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HISTORY OF THE OFFICE OF MEDICAL HISTORY
Planning for and Expanding Hospitals in the United States
Early Basic Decisions
Any large-scale expansion of "hospital facilities"-that is, wards, offices, and clinics normally found in civilian hospitals, plus housing for commissioned and enlisted personnel, storage for medical and military supplies and equipment, and administrative space for nonmedical military activities-demanded a simple method of estimating requirements and authorizing beds. Such expansion also demanded that additional housing be provided as rapidly and inexpensively as possible.
The method prescribed by mobilization regulations for estimating bed requirements was one that Colonel Love had devised from World War I experience. It involved computation of the number of beds needed for successive 15-day periods of mobilization on the basis of average daily admission rates, the rate of accumulation of patients in hospitals by 15-day periods, and increases and decreases in troop strengths during these periods. When hospitals were expanded for the September 1939 increase in the Army, this method proved too complicated for general use and The Surgeon General included in his Protective Mobilization Plan of December 1939 a simpler one, also devised by Colonel Love-the multiplication of troop strength by a predetermined percentage of beds. In August 1940 G-4 adopted the latter, and its simplicity made its ready acceptance by all agencies of the War Department a foregone conclusion.1
Opinion differed on the proper percentage to use in estimating and authorizing station hospital beds. The Surgeon General used 4 percent in calculating requirements in the fall of 1939, and G-4 began to use this figure in planning for mobilization in August 1940. Experience of the previous winter made some surgeons believe it provided insufficient beds for "green troops,"2 and on 6 September 1940 General Magee asked the General Staff to consider 5 percent as the probable
requirement for station hospital beds.3 G-4's Construction Branch verbally approved this ratio, but the Assistant Chief of Staff, G-4, Brig. Gen. Richard C. Moore, later reversed this action, authorizing station hospital beds for only 4 percent of the strength served but permitting provisions for expansion to 5 percent if necessary.4 This meant in the case of new hospitals that wards would be constructed with space for beds for 4 percent of a command but that utilities, administrative buildings, and clinical facilities would be constructed to serve a hospital with beds for 5 percent. Thus additional wards could be erected later without overloading the "chassis" of a hospital. The ratio of beds in general hospitals to the total strength of the Army-1 percent-received official sanction at the same time. General Magee did not protest the decision as to station hospitals but observed a policy during the following year of supporting local requests or initiating action for increases in bed ratios in specific instances.5
The manner of providing additional housing was a subject on which The Surgeon General and the General Staff eventually came to marked disagreement. Based on a belief that unnecessary construction should be avoided and a fear that sudden attack would require mobilization before requisite construction could be completed, War Department policy in 1939 was to use existing housing to the maximum extent possible.6 Mobilization regulations therefore called for the use of existing Army hospitals, with emergency expansions, for the initial beds required. To house additional beds other buildings would be used in the following order: (1) Federal hospitals, (2) civilian hospitals, (3) vacated Army posts, and (4) public and private buildings such as schools and hotels. Finally, as a last resort, new station and general hospitals would be consructed.7
For all new buildings the War Department planned to use one-story frame construction, called "cantonment-type." It required The Quartermaster General to keep on file standard plans for such buildings.8 Those for hospitals had been prepared in 1935 in collaboration with The Surgeon General's Hospital Construction and Repair Subdivision. They consisted of forty-nine drawings: forty-five for administrative offices, clinics, wards, messes, quarters for personnel, and service buildings, and four for twenty different combinations of these buildings to make hospitals ranging in size from 25 to 2,000 beds. Most of the buildings were of a standard size. To reduce the danger of fire, all were separated by a minimum of fifty feet. For each group of not more than five, this space was increased to 100 feet. Each hospital therefore covered a large area, a 500-bed installation spreading over twenty acres. Advantages of this hospital were its relatively low cost, the rapidity with which it could be erected, and the small number
of highly skilled workmen needed to construct it. Its most obvious disadvantages were the danger of fire and the administrative difficulties caused by the wide area covered.9
The hospital construction policy enunciated in mobilization regulations was not made the official guide for the provision of hospitals for Regular Army expansions in 1939 and 1940, but certain aspects of it were followed. Thus, although apparently no attempt was made to use non-Army buildings, existing Army hospitals were expanded and new construction was authorized only at stations not served by such. For example, essential units of a 350-bed cantonment-type hospital-a mess hall, a clinical building, and several wards-were constructed at Camp Jackson (South Carolina), a National Guard encampment. Regular Army posts which already possessed hospitals, such as Fort McClellan (Alabama) and Fort Benning (Georgia), expanded them by converting hospital porches, barracks, and other available buildings into hospital wards.10 In such instances results were unsatisfactory. At Fort Benning, for example, the surgeon had to enlarge a 230-bed hospital, built for a garrison of 4,000, to serve a strength of 19,000 in January 1940. He did this by adding 334 beds in porches, barracks, and a portable wooden building. The operating rooms, clinics, laboratory, and mess halls of the permanent hospital were then too small for the greater bed capacity. Thus there was created, he explained, "a relative giant with inadequate heart and internal viscera."11
