CHAPTER XV
THE DIVISION OF HOSPITALIZATION (Continued)
HOSPITAL CONSTRUCTION; PROCUREMENT
CONSTRUCTION
Despite the possibility of procuring from the French certain buildingsthat could be adapted to hospital purposes, it was apparent to the MedicalDepartment, A. E. F., from the outset that these would have to be supplementedby new construction.1 Even before the arrival of headquarters,A. E. F., the erection of a barrack hospital was commenced in the debarkationcamp at St. Nazaire.1
An important factor in expediting the development of our needs in thismatter was the fact that the French did not have in the training areaswhich they were to turn over to our troops sufficient hospitalization tomeet our needs, and it quickly became essential that we then constructbuildings of our own.2 A set of plans for a large hospital ofbarrack type had been sent to France when the staff of the American ExpeditionaryForces went overseas, but these were found to be wholly impracticable.2The ground plan of the unit as defined by the War Department called forthree times as large an area as did the plans eventually adopted for aunit with the same number of beds in the American Expeditionary Forces.Also, it prescribed porches, a sewerage system, extensive plumbing andheating appliances and other features which could not have been realizedwith the limited resources available in France. Neither lumber nor thelabor necessary for their construction were procurable overseas.2Accordingly, as soon as it was ascertained that the plans prepared by theWar Department could not be utilized, an assistant to the chief surgeon,A. E. F., after collecting suggestions from various medical officers commandingbase hospitals of the American Expeditionary Forces, formulated plans forconstruction and layout which were more compatible with our resources.1Many of the good features that had been developed by our Allies were incorporatedin the plans which he developed, but he also considered in their formulationthe general layout of the Letterman General Hospital in San Francisco.The plans now formulated were made the basis of hospital construction inthe American Expeditionary Forces.PLANS FOR A BASE HOSPITAL, TYPE A
The plan for the layout and for the buildings to be erected for eachbase hospital, whether located separately or in conjunction with others,was designated that of a type A unit.3
To conserve wear and tear on personnel and to facilitate administrativecontrol, the area to be covered by these hospital units was reduced toa minimum, consistent with safety from fire.2 To economize inheating, lighting, structural material, etc., and to centralize and standardizethe units, only 20
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feet of space was allowed between most of the buildings. From an administrativeand clinical standpoint this concentration proved preferable, and, thoughit increased the fire risk, not a single serious fire occurred in any ofthese units.2
The type A unit required a frontage of 850 feet and a similar depth,its normal layout comprising 3 rows of buildings, divided by suitable intercommunicatingroadways and walks.4 The central row of buildings included thosepertaining to general service such as administration, reception of patients,baths, operating and X-ray section, clinic, and dining room. On each sideof this central row of buildings was a block of 5 or 10 wards, dependentupon their size, and in rear of these sufficient space for the erectionof tents, the crisis expansion, which in prolongation of the several wardswould provide additional bed capacity in emergencies.
FIG. 21.-Generallayout of hospital unit, type A (base hospital), with wards 20 feet wide.Demountable buildings. In a hospital center one recreation hall and onedisinfector were provided for each two hospital units; the nurses' recreationclub was omitted when a central nurses' recreation club was provided
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In the type A unit the ward buildings were of two sizes;4the scarcity of building material, and the different contracts made itnecessary to have in one part of France buildings entirely different fromthose in another part.5 Thus the dimensions of one ward usedwas 20 by 164 feet; of another, 36 by 156 feet. The number of patientsper ward varied, of course, with its size, normally being about 50 forthe narrower ward and double that number for the wider one. In addition,the wards provided space for the necessary administrative, culinary andtoilet facilities. Twenty of these buildings (10 when the wider wards wereused), half being on each side of the central administrative or clinicalgroup, provided accommodations for 1,000 patients, the normal capacityof these units. Extension of each ward by tentage, the crisis expansion,doubled this capacity, and gave accommodations for 1,000 emergency beds.In the corners of the general plan were located the quarters of the officers,nurses, enlisted men and accommodations for the isolated or psychiatriccases.3
FIG. 22.-Generallayout of hospital unit, type A, with wards 20 feet wide. Permanent buildings.In a hospital center one recreation hall and one disinfector were providedfor each two hospital units; the nurses' recreation club was omitted whena central nurses' recreation club was provided
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Originally the plans for type A units provided for a recreation hallin the central row of buildings, and a space had been designed for sucha structure. The American Red Cross undertook to install, equip, and operatethese buildings, and in the fall of 1917 sent to France 5,000,000 feetof lumber for this and other purposes.2 Building material, however,was so scarce that the general staff, A. E. F., requested the AmericanRed Cross to transfer this material to the American Expeditionary Forces,engaging itself to construct these buildings from material that would beobtained later.2 This created a regretable situation, becauseat no time did sufficient material become available for the American ExpeditionaryForces to fulfill this obligation.2 Accordingly when the AmericanRed Cross realized that fact, it again undertook the provision of recreationbuildings, construction being effected by the engineers, but, when hostilitiesceased many hospital units lacked their authorized recreation huts.2FIG. 23.-Generallayout of hospital unit, type A, with wards 36 feet wide, 156 feet long.In a hospital center one recreation hall and one disinfector were providedfor each two hospital units; the nurses' recreation club was omitted whena central nurses' recreation club was provided
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FIG. 24.-Wardbuilding (20 feet wide), hospital unit, type A. Demountable
FIG. 25.-Wardbuilding (36 by 156 feet), hospital unit, type A
FIG. 26.-Administrationbuilding, hospital unit, type A
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FIG. 27.-Nurses'quarters, hospital unit, type A
FIG. 28.-Nurses'dining room and kitchen, hospital unit, type A; for use with demountablebuildings
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FIG. 29.-Officers' quarters and dining room, hospital unit, type A; for use with demountable buildings
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FIG. 30.-Officers' quarters, hospital unit, type A; for use with permanent type of buildings
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This was a graver matter than might at first appear, for, in the absenceof legitimate diversions otherwise obtainable, the facilities of the recreationbuildings had a noteworthy influence in promoting the morale of the hospital.
