Wediccd 
in the 
Gounties of fnaryland 
TYlaryland State Planning Commission 
J-lpril — tfledical Care 
in 
C ounties of 
Report of the 
Committee on tfledical Cave 
of the 
Maryland State TPlanning C owimission 
Idpril — ig-l—l- PUBLICATION NO. 40 
lor sale by the Maryland State Planning Commission 
301 Latrobe Hall, The Johns Hopkins University 
Baltimore, Maryland 
Price 50 cents Two contrary laws seem to be wrestling with each 
other nowadays; the one, a law of blood and of death, ever imagining 
new means of destruction and forcing nations to be constantly ready 
for the battlefield—the other, a law of peace, work and health, ever 
evolving new means of delivering man from the scourges which 
beset him. 
The one seeks violent conquests, theother the relief of humanity. The 
latter places one human life above any victory;—while the former 
would sacrifice hundreds and thousands of lives . . . 
Louis Pasteur, 
At the opening of the Pasteur Institute, 
November 14, 1883- 
Ill Gonients 
Page 
Page 
LIST OF TABLES AND CHARTS vi 
CHAPTER I 
THE FIELD SURVEY 1 
Objectives 1 
Individuals Interviewed 1 
CHAPTER II 
CHARACTERISTICS OF THE POPULATION 3 
Distribution 3 
Economic Status 3 
Birth and Death Rates 5 
Medical Care Facilities 5 
SUMMARY TABLE 5 
CHAPTER III 
PHYSICIANS’ SERVICES 9 
Changes in the Distributionof Physicians 9 
Advantages in Trend 9 
Disadvantages of Concentration 9 
Decline in Number of Physicians in Some Areas 9 
Changes in Age Distribution 12 
Economic Status of Counties and Relative Number of Physicians . . 12 
Distribution of Physicians in 1941 12 
The Physician: Population Ratio 12 
Age Distribution in 1941 13 
Relative Activity 13 
Specialization 14 
PHYSICIANS AND THE PROBLEMS OF MEDICAL CARE 14 
Physicians Interviewed 14 
Characteristics of Physicians Interviewed * 14 
Topics Discussed and Opinions Expressed 15 
SUMMARY 19 
CHAPTER IV 
NURSES’ SERVICES 21 
Distribution of Nurses 21 
Types of Nursing Service 21 
SUMMARY 22 
CHAPTER V 
DENTISTS’ SERVICES 23 
Distribution of Dentists 23 
Dental Care Among Negroes 24 
Public Dental Services 24 
The State Oral Hygiene Program 24 
Cost of Clinics 24 
Programs for Dental Care for the Indigent 25 
Comments on Determination of Eligibility 25 
Local Administrative Representation 25 
Essential Steps 25 
SUMMARY 26 
CHAPTER VI 
GENERAL HOSPITALS 27 
Distribution 27 
Ownership and Administration 27 
Board of Directors 27 
Superintendents 27 
Ladies’ Auxiliaries 28 
The Medical Staff 28 
Residents and Internes 29 
The Nursing Staff 29 
Other Members of Staff 29 
Departments and Services 29 
Types of Construction 31 
Financial Resources 31 
Summary 34 
Important Deficiencies 34 
RESIDENTS OF COUNTIES HOSPITALIZED ELSEWHERE 36 
County Patients Admitted to Hospitals in the City of Baltimore. . 36 
County Patients Hospitalized in the District of Columbia 38 
County Residents Hospitalized in Other States 39 
SUMMARY 39 
CHAPTER VII 
HEALTH DEPARTMENT SERVICES 43 
Introduction 43 
Full-Time County Health Service 43 
The Program of County Health Departments 43 
Maintenance Costs 44 
INTERVIEWS WITH COUNTY HEALTH OFFICERS 45 
Increase Reported in Requests for Medical Care 45 
Analysis of Requests for Medical Care Received by County Health 
Departments 46 
Characteristics of Applicants 46 
Origin of Requests 47 
Disposition of Requests 48 
Data Inadequate for Accurate Estimate of Number of Medically 
Indigent 48 
Health Departments Prevent Unnecessary Hospitalization 48 
COUNTY MEDICAL CARE PROGRAMS IN DEPRESSION YEARS 48 
Discussion of Program 48 
CLINICS AND EQUIPMENT IN THE COUNTY HEALTH DEPT... 49 
SUMMARY 49 
CHAPTER VIII 
WELFARE DEPARTMENT SERVICES 51 
Types of Assistance 51 
Usual Procedures for Securing Assistance and Medical Care 51 
Selection of Physicians and Authorization of Service 53 
Financial Provisions for Medical Care 53 
Expenditures for Medical Care 53 
Agreements for Procuring Medical Care 54 
Plans for Payment 54 
Financial Arrangements with Physicians 55 
iv Page 
Page 
Physicians’ Fees 55 
Opinions on the Availability of Medical Care 55 
Medical Care Problems Outlined by Welfare Executives 55 
Suggested Solutions for Problems 57 
SUMMARY 57 
CHAPTER IX 
THE SCOPE AND COSTS OF A MEDICAL CARE PROGRAM. . 58 
THE NUMBER OF BENEFICIARIES 58 
The Number of Indigent in the Counties in 1940 58 
Classification of Counties 58 
The Medically Indigent Not Included in Calculations 59 
THE FREQUENCY OF ILLNESS AND VOLUME OF MEDICAL 
CARE 59 
Distribution of Calls 60 
Cases Attending Clinics 60 
THE CHARACTER OF MEDICAL SERVICES NEEDED 60 
Private Practitioners’ Services 60 
Types of Clinics 62 
Clinic Services Now Functioning 62 
Hospitalization 63 
Health Department Services 63 
Administration 64 
THE COSTS OF OPERATION 65 
Future State Appropriations for Hospitalization 67 
SUMMARY OF ESTIMATED ANNUAL COSTS OF MEDICAL 
CARE PROGRAM FOR 82,726 INDIVIDUALS IN THE 
COUNTIES OF MARYLAND. 69 
CHAPTER X 
ACTIVITIES OF THE EXECUTIVE COMMITTEE 70 
Special Inquiries 70 
SUMMARY 74 
CHAPTER XI 
FURTHER ACTIVITIES OF THE EXECUTIVE COMMITTEE... 75 
Introduction..; 75 
The Nature of the Problem of Medical Care in the Counties 75 
Essential Features in a Long Term Program for Medical Care in the 
Counties 76 
SUMMARY 78 
CHAPTER XII 
CONCLUSIONS AND RECOMMENDATIONS 79 
Conclusions 79 
Recommendations 79 
Course of Action Recommended 79 
The Need for a Separate Study for Baltimore City is Indicated.... 80 
Hospitals for Treatment of Chronic Disease 80 
APPENDIX 81 
V List of Tables and Charts 
Page 
Page 
Table 1—The total Population of the Counties of Maryland Ac- 
cording to the U. S. Census Taken as of April 1, 1940, Together 
with the Total White, Colored and Percentage of Each 4 
Table 2-—Proportion of White and Colored Population in the 
Counties of Maryland, U. S. Census, 1940 4 
Table 3—Population Density in the Counties of Maryland—Persons 
per Square Mile in Rural Areas, U. S. Census 1940 and Maryland 
Geological Survey 4 
Table 4-—Proportion of Families Residing on Farms in the Counties 
of Maryland, U. S. Census, 1940 4 
Table 5—The Total Population of the Counties of Maryland Ac- 
cording to the U. S. Census of 1790 and 1940, by Color 6 
Table 6—Percent Increase or Decrease in the Population of the 
Counties of Maryland Since Their Dates of Establishment 6 
Table 7—Income Tax Returns per 1,000 Population, from the 
Counties of Maryland, U. S. Department of Commerce, 1938 6 
Table 8—Households Receiving Assistance from County Welfare 
Departments in Maryland in 1940, and the Number per 1,000 
Population 6 
Table 9—Total Persons Employed and Awaiting Employment by 
Works Projects Administration of Maryland for Week Ending 
June 19, 1940, and the Number per 1,000 in the County of Residence 7 
Table 10—Annual Births per 1,000 Population in the Counties of 
Maryland. Average 1936-1940, Corrected for Residence 7 
Table 11—Mortality per 1,000 Persons in the Counties of Maryland, 
Average 1936-1940, Corrected for Residence 7 
Table 12—Deaths Under One Year of Age per 1,000 Live Births in 
the Counties of Maryland. Average 1936-1940, Corrected for 
Residence 7 
Table 13—Summary Table 8 
Table 14—Total Physicians in the Counties of Maryland in 1909, 
1923 and 1938, the Estimated Population, the Number of Persons 
per Physician, and the Percentages of Increase in 1938 over 1909.. 9 
Chart I—Distribution of Physicians 1906 10 
Chart II—Distribution of Physicians 1940 11 
Table 15—Total Physicians in Active Practice in the State of Mary- 
land, July 1, 1941, by Color and Sex. Practitioners Employed 
Full-Time in Hospitals, Sanatoria and Health Departments are not 
Included 12 
Table 16—Physicians in Active Practice in the State of Maryland, 
July 1, 1941, and the Physician: Population Ratio. Practitioners 
Employed Full-Time in Hospitals, Sanatoria and Health Depart- 
ments are not Included 13 
Table 17—Physicians in Active Practice in 1940 in the Counties of 
Maryland in Age Groups—Under 45, 45-64, 65 and over—Together 
with the Percentages in Each Group 13 
Table 18—Total Physicians and Specialists in the State of Maryland, 
July 1, 1941 14 
Table 19—Total Specialists and Their Fields of Specialty in the State 
of Maryland July 1, 1941 15 
Table 20—Active Registered Nurses in Maryland in 1941 by Race, 
Sex and the Nurse: Population Ratio 21 
Table 21—Active Female Registered Nurses and Limited Types of 
Nursing in the State of Maryland in 1941 21 
Table 22—Percentage of Female Registered Nurses by General and 
Special Types of Nursing in Maryland in 1941 22 
Table 23—Distribution of Dentists in Active Practice in the State of 
Maryland, Baltimore City and in the Counties of Maryland in 1940, 
Together with the Total Population and the Dentist: Population 
Ratio 23 
Table 24—School Dental Clinics Conducted in the Counties of 
Maryland, 1940 26 
Table 25—Distribution of General Hospitals in the Counties of 
Maryland in 1940, Together with Their Bed Capacity (Excluding 
Bassinets) and the Hospital-Bed; Population for the County in 
which the Institution was Located 28 
Table 26—Partial List of Ambulance Services in the Counties of 
Maryland in 1941, Indicating the Owners or Operators, the Number 
and Total Capacity of Vehicles 31 
Table 27—State and Local Appropriations to Hospitals in Counties 
of Maryland, 1939-40 32 
Table 28—Number and Percent of Pay and Free Patients in Hospitals 
in the Counties of Maryland, 1939-40 32 
Table 29—Number and Percent of Pay and Free Hospital Days in 
Hospitals in the Counties of Maryland, 1939-40 33 
Table 30—Total Free Hospital Days, 1939-40, the Amount Received 
per Free Hospital Day from State and State and Local Sources, 
Together with the Estimated Cost per Hospital Day 34 
Chart III—Flow Chart of the Annual Rate of Admissions of County 
Residents to Baltimore City Hospitals, 1940 37 
Table 31—Number of Admissions of County Residents to Hospitals 
in the City of Baltimore in 1940, Together with the Total Patient- 
Days and Admissions per 1,000 Population in the County of 
Residence 35 
Table 32—County Residents Admitted to Hospitals in City of 
Baltimore in 1940. The Total Number of Patients, the Number per 
1,000 Population in the County of Residence and the Pay Status .. 38 
Table 33—Patient-Days Hospitalization of County Residents in 
Hospitals in the City of Baltimore in 1940 39 
Table 34—County Residents Hospitalized in the District of Columbia 
in 1940, Their Color and Pay Status, by Hospitals 40 
Table 35—County Residents, both White and Colored, Hospitalized 
in the District of Columbia in 1940, Their County of Residence and 
Pay Status 40 
Table 36—Residents of the Counties of Maryland Hospitalized in 
District of Columbia Hospitals in 1940, indicating the Total Hos- 
pital Days and Pay Status, by Hospitals 41 
Table 37—Hospital Days Provided County Residents in the District 
of Columbia in 1940, Indicating Pay Status and County of Residence, 
Together with the Percent of Total Hospital Days 41 
VI Table 38—The Number of Patients, Total Patient Days and Average 
Stay in Hospital of Pay, Part-Pay and Free Patients in Institutions 
in the Counties of Maryland in 1939-40, and for County Residents 
Hospitalized in the City of Baltimore and in the District of Colum- 
bia in 1940 41 
Table 39—Organization of the County Health Departments in 1940, 
Indicating the Number of Full-Time County Health Officers, Public 
Health Nurses, Sanitary Officers and Dentists, Together with the 
Personnel; Population Ratio 44 
Table 40—Budget of State Department of Health in 1940-41 Showing 
Total Expenditures for the Counties of Maryland, Baltimore City 
and for Administrative Purposes 45 
Table 41—The Budgets of the County Health Departments for the 
Year 1940-41, Indicating the Expenditures per Capita, the Total 
Local Appropriations, and the Percentage of the Total Budget 
Appropriated Locally, in Order of the per Capita Expenditures.... 46 
Table 42—Requests for Medical Care Received in Eight County 
Health Departments in Maryland in the Late Winter and Spring 
Months of 1940 47 
Table 43—Budget of the State and County Welfare Departments for 
the State of Maryland for the Year 1942 53 
Table 44—Unduplicated Number of Households Receiving As- 
sistance from the Various Categories of Assistance in the Counties 
of Maryland in June, 1940 54 
Table 45—Summary of Procedures Used by County Welfare Depart- 
ments to Compensate Physicians for Medical Care in the Home 56 
Table 46—Total Households and Estimated Number of Individuals 
Receiving Assistance Assuming that the Average was 3-5 Persons 
per Family; and the Number per 1,000 Population in the County of 
Residence in June, 1940 59 
Table 47—Total Persons Employed and Awaiting Employment in 
the Works Projects Administration in the Counties of Maryland 
for the Week Ending June 19, 1940 60 
Table 48—Estimated Number of Individuals Receiving Assistance 
from County Welfare Departments, and Persons in Households in 
which one of the Members was Employed by the W.P.A 61 
Page 
Table 49—The Total Number of Individuals Receiving Assistance 
from County Welfare Departments and those in Families in which 
the Head of Household or one of its Members was Employed in the 
W.P.A 61 
Table 50—The Total Individuals Receiving Assistance and Those 
in Families in which at least one Member was Employed by the 
W.P.A., the Estimated Number of Cases attended by a General 
Practitioner Annually, on the Assumption that there were 526 
Cases per 1,000 Population 62 
Table 51—Estimated Number of Calls by General Practitioners by 
Counties, Assuming that 73 Percent were Office, 5 Percent Hospital 
and 22 Percent Home Calls 63 
Table 52—The Total Beneficiaries with Estimated Total Clinic Cases; 
and the Estimated Total Clinic Visits per Year, Assuming an Aver- 
age of 5-0 Clinic Calls per case 64 
Table 53—Cost of Calls by General Practitioners in the Office, 
Hospital and the Patient’s Home, at $1.50, $1.50 and $2.50 per 
Call, Respectively 64 
Table 54—The Total Indigent and the Resident Birth Rate in the 
Counties of Maryland in 1940, Together with the Estimated Num- 
ber of Births and the Total Fees for Obstetrical Care During Labor, 
Delivery and the Immediate Puerperium at $25 per Case 65 
Table 55—The Total Clinics per Year in Each County and in Each 
Group of Counties, with Total Clinicians Fees at $10 per Clinic and 
Travel at $20 per Clinic 66 
Table 56—The Number of Nurses Suggested for each County and 
in Each Group of Counties, Together with Estimates of the Costs.. 67 
Table 57—The Number of Dentists Suggested for Each County and 
Each Group of Counties, Together with the Salaries and Travel.. 68 
Table 58—The Number of County Health Officers with the Suggested 
Minimum Increases in Salary for Administering the Program of 
Medical Care 68 
Table 59—The Estimated Cost of Equipment, Supplies, Drugs and 
Biologicals 69 
Page MARYLAND STATE PLANNING 
COMMISSION 
Abel Wolman, Chairman 
Member at Large 
William L. Galvin 
Thomas B. Symons 
State Board of Public Welfare 
Member at Large 
Robert H. Riley 
Ezra B. Whitman 
State Department of Health 
State Roads Commission 
I. Alvin Pasarew, Director COMMITTEE ON MEDICAL CARE 
of the 
MARYLAND STATE PLANNING COMMISSION 
R. Austrian, M. D., Baltimore City Medical Society 
F. V. Beitler, M. D., Maryland Academy of Medicine and 
Surgery 
T. Roy Brookes, Maryland State Grange 
B. Lucien Brun, D. D. S., The Maryland Dental Association 
James D. Carr, M. D., Maryland Medical, Dental and 
Pharmaceutical Association 
Alan M. Chesney, M. D., School of Medicine of The Johns 
Hopkins University 
*J. Douglas Colman, Associated Hospital Service of Balti- 
more, Inc. 
*Victor F. Cullen, M. D., Medical and Chirurgical Faculty of 
Marylaod 
Louis H. Douglass, M. D., School of Medicine of the Uni- 
versity of Maryland 
*Allen W. Freeman, M. D., School of Hygiene and Public 
Health of The Johns Hopkins University 
*Harry Greenstein, The Maryland Conference of Social Welfare 
*Maurice C. Pincoffs, M. D., Baltimore City Medical 
Society 
George H. Preston, M. D., State Board of Mental Hygiene 
Robert H. Riley, M. D., State Department of Health 
Henry E. Sigerist, M. D., Institute of the History of Medicine 
of The Johns Hopkins University 
*Winford H. Smith, M. D., Baltimore Hospital Conference 
Walter Sondheim, The Lay Public 
Harvey B. Stone, M. D., Medical and Chnrurgical Faculty 
of Maryland 
Miss Helen E. Wright, R. N., Maryland State Nurses 
Association 
John T. Jones, Maryland and District of Columbia Industrial 
Union Council 
E. F. Kelly, Maryland Pharmaceutical Association 
R. C. Lamb, Maryland Congress of Parents and Teachers 
Carroll Lockard, M. D., Baltimore City Medical Society 
Mrs. George V. Lottier, The Lay Public 
George M. Moffett, The Lay Public 
Joseph P. McCurdy, Maryland State and District of Columbia 
Federation of Labor 
Thomas W. Pangborn, The Lay Public 
I. Alvin Pasarew, Maryland State Planning Commission 
J. Milton Patterson, State Department of Public Welfare 
Mrs. Thomas J. Tingley, The Maryland Federation of 
Women’s Clubs 
Ralph P. Truitt, M. D., Mental Hygiene Society of Maryland 
Thomas J. S. Waxter, Baltimore City Department of Public 
Welfare 
*C. E. Wise, Jr., Maryland Farm Bureau, Inc. 