Despite this experience, in the spring of 1940 G-4 planned to establish the practice of expanding existing hospitals as official policy for subsequent increases in the Regular Army. Both The Surgeon General and The Quartermaster General opposed this move. Among the many objections they raised, probably the most important from the medical viewpoint was the one just noted-limits upon expansion of bed capacity imposed by the size of operating rooms and clinical facilities. Of equal importance, from the construction viewpoint, was the unsuitability of many barracks for hospital use because of their location or structural characteristics. Moreover, it was improbable that their conversion and eventual reconversion would be cheaper in the long run than the erection of cantonment-type hospitals. On 24 May 1940, therefore, Colonel Love, Acting The Surgeon General, recommended that all additional beds should be housed in new cantonment-type hospitals. G-4 disapproved this recommendation, perhaps because of shortages of funds and uncertainty about the nature of increases in the Regular Army, and on 7 June 1940 issued an official "Policy for Hospitalization during the Emergency." It authorized cantonment-type hospitals for new stations but required the expansion of existing hospitals on all Regular Army posts.12
The inapplicability of this policy soon became apparent. For example, despite a recommendation by The Surgeon General that a 550-bed cantonment-type hospital be constructed for Camp Ord, G-4 directed on 6 June 1940 that the camp continue to use an expanded hospital at the Presidio of Monterey. The Surgeon, the Quartermaster, and G-4 of the Ninth Corps Area opposed this decision. They pointed out that the hospital and barracks at Monterey did not have enough total space to accommodate all the beds needed and that some cantonment-type construction would be necessary. In addition, both the barracks and the hospital were old and in need of repairs, were potential firetraps, were separated by a public road, and were located six miles from the troops at Ord. In view of these arguments, the General Staff reversed its decision and authorized the construction of a cantonment-type hospital at Camp Ord.13
As plans were made to receive draftees in the fall of 1940, dissatisfaction with the existing policy increased and The Surgeon General attempted to get it changed. His
Office supported requests of local surgeons for exemption from its provisions.14 On 5 September 1940 General Magee conferred with General Moore and the next day sent him a personal note. Referring to the impossibility of providing an adequate hospital at Fort Benning under the established policy, he stated: "There is so much dynamite in this that I think you should know about it."15 Nevertheless, the War Department did not immediately revise the policy, and G-4 permitted few exceptions to it.16 As a result the situation became so serious by mid-September that the Chief of Staff asked The Inspector General to investigate the rights and wrongs of interchanges between G-4 and The Surgeon General as well as delays in deciding the type of construction to be used.17 Apparently The Inspector Gen-
eral's report favored The Surgeon General's position, for soon afterward the Chief of Staff personally approved General Magee's recommendation "that the erection of cantonment hospitals be announced as the normal procedure" for all large posts, whether Regular Army or not.18
The revised policy on hospital construction, issued by the War Department on 26 September 1940, discarded the long-established plan to construct additional buildings for hospitals as a last resort only. Thereafter peacetime hospitals were to be expanded only on small posts where clinical facilities were generally sufficient for additional patients. Cantonment-type hospitals were to be constructed elsewhere.19 Without this change hospitals on Regular Army posts would have consisted of a hodgepodge of small permanent hospitals, permanent barracks, and temporary buildings required to supplement them. Delay in making the revision was responsible for much confusion and some delay in the erection of suitable hospital buildings on Regular Army posts,20 but it had no effect on hospitals for new posts because cantonment-type construction had been authorized for them since June 1940.
Planning for Construction
Planning for station hospitals was done on a day-to-day rather than a long-term basis, because their size, number, and location depended almost entirely upon a constantly changing troop distribution. In the fall of 1940 the Surgeon General's Office prepared two studies showing the additional beds that would be required by June 1941 at each post in the United States,21 but lack of information about ultimate troop distribution and changes in station strengths limited their value. In some instances three or more increases in authorized strengths required the same number of revisions of hospital construction plans for a single post.22 As information about stations and their strengths became available, the Construction and Repair Subdivision prepared plans for hospital construction for each. Consisting of the number of beds needed, the types and numbers of buildings required, and the layout or arrangement of buildings, these plans amounted only to recommendations. Final decisions on hospital construction were made by G-4 for ground force stations and by the Chief of the Air Corps for air stations. Because of the day-to-day type of planning and the lack of information about action on his recommendations, The Surgeon General found it difficult to keep track of station hospitals authorized for construction.23
Planning for general hospitals was on a more comprehensive basis. Although it
depended to some extent upon troop distribution, the fact that general hospitals would serve more than one post and would operate directly under The Surgeon General gave him considerable latitude in determining their size, number, and location. On 10 August 1940 G-4 sought information on increases in general hospitals that passage of the Selective Service Act would require.24 In response The Surgeon General proposed the construction of ten new general hospitals with a total capacity of 9,500 beds-one each in the First, Second, Fifth, Sixth, and Seventh Corps Areas; three in the Fourth, where the troop concentration would be heaviest; and two in the Ninth, where troops would be spread from Canada to Mexico. In the Eighth Corps Area, he proposed redesignation of the 1,700-bed Fort Sam Houston (Texas) Station Hospital as a general hospital, since it was already performing the functions of both types.25 Plans had already been made to increase the capacity of Walter Reed General Hospital, in the Third Corps Area, by relieving it of station-hospital cases which it had previously received from near-by posts.26 With the general hospitals already in operation, this plan would have provided a total of over 15,000 general hospital beds in the United States for an expected Army strength of 1,400,000.