FIG. 31.-Receiving and evacuating hall, hospital unit, type A; for use with demountable buildings
FIG. 32.-Receivingand evacuating hall and patients' bath, hospital unit, type A. Permanenttype
FIG. 33.-Patients'bath, hospital unit, type A; for use with demountable buildings. Permanenttype is shown in Figure 32
In order to standardize and simplify construction, each hospital wasdesigned on the principle of using only portable wooden huts with floordimensions of 20 by 100 feet, or any huts built of other materials butapproximating these dimensions and obtainable in Europe.2 Thesestandard units as designed were complete in every particular.1Most of the type A hospitals were built of wood. Some, where local resourcespermitted, were superior, and, especially
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FIG. 34.-Recreationhall, hospital unit, type A; permanent building type
in those units constructed by English or French contractors, tile, brick,sheet steel, and concrete were frequently used.2 The buildingsthat were made of wood or sheet steel (Adrian barracks) were composed ofunit mill-fabricated sections 10 feet high and 81/3feet wide, each side of the average buildings which had a length of 100feet comprising 12 sections. These sections consisted of side frames androof trusses to which, when set up, the walls and roof panels were bolted.They were bolted together while flat on the ground, then raised to a verticalposition and temporarily secured until the side and roof panels had beenbolted. The wall panels, 10 feet long and 41/6feet wide, were provided with exterior and interior board walls, the latterhaving a smooth finish. Roofs consisted of boards covered with tar paper;floors and ceilings, of planks. The windows, though adequate, were comparativelysmall, for glass was scarce and substitutes frequently were necessary.Among these substitutes for glass were plain or oiled cotton fabrics, andan isinglass preparation on thin wire mesh. The isinglass preparation provedunsatisfactory in the damp climate of France.2 The first typeA hospital, which was at Bazoilles, was reported as one-third completedin December, 1917.2
The component parts of the huts were interchangeable and were so dividedthat it was possible by adding sections to erect a building of any lengthdesired; for example, ward buildings in the type A unit measuring 20 by164 feet.2,4 Changes in width were made with more difficultybut could be effected by an adjustment of paneling or by doubling up buildings.Considerable latitude was thus possible in the dimensions of buildings.
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Erection of these huts was relatively simple and, if the military situationso required, they could be taken down (no nails having been used in theassemblage of the component parts), shipped and reerected on another sitein a minimum space of time.2 They left much to be desired, whencompared with permanent structures, but met requirements, though the greatscarcity of lumber frequently necessitated the use of green timber whichresulted in some warping of the walls.2 The great advantageswhich structures of this type presented were availability, mobility, quicknessof erecting, and low initial cost. The average price paid for them was$2,000. These huts, frequently called barracks, had been in use among thearmies in France and had proven satisfactory.2 They became thebackbone of our hospitalization program.FIG. 35.-Nurses'recreation club, hospital unit, type A; demountable
In order to preserve symmetry and to facilitate assembly it was prescribedthat as far as possible huts should all be of similar design and of thesame dimensions in any one unit. The demand for these structures graduallybecame so great that it was necessary to comb every available Europeanmarket for building materials for them, and, as a result, a half dozendifferent materials for hospital huts eventually came into use.2 Ofwhatever material they were built the huts had the same design and dimensionsas those prescribed for the portable wooden huts.FIG. 36.-Laboratoryand morgue, hospital unit, type A; for use with demountable buildings
Soon after the Medical Department began its construction program generalheadquarters, A. E. F., was confronted by a severe shortage in the buildingmaterial necessary for its many construction projects.2 Accordingly,in an effort to retrench, it reexamined the plans for hospitals and otherbuildings and ordered a reduction in the space allowed for living quartersof officers, nurses, and enlisted men.6 The chief surgeon'soffice acceded to this reduction except in so far as it affected nurses.2Though it strenuously opposed diminution of the modest allowance that hadbeen made for them, this reduction in their quarters was enforced untilApril, 1918,7 when one room, 10 by 14 feet, was allowed foreach 2 nurses. Covered passageways connecting wards, clinical buildingsand dining rooms were eliminated as mentioned above, but
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the plans successfully resisted further pruning except where the unitswere grouped in centers. Certain further reduction was then possible; forexample, some of the psychiatric or isolation buildings were eliminatedand the general staff strongly advocated elimination also of unit administrationbuildings and storehouses.2 Fortunately it receded from thisposition, otherwise it would have been impossible promptly to equip thefrequent drafts of outgoing patients.2