Huntington Williams, M. D., Baltimore City Health 
Department 
Samuel Wolman, M. D., The Maryland Tuberculosir 
Association 
Committee 
Maurice C. Pincoffs, M. D., Chairman (now with U. S. Army Medical Corps) 
Victor F. Cullen, M. D., Acting Chairman 
Joint Committee for the Survey of Medical Care in the Counties of Maryland 
State Department of Health: 
Robert H. Riley 
State Department of Public Welfare: 
J. Milton Patterson 
W. Wallace Lanahan 
William L. Galvin 
Benjamin C. Perry 
Walter N. Kirkman 
Committee on Medical Care of the Maryland State Planning Commission 
Allen W. Freeman 
Victor F. Cullen 
Maurice C. Pincoffs, Chairman: 
W. Ross Cameron, Director of Survey 
X MARYLAND STATE PLANNING COMMISSION 
WILLIAM L. GALVIN 
ROBERT H. RILEY 
THOMAS B. SYMONS 
EZRA B. WHITMAN 
ABEL WOLMAN 
BALTIMORE, 
MARYLAND 
Chairman 
I. ALVIN PASAREW 
Director 
April 15, 1944. 
Honorable Herbert R. O’Conor, 
Governor of Maryland, 
Annapolis, Maryland. 
My dear Governor O’Conor: 
I take pleasure in transmitting herewith, for your consideration, the report of 
the State Planning Commission’s Committee on Medical Care. In the report the 
findings and recommendation for a long-term medical care program for the State’s 
indigent and medically indigent are summarized. 
The Committee has devoted itself during the past three years to the task of as- 
sembling data and information in the field. Upon the basis of these findings it has 
developed a State program embracing medical care services for the indigent and 
medically indigent for the counties. This program has the acceptance of the various 
public agencies and professional and lay groups associated with the administration 
of medical care services throughout the State. 
This report represents the first stage of the Committee’s planning program. Plans 
have been formulated to study and recommend a program for Baltimore City, which 
represents a far more complex problem. The Committee will also continue to serve 
the Commission as its advisory body on all phases of medical care plan and program. 
Your attention is particularly called to the recommendations of the Committee 
suggesting “important and basic extension of the duties of the State Department of 
Health’’, since these should obtain your early attention so as to bring about effective 
implementation of the recommendations. 
The Commission takes pleasure in acknowledging its indebtedness to the members 
of the Committee who gave so unstintingly of time and effort, and to various public 
and private groups which contributed so generously to this work. 
The Commission deeply appreciates your support and full cooperation in the 
development of this program. 
Respectfully yours, 
Abel Wolman, Chairman 
xi Maryland State Planning Commission 
Committee on Medical Care 
BALTIMORE. MARYLAND 
527 Bressler Building 
University of Maryland 
April 10, 1944 
Abel Wolman, Dr. Eng., Chairman, 
Maryland State Planning Commission 
Baltimore, Maryland 
Dear Dr. Wolman: 
I have the honor to transmit herewith the report of the Committee on Medical 
Care recording the findings of its survey of medical care in the counties of Maryland 
and its initial recommendations. 
The Committee’s work to date has strengthened our belief in the soundness of the 
original concept of the Committee as a continuing instrument for study of the medical 
care problems of the State. The obvious next concern of the Committee is the medical 
care problems of Baltimore City, as well as the many post-war projects affecting the 
State’s responsibilities for health and medical care which doubtless will come to the 
Committee for study and comment. 
It should be recognized that the initial recommendations included herein propose 
an important and basic extension of the duties of the State Department of Health. 
Its functions traditionally have been limited strictly to environmental health matters. 
We propose extending its scope to include responsibility for personal health service 
to the indigent and medically indigent. 
While we propose the use of governmental funds only for the care of the indigent 
and medically indigent, we believe this use, in the manner suggested in the body of 
this report, will encourage more effective integration of all the State’s medical 
resources (private, voluntary and governmental) and assure more and better health 
services to all our citizens. 
Sincerely yours, 
Victor F. Cullen, M. D., Acting Chairman 
XIII FOREWORD 
r I Medical and Chirurgical Faculty of Maryland, 
aware of many deficiencies in the present status of 
medical care1 in this State and of the absence, in Maryland, 
of an official warrant for any group to evolve a coordinated 
program of medical care, proposed on August 23, 1939, in 
an open letter2 to the Chairman of the Maryland State 
Planning Commission that a standing committee of the 
Commission be formed continuously to survey the problems 
of medical care for the citizens of this State. It was suggested 
that this Committee should formulate, from time to time, 
recommendations for the extension and better utilization 
of existing medical facilities, and for the development of 
such new facilities as may be required. The Faculty recom- 
mended that this Committee be composed of representatives 
from all agencies concerned with the various aspects of 
medical care as well as from the general public. 
After conferences with the various agencies in this field, 
the Maryland State Planning Commission, with the ap- 
proval of Governor Herbert R. O’Conor, appointed the 
following persons to serve as a standing committee of the 
Maryland State Planning Commission, to be named the 
Committee on Medical Care, and designated Maurice C. 
Pincoffs, M. D., as its Chairman: 
requested that the Committee be prepared to suggest 
necessary corrective measures, to indicate what costs would 
be involved in such a program of correction, at what rate 
such changes might be introduced, and the most logical 
source of funds. 
The following Executive Committee was appointed and 
authorized to act for the General Committee: 
Maurice C. Pincoffs, M.D. Allen W. Freeman, M.D. 
Chairman Harry Greenstein 
J. Douglas Colman Winford H. Smith, M.D. 
Victor F. Cullen, M.D. C. E. Wise, Jr. 
Activities of the Executive Committee 
During the first year the Executive Committee met 
weekly, and thereafter, at less frequent intervals. Members 
of the General Committee were called from time to time 
to assist in special studies. 
The Executive Committee reviewed at length the status 
of medical and hospital care in the counties of Maryland. 
A summary of their deliberations was presented to the 
Maryland State Planning Commission on October 1, 1940. 
This report emphasized the need for more detailed and 
comprehensive information and recommended that a field 
survey be undertaken. 
Appointment of the Joint Committee 
The Maryland State Planning Commission approved the 
recommendation that a field survey be made, and formed 
a special committee, known as the Joint Committee, for 
the purpose of securing funds for this study. The Joint 
Committee included representatives of the Committee on 
Medical Care, the State Department of Health and the 
State Department of Welfare. The expenses of the survey 
were financed by appropriations from these two Depart- 
ments. The members of the Joint Committee were: 
Allen W. Freeman, M.D. Benjamin C. Perry, M.D. 
Chairman Walter N. Kirkman 
Victor F. Cullen, M.D. J. Milton Patterson 
Maurice C. Pincoffs, M.D. W. Wallace Lanahan 
Robert H. Riley, M.D. William L. Galvin 
Survey Plans with Subsequent Modifications 
On February 1, 1941, the office and field staff was or- 
ganized with W. Ross Cameron, M.D., in charge. Dr. 
Cameron was assigned by the State Department of Health 
to act as Director of the Survey. It was planned that the 
Maurice C. Pincoffs, M.D. 
Chairman 
Charles R. Austrian, M.D. 
F. V. Beitler, M.D. 
T. Roy Brookes 
Lucien Brun, D.D.S. 
James D. Carr, M.D. 
Alan M. Chesney, M.D. 
J. Douglas Colman 
Victor F. Cullen, M.D. 
Louis H. Douglass, M.D. 
Allen W. Freeman, M.D. 
Harry Greenstein 
Miss Helen E. Wright, R. N. 
John T. Jones 
E. F. Kelly, M.D. 
R. C. Lamb 
Mrs. George V. Loftier 
George M. Moffett 
Joseph P. McCurdy 
Thomas W. Pangborn 
I. Alvin Pasarew 
J. Milton Patterson 
Robert H. Riley, M.D. 
George H. Preston, M.D. 
Henry E. Sigerist, M.D. 
Winford H. Smith, M.D. 
Walter Sondheim 
Harvey B. Stone, M.D. 
Mrs. Thomas J. Tingley 
Ralph E. Truitt, M.D. 
Thomas J. S. Waxter 
Huntington Williams, M.D. 
C. E. Wise, Jr. 
Samuel Wolman, M.D. 
The Committee on Medical Care held its first meeting 
on January 23, 1940. At this meeting, Abel Wolman, 
Dr. Eng., Chairman of the Maryland State Planning 
Commission, charged the Committee with the task of 
determining the existing defects, if any, in our present 
private and public facilities for medical care. If deficiencies 
were found, the Committee was expected to determine and 
evaluate their amount and character. Furthermore, he 
JAs a rule, “Medical Care’’ is used throughout this report in an inclusive 
sense to cover the services rendered by all agencies engaged in safeguarding 
and improving the health of the people. 
2See Appendix. 
XV work would extend over a period of approximately 15 
months, including about 12 for the field survey and 3 for 
the preparation of the report. 
About July 1, 1941, world conditions were such that 
war seemed imminent. Since several of the Committee and 
its staff were expecting to be called into active service 
momentarily, it was decided to modify the program. For 
example, instead of attempting to interview all physicians 
in the counties of Maryland, representative groups were 
selected in three sections of the State. 
On September 15, 1941, Dr. Cameron was called into 
active duty with the U. S. Public Health Service. Work 
in the field was discontinued and, unfortunately, it was 
necessary to abandon several important phases of the 
survey. 
Due to the exigencies of war, it was necessary to make 
important changes not only in- the field staff, but in the 
membership of the committees. On April 1, 1942, Dr. 
Pincoffs, the Chairman, who devoted many invaluable 
hours to the work of the Committee, volunteered for 
active service with the U. S. Army Medical Corps and is 
now overseas. On July 1, 1942, Allen W. Freeman, M.D., 
who first served as Chairman of the Joint Committee and 
later replaced Dr. Pincoffs as Chairman of the Executive 
Committee, retired from active participation due to illness. 
Victor F. Cullen, M.D., was elected to replace Dr. 
Freeman as the Chairman of the Executive Committee and 
Charles R. Austrian, M.D., president-elect of the Medical 
and Chirurgical Faculty of Maryland, was elected to 
replace Dr. Pincoffs on the Executive Committee. 
Scope of Report 
In response to a request of the Maryland State Planning 
Commission that a summary of its work from the date of 
appointment to the present be made available, the Com- 
mittee on Medical Care presented an initial report of its 
findings and recommendations1. 
It has been indicated that, due to conditions beyond the 
control of the Committee, the field survey and report are 
incomplete. It is believed, however, that the data ac- 
cumulated in the field, together with the' considered 
opinions of the Committee, justify adoption of the recom- 
mendations for reorganizing and strengthening the medical 
care structure in the counties of Maryland. 
Since changes in the field of medical care have been 
occurring rapidly, recommendations based on conditions 
at the time of the survey may not all be applicable on the 
date of publication. The Committee is of the opinion, 
however, that, in general, these recommendations are 
basic and, if conditions are comparable at the termination 
of hostilities, they should be adopted as soon as funds and 
manpower are available. 
Relationship of Survey to Baltimore City 
While the Committee on Medical Care was aware that 
there were serious problems in medical care in the City of 
Baltimore, it seemed obvious to it that facilities available, 
particularly the hospitals and clinics, were more adequate 
than those in the counties and, therefore, that the problem 
pressed less urgently for solution. For this reason, as well 
as the magnitude of the task, the scope of the survey was 
limited strictly to the counties of Maryland. The Committee 
believes now that the medical care problems of the City 
of Baltimore should be studied as soon as arrangements 
can be effected. 
Additional Activities of Committee 
In addition to the activities outlined in this report, the 
members of the Committee, both individually and col- 
lectively, served as consultants to consider a variety of 
State-wide medical care problems which were presented 
for immediate solution. These included the extension of 
the laboratory services of the State Department of Health, 
the need to replace almshouses by chronic disease hospitals 
and the plans for the construction of general hospitals to 
meet acutely increased demands. In addition, information 
on the distribution of physicians was provided the Pro- 
curement and Assignment Service and data on other aspects 
of the general problem of medical care were made available 
to other governmental and private agencies. Several of 
these activities were the subjects of written reports, in 
other instances the consultations were quite informal. 
Suggestions were received from several sources that the 
Committee extend its activities to include the study of 
many new problems which were developing as the war 
progressed. It was decided, however, that the Committee 
would confine its attention to the tasks to which it had 
been assigned. 
Acknowledgments 
The Committee deeply appreciates the valuable assistance 
given by many departments of the State government, 
especially the State and County Departments of Health 
and the State and County Departments of Welfare. A large 
number of officials in every county of the State, as well 
as members of the medical, dental, nursing professions and 
hospital administrators provided much of the material 
upon which this report is based. The Committee also is 
indebted to the U. S. Public Health Service for the as- 
sistance of Anthony Ciocco, Ph.D., who helped to assemble 
much of the information essential to the preparation of 
this report. 
initial Report of Committee on Medical Care, Maryland State Planning 
Commission, Publication 38, March, 1943- Chapter I 
THE FIELD SURVEY 
Objectives 
On February 1, 1941, a field survey of medical facilities 
in the counties of Maryland was instituted. The 
staff consisted of a director, a secretary and occasional 
assistance from an additional secretary and seven part-time 
clerks employed by the Works Projects Administration. 
Plans for the survey having been outlined, forms were 
prepared for the collection of data. From February 15 to 
September 15, the director spent most of his time in the 
counties of Maryland and reported to the Executive Com- 
mittee twice each month. During this period the office 
staff transcribed and tabulated notes received from the 
field, obtained from the hospitals of Baltimore City and 
the District of Columbia detailed information on the 
admission of county patients, and carried on a number of 
other activities. 
The objectives of the survey were as follows: 
1. A study of certain characteristics of the population. 
2. A description of medical care facilities including: 
(a) The distribution of physicians, nurses, and 
dentists and types of service rendered by each, 
(b) The function of hospitals, health and welfare 
departments. 
(c) The activities of other governmental, vol- 
untary and private agencies. 
3- Estimates of the number of indigent1 and medically 
indigent2 and procedures followed by such in- 
dividuals in securing medical care. 
4- A study of the health needs with suggestions for 
securing more effective use of existing agencies either 
by improving or extending their activities, or by 
the organization of other services. 
5. Estimates of the costs of such a program. 
Individuals Interviewed 
The following persons were interviewed: 
1. The President or Secretary of every County Medical 
Society. 
To each the objectives of the survey were ex- 
plained. In addition, the names of all physicians in 
active practice, their addresses and other details, 
obtained from the Directory of the American Medical 
Association, were checked for accuracy. The names 
and addresses of those not included in the Directory 
were obtained. 
2. All physicians in seven counties, and others selected 
at random from widely separated areas. 
A total of 88 physicians, or about 20 percent of 
those in active practice in the counties, were inter- 
viewed at length. Subjects discussed included: 
(a) description of the local medical and hospital 
facilities, (b) opinions on present provisions for the 
medical care of the indigent, (c) recommendations 
for correcting deficiencies, and (d) other pertinent 
data. A summary of each interview was recorded 
on a special form and placed on file. 
3. The superintendents of the 18 general hospitals. 
With each superintendent the details of organiza- 
tion, operation and maintenance of the hospital were 
discussed and the buildings and equipment inspected. 
A summary of all interviews and reports of inspec- 
tions were recorded on forms prepared for the 
purpose. 
4. The superintendents, or their representatives, in all 
general hospitals in the City of Baltimore and in 
the District of Columbia. 
From each was obtained the number of residents 
of the counties of Maryland admitted during the 
year 1940, their addresses, pay status and number 
of days hospitalized. 
5. The Director of the State Department of Health and 
the Chiefs of Bureaus. 
The activities of the State Health Department 
relating to medical care were discussed in detail and 
printed reports were received. 
6. The 23 county health officers and a total of 68 public 
health nurses. 
With each county health officer an inspection was 
made of the diagnostic and clinical facilities now 
provided by the department. Opinions of each officer 
were obtained on the need for and practicability of 
expanding these facilities. Estimates of costs were 
secured. Public health nursing and laboratory serv- 
ices also were studied. 
7. The Director of the Department of Welfare and 
members of his staff. 
irThe indigent include only those receiving assistance from a welfare or- 
ganization. 
medically indigent are those who are usually able to pay the costs of 
minor illnesses but unable to meet expenses in the event of severe or pro- 
longed disabilities. Medical Care in the Counties of Maryland 
2 
The methods of classifying applicants for assist- 
ance were discussed as well as the State Department 
of Welfare policies with respect to providing phy- 
sicians’ services and hospitalization for those on 
relief. 
8. The executives of the 23 county welfare departments. 
From each was obtained an outline of the local 
procedures for securing medical care for those 
receiving assistance. An attempt was made to obtain 
an estimate of the type and costs of care thus pro- 
vided. A summary of each interview was filed. 
9. At least one county commissioner in each of seven 
counties. 
With each official the local provisions for medical 
care of the indigent were discussed and, wherever 
possible, a report of expenditures for this purpose 
was obtained. 
10. Many private citizens. 
Opinions on the need for providing medical care 
for the indigent and medically indigent were ob- 
tained from many citizens in all economic levels. 
Their experiences with various phases of this subject 
were recited. 
In the interest of economy, the reproduction of 
forms has been omitted. Chapter II 
CHARACTERISTICS OF THE POPULATION 
Tn approaching the survey of medical care, certain 
characteristics of the population were studied, in- 
cluding the distribution and economic status, as well as 
the medical care facilities. 
Distribution 
1. Total 
In Table 1, page 4, it will be seen that the total popula- 
tion, according to the U. S. Census taken as of April 1, 
1940, was 962,144; Baltimore County with 155,825 had the 
largest and Calvert County, with 10,484, the smallest 
population. 
2. Color 
In Table 1, it also will be noted that the white population 
totalled 825,776, and the colored 136,368; Baltimore County 
had the largest and Calvert the smallest white population 
with 145,295 and 5,604, respectively; and while Anne 
Arundel had 17,841 colored persons, there were only 5 in 
Garrett County. 
In Table 2, page 4, it will be observed that in Garrett 
County the white population comprised 99.9 percent of 
the total and in Calvert County the white population was 
52.1 percent of the total. 
3. Density 
The population density, the number of persons per square 
mile in rural areas, has been tabulated in Table 3, page 4, 
the land areas in square miles having been obtained from 
the Maryland Geological Survey. It will be noted that the 
number of persons per square miles varied from 256.5 in 
Baltimore to 33-1 in Garrett County. 
4. Urban and Rural Residents 
The proportion of families residing on farms in the 
counties of Maryland according to the U. S. Census of 1940, 
has been tabulated in Table 4, page 4. It will be seen that 
the percentage of families residing on farms ranged from 
6 in Allegany to 61 in Charles County. 
y Percent Increase or Decrease 
In reviewing the past and considering the probable 
future trends in population, the total for each county was 
tabulated for the years 17901 and 1940. These data are 
reproduced in Table 5, page 6. 
In Table 6, page 6, the percent increase or decrease is 
shown in the total population of each county since the 
date of establishment. It will be seen that, during the 
period under review, the population of Allegany County 
increased by 1,708.5 percent; in 18 other counties the 
increases varied from 512.7 percent in Baltimore to as low 
as 4.9 in Kent County; in St. Mary’s, Queen Anne’s and 
Charles counties decreases in population of 5-9, 6.4 and 
14.6 percent were recorded. 
Economic Status 
1. Income Tax Returns 
The income tax returns per 1,000 population for the 
counties of Maryland, as reported by the U. S. Department 
of Commerce for the year 1938, will be found in Table 7, 
page 6. The returns varied from 129 per 1,000 population 
in Montgomery to 6 per 1,000 in St. Mary’s and Somerset 
counties. 
