CHAPTER II
Planning for and Expanding Hospitals in the United States
Hospital Construction
Early Basic Decisions
Any large-scale expansion of "hospital facilities"-thatis, wards, offices, and clinics normally found in civilian hospitals, plushousing for commissioned and enlisted personnel, storage for medical andmilitary supplies and equipment, and administrative space for nonmedicalmilitary activities-demanded a simple method of estimating requirements andauthorizing beds. Such expansion also demanded that additional housing beprovided as rapidly and inexpensively as possible.
The method prescribed by mobilization regulations forestimating bed requirements was one that Colonel Love had devised from World WarI experience. It involved computation of the number of beds needed forsuccessive 15-day periods of mobilization on the basis of average dailyadmission rates, the rate of accumulation of patients in hospitals by 15-dayperiods, and increases and decreases in troop strengths during these periods.When hospitals were expanded for the September 1939 increase in the Army, thismethod proved too complicated for general use and The Surgeon General included in his ProtectiveMobilization Plan of December 1939 a simpler one, also devised by Colonel Love-themultiplication of troop strength by a predetermined percentage of beds. InAugust 1940 G-4 adopted the latter, and its simplicity made its readyacceptance by all agencies of the War Department a foregone conclusion.1
Opinion differed on the proper percentage to use in estimating and authorizingstation hospital beds. The Surgeon General used 4 percent in calculatingrequirements in the fall of 1939, and G-4 began to use this figure in planningfor mobilization in August 1940. Experience of the previous winter made somesurgeons believe it provided insufficient beds for "green troops,"2 and on 6 September 1940 General Magee asked theGeneral Staff to consider 5 percent as the probable
1(1) Albert G. Love, "War Casualties," Army Medical Bulletin, No. 24 (1931), pp. 18, 37, 38, 68.(2) MR 4-3, 2 Apr 34; MR 4-2, 13 Feb 40; and SG PMP 1939, Annex No 29. (3) Ltr AG 600.12 (8-6-40)M-D-M,TAG to C of Arms and Servs, CGs of CAs, and COs of Exempted Stas, 7 Aug40, sub: Supp No 2 to WD Cons Policy. SG: 600.12-1.
2(1) Synopsis Ltr, Surg 4th CA to SurgFt McClellan, 13 Aug 40, sub: Expansion of Hosp Fac, and 8 inds, SG: 632.-1(Ft McClellan) N. (2) Ltr, Surg 7th CA to SG, 10 Sep 40, sub: Hosp .. . NG. SG: 632.-1 (7th CA)AA.
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requirement for station hospital beds.3 G-4'sConstruction Branch verbally approved this ratio, but the Assistant Chief ofStaff, G-4, Brig. Gen. Richard C. Moore, later reversed this action,authorizing station hospital beds for only 4 percent of the strength served butpermitting provisions for expansion to 5 percent if necessary.4 Thismeant in the case of new hospitals that wards would be constructed with spacefor beds for 4 percent of a command but that utilities, administrativebuildings, and clinical facilities would be constructed to serve a hospital withbeds for 5 percent. Thus additional wards could be erected later withoutoverloading the "chassis" of a hospital. The ratio of beds in generalhospitals to the total strength of the Army-1 percent-received officialsanction at the same time. General Magee did not protest the decision as tostation hospitals but observed a policy during the following year of supportinglocal requests or initiating action for increases in bed ratios in specificinstances.5
The manner of providing additional housing was a subject onwhich The Surgeon General and the General Staff eventually came to markeddisagreement. Based on a belief that unnecessary construction should be avoidedand a fear that sudden attack would require mobilization before requisiteconstruction could be completed, War Department policy in 1939 was to useexisting housing to the maximum extent possible.6 Mobilizationregulations therefore called for the use of existing Army hospitals, withemergency expansions, for the initial beds required. To house additional bedsother buildings would be used in the following order: (1) Federal hospitals, (2)civilian hospitals, (3) vacated Army posts, and (4) public and private buildingssuch as schools and hotels. Finally, as a last resort, new station and general hospitals would beconsructed.7
For all new buildings theWar Department planned to use one-story frame construction, called"cantonment-type." It required The Quartermaster General to keep onfile standard plans for such buildings.8 Those for hospitals had beenprepared in 1935 in collaboration with The Surgeon General's HospitalConstruction and Repair Subdivision. They consisted of forty-nine drawings:forty-five for administrative offices, clinics, wards, messes, quarters forpersonnel, and service buildings, and four for twenty different combinations ofthese buildings to make hospitals ranging in size from 25 to 2,000 beds. Most ofthe buildings were of a standard size. To reduce the danger of fire, all wereseparated by a minimum of fifty feet. For each group of not more than five, thisspace was increased to 100 feet. Each hospital therefore covered a large area, a500-bed installation spreading over twenty acres. Advantages of this hospitalwere its relatively low cost, the rapidity with which it could be erected, andthe small number
3Ltr, SG (Magee) to TAG, 6 Sep 40, sub: MD in Mob. AG: 381 (1-1-40)Sec 3.
4(1) Memo, SG for ACofS G-4 WDGS, 10 Sep 40. (2) D/S, ACofS G-4WDGS to SG, 13 Sep 40, sub: Hosp. . . Mob. . . . (3) Memo, Cons BrG-4 WDGS for Maj Gen [Eugene] Reybold, 7 Mar 41, sub: Four Percent Hosp. All inHRS: G-4/29135-12.
5(1) Synopsis Ltr, CG Ft Jackson toTAG, 11 Dec 40, sub: Cons Sta Hosp, and 4 inds. SG: 632.-1 (Ft Jackson) N. (2) 5th ind, Surg Ft Sill to CG 8th CA, 12 Mar 41, on cy Ltr, CG FtSill to TAG, 10 Dec 40, sub: Add Hosp, Ft Sill. SG: 632.-1 (Ft Sill) N. (3) LtrSG to TAG, 27 May 41, sub: Add Hosp Fac. . . SG: 632-1. (4) Ltr, CG 4th CA to TAG, 1 May 41, sub: Add HospBed Reqmts, and 11 inds. SG: 632.-1 (4th CA) AA.
6The War Department Mobilization Plan, speech by Lt Col HarryL. Twaddle, GSC, Chief Mob Br G-3 Div WDGS, 30 Sep 39. G-3 Course No 13 and13A, AWC, 1939-40.
7MR 4-3, 2 Apr 34; MR 4-3, C-l, 31 Dec 34; and MR 4-2,13 Feb 40.
8MR 4-1, Sup; Cons; Trans, 5 Jan 40.
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of highly skilled workmen needed to construct it. Its mostobvious disadvantages were the danger of fire and the administrativedifficulties caused by the wide area covered.9
The hospital construction policy enunciated in mobilizationregulations was not made the official guide for the provision of hospitals forRegular Army expansions in 1939 and 1940, but certain aspects of it werefollowed. Thus, although apparently no attempt was made to use non-Armybuildings, existing Army hospitals were expanded and new construction wasauthorized only at stations not served by such. For example, essential units ofa 350-bed cantonment-type hospital-a mess hall, a clinical building, andseveral wards-were constructed at Camp Jackson (South Carolina), a NationalGuard encampment. Regular Army posts which already possessed hospitals, such asFort McClellan (Alabama) and Fort Benning (Georgia), expanded them by convertinghospital porches, barracks, and other available buildings into hospital wards.10In 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, toserve a strength of 19,000 in January 1940. He did this by adding 334 beds inporches, barracks, and a portable wooden building. The operating rooms, clinics,laboratory, and mess halls of the permanent hospital were then too small for thegreater bed capacity. Thus there was created, he explained, "a relativegiant with inadequate heart and internal viscera."11
Despite this experience, in the spring of 1940 G-4 plannedto establish the practice of expanding existing hospitals as official policy forsubsequent increases in the Regular Army. Both The Surgeon General and TheQuartermaster General opposed this move. Among the many objections they raised, probablythe most important from the medical viewpoint was the one just noted-limitsupon expansion of bed capacity imposed by the size of operating rooms andclinical facilities. Of equal importance, from the construction viewpoint, wasthe unsuitability of many barracks for hospital use because of their location orstructural characteristics. Moreover, it was improbable that their conversionand eventual reconversion would be cheaper in the long run than the erection ofcantonment-type hospitals. On 24 May 1940, therefore, Colonel Love, Acting TheSurgeon General, recommended that all additional beds should be housed in newcantonment-type hospitals. G-4 disapproved this recommendation, perhapsbecause of shortages of funds and uncertainty about the nature of increases inthe Regular Army, and on 7 June 1940issued an official "Policy for Hospitalization during the Emergency."It authorized cantonment-type hospitals for new stations but required theexpansion of existing hospitals on all Regular Army posts.12
9(1) Floyd Kramer, "Mobilization Type Hospitals," ArmyMedical Bulletin, No. 31 (1935), pp. 1-19. (2) Tynes, Construction Branch,HD.
