been stabilized in forward field hospitals.3

All things considered, while evacuation of casualties from the battlefront was chaotic and prolonged at times, the function of the surgical teams in AEF forward field hospitals was considered exceptional and established the modern foundation of early forward surgical care for the seriously injured.

“The Army Commander has observed the efficient manner in which your department has handled the numerous duties in connection with our recent operation,” [Meuse-Argonne], so wrote General H. A. Drum, First Army chief of staff. These practices would carry forward in future wars in the 20th and 21st centuries.4

Dr. Thomas Helling is professor of surgery and a member of the Division of General Surgery at the University of Mississippi (UM) School of Medicine and UM Medical Center in Jackson.

  1. Lynch C, Ford JH, Weed FW. The Medical Department of the United States in the World War Volume III: Field Operations. Washington, DC: Office of the US Surgeon General, 1925.
  2. Center of Military History. United States Army in the World War 1917–1919: General Orders, GHQ, AEF Volume 16. Washington, DC: Center of Military History, United States Army, 1997.
  3. Mignon AHA. Le Service de Santé Pendant la Guerre 1914–1918, Vol II: La Bataille de Verdun. Paris: Masson & Cie, 1926.
  4. Lyle HHM. The principles of the surgery, hospitalization and the evacuation of the wounded in the Meuse-Argonne offensive. Military Surgeon. 1939;84(6):580-591.