2. Recipients of Relief 
In Table 8, page 6, the total households in each county 
receiving assistance from county welfare departments in 
1940, together with the number per 1,000 population have 
been tabulated. In Baltimore County 6.7 households per 
1,000 population were recipients of relief, and the propor- 
tion increased to 30.4 per 1,000 in Somerset County. This 
group represents those classified as “indigent”. 
3. Persons Employed by Federal Works Projects 
In Table 9, page 7, the total employed and awaiting 
employment by the Works Projects Administration of 
Maryland for the week ending June 19, 1940, has been 
shown. The largest number employed by this U. S. Govern- 
ment works project was 1,949 in Allegany and the lowest 
was 14 in Baltimore County. There were no Federal projects 
of this type in Calvert and Kent counties. In those counties 
in which the organization existed, the total employed 
per 1,000 population in the county of residence varied 
between 35-6 per 1,000 in Garrett and 0.2 in Baltimore 
County. 
Those employed by the WPA would have been receiving 
assistance from the county welfare departments if this type 
of employment had not been provided by Federal, State 
and local governments. The average wage was about 
$45 per month. 
During the year 1940 a total of 2,427 youths between 
the ages of 17 and 23 years were employed in the Civilian 
Conservation Corps, another works agency of the Federal 
Government. The distribution by counties was not avail- 
able. As a rule, these youths were members of households 
2. Color 
T‘Population of Maryland 1790-1930”, a publication of the Maryland 
State Department of Health and the Maryland State Planning Commission. 4 
Medical Care in the Counties of Maryland 
TABLE 1 
THE TOTAL POPULATION OF THE COUNTIES OP MARYLAND 
ACCORDING TO THE U. S. CENSUS TAKEN AS OF APRIL 
1, 1940, TOGETHER WITH THE TOTAL WHITE, 
COLORED AND PERCENTAGE OF EACH. 
TABLE 2 
PROPORTION OF WHITE AND COLORED POPULATION IN THE 
COUNTIES OF MARYLAND, U. S. CENSUS 1940 
County 
Total 
White 
Colored 
PERCENT 
White 
Colored 
State of Maryland 
1,821,244 
1,518,481 
302,763 
83.4 
16.6 
Baltimore City 
859,100 
692,705 
166,395 
80.6 
19.4 
Total Counties 
962,144 
825,776 
136,368 
85.8 
14.2 
Baltimore 
155,825 
145,295 
10,530 
93.2 
6.8 
Prince George’s 
89,490 
73,217 
16,273 
81.8 
18.2 
" Allegany 
86,973 
85,651 
1,322 
98.5 
1.5 
Montgomery 
83,912 
74,986 
8,926 
89.4 
10.6 
O Washington 
68,838 
67,048 
1,790 
97.4 
2.6 
Anne Arundel 
68,375 
50,524 
17,851 
73.9 
26.1 
Frederick 
57,312 
52,607 
4,705 
91.8 
8.2 
Carroll 
39,054 
36,973 
2,081 
94.7 
5.3 
Harford 
35,060 
31,076 
3,984 
88.6 
11.4 
Wicomico 
34,530 
27,035 
7,495 
78.3 
21.7 
N Dorchester 
28,006 
19,917 
8,089 
71.1 
28.9 
Cecil 
26,407 
24,051 
2,356 
91.1 
8.9 
C Garrett 
21,981 
21,976 
5 
99.9 
.1 
0 Worcester 
21,245 
14,575 
6,670 
68.6 
31.4 
Somerset 
20,965 
13,904 
7,061 
66.3 
33.7 
Talbot 
18,784 
13,048 
5,736 
69.5 
30.5 
Charles 
17,612 
10,384 
7,228 
59.0 
41.0 
co Caroline 
17,549 
14,102 
3,447 
80.4 
19.6 
C. Howard 
17,175 
14,369 
2,806 
83.7 
16.3 
q St. Mary’s 
14,626 
9,901 
4,725 
67.7 
32.3 
02 Queen Anne’s 
14,476 
10,129 
4,347 
70.0 
30.0 
Kent 
13,465 
9,404 
4,061 
69.8 
30.2 
Calvert 
10,484 
5,604 
4,880 
53.5 
46.5 
County 
Percent 
White 
Colored 
Garrett 
99.9 
.023 
Allegany 
98.5 
1.5 
Washington 
97.4 
2.6 
Carroll 
94.7 
5.3 
O Frederick 
91.8 
8.2 
Baltimore 
93.2 
6.8 
Cecil 
91.1 
8.9 
Harford 
88.6 
11.4 
Montgomery 
89.4 
10.6 
Howard 
83.7 
16.3 
N Caroline 
80.4 
19.6 
Wicomico 
78.3 
21.7 
O Prince George’s 
81.8 
18.2 
Anne Arundel 
73.9 
26.1 
Dorchester 
71.1 
28.9 
Queen Anne’s 
70.0 
30.0 
Worcester 
68.6 
31.4 
m Kent 
69.8 
30.2 
Pi Talbot 
69.5 
30.5 
q Somerset 
66.3 
33.7 
CJ St. Mary’s 
67.7 
32.3 
Charles 
59.0 
41.0 
Calvert 
53.5 
46.5 
TABLE 3 
POPULATION DENSITY IN THE COUNTIES OF MARYLAND— 
PERSONS PER SQUARE MILE IN RURAL AREAS, U. S. CENSUS 
1940 AND MARYLAND GEOLOGICAL SURVEY 
TABLE 4 
PROPORTION OF FAMILIES RESIDING ON FARMS IN THE 
COUNTIES OF MARYLAND, U. S. CENSUS, 1940 
County 
Total 
Population 
(1940) 
Land Area 
in 
Square Miles 
Persons 
per 
Square Mile 
Baltimore 
155,825 
607.4 
256.5 
Allegany 
86,973 
425.2 
204.5 
Prince George’s 
89,490 
486.2 
184.1 
£ 
Montgomery 
83,912 
497.0 
168.8 
O 
Anne Arundel 
68,375 
419.9 
162.8 
o 
Washington 
68,838 
458.5 
150.1 
Wicomico 
34,530 
378.4 
91.3 
Carroll 
39,054 
452.8 
. 86.3 
Frederick 
57,312 
664.7 
86.2 
Harford 
35,060 
442.8 
79.2 
LJ 
Cecil 
26,407 
351.2 
75.2 
pH 
Talbot 
18,784 
271.8 
69.1 
o 
Howard 
17,175 
252.9 
67.9 
o 
Somerset 
20,965 
334.9 
62.6 
Caroline 
17,549 
322.1 
54.5 
Calvert 
10,484 
216.7 
48.4 
Dorchester 
28,006 
580.9 
48.2 
CO 
Kent 
13,465 
283.4 
47.5 
cu 
Worcester 
21,245 
482.5 
44.0 
o 
St. Mary’s 
14,626 
365.0 
40.1 
o; 
Queen Anne’s 
14,476 
375.4 
38.6 
o 
Charles 
17,612 
457.8 
38.5 
Garrett 
21,981 
664.3 
33.1 
County 
Percent of Families 
Residing 
on Farms 
Not Residing 
on Farms 
Allegany 
6 
94 
Baltimore 
15 
85 
Washington 
17 
83 
Montgomery 
20 
80 
O Anne Arundel 
22 
78 
0 Prince George’s 
22 
78 
Dorchester 
26 
74 
Cecil 
28 
72 
Kent 
29 
71 
Somerset 
29 
71 
N Wicomico 
29 
71 
[j Talbot 
30 
70 
O Frederick 
31 
69 
Carroll 
40 
60 
Harford 
42 
58 
Howard 
43 
57 
Worcester 
43 
57 
m Caroline 
44 
56 
Oh Queen Anne’s 
45 
55 
q Garrett 
49 
51 
Oh St. Mary’s 
49 
51 
l“3 Calvert 
58 
42 
Charles 
61 
39 Characteristics of the Population 
5 
receiving assistance from county welfare departments, or 
of families in which another member was employed by 
the Works Projects Administration. 
Birth and Death Rates 
1. Birth Kates 
The average birth rates per 1,000 population for the 
years 1936-40 are included in Table 10, page 7- The highest 
average birth rates occurred in Charles County in which 
the average was 27-3 per 1,000, in contrast to 15-4 per 
1.000 in Baltimore County. The birth rates for the white 
and colored are also included. 
2. Death Kates 
In Table 11, page 7, the average mortality rates per 
1.000 persons for the years 1936-40 are shown. The average 
death rate varied between 15-7 in Somerset and 9-1 in 
Baltimore County. The average rates for white and colored 
are also tabulated. 
The average annual deaths under one year of age per 
1.000 population for the years 1936-40 have been computed 
in Table 12, page 7. The annual infant mortality rate was 
106.1 in Worcester and 43-8 in Montgomery County. The 
annual infant mortality rates for the white and colored 
are also included. In all counties the rate for the colored 
was considerably higher than for the white. 
Medical Care Facilities 
The tables from which the following observations have 
been made will be found on pages 13, 21, 23 and 28. 
1. Physicians in Active Practice 
The physicians in active practice in the counties as of 
July 1, 1941, and the physician: population ratio have 
been shown in Table 16, page 13- The largest number of 
physicians was found in Baltimore County with 80, while 
there were only 5 in Calvert County. The physician: 
population ratio was highest, 1:962, in Kent and lowest, 
1:2,442, in Anne Arundel County. 
2. Registered Nurses 
In Table 20, page 21, the active registered nurses in the 
counties have been tabulated by race, sex and the nurse: 
population ratio. The largest number of nurses were 
registered in Montgomery where there were 195 while 
there were only 4 in Garrett County. The nurse: population 
ratio ranged from 1:376 in Talbot to 1:5,495 in Garrett 
County. 
3. Dentists 
The distribution of dentists in active practice in 1940, 
and the dentist: population ratio is shown in Table 23, 
page 23- A total of 38 dentists were in practice in Baltimore 
County while there were no full-time dentists in Calvert. 
Of the remaining counties, the dentist: population ratio 
varied from 1:2,025 in Washington to 1:8,588 in Howard 
County. 
4. Hospitals 
In Table 25, page 28, the distribution of general hospitals* 
in 1940 together with the bed capacity and the hospital-bed: 
population ratios have been recorded. A total of 304 
hospital beds were available in Allegany County while 
Calvert County had but 23 beds. The hospital-bed: popula- 
tion ratio extended between 1:172 in Talbot County and 
1:2,098 in Montgomery. It should be noted that in 8 
counties there were no general hospitals. 
Summary Table 
In all of the tables to which reference has been made, the 
principal subject has been arranged by rank. 
In comparing figures for one county with those of 
another, it is obvious that in many instances the differences 
are not significant. In each of the tables, therefore, the 
first 8 counties have been considered an entity, designated 
as Group 1, the next 8 counties Group 2, and the remaining 
7 counties Group 3- These figures are tabulated in Table 13, 
page 8, in which are compared 5 characteristics of the 
population, 3 on the economic status, 3 on the birth and 
death rates and 4 on the distribution of medical care 
facilities. 
In the first column of Table 13, the population of each 
county has been classified in Groups 1, 2 and 3. In the 
columns which follow, it will be noted that the first 8 
counties, with notable exceptions, are included, as a rule, 
in Group 1; the next 8 counties fall for the most part within 
Group 2; and the remainder, in general, are included in 
Group 3- The most striking exceptions are the households 
receiving assistance per 1,000 population, (Table 8) the 
average birth, general mortality and infant mortality 
rates, (Tables 10, 11 and 12) and the physician and dentist 
population ratios (Tables 16 and 23). 
In general, it may be said that the counties with the 
greatest total populations have the highest proportion of 
white persons; the greatest population density; the highest 
proportion of urban residence; the greatest proportionate 
increase in population from 1790-1940; the highest income 
tax receipts per 1,000 population; and the highest registered 
nurse: population ratio. On the other hand, the counties 
in Group 1 have the lowest proportionate number of 
individuals receiving assistance and employed by the WPA, 
as well as the lowest birth, general and infant mortality 
rates. Conversely, in counties which have relatively low 
total populations, the characteristics are, in general, 
reversed. 
*Unless otherwise specified, the term “hospital” as used throughout this 
report, connotes general hospital. 6 
Medical Care in the Counties of Maryland 
TABLE 5 
THE TOTAL POPULATION OF THE COUNTIES OF MARYLAND 
ACCORDING TO THE U. S. CENSUS OF 1790 AND 1940, BY COLOR 
TABLE 6 
PERCENT INCREASE OR DECREASE IN THE POPULATION OF 
THE COUNTIES OF MARYLAND SINCE THEIR DATES OF 
ESTABLISHMENT 
County 
Year 1790 
Year 1940 
Total 
White 
Colored 
Total 
White 
Colored 
State of Maryland 
319,728 
208,649 
111,079 
1,821,244 
1,518,481 
302,763 
Baltimore City 
13,503 
11,925 
1,578 
859,100 
692,705 
166,395 
Total Counties 
306,225 
196,724 
109,501 
962,144 
825,776 
136,368 
Allegany 
4,809 
4,539 
270 
86,973 
85,651 
1,322 
Anne Arundel 
22,598 
11,664 
10,934 
68,375 
50,524 
17,841 
Baltimore 
25,434 
18,953 
6,481 
155,825 
145,295 
10,530 
3- 
D 
Calvert 
8,652 
4,211 
4,441 
10,484 
5,604 
4,880 
q 
Caroline 
9,506 
7,028 
2,478 
17,549 
14,102 
3,447 
o 
Carroll 
39,054 
36,973 
2,081 
Cecil 
13,625 
10,055 
3,570 
26,407 
24,051 
2,356 
Charles 
20,613 
10,124 
10,489 
17,612 
10,384 
7,228 
Dorchester 
15,875 
10,010 
5,865 
28,006 
19,917 
8,089 
Frederick 
30,791 
26,937 
3,854 
57,312 
52,607 
4,705 
(M 
Garrett 
21,981 
21,976 
5 
Ch 
D 
Harford 
14,976 
10,784 
4,192 
35,060 
31,076 
3,984 
o 
Howard 
17,175 
14,369 
2,806 
Dh 
O 
Kent 
12,836 
6,748 
6,088 
13,465 
9,404 
4,061 
Montgomery 
18,003 
11,679 
6,324 
83,912 
74,986 
8,906 
Prince George’s 
21,344 
10,004 
11,340 
89,490 
73,216 
16,273 
Queen Anne’s 
15,463 
8,171 
7,292 
14,476 
10,129 
4,347 
CO 
St. Mary’s 
15,544 
8,216 
7,328 
14,626 
9,901 
4,725 
ft. 
Somerset 
15,610 
8,272 
7,338 
20,965 
13,904 
7,061 
£ 
n 
Talbot 
13,084 
7,231 
5,853 
18,784 
13,048 
5,736 
& 
Washington 
15,822 
14,472 
1,350 
68,838 
67,048 
1,790 
o 
Wicomico 
34,530 
27,035 
7,495 
Worcester 
11,640 
7,626 
4,014 
21,245 
10,767 
10,478 
County 
Date of 
Establish- 
ment 
Population 
on Date 
Established 
Population 
in 
1940 
Percent 
Increase 
or Decrease 
Since 
Date of 
Establish- 
ment 
Allegany 
1790 
4,809 
86,973 
1708.5 
Baltimore 
1790 
25,434 
155,825 
512.7 
Montgomery 
1790 
18,003 
83,912 
366.1 
£3 Washington 
1790 
15,822 
68,838 
335.1 
O Prince George’s 
1790 
21,344 
89,490 
319.3 
Anne Arundel 
1790 
22,598 
68,375 
202.6 
Harford 
1790 
14,976 
35,060 
134.1 
Carroll 
1840 
17,241 
39,054 
126.5 
Wicomico 
1870 
15,802 
34,530 
118.5 
Cecil 
1790 
13,625 
26,407 
93.8 
N Garrett 
1880 
12,175 
21,981 
80.5 
►j Frederick 
1790 
30,791 
57,312 
86.2 
O Caroline 
1790 
9,506 
17,549 
84.6 
Worcester 
1790 
11,640 
21,245 
82.5 
Dorchester 
1790 
15,875 
28,006 
76.4 
Talbot 
1790 
13,084 
18,784 
43.6 
Somerset 
1790 
15,610 
20,965 
34.3 
co Howard 
1860 
13,338 
17,175 
28.8 
Calvert 
1790 
8,652 
10,484 
21.2 
g Kent 
1790 
12,836 
13,465 
4.9 
Pi St. Mary’s 
1790 
15,544 
14,626 
-5.9 
Queen Anne’s 
1790 
15,463 
14,476 
-6.4 
Charles 
1790 
20,613 
17,612 
-14.6 
TABLE 8 
HOUSEHOLDS RECEIVING ASSISTANCE FROM COUNTY WELFARE 
DEPARTMENTS IN MARYLAND IN 1940, AND THE NUMBER 
PER 1,000 POPULATION 
County 
Total 
Population 
(1940) 
Total 
Households 
Receiving 
Assistance 
(1940) 
Households 
Receiving 
Assistance 
per 1,000 
Population 
State of Maryland 
1,821,244 
29,616 
16.3 
Baltimore City 
859,100 
15,313 
17.8 
Total Counties 
962,144 
14,303 
14.9 
Somerset 
20,965 
637 
30.4 
Wicomico 
34,530 
1,000 
29.0 
Queen Anne’s 
14,476 
400 
27.6 
p Garrett 
21,981 
583 
26.5 
O Caroline 
17,549 
464 
26.4 
St. Mary’s 
14,626 
384 
26.3 
Dorchester 
28,006 
717 
25.6 
Worcester 
21,245 
486 
22.9 
Talbot 
18,784 
412 
21.9 
Calvert 
10,484 
229 
21.8 
N Cecil 
26,407 
554 
21.0 
Kent 
13,465 
281 
20.9 
O Washington 
68,838 
1,378 
20.0 
q Charles 
17,612 
335 
19.0 
Howard 
17,175 
307 
17.9 
Harford 
35,060 
523 
14.9 
Allegany 
86,973 
1,288 
14.8 
co Frederick 
57,312 
745 
13.0 
CP Carroll 
39,054 
468 
12.0 
Q Anne Arundel 
68,375 
605 
8.8 
04 Montgomery 
83,912 
709 
8.4 
Prince George’s 
89,490 
749 
8.4 
Baltimore 
155,825 
1,049 
6.7 
TABLE 7 
INCOME TAX RETURNS PER 1,000 POPULATION, FROM THE 
COUNTIES OF MARYLAND, U. S. DEPARTMENT OF 
COMMERCE, 1938 
County 
Returns per 
1,000 Population 
Montgomery 
129 
Prince George’s 
55 
Baltimore 
38 
Allegany 
33 
O Anne Arundel 
32 
Harford 
26 
Howard 
25 
Washington 
25 
Talbot 
22 
Cecil 
21 
N Frederick 
18 
p Wicomico 
18 
O Carroll 
15 
Dorchester 
15 
Charles 
14 
Kent 
13 
Queen Anne’s 
13 
Worcester 
12 
Pt Caroline 
11 
0 Calvert 
8 
— Garrett 
7 
St. Mary’s 
6 
Somerset 
6 Characteristics of the Population 
7 
TABLE 9 
TOTAL PERSONS EMPLOYED AND AWAITING EMPLOYMENT BY 
WORKS PROJECTS ADMINISTRATION OF MARYLAND FOR WEEK 
ENDING JUNE 19, 1940 AND THE NUMBER PER 1,000 IN THE 
COUNTY OF RESIDENCE 
TABLE 10 
ANNUAL BIRTHS PER 1,000 POPULATION IN THE COUNTIES OF 
MARYLAND. AVERAGE 1936-1940, CORRECTED 
FOR RESIDENCE 
County 
Employed 
on 
WPA 
Awaiting 
Employment 
on WPA 
Total 
Number per 
1,000 Popula- 
tion in County 
of Residence 
Garrett 
676 
107 
783 
35.6 
Allegany 
1,949 
531 
2,480 
28.5 
Washington 
1,437 
266 
1,703 
24.7 
£ 
Frederick 
1,050 
99 
1,140 
20.0 
O 
Wicomico 
254 
113 
367 
10.6 
o 
Somerset 
147 
66 
213 
10.2 
St. Mary’s 
113 
15 
128 
8.8 
Queen Anne's 
92 
30 
122 
8.4 
Worcester 
128 
49 
177 
8.3 
Harford 
274 
16 
290 
8.3 
Caroline 
56 
90 
146 
8.3 
£h 
Dorchester 
70 
150 
220 
7.9 
o 
Howard 
117 
17 
134 
7.8 
o 
Prince George’s 
468 
27 
496 
5.4 
Anne Arundel 
375 
15 
390 
5.7 
Cecil 
121 
6 
127 
4.8 
Charles 
71 
14 
85 
4.8 
CO 
Carroll 
137 
5 
142 
3.6 
Qh 
Montgomery 
122 
8 
130 
1.5 
p 
o 
Talbot 
19 
9 
28 
1.5 
OS 
Baltimore 
14 
14 
28 
0.2 
o 
Calvert 
None 
Kent 
None 
Total 
6,558 
468 
7,026 
7.3 
County 
Birth Rate 
Total 
White 
Colored 
Charles 
27.3 
23.0 
52.7 
Calvert 
27.2 
21.7 
33.4 
St. Mary’s 
25.6 
25.2 
26.4 
Garrett 
24.6 
24.6 
— 
O Montgomery 
22.4 
22.5 
22.0 
Howard 
21.9 
21.0 
26.2 
Prince George’s 
21.5 
20.9 
24.2 
Allegany 
19.8 
19.8 
20.9 
Anne Arundel 
19.3 
19.3 
27.8 
Caroline 
18.4 
17.3 
22.7 
N Worcester 
17.9 
14.8 
24.0 
Harford 
17.8 
17.3 
22.5 
O Queen Anne’s 
17.8 
17.3 
19.0 
Washington 
17.7 
17.7 
16.4 
Frederick 
17.6 
17.3 
21.3 
Dorchester 
17.5 
16.1 
21.0 
Cecil 
17.2 
16.9 
20.8 
co Talbot 
17.0 
15.6 
20.0 
Oh Somerset 
16.9 
14.6 
21.3 
§ Carroll 
16.9 
16.5 
22.6 
« Kent 
16.2 
14.8 
19.4 
Wicomico 
15.9 
14.6 
20.4 
Baltimore 
15.4 
15.4 
16.2 
TABLE 11 
MORTALITY PER 1,000 PERSONS IN THE COUNTIES OF MARYLAND. 