10See correspondence in SG: 632.-1 (Cp Jackson)D. 632.-1 (FtMcClellan)N, and 632.-1 (Ft Benning)N.
11Ltr, Surg Ft Benning to SG, 19 Jan 40, sub: An Rpt of StaHosp. SG: 632.-1 (Ft Benning)N
12(1) Memo, Exec Off G-4 for Cons BrG-4 WDGS, 22 May 40, sub: Hosp. (2) Memo QM 600.1 C-C, QMG for ACofS G-4 WDGS,28 May 40, sub: Util of Bks for Temp Hosp Accommodations. (3) Memo, Act SGfor ACofS G-4 WDGS, 24 May 40, sub: Hosp for Increase in the Army above 227,000.(4) Memo, Chief Cons Br G-4 for ACofS G-4 WDGS, 3 Jun 40, sub: Util of Bks forTemp Hosp Accommodations. (5) Memo, Chief Cons Br G-4 for ACofS G-4 WDGS, 5Jun 40, sub: Hosp for Increases of Army. (6) Ltr AG 705 (6-5-40)M-DM, TAGto CGs of all CAs, COs of Exempted Stas, and CofArms and Servs, 7 Jun 40, sub:Policy for Hosp during Emergency. All in HRS: G-4/31757.
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PLAN FOR CANTONMENT-TYPE HOSPITAL
The inapplicability of this policy soon became apparent. Forexample, despite a recommendation by The Surgeon General that a 550-bedcantonment-type hospital be constructed for Camp Ord, G-4 directed on 6 June1940 that the camp continue to use an expanded hospital at the Presidio ofMonterey. The Surgeon, the Quartermaster, and G-4 of the Ninth Corps Areaopposed this decision. They pointed out that the hospital and barracks atMonterey did not have enough total space to accommodate all the beds needed andthat some cantonment-type construction would be necessary. In addition, both thebarracks and the hospital were old and in need of repairs, were potentialfiretraps, wereseparated 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 andauthorized 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 Generalattempted to get it changed. His
13(1) Ltr, SG to Surg 9th CA, 6 Jun 40, sub: Hosp for CantonmentGarrison, Cp Ord, with 3 inds. SG: 632.-1 (Cp Ord) C. (2) Rad 265 WVY V 50 WD, CG 9th CA to TAG,15 Jul 40. Same file. (3) Correspondence in SG: 632.-1 (Ft Sill)N.
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LAWSON GENERAL, A CANTONMENT-TYPE HOSPITAL
Office supported requests of local surgeons for exemptionfrom its provisions.14 On 5 September 1940 General Magee conferredwith General Moore and the next day sent him a personal note. Referring to theimpossibility of providing an adequate hospital at Fort Benning under theestablished policy, he stated: "There is so much dynamite in this that Ithink you should know about it."15 Nevertheless,the War Department did not immediately revise the policy, and G-4 permittedfew exceptions to it.16 As a result the situation became so seriousby mid-September that the Chief of Staff asked The Inspector General toinvestigate 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-
14For example, see: Memo, SG for ACofS G-4 WDGS, 11 Sep 40, sub: Hosp, Ft McClellan. SG: 632-1 (Ft McClellan)N.
15Memo, Maj Gen J[ames] C. Magee for Brig Gen R[ichard] C.Moore. 6 Sep 40. SG: 632.-1 (Ft Benning)N.
16(1) Rad AG 600.12 (9-5-40), TAGto CG 9th CA, 10 Sep 40. SG 632.-1 (Ft Lewis)N. (2) Ltr, Surg Ft Benning to SG, 21 Aug 40, sub: Cons of Med Fac, and 3 inds. SG: 632.-1 (Ft Benning)N. (3) Synopsis Ltr,CG Ft Bragg to CG 4th CA, 6 Sep 40, and 5 inds. SG: 632.-1 (Ft Bragg)N.
17Memo, CofSA for IG, 14 Sep 40. HRS:OCS 17749-225. The reply to this memorandum has not been located in WarDepartment files.
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eral's report favored The Surgeon General's position, forsoon afterward the Chief of Staff personally approved General Magee'srecommendation "that the erection of cantonment hospitals be announced asthe normal procedure" for all large posts, whether Regular Army or not.18
The revised policy on hospital construction, issued by theWar Department on 26 September 1940, discarded the long-established plan toconstruct additional buildings for hospitals as a last resort only. Thereafterpeacetime hospitals were to be expanded only on small posts where clinicalfacilities were generally sufficient for additional patients. Cantonment-typehospitals were to be constructed elsewhere.19 Without this changehospitals on Regular Army posts would have consisted of a hodgepodge of smallpermanent hospitals, permanent barracks, and temporary buildings required tosupplement them. Delay in making the revision was responsible for much confusionand some delay in the erection of suitable hospital buildings on Regular Armyposts,20 but it had no effect on hospitals for new posts becausecantonment-type construction had been authorized for them since June 1940.
Planning for Construction
and Selecting Sites of Hospitals
Planning for station hospitals was done on a day-to-dayrather than a long-term basis, because their size, number, and location dependedalmost entirely upon a constantly changing troop distribution. In the fall of1940 the Surgeon General's Office prepared two studies showing the additionalbeds that would be required by June 1941 at each post in the United States,21 but lack of information about ultimatetroop distribution and changes in station strengths limited their value. In someinstances three or more increases in authorized strengths required the samenumber of revisions of hospital construction plans for a single post.22 Asinformation about stations and their strengths became available, theConstruction and Repair Subdivision prepared plans for hospital construction foreach. Consisting of the number of beds needed, the types and numbers ofbuildings required, and the layout or arrangement of buildings, these plansamounted only to recommendations. Final decisions on hospital construction weremade by G-4 for ground force stations and by the Chief of the Air Corps forair stations. Because of the day-to-day type of planning and the lack ofinformation about action on his recommendations, The Surgeon General found itdifficult to keep track of station hospitals authorized for construction.23
Planning for general hospitals was on a more comprehensivebasis. Although it
18(1) Memo, SG for ACofS G-4 WDGS, 20 Sep 40, and note thereon signed G. C. M[arshall]. (2) D/S, ACofS G-4 WDGS to TAG, sub: Revised Policy for Hosp during Emergency. Both in HRS: G-4/31757.
19Ltr AG 600.12 (9-25-40) MD, TAG to CofArms and Servs, CGsof CAs, and COs of exempted Stas, 26 Sep 40, sub: Revised Policy for Hosp duringEmergency. HRS: G-4/31757.
20SG: 632.-1 (Ft McClellan)N; 632.-1 (Ft Benning)N; 632.-l (Ft Bragg)N.
21SG Ltrs, 1 Oct and 7 Nov 40, sub: Bed Reqmt Study. SG:632.-2.
22SG: 632.-1 (Ft Jackson)N, 1940; SG: 632.-1 (Ft Ord)C,1940; SG: 632.-1 (Ft Bragg)N, 1940.
23(1) Ltr, CofAC to SG, 17 Apr 41, sub: Increases in Strfor Pilot Tng Sch, and 9 inds. AAF: 632B Hosp and Infirmaries. (2) Ltr AG 600.12(9-28-40)M-D, TAG to QMG, 3 Oct 40, sub: Temp Cons .. . 5th CA. SG: 632.-1 (5th CA)AA. (3) Memo, SG for QMG,7 Oct 40, sub: Ft Knox. SG: 632.-1 (Ft Knox)N. (4) Ltr, SG to Fed Bd of Hosp,5 May 41. SG: 632.-1.
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depended to some extent upon troop distribution, the factthat general hospitals would serve more than one post and would operate directlyunder The Surgeon General gave him considerable latitude in determining theirsize, number, and location. On 10 August 1940 G-4 sought information onincreases in general hospitals that passage of the Selective Service Act wouldrequire.24 In response The Surgeon General proposed the constructionof ten new general hospitals with a total capacity of 9,500 beds-one each inthe First, Second, Fifth, Sixth, and Seventh Corps Areas; three in the Fourth,where the troop concentration would be heaviest; and two in the Ninth, wheretroops would be spread from Canada to Mexico. In the Eighth Corps Area, heproposed redesignation of the 1,700-bed Fort Sam Houston (Texas) StationHospital as a general hospital, since it was already performing the functions ofboth types.25 Plans had already been made to increase the capacity ofWalter Reed General Hospital, in the Third Corps Area, by relieving it ofstation-hospital cases which it had previously received from near-by posts.26With the general hospitals already in operation, this plan would haveprovided a total of over 15,000 general hospital beds in the United States foran expected Army strength of 1,400,000.