As discussed below, under procurement, the French were primarily chargedwith coordination of construction, several agencies often seeking the samesite.2 After the approval of the French had been received forthe construction of a project, the chief surgeon recommended to the assistantchief of staff, G-4, general headquarters that such construction be effected.The latter then directed the commanding general, Services of Supply, toproceed with construction of a designated number of hospital units at acertain place. The Engineer Corps then proceeded with the construction,much of this being effected, under engineer control by civilian contractors.Even when buildings were taken over from the French it was almost alwaysnecessary to have extensive additions, repairs or alterations made beforethey were suitable for our hospital use.2
FIG. 37.-Operatingand X-ray building, hospital unit, type A. This plan was adopted December15, 1917, and was to be used only when demountable buildings were to beused. The permanent type is shown in Figure 38
During the early period of our hospital construction it was necessaryto secure from the French a promise that their Engineer Corps would constructthe necessary railroad sidings and loading quais.2 In view oftheir shortage of man power and matériel, such promises were difficultto obtain. On the whole, however, without the assistance at this time ofthe French, who took
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immediate and actively helpful interest in the prosecution of our program,we would have experienced great difficulty in having ready sufficient hospitalsto shelter the large number of wounded of the following summer and fall.2As it was, very few of our barrack hospitals were ever entirely finished.2It was necessary to occupy them long before the construction work was completedand wounded were moved into the wards when these furnished little morethan protection from the elements.1 During the warm weatherthis situation was not serious, but after cold weather came on it was onlythe early termination of hostilities that prevented very great suffering:Thousands of casualties were sheltered in unfloored and unheated tents.1The personnel of base and camp hospitals frequently assisted in the buildingor modification of the structures which their respective units utilizedand continued to perform this work even after patients were admitted. Convalescentpatients and, later, labor troops also assisted and were an important factorin the efforts to overcome the shortage of civilian labor.2The situation was fraught with great anxiety to those charged with theprovision of hospital accommodations for the rapidly increasing numbersof casualties, but in view of the difficulties encountered it was not surprisingthat the construction program was never fully realized.1
PLANS FOR HOSPITAL CENTERS
The necessity for doubling, or in emergencies quadrupling, the sizeof a base hospital with relatively small increase in the number of thepersonnel serving the unit, suggested that further economies might be madeby grouping these organizations into hospital centers.2 Thoughthe expedient offered many advantages theFIG. 38.-Operating,X-ray, and clinic building, hospital unit, type A. This plan, adopted August12, 1918, superseded the plan of December 15, 1917, shown in Figure 37.When one type A unit only was constructed, this plan was used; however,when two or more units were constructed at a hospital center, this planand the plan shown in Figure 40 were alternated
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FIG. 39.-Dispensaryand clinic building, hospital unit, type A; to be used for demountablebuilding only
FIG. 40.-Clinicandsurgical dressings building, hospital unit, type A. This building was toalternate with the operating X-ray, and clinic building shown in Figure38; that is, when there were more than one type A unit in a hospital center,half were to have buildings according to this plan, and half accordingto the plan shown in Figure 38
FIG. 41.-Patients'kitchen, hospital unit, type A. Temporary type
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FIG. 42.-Patients' kitchen and dining halls, hospital unit, type A. Permanent type
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FIG. 43.-Patients' dining hall, hospital unit, type A, for use only when demountable buildings were furnished
FIG.44.-Quartermaster's storehouse, hospital unit, type A, for use only whendemountable buildingswere furnished
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FIG. 45.-Quartermaster's and medical storehouse, hospital unit, type A. Permanent type
dominant consideration causing its adoption was the need to compensateas far as possible for the shortage in personnel, by reducing staff andoverhead demands to a minimum. It was planned as early as September, 1917,to group from 2 to 20 hospitals and a convalescent camp at each of theseformations and that the largest of them should have from 30,000 to 36,000beds.2
The geometrical layout of the individual unit admirably fitted in withany grouping scheme. When a site capable of accommodating a number of thetype A units was selected, an initial survey, with particular referenceto contours, was made by the Engineer Corps, A. E. F., and the groupingeventually adopted with reference to the most adaptable conformation tothese contour lines.2 By doing this and by bearing in mind thatthe majority of the buildings were but 20 feet wide, a considerable savingin piering matériel or excavation work was effected. The locationof the units, moreover, was made with a view of harmonizing the administrationof the center.