AVERAGE 1936-1940, CORRECTED FOR RESIDENCE 
TABLE 12 
DEATHS UNDER ONE YEAR OF AGE PER 1,000 LIVE BIRTHS IN 
THE COUNTIES OF MARYLAND .AVERAGE 1936-1940, 
CORRECTED FOR RESIDENCE. 
County 
Average Annual Death Rate 
Total 
White 
Colored 
Somerset 
Worcester 
15.7 
13.9 
19.2 
Dorchester 
15.6 
13.9 
19.3 
Kent 
14.7 
12.5 
19.8 
O Talbot 
14.7 
13.3 
17.7 
Caroline 
14.3 
13.2 
16.2 
Calvert 
14.3 
13.2 
18.2 
Queen Anne’s 
13.8 
12.4 
15.4 
13.4 
12.2 
16.4 
Wicomico 
13.1 
12.3 
16.2 
Cecil 
13.0 
12.3 
19.8 
N Harford 
12.5 
11.6 
20.1 
Carroll 
12.4 
12.1 
17.9 
O Frederick 
12.4 
12.0 
15.9 
q Howard 
12.0 
11.3 
15.6 
St. Mary’s 
11.9 
10.0 
15.2 
Charles 
11.6 
9.9 
13.7 
11.5 
10.7 
16.7 
Montgomery 
11.0 
10.6 
26.5 
co Washington 
10.9 
10.9 
— 
Pi Garrett 
10.6 
9.1 
15.5 
q Anne Arundel 
10.2 
10.1 
19.6 
Pi Allegany 
10.2 
9.4 
13.5 
Prince George’s 
9.1 
9.0 
10.7 
Baltimore 
County 
Annual Infant Mortality Rate 
Total 
White 
Colored 
Worcester 
106.1 
70.0 
154.3 
Calvert 
97.2 
69.7 
116.5 
Dorchester 
93.5 
66.2 
147.7 
p Somerset 
87.1 
58.3 
124.6 
O Charles 
80.2 
53.4 
103.1 
St. Mary’s 
78.8 
63.0 
106.7 
Kent 
77.0 
52.0 
121.6 
Anne Arundel 
70.5 
49.9 
84.9 
Queen Anne’s 
67.8 
43.1 
121.3 
Garrett 
67.7 
67.7 
— 
N Wicomico 
67.6 
59.4 
72.2 
£3 Talbot 
65.8 
48.1 
98.0 
O Cecil 
59.1 
55.0 
91.3 
02 Caroline 
58.6 
51.2 
81.3 
Frederick 
57.9 
53.1 
100.2 
Allegany 
57.4 
57.1 
74.8 
Prince George’s 
56.2 
40.9 
108.4 
Harford 
55.7 
50.8 
84.9 
Pi Washington 
51.6 
50.1 
132.9 
§ Carroll 
51.4 
45.5 
130.1 
Pi Baltimore 
45.0 
41.7 
79.7 
Howard 
44.7 
32.5 
87.9 
Montgomery 
43.8 
34.8 
105.5 8 
Medical Care in the Counties of Maryland 
TABLE 13 
SUMMARY TABLE: CERTAIN CHARACTERISTICS OF THE POPULATION OF THE COUNTIES OF MARYLAND, THEIR ECONOMIC STATUS, 
BIRTH AND DEATH RATES AND DISTRIBUTION OF MEDICAL CARE FACILITIES ARE SHOWN. IN THE FIRST COLUMN THE POPULA- 
TION IS ARRANGED BY RANK. THE FIRST 8 COUNTIES HAVE BEEN DESIGNATED AS GROUP 1, THE NEXT 8 AS GROUP 2, 
AND THE LAST 7 AS GROUP 3. IN THE REMAINING COLUMNS EACH COUNTY HAS BEEN CLASSIFIED IN 
ACCORDANCE WITH THE NUMBER OF THE GROUP WITHIN WHICH IT FALLS 
IN THE ORIGINAL TABLE. 
County 
Population 
Economic Status 
Birth and Death Rates 
Medical Care Facilities 
Table 
(1) 
Popu- 
lation 
(1940) 
Table 
(2) 
Percent 
White 
(1940) 
Table 
(3) 
Popu- 
lation 
Density 
(1940) 
Table 
(4) 
Percent 
Urban 
Resi- 
dents 
(1940) 
Table 
(6) 
Percent 
Increase 
or 
Decrease 
in 
Popu- 
lation 
(1790- 
1940) 
Table 
(7) 
Income 
Tax 
Receipts 
Per 
1,000 
Popu- 
lation 
(1936) 
Table 
(8) 
House- 
holds 
Receiv- 
ing 
Assist- 
ance 
Per 
1,000 
Popu- 
lation 
(1940) 
Table 
(9) 
Number 
Employ- 
ed by the 
WPA 
Per 
1,000 
Popu- 
lation 
(1940) 
Table 
(10) 
Average 
Birth 
Rate 
(1936- 
40) 
Table 
(11) 
Average 
General 
Mortal- 
ity Rate 
(1936- 
40) 
Table 
(12) 
Average 
Infant 
Mortal- 
ity Rate 
(1936- 
40) 
Table 
(16) 
Physi- 
cian 
Popu- 
lation 
Ratio 
Table 
(20) 
Regis- 
tered 
Nurse: 
Popu- 
lation 
Ratio 
Table 
(23) 
Dentist: 
Popu- 
lation 
Ratio 
Table 
(25) 
Hospi- 
tal 
Bed: 
Popu- 
lation 
Ratio 
1. 
Baltimore 
1 
1 
1 
1 
1 
1 
3 
3 
3 
3 
3 
3 
1 
2 
** 
2. 
Prince George’s 
1 
2 
1 
1 
1 
1 
3 
2 
1 
3 
3 
3 
1 
3 
** 
3. 
Allegany 
1 
1 
1 
1 
I 
1 
3 
1 
2 
3 
2 
1 
1 
1 
1 
4. 
Montgomery 
1 
2 
1 
1 
1 
1 
3 
3 
1 
3 
3 
2 
1 
1 
2 
5. 
Washington 
1 
1 
1 
1 
1 
1 
2 
1 
2 
3 
3 
1 
1 
1 
1 
6. 
Anne Arundel 
1 
2 
1 
1 
1 
1 
3 
2 
2 
3 
1 
3 
1 
3 
2 
7. 
Frederick 
1 
1 
2 
2 
2 
2 
3 
1 
2 
2 
2 
1 
2 
1 
1 
8. 
Carroll 
1 
1 
1 
2 
1 
2 
3 
3 
3 
2 
3 
1 
3 
1 
** 
9. 
Harford 
2 
1 
2 
2 
1 
1 
2 
2 
2 
2 
3 
2 
2 
1 
2 
10, 
Wicomico 
2 
2 
1 
2 
2 
2 
1 
1 
3 
2 
2 
2 
1 
2 
1 
11. 
Dorchester 
2 
2 
3 
1 
2 
2 
1 
2 
2 
1 
1 
1 
2 
3 
1 
12. 
Cecil 
2 
1 
2 
1 
2 
2 
2 
2 
3 
2 
2 
3 
2 
1 
2 
13. 
Garrett 
2 
1 
3 
3 
2 
3 
1 
1 
1 
3 
2 
2 
3 
3 
** 
14. 
Worcester 
2 
3 
3 
3 
2 
3 
1 
2 
2 
1 
1 
2 
3 
1 
** 
15. 
Somerset 
2 
3 
2 
2 
3 
3 
1 
1 
3 
1 
1 
1 
3 
2 
2 
16. 
Talbot 
2 
3 
2 
2 
2 
2 
2 
3 
3 
1 
2 
1 
1 
2 
1 
17. 
Charles 
3 
3 
3 
3 
3 
2 
2 
3 
1 
2 
1 
2 
3 
3 
2 
18. 
Caroline 
3 
2 
2 
3 
2 
3 
1 
2 
2 
1 
2 
2 
3 
2 
** 
19. 
Howard 
3 
2 
2 
2 
3 
1 
2 
2 
1 
2 
3 
3 
2 
3 
** 
20. 
St. Mary’s 
3 
3 
3 
3 
3 
3 
1 
1 
1 
2 
1 
3 
3 
2 
1 
21. 
Queen Anne’s 
3 
2 
3 
3 
3 
3 
1 
1 
1 
1 
2 
2 
2 
2 
22. 
Kent 
3 
3 
3 
2 
3 
2 
2 
* 
3 
1 
1 
1 
2 
2 
2 
23. 
Calvert 
3 
3 
2 
3 
3 
3 
2 
* 
1 
1 
1 
3 
2 
3 
1 
*No WPA project in this county. 
**In 1940 there was no general hospital in this county. Chapter 
PHYSICIANS’ SERVICES 
Changes in the Distribution of Physicians 
In determining the changes in the distribution of phy- 
sicians three years were selected—1909, 1923 and 1938— 
separated by intervals of fourteen and fifteen years, 
respectively. 
In 1909 a total of 746 physicians were in active practice 
in Maryland outside the City of Baltimore. In 1923 the 
total was 850, and in 1938 it had reached 902. The popula- 
tion of the counties increased from an estimated total1 of 
732,229 in 1909, to 753,675 in 1923 and 938,433 in 1938. 
In 1909 the number of persons per physician was 888; in 
1923, 793; and in 1938, 1,026. In Table 14, page 9, these 
data are shown together with the percentages of increase 
of physicians, population and persons per physician in 
1938 over 1909- 
Advantages in Trend 
Although the tendency of physicians to concentrate is 
very apparent, it does not seem to have reached proportions 
which, in view of the improvements in transportation, 
need be regarded with undue alarm. On the contrary, there 
are some obvious benefits in this change of distribution; 
(a) physicians living near a hospital will meet more 
frequently for consultation and discussion of professional 
problems, and (b) there are increased opportunities for the 
development of specialization. 
Disadvantages of Concentration 
Many have expressed the opinion that, because of the 
development of rapid transportation, an area of con- 
siderable size surrounding a town could be adequately 
covered by physicians resident in that municipality. 
In the experience of the Committee, however, there is 
another side to the picture, in that the expense of physi- 
cians’ visits is greatly increased for those living at a dis- 
tance. The result is that calling a doctor is not infrequently 
postponed until harmful delay has made it evident that the 
condition is a serious one. During the field survey t-his 
opinion was emphasized by several physicians but more 
.particularly by patients living more than a few miles from 
a physician. The latter complained that the cost of a single 
visit was high, and that if more than one or two calls 
were necessary, the expense was beyond their means. 
These patients declared that they were most anxious to 
have a physician live close at hand where, in case of need, 
he could be quickly summoned. It was also pointed out 
that a physician residing nearby could safely treat many 
types of illness in the home whereas, if he lived more than 
a few miles distant, it would be necessary to remove the 
patient to a hospital. 
Decline in Number of Physicians in Some Areas 
In general, those counties whose towns had great in- 
creases in population between 1906 and 1940 have shown 
an even greater increase in the number of physicians. For 
example, in Allegany County the number of physicians has 
risen from 28 in 1906 to 80 in 1938; in Wicomico County 
the number has increased from 20 to 29- In the counties 
adjacent to large cities, such as Baltimore, Prince George’s 
and Montgomery counties, suburban developments also 
have led to increases in the number of physicians. 
In counties with stationary or declining populations, 
however, the number of physicians has shown a striking 
TOTAL PHYSICIANS IN THE COUNTIES OF MARYLAND IN 1909, 1923, 
AND 1938, THE ESTIMATED POPULATION, THE NUMBER OF 
PERSONS PER PHYSICIAN, AND THE PERCENTAGES OF 
INCREASE IN 1938 OVER 1909 
TABLE 14 
Counties of Maryland 
Year 
Percent Increase 
in 1938 over 
1909 
1909 
1923 
1938 
Total physicians 
746 
850 
902 
20.9 
Estimated population 
732,229 
753,675 
938,433 
28.2 
Persons per physician 
888 
793 
1,026 
15.5 
The distribution of physicians in the years 1906 and 
1940 is shown graphically in Charts I and II on pages 10 
and 11. In 1906 it will be observed that the practitioners 
were quite uniformly distributed, whereas in 1940 a greater 
number of physicians was concentrated in the larger towns 
and cities. 
The extent to which physicians have become concentrated 
is indicated by the observation that in 1906 there were 
only eight towns and cities in the State, outside of Baltimore 
City, which contained ten or more physicians, and the 
total number of physicians in these eight towns was 159. 
In 1940, however, there were fourteen towns and cities in 
which ten or more physicians were located, and the total 
equalled 325. It is clear, therefore, that the number of 
physicians located in towns had more than doubled in a 
period of 34 years. 
This movement of physicians into the larger centers was 
no doubt due in part to a concurrent growth in the towns 
and cities. It probably was also the result of the attraction 
of physicians to general hospitals which were constructed 
in the centers of population during that period. 
1Maryland State Department of Health, Bureau of Vital Statistics. 10 
Medical Care in the Counties of Maryland 
GEOGRAPHIC DISTRIBUTION 
OF 
PHYSICIANS IN PRIVATE PRACTICE 
IN 
MARYLAND 
EACH DOT REPRESENTS ONE PHYSICIAN IN ACTIVE PRACTICE- 
1906 
(EXCLUDING BALTIMORE CITY) 
CHART I Physicians’ Services 
11 
GEOGRAPHIC DISTRIBUTION 
OF 
PHYSICIANS IN PRIVATE PRACTICE 
IN 
MARYLAND 
•EACH DOT REPRESENTS ONE PHYSICIAN IN ACTIVE PRACTICE- 
1940 
(EXCLUDING BALTIMORE CITY) 
CHART n 12 
Medical Care in the Counties of Maryland 
tendency to decrease. In Calvert County, for example, the 
number has been reduced from 9 to 6; in St. Mary’s from 
17 to 12, and in Caroline County from 22 to 16. 
Changes in the Age Distribution 
In view of better roads and improved transportation in 
the counties in which the population is stationary or 
declining, the decreased number of physicians might be 
expected to meet the needs of the county. However, a 
study of the age distribution of physicians in these counties 
indicates serious potentialities. 
In 1906 there was only one county in Maryland in which 
the number of physicians over sixty years of age exceeded 
one third of the total number of physicians in the county. 
In 1940, in nine out of the twenty-three counties over one 
third of the physicians had passed the age of sixty. In one 
county, 13 of the 23 physicians were over sixty, in another 
8 out of 12. Unless there is an influx of young physicians 
into these counties within the next decade, it is obvious 
that the day is not far distant when there will be a serious 
shortage of physicians. 
Economic Status of Counties and Relative Number 
of Physicians 
A partial analysis of collected data shows that, in general, 
there is a definite relationship between the economic status 
of each county and the number of practicing physicians 
under 40 years of age in the county. This partially com- 
pleted study also has revealed that the lower the economic 
level of the county, the smaller the number of physicians 
who have become located there in the past decade. 
Distribution of Physicians in 1941 
On July 1, 1941, a total of 627 physicians were engaged 
in the private practice of medicine in the counties of 
Maryland. Of these, as indicated in Table 15, page 12, 
580, or 93 percent were white males, 19, or 3 percent, white 
females, and 28, or 4 percent, colored males. Practitioners 
employed on a full-time basis in health departments, 
hospitals, sanatoria and other institutions were not in- 
cluded, and physicians residing in a county but practicing 
in Baltimore City and the District of Columbia also were 
omitted. The figures for the City of Baltimore and the 
State of Maryland also have been presented. 
In Table 16, page 13, the distribution of physicians is 
shown, together with the physician: population ratio. 
It will be noted that the latter ratio varies between 1 ;962 
in Kent County and 1:2,442 in Anne Arundel County. 
A ratio of one physician per 1,500 population is generally 
regarded as a minimum for adequate medical care. Twelve 
counties possessed less than that ratio: Worcester, Harford, 
Caroline, Charles, Garrett, Cecil, St. Mary’s, Baltimore, 
Prince George’s, Calvert, Howard and Anne Arundel. 
Since Baltimore and Howard counties are adjacent to 
Baltimore City, and Montgomery and Prince George’s are 
contiguous with the District of Columbia, residents of 
these areas have access to these large medical centers. 