The expansion of general hospitals during 1941 followedbasically The Surgeon General's plan. On 25 September 1940 G-4 approved theconstruction of ten general hospitals, with a total capacity of 10,000 beds, inlocations substantially the same as those recommended by The Surgeon General.27Objections of the commander of the Eighth Corps Area to redesignation ofthe 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 Armyalready had: Lovell at Fort Devens, Mass.; Tilton at Fort Dix, N.J.; Stark atCharleston, S. C.; Lawson at Atlanta, Ga.; LaGarde at New Orleans, La.; Billingsat Fort Benjamin Harrison, Ind.; O'Reilly at Springfield, Mo.; Hoff at SantaBarbara, Calif.; and Barnes at Vancouver Barracks, Wash.29 Noadditional ones were required until September 1941, when an increase in the sizeof the Army was anticipated. At that time The Surgeon General submitted aproposal for a proportionate increase in the number of general hospital beds,30but 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 planningfor hospital construction. It was important, for instance, for both station andgeneral hospitals to have sufficient space for future expansion; to be free fromobjectionable neighbors such as factories, railroad yards, warehouses, utilitiesareas, and training grounds; and
24Memo, ACofS G-4 WDGS for SG, 10 Aug 40, sub: Increase in Number of Gen Hosps. HRS: G-4/29135-11.
251st ind, SG to TAG, 23 Aug 40, on Memo G-4/29135-11, ACofS G-4 WDGS for SG, 10 Aug 40, sub: Increase in Number of Gen Hosps. AG: 322.3 Gen Hosp (8-10-40)(l).
264th ind SGO 701.-1, SG to TAG, 5 Aug 40, and 7th ind, TAG to SG, 30 Sep 40, on Ltr, SG to TAG, 15 Jul 40,sub: Gen Hosp Beds for Enlarged Army. AG: 322.3 Gen Hosp (7-15-40)(1) Sec 1.
27D/S, ACofS G-4 WDGS to TAG, 25 Sep 40, sub: Increase inNumber of Gen Hosps. HRS: G-4/29135-11.
28Ltr, SG to TAG, 9 Oct 40, sub: New Gen Hosp (Ft Sam Houston, Tex), with 2d ind, CG 8th CA to TAG, 7 Nov 40, and 4th ind, SG to QMG, 9 Dec 40. AG: 322.3 Gen Hosp (8-l0-40)(l).
29SG: 632.-1, 1941, for each hospital named.
30Memo, SG for ACofS G-4 WDGS, 19 Sep 41, sub: DF G-4/20052-103,Augmented PMP, 1942. SG: 632.-l.
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to be located on terrain that was moderately level andproperly drained. The accessibility of good highway and railroad nets wasespecially important for general hospitals, whose function was to receivepatients from other hospitals. The availability of good water supplies and ofadequate utilities connections had also to be considered. The QuartermasterGeneral's chief interest in hospital sites lay in their suitability from anengineering and construction standpoint.
During the emergency period The Quartermaster Generalselected construction sites in collaboration with other interested WarDepartment agencies. For hospitals, this meant both The Surgeon General andcorps area commanders.31 In the early phases of mobilization theselection of sites for station hospitals was left in many instances to localauthorities, for The Surgeon General's Hospital Construction and RepairSubdivision had little personnel to spare for such activities. Sites so selectedwere generally satisfactory but sometimes had undesirable features, such aspromixity to training areas, poor drainage, or inadequate space for expansion.As the press of work abated during 1941, The Surgeon General began to exercisemore direct supervision over site selection through visits of hisrepresentatives to stations where hospital construction was anticipated.32 Theselection of sites for general hospitals was more complicated and timeconsuming, even though the general areas in which they were to be located werefirst approved by the General Staff. As a rule, the War Department directedcorps area commanders to appoint boards, with medical representatives, to makeinvestigations and recommendations. Their surveys required considerable time andtheir recommendations in some instances were deemed unsatisfactory. In suchcases, the Secretary of War appointed other boards representing The SurgeonGeneral, The Quartermaster General, the General Staff, and corps area surgeonsto make further surveys and recommendations.33
Difficulties in Providing
Satisfactory Hospital Plants
The Surgeon General and The Quartermaster General disagreedabout the manner in which the Medical Department as the using agency shouldexercise advisory supervision over hospital construction. The Surgeon Generalinsisted that his office should review each building schedule which was sent outand each change in plans proposed by the field. He believed that this procedurewas necessary to maintain the proper division of space among various hospitalservices, an appropriate relationship among different buildings of a hospitalplant, and the possibility of future expansion. In his opinion experiencejustified this position. For example, hospital construction at Fort Francis E.Warren (Wyoming) was delayed from early November 1940 until
31Memo QM 322.2 C-OT (Gen Hosps), QMG for ACofS G-4WDGS, 11 Jan 41, sub: Gen Hosps, and D/S G-4/32445, ACofS G-4 WDGS to TAG, 15 Jan41, sub: Control of Cons Projects. AG: 322.2 Gen Hosp (7-15-40)(1) Sec 1.
32(1) Tynes, Construction Branch, p. 32. (2) Memos from offsof Hosp Cons and Repair Subdiv dated 18 Jan, 11 Apr, 28 Jul, 20 Aug, 22 Aug, 2Sep, and 16 Sep 41. HD: 333(Hosp).
33(1) Memo, ACofS G-4 WDGS for DepCofSA, 14 Nov 40, sub: Gen Hosps. HRS: G-4/29135-11. (2) Ltr, TAG to CG 4th CA, 29 Sep 40, sub: Cons of Cantonment Hosps 4th CA (Atlanta, Charleston, New Orleans). AG: 322.3 Gen Hosp (9-27-40) M-D. (3) Rad, TAG to CG 7th CA, 19 Dec 40, and D/S G-4/ 29135-14, ACofS G-4 WDGS to TAG, 14 Jan 41, sub: Convening a WD Board .. . . AG: 322.3 Gen Hosps (7-15-40) (1) Sec 4.
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January 1941 because The Quartermaster General sent out planswhich The Surgeon General had not approved and against which local authoritiesprotested. At Fort Rosecrans (California) local quartermaster and medicalofficers erected a two-story wooden hospital which The Surgeon Generalconsidered unsafe. In other places, such as Camp Wallace (Texas), Camp Custer(Michigan), Camp Roberts (California), and Camp Leonard Wood (Missouri), localchanges in approved plans produced hospitals considered unsatisfactory by TheSurgeon General.34
Hoping to speed construction, The Quartermaster Generalproposed standardization and decentralization-the use of standard buildingschedules (that is, lists of buildings for hospitals ranging in size from 25 to2,000 beds) approved initially by the Surgeon General's Office and subject tono further changes by it, and thedelegation of authority to make changes in hospital layouts and building plansto medical and quartermaster officers in the field.35 Nevertheless,because of The Surgeon General's insistence, both the Quartermaster Corps andthe Corps of Engineers followed the practice of referring hospital buildingschedules and layouts to his Office for approval and twice during 1941 TheQuartermaster General instructed his field agents not to change hospitalconstruction plans without prior approval of the Surgeon General's Office.36
Centralization of the Medical Department's advisorysupervision over hospital construction did not necessarily assure erection ofsatisfactory 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'sOffice that they would not be entirely satisfactory, and in October 1940 ColonelHall, 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 thatthey did not. Hospitals built on such plans had insufficient space for someactivities and none at all for others. X-ray clinics and laboratories were toosmall for use in modern medicine. Administration buildings had insufficientspace for extensive records required for patients and civilian employees andwere cut up into too many small rooms for efficient use. Post dental workrequired more room than originally expected. General hospitals needed more spacefor quartermaster activities. Inadequate kitchens and mess storerooms became thesource of frequent complaints. Offices for the medical supply officer and themedical detachment commander, recreation buildings for patients and for nurses,post exchange
34(1) Ltr, SG to QMG, 5 Jan 41, sub: Unauth Changes in Cantonment Hosps. .. , with 2d ind, SG to QMG, 14 Feb 41. SG: 632.-1. (2) 1st ind, SG to QMG, 17 Jul 41, on Synopsis Ltr, QMG to SG, 17 Jul 41. Same file. (3) SG: 632.-1 (Ft F. E. Warren)N, 1940-41 and (Ft Rosecrans)N, 1940-41.
35(1) 1st ind QM 632 C-ED, QMG to SG, 8 Feb 41, on Ltr, SG toQMG, 5 Jan 41, sub: Unauth Changes in Cantonment Hosps. .. . (2) Synopsis Ltr, QMG to SG, 17 Jul 41. Both in SG: 632.-1.
36(1) Ltr QM 632 C-EP Hosp Fac, QMG to SG, 9 Aug 41, sub: Add Hosp Fac. SG: 632.-1. (2) 2d ind, CofAC to CofEngrs, 11 Aug 41, on Ltr, SG to CofEngrs, 31 Jul 41, sub: Hosp Insp, AC Sta, 8th CA. Same file. (3) Ltr, QMG to Cons QMs, 8 Feb 41, sub: Hosp Layouts. Same file. (4) Ltr QM 632 C-EP (Zone VII), QMG to Zone Cons QM, Zone VII, 12 Sep 41, sub: Revisions in Hosp Plans and Layouts. Off file, Hosp Cons Div SGO, "Policy File."