In consultation with those in charge of construction, representativesof the chief surgeon's office worked out and adopted an appropriate layoutfor each center.2 The primary requisite was the decision asto the location and adequacy of railroad sidings, all of which had to benewly installed, and the frontage of units on these sidings. The requirementsfor the administration and supply of these centers were made by providingsuitable extra buildings for that purpose. Central water, sewerage andlighting systems, garages, storehouses, etc., also had to be installed.In fact, the larger centers, in some of which we had projected a capacityof 20,000 beds, approximated the creation of a veritable city with allits accessory requirements.PLANS FOR CAMP HOSPITALS, TYPE B UNITS
The layouts of the type A and type B units were highly similar, differencesbetween the two consisting chiefly in the size and completeness of thebuildings employed.8
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Type B hospitals were much less elaborate than those of type A, forit was intended that they would provide only the barest hospital necessities.2Though each of these was a fairly complete working plant with operatingroom, X-ray laboratory, etc., they were not designed to give definitivetreatment. Each type B unit required an area 600 feet square and consistedof a central block of service buildings and two lateral rows of five wardseach.2 Each of the wards was 100 feet long by 20 feet broadand accommodated 30 patients. In each of these units also, space was reserved,in prolongation of the wards, for crisis expansion by tentage, or wherepermanent expansion was desired, by huts.8 The normal capacityof the units was 300 beds but with the crisis expansion a total capacityof 1,000 beds was provided.
Type B hospitals were never grouped, but were scattered throughout France,to meet needs arising in isolated commands and in training areas.2
FIG. 46.-Barrack building, hospital unit, type A. Demountable
FIG. 47.-Personneldining hall, hospital unit, type A. Demountable
They were a very important element of American Expeditionary Forceshospitalization and proved to be quite indispensable. On the day the armisticewas signed 66 of these units were in operation.2
QUALITY OF CONSTRUCTION WORK
The quality of the construction work performed in our various individualhospitals and hospital centers varied from good to bad, seemingly conformingto the individual experience and efforts of the officer locally in chargeof construction.2 Many of the projects were turned over to Frenchor English contractors who secured the best results. The work performedon some of the hospital projects, particularly those in the advance section,was highly unsatisfactory, being of a makeshift character with apparentlyno attention to detail or desire to make the best of the material at hand.2It was early pointed out and particularly emphasized by the chief surgeon'soffice that the first requisite
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in any construction program was the building of good roads, and thedevelopment of the water and sewer systems. In many of the projects thesedesiderata were overlooked, construction of buildings being started beforeany work had been done upon roads. Hospital sites, when this procedurewas followed, soon became small seas of mud, and progress was materiallyhandicapped. As late as December, 1918, many of the essential roadwaysin these units were in inexcusably bad condition.2
In those parts of France where our base hospitals were erected, cloudydays prevailed for the major part of the year and for this reason north-southorientation with east-west exposure to sunlight was not as important afactor as it would have been in more sunny localities, nevertheless, whereverpracticable, this orientation was practiced.
To avoid excessive piering, all buildings were arranged on parallellines with the general layout conforming as far as possible to contourlines.
Recognizing the shortage in material, and the great difficulty of obtainingin adequate quantities many of the essential articles required in a greatconstruction project of this nature, every conceivable refinement was eliminatedfrom these type A and type B hospital units.2 For example, porcheswere not included. Because of the prevalence of inclement weather in France,particularly in the territory in which we were required to hospitalize,it was believed that overhead protection in the form of covered passagewaysalong the front of the ward entrance and connecting up the central groupof clinical and mess buildings should be provided. These were prescribedin the plans as finally adopted, but were never installed in any of theunits, owing to scarcity of lumber. Because of the fact that plumbing materialcould be procured in very limited amounts only, plumbing fixtures werereduced to a minimum. Buildings were heated by stoves; fecal matter wasdisposed of by the pail method and incineration.
FIG. 48.-Medical storehouse, hospital unit, type A. This building was to be used only when demountable barracks were used.