The expansion of general hospitals during 1941 followed basically The Surgeon General's plan. On 25 September 1940 G-4 approved the construction of ten general hospitals, with a total capacity of 10,000 beds, in locations substantially the same as those recommended by The Surgeon General.27 Objections of the commander of the Eighth Corps Area to redesignation of the Fort Sam Houston Station Hospital caused The Surgeon General to withdraw that proposal.28 During 1941, therefore, the following general hospitals were added to the five the Army already had: Lovell at Fort Devens, Mass.; Tilton at Fort Dix, N.J.; Stark at Charleston, S. C.; Lawson at Atlanta, Ga.; LaGarde at New Orleans, La.; Billings at Fort Benjamin Harrison, Ind.; O'Reilly at Springfield, Mo.; Hoff at Santa Barbara, Calif.; and Barnes at Vancouver Barracks, Wash.29 No additional ones were required until September 1941, when an increase in the size of the Army was anticipated. At that time The Surgeon General submitted a proposal for a proportionate increase in the number of general hospital beds,30 but it was later merged with a larger plan to meet the needs of a wartime Army.
Selection of proper sites was an essential factor in planning for hospital construction. It was important, for instance, for both station and general hospitals to have sufficient space for future expansion; to be free from objectionable neighbors such as factories, railroad yards, warehouses, utilities areas, and training grounds; and
to be located on terrain that was moderately level and properly drained. The accessibility of good highway and railroad nets was especially important for general hospitals, whose function was to receive patients from other hospitals. The availability of good water supplies and of adequate utilities connections had also to be considered. The Quartermaster General's chief interest in hospital sites lay in their suitability from an engineering and construction standpoint.
During the emergency period The Quartermaster General selected construction sites in collaboration with other interested War Department agencies. For hospitals, this meant both The Surgeon General and corps area commanders.31 In the early phases of mobilization the selection of sites for station hospitals was left in many instances to local authorities, for The Surgeon General's Hospital Construction and Repair Subdivision had little personnel to spare for such activities. Sites so selected were generally satisfactory but sometimes had undesirable features, such as promixity to training areas, poor drainage, or inadequate space for expansion. As the press of work abated during 1941, The Surgeon General began to exercise more direct supervision over site selection through visits of his representatives to stations where hospital construction was anticipated.32 The selection of sites for general hospitals was more complicated and time consuming, even though the general areas in which they were to be located were first approved by the General Staff. As a rule, the War Department directed corps area commanders to appoint boards, with medical representatives, to make investigations and recommendations. Their surveys required considerable time and their recommendations in some instances were deemed unsatisfactory. In such cases, the Secretary of War appointed other boards representing The Surgeon General, The Quartermaster General, the General Staff, and corps area surgeons to make further surveys and recommendations.33
Difficulties in Providing
The Surgeon General and The Quartermaster General disagreed about the manner in which the Medical Department as the using agency should exercise advisory supervision over hospital construction. The Surgeon General insisted that his office should review each building schedule which was sent out and each change in plans proposed by the field. He believed that this procedure was necessary to maintain the proper division of space among various hospital services, an appropriate relationship among different buildings of a hospital plant, and the possibility of future expansion. In his opinion experience justified this position. For example, hospital construction at Fort Francis E. Warren (Wyoming) was delayed from early November 1940 until
January 1941 because The Quartermaster General sent out plans which The Surgeon General had not approved and against which local authorities protested. At Fort Rosecrans (California) local quartermaster and medical officers erected a two-story wooden hospital which The Surgeon General considered unsafe. In other places, such as Camp Wallace (Texas), Camp Custer (Michigan), Camp Roberts (California), and Camp Leonard Wood (Missouri), local changes in approved plans produced hospitals considered unsatisfactory by The Surgeon General.34
Hoping to speed construction, The Quartermaster General proposed standardization and decentralization-the use of standard building schedules (that is, lists of buildings for hospitals ranging in size from 25 to 2,000 beds) approved initially by the Surgeon General's Office and subject to no further changes by it, and the delegation of authority to make changes in hospital layouts and building plans to medical and quartermaster officers in the field.35 Nevertheless, because of The Surgeon General's insistence, both the Quartermaster Corps and the Corps of Engineers followed the practice of referring hospital building schedules and layouts to his Office for approval and twice during 1941 The Quartermaster General instructed his field agents not to change hospital construction plans without prior approval of the Surgeon General's Office.36
Centralization of the Medical Department's advisory supervision over hospital construction did not necessarily assure erection of satisfactory hospital buildings. That depended considerably upon the plans used. Drawn in 1935, they were simply pulled "off the shelf" when needed. The medical officer (Col. Floyd Kramer) who had helped prepare them warned the Surgeon General's Office that they would not be entirely satisfactory, and in October 1940 Colonel Hall, of the Hospital Construction and Repair Subdivision, indicated that he was "by no means certain" that they would "suit our 1940 ideas."37 It soon appeared that they did not. Hospitals built on such plans had insufficient space for some activities and none at all for others. X-ray clinics and laboratories were too small for use in modern medicine. Administration buildings had insufficient space for extensive records required for patients and civilian employees and were cut up into too many small rooms for efficient use. Post dental work required more room than originally expected. General hospitals needed more space for quartermaster activities. Inadequate kitchens and mess storerooms became the source of frequent complaints. Offices for the medical supply officer and the medical detachment commander, recreation buildings for patients and for nurses, post exchange