The Physician: Population Ratio 
While one may compare the number of persons per 
physician in one county with that in another, the char- 
acteristics of the physicians in each may differ widely. 
For example, it was observed that one county possessed 
eight comparatively young doctors with quite extensive 
training and clinical experience, while in another of about 
the same total population there were eight older, less well 
trained and relatively inactive physicians. In the latter 
group one physician was president of a bank and devoted 
several hours each day to this activity, another owned two 
large farms and spent a considerable proportion of his 
working hours in their management. In the first county 
it was apparent that the problems of medical care were 
being met and solved to a notable degree, while in the 
second little progress was observed, and, incidentally, 
fears of the possible advent of “State medicine’’ were 
frequently expressed. 
TOTAL PHYSICIANS IN ACTIVE PRACTICE IN THE STATE OF 
MARYLAND, JULY 1, 1941, BY COLOR AND SEX. PRAC- 
TITIONERS EMPLOYED FULL-TIME IN HOSPITALS, 
SANATORIA AND HEALTH DEPARTMENTS ARE 
NOT INCLUDED 
TABLE 15 
Number of Physicians 
Total 
White 
Colored 
Male 
Female 
Male 
Female 
State of Maryland 
1956 
1801 
57 
96 
2 
Baltimore City 
1329 
1221 
38 
68 
2 
Total Counties 
627 
580 
19 
28 
0 
Allegany 
69 
64 
3 
2 
Anne Arundel 
28 
23 
2 
3 
Baltimore 
80 
74 
2 
4 
Calvert 
5 
5 
Caroline 
11 
10 
1 
Carroll 
31 
30 
1 
Cecil 
15 
13 
1 
1 
Charles 
11 
11 
Dorchester 
21 
18 
1 
2 
Frederick 
50 
47 
3 
Garrett 
13 
13 
Harford 
23 
22 
1 
Howard 
8 
8 
Kent 
14 
13 
1 
Montgomery 
58 
50 
7 
1 
Prince George’s 
43 
40 
3 
Queen Anne’s 
10 
10 
Saint Mary’s 
8 
8 
Somerset 
15 
12 
1 
2 
Talbot 
17 
14 
1 
2 
Washington 
59 
59 
Wicomico 
24 
22 
2 
Worcester 
14 
14 Physicians’ Services 
13 
TABLE 16 
PHYSICIANS IN ACTIVE PRACTICE IN THE STATE OF MARYLAND, 
JULY 1, 1941, AND THE PHYSICIAN: POPULATION RATIO. PRAC- 
TITIONERS EMPLOYED FULL-TIME IN HOSPITALS, SANA- 
TORIA AND HEALTH DEPARTMENTS ARE NOT 
INCLUDED 
in the percentage. A comparison of the proportions in 
most instances, therefore, is not significant. It will be 
noted that Calvert, Caroline, Garrett, Prince George’s 
and Wicomico counties have the highest percentage of 
physicians under 45 years, and St. Mary’s, Worcester, Kent 
and Dorchester counties have the highest proportion over 
65 years of age. 
During the survey it was observed that many of the 
older physicians, stimulated by a patriotic desire to render 
the greatest possible service during “the emergency’’, 
appeared as alert and energetic as the average young man. 
However, it must be conceded that activity, in general, 
decreases with the passage of years and, therefore, the 
age distribution of physicians is of considerable significance 
in measuring the quantity of medical care in a particular 
locality. 
Total 
Practicing 
Physicians 
Physician: 
Population 
Ratio 
State of Maryland 
1,956' 
1: 931 
Baltimore City 
1,3292 
1: 646 
Total Counties 
627 
1:1,534 
Kent 
14 
1: 962 
Talbot 
17 
1:1,105 
Frederick 
50 
1:1,146 
Washington 
59 
1:1,167 
Allegany 
69 
1:1,258 
Carroll 
31 
1:1,260 
Dorchester 
21 
1:1,334 
Somerset 
15 
1:1,398 
Wicomico 
24 
1:1,439 
Montgomery 
58 
1:1,447 
Queen Anne’s 
10 
1:1,448 
Worcester 
14 
1:1,518 
Harford 
23 
1:1,524 
Caroline 
11 
1:1,595 
Charles 
11 
1:1,601 
Garrett 
13 
1:1,691 
Cecil 
15 
1:1,760 
St. Mary’s 
8 
1:1,828 
Baltimore 
80 
1:1,948 
Prince George’s 
43 
1:2,081 
Calvert 
5 
1:2,097 
Howard 
8 
1:2,147 
Anne Arundel 
28 
1:2,442 
TABLE 17 
PHYSICIANS IN ACTIVE PRACTICE IN 1940 IN THE COUNTIES OF 
MARYLAND IN THE AGE GROUPS—UNDER 45, 45-64, 65 AND 
OVER—TOGETHER WITH THE PERCENTAGES IN 
EACH GROUP 
Total 
Physicians 
Total 
in Age Groups 
Percent in Age Groups 
Under 
45 
45-64 
65 & 
Over 
Under 
45 
45-64 
65 & 
Over 
State of Maryland 
1,956 
851 
826 
279 
43 
42 
15 
Baltimore City 
1,329 
564 
576 
189 
42 
43 
15 
Total Counties 
627 
287 
250 
90 
46 
40 
14 
Allegany 
69 
29 
35 
5 
43 
42 
15 
Anne Arundel 
28 
15 
12 
1 
52 
38 
10 
Baltimore 
80 
46 
29 
5 
57 
36 
7 
Calvert 
5 
4 
1 
— 
80 
20 
— 
Caroline 
11 
7 
3 
1 
64 
27 
9 
Carroll 
31 
12 
12 
7 
32 
42 
26 
Cecil 
15 
4 
10 
1 
25 
56 
19 
Charles 
11 
6 
2 
3 
54 
19 
27 
Dorchester 
21 
11 
6 
4 
35 
35 
30 
Frederick 
50 
16 
20 
14 
32 
40 
28 
Garrett 
13 
8 
3 
2 
60 
20 
20 
Harford 
23 
11 
8 
4 
46 
37 
17 
Howard 
8 
3 
4 
1 
50 
40 
10 
Kent 
14 
3 
6 
5 
21 
44 
35 
Montgomery 
58 
29 
24 
5 
50 
41 
9 
Prince George’s 
43 
23 
12 
8 
60 
22 
18 
Queen Anne’s 
10 
3 
5 
2 
30 
50 
20 
Saint Mary’s 
8 
2 
2 
4 
25 
25 
50 
Somerset 
15 
4 
8 
3 
21 
58 
21 
Talbot 
17 
5 
8 
4 
33 
45 
22 
Washington 
59 
28 
25 
6 
45 
39 
16 
Wicomico 
24 
13 
10 
1 
59 
37 
4 
Worcester 
14 
5 
5 
4 
31 
31 
38 
totals 2,464, or 1:739 when internes and residents are added. 
2Totals 1,837, or 1:468 when internes and residents are added. 
In addition to age, training and activity, other factors 
which discount the significance of the physician: popula- 
tion ratio as an index of the distribution of medical care 
are: variations in race, economic status, density of popula- 
tion, differences in climate, terrain, transportation, and the 
presence or absence of hospitals. 
To obtain an accurate picture of the medical services 
available to the population of a given county, consideration 
must also be given to the services rendered by local phy- 
sicians to non-residents, as well as to the proportion of 
county residents who usually secure medical services from 
physicians living outside its boundaries. In several counties 
of Maryland, these factors appear to have considerable 
importance. 
Age Distribution in 1941 
The age distribution of practicing physicians varied 
widely from county to county. In Table 17, page 13, the 
total in the age groups under 45, 45-64, and 65 and over 
are shown, as well as the percentage in each group. In 
many instances the numbers are small and one or two, 
more or less, in one group would produce a great variation 
Relative Activity 
Physicians in the counties of Maryland were classified 
on the basis of proportion of working hours said to be 
devoted to the practice of medicine. Of 627 practitioners, 
92 or 14.7 percent were classified as part-time physicians. 
Physical disability was said to be the cause in all except 
five. Of the 92 physicians, 2 were below 45 years, 42 be- 14 
Medical Care in the Counties of Maryland 
tween 45 and 64, while 48 were over 65 years of age. The 
total physicians in active practice, the total part-time 
physicians, and the percentage in part-time practice are 
tabulated below: 
3. Eastern Shore of Maryland 
(a) Somerset County 
(b) Worcester County 
(c) Talbot County 
A total of 88 or 15 percent of the 627 physicians were 
interviewed. In addition to those who were seen formally, 
more than 100 were interviewed quite informally in other 
counties of the State. 
Characteristics of Physicians Interviewed 
Of the 88 recorded interviews, 35 (40 percent) were below 
40 years of age, 27 (31 percent) were between 40 and 59 
years, and 26 (29 percent) were 60 years or over. Among 
all the practicing physicians of the State, the percentages 
in each of these three age groups were 31, 44 and 25, 
respectively. In regard to age, therefore, a fairly repre- 
sentative sample was selected. 
Age Groups 
Physicians in 
Active 
Practice 
Physicians in 
Part-time 
Practice 
Percent 
in 
Part-time 
Practice 
Under 45 years 
287 
2 
.7 
45-64 
250 
42 
16.8 
65 and over 
90 
48 
53.3 
Total 
627 
92 
14.7 
Specialization 
In 1941, a total of 186, or 30 percent of the 627 practicing 
physicians, either limited their practice or asserted that a 
large proportion of their time was devoted to a specialty. 
In Table 18, page 14, the physicians in each of these groups 
are enumerated by counties. 
Specialists were concentrated in the largest centers of 
population, notably in Allegany, Washington, Frederick 
and Wicomico counties. There were three counties that 
did not possess a specialist of any kind. 
In Table 19, page 15, the total specialists and their field 
of specialty are listed. The most frequent forms of limited 
practice included surgery, eye, ear, nose and throat, ob- 
stetrics and gynecology, pediatrics and internal medicine. 
These data are based upon declarations of physicians. 
PHYSICIANS AND THE PROBLEMS OF 
MEDICAL CARE 
Physicians Interviewed 
It was originally planned to interview all physicians in 
the counties and obtain from each a summary of the local 
problems in medical care and elicit their opinions as to the 
methods by which these problems might best be solved. 
When the field survey was terminated, all or nearly all 
practitioners in the following counties had been inter- 
viewed : 
1. Western Maryland 
(a) Garrett County 
(b) Allegany County 
(c) Washington County 
2. Southern Maryland 
(a) Calvert County 
(b) St. Mary’s County 
(c) Charles County 
TOTAL PHYSICIANS AND SPECIALISTS IN THE STATE OF MARYLAND 
JULY 1, 1941 
TABLE 18 
Number of Specialists 
Total 
Total* 
Practice Limited 
Physicians 
to Specialty** 
State of Maryland 
1,956 
817 
Unknown 
Baltimore City 
1,329 
631 
Unknown 
Total Counties 
627 
186 
71 
Allegany 
69 
39 
24 
Anne Arundel 
28 
9 
1 
Baltimore 
80 
23 
6 
Calvert 
5 
1 
Caroline 
11 
2 
Carroll 
31 
1 
Cecil 
15 
7 
Charles 
11 
Dorchester 
21 
6 
1 
Frederick 
50 
17 
6 
Garrett 
13 
1 
1 
Harford 
23 
5 
Howard 
8 
Kent 
14 
2 
1 
Montgomery 
58 
21 
5 
Prince George’s 
43 
5 
Queen Anne’s 
10 
Saint Mary’s 
8 
1 
Somerset 
15 
2 
1 
Talbot 
17 
6 
2 
Washington 
59 
25 
17 
Wicomico 
24 
10 
6 
Worcester 
14 
3 
*Physicians in the group asserted that they were specialists and that they 
devoted most of their working hours to a limited practice. 
♦♦Practice strictly limited. 
The majority of these physicians practiced in rural areas 
or small towns. Only 9 (10 percent) practiced in a purely 
urban environment. Approximately 18 percent of the 
physicians declared that their patients resided within a Physicians’ Services 
15 
radius of less than 5 miles, 60 percent stated that the 
distance was from 5 to 10 miles, while 22 percent declared 
that the radius was greater than 10 miles. 
Of 65 physicians who presented estimates, almost 30 
percent stated that their annual net income was over 
$3,000, while 15 percent declared that the figure was less 
than $3,000. The remainder, or 55 percent, said that their 
net incomes were between $3,000 and $5,000 per year. 
Sixty-six out of 70 physicians were members of a county 
medical society, and most of them said that they were 
active in its work. 
Although there was no hospital in two of the counties 
in which these physicians resided, two-thirds of the 
practitioners were members of the staff of a hospital in 
their own or in an adjoining county. 
Topics Discussed and Opinions Expressed 
With a high proportion of these physicians, the following 
specific topics were discussed: 
1. Local facilities for medical care. 
2. Availability of physicians’ services to the total 
population. 
3. Local provisions for the care of the medically indigent. 
4. Proportion of physicians’ time devoted to care of 
medically indigent. 
5- Recommended changes in the present provisions for 
medical care of the indigent. 
6. Experiences with programs for medical care of 
indigent in adjoining states. 
7. Experiences with medical service systems in in- 
dustrial groups. 
8. The advisability of adopting a system of public 
payment for medical care for (a) those on relief and 
(b) those in low income groups. 
9. Opinions on provisions of public payment systems 
relating to (a) choice of physician, (b) compensation 
and (c) administration. 
TOTAL SPECIALISTS1 AND THEIR FIELDS OF SPECIALTY IN THE 
STATE OF MARYLAND, JULY 1, 1941 
Total 
Specialists 
Internal 
Medicine 
Surgery* 
Obstetrics & 
Gynecology 
Pediatrics 
Urology 
Eye, Ear, Nose 
and Throat** 
Psychiatry*** 
>» 
M 
C 
'S 
c3 
Dermatology 
Industrial 
Medicine 
& 
JD 
O 
-C 
o3 
Ph 
Anaesthesia 
State of Maryland 
Baltimore City 
Total Counties 
817 
631 
186 
145 
129 
17 
169 
123 
46 
123 
97 
25 
85 
63 
22 
43 
34 
9 
111 
79 
32 
35 
33 
2 
29 
19 
10 
19 
17 
2 
30 
17 
13 
13 
11 
2 
15 
9 
6 
Allegany 
39 
4 
10 
4 
3 
3 
9 
3 
1 
2 
Anne Arundel 
9 
1 
2 
2 
1 
3 
Baltimore 
23 
1 
4 
3 
4 
3 
1 
6 
1 
Calvert 
1 
1 
Caroline 
2 
2 
Carroll 
1 
1 
Cecil 
7 
2 
1 
1 
1 
2 
Charles 
— 
Dorchester 
6 
3 
1 
1 
1 
Frederick 
17 
2 
4 
2 
2 
3 
2 
1 
1 
Garrett 
1 
1 
Harford 
5 
2 
2 
1 
Howard 
— 
Kent 
2 
1 
1 
Montgomery 
21 
6 
3 
5 
1 
2 
2 
2 
Prince George’s 
5 
2 
2 
1 
Queen Anne’s 
— 
Saint Mary’s 
1 
1 
Somerset 
2 
1 
1 
Talbot 
6 
2 
1 
1 
1 
1 
Washington 
25 
3 
4 
4 
3 
2 
6 
1 
1 
1 
Wicomico 
10 
4 
1 
1 
3 
1 
Worcester 
3 
1 
2 
'Based upon declarations of physicians. 
♦Including Orthopedics and Neurosurgery. 
♦♦Including Otolaryngology and Ophthalmology. 
♦♦♦Including Neuropsychiatry. 16 
Medical Care in the Counties of Maryland 
1. Local Facilities for Medical Care 
(a) Consultants 
Of 69 physicians who discussed the subject, 58 said that 
they rarely had great difficulty in securing the services of 
a consultant, however that consultants’ services were by 
no means routinely available. In most instances consultants 
were located in the larger medical centers and it sometimes 
was necessary for them to travel a considerable distance 
to confer with county physicians. Many practitioners stated 
that if the same consultants were called each time, and if 
fees were received from those able to pay, little difficulty 
was experienced in obtaining occasional consultants’ serv- 
ices for the medically indigent. 
Physicians in the more remote areas, however, stated 
that since the distance to the nearest medical center was 
great, it was too expensive for all but a very few of their 
patients to procure the services of a consultant. The other 
alternative was a long drive to the medical center and 
hospitalization of a patient who otherwise might have 
been treated in the home. 
(b) Hospitals 
(i) General Hospitals 
A high percentage of physicians expressed the belief 
that the usefulness of small hospitals was limited on 
account of the absence of a resident staff, and because of 
the necessity of treating a wide variety of conditions for 
which adequate facilities were not available. 
A number of doctors said that they hesitated to send 
their patients to the larger hospitals in Baltimore and in 
the District of Columbia because in doing so they incurred 
the displeasure of some of their local associates. This group 
expressed the hope that something might be done to make 
consultants’ services more readily available in local 
hospitals. 
In deciding whether a patient should be sent to a hospital, 
the distance to the institution from the physician’s office 
was sometimes a matter of serious moment. If the type of 
illness made it necessary for the physician to visit the 
hospital each day, a distance of five or six miles might 
make the cost prohibitive to the patient. 
Another reported difficulty was that hospital adminis- 
trators, except in very obvious emergencies, seemed prone 
to discourage the admission of free and even part-pay 
patients. In more than one area physicians bitterly com- 
plained that they were frequently subjected to cross- 
examination as to the urgency of the need for hospital 
care for an indigent patient. The Committee on Medical 
Care was urged to recommend that the hospitalization of 
the medically indigent be placed on a more equitable basis. 
In several instances the necessity for restricting admis- 
sions was said to be a lack of accommodations and hospital 
personnel. In others this was not the case. In the opinion 
of some physicians, several hospitals appeared to be 
receiving funds from State, city and county governments 
in amounts sufficient to provide hospitalization for a larger 
proportion of indigent patients than were being admitted. 
Nearly all of the physicians reported that it was prac- 
tically impossible to hospitalize a normal indigent ob- 
stetrical case, and that an abnormal case sometimes had to 
be almost in extremis before the patient could be admitted. 
In many institutions the number of beds provided for 
Negro patients was said to be inadequate. A few were 
reported to have excellent facilities for the care of Negroes. 
(li) Chronic Disease Hospitals 
The lack of institutions for the treatment of patients 
suffering from chronic disease was unanimously deplored. 
It was pointed out that the large majority of the chroni- 
cally ill could not afford the services of a graduate nurse 
in the home, and that it was almost impossible to provide 
adequate care for such patients without; (a) immobilizing 
a general hospital bed for a long period, provided the 
patient could be admitted to a hospital; (b) overloading 
the physician so that he would be unable to treat all patients 
who were acutely ill; (c) exhausting the financial resources 
of the patient and his family. 
(iii) Home Nursing 
Outside the hospitals centers there were said to be 
relatively few graduate nurses because, in the opinion of 
physicians, a very small proportion of their patients could 
afford to pay the cost. “Practical nurses” were found to 
be more numerous. These were individuals who either had 
a limited amount of hospital training, or, believing that 
they possessed an aptitude for this type of work, considered 
themselves qualified by experience. 
