SECTION I
PROCUREMENT
CHAPTER I
EVOLUTION OF HOSPITAL PROCUREMENT METHODS
PRE-WAR PROCUREMENT
The Surgeon General personally authorized all hospital projects and approved all preliminary or sketch plans,1 often as the result of conferences in which other officers of his staff joined. Three or four clerks, draftsmen, were employed in sketching preliminary plans for new hospital buildings. These preliminary plans, with supporting data, were furnished the Quartermaster General, to be used by him as a basis for the completed plans prepared in his office.2 Frequently necessary changes were made in the preliminary plans by the Quartermaster General, in which event they were returned to the Surgeon General for his approval. Specifications were likewise prepared by collaborating with the Quartermaster General`s Office. Complete prints and specifications were finally approved by the Surgeon General and returned to the Quartermaster General, together with a request for construction.3
Funds for the construction of hospitals were secured from Congress4 as an appropriation specifically termed-
Construction and repair of hospitals: For construction and repair of hospitals at military posts already established and occupied, including extra duty pay of enlisted men employed on the same, and including also all expenditures for construction and repairs at the Army and Navy Hospital at Hot Springs, Arkansas, and for construction and repair of general hospitals and expenses incident thereto, and for activities to meet the requirements of increased garrisons.
Difficulty had been experienced in securing the complete construction of Army hospitals with money thus appropriated. This was due to the fact that several other appropriations, in addition to that for construction and repair of hospitals, were required to install electric fixtures, sewerage, cooking ranges, and, in large hospitals, the additional construction of barracks, quarters, roads, walks, etc. Even though ample funds were provided for the erection of buildings, occupancy could not be effected unless funds existed in at least three other appropriations to cover expenditures for electric fixtures, sewers, etc.
The average yearly appropriation under "Construction and repair of hospitals," for the 10 years prior to the war, was $400,000, of which, as a rule, 55 per cent was used for repair and 45 per cent for new construction.5
Funds for the construction of hospital stewards` quarters were secured under separate, appropriate headings.6
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WARTIME ORGANIZATION FOR HOSPITAL PROCUREMENT
The preliminary study of the hospital problem, as applied to our Army after the declaration of war, was made the duty of an officer of the Medical Corps, especially detailed to the Office of the Surgeon General for that purpose because of his broad experience with the larger type of military hospitals.
Early in July, 1917, a hospital division was created in the Surgeon General`s Office, under the officer mentioned, which was charged with the responsibility of producing hospital space in the United States for the cantonments of the National Army and encampments of the National Guard, and general and special hospitals for the care and treatment of sick and wounded from overseas, as well as those from numerous camps, requiring special or prolonged treatment.7
There were 32 mobilization camps each of which required a large hospital.8 Inasmuch as the first divisions of the new National Army were scheduled for mobilization in the early fall of 1917, it was essential to proceed rapidly with the development of preparations for the establishment of hospitals at the various camps of these divisions. At the same time plans had to be formulated for the provision of hospitals for the sick and wounded from overseas. That these latter hospitals would be numerous became early apparent from the experiences of the British and French.
It was finally decided that provision would have to be made for 5 per cent casualties and 2 per cent sickness, the percentage referring to the total number of troops overseas and indicating the number estimated to require treatment and care on their return to the United States. This would make a total of beds equal to 7 per cent of the expeditionary troops. It was assumed that a turnover could be made, on the average, every six months, and a 3? per cent basis was adopted as a required number of beds for returning sick and wounded.9 As the United States had been divided into 16 draft districts, the policy was adopted of providing in each draft district the number of hospitals and beds to be proportionate to the number of men inducted from each district. For obtaining these hospital facilities various methods were used.
The Council of National Defense classified the hospitals of the United States as to size, convenience to railroad, equipment, facilities for expansion, and arrangements for handling special work. Tuberculosis sanitaria and dispensaries were inventoried and a survey was made as to hospitals for convalescents. Offers of private houses and other larger buildings, tendered to the Surgeon General for use as military hospitals, were classified and tabulated for the Surgeon General`s use.10
After due consideration, it was decided that the use of civil hospitals for the care and treatment of troops was not feasible because of the uncertainty of the supply of beds, the impracticability of taking over entirely civil hospitals in sufficient number without creating hardship on the civil population, and the difficulty in operating a military and civil organization in the same institution. The Surgeon General concluded that a program must be developed for obtaining a sufficient number of hospitals absolutely under military control, and proceeded to develop that program.