37(1) Lessons Learned from Planning and Constructing ArmyHospitals, Speech by Col John R. Hall, 16 Sep 43. HD: 632-1. (2) Ltr, Col J. R.Hall to Col H. C. Coburn, Jr, MC, Sta Hosp Ft Bragg, 16 Oct 40. SG: 632.-1 (Ft Bragg)N.
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buildings, ambulance garages, and strong rooms forsafeguarding narcotics as required by Federal law were not included in existingplans. Of equal importance, neuropsychiatric wards for which plans were providedlacked sufficient strength and safety features to prevent patients fromattempting escape or suicide.38
The question of whether to revise existing plans completelyor to make piecemeal changes arose in the fall of 1940. General Love, Chief ofthe Planning and Training Division, advocated their complete revision, butColonel Hall demurred on the ground that he would encounter delays anddifficulties in securing approval of G-4 and co-operation of The QuartermasterGeneral.39 That his position had some basis in fact is indicated by acontroversy from August through October over proposed changes for separatebuildings. After The Quartermaster General complained that requests of TheSurgeon General for piecemeal changes were delaying construction, their officeshurled charges and countercharges against each other until G-4 forbade furtherchanges in standard designs without Staff approval, and the chief of the G-4Construction Branch, concluding that further argument was useless, closed thecontroversy by recommending on 18 October 1940 that all papers pertaining to itbe filed.40 Two months later The Quartermaster General proposed acomplete revision of cantonment-type hospital plans, but Colonel Hall maintainedhis former position, this time for a different reason. "It is the opinionof this office," he wrote, "that sufficient experience with the plantsto be erected according to the present plans has not yet been had to make acomplete and satisfactory revision possible at this time."41
As soon as hospitals built on the 1935 plans were receivedfrom contractors, steps had to be taken to correct their defects and overcometheir deficiencies. Several methods were adopted. One was to rearrange the useof space. For example, local commanders converted wards into X-ray clinics andlaboratories and used the space vacated in clinical buildings to increasesurgical facilities. To replace the bed capacity thus lost, The Surgeon Generalobtained additional wards.42 Another method was to modify thebuildings erected. Changes in neuropsychiatric wards, such as the removal ofexposed pipes, were made to increase the safety of mentally disturbed patients;and kitchens and mess halls were enlarged by adjacent construction.43 Athird method was to construct additional buildings, such as storehouses,
38(1) An Rpts, 1941, Sta Hosps at Fts Knox and Bragg, Cps Lee, Roberts, Claiborne, and Bowie, and O'Reilly Gen Hosp. HD. (2) Memo, IG for ACofS G-4 WDGS 22 Apr 41, sub: Cons Defects. HRS: G-4/32900. (3) Tynes, Construction Branch, pp. 16-18. (4) Rpt, Conf of SG with CA Surgs, 10-12 Mar 41. HD: 337.
39Interv, MD Historian with Col Albert G. Love, 27 Aug 47. HD:000.71.
40(1) Ltr AG 600.12(8-15-40), TAG to SG, 17 Aug 40, sub: Changes in Standard Design, with 3d ind, QMG to TAG, 7 Sep 40, 4th ind, TAG to SG, 20 Sep 40, and 5th ind, SG to TAG, 8 Oct 40. SG: 632.-1. (2) Memo, Lt Col Stephen J. Chamberlin for ACofS G-4 WDGS, 18 Oct 40, same sub. HRS: G-4/31741.
41Memo, SG (Hall) for QMG, 17 Dec 40. SG: 632.-1.
42(1) An Rpts, 1941, Sta Hosps at Ft Bragg and Cp Robertsand O'Reilly Gen Hosp. HD. (2) Ltr, SG to TAG, 7 May 41, sub: Request forUrgent Emergency Cons, and 2d ind AG 600.12 (5-7-41), TAG to QMG, 5 Jul 41. SG: 632.-1. (3) Ltr, SG to QMG. 14 Jul 41, same sub. Same file.
43(1) Memo, Col John R. Hall for SG, 28 Jul 41, sub: Rpt ofInsp, 8th CA. HD: 333. (2) 2d ind, SG to Hq AAF, 9 May 42, on Ltr, Surg SoutheastAC Tng Ctr to SG, 5 May 42, sub: Hosp Messes. SG: 632.-1. (3) Ltr QM 300.5 C-ED(Gen), QMG to all Cons QMs,21 May 41, sub: Piping-Detention Wards. SG: 632.-1.
23
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 preventperpetuation of the process of building and changing.45
Development of a New Type
of Hospital Plant
In the spring of 1941 complaints were made in both militaryand civilian circles that the hospitals constructed not only lacked space forcertain activities but also were unsatisfactory from an administrative andsafety viewpoint.46 Wide dispersal of buildings intensifiedadministrative problems without assuring adequate fire protection. As early asJanuary 1941 the offices of The Quartermaster General and The Surgeon Generalhad agreed upon a program of installing draft-stops in closed corridors thatconnected different buildings of hospital plants, as a fire-protection measure.47In May the Chief of the Air Corps secured appropriations for theinstallation of automatic fire-sprinkler systems in fifty-eight Air Corpshospitals and The Quartermaster General made plans for their installation in allother hospitals with 400 or more beds. By December 1941 the installation of suchsystems 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 ofhospital. When complaints about existing plants were first made, Colonel Hallexpressed The Surgeon General's preference for more compact hospitals built offire-resistant materials.49 Soon afterward his Office began tocollaborate with the Quartermaster General's in designing such a plant. It consisted ofbuildings that were generally two stories high with exterior walls of masonryand interiors of slow-burning materials. Such construction permitted a morecompact arrangement of structures than had previously been possible. Wardbuildings were placed opposite each other on a central connecting corridorpermitting one diet kitchen and one ward office and examining room to serve twowards. Two-story corridors connected the buildings of a hospital group, andramps were placed at suitable intervals to give access from one story to theother. To allow more
44(1) Ltr, SG to Off of Budget Off, 26 Dec 40, sub: Supp Est, FY 1941. SG: 632.-1. (2) D/S G-4/29135-17, ACofS G-4 WDGS to TAG for transmittal to SG, 13 Jan 41, sub: Med Fac. .. . AG: 322.3 Gen Hosp (7-15-40)(1) Sec 1. (3) Ltr, SG to ACofS G-4 WDGS, 15 Mar 41, sub: PXs for Hosps. SG: 632.-1. (4) Ltr AG 600.12 (8-4-41)MO-D-M, TAG to CGs of all Depts et al., 19 Aug 41, sub: WD Cons Policy. HD: 600.12-1.
45(1) Ltr, SG to Cons Div OQMG, 4 Jun 41, sub: Plans for Ward 8-NP Bldgs. (2) Ltr, SG to QMG, 7 Aug 41, sub: Modification of M-16 Mess, with 1st ind QM 633 C-ED(Danville GH), QMG to SG, 4 Sep 41. Both in SG: 632.-1.
46(1) Ltr, Nathaniel O. Gould,Architect and Engr, Detroit, to SecWar, 27 Mar 41. AG: 600.12 (3-27-41)(1).(2) Ltr, F. A. Arnold to SG USPHS, 4 Apr 41. SG: 632.-1. (3) Ltr, CofEngrs to SG, 9 May 41, sub: Type of Hosp Cons. Same file. (4) Memo, Exec Asst OCE for Engr Div OCE, 3 May 41, and Memo, Head Engr for Exec Asst OCE, 6 May 41, sub: Hosp Layouts. CE: 632Pt I.
47Memo, SG (Hall) for QMG, 29 Jan 41. SG: 632.-1.
48(1) Synopsis Ltr, CofAC to CofEngrs, 9 May 41, sub: FirePrevention in Hosps, with 1st ind, CofEngrs to CofAC, 17 May 41, and threesubsequent inds. SG: 671.2. (2) Memo QM 632 C-ED (Gen), Design Sec OQMG forChief Design Sec OQMG, 13 May 41, sub: Sprinkler and Alarm Systs-Hosps. CE:671.3 Pt 1. (3) 3d ind AG 671.7 (10-21-41)MO-D, TAG to CofEngrs, 26 Dec 41,on Ltr QM 671 C-RU (Gen), QMG to TAG, 21 Oct 41, sub: Fire Protection. Samefile.
492d ind SGO 600.12-1, SG (Hall) for TAG, 16 Apr 41, on Ltr,Nathaniel O. Gould to Sec War, 27 Mar 41. AG: 600.12 (3-27-41)(1).
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VALLEY FORGE GENERAL, ASEMIPERMANENT-TYPE HOSPITAL
space for medical care, the width of all wards, clinics, andother key buildings was increased from twenty-five to thirty-two feet, andfacilities that were either lacking or inadequate in cantonment-type hospitalswere introduced or redesigned in plans for the new type.50 On 6August 1941 the Staff authorized the construction of two-story, semipermanent,fire-resistant plants for all future hospitals.51 Final drawings werenot completed for several months, and before they could be put into general usethe United States was at war.