Since skilled nursing service can not, as a rule, be secured 
in the rural areas which comprise a large part of the State, 
the suggestion was advanced by a number of physicians 
that practical nurses should be made more generally 
available, and that those now active should be encouraged 
or even required to take a course of training in standard 
nursing procedures so that they might be better prepared 
to render more efficient service. It was fully realized by 
these physicians that most nursing authorities considered 
such developments unsound and unwarranted. 
In the absence of adequate and inexpensive nursing 
service in the home, the alternative, in the opinion of 
physicians is the hospitalization of a patient who otherwise 
might not require institutional care. In that event, the 
hospital expenses frequently are greater than the financial 
resources of the patient and the public is compelled either 
to bear the entire cost or to underwrite the difference. Physicians’ Services 
17 
(iv) Drugs and Medical Supplies 
In most rural areas, drugs and other medical necessities 
can not be purchased within a reasonable distance. A large 
majority of physicians, therefore, find it necessary to dis- 
pense drugs and other medical supplies. One of the un- 
fortunate consequences, from the standpoint of the physi- 
cian, is that for the medically indigent a practitioner not 
only must render professional services without compensa- 
tion but also furnish the drugs. 
(v) Post Graduate Training for Physicians 
In order to keep abreast of medical progress, physicians 
stated that it usually was necessary to attend lectures and 
clinics in relatively distant points with loss of valuable 
time. 
Many practitioners expressed the desire for the re- 
establishment of refresher courses formerly conducted 
throughout the State by the Medical and Chirurgical 
Faculty. 
2. Availability of Physicians' Services to the Total Population 
Physicians almost invariably agreed that there were 
unmet needs in their community, and in most cases they 
did not hesitate to indicate the magnitude of such needs. 
Nearly all of those interviewed expressed the belief that 
in their community there were persons who, because they 
lacked sufficient funds, were unable at times to obtain 
medical care, and that there were others who, having 
little cash or credit, sometimes delayed calling a physician 
even to the point of danger. In several counties, particularly 
in those in which the proportion of physicians over 50 
years of age was high, a majority of the doctors declared 
that they would not be surprised if indigent patients 
complained that they could not get medical attention at 
times other than during the usual office hours. 
On the other hand, a number of physicians asserted that 
they never had declined to treat a case regardless of financial 
status and there was abundant evidence that this was the 
case. One doctor said “I have never turned down a patient 
in my life”, and added with a twinkle “but, believe me, 
I’ve done a hell of a lot of grumbling in my time”. 
In chronic illness the situation was quite different. In 
the absence of home nursing service and chronic disease 
hospitals there were “more than a few” who, physicians 
declared, did not receive adequate medical care. 
3. Local Provisions for the Care of the Medically Indigent 
Under the public welfare laws, no specific provision is 
made for medical care except as can be included in the 
budget of the individual. Relief clients must make their 
own arrangements for doctors. No authorization is neces- 
sary, but proof of medical expenses is required for bud- 
getary purposes. This has resulted in different procedures in 
many of the counties, and among the physicians there was 
wide-spread and almost unanimous dissatisfaction with 
the effort to provide medical care for those who were 
receiving relief. Of 72 practitioners interviewed, only 3 
expressed any degree of approval of these attempts. 
The chief criticisms have been classified as follows: 
(a) Because of the complicated system for authorizing 
even the limited payments for physicians’ services 
available under the former relief program, most phy- 
sicians still felt there was considerable red tape 
involved. 
To avoid filling out complex forms some phy- 
sicians preferred to continue to treat these patients 
as “charity cases”, as they always had done, and 
forget about the possibility of receiving compensa- 
tion; others declined to treat welfare cases. 
Typical comments were: (i) “I do not bother 
putting their accounts on my books because I know 
that I will not be paid more than a quarter of the 
time,” and (ii) “As for welfare patients—I never 
accept them since entirely too much red tape is 
involved.” 
Physicians objected to the necessity for prolonged 
debates with welfare workers as to the need for 
repeated visits to patients, particularly in cases 
in which medical judgment was involved. 
Due to complex procedures it was reported that 
harmful delays sometimes occurred in providing 
patients with drugs which the physician did not 
possess. 
(b) A few of the county welfare departments contracted 
with the physician to treat a recipient of relief but 
the doctor was compelled to collect from the 
patient. 
In several counties in which arrangements had 
been made by the welfare department to compen- 
sate physicians, at least in part, for service to relief 
cases, the amount agreed upon was added to the 
monthly check of the welfare case. Physicians 
believed that patients often were urged by welfare 
workers to pay their bills. If, however, the physi- 
cian did not happen to be in the vicinity on the day 
on which the next check was received, according 
to physicians, the account was paid in only about 
25 percent of cases. A number of physicians said 
that they did not always blame the welfare cases 
because in many instances the amount of the check 
was small. However, in their opinion, if a specific 
portion of the check had been allocated for medical 
care or other legitimate expenditures, it seemed 
reasonable to expect, as a matter of principle, that 
the money would be expended for that purpose. 18 
Medical Care in the Counties of Maryland 
(c) If a patient dies before a welfare check is mailed 
the check becomes null and void and the physician 
can not collect the amount due. 
(d) The opinions of five of the 69 critics were sum- 
marized in the words of one who said “The people 
on relief are being pauperized. They used to ask 
for medical assistance and say ‘thank you’ when 
it was given, and the service was rendered cheer- 
fully. Now they come to us demanding attention 
without expecting or offering to pay even a penny 
for it. The whole system, in my opinion, is wrong.’’ 
(e) The opinions of another group were epitomized in 
the words of one of their number: “Many of these 
unfortunate people are on relief because they were 
unable to manage their own financial affairs, and 
yet these same individuals are now expected to 
act wisely in expending funds received from govern- 
mental sources. Furthermore, I can not understand 
why the Federal, State and local governments 
require strict accounting for every nickel of all 
other types of appropriations, and in these ex- 
penditures of very large sums, there appears to be 
no thought of requiring the recipients to render 
an accounting.’’ 
4. Proportion of Physicians' Time Devoted to Treatment of 
Medically Indigent 
On the basis of statements of 58 physicians, the propor- 
tion of patients given free medical services varied from 
10 to 50 percent with an average of approximately 30 
percent. It would appear, therefore, that physicians, on 
an average, contributed about one-third of their time and 
talents to the care of the medically indigent. 
About 30 percent of physicians reported that during the 
preceding five-year period their ability to earn a livelihood 
had been definitely impaired by the magnitude of the free 
and part-pay patient load they were obliged to carry. 
5- Recommended Changes in Present Provisions for Medical 
Care of the Indigent 
The following modifications in the present system for 
providing medical care for the indigent were suggested 
by physicians: 
(a) The reduction of “red tape’’ to a minimum. 
(b) The establishment of a definite fee schedule. 
(c) Legislation to make possible direct compensation 
of physicians by the welfare departments. 
(d) Greater participation of county medical societies. 
6. Experiences with Programs for Medical Care of Indigent in 
Adjoining States 
In contrast to the general dissatisfaction with provisions 
for the medical care of welfare cases in the counties of 
Maryland, many physicians in Western Maryland expressed 
quite enthusiastic approval of the provisions for medical 
care of the indigent in West Virginia and Pennsylvania. 
Most of these physicians had personal experience with 
these programs since some of their patients resided in one 
or the other of these States. 
It was decided to investigate these plans in as much 
detail as time would permit. Four physicians in each of 
these States were interviewed. The impression was gained 
that these physicians were reasonably well satisfied with 
most of the provisions of the programs. However, a number 
of objections were raised which had not been mentioned 
by Maryland physicians. While there were certain funda- 
mental differences in the plans in West Virginia and in 
Pennsylvania, features common to both appeared to be as 
follows: 
(a) The first call to a welfare case was usually made 
without preliminary authorization, thus avoiding 
unnecessary delay in instituting treatment. 
(b) Physicians’ statements were presented to a com- 
mittee of the county medical society each month. 
After being reviewed and, if necessary, revised, the 
bills were forwarded to the county welfare depart- 
ment for payment. 
(c) If full payment were not received, physicians were 
sure that some compensation would be forthcoming. 
(d) The “red tape” was minimal. 
7. Experiences with Medical Service Systems in Industrial 
Groups 
In two counties, Allegany and Garrett, physicians have 
had long experience with medical services in industrial 
groups. In some of the mines and other industries of the 
region a check-off system, not unlike the British panel 
system, was in operation. 
In each family all workers over 21 years of age entered 
into a contract with a physician, through the company 
by which they were employed. Under the terms of this 
contract $2 a month was paid for medical care in the home 
and in the physician’s office. All members of the family 
were entitled to receive treatment without additional 
charge. Professional services for obstetrical cases, accidents 
and venereal disease were not included. 
It was stated that collections from employees were made 
each pay day and, as a rule, a collection charge (reported 
to have been 5%), was deducted before the company paid 
the balance to the physician named by the employee. It 
was said that the physician had the right to accept or 
reject the application of any worker. 
On the whole, this system seemed to be regarded with 
favor but the following misgivings were expressed: Physicians’ Services 
19 
(a) Some patients called physicians to their homes for 
minor illnesses while others sometimes came to the 
office for trivial reasons, presumably because they 
wished to “get something in return’’. 
(b) If employment was irregular, the physicians’ income 
also was variable. 
(c) In order to be assured of adequate remuneration for 
treatment of the group, physicians estimated that 
they must have at least one hundred employees 
under contract. 
(d) It was stated that occasionally one physician or a 
group of physicians seemed, in one way or another, 
to secure the enlistment of a high percentage of the 
employees of a particular company, leaving few 
for other doctors in the area. 
(e) Patients who had a relatively high income obtained 
medical care at a cost considerably less than they 
otherwise would have been expected to pay. 
8. The Advisability of Adopting a System of Public Payment 
for M.edical Care for (a) Those on Relief and (li) Those in 
Low Income Groups 
A total of 77 physicians were asked this question: 
“Do you favor the adoption of a well-controlled plan for 
public payment for medical care for (a) those on relief and 
(b) those in the low income group?” By the term “well- 
controlled” it was implied that under the plan the interests 
of both physicians and patients would be properly safe- 
guarded. The responses were classified as follows: 
(i) Fifty-eight (76 percent) favored a public payment 
plan for medical care for relief cases. Of this 
number, 22 physicians also favored a plan for 
those with low incomes. 
(ii) Eleven (14 percent) were satisfied with existing 
conditions. 
(iii) Eight (10 percent) were non-committal. 
From the foregoing, it is obvious that the large majority 
of physicians favored the development of a well-controlled 
program for the public payment for medical care for 
“those on relief”. Of this group, 22 physicians expressed 
the opinion that those in the low income group also 
should be included. 
Of the 11 physicians in group (ii), nine expressed the 
fear that the introduction of such a plan would be “just 
one more step in the direction of socialized medicine” 
while two asserted that “all is well”. 
The 8 physicians in group (iii) included: (a) Older 
physicians who preferred to leave settlement of the question 
in the hands of younger men; (b) Those who professed lack 
of interest because all their patients were in the higher 
income brackets; (c) Those who declined to express an 
opinion. 
9. Opinions on Provisions of Public Payment Systems Relating 
to (a) Choice of Physician, (h) Compensation, and (V) 
Administration 
(a) Choice of Physician 
All physicians were in agreement on one point, namely, 
that any plan that may be developed should provide for 
freedom of choice of physicians by all its beneficiaries. 
(b) Compensation 
Physicians desired assurance of receiving payment for 
services rendered, but opinion was almost equally divided 
as to whether full or reduced fees should be charged. 
(c) Administration 
In the opinion of most physicians such a plan could best 
be administered by the county health department in 
collaboration with the county medical society. In two 
counties the formation of a new organization for ad- 
ministrative purposes was advocated. These were areas in 
which the administration of the county health departments 
did not appear to meet the general approval of the medical 
profession. A very small number of physicians thought 
that the work could be done by county commissioners or 
by the welfare department. 
While it was realized that there were many problems in 
medical care common to all counties, there was scarcely 
a county, in the opinion of physicians, that did not possess 
problems peculiar to that locality. It was agreed that a 
State agency should formulate and administer general 
policies. In the interests of achieving maximum efficiency, 
however, it was considered advisable to establish in each 
county an administrative unit with power to modify a 
State policy, within appropriate limits, in order to solve 
a specific local problem. 
Summary 
Since 1906 the proportion of physicians in active practice 
in the cities and towns of Maryland has increased to a 
significant degree. Concurrently, a marked decrease in the 
number of physicians has occurred in counties with sta- 
tionary or declining populations. 
In the counties in the lower economic level, the propor- 
tion of physicians over 60 years of age was high. In the 
absence of a flow of young practitioners into these areas 
within the next ten years, a serious shortage is inevitable. 
In 1941, a total of 627 physicians were in active practice 
in the counties. Of these 580, or 93 percent, were white 
males; 9, or 3 percent were white females; and 28, or 4 
percent, were colored males. 20 
Medical Care in the Counties of Maryland 
The number of persons per physician varied between 
1:962 in Kent and 1:2,442 in Anne Arundel County. 
Calvert, Caroline, Garrett, Prince George’s and Wicomico 
had the highest percentage of physicians under 45 years, 
and St. Mary’s, Worcester, Kent and Dorchester had the 
greatest proportion over 65 years of age. 
Of 627 practitioners, 92, or 14.7 percent were classified as 
part-time physicians, chiefly on account of physical disa- 
bility. 
In 1941, a total of 186, or 30 percent of 627 physicians, 
declared that they devoted all or nearly all of their working 
hours to the practice of a specialty. 
A total of 88, or 15 percent of the 627 physicians in 
9 counties, were interviewed at length. These comprised 
a large majority of practitioners in these counties. 
Physicians interviewed were representative in age, most 
of them were engaged in rural practice within a radius of 
5 to 10 miles from their office, had a net income of from 
$3,000 to $5,000 per year, belonged to the county medical 
society and to the visiting staff of a hospital. 
Physicians in remote areas reported inability to secure 
consultants, except in unusual circumstances. 
The need for a resident medical staff and consultants in 
local hospitals was stressed. 
Difficulties in obtaining hospitalization, particularly for 
medically indigent, and especially for normal obstetrical 
cases were reported. 
The absence of chronic disease hospitals was almost 
unanimously deplored. 
It was declared that only a small proportion of the 
population was able to pay for graduate nursing service in 
the home. Difficulties were also reported in obtaining 
graduate nurses for duty in small hospitals. The training 
of “practical’’ nurses was suggested. 
In most rural areas physicians dispensed drugs and other 
medical necessities to those who could pay as well as to 
those who could not. 
Physicians almost invariably agreed that in their counties 
there were persons who, because they lacked sufficient 
funds, were unable at times to obtain medical care, and 
that there were others who, having little cash or credit, 
sometimes delayed calling a physician even to the danger 
point. The proportion of such persons was thought to be 
considerably higher among the chronically ill than in 
acute cases. 
Among physicians there was general dissatisfaction with 
current efforts to provide medical care for those receiving 
assistance from welfare agencies. 
Physicians estimated that about one-third of their 
professional services were rendered without compensation. 
About 30 percent asserted that the number of indigent 
persons treated was such that their ability to earn a liveli- 
hood had been definitely impaired during the previous 
five-year period. 
The changes recommended in present provisions for care 
of the indigent included a reduction of “red tape”, the 
establishment of a fee schedule, a direct compensation by 
welfare agencies to physicians, and greater participation 
by county medical societies. 
Experiences with programs for care of the indigent in 
West Virginia and Pennsylvania were reported to be 
reasonably satisfactory. 
Experiences with medical service systems in industries 
in Allegany and Garrett counties were said to be fairly 
satisfactory. 
Approximately 76 percent of physicians favored the 
adoption of a well-controlled plan for public payment for 
medical care for those on relief. About one-quarter of these 
also favored a plan for those in the low income brackets. 
Fourteen percent were satisfied with existing conditions. 
Ten percent were non-committal. 
All practitioners agreed that any plan which might be 
developed should provide for freedom of choice of physician. 
Opinions were about equally divided between those who 
favored full or reduced fees under such a plan. 
The majority of physicians were of the opinion that a 
public payment plan could best be administered locally 
by the county health department in collaboration with 
the county medical society. While a State agency, in 
coordination with the Medical and Chirurgical Faculty of 
Maryland, might formulate general policies, it seemed 
essential, in their opinion, to provide for a certain amount 
of local autonomy to solve specific local problems. Chapter IV 
NURSES’ SERVICES 
Distribution of Nurses 
In 1941, a total of 1,143 active registered nurses was 
located in the counties of Maryland, according to the 
National Survey of Registered Nurses made by the U. S. 
Public Health Service in cooperation with the National 
and State Nurses Association. In Table 20, page 21, their 
distribution is shown by color and sex, as well as the 
nurse: population ratio. It will be noted that 1,119 or 
98 percent, were white females, while 13 white males and 
11 colored female nurses comprised the remaining 2 percent. 
The largest number of nurses, 195, was found in Mont- 
gomery, and the smallest, 4, in Garrett County. The 
highest nurse: population ratio, 1:376, was noted in Talbot, 
and the lowest, 1:5,495, in Garrett County. 
In Table 20, page 21, it also will be observed that, in 
general, the highest relative number of active registered 
nurses was located in those counties which have been 
classified in the higher economic level. 
Types of Nursing Service 
In Table 21, page 21, the number of active female registered 
nurses in private duty and in other types of nursing has 
been indicated by the counties in which they were located 
in the year 1941. Of the total of 1,130 in all counties, 
412 were in private duty, 457 were employed in hospitals 
or other institutions, 144 were in public health, 46 in 
industrial nursing, while 71 were engaged in other limited 
types of nursing. 
In Table 22, page 22, the percent of registered nurses 
in private duty and in limited categories have been shown 
for the State of Maryland. In the total counties 36.5 percent 
of nurses were in private duty, 40.4 percent were in in- 
stitutional nursing, 12.7 percent in public health, 4.1 per- 
cent in industrial nursing and 6.3 percent in other limited 
types, in striking similarity with the percentages in 
Baltimore City. 
In 1940 in the counties of Maryland, there were no 
public organizations of nurses engaged in bedside service. 