buildings, ambulance garages, and strong rooms for safeguarding narcotics as required by Federal law were not included in existing plans. Of equal importance, neuropsychiatric wards for which plans were provided lacked sufficient strength and safety features to prevent patients from attempting escape or suicide.38
The question of whether to revise existing plans completely or to make piecemeal changes arose in the fall of 1940. General Love, Chief of the Planning and Training Division, advocated their complete revision, but Colonel Hall demurred on the ground that he would encounter delays and difficulties in securing approval of G-4 and co-operation of The Quartermaster General.39 That his position had some basis in fact is indicated by a controversy from August through October over proposed changes for separate buildings. After The Quartermaster General complained that requests of The Surgeon General for piecemeal changes were delaying construction, their offices hurled charges and countercharges against each other until G-4 forbade further changes in standard designs without Staff approval, and the chief of the G-4 Construction Branch, concluding that further argument was useless, closed the controversy by recommending on 18 October 1940 that all papers pertaining to it be filed.40 Two months later The Quartermaster General proposed a complete revision of cantonment-type hospital plans, but Colonel Hall maintained his former position, this time for a different reason. "It is the opinion of this office," he wrote, "that sufficient experience with the plants to be erected according to the present plans has not yet been had to make a complete and satisfactory revision possible at this time."41
As soon as hospitals built on the 1935 plans were received from contractors, steps had to be taken to correct their defects and overcome their deficiencies. Several methods were adopted. One was to rearrange the use of space. For example, local commanders converted wards into X-ray clinics and laboratories and used the space vacated in clinical buildings to increase surgical facilities. To replace the bed capacity thus lost, The Surgeon General obtained additional wards.42 Another method was to modify the buildings erected. Changes in neuropsychiatric wards, such as the removal of exposed pipes, were made to increase the safety of mentally disturbed patients; and kitchens and mess halls were enlarged by adjacent construction.43 A third method was to construct additional buildings, such as storehouses,
ambulance garages, post exchanges, and strong rooms.44 Finally, existing plans for a few buildings, such as neuropsychiatric wards, kitchens, and messes, were revised during 1941 for subsequent use, in order to prevent perpetuation of the process of building and changing.45
Development of a New Type
In the spring of 1941 complaints were made in both military and civilian circles that the hospitals constructed not only lacked space for certain activities but also were unsatisfactory from an administrative and safety viewpoint.46 Wide dispersal of buildings intensified administrative problems without assuring adequate fire protection. As early as January 1941 the offices of The Quartermaster General and The Surgeon General had agreed upon a program of installing draft-stops in closed corridors that connected different buildings of hospital plants, as a fire-protection measure.47 In May the Chief of the Air Corps secured appropriations for the installation of automatic fire-sprinkler systems in fifty-eight Air Corps hospitals and The Quartermaster General made plans for their installation in all other hospitals with 400 or more beds. By December 1941 the installation of such systems in all the wards, except detention wards, and in the patients' kitchens of cantonment-type hospitals became War Department policy.48
Meanwhile work had begun on the development of a new type of hospital. When complaints about existing plants were first made, Colonel Hall expressed The Surgeon General's preference for more compact hospitals built of fire-resistant materials.49 Soon afterward his Office began to collaborate with the Quartermaster General's in designing such a plant. It consisted of buildings that were generally two stories high with exterior walls of masonry and interiors of slow-burning materials. Such construction permitted a more compact arrangement of structures than had previously been possible. Ward buildings were placed opposite each other on a central connecting corridor permitting one diet kitchen and one ward office and examining room to serve two wards. Two-story corridors connected the buildings of a hospital group, and ramps were placed at suitable intervals to give access from one story to the other. To allow more
space for medical care, the width of all wards, clinics, and other key buildings was increased from twenty-five to thirty-two feet, and facilities that were either lacking or inadequate in cantonment-type hospitals were introduced or redesigned in plans for the new type.50 On 6 August 1941 the Staff authorized the construction of two-story, semipermanent, fire-resistant plants for all future hospitals.51 Final drawings were not completed for several months, and before they could be put into general use the United States was at war.
Evaluation of Hospital
Although hospitals constructed during the period of peacetime mobilization did not "even approach the ideal," in Colonel Hall's opinion the wonder was "not that so many mistakes were made but rather that we have been able in a somewhat satisfactory manner to meet our obligation to the sick and wounded."52 Hospital beds had to be provided on a scale unknown in ordinary times. Between September 1940 and December 1941 the number of normal beds (that is, those for which 100 square feet of space each was provided in ward buildings) in station hospitals increased from 7,391 to 58,736 and in general hospitals, from 4,925 to 15,533. (Chart 1) Only in the fall and winter of 1940-41 was there a shortage of normal beds. At that time the Medical Department used emergency and expansion beds (that is, those set up on the basis of seventy-two square feet each not only in
wards but also in porches, halls, barracks, and tents) and sent some patients to nearby civilian and Veterans Administration hospitals.53 It also continued a policy, begun early in 1940, of reducing the number of Civilian Conservation Corps and Veterans Administration patients in Army hospitals and in December secured War Department approval of a policy of limiting sharply the hospitalization of dependents of military personnel.54 In the spring of 1941 construction began to catch up with needs and after March the number of patients in hospitals at no time exceeded the total number of normal beds. (See Chart 1.)