At the beginning of the fiscal year 1917-18, the plans prepared for the hospitals for the National Army and the National Guard divisions were being turned over to the Quartermaster Department for execution. Due to the
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antiquated printing apparatus in the construction branch of the Surgeon General`s Office, there was some delay incident to the printing of large numbers of plans requisite for erection purposes in the field, and it was necessary to run the printing machine 21 hours per day for weeks and demand overtime labor, on the part of the civilian employees concerned, with no increase of pay possible. Therefore a modern, motor-driven press and a motor-driven gas-heater drier were installed. The majority of the printing firms were well behind on work orders and in consequence could not be depended upon. In the preparation of these plans, medical officers, representing the various specialties, such as surgery, medicine, laboratory, were consulted, and, in so far as time, necessary construction, standardization, and funds permitted, plans were prepared to embody the essential features desired. These features were included with other usual hospital features and activities, and a general plan was evolved for the typical 1,000-bed hospital. A 500-bed hospital was planned by a similar process. In order to standardize equipment, materials, personnel, construction, and administrative requirements, it was thought best to accomplish this, and the 1,000-bed and the 500-bed hospital types were considered as more nearly approximating the majority of the proposed perfected features. The 500-bed hospital differed from the 1,000-bed hospital not only in number of wards, which were of the same type, but in the size of the administration building, receiving building, general mess hall, kitchen, and other service buildings.11
During the execution of this planning work, considerable expansion occurred in the section of the Office of the Surgeon General charged with it. At the beginning five civilian employees were engaged in the work, under the supervision of one officer, who had other activities as well, and the section functioned directly under the officer in charge of the Hospital Division. It was necessary at this period to increase the drafting force. This was rendered difficult because the Civil Service Commission was unable to supply draftsmen, and the law did not permit the Medical Department to employ draftsmen except at a very low wage. To overcome this impediment, in a measure, architects, versed in hospital design and construction, or in military procedure, were commissioned in the Sanitary Corps, for supervisory duties.12 By considerable effort and after extended delays, the drafting and designing force was organized and the hospital plans were studied and revised as occasions demanded.
The difficulty incident to securing complete construction of Army hospitals from congressional appropriations, as they were made previous to the war, was overcome by adding the following phrase for incorporation into the enactment:
* * * and for temporary hospitals in standing camps and cantonments. For the alteration of permanent buildings at posts, for use as hospitals, construction and repair of temporary hospital buildings at posts for use as hospitals, construction and repair of temporary hospital buildings at permanent posts, construction and repair of temporary general hospitals, rental or purchase of grounds and rental and alteration of buildings for use for hospital purposes in the District of Columbia and elsewhere, for use during the existing emergency, including necessary temporary quarters for hospital personnel, outbuildings, heating and laundry apparatus, plumbing, water and sewers, and electric work, cooking apparatus, and roads and walks for the same.13
In the latter part of the year 1917, the necessity for closer cooperation between the Surgeon General`s Office and the Construction Division, War Department, became apparent to both bureaus, and as a result a hospital
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section was organized in the latter. At this time about 250 hospital construction projects were in the Construction Division, and the number was rapidly increasing. The creation of a hospital section in the Construction Division14 proved to be an excellent innovation, most advantageous to all concerned, and eventually it grew to a considerable size.
Upon the organization of the Hospital Division of the Surgeon General`s Office one of its sections was designated the procurement section.15 Prior to that time the branch in charge of construction had not been concerned with the leasing or investigation of properties suitable for hospital purposes. Subsequently, however, all activities relating to the acquisition of places for hospital uses were initiated and followed up by the procurement section, necessitating the assignment of additional medical officers and architects to it from time to time. Its functions16 were to determine requirements for hospital space; to secure adequate congressional appropriations; to locate and procure hospital space by lease; to make preliminary plans; to make request for new construction; to pass upon the requests for hospital space from War Department representatives in the field; to authorize allotments from the appropriations made by Congress for the construction and repair of hospitals and quarters of hospital stewards.
In June, 1918, the planning subsection was physically placed in the Construction Division of the War Department.17 This was done to obtain better liaison with the engineering and building activities and to economize in time. An officer from the Office of the Surgeon General was assigned to duty as liaison officer and to follow up projects which had been initiated.18
After the necessity for hospital construction was determined in the Office of the Surgeon General, and the plans therefor completed in the Construction Division, in collaboration with the construction branch of the Surgeon General`s Office, estimates for necessary funds, with a request that their expenditure be authorized, were made and sent to the War Industries Board,19 through the Purchase, Storage, and Traffic Division, General Staff, for clearance.20 After clearance by the War Industries Board, they were returned through the Purchase, Storage, and Traffic Division to the Operations Division, General Staff, for the approval of the Secretary of War,20 after which they were returned to the Construction Division, whence they were sent to the field for execution.