TABLE 20 
ACTIVE REGISTERED NURSES IN MARYLAND IN 1941 BY RACE, 
SEX AND THE NURSE: POPULATION RATIO* 
ACTIVE FEMALE REGISTERED NURSES AND LIMITED TYPES OF 
NURSING IN THE STATE OF MARYLAND IN 1941* 
TABLE 21 
Total 
Wh 
Male 
ite 
Female 
Colored 
Female 
Nurse: 
Population 
Ratio 
State of Maryland 
3,187 
17 
3,112 
58 
1: 571 
Baltimore City 
2,044 
4 
1,993 
47 
1: 420 
Total Counties 
1,143 
13 
1,119 
11 
1: 842 
Talbot 
50 
49 
1 
1: 376 
Montgomery 
195 
4 
191 
1: 430 
Wicomico 
69 
68 
1 
1: 500 
Allegany 
132 
1 
131 
1: 658 
Prince George’s 
108 
106 
2 
1; 829 
Washington 
82 
82 
1: 839 
Baltimore 
184 
8 
176 
1: 847 
Anne Arundel 
79 
78 
1 
1: 866 
Dorchester 
31 
31 
1: 903 
Frederick 
59 
59 
1: 971 
Cecil 
27 
26 
1 
1: 978 
Kent 
12 
11 
1 
1:1,122 
Harford 
26 
26 
1:1,348 
Howard 
12 
11 
1 
1:1,431 
Queen Anne’s 
10 
10 
1:1,448 
Calvert 
6 
5 
1 
1:1,747 
Caroline 
10 
10 
1:1,755 
Carroll 
18 
16 
2 
1:2,170 
Somerset 
9 
9 
1:2,329 
Saint Mary’s 
6 
6 
1:2,438 
Charles 
7 
7 
1:2,516 
Worcester 
7 
7 
1:3,035 
Garrett 
4 
4 
1:5,495 
Total 
Private 
Duty 
Hospital 
or other 
Institu- 
tion 
Public 
Health 
Indus- 
trial 
Others 
State of Maryland 
3,170 
1,283 
1,322 
336 
115 
114 
Baltimore City 
2,040 
871 
865 
192 
69 
43 
Total Counties 
1,130 
412 
457 
144 
46 
71 
Allegany 
131 
73 
30 
10 
9 
9 
Anne Arundel 
79 
27 
32 
18 
1 
1 
Baltimore 
176 
52 
84 
25 
10 
5 
Calvert 
6 
3 
1 
2 
Caroline 
10 
5 
3 
2 
Carroll 
18 
3 
9 
4 
2 
Cecil 
27 
8 
12 
3 
2 
2 
Charles 
7 
1 
3 
2 
1 
Dorchester 
31 
18 
11 
2 
Frederick 
59 
15 
29 
7 
2 
6 
Garrett 
4 
1 
1 
2 
Harford 
26 
12 
9 
3 
2 
Howard 
12 
4 
5 
3 
Kent 
12 
3 
3 
4 
1 
1 
Montgomery 
191 
60 
68 
23 
13 
27 
Prince George’s 
108 
16 
69 
10 
4 
9 
Queen Anne’s 
10 
3 
3 
3 
1 
Saint Mary’s 
6 
1 
2 
3 
Somerset 
9 
5 
3 
1 
Talbot 
50 
33 
15 
1 
1 
Washington 
82 
39 
38 
4 
1 
Wicomico 
69 
33 
25 
5 
1 
5 
Worcester 
7 
2 
5 
♦National Survey of Registered Nurses made by the U. S. Public Health Service 
in cooperation with the National and State Nursing Associations. 
♦National Registry of Registered Nurses. 22 
Medical Care in the Counties of Maryland 
The unexpected termination of field activities made it 
necessary to omit a detailed study of nursing care in the 
counties which had been projected. References to various 
aspects of this subject, however, have been made in other 
Chapters of this report. For example, in Chapter III it was 
pointed out that, outside the medical centers, there were 
relatively few graduate nurses available for home nursing, 
because, it was asserted, very few persons were able to pay 
the cost. In such areas, “practical” nurses were found in 
larger numbers than in the cities. The opinion was ad- 
vanced by physicians that practical nurses should be 
encouraged to become located in these rural areas, which 
comprise a large part of the State. It also was suggested 
that practical nurses should be urged, and even required, 
to take training in the more simple of the standard nursing 
procedures. This suggestion is one which might well be 
given serious consideration by those in authority in the 
field of nursing. It might also be included among the 
subjects for possible future study by the Committee on 
Medical Care. 
In Chapter VI, brief reference is made to institutional 
nursing, while in Chapter VII the activities of public 
health nurses are outlined. In Chapter VIII, it will be 
noted that the county welfare executives asserted that the 
services of a registered nurse rarely, if ever, could be 
obtained for those receiving relief because of the cost. 
These officials also urged that a bedside nursing service 
be organized for indigent patients. 
Summary 
In 1941, a total of 1,143 active registered nurses was 
located in the counties. Of these, 1,119, or 98.0 percent 
were white females, while 13 white males and 11 colored 
females comprised the remaining 2 percent. 
The highest relative number of graduate nurses was 
located in the counties in the higher economic level. 
Of the 1,130 active female registered nurses, there were 
412, or 36.6 percent in private duty; 457, or 40.4 percent 
in institutions; 144, or 12.7 percent, in public health; 
46, or 4.1 percent, in industrial nursing; and 71, or 6.3 
percent, in other limited types of service. There were no 
organized public visiting nurses in the counties. 
The suggestions have been reiterated that practical 
nurses be encouraged to locate in the rural areas and that 
those now at work should be urged to take limited 
training. Reference was also made to the suggestion of 
county welfare executives that visiting nurses be organized 
to render bedside nursing in the homes of those receiving 
assistance. 
TABLE 22 
PERCENT OF FEMALE REGISTERED NURSES BY GENERAL 
AND SPECIAL TYPES OF NURSING IN MARYLAND IN 1941 
Total 
Private 
Duty 
Insti- 
tution 
Public 
Health 
Indus- 
trial 
Other 
State of Maryland 
3,170 
40.5 
41.7 
10.6 
3.6 
3.6 
Baltimore City 
2,040 
42.7 
42.4 
9.4 
3.4 
2.1 
Total Counties 
1,130 
36.5 
40.4 
12.7 
4.1 
6.3 Chapter 
DENTISTS’ SERVICES1 
\ survey of the dental services in the counties of 
Maryland was based upon a study of the distribution 
of private and public dental facilities and consultations 
with dentists in private practice and with State and county 
health officials. 
Distribution of Dentists 
In Table 23, page 23, the number of dentists is shown by 
counties with the number of persons per dentist in each. 
It will be seen that a total of 295 dentists was in active 
practice in 1940. The dentist: population ratio varied 
between 1:2,025 in Washington County and 1:8,588 in 
Howard County with 1:7,001 in Dorchester County. The 
latter probably is the more significant ratio, since Howard 
County adjoins Baltimore City and many county residents 
undoubtedly obtain dental treatment in that center. 
Committees of the American Dental Association, the 
U. S. Public Health Service and other professional groups 
have developed dentist: population ratios desirable for 
“adequate” dental care: (i) during “normal” conditions, 
1:1,000, and (ii) during emergencies; 1:2,500. The first 
ratio implied adequate dental care for each 1,000 potential 
patients—generally assumed to mean 60 percent of needed 
dental service per individual. The second ratio connotes 
complete dental care for some, adequate service for others 
and emergency care only for the remainder of the 2,500 
patients. 
If these formulae are compared with those which existed 
in the counties of Maryland in 1940, it is found that no 
county even approximated the ratio of 1:1,000—the nearest 
being Washington County with 1:2,025—and the first 
7 counties listed in Table 23 exceeded or approximated the 
1 ;2,500 ratio. 
The need for additional dentists appeared to be greatest 
in Calvert, Queen Anne’s, St. Mary’s, Garrett, Charles and 
Dorchester counties. 
The proximity of Baltimore, Howard and Prince George’s 
counties to Baltimore and the District of Columbia un- 
doubtedly explain, in part, the relatively low dentist: 
population ratios in these counties. On the other hand, 
while suburban residents usually have comparatively easy 
access to dental services in the cities, it was observed in 
each of these counties that there were large sections in 
which dentists rarely were found—places in which such 
services were sorely needed. 
It is obvious that the dentist; population ratios for the 
counties of Maryland are not always comparable, as was 
observed in discussing the physician: population ratios— 
and for practically the same reasons. At best, such ratios 
serve only in a general way to indicate the distribution of 
dentists in a given population. 
TABLE 23 
DISTRIBUTION OF DENTISTS IN ACTIVE PRACTICE IN THE STATE 
OF MARYLAND, BALTIMORE CITY AND IN THE COUNTIES OF 
MARYLAND IN 1940, TOGETHER WITH THE TOTAL POPULA- 
TION AND THE DENTIST: POPULATION RATIO 
Total 
Dentists in 
Active Practice 
(1940) 
Total 
Population 
(1940) 
Dentist: 
Population 
Ratio 
State of Maryland 
862 
1,821,244 
1:2,113 
Baltimore City 
567 
859,100 
1:1,515 
Total Counties 
295 
962,144 
1:3,262 
Washington 
34 
68,838 
1:2,025 
Frederick 
28 
57,312 
1:2,047 
Worcester 
10 
21,245 
1:2,125 
Montgomery 
35 
83,912 
1:2,397 
Allegany 
35 
86,793 
1:2,480 
Carroll 
15 
39,054 
1:2,604 
Harford 
13 
35,060 
1:2,697 
Cecil 
8 
26,407 
1:3,301 
Kent 
4 
13,465 
1:3,366 
Wicomico 
10 
34,530 
1:3,453 
Somerset 
6 
20,965 
1:3,494 
Caroline 
5 
17,549 
1:3,510 
Baltimore 
38 
155,825 
1:4,101 
Talbot 
4 
18,784 
1:4,696 
Queen Anne’s 
3 
14,476 
1:4,825 
Saint Mary’s 
3 
14,626 
1:4,875 
Anne Arundel 
14 
68,375 
1:4,884 
Prince George’s 
17 
89,490 
1:5,264 
Garrett 
4 
21,981 
1:5,495 
Charles 
3 
17,612 
1:5,871 
Dorchester 
4 
28,006 
1:7,001 
Howard 
2 
17,175 
1:8,588 
Calvert 
* 
10,484 
* 
'One dentist in part-time practice. 
In Table 23, page 23, it will be observed that the dentist: 
population ratio, like that of physicians and nurses, was, 
in general, higher in the counties in the higher economic 
level, and lower in the remaining counties. If this con- 
centration of dentists in the more wealthy counties has 
been developing for a number of years, as was found with 
physicians, the proportion of those requiring dental care 
in the less fortunate areas has been increasing from year to 
year. 
ipor much of the basic material in this chapter the Committee is indebted 
to Richard C. Leonard, D.D.S., Chief, Division of Oral Hygiene, Maryland 
State Department of Health. The names and addresses of dentists in practice 
in the counties were provided by H. B. McCarthy, D.D.S., Professor of 
Dental Anatomy, University of Maryland. 24 
Medical Care in the Counties of Maryland 
Denial Care Among Negroes 
The Negro population presents another specific problem 
in dental care. In the 23 counties of Maryland there was a 
total of 136,368 Negroes, according to the U. S. Census of 
1940. In the same year there were only seven Negro dentists 
located in four counties—Anne Arundel, Frederick, Prince 
George’s and Wicomico. If all Negroes were treated by 
colored dentists, the dentist: Negro population ratio would 
be 1:19,481. The number of Negroes obtaining treatment 
from white dentists probably is not sufficient to change 
this ratio significantly, or to lessen the magnitude of the 
problem. 
Public Dental Services 
For many years before the inauguration of a State-wide 
oral hygiene program, dental clinics for treatment of the 
indigent were conducted by dentists in several counties of 
Maryland. In most, if not all of these clinics the prac- 
titioners served on a voluntary basis and at considerable 
personal sacrifice. These volunteer activities were the 
foundation stones upon which the modern oral hygiene 
program was built. 
In 1929, a law1 was amended by the State legislature to 
provide for the addition of “an experienced dental surgeon’’ 
to the membership of the State Board of Health. On 
September 26, 1929, the latter established a Division of 
Oral Hygiene and appointed a Division Chief. 
The State Oral Hygiene Program 
The State oral hygiene program has been primarily 
educational, enlightening the public in general, under- 
graduates in dentistry, teachers-in-training and school 
children in particular, in the ways and means of main- 
taining mouth health. 
School dental clinics for the first three grades, ages 6, 7 
and 8 years, were established in public and parochial 
schools. Efforts were made to limit examination and 
treatment to children of indigent parents. In the absence 
of investigating facilities, however, it was found more 
satisfactory, with the consent of local dental practitioners, 
to treat every child in the limited age group without 
regard to financial status. 
The clinics varied in character. Some of the clinicians 
were full-time salaried dentists, as in Allegany, Mont- 
gomery and Washington counties; in other counties, local 
practitioners devoted half time or less on a per diem salary 
as in Anne Arundel, Baltimore, Calvert, Charles, Fred- 
erick, Harford, Carroll, Howard, Kent, Prince George’s, 
Queen Anne’s, Talbot, Wicomico and Worcester counties. 
In Garrett County an experiment was conducted, with 
more or less success, in which a group of dentists agreed 
to treat all school children in their offices. Another unusual 
feature of the Maryland program in recent years was the 
use of the Healthmobile, an itinerant bus which brought 
medical and dental inspection plus emergency dental 
treatment to pre-school and school children. In the Health- 
mobile service, five dental clinicians devoted part-time for 
four months each summer in Calvert, Caroline, Charles, 
Cecil, Kent, Prince George’s, Queen Anne’s, St. Mary’s, 
Somerset and Worcester counties. 
Some county dental clinics provided entirely free service 
only to children of indigent parents, others gave free and 
low cost service, the latter at a flat rate per child. 
In all counties the dentists either served on the staff of 
the county health department or functioned in close co- 
operation with the county health officer and public health 
nurses. 
Few of the counties had an adequate school dental 
service. There were no organized dental services, with the 
exception of the very limited Healthmobile activities, in 
Caroline, Cecil, Dorchester and St. Mary’s counties. The 
number of children examined and treated in the school 
dental clinic, with the total operations in the years 1930 
and 1940 were as follows: 
Children 
Children 
Percent 
Total 
Operations 
Year 
Examined 
Treated 
Treated 
Operations* 
Per Child 
1930 
14,945 
7,606 
50.9 
21,532 
2.8 
1940 
30,052 
12,461 
41.5 
46,868 
3.8 
*Total operations included all fillings, extractions and treatments. 
In the ten-year period, 1930-40, it will be noted that the 
number of children attending clinics has approximately 
doubled. The percent of those treated in the school clinics 
has somewhat decreased; and the operations per child 
have increased from 2.8 to 3-8 per child. It is probable 
that a fairly large, but as yet undetermined number of 
children examined in the clinics were treated in the offices 
of private dentists. 
In Table 24, page 26, the distribution of the school 
dental clinic services in the counties of Maryland in 1940 
is shown. In 2,263 clinic sessions in all counties there were 
30,052 children examined and 12,461 treated. Operations 
totalled 51,563 of which there were 26,794 fillings, 15,974 
extractions, 4,636 prophylactic and 4,159 other treatments. 
Cost of Clinics 
For the year 1940, the total dental clinic expenditures 
was $19,801. Of this amount $4,063 was received from the 
State and/or Federal Government; $9,396 from county and 
city governments; $3,683 from local organizations, chiefly 
Parent-Teacher Associations; and $2,659 from clinic fees. 
Article 43, Section 1, Annotated Code of Maryland, 1929. Dentists’ Services 
23 
The work was continued only so long as funds were availa- 
ble. Deficits in State or local funds were carefully avoided. 
As a result of the relatively small appropriations for 
dental clinics, particularly by the State of Maryland, very 
limited amounts could be granted to each clinic. It was 
practically impossible to set up a dental clinic service 
without substantial aid from local authorities. In the 
counties in the lower economic levels full-time dental 
services could not be provided. Furthermore, it was not 
possible, except in rare instances, to offer sufficient salaries 
to young graduates to induce them to adopt this type of 
service as a career. 
It is obvious that the oral hygiene program has been 
seriously handicapped by inadequate appropriations. It is 
also clear that a great deal has been accomplished with 
very little. Unfortunately, however, the figures available 
indicate that only a beginning has been made in providing 
dental care for school children, and that the treatment of 
indigent adults has received little or no attention. 
Programs for Denial Care for the Indigent 
Dental care for the indigent is a problem of such magni- 
tude that it would be advantageous, according to dental 
authorities, to divide the potential patients into age groups 
and provide, so far as possible, the most appropriate types 
of treatment for each group. The need for at least two 
divisions of the population is indicated for (1) pre-school 
and school children, and (2) adolescents and adults. 
1. A Program for Pre-School and School Children 
On account of its potentially enduring effect, the treat- 
ment of pre-school and school children should be as com- 
plete and long continued as possible. 
It seems logical that a program for dental care for these 
age groups should be centered around a school dental 
clinic. Indeed, this has been found by experience to be the 
method of choice. It is taken for granted that clinics should 
be established in both public and parochial schools. In all 
school clinics opportunities should be provided for as 
much care for pre-school children as is practicable. 
Treatment in school clinics should not be confined to 
emergency types alone—on the contrary, such prophylactic 
measures as are of proven value should be used as a matter 
of routine. It has been asserted that preventive, in contrast 
to “restorative” treatment, can be made available to a 
larger proportion of the population in a given time—and 
at much less cost. 
This program for pre-school and school children would 
require the services of at least one full-time dentist in each 
county in Maryland. In the past it has been found decidedly 
advantageous to have school dentists attached to the staff 
of the county health departments. 
2. A Program for Adolescents and Adults 
For economic reasons, the care of adolescents and adults, 
in the opinion of competent dental authorities, must be 
limited to less than complete treatment. Certainly the 
relief of pain should be possible and, so far as practicable, 
the restoration of part normality of dental function. 
For the treatment of adolescents and adults, clinics need 
not be established where reasonably adequate service may 
be rendered by private practitioners without seriously 
affecting the dentist: population among those able to pay 
for dental care. 
In the counties having the highest numbers of dentally 
indigent, at least one full-time dentist for treatment of 
adults, in addition to the school dentist, should be em- 
ployed. In counties in which the number of dentally 
indigent is not so great, it is believed that an additional 
dentist should be employed for treatment of adults until 
the school dental program has become well established. 
When this has been accomplished, the services of the ad- 
ditional dentist might be discontinued or the practitioner 
transferred elsewhere. In counties with a relatively small 
number of dentally indigent, it is felt that one full-time 
dentist might be able to conduct both programs. In all 
cases, the dentists should serve as members of the staff of 
the county health department. 
Comments on Determination of Eligibility 
In discussing the question with dentists in various parts 
of the State, it has been emphasized repeatedly that the 
criteria for determining eligibility for free or part-pay 
dental care should be identical with those for medical 
treatment. 
Local Administrative Representation 
In counties in which corrective clinics are necessary, it 
has been stressed that it is important that they should be 
established with the full cooperation of the local dentists. 
To this end, it has been suggested by a number of dental 
practitioners that a representative of the county dental 
society should be included in any county organization that 
subsequently may be established for the administration of 
medical care and dental care. 
Essential Steps 
In order to secure a more equitable distribution of dental 
facilities, the following steps appear to be indicated: 
(a) Provide ways and means of encouraging young 
graduates in dentistry to practice in the counties 
in the lower economic levels. 
(b) Increase appropriations so that the school dental 
clinics may be expanded. 26 
Medical Care in the Counties of Maryland 
(c) Provide dental treatment of indigent adults. 
(d) Intensify public education in the value of dental 
health, and in the advantages of early and continued 
observation and treatment. 
Summary 
A total of 295 dentists was in active practice in the 23 
counties of Maryland in 1940. 
In no county did the dentist: population ratio equal that 
regarded as adequate for normal conditions, namely: 
1:1,000. In Washington, Frederick, Worcester, Mont- 
gomery, Allegany, Carroll and Harford counties the ratios 
approximated that considered adequate only during emer- 
gencies, 1:2,500. Using these ratios as criteria, the distri- 
bution of dentists in other counties appeared quite 
inadequate. 
The need for additional dentists appeared to be greatest 
in Calvert, Charles, Garrett, St. Mary’s and Queen Anne’s 
counties. 
It seems evident that dentists have become more con- 
centrated in counties in the higher economic levels, with the 
result that the need for dental care has increased signi- 
ficantly in the counties in the lower economic levels. 