When mobilization began, the only guide to the organization and administration of Army hospitals was an Army regulation published in the mid-1930's. It gave hospital commanders much discretion in both fields and lacked detailed instructions for inexperienced officers to follow.55 A more specific guide was therefore necessary. In October 1940 the Medical Department devoted an entire issue of the Army Medical Bulletin to an article prepared by Col. Charles M. Walson, then surgeon of the Second Corps Area, entitled "Station Hospital Organization Chart, Regulations, and Medical Department Questionnaire." During the first half of 1941 the Training Subdivision of the Surgeon General's Office revised this article and the War Department issued it in July as a technical manual.56
The manual described hospital organization in considerable detail, advocating the separation of activities into two major categories, administrative and professional, and the grouping of professional activities into services composed of subunits called sections. For example, the surgical service of a station hospital might contain sections devoted to general surgery, orthopedics, obstetrics and gynecology, urology, eye-ear-nose-and-throat disorders, anesthesia, roentgenology, and physiotherapy; the medical service, sections for general medicine, contagious diseases, dermatology, neuropsychiatry, and detention. The manual also provided for a headquarters, or commanding officer's staff, separate from other administrative units of general hospitals. In addition, it described the duties and responsibilities of staff officers, as well as important administrative procedures, and contained checklists for chiefs of services to use in measuring the efficiency of operations. While it was somewhat more specific than the Army regulation governing hospital administration, this manual also gave local commanders considerable autonomy. (Chart 2)
Lack of a specific directive requiring standard hospital organization resulted in many local variations.57 The one general point of similarity was the separation of administrative from professional activities. In most hospitals the latter were organized as sections that were grouped in services: medical, surgical, dental, and laboratory. Some hospitals looked upon nursing as a separate professional service, although the manual recommended that the nursing unit be considered an administrative one. Others gave activities that might have been included as sections of either the medical or surgical service a higher status. For example, the station hospitals at Fort Lewis (Washington) and Fort Knox (Kentucky) possessed orthopedic services; that at Fort Ord (California) had separate genitourinary and eye-ear-nose-and-throat services; and that at Fort Bragg (North Carolina), a separate neuropsychiatric service. On the other hand there were but three professional services at the 1,200-bed station hospital at Camp Bowie (Texas): medical, surgical, and nursing.
Administrative units were usually not grouped in services, and their number varied from one hospital to another. For example at Stark General Hospital there were 29, including staff offices; at LaGarde, 14; while the number proposed in the manual was 12. Station hospitals likewise varied. On some posts they were under the supervision of station surgeons, who supplied certain administrative services. In one such instance the station surgeon handled all hospital personnel and supply activities. On other posts, a single officer served both as station surgeon and as hospital commander. The Fort Bragg Station Hospital, which was divided into three sections located from one quarter of a mile to a mile apart, had separate cornmanders for each unit, but possessed a central registrar's office, medical supply section, nursing section, mess and hospital fund, military and civilian personnel divisions, and medical detachment. General hospitals not located on Army posts usually had administrative sections not found in station hospitals, such as the finance and provost marshal's offices.
Neither Army regulations nor the manual on organization limited the number of officers a hospital commander could supervise directly. Thus the number of individuals reporting to him varied as did the organization of administrative and professional activities. As a rule, only chiefs of professional services, not of sections under them, reported to the commanding officer, but in most hospitals the chief of each administrative section reported directly to the commander or his executive officer. Thus the officers supervised directly by a hospital commander sometimes reached large numbers. For example, at Stark General Hospital the chiefs of four professional services and twenty-nine different administrative sections reported directly to the commander. In some instances the number of officers actually reporting was smaller than it seemed, because one officer frequently held several positions. (Chart 3)
Administrative procedures likewise varied from hospital to hospital. Since there was no manual covering hospital operations in detail, hospital commanders were free to supplement general procedures outlined in Army regulations as they saw
fit. Hospital regulations published in the Army Medical Bulletin in October 1940 and in Technical Manual 8-260 in July 1941 were probably of value to some, but officers opening new hospitals often borrowed copies of regulations and administrative forms of other hospitals to use as guides in establishing their own administrative procedures.58
The Surgeon General supervised and directed the professional work of hospitals through inspections by members of his Office and the issuance of technical instructions, but he exercised little direct control during this period over their administrative activities. Rather he depended on The Inspector General and corps area authorities to keep hospitals in line with Army procedures and to report administrative problems that arose.59
The question of whether the autonomy given hospital commanders resulted in less efficient operations than might have otherwise been the case was not discussed during the period under consideration. Arguments might have been raised in favor of flexibility which permitted accommodation to local situations. Later on, lack of uniformity in organization and administration became a subject of much discussion and efforts were made to develop standardized organizations and simplified administrative procedures.60
Manning of Hospitals: Manning
In September 1940 there was no up-to-date guide for manning named hospitals. Since they were then small, few in number, and widely different in construction none was needed, for personnel requirements of each installation could be determined best on an individual basis. With the opening of large hospitals built on standard plans, corps area surgeons began to need a guide to use in computing requirements and distributing personnel. The only available one was a 1929 table of organization for wartime station hospitals in the zone of interior.61 Although named hospitals were not being organized under it the General Staff early in 1940 had given the Third Corps Area permission to use this table as a guide, pending the publication of a "table for converting bed requirements into personnel requirements." Preparation of the latter in the Surgeon General's Office was delayed until December 1940, because the revision of tables of organization for field force units had priority.62
As submitted to the General Staff, the new guide called for more personnel, especially officers and enlisted men, than did the old one. For example, a 500-bed station hospital under the old table was to have 25 officers, 60 nurses, and 200 enlisted men; under the new guide, 37 officers, 60 nurses, and 275 enlisted men. The Surgeon General thought that the old table did not provide sufficient personnel for "a present day hospital." Although G-1 agreed that the amount called for by