Evaluation of Hospital
Construction Program
Although hospitals constructed during the period of peacetimemobilization did not "even approach the ideal," in Colonel Hall'sopinion the wonder was "not that so many mistakes were made but rather thatwe have been able in a somewhat satisfactory manner to meet our obligation to the sick and wounded."52 Hospitalbeds had to be provided on a scale unknown in ordinary times. Between September1940 and December 1941 the number of normal beds (that is, those for which 100square feet of space each was provided in ward buildings) in station hospitalsincreased from 7,391 to 58,736 and in general hospitals, from 4,925 to 15,533. (Chart1) Only in the fall and winter of 1940-41 was there a shortage of normalbeds. 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
50(1) Tynes, Construction Branch, pp. 39-40. (2) Ltr, SGto CofEngrs, 7 Feb 42, sub: Fire-Resistant Type of Hosp. SG: 632.-1.
512d ind AG 632 (7-7-41)MO-D, TAG to QMG and SG in turn, 6 Aug 41,on Ltr, SG to TAG, 7 Jul 41, sub: Fire-Resistant Type of Cons for Hosp. SG: 632.-1.
52Lessons Learned from Planning and Constructing ArmyHospitals, speech by Col Hall, 16 Sep 43. HD: 632.-1.
25
26
wards but also in porches, halls, barracks, and tents) andsent some patients to nearby civilian and Veterans Administration hospitals.53It also continued a policy, begun early in 1940, of reducing the number ofCivilian Conservation Corps and Veterans Administration patients in Armyhospitals and in December secured War Department approval of a policy oflimiting sharply the hospitalization of dependents of military personnel.54In the spring of 1941 construction began to catch up with needs and afterMarch the number of patients in hospitals at no time exceeded the total numberof normal beds. (See Chart 1.)
Hospital Administration
Internal Organization
and Administrative Procedures
When mobilization began, the only guide to the organizationand administration of Army hospitals was an Army regulation published in themid-1930's. It gave hospital commanders much discretion in both fields andlacked detailed instructions for inexperienced officers to follow.55 Amore specific guide was therefore necessary. In October 1940 the MedicalDepartment devoted an entire issue of the Army Medical Bulletin to anarticle prepared by Col. Charles M. Walson, then surgeon of the Second CorpsArea, entitled "Station Hospital Organization Chart, Regulations, andMedical Department Questionnaire." During the first half of 1941 theTraining Subdivision of the Surgeon General's Office revised this article andthe War Department issued it in July as a technical manual.56
The manual described hospital organization in considerabledetail, advocating the separation of activities into two major categories, administrative and professional, and the groupingof professional activities into services composed of subunits called sections.For example, the surgical service of a station hospital might contain sectionsdevoted 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 aheadquarters, or commanding officer's staff, separate from otheradministrative units of general hospitals. In addition, it described the dutiesand responsibilities of staff officers, as well as important administrativeprocedures, and contained checklists for chiefs of services to use in measuringthe efficiency of operations. While it was somewhat more specific than the Armyregulation governing hospital administration, this manual also gave localcommanders considerable autonomy. (Chart 2)
53(1) An Rpts, 1941, Sta Hosps atCps Beauregard, Shelby, Blanding, Custer, and Roberts, and Fts Leonard Wood,Sill, and Bragg. HD. (2) AR 40-1080, par 2 n (1), (2), and (3), 31 Dec34, and C 2, AR 40-1080, par 2 n (1), (2), and (3), 16 Mar 40. (3) Ltr,CO Sta Hosp Ft Snelling to Surg 7th CA, 9 Sep 40, sub: Auth to Reduce FloorSpace. . . , and 3 inds. SG: 632.-1(Ft Snelling)N.
54(1) Rpt, Conf of SG with CASurgs, 14-16 Oct 40, and 10-12 Mar 41. HD: 337. (2) Memo, ACofS G-4 WDGS for CofSA, 5 Dec 40, sub: Reply of SecWar to VA. HRS: G-4/28901-17. (3) Ltr, SG to TAG, 28 Nov 40, sub: Med Care forDependents . . . and cy Ltr AG 702 (11-28-40) M-A-M, TAG to CGs of CAs and Depts and COs of Exempted Stas, 18 Dec 40,same sub. HD: 701.-l.
55AR 40-590, 21 Nov 35, The Adminof Hosps, Gen Provisions.
56(1) Army Medical Bulletin, No. 54, (1940). (2) TM 8-260, Fixed Hosps of the MD (Gen and Sta Hosps), Jul 41. (3) Memo for Record on D/S G-3/44468, ACofS G-3 WDGS to TAG, 17 Apr 41, sub: TM 8-260. AG: 300.7 TM 8-260 (4-15-41)(1).
27
CHART 2-HOSPITAL ORGANIZATION AS SUGGESTED BYTM8-260, JULY 1941
28
Lack of a specific directive requiring standard hospitalorganization resulted in many local variations.57 The one generalpoint of similarity was the separation of administrative from professionalactivities. In most hospitals the latter were organized as sections that weregrouped in services: medical, surgical, dental, and laboratory. Some hospitalslooked upon nursing as a separateprofessional service, although the manual recommended thatthe nursing unit be considered anadministrative one. Others gave activities that might have been included assections of either the medical or surgical service a higher status. For example,the station hospitals at Fort Lewis (Washington) and FortKnox (Kentucky) possessed orthopedic services; that at Fort Ord (California) hadseparate genitourinary and eye-ear-nose-and-throat services; and that at FortBragg (North Carolina), a separate neuropsychiatric service. On the other handthere were but three professional services at the 1,200-bed station hospital atCamp Bowie (Texas): medical, surgical, and nursing.
Administrative units were usually not groupedin services, and their number varied from one hospital to another. For exampleat Stark General Hospital there were29, including staff offices; at LaGarde, 14; while the number proposed in the manual was 12. Station hospitalslikewisevaried. On some posts they were under the supervision of station surgeons, whosupplied certain administrative services. In one suchinstance the station surgeon handled all hospital personnel and supplyactivities. On other posts, a single officer served both as station surgeon andas hospital commander. The Fort Bragg Station Hospital, which was divided intothree sections located from one quarter of a mile to a mile apart, had separatecornmanders for each unit, but possessed a central registrar'soffice, medical supply section, nursing section, mess and hospital fund,military and civilian personnel divisions, and medical detachment. Generalhospitals not located on Army posts usually had administrative sections notfound in station hospitals, such as the finance and provost marshal's offices.
Neither Army regulations nor the manual on organizationlimited the number of officers a hospital commander could supervise directly.Thus the number of individualsreporting to him varied as did the organization ofadministrative and professional activities. As a rule,only chiefs of professional services,not of sections under them, reported to the commanding officer, but in mosthospitals the chief of each administrative section reported directly to thecommander or his executive officer. Thus the officers supervised directly by ahospital commander sometimes reached large numbers. For example, at Stark GeneralHospital the chiefs of four professional services and twenty-nine differentadministrative sections reported directly to the commander. In some instancesthe number of officers actually reporting was smaller than it seemed, becauseone officer frequently held several positions. (Chart 3)
Administrative procedures likewise varied from hospital tohospital. Since there was no manualcovering hospital operations in detail, hospital commanders were free tosupplement general procedures outlined in Army regulations as they saw
57(1) The following three paragraphs are based on: An Rpts, 1941, Sta Hosps at Fts Knox, Leonard Wood, Lewis, Bragg, Sill, Ord, and G. G. Meade, and Cp Bowie, and Stark, Billings, Hoff, LaGarde, and Lawson Gen Hosps. HD. (2) See also: Edward J. Morgan and Donald O. Wagner, The Organization of the Medical Department in the Zone of the Interior (1946), pp. 102-06. HD.