The permanent type is shown in Figure 45
CONVALESCENT CAMPS
With the speeding up of troop movements early in the summer of 1918,it was soon realized that fixed hospitalization, as its acquisition wasthen progressing, could not keep pace with the arrival of troops. To meetthis situation it was decided to provide convalescent camps in the vicinityof and as part of large
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hospital centers to which men not yet fit for duty, but who no longerrequired careful hospital treatment, could be sent pending their fitnessfor return to duty.9 In these camps the men were provided withshelter. The bed space was limited but the food was good, and the men weregiven a certain amount of work and exercise to fit them for their forthcomingduty. The assistant chief of staff, G-4, general headquarters, on June1, 1918, authorized the construction or establishment by tentage of theseconvalescent camps, on the ratio of 20 per cent of our total bed capacity.10Many of these camps were in operation upon the conclusion of hostilitieson November 11, 1918, and it was through their operation only that we wereable to provide accommodations for the battle casualties occurring duringthe summer and fall of 1918.2
FIG. 49.-Disinfector building, hospital unit, type A, for use only when demountable barracks were used
TENTAGE
The intended use of tents in connection with fixed hospitals in theAmerican Expeditionary Forces was to permit a rapid expansion of the bedcapacity of a hospital during stress3 and to shelter patientsin convalescent camps.9 As stated above, in the plans of bothtype A and type B hospitals the permanent wards were so situated as toleave space at their outer ends for ward tents. Thus patients in the permanentwards so far improved as to be no longer in need of close supervision byward surgeons and nurses could with safety be removed to the contiguoustent wards, leaving space for the more seriously sick or wounded.FIG. 50.-Ablutionbuilding, hospital unit, type A. Demountable
The kinds of tents used were two European models, the marquee and theBessonneau and our own Medical Department ward tent.11 Contractswere made with three companies in France for 10,000 Bessonneau tents.11This is a double-wall tent, capacity 26 beds normal, 30 beds emergency.It is well lighted with windows, and since stoves may easily be installed,this tent is quite warm. If supplied with electricity, suitable walks androads, this tent makes an admirable ward as it is warmer than the barrackward. The Bessonneau tents did not begin to arrive until about the 1stof October, and there were only 800 of them in use on November 11.11Three thousand marquee tents had been delivered by the British, and deliverieswere coming in at the rate of 50 per day at the time of the signing ofthe armistice.11
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FIG. 51.-General layout, hospital center, Bazoilles
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Because of the inability to obtain an adequate number of either themarquee or Bessonneau tents, practically all hospitals with crisis expansionmade use of all three of the kinds of tents referred to. However, the greatestuse was made of the United States Army ward tent in connection with theconvalescent camps, since the patients therein had convalesced to a pointwhere they needed little or no strict hospital treatment.11
It was necessary to employ approximately 2,500 American ward tents inconvalescent camps in the fall of 1918, and when the armistice was signedthe chief surgeon's office had placed in use practically all its resourcesin tentage.11
The question might logically be asked why type A units were not constructedon a 2,000-bed capacity basis from the start, and thus eliminate the necessityfor tentage. The reasons for this were obvious. There was not sufficientbuilding material on hand in France to permit of this action; and evenhad there been, it would have been unnecessary and expensive installation.2In providing for this expansion by the use of tentage we divided our sourcesof supply and retained a mobility in crisis matériel that was essentialin expanding at places requiring it, and, as the name implies, these crisesoccurred only in certain phases of our combat activities. By expandingonly during them, overhead and upkeep expenses were reduced materially.
FIG. 53.-Generallayout, hospital unit, type B (camp hospital)
In this connection, the chief surgeon, A. E. F., expressed the opinionin March, 1919, that a crisis expansion of 1,000 beds made a hospital toounwieldy, and that it should be no greater than 500 beds.5
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FIG. 54.-Ward,hospital unit, type B
FIG. 55.-Administrationbuilding and officers' quarters, hospital unit, type B
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FIG. 56.-Patients'mess, hospital unit, type B
FIG. 57.-Bathand disinfector, hospital unit, type B
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FIG. 58.-Operating and clinic building, hospital unit, type B
PROCUREMENT
Prior to the approval, on August 13, 1917, of a program authorizing73,000 beds,12 the chief surgeons' office, A. E. F., had steadilybeen acquiring existing hospitals from the French, for it was impossibleto construct buildings in time to meet the immediate needs of our troopswho had begun to arrive in June, 1917.2 But when the programauthorized June 1 became effective a progressive system of hospital procurementwas adopted.2 As it was evident that any attempt to administerour base hospitals under canvas would prove impracticable, it was essentialthat the chief surgeon find buildings in which base hospital units couldoperate, and during many months he took over the most suitable availablestructures that could be found. These accommodations could be providedby (1) taking over military hospitals from the French Army; (2) leasingthe most suitable buildings available. Buildings in the first categorywere transferred by the French to the limit of their capacity. No reasonablerequest was ever refused, and among the hospitals thus transferred weresome of the very best in France, but evidently it was neither expedientnor possible that that country deplete its own resources of this characterunduly in order to meet our needs.2 From our own point of view,too, there were definite objections to taking over French military hospitals,despite the willingness of France to help us to the utmost. One objectionwas the fact that most of these hospitals were small institutions of from25 to 300 beds, and that the limited personnel authorized for our servicecould be used much more economically in operating much larger units.13Moreover, these hospitals, widely scattered, were served largely by Frenchresidents of the communities where they were located. When we took oversuch a formation it was necessary either to lease neighboring quartersfor our personnel or to diminish its bed capacity by quartering them ina part of the hospital itself. As explained more fully in Chapter XVI,the bed capacity of our base hospital
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in order to compensate to a degree for the low percentage of MedicalDepartment personnel authorized on the priority schedule by the generalstaff, had been increased to 1,000 and made capable of expansion in emergenciesto double that size.14 It was recognized from the outset thatonly under unusual circumstances could French hospitals be used to advantage,except to meet transient needs or to form a nucleus around which barrackextensions could be constructed. Practically all of those which were transferredto our service were much increased shortly after they came under our control.13FIG. 59.-General layout, hospital unit, typeC (convalescent camp), 2,000 beds
Therefore, in attempting to meet hospitalization requirements, medicalofficers charged with the procurement of buildings quickly turned to theadap-
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FIG. 60.-Administration and clinic building, hospital unit, type C
tation of suitable buildings. These, however, were comparatively few,most of them having been preempted by the French or by her allies, Belgium,Italy, and Portugal, and were being utilized either for hospital purposesor as habitations for French and Belgian refugees.13 Many wereoccupied by Red Cross and other volunteer aid societies from all partsof the world. Under these circumstances, when the United States enteredthe field it was found that the majority of possible hospitals discoveredor offered were lacking essential and rudimentary hospital facilities orpotentialities.13 Common defects were inaccessibility, poorstate of repair, lack of sanitary plumbing, small size and wide dispersionof buildings. Nevertheless, anticipating the arrival of large bodies oftroops from the United States necessitated the procurement of existingbuildings. This was pushed to the utmost, though most buildings taken overrequired alterations, additions, and repairs in order to make them suitablefor hospital use.13 On September 27, 1917, the chief surgeon,A. E. F., reported in some detail the difficulties which would be encounteredin adapting existing buildings to hospital needs. On the 17th of the followingmonth he wrote the Chief of Staff as follows:15
It is recognized that in the present emergency anythingthat offers shelter for patients must be used. However, the use of suchbuildings as the French have offered can be considered only as an emergencymeasure and in no wise meets, from our point of view, the demands for adequatehospital facilities.