the new guide was reasonable,63 the Staff delayed its publication because it expressed requirements in terms of military personnel only and called for more enlisted men than the number already allotted to hospitals. The first objection was apparently removed in January 1941 when Maj. (later Col.) Arthur B. Welsh, of The Surgeon General's Planning and Training Division, stated that civilians could be substituted for enlisted men on an approximate man-for-man basis.64 Two months later, incidentally, his superior officer, General Love, informed corps area surgeons that civilians should replace enlisted men on a three-for-two basis.65 In view of continued disagreement among members of the General Staff over the total number of enlisted men involved, the question of publication was submitted in March 1941 to the Chief of Staff. As a result a "Guide for Determination of Medical Department Personnel" was published on 9 April 1941 with the understanding that it represented requirements, not availabilities.66
Publication of the guide did not mean that hospitals were to have the strength prescribed. The Surgeon General apparently had no trouble in getting the General Staff to authorize the number of physicians, dentists, and nurses whom he desired, but he encountered difficulty in procuring the number authorized.67 During the fall and winter of 1940-41 hospitals considered the shortage of physicians and nurses acute. To alleviate it they employed civilian nurses on a temporary basis and used Medical Corps officers from field force units located near by. Medical Administrative Corps officers filled a few administrative positions, but the Army had few such officers and their substitution for Medical Corps officers in administrative work gained little headway prior to the war years. By the spring of 1941 the procurement situation had apparently improved and many hospital commanders reported that the number of officers and nurses assigned to them was adequate.68
The question of the number of enlisted men to be assigned to named hospitals was bound up with the use of civilian employees and the training of medical personnel. The Surgeon General contended that the Medical Department needed proportionately as many enlisted men in named hospitals during mobilization as in peacetime in order to train enlisted men in technical duties for use later as cadres and fillers for new units and installations. He insisted, therefore, that hospital staffs should have no higher proportion of civilians than 20 percent of the total enlisted
and civilian staff.69 On the other hand, faced with the problem of dividing a given number of enlisted men among field force units (including numbered hospital units) and zone of interior installations of the various arms and services, the General Staff believed that civilians should constitute as much as 50 percent of the staffs of named hospitals. In this connection G-3 suggested that the Medical Department might affiliate (not explaining what it meant by this term) numbered hospital units with named hospitals to provide additional enlisted men for service in the named hospitals and at the same time to give the numbered hospital units the best possible training.70 The Surgeon General planned to train numbered units in named hospitals, but he apparently expected the members of such units to be used not as regular operating personnel but as understudies of their opposite numbers. Repeatedly, therefore, he asked for greater allotments of enlisted men for fixed installations of the Medical Department, but without success.71 Hence, the enlisted men authorized for assignment to general and station hospitals were fewer than The Surgeon General desired, and those received by hospitals were fewer than the number authorized. To supplement them hospitals used civilians and men from near-by field medical units, the former sometimes constituting more than half of the total enlisted and civilian staffs.72
In addition to having less military personnel than they considered desirable, hospitals received officers and enlisted men who needed further training. Nurses and Medical Corps Reserve officers were of course qualified by training and experience to care for the sick and injured, but most who entered the Army after September 1940 knew little about the administration of Army hospitals. In some instances this resulted in devotion of more time and energy to paper work than was ordinarily thought proper. Recognizing the need for training Reserve officers in administrative procedures before assigning them to hospitals, The Surgeon General authorized a program in November 1940 to train fifty Reserve and National Guard officers each month for such positions as registrar, detachment commander, receiving and disposition officer, adjutant, executive officer, medical supply officer, and mess officer. In general, though, the burden of training officers and nurses in administrative work fell upon the commanding officers of the hospitals to which they were assigned.73
A majority of enlisted men available for service in hospitals during 1941 lacked a knowledge of both military and technical matters. The number of Medical Department men in the enlisted Reserves was
negligible, and the Medical Department's replacement training centers and enlisted technicians' schools did not begin to turn out trained men in large numbers until the summer of 1941.74 Regular Army enlisted men from hospitals already in operation formed the cadres of enlisted detachments of new hospitals. The remainder were usually men assigned direct from reception centers. The necessity of giving them basic military training interfered with their performance of technical duties, and hospital commanders generally preferred men from replacement training centers after they became available. To make up for the lack of technical training, hospitals instituted on-the-job training programs which varied in content and value from one installation to another.75
Civilians in Army hospitals were normally used in jobs traditionally held by such enlisted men as medical technicians, ward orderlies, clerks, cooks and cooks' helpers, repair and maintenance men, and janitors. In some instances civilian nurses were employed, and until the end of the first year of the war all female dietitians and physical therapy aides were in civilian status. The chief problem in the use of civilians was procurement. To reduce difficulties in that connection The Surgeon General in September 1940 decentralized to corps areas the employment of civilians for station hospitals, including those on exempted stations. He retained in his Office for a time the employment of civilians for named general hospitals.76 Among local conditions that continued to hamper the procurement of sufficient numbers of qualified civilians, the most important were lack of housing near hospitals in isolated areas, inadequate transportation to such hospitals, absence of labor markets in some places, and competition of other government agencies for available civilians.77
Shortages of Supplies and Equipment
Another difficulty encountered in opening new hospitals was a shortage of suitable supplies and equipment, and complaints of hospital commanders on this score were frequent.78 Depots met earliest needs by issuing reserves stored after World War I. As a result, much that hospitals received, such as surgical instruments, plaster of paris bandages, and ward furniture, was of 1918 vintage. When reserves proved insufficient, depots supplemented them with local emergency
purchases but even so had to ship many assemblages 50- to 60-percent complete.79 Hospitals thus failed initially to receive many critical items. Most frequently lacking were sterilizers, X-ray equipment, orthopedic equipment, dental operating units, cystoscopic instruments, and catheters.