29
CHART 3-ORGANIZATION OF LAWSON GENERALHOSPITAL, 1941
30
fit. Hospital regulations published in the Army MedicalBulletin in October 1940 and in Technical Manual 8-260 in July 1941 wereprobably of value to some, but officers opening new hospitals often borrowedcopies of regulations and administrative formsof other hospitals to use as guides in establishing their own administrative procedures.58
The Surgeon General supervised and directed the professionalwork of hospitals through inspectionsby members of his Office andthe issuance of technical instructions, but he exercisedlittle direct control during this period over their administrative activities.Rather he depended on The Inspector General and corps area authorities to keephospitals in line with Army procedures and to report administrative problemsthat arose.59
The question of whether the autonomy given hospitalcommanders resulted in less efficient operations than might have otherwise beenthe case was not discussed during the period under consideration. Argumentsmight have been raised in favor of flexibility which permitted accommodation tolocal situations. Later on, lack of uniformity in organization andadministration became a subject of much discussion and efforts were made todevelop standardized organizations and simplified administrative procedures.60
Manning of Hospitals: Manning
Guides and Personnel Problems
In September 1940 there was no up-to-dateguide for manning named hospitals. Since they were then small, few in number,and widely different in construction none was needed, for personnel requirementsof each installation could be determined best on an individual basis. With the opening of large hospitals built on standard plans, corpsarea surgeons began to need a guide to use in computing requirements anddistributing personnel. The only available one was a 1929 table of organizationfor wartime station hospitals in the zone of interior.61 Althoughnamed hospitals were not being organized under it the General Staff early in1940 had given the Third Corps Area permission to use this table as a guide,pending the publication of a "table for converting bed requirements intopersonnel requirements." Preparation of the latter in the Surgeon General'sOffice was delayed until December 1940, because the revision of tables oforganization for field force units had priority.62
As submitted to the General Staff, the new guide called formore personnel, especially officers and enlisted men, than did the old one. Forexample, 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 notprovide sufficient personnel for "a present day hospital." Although G-1agreed that the amount called for by
58(1) Interv, MD Historian withMaj Gen Howard McC. Snyder, 25 May 48. HD: 000.71. (2) See also: An Rpt, 1941, Lovell Gen Hosp. HD.
59(1) Interv, MD Historian with Col Albert G. Love, 27 Aug 47. HD: 000.71. (2) Interv, MD Historian with Gen Snyder, 25 May 48. HD:000.71.
60See below, pp. 121-24, 268-78.
61T/O 786 W, Sta Hosp, ZI, 1 Jul 29.
62(1) 2d ind, TAG to CG 3d CA, 28 Mar 40, on Ltr, Surg 3d CAto SG, 22 Jan 40, sub: Civ Employees in Sta Hosps. AG: 381 (1-1-40) Sec 1.(2) 1st ind SGO 370.01-1, SG to TAG, 9 Apr 40, on Ltr, TAG to CGs of CAs, COs ofExempted Stas, C of Arms and Servs, 28 Mar 40, same sub. Same file. (3) Ltr SGO370.01-1, SG to TAG, 19 Dec 40, sub: Guide for Determining Pers Reqmts, StaHosps, ZI. AG: 381 (11-3-37) Sec 1-12.
31
the new guide was reasonable,63 theStaff delayed its publication because itexpressed requirements in terms of military personnel only and called for moreenlisted men than the number already allotted to hospitals. The first objectionwas apparently removed in January 1941 when Maj. (later Col.) Arthur B. Welsh,of The Surgeon General's Planning and Training Division, stated that civilianscould be substituted for enlisted men on an approximate man-for-man basis.64Two months later, incidentally, his superior officer, General Love,informed corps area surgeons that civilians should replace enlisted men on athree-for-two basis.65 In view of continued disagreement amongmembers of the General Staff over the total number of enlisted men involved, thequestion of publication was submitted in March 1941 to the Chief of Staff. As aresult a "Guide for Determination of Medical Department Personnel" waspublished on 9 April 1941 with the understanding that it representedrequirements, not availabilities.66
Publication of the guide did not mean that hospitals were tohave the strength prescribed. The Surgeon General apparently had no trouble ingetting the General Staff to authorize the number of physicians, dentists, andnurses whom he desired, but he encountered difficulty in procuring the numberauthorized.67 During the fall and winter of 1940-41 hospitalsconsidered the shortage of physicians and nursesacute. To alleviate it they employed civilian nurses on atemporary basis and used Medical Corps officers from field force units locatednear by. Medical Administrative Corps officers filled a few administrativepositions, but the Army had few such officers and their substitution for MedicalCorps officers in administrative work gained little headway prior to the war years.By the spring of 1941 the procurement situation hadapparently improved and many hospital commanders reported that the number ofofficers and nurses assigned to them was adequate.68
The question ofthe number of enlisted men to be assigned to named hospitals was bound up with theuse of civilian employees and the training of medical personnel. The SurgeonGeneral contended that the Medical Department needed proportionately as manyenlisted men in named hospitals during mobilization as in peacetime in order totrain enlisted men in technical duties for use later as cadres and fillers fornew units and installations. He insisted, therefore, that hospital staffs shouldhave no higher proportion of civilians than 20 percent of the total enlisted
63(1) Memo, Act SG for ACofS G-1WDGS, 1 Apr 41, sub: Approval of T/O for Sta Hosps in the ZI. HD: 322.052-1. (2) Memo G-1/13308-291, ACofS G-l WDGS for ACofS G-4 WDGS, 14 Feb 41, sub: Guide for Determining Pers Reqmts, Sta Hosp, ZI. AG: 381(11-3-37) Sec 1-12.
64D/S G-4/31697, ACofS G-4WDGS to TAG, 30 Dec 40, sub: Guide for Determining Pers Reqmts, Sta Hosp,ZI, and Memo G-1/13308-291, ACofS G-1 WDGS for ACofS G-4 WDGS, 8 Jan 41, samesub. AG: 381(11-7-37) Sec 1-12.
65Rpt, Conf of SG with CASurgs, 10-12 Mar 41. HD: 337.
66(1) Memo G-1/13308-291,ACofS G-1 WDGS for ACofS G-4 WDGS, 14 Feb 41, sub: Guide for Determining PersReqmts, Sta Hosp, ZI. (2) Memo G-3/42107, ACofS G-3 WDGS for ACofS G-4 WDGS, 28Feb 41, same sub. (3) Memo G-4/31697, ACofS G-4 WDGS for ACofS G-1 WDGS, 11Mar 41, same sub. (4) Memo G-4/31697, ACofS G-4 WDGS for CofSA, 22 Mar 41,same sub. All in AG: 381(11-3-37) Sec 1-12. The Chief of Staff's stamp ofapproval for publication was dated 28 March 1941. (5) MR 4-2, Hospitalization,C-1, 9 Apr 41.
67John H. McMinn and Max Levin, Personnel (MS forcompanion vol. in Medical Dept. series), HD.
68An Apts, 1941, Hoff, O'Reilly, and Billings GenHosps and Sta Hosps at Cps Livingston and Forrest, Fts Knox and Jackson, andIndiantown Gap Mil Res. HD.
32
and civilian staff.69 On the other hand, facedwith the problem of dividing a given number of enlistedmen among field force units (includingnumbered hospital units) and zone of interior installations of the various armsand services, the General Staff believed that civiliansshould constitute as much as 50 percent of the staffs of namedhospitals. In this connection G-3 suggested that the Medical Department mightaffiliate (not explaining what it meant by this term) numbered hospital unitswith named hospitals to provide additional enlisted men for service in the namedhospitals and at the same time to give the numbered hospital units the bestpossible training.70 The Surgeon General planned to train numberedunits in named hospitals, but he apparently expected the members of such unitsto be used not as regular operating personnel but as understudies of theiropposite numbers. Repeatedly, therefore, he asked for greater allotments ofenlisted men for fixed installations of the Medical Department, but withoutsuccess.71 Hence, the enlisted men authorized for assignment togeneral and station hospitals were fewer than The Surgeon General desired, andthose received by hospitals were fewer than the number authorized. To supplementthem hospitals used civilians and men from near-by field medical units, theformer sometimes constituting more than half of the total enlisted and civilianstaffs.72
In addition to having less military personnel than theyconsidered desirable, hospitals received officers and enlisted men who neededfurther training. Nurses and Medical Corps Reserve officers were of coursequalified by training and experience to care for the sick and injured, but mostwho entered the Army after September 1940 knew little about the administration of Army hospitals. In some instances this resulted indevotion of more time and energy to paper work than was ordinarily thoughtproper. Recognizing the need for training Reserve officers in administrative proceduresbefore assigning them to hospitals, The Surgeon General authorized a programin November 1940 to train fifty Reserve and National Guard officers each monthfor such positions as registrar, detachment commander, receiving and dispositionofficer, adjutant, executive officer, medicalsupply officer, and mess officer. In general, though, the burden of trainingofficers and nurses in administrative work fell upon the commanding officers ofthe hospitals to which they were assigned.73
A majority of enlisted men availablefor service in hospitals during 1941lacked a knowledge of both military and technical matters. The number of MedicalDepartment men in the enlisted Reserves was
69(1) Ltr, SG to TAG, 3 Sep 40, sub: Employment of Civs. AG:381(1-1-40) Sec 3. (2) Ltr, SG (init J. C. M[agee]) to TAG, 6 Sep 40, sub: MDin Mob. Same file. (3) Memo, Act SG (Brig Gen A[lbert] G. Love) to ACofS G-lWDGS, 1 Apr 41, sub: Increase in Auth for MD EM for .. . Overhead. HD: 322.052-1.
70Memo G-l/15081 Med, ACofS G-1 WDGS for ACofS G-3 WDGS, 13 Sep 40, sub: Allocation of MD Pers, and Memo G-3/6541 Med 68, ACofS G-3 WDGS for ACofS G-1 WDGS, same sub. AG: 381 (1-1-40) Sec 3.