Among the buildings taken over were school buildings, hotels, chateaux,barracks, factories, and even stables. School buildings, as a rule, wereamong the earliest buildings utilized.13 Almost invariably theywere unsatisfactory; few had running water, sewer connections, or toiletfacilities. Under the French law, when schools were requisitioned for militarypurposes the teaching personnel, which were furnished living quarters inthe building, had to be allowed to
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FIG. 61.-Officers'quarters and mess hall, hospital unit, type C
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FIG. 62.-Standard barrack, hospital unit, type C
retain them.2 The result was that in the same buildings therewould be wards for patients, quarters for personnel, and living quartersfor French civilians-arrangements that were inevitably unsatisfactory toall concerned.
Objections to the use of hotels as hospitals rested on other grounds.13As practically all the best and most suitably located buildings of thisclass had been taken over by the allied governments, those available werevery largely summer hotels without heating facilities. Usually, they hadinsufficient water and very limited plumbing, and they required many alterationsbefore they were suitable for hospital purposes. Also the rate of rentalswas very high. In addition, when a private building was taken over formilitary purposes the owner was allowed by law to reserve certain partsof the building; also the law required that a building should be returnedto the owner in the same condition as when taken out of his control.2The latter provision necessitated refurnishing these structures at highcost and removing all improvements or additions which might have been installed.Furthermore, they were difficult to administer and extravagant in theirrequirement of personnel.
With many differences in detail, the difficulties incident to the useof other buildings were comparable to those pertaining to hotels. Barracks,because of their large ward space, were more easily administered, generallyspeaking, than the hospital established in other preexisting structures.13
When we desired an existing French hospital, or buildings being utilizedby the French as a hospital, a representative of the chief surgeon inspectedit and if it was deemed suitable, a request by letter was made upon theFrench for its transfer to the American Expeditionary Forces, through thechief of the mission attached to headquarters of the American ExpeditionaryForces.2 The date of transfer was decided upon and the Frenchthereupon notified us when we could take control. As a rule, the MedicalDepartment of the American Expeditionary
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Forces usually took over in these buildings all the hospital propertythat was still serviceable.2
Careful inventories, which included the conditions of buildings andlists of the property contained therein, were prepared by representativesof the American and French Armies, acting jointly.2 These inventorieswere prepared in quadruplicate and each interested party was furnisheda copy. Record of these transactions was maintained in the chief surgeon'soffice, A. E. F. From this beginning gradually developed the service laterknown as "rents, requisitions, and claims," which later took charge ofall such transactions and became the custodian of these records.2The personnel of the chief surgeon's office which had been gathered togetherfor this purpose was transferred to that service when it was officiallyput into operation.FIG. 63.-Kitchen,hospital unit, type C
The acquisition of schools, hotels, and other buildings not previouslyoccupied as hospitals was accomplished through leases obtained generallythrough a local representative of the French Army.2 Rarely wasit necessary to resort to military requisition, although in a few isolatedcases this proved necessary.2
Securing private buildings was not unattended with great difficulty;on the contrary, much opposition was encountered even after they becameavailable to us. Endless bickerings with proprietors and directors ledto almost endless correspondence which could result only in the greatestamount of delay in making the buildings over into hospitals.16
In July, 1918, when our hospitals in France provided beds for but 5.7per cent of our troops there, the French were asked for buildings sufficientfor 45,000 beds, because of the difficulties in the way of construction.16The beds requested were to be in buildings located either on our line ofcommunications or, if not there obtainable, then in the more remote partsof France. The central bureau, Franco-American relations, which controlledall such requests, unofficially
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FIG. 64.-Quartermasterbuilding, hospital unit, type C
FIG. 65.-Shopsand disinfector building, hospital unit, type C
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FIG. 66.-Laundrybuilding, hospital unit, type C
FIG. 67.-Dininghall, hospital unit, type C
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FIG. 68.-Bathhouse, hospital unit, type C
FIG. 69.-Venerealand skin clinic, hospital unit, type C
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FIG. 70.-Perspectiveof a Bessonneau tent in a two-tent unit
FIG. 71.-Perspectiveof a Bessonneau tent, showing framing and double walls
FIG. 72.-Planof a two-tent (Bessonneau) ward
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FIG. 73.-Showing heating arrangements in a Bessonneau tent
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FIG. 74.-Perspective of a marquee tent, showing a unit of three tents
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FIG. 75.-Plan of a marquee tent ward of three tents
FIG. 76.-Showingheating arrangements in a marquee tent ward
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FIG. 77.-Perspective of closet in a marquee tent ward, showing construction
FIG. 78.-Planof a two-tent ward, United States hospital ward tent
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answered all the requests made by furnishing lists of buildings thatwere quite different from those desired, thus necessitating our rejectingmany buildings as being unpractical for our purposes.17 Becauseof the urgency of the situation, General Pershing addressed the Premierof France as follows
GENERAL HEADQUARTERS,
AMERICAN EXPEDITIONARY FORCES,
France, August 16, 1918.