The dentist: Negro population ratio was 1:19,481. 
For the year 1940, expenditures for oral hygiene totalled 
$19,801. The program has been seriously handicapped by 
inadequate appropriations. 
Outlines of programs for the care of the dentally indigent 
have been presented, including (1) a program for pre-school 
and school children, and (2) a program for adolescents and 
adults. 
In general, a minimum of one full-time dentist for each 
of- these programs would be required in each county in the 
State, with these practitioners serving on the staff of the 
county health departments. 
It has been suggested that the criteria for determining 
eligibility for free or part-pay dental care should be identical 
with those for medical treatment. 
It was also suggested that a representative of each county 
dental society should be included in any county organiza- 
tion which may subsequently be established for the ad- 
ministration of medical and dental care for the indigent 
and medically indigent. 
The following steps are deemed essential to obtain a 
better distribution of dental care: 
1. Assist young graduates to become established in the 
counties with the largest proportions of dentally 
indigent. 
2. Provide appropriations for expansion of school dental 
programs and establishment of clinics for treatment 
of dentally indigent. 
3- Intensify education in the importance of dental, 
health. 
TABLE 24 
Co. 
Number 
of 
Clinics 
Number of 
Operations 
Examined 
aren 
Treated 
Fillings 
Inserted 
Teeth 
Extracted 
Prophy- 
lactic Treat. 
Other 
Treat. 
Total 
Allegany 
283 
3,460 
1,690 
1,076 
3,727 
575 
1,397 
6,775 
Anne Arundel 
243 
3,827 
1,515 
3,328 
1,461 
654 
109 
5,552 
Baltimore 
323 
7,396 
1,627 
3,734 
1,557 
856 
651 
6,798 
Calvert 
29 
528 
323 
844 
389 
10 
22 
1,265 
Charles 
32 
293 
131 
417 
173 
72 
0 
662 
Frederick 
129 
1,284 
1,112 
1,728 
1,061 
63 
1 
2,853 
Garrett 
7 
66 
47 
79 
166 
2 
1 
248 
Harford 
39 
723 
704 
1,681 
885 
634 
20 
3,012 
Howard 
80 
856 
236 
893 
437 
177 
125 
1,632 
Kent 
70 
730 
343 
1,581 
494 
157 
7 
2,239 
Montgomery 
179 
1,475 
1,191 
3,007 
1,478 
426 
69 
5,188 
Prince George’s 
132 
1,364 
867 
1,822 
698 
77 
173 
2,770 
Queen Anne’s 
78 
729 
204 
582 
251 
145 
21 
999 
St. Mary’s 
* 
18 
30 
0 
0 
48 
Talbot 
73 
1,249 
210 
419 
138 
210 
60 
827 
Washington 
282 
1,779 
1,034 
2,634 
1,587 
391 
132 
4,744 
Wicomico 
37 
427 
122 
153 
251 
70 
34 
472 
Worcester 
177 
2,355 
575 
2,123 
859 
101 
775 
3,838 
Healthmobile 
** 70 
1,511 
530 
675 
368 
16 
582 
1,641 
Total 
2,263 
30,052 
12,461 
26,794 
15,974 
4,636 
4,159 
51,563 
SCHOOL DENTAL CLINICS CONDUCTED IN THE COUNTIES OF MARYLAND, 1940 
*No special clinic days set aside-—work done in private dental offices. 
**In Healthmobile service, five dental clinicians devoted part-time for four months in the following counties: Calvert, Caroline, Cecil, 
Charles, Kent, Prince George’s, Queen Anne’s, St. Mary’s, Somerset and Worcester. Chapter 
GENERAL HOSPITALS 
2. Residents of every county in the State were admitted 
to hospitals in Baltimore City and, less frequently, 
to those in the District of Columbia and in the 
neighboring States, Pennsylvania, West Virginia and 
Delaware. 
Ownership and Administration 
Fifteen hospitals were owned by non-profit corporations, 
and the business of each was administered by a board of 
directors with a superintendent appointed by that body. 
There were three hospitals—Miners, Frederick Emergency 
and Allegany County—which were organized upon different 
lines: 
1. Miners Hospital in Frostburg was owned and oper- 
ated by the State of Maryland, its Board of Managers 
appointed by the Governor of the State, and the 
financial transactions were conducted through the 
office of the State Comptroller in Annapolis. 
2. The Frederick Emergency Hospital was owned and 
operated by the County Commissioners of Frederick 
County. This was the only hospital maintained solely 
for the indigent. 
3. Allegany County Hospital was owned by the Catholic 
Sisters of Charity and, at the time of the survey, 
its Board of Directors were four members of that 
Sisterhood. 
Board of Directors 
The impression was gained that each board of directors 
was composed of men and women who, as a rule, gave 
generously of their time and talents in promoting the 
welfare of the hospital which they served. In the majority 
of institutions, however, the board appeared to be a closed, 
self-perpetuating body, since replacements were usually 
made in accordance with the desires of those remaining on 
the board. In only a very small proportion of the hospitals 
was it evident that membership was fully representative 
of and open to the community as a whole. 
Superintendents 
In fourteen hospitals the superintendents were graduate 
nurses, while in the three largest—Peninsula General, 
Memorial (Cumberland) and Washington County, laymen, 
with experience in hospital administration, served in that 
capacity. In Calvert County a member of the medical staff 
also served as the superintendent. 
Distribution 
Tn 1940 THERE WAS A TOTAL OF 18 GENERAL HOSPITALS1 
A in the counties of Maryland. Thirteen counties had one 
hospital each, while Allegany had 3 and Frederick County 2. 
The following 8 counties were without hospitals: Balti- 
more, Carroll, Caroline, Garrett, Howard, Prince George’s, 
Queen Anne’s and Worcester. 
With respect to bed capacity, excluding bassinets, the 
18 hospitals may be divided into 3 groups. 
1. More than 100 beds 
Total 
Name 
Location 
Beds 
Peninsula General 
Salisbury 
177 
Memorial 
Cumberland 
160 
Washington County 
Hagerstown 
142 
Frederick City 
Frederick 
112 
Emergency 
Easton 
109 
Allegany County 
Cumberland 
105 
From 50-99 beds 
Annapolis Emergency 
Annapolis 
85 
Cambridge-Maryland 
Cambridge 
85 
Emergency 
Frederick 
50 
Less than 50 beds 
Union Hospital of 
Cecil County 
Elkton 
45 
Harford Memorial 
Havre de Grace 
42 
Montgomery County 
Olney 
40 
Miners 
Frostburg 
39 
E. W. McCready Memorial 
Crisfield 
35 
St. Mary’s 
Leonardtown 
32 
Kent and Upper 
Queen Anne’s 
Chestertown 
25 
Physicians’ Memorial 
La Plata 
25 
Calvert County 
Prince Frederick 
23 
In Table 25, page 28, hospitals have been listed with the 
number of beds in order of the hospital bed: population 
ratio for each county. The number of beds in all hospitals 
was 1,331 and the bed capacity ranged from 177 in Peninsula 
General to 23 in Calvert County Hospital. It will be noted 
that the hospital bed: population ratio for the counties in 
which the institutions were located varied from 1:172 in 
Talbot County to 1:2,098 in Montgomery County. 
A ratio of 4-5 hospital beds per 1,000 population, or 
1 hospital bed for every 222 persons, is regarded by some 
authorities as a suitable standard of adequacy. In Table 25, 
it will be observed that Talbot and Wicomico are the only 
counties in which the relative bed capacity exceeds that 
ratio, although Allegany County closely approximates it. 
In the counties of Maryland, however, too much depend- 
ence can not be placed upon the utilization of this ratio 
for the following reasons: 
1. Hospitals in several counties serve either the whole 
or a part of adjacent counties. 
this chapter, and elsewhere in this report, the term “hospital” connotes- 
general hospital—unless otherwise qualified. 28 
Medical Care in the Counties of Maryland 
In the majority of institutions the superintendent 
participated in the meetings of the board of directors and, 
less frequently, in the deliberations of the medical staff. 
In one or two of the smaller hospitals the superintendent 
not only transacted the business of the institution but 
functioned as superintendent of nurses, dietitian, anesthetist 
or even as clerk. 
Ladies’ Auxiliaries 
Nearly every hospital had a ladies’ auxiliary or similar 
organization which performed the very useful function of 
providing supplies and equipment which added to the 
comfort and well-being of patients. Some of these auxiliaries 
extended their activities still farther, contributing quite 
large sums each year toward the maintenance of the in- 
stitution by conducting fairs, sales, and maintaining other 
sources of revenue. 
The Medical Staff 
For appointment to the medical staff a physician was 
obliged, as a rule, to present a written application giving 
his training and experience. If membership requirements 
were fulfilled, the application was approved and sent to 
the board of directors for ratification. In the larger in- 
stitutions, a probationary period of one year was necessary 
before full staff privileges were granted. In the meantime 
courtesy privileges were extended. 
In most hospitals medical staff meetings were held each 
month to discuss clinical and other matters having to do 
with the medical management of the institution. In some 
hospitals the activities of the staff were even more com- 
prehensive. For example, in Washington County Hospital, 
in addition to the usual monthly meetings, clinics and 
symposia were held each Sunday morning throughout the 
year. As a rule, a physician or surgeon from a larger medical 
center was the guest clinician or lecturer. The attendance 
DISTRIBUTION OF GENERAL HOSPITALS IN THE COUNTIES OF MARYLAND IN 1940, TOGETHER WITH THEIR 
BED CAPACITY (EXCLUDING BASSINETS) AND THE HOSPITAL-BED: POPULATION FOR THE COUNTY 
IN WHICH THE INSTITUTION WAS LOCATED. 
TABLE 25 
County 
Name of Hospital 
Location 
Total 
Beds 
Hospital 
Bed: 
Population 
Ratio 
Talbot 
Emergency Hospital 
Easton 
109 
1: 172 
Wicomico 
Peninsula General Hospital 
Salisbury 
177 
1: 195 
Allegany 
Allegany County Hospital 
Memorial Hospital 
Miners Hospital 
Cumberland 
Cumberland 
Frostburg 
105} 
160 > 
39 ; 
1: 286 
Dorchester 
Cambridge-Maryland Hospital 
Cambridge 
85 
1: 329 
Frederick 
Emergency Hospital 
Frederick City Hospital 
Frederick 
Frederick 
50 / 
112 
1: 354 
Calvert 
Calvert County Hospital 
Prince Frederick 
23 
1; 456 
St. Mary’s 
St. Mary’s Hospital 
Leonardtown 
32 
1; 457 
Washington 
Washington County Hospital 
Hagerstown 
142 
1: 485 
Kent 
Kent and Upper Queen Anne’s 
General Hospital 
Chestertown 
25 
1: 539 
Cecil 
Union Hospital of Cecil County 
Elkton 
45 
1: 587 
Somerset 
E. W. McCready Memorial Hospital 
Crisfield 
35 
1: 599 
Charles 
Physicians Memorial Hospital 
La Plata 
25 
1: 704 
Anne Arundel 
Annapolis Emergency Hospital 
Annapolis 
85 
1: 804 
Harford 
Harford Memorial Hospital 
Havre de Grace 
42 
1: 835 
Montgomery 
Montgomery County General Hospital 
Olney 
40 
1:2,098 
Total 
1,331 
1: 723* 
bed: population for total counties. General Hospitals 
29 
was uniformly high. In this manner the staff were assisted 
in keeping abreast of progress in medicine. 
In the larger hospitals, medical, surgical, obstetrical, 
pediatric and accident departments have been organized, 
with a physician or surgeon in charge of each. 
Residents ami Internes 
In Montgomery County General, Easton Emergency and 
Peninsula General Hospitals, resident physicians were 
employed. In Allegany County, Memorial (Cumberland) 
and Annapolis Emergency Hospitals, “summer” internes 
were in residence whenever they could be obtained. In 
other hospitals, members of the staff were assigned in 
rotation to ward and emergency services. 
In each hospital in which residents or internes were 
employed, the superintendent expressed deep appreciation 
of their work. Medical records were well organized, his- 
tories were complete; progress notes were up to date; 
physicians’ services were immediately available day or 
night. In institutions in which residents or internes were 
not employed the need for such services was all too apparent. 
The Nursing Staff 
The number of graduate nurses employed by hospitals 
varied widely. In Frederick City Hospital thirty were on 
the nursing staff, while in Frederick Emergency Hospital 
only one graduate was on duty. 
Training schools for nurses were conducted in Allegany 
County, Memorial (Cumberland), Easton Emergency, 
Frederick City, Washington County and Peninsula General 
hospitals. 
In some of the smaller hospitals nurse-assistants were 
employed. In Calvert County, Union Hospital of Cecil 
County and in the Harford Memorial hospitals, nurses of 
this type constituted the majority of the nursing staff. 
In most hospitals the quarters provided for nurses were 
adequate and comfortable. In larger institutions a separate 
building was used. In smaller hospitals nurses usually 
resided at home, or occupied rooms in the institutions. 
Other Members of Staff 
Pharmacists, dietitians, X-ray and laboratory techni- 
cians and physio-therapists were, as a rule, employed by 
hospitals of 100 beds or larger. In smaller institutions one 
person sometimes functioned in more than one of these 
capacities. 
Departments and Services 
1. Surgery 
All but four hospitals had modern operating rooms and 
equipment. In a few institutions the surgical departments 
appeared unnecessarily elaborate in striking contrast to 
equipment in other services. As a rule, a graduate nurse, 
with special training, was in charge of the operating room, 
with a staff of graduates and undergraduates. In some 
hospitals, nurses assisted at operations. In most institu- 
tions, the recording of preoperative diagnoses and operative 
techniques and findings appeared to be well-established 
routines. 
2. Anesthesia 
Well-equipped departments of anesthesia were found in 
all the larger institutions. Quite commonly graduate 
nurses with special training served as anesthetists. In the 
smaller hospitals, the attending physician usually ad- 
ministered anesthetics. 
In the larger hospitals, a routine physical examination 
was made shortly before the induction of anesthesia. In 
several of the smaller institutions it was said that the 
examination, as a rule, was made by the attending physi- 
cian usually before the patient was hospitalized. 
3. Emergency Services. 
Almost all of the hospitals had a well-equipped emer- 
gency service. In four of the smaller institutions: Calvert 
County, Physicians Memorial, Harford Memorial and in 
St. Mary’s hospitals, this service was not regarded as 
adequate. 
Hospital care of accident cases was a major problem of 
superintendents. Many patients treated in the accident 
room were not admitted to the hospital, but if hospitaliza- 
tion were necessary, it was usually prolonged, costly, and 
a high proportion of individuals was unable to pay its 
expenses. In those hospitals near main arteries of traffic, 
the ever-increasing number of highway accidents not 
infrequently overtaxed the capacity and resources of the 
institution. 
4. Outpatient Departments. 
Except for emergency service in accident rooms, none of 
the hospitals operated outpatient departments, although 
in Easton Emergency Hospital facilities were being added 
in which treatment of patients after discharge from the 
hospital was planned. In Washington County Hospital 
an excellent outpatient department was constructed, but 
the facilities have not been used for that purpose. 
In Memorial (Cumberland), Cambridge-Maryland, Har- 
ford Memorial, Montgomery County General, Washington 
County and Peninsula General hospitals, space for clinics 
conducted by the county health departments was provided, 
either in the hospital proper or in a building on the hospital 
grounds. In several hospitals, certain types of patients 
were referred to these clinics for further observation or 
treatment after discharge from the hospital. 30 
Medical Care in the Counties of Maryland 
dietitian. A nurse or cook was in charge of the diet kitchen 
in other institutions. 
9. Pharmacies and Drug Rooms 
A pharmacist was employed in Allegany County, Mem- 
orial Hospital (Cumberland), Frederick City, Easton 
Emergency and Washington County hospitals, while in 
other institutions the drug room was in charge of a graduate 
nurse. 
10. Physiotherapy 
The Memorial Hospital in Cumberland was the only 
hospital which had a Department of Physiotherapy. 
11. Medical Social Service 
None of the county hospitals maintained a medical 
social service department. In larger hospitals the need for 
such a service was indicated. In several institutions, public 
health nurses or welfare department workers were pressed 
into service in emergencies. In the smaller hospitals there 
was not a sufficient demand for medical social service work 
to justify the employment of a trained person. 
12. Medical Records 
The larger hospitals maintained a well-organized medical 
record room. Except in hospitals employing resident 
physicians, however, this activity was a constant source 
of concern to hospital administrators. 
The attending physician, as a rule, was held responsible 
for writing histories and keeping progress notes up to date. 
In a few hospitals stenographic assistance was provided. 
Some physicians, presumably because of a lack of time, 
permitted large numbers of incomplete histories to ac- 
cumulate. Various schemes were employed by hospitals 
to induce doctors to complete case records within a rea- 
sonable time after discharge of the patient. 
Allegany County, Memorial Hospital (Cumberland), 
Easton Emergency, Montgomery General and Peninsula 
General hospitals were listed as institutions in which 
records were maintained in a satisfactory manner. 
In some of the smaller hospitals the histories were usually 
very brief, progress notes were often omitted, and the 
records which rarely were indexed, were stored in in- 
accessible and unsafe places. 
13. Ambulance Service 
Easton Emergency and Harford Memorial were the 
only hospitals operating an ambulance service. 
In several counties it was customary for the families, 
or agency which assumed responsibility for care of the 
patient, to negotiate with ambulance owners, usually 
funeral directors. In other counties local authorities, such 
as health departments, depended upon the Maryland State 
5. Obstetrics. 
Almost invariably obstetrical departments were super- 
vised by well-trained nurses and provided with reasonably 
adequate equipment. In most instances an isolation unit 
for mothers and the new born was available. 
6. Clinical Laboratories. 
In all except Calvert County, Frederick Emergency, 
Kent and Upper Queen Anne’s, and St. Mary’s hospitals, 
a laboratory was maintained for such routine tests as 
urinalysis, blood counts, estimations of coagulation time 
and other relatively simple procedures. In most institutions, 
especially those of more than 100 beds, a fairly complete 
laboratory service was provided. 
At the Physicians Memorial Hospital, a bacteriologist 
employed by the State Department of Health directed a 
combined public health and clinical laboratory. It was 
planned that this service would also be extended to include 
St. Mary’s and Calvert County hospitals, the bacteriol- 
ogist’s time being divided between three institutions, with 
an assistant bacteriologist working full time in each. This 
plan was inaugurated on the recommendation of the 
Committee on Medical Care as the result of a special study. 
In Washington County Hospital a full-time pathologist 
was in charge of a well-equipped bacteriological and 
pathological laboratory, while in Peninsula General 
Hospital a full-time bacteriologist and a part-time pathol- 
ogist were employed. Wasserman tests or modifications 
of this technique were made routinely in Washington 
County and in Peninsula General hospitals. In all others, 
specimens of blood and spinal fluid for syphilis serology 
were sent to laboratories of the State Department of Health 
in Baltimore or Cumberland. 
7- X.-ray. 
All of the hospitals except Frederick Emergency owned 
and operated diagnostic X-ray machines. In Memorial 
Hospital (Cumberland), Annapolis Emergency, Peninsula 
General and Washington County Hospitals, a physician, 
experienced in Roentgenology, was in charge of the X-ray 
department. In most of the remaining institutions, techni