To make up for shortages hospitals resorted to a variety of expedients. In some instances medical and dental officers sent home for their own instruments. At Camp Claiborne (Louisiana) they personally purchased medical supplies which they considered requisite. The station hospital at Camp Blanding (Florida) made up for its lack of laboratory supplies and equipment by borrowing from the University of Florida and the Florida State Board of Health, while the Camp Claiborne Station Hospital borrowed an X-ray developing tank from a dealer in Shreveport, Louisiana. In other instances Army authorities arranged locally to use the facilities of neighboring hospitals. For example, the Camp Beauregard (Louisiana) Station Hospital sent cases requiring X-ray and electrocardiographic work to the Veterans Administration Facility at Pineville, La.; used the diagnostic and clinical facilities of the Central Louisiana State Mental Hospital for neuropsychiatric patients; and sent fractures requiring reductions or large casts to the Baptist Hospital in Alexandria, La. Where office and ward furniture was lacking, hospitals improvised desks, chairs, and tables from boxes and lumber salvaged from the hospital's construction. Thus the improvisation and ingenuity of local personnel compensated to a great extent for shortages of supplies and equipment.
The above situation resulted initially from the inadequacy and obsolescence of the war reserve. It continued because considerable time was required both for industry to convert to the production of goods on the scale demanded and for the Medical Department to modify its peacetime methods of requirements-computation, purchasing, stock-control, storage, and distribution. Although the quantity of supplies became more adequate by the fall of 1941, the situation was by no means satisfactory at the end of the year and many items were still on "back order."80
Development of Procedures Affecting
As new station and general hospitals opened, broad policies and procedures to govern the hospital system in general became necessary and The Surgeon General's Hospitalization Division concentrated its efforts in those fields.81 The need for a new policy to govern the selection of patients for transfer to general hospitals developed in the spring of 1941. Until that time hospital commanders and corps area surgeons decided which cases were sufficiently "serious, complicated, or obscure" to require treatment in the five general hospitals then in operation. Few restrictions were placed upon them: cases of resection and amputation requiring the fitting of prostheses were to be transferred to Walter Reed, Letterman, or Army and Navy General Hospitals; patients with tuberculosis, to Fitzsimons; and "cases of such diseases as the waters of the hot springs of Arkansas have an established reputation for benefiting," to Army and
Navy.82 To provide a more exact guide the Hospitalization Division developed a policy that was published on 26 March 1941.83 While it did not relieve local surgeons of responsibility for selecting patients to be transferred, it provided generally that all requiring more than sixty days of hospitalization as well as those needing specialized treatment not available at station hospitals should be sent to general hospitals. Major elective84 operations were to be performed at general hospitals only. Station hospitals were to dispose of enlisted neuropsychiatric or psychotic patients locally, but were to send officers, nurses, and warrant officers who were similarly affected or who had other disabilities which made them unfit for further military service to general hospitals for observation and disposition. Hospitals previously designated for the care and treatment of special cases were to continue to receive them as in the past.