Monsieur GEORGES CLEMENCEAU,
President du Conseil, Paris.
MY DEARMR.PRESIDENT: General Ireland, thechief of our Army Medical Service, has brought to my attention the vitalneed of extra hospital facilities, which we must have as soon as possible.At present we have at the most but 6 per cent of beds for our troops inFrance, and it is agreed that 10 per cent is the lowest safe margin. Inview of the increased program of troop arrivals, it will be impossiblefor our hospital construction to keep pace with the influx of troops, sothat it is necessary to call on your people for an increasingly large amountof hospital space in buildings already constructed. On July 13 a requestwas made for 45,000 beds in buildings either on our line of communicationsor, if this were impossible, in the more remote parts of France, and aspecific request has been made for various hotels, schools, and militarybarracks which have been inspected by our medical officers. A copy of thislist is herewith attached, with the addition that we have made a requestfor and need the École de Legion d'Honneur at St. Denis.
In accordance with instructions No. 9 of February 12,from the office of the Undersecretary of State, these questions have beenhandled entirely with the central office of the Franco-American relationsin Paris. General Ireland informs me, however, that he fears that it willbe impossible to get the quick action needed. Experience has shown thatany specific request for buildings which have been inspected by our medicalofficers are usually met by a counterproposition which, after a certainlength of time, has been made to the American officers in charge of thiswork. May I not suggest that the central bureau of Franco-American relationshasten to make inspections of a number of buildings suitable for hospitalswith a view of meeting, without delay, the increasing necessity for largelyincreased accommodations for our sick and wounded? Just now, time is theall-important factor, and anything you may be able to do to enable us tomeet our early requirements will be most highly appreciated.
I regret having to bother you with this matter, but inview of its importance I bring it to your attention, knowing well thatwith your powerful assistance we will achieve the results that we desirein the quickest possible time.
Permit me to express my thanks for the splendid effortsmade by your officials to aid us in every way.
With highest personal and official regards, believe me,
Very sincerely yours,
(Signed) JOHN J. PERSHING.
At the instance of the Premier, the French mission now submitted a list of public buildings which, it was stated, had been reserved for the American Medical Service.18 The French Government wished to divide equally the burden of hospitalization among the territorial departments and among the different classes of buildings in the departments. Long lists of buildings were sent at intervals to the chief surgeon through the French mission, but for various reasons (such as the delapidated condition of some of the buildings, their small size, their remote location) many buildings included in these lists had to be rejected.13 Buildings thus offered fell, in the main, into four classes: Military casernes, public or private hotels, schools, and miscellaneous buildings which comprised factories, storehouses, etc. The amount of buildings thus
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offered potentially represented beds to the number of 155,422.13Possible accommodations for many more had been taken over by us, but thesewere found unnecessary after the armistice had been signed.
After the signing of the armistice the buildings which had been acceptedfrom the French on November 11 were returned with the exception of oneat Lucon,19 but procurement of buildings continued for severalweeks in order to provide hospital facilities in new locations conformableto the new conditions which arose by the armistice.15
On November 27, in reply to a request for a conference concerning relinquishmentof buildings used for hospital purposes, the commanding general, Servicesof Supply, wrote the commissioner general for Franco-American war affairsas follows:20* * * * * * *
2. Owing to the indefinite information regarding the militarysituation at present, it is not believed that a conference on this subjectshould be undertaken at this time, but this can be undertaken as soon asa definite plan of demobilization of the American Expeditionary Forceshas been made.
3. Although a reduction of the necessity for hospitalizationhas been made from 15 per cent to 7½ per cent, since November 11,yet this reduction comes at a time when there are approximately 190,000patients in hospitals, and we can not operate upon the lesser figure untilthese cases are returned to duty with their units or evacuated to States.
4. All offers of buildings made on the various lists havebeen definitely accepted or rejected. Since August 1 these have amountedto approximately 125,000 beds, of which approximately 51,000 have beenaccepted and approximately 74,000 rejected. Since this time many buildingsthat have been accepted have been returned through the French mission asbeing necessary for hospitalization, and from time to time many otherswill be returned when it is definitely ascertained that they will not beneeded and that no troops will be located in the localities concerned.