71(1) For example, see: Memo, Act SG for ACofS G-l WDGS, 1 Apr 41, sub: Increase in Auth for MD EM for CA, SvC, and WD Overhead. HD: 322.052-1. (2) Also see McMinn and Levin, op. cit.
72For example, see: An Rpts, 1941, Sta Hosps at Cps Blanding, Bowie, and Forrest, Fts Bragg and Knox, Indiantown Gap Mil Res, and Hoff Gen Hosp. HD.
73(1) Interv, MD Historian with GenSnyder, 25 May 48. HD: 000.71. (2) An Rpts, 1940, Sta Hosps at Cps Livingston,Blanding, Edwards, Shelby, Forrest, J. T.Robinson, and Claiborne, Fts Jackson, Bragg, and Knox, and O'Reilly, Lawson,Hoff, Billings, and Tilton Gen Hosps. HD. (3) SG Ltrs 79, 7 Nov 40; 14, 26 Feb41; and 32, 5 Apr 41.
33
negligible, and the Medical Department's replacement training centers andenlisted technicians' schools did not begin to turn outtrained men in large numbers until the summer of 1941.74Regular Army enlisted men from hospitals already in operation formed the cadresof enlisted detachments of new hospitals. The remainder were usually menassigned direct from reception centers.The necessity of giving them basic military traininginterfered with their performance oftechnical duties, and hospital commanders generallypreferred men from replacement training centersafter they became available. To make up for the lack oftechnical training, hospitalsinstituted on-the-job training programs which varied incontent and value from one installation to another.75
Civilians in Army hospitals were normally used in jobs traditionally held bysuch enlisted men as medical technicians, ward orderlies, clerks, cooks andcooks' helpers, repair and maintenance men, and janitors. In some instancescivilian nurses were employed, and until the end of the first year of the warall female dietitians and physical therapy aides were in civilian status. Thechief problem in the use of civilians was procurement. To reduce difficulties inthat connection The Surgeon General in September 1940 decentralized to corpsareas the employment of civilians for station hospitals, including those onexempted stations. He retained in his Office for a time the employment ofcivilians for named general hospitals.76 Amonglocal conditions that continued to hamper the procurementof sufficient numbers of qualified civilians, the most important were lack ofhousing near hospitals in isolated areas, inadequate transportation to suchhospitals, absence of labor markets in some places, and competition of other government agencies for availablecivilians.77
Shortages of Supplies and Equipment
Another difficulty encountered in opening new hospitals was ashortage of suitable supplies and equipment, and complaints of hospitalcommanders on this score were frequent.78 Depots met earliest needsby issuing reserves stored after World War I. As a result, much that hospitalsreceived, such as surgical instruments, plaster of paris bandages, and wardfurniture, was of 1918 vintage. When reserves proved insufficient, depotssupplemented them with local emergency
74(1) AnnualReport of The Secretary of War, 1941 (Washington, 1941), pp. 95, 134. (2)McMinn and Levin, op. cit. (3)[Samuel M. Goodman], A Summary of the Training of Army Service Forces MedicalDepartment Personnel, 1 July 1939-31 December 1944 ([1946]), pp. 38, 46-48.
75(1) An Rpts, 1941, Sta Hosps at Cps Livingston, Blanding,Edwards, Shelby, Forrest, J. T. Robinson, Bowie, and Claiborne, Fts Jackson,Bragg, and Knox, and O'Reilly, Lawson, Hoff, Billings, and Tilton Gen Hosps.HD.
76Ltr, SG (Fin and Sup Div) to Surgs CAs and Depts, 12 Sep40, sub: Use of Civ Pers in Army Hosps, and Ltr, TAG to C of Arms and Servs, CGsof Exempted Stas, 31 Oct 40, sub: Provision for Civ Employees in Hosps ofExempted Stas. AG 381 (1-1-40) Sec 3.
77An Rpts, 1941, Sta Hosps at Cps Livingston, Blanding,Edwards, Shelby, Forrest, J. T.Robinson, Bowie, and Claiborne, Fts Jackson, Bragg, and Knox, and O'Reilly,Lawson, Hoff, Billings, and Tilton Gen Hosps. HD.
78Unless otherwise indicated, the following paragraphs arebased upon annual reports of Barnes, Hoff, Lawson, and O'Reilly GeneralHospitals, and Camps Beauregard, Blanding, Claiborne, Croft, Forrest, Shelby,and Forts Bragg, Jackson, Lewis, and Leonard Wood Station Hospitals. In aconference on 10 November 1950, General Magee disagreed with the interpretationgiven here, stating that he personally found a high state of satisfaction withsupplies when he inspected hospitals. (Notes filed in HD: 314 [Correspondence onMS] I.) For a statement about the general shortage of Army supplies in 1940, seeMark S. Watson, Chief of Staff: Prewar Plans and Preparations (Washington, 1950), p. 209, in UNITEDSTATES ARMY IN WORLD WAR II.
34
purchases but even so had to ship many assemblages 50- to 60-percentcomplete.79 Hospitals thusfailed initially to receive many critical items. Mostfrequently lacking were sterilizers, X-ray equipment, orthopedicequipment, dental operating units, cystoscopic instruments, and catheters.
To make up for shortages hospitals resorted to a variety ofexpedients. In some instances medical and dental officers sent home for theirown instruments. At Camp Claiborne (Louisiana) they personally purchased medicalsupplies which they considered requisite. The station hospital at Camp Blanding(Florida) made up for its lack of laboratory supplies and equipment by borrowingfrom the University of Florida and theFlorida State Board of Health, while the Camp Claiborne Station Hospitalborrowed an X-ray developing tank from a dealer in Shreveport, Louisiana. Inother instances Army authorities arranged locally to usethe facilities of neighboring hospitals. For example, the Camp Beauregard(Louisiana) Station Hospital sent casesrequiring X-ray and electrocardiographic work to theVeterans Administration Facility at Pineville,La.; used the diagnostic and clinicalfacilities of the Central Louisiana State Mental Hospital for neuropsychiatricpatients; and sent fractures requiring reductionsor large casts to the Baptist Hospital in Alexandria, La. Where office and wardfurniture was lacking, hospitals improvised desks, chairs, and tables from boxesand lumber salvaged from the hospital's construction.Thus the improvisation and ingenuity of local personnel compensated to a greatextent for shortages of supplies and equipment.
The above situation resulted initially fromthe inadequacy and obsolescence of thewar reserve. It continued because considerable time was required both for industry to convert tothe production of goods on the scaledemanded and for the Medical Department to modify itspeacetime methods of requirements-computation,purchasing, stock-control, storage, and distribution. Although the quantity ofsupplies became more adequate by the fallof 1941, the situation was by no means satisfactory at the end of the year and manyitems were still on "back order."80
Development of Procedures Affecting
Operation of the HospitalSystem
As new station and general hospitals opened,broad policies and procedures to govern thehospital system in general became necessary and TheSurgeon General's Hospitalization Division concentrated its efforts in thosefields.81 The need for a new policy to govern the selection of patientsfor transfer to general hospitals developed in the spring of 1941. Until thattime hospital commanders and corps area surgeons decidedwhich cases were sufficiently "serious, complicated, or obscure" torequire treatment in the five general hospitals then in operation. Fewrestrictions were placed upon them: cases of resection and amputation requiringthe fitting of prostheses were to be transferred to Walter Reed, Letterman, orArmy and Navy General Hospitals; patients with tuberculosis,to Fitzsimons; and "cases of such diseases as the waters of the hot springsof Arkansas have an established reputation forbenefiting," to Army and
79(1) Memo, Lt Col R. L. Black, Dir Storage and Maintenance Div SGO for HD SGO, 16 Nov 44, sub: Sup [Depot] Hist Highlights. HD: 400.24 (Storage and Distr). (2) Hist and Procedure Manual of the Toledo Med Depot, 1941-45. HD.
80Richard E. Yates, The Procurement and Distribution ofMedical Supplies in the Zone of the Interior during World War II (1946), pp. 22-46. HD.
81Cmtee to Study the MD, 1942, Testimony of Col Harry D.Offutt, pp. 196-98. HD.
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Navy.82 To provide a more exact guide theHospitalization Division developed a policy that was published on 26 March 1941.83While it did not relieve local surgeons of responsibilityfor selecting patients to be transferred, it provided generally that allrequiring more than sixty days of hospitalization as well as those needingspecialized treatment not available at station hospitals should be sent togeneral hospitals. Major elective84 operationswere to be performed at general hospitals only. Station hospitals were todispose of enlisted neuropsychiatric or psychoticpatients locally, but were to send officers, nurses, andwarrant officers who were similarlyaffected or who had other disabilities which made themunfit for further military service to general hospitals for observation anddisposition. Hospitals previously designated for the careand treatment of special cases were to continue to receive them as in the past.