Soon after this policy was established the Hospitalization Division developed a procedure to implement it. Under current Army regulations hospital commanders needed corps area approval for each transfer of a patient from a station to a general hospital.85 As new hospitals opened, this requirement resulted in much paper work for corps area surgeons and in delayed treatment for patients. On 19 May 1941, therefore, The Surgeon General requested authority to set aside specific numbers of general hospital beds to which station hospitals might transfer patients without reference to corps area headquarters. The General Staff approved this request and on 21 June 1941 authorized the establishment of a system of bed credits. This permitted the Hospitalization Division to allot a certain number of beds in general hospitals to each large station hospital and, through corps area surgeons, to small ones. Thereafter post commanders normally transferred patients to general hospitals without reference to higher authority. When stations needed changes in allotments, they ordinarily requested them through corps area surgeons. In emergencies, they were authorized to communicate directly with The Surgeon General.86
The procedure for transferring patients from station to general hospitals was further simplified in the late summer of 1941. Until then Army regulations required each hospital to make extracts or copies of the clinical records, including case histories, of patients being transferred, to be sent along with them. As the number of patients increased, this time-consuming process began to delay their transfer and hence their treatment. The Surgeon General then secured approval of a change which permitted station hospital authorities to transfer to general hospitals, along with patients, the original clinical records of their cases. The transferring hospital kept only clinical-record briefs and cross references indicating the disposition of original records.87
Another problem for the Hospitalization Division was the disposition of patients. It concerned the Hospital Construction and Repair Subdivision also, for prompt disposition of patients reduces total bed requirements by making available for patient care more of the beds al-
ready set up. During 1941 there was considerable local dissatisfaction with difficulties and delays encountered in granting patients disability discharges from the Army. Believing that lack of experience on the part of many medical officers was responsible, one corps area surgeon issued a directive in 1940 to clarify procedures for handling such cases.88 In general, the centralization in corps area headquarters of authority to discharge men on certificates of disability, rather than inefficient hospital procedures, seems to have been considered the most important reason for delays.89 Apparently sharing this view, The Surgeon General secured authority in September 1941 for the commanders of general hospitals to grant disability discharges. At the same time, it should be noted, the War Department was further decentralizing such authority to other local commanders, including those of divisions, reception centers, replacement training centers, and exempted stations. The Surgeon General also secured authority for general hospital commanders to issue travel orders for men returning to duty or being discharged from the Army.90
In the fall of 1941 the Chief of Staff became concerned about delays in the retirement of disabled officer-patients. When General Marshall called a case of this kind to his attention, The Surgeon General replied that such delays were "chronic" but that they occurred in large part in Army administrative channels after general hospitals had completed their work and made their recommendations. Soon afterward he directed general hospital commanders to "personally assure themselves that the disposition of officer patients is expedited insofar as this can be done without prejudice to the interest of the individual or of the Government."91 Further steps to speed the disposition of officer-patients were not taken at this time.
Partial simplification of the procedure for granting disability discharges went some distance, though not as far as possible, toward relieving Army hospitals of patients who were unnecessarily occupying beds. Action was also taken to relieve hospitals of certain other patients-that is, some of those suffering from tuberculosis, psychosis, and other chronic diseases. At the beginning of mobilization the President approved a recommendation of the Federal Board of Hospitalization that members of the armed forces who were injured or incurred disabilities "in line of duty" and whose physical rehabilitation by the Army or Navy was not feasible should be cared for by the Veterans Administration. Accordingly the Surgeon General's Office secured approval in March 1941 for the transfer to the Veterans Administration of most enlisted men who were permanently disabled by the development of pulmonary tuberculosis. Two months later this provision was extended to all classes of chronic disability cases. Three classes of tuberculous patients-those nearing retirement after thirty years of service, those in the first three noncommissioned grades whose recovery was probable within a year, and those whose cases were considered not to have been incurred in line of duty-were to be kept in the Army and transferred to Fitzsimons General Hospital. As soon as
patients in the last group were able, they were to be discharged to their own care or that of relatives.92
The removal of psychotic patients from Army hospitals was more complicated. Many could not be transferred to the Veterans Administration because their disabilities had existed before induction. State institutions were often reluctant to accept those who required care in locked wards. As a result psychotic patients began to accumulate in Army hospitals. Early in the mobilization period a large three-story section of Walter Reed General Hospital was converted into closed wards and the Medical Department arranged to use, as an annex to that section, 100 beds in St. Elizabeth's Hospital in Washington. One or two closed wards more than had been planned were constructed at each new general hospital erected during 1941. In the summer of that year, after Walter Reed General Hospital had demonstrated the rather elementary fact that transfer of psychotic patients to state institutions was expedited by addressing requests to proper state agencies or authorities, The Surgeon General issued a circular letter naming those in each state. About the same time his Office arranged to establish a special neuropsychiatric center in the just-completed and unused State Hospital at Danville, Ky. Called Darnall General Hospital, it was ready to receive patients a few months after the Japanese attacked Pearl Harbor.93
Starting almost from scratch in September 1939, the Medical Department reached a state of partial preparation for war by December 1941. To provide hospitals for a rapidly expanding Army in the United States, a simple method of computing requirements was adopted and ratios of beds to troop strength-smaller than The Surgeon General considered desirable-were officially established. Experience in expanding hospital facilities showed that it was impracticable to rely upon the use of existing Army hospitals and available non-Army buildings. It also revealed imperfections and shortcomings in cantonment-type hospitals planned in the thirties, with the result that a new type of hospital more compact and fire resistant was developed. As new hospitals opened, the Surgeon General's Office evolved general guides for their organization and administration but left hospital commanders with much autonomy in this field. Attention was focused not upon internal hospital administration but upon simplifying procedures affecting the hospital system in general. In this connection attempts were made to reduce unnecessary occupancy of beds by patients no longer needing treatment or of no further use to the Army. There were shortages of personnel, though authorized allotments for hospitals were generous, and it was necessary in many instances to substitute civilians for enlisted men. Shortages of supplies and equipment were alleviated by the ingenuity of hospital commanders and their staffs. Meanwhile, the Surgeon General's Office was also concerned with plans and preparations for overseas hospitalization, the subject to which the discussion now turns.