5. Your attention is called to the fact that every considerationhas been given to disturbing schools as little as possible, that whereverpossible schools have been evacuated and returned, and this plan will becontinued. Attention is also called to the fact that it will be only necessaryto requisition buildings in those localities where troops may hereafterbe stationed and where no buildings exist. This number will be reducedto a minimum.
6. Regarding the matter of deoccupation of the older establishmentsobtained during the early part of the American occupation, attention iscalled to the fact that considerable construction in barracks, or watersupply, electric lighting, sewers, roads, drainage, etc., has been done,and it is believed that on this account these should be retained untilthe last to be evacuated.
7. It will not be necessary to requisition buildings notalready in process of organization, but it is desired to occupy many hotelson the Mediterranean and in the Pyrenees, in which it is expected to treatconvalescents. These properties were obtained through amicable lease inthe main. But few requisitions were made, and their retention is in themain agreeable to the owners. In other localities no buildings have beentaken or will be taken where hospitals have not been organized and operated.REFERENCES
(1) Wadhams, S. H., Col., M. C., and Tuttle, A. D., Col.,M. C.: Some of the early problems of the Medical Department, A. E. F. The Military Surgeon, 1919, Washington,D. C., xlv, No. 6, 636.
(2) Report of activities of G-4-B, medical group, generalstaff, G. H. Q., A. E. F., December 31, 1918, by Wadhams, S. H., Col.,M. C. On file, Historical Division, S. G. O.
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(3) Letter from the chief surgeon, A. E. F., to the chiefengineer, A. E. F., September 17, 1917. Subject: Design for a 1,000-bedcrisis expansion, A. E. F., Army Hospital, Type A. Copy on file, A. G.O., World War Division, chief surgeon's files (322.32911).
(4) Plans on file, Record Room, S. G. O., 632 (A. E. F.,France).
(5) Letter from the chief surgeon, A. E. F., to the SurgeonGeneral, U. S. Army, March 28, 1919. Subject: Plans for hospitalization.On file, Record Room, S. G. O., 632 (A. E. F., France).
(6) G. O. No. 46, H. A. E. F., October 10, 1917.
(7) G. O. No. 58, G. H. Q., A. E. F., April 18, 1918.
(8) Letter from the chief surgeon, A. E. F., to the chiefengineer, A. E. F., September 30, 1918. Subject: Plan of type B (300-bed)camp hospital unit. Copy on file, A. G. O., World War Division, chief surgeon'sfiles (329.32914).
(9) Memorandum for the assistant chief of staff, G-4,G. H. Q., A. E. F., from Col. S. H. Wadhams, G. S., May 24, 1918. Subject:Hospitalization. Copy on file, Historical Division, S. G. O.
(10) Memorandum for the commanding general, Services ofSupply, A. E. F., from the assistant chief of staff, G-4, G. H. Q., A.E. F., June 1, 1918. Copy on file, Historical Division, S. G. O.
(11) Report on hospitalization and evacuation of sickand wounded, for the military board of Allied supply, April 10, 1919, byBrig. Gen. J. R. Kean, M. D. Copy on file, A. G. O., World War Division,chief surgeon's files (314.7).
(12) Memorandum for the chief of staff from the chiefof operations section, General Staff, G. H. Q., A. E. F., August 11, 1917.Subject: Hospitalization. On file, A. G. O., World War Division (632).
(13) Report of the activities of the chief surgeon's office,A. E. F., from the arrival of the American Expeditionary Forces in Europeto the armistice, by the chief surgeon, A. E. F., March 20, 1919. On file,Historical Division, S. G. O.
(14) Memorandum for the chief engineer, A. E. F., fromthe chief surgeon, A. E. F., September 20, 1917. Copy on file, HistoricalDivision, S. G. O.
(15) War diary, chief surgeon, A. E. F.
(16) Letter from the commander in chief, A. E. F., tothe chief of French Mission, Tours, July 13, 1918. Subject: Hospitalization.On file, A. G. O., World War Division, chief surgeon's files (322.32911).
(17) Letter to M. Georges Clemenceau, President du Conseil,Paris, from General Pershing, August 16, 1918. Subject: Hospitalization.On file, A. G. O., World War Division, chief surgeon's files (322.3291).
(18) Memorandum for the assistant chief of staff, G-4,S. O. S., from the chief surgeon, A. E. F., August 13, 1918. Subject: Hospitalprogram, A. E. F. On file, A. G. O., World War Division, chief surgeon'sfiles (322.32911).
(19) Letter from the chief surgeon, A. E. F., to the chief,French Military mission, S. O. S., November 23, 1918. Subject: Hospitalization.Copy on file, A. G. O., World War Division, chief surgeon's files (329.32911).
(20) Letter from the commanding general, S. O. S., A.E. F., to the commissioner general, Franco-American war affairs, November27, 1918. Subject: Hospitalization. Copy on file, A. G. O., World War Division,chief surgeon's files (329.32911).