Soon after this policy was established the HospitalizationDivision developed a procedure to implement it. Under current Army regulationshospital commanders needed corps area approval for each transferof a patient from a station to a general hospital.85 Asnew hospitals opened, this requirement resulted in much paper work for corpsarea surgeons and in delayed treatmentfor patients. On 19 May 1941, therefore, TheSurgeon General requested authority to set aside specificnumbers of general hospital beds to which station hospitals might transfer patientswithout reference to corps area headquarters. The GeneralStaff approved this request and on 21 June 1941 authorized the establishment ofa system of bed credits. This permittedthe Hospitalization Division to allot a certain number ofbeds in general hospitals to each large station hospital and, through corps areasurgeons, to small ones. Thereafter post commandersnormally transferred patients togeneral hospitals without reference to higher authority.When stations needed changes in allotments, they ordinarily requested themthrough corps area surgeons. In emergencies, they were authorized to communicatedirectly with The Surgeon General.86
The procedure for transferring patients fromstation to general hospitals was further simplified in thelate summer of 1941. Until then Army regulations required eachhospital to make extracts or copies of the clinicalrecords, including case histories, of patients beingtransferred, to be sent along with them. As the number of patientsincreased, this time-consuming process began to delaytheir transfer and hence their treatment. The Surgeon General then securedapproval of a change which permitted station hospital authorities to transfer togeneral hospitals, along with patients,the original clinical records of their cases. Thetransferring hospital kept only clinical-record briefs and cross referencesindicating the disposition of original records.87
Another problem for the Hospitalization Division was thedisposition of patients. It concerned the Hospital Construction and RepairSubdivision also, for prompt disposition of patients reduces total bedrequirements by making available for patient care more of the beds al-
82(1) AR 40-600, Gen Hosp, Gen Provisions, 31 Dec 34. (2) Mins, SGO Conf with CA Surgs, 10-12 Mar 41. SG:337.-1.
83(1) SG Ltr 24, 26 Mar 41. (2) AnnualReport. . . SurgeonGeneral, 1941 (1941), p. 253.
84Advantageous to the patient but not necessary to savelife.
85AR 40-600, par 4 a (1), 31 Dec 34.
86(1) Ltr, SG to TAG, 19 May 41, sub: Trf of Pnts to Gen Hosps. SG: 705.-1. (2) WD Cir 120, 21 Jun 41.
87(1) Ltr, Brig Gen H. D. Offutt to Col H. W. Doan, 10 Jun48, annex 1. HD: 322. (2) WD Cir 184, 26 Aug 41. (3) SG Ltr 94, 16 Sep 41.
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ready set up. During 1941 there was considerable localdissatisfaction with difficulties and delays encountered in granting patientsdisability discharges from the Army.Believing that lack of experience on the part of manymedical officers was responsible, one corps area surgeon issued adirective in 1940 to clarify procedures for handling suchcases.88 In general, the centralization in corps area headquarters ofauthority to discharge men on certificates of disability, rather thaninefficient hospital procedures, seems to have been considered the mostimportant reason for delays.89 Apparently sharing this view, TheSurgeon General secured authority in September 1941 for the commanders ofgeneral hospitals to grant disability discharges. At the same time, it should benoted, the War Department was further decentralizing such authority to otherlocal commanders, including those of divisions, reception centers, replacementtraining centers, and exempted stations. The Surgeon General also securedauthority for general hospital commanders to issue travel orders for menreturning to duty or being discharged from the Army.90
In the fallof 1941 the Chief of Staff became concerned about delays in the retirement ofdisabled officer-patients. When General Marshall called a case of this kind tohis attention, The Surgeon General replied that such delays were"chronic" but that they occurred in large part in Army administrativechannels after general hospitals had completed their work and made theirrecommendations. Soon afterward he directed general hospital commanders to"personally assure themselves that the disposition of officer patients isexpedited insofar as this can be done without prejudice to the interest of theindividual or of the Government."91 Furthersteps to speed the disposition of officer-patients were not taken at this time.
Partial simplification of the procedure for granting disability dischargeswent some distance, though not as far as possible, toward relieving Armyhospitals of patients who were unnecessarily occupying beds. Action was alsotaken to relieve hospitals of certain other patients-that is, some of thosesuffering from tuberculosis, psychosis, and other chronic diseases. At thebeginning of mobilization the President approved a recommendation of the FederalBoard of Hospitalization that members of the armed forces who were injured orincurred disabilities "in line of duty" and whose physicalrehabilitation by the Army or Navy was not feasible should be cared for by theVeterans Administration. Accordingly the Surgeon General's Office securedapproval in March 1941 for the transfer to the Veterans Administration of mostenlisted men who were permanently disabled by the development of pulmonarytuberculosis. Two months later this provision was extended to all classes ofchronic disability cases. Three classes of tuberculous patients-those nearingretirement after thirty years of service, those in the first threenoncommissioned grades whose recovery was probable within a year, and thosewhose cases were considered not to have been incurred in line of duty-were tobe kept in the Army and transferred to Fitzsimons General Hospital. As soon as
88An Rpt, 1940, Surg 2d CA. HD.
89Rpt, Conf of SG with CA Surgs, 10-12 Mar 41. HD: 337.
90(1) Cmtee to Study the MD, 1942, Testimony of Col Offutt, pp. 196-98. HD.(2) WD Cirs 194, 17 Sep 41; 196, 19 Sep 41; and 187, 4 Sep 41.
91(1) Memo, CofSA for SG, 23 Sep 41. (2) Memo, CG WRGH for SG, 26 Sep 41. (3) Ltr, SG to COs Gen Hosps, n d, sub: Disposition of Off Pnts. (4) Memo, Act SG to CofSA, 6 Oct 41,same sub. All in SG: 705.-1. (5) WD Cir 217, 15 Oct 41.
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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 wasmore complicated. Many could not be transferred to the Veterans Administrationbecause their disabilities had existed before induction. State institutions wereoften reluctant to accept those who required care in locked wards. As a resultpsychotic patients began to accumulate in Army hospitals. Early in themobilization period a large three-story section of Walter Reed General Hospitalwas converted into closed wards and the Medical Department arranged to use, asan 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 newgeneral hospital erected during 1941. In the summer of that year, after WalterReed General Hospital had demonstrated the rather elementary fact that transferof psychotic patients to state institutions was expedited by addressing requeststo proper state agencies or authorities, The Surgeon General issued a circularletter naming those in each state. About the same time his Office arranged toestablish a special neuropsychiatric center in the just-completed and unusedState Hospital at Danville, Ky. Called Darnall General Hospital, it was ready toreceive patients a few months after the Japanese attacked Pearl Harbor.93
Starting almost from scratch in September 1939, the MedicalDepartment reached a state of partial preparation for war by December 1941. Toprovide hospitals for a rapidly expanding Army in the United States, a simplemethod of computing requirements was adopted and ratios of beds to troop strength-smaller than The SurgeonGeneral considered desirable-were officially established. Experience inexpanding hospital facilities showed that it was impracticable to rely upon theuse of existing Army hospitals and available non-Army buildings. It alsorevealed imperfections and shortcomings incantonment-type hospitals planned in the thirties, with the result that a newtype of hospital morecompact and fire resistant was developed. As new hospitalsopened, the Surgeon General's Office evolved general guides for theirorganization and administration but left hospital commanders with much autonomyin this field. Attention was focused not upon internal hospital administrationbut upon simplifying procedures affecting the hospital system in general. Inthis connection attempts were made to reduce unnecessary occupancy of beds bypatients no longer needing treatment or of no further use to the Army. Therewere shortages of personnel, though authorized allotments for hospitals weregenerous, and it was necessary in many instances to substitute civilians forenlisted men. Shortages of supplies and equipment were alleviated by theingenuity of hospital commanders and their staffs. Meanwhile, the SurgeonGeneral's Office was also concerned with plans and preparations for overseashospitalization, the subject to which the discussion now turns.
92(1) AnnualReport . . . SurgeonGeneral, 1941 (1941), p. 253. (2) Ltr SGO 300.3-1, SG to TAG, 7 Apr 41, sub: Proposed Change in AR 615-360. AG: 220.8 (8-1-34) Case 1. (3) WD Cirs 100, 19 May 41; 44, 17 Mar41; 226, 27 Oct 41; and 252, 11 Dec 41.
93(1) Ltr,Brig Gen H. D. Offutt to Col H. W. Doan, 10 Jun 48, incl. 1. HD: 322.(2) Ltr, SG to QMG, 17 Dec 40, sub: Add Fac for the Careof Insane, and 1st ind QM 632 C-EP (Gen Hosp), QMG to SG, 31 Jan 41. SG: 632.-1. (3)SG Ltr 64, 24 Jun 41, sub: Disposition of NP Pnts. (4) AnnualReport . . . SurgeonGeneral, 1941 (1941), p. 165.