PROCUREMENT OF EXISTING BUILDINGS FOR HOSPITAL PURPOSES
The spirit of patriotic service which swept the country prompted many persons to offer their properties to the War Department for hospital purposes. These offers included buildings of every conceivable kind, such as lofts, department stores, sanatoria, private establishments, hospitals, and private homes.21 Upon investigation, it was found that many of these could be utilized with advantage and could be obtained and converted into hospitals much more expeditiously than barrack hospitals could be constructed, and at less cost. Therefore, dependence was placed in the greatest degree upon these sources of supply, though many of the buildings offered required extensive remodeling and additional construction.
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When it was desired to lease a building, the Surgeon General requested the Quartermaster General to lease a specific property. Authorization was obtained from the Secretary of War, after which the approved lease was transmitted, by the Quartermaster General, to a local quartermaster, for accomplishment.22 In August, 1918, this time-consuming routine was changed by the organization of a real-estate unit in the General Staff.20 From that time on requests emanating from the Office of the Surgeon General, for the leasing of property, were forwarded directly to the General Staff, which, within its divisions, conducted investigations, authorized expenditures, and executed leases.
When it was desired to establish a hospital in a building which required leasing and then had to be altered, after the lease had been accomplished, the routine was proceeded with as though new construction were being provided.
As a rule, from two to six months were consumed in the establishment of large hospitals, representing the time between that when a request for a lease was forwarded from the Surgeon General`s Office, and the completion of any alteration work and the opening of the hospital for the reception of the sick. This necessitated the initiation of projects at a date from two to six months prior to anticipated needs. It was highly desirable that the method be simplified to save time, for during 1918 there was a progressively rapid increase in troop movement overseas.
The increase in the active operations at the front portended an influx of sick and wounded into the hospitals of the United States; and to hasten the acquisition of a greater amount of general hospital space, the following plan was instituted:21 Two groups of officers were formed, each consisting of a representative of the real-estate section of the Purchase, Storage, and Traffic Division of the General Staff, the Construction Division, and the Office of the Surgeon General. The duties of these groups were to investigate properties in the large cities; one for the eastern section of the country and one for the western. Upon the recommendation of the Surgeon General, the Secretary of War, on September 21, 1918, authorized the groups to close leases where rentals would not exceed $250 per bed per annum; and to authorize necessary funds for alteration purposes, provided each project would be cleared by the regional adviser of the War Industries Board and, further, that the three members of the group of officers were unanimous in their opinions.21 When the described condition could not be effected the project required separate action in the War Department.
Under the changed routine, hospital procurement progressed rapidly. Upon the execution of a lease and after the expenditure of funds for alterations had been authorized, the War Department was at once notified.
To take up the work on projects where these groups stopped, other groups, consisting of an officer versed in Medical Department requirements, from the procurement section of the Surgeon General`s Office, together with assistants from the hospital section of the Construction Division, War Department, went to the site and, collaborating with the local quartermaster, completed the plans.23 Definite knowledge was at hand as to when the conversion might be expected to be completed which permitted the advanced assemblage of per-
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sonnel for the organization of the hospital and utilization of the hospital for patients at a much earlier date. It was found that work progressed smoothly and rapidly; uncertainty was largely eliminated; and arrangements, covering many details, could be completed locally without undue loss of time.
REFERENCES
(1) A. R. 1465, 1913.
(2) A. R. 1000, 1913.
(3) A. R. 1468, 1913.
(4) Bull. No. 30, W. D., May 22, 1917.
(5) Table compiled from Annual Reports, Quartermaster General, 1907 to 1916. On file, Record Room, Surgeon General`s Office, Correspondence File 632.1 (General).
(6) Bull. No. 30, W. D., May 22, 1917.
(7) Annual Report of the Surgeon General, U. S. Army, 1918, 304.
(8) Ibid., 305.
(9) Ibid., 306.
(10) Report of the Chairman of the Committee on Medicine and Sanitation of the Advisory Commission of the Council of National Defense, Washington, April 1, 1918, 23.
(11) Annual Report of the Surgeon General, U. S. Army, 1918, 317.
(12) Ibid., 318.
(13) Bull. No. 43, W. D., July 22, 1918.
(14) Annual Report of the Surgeon General, U. S. Army, 1918, 319.
(15) Ibid., 308.
(16) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1141.
(17) Annual Report of the Surgeon General, U. S. Army, 1918, 319; and 1919, Vol. II, 1142.
(18) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1142.
(19) Second Annual Report of the Council of National Defense, for the Fiscal Year Ended June 30, 1918, 117.
(20) G. O. No. 80, W. D., Aug. 26, 1918.
(21) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1144.
(22) A. R. 1046, 1913.
(23) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1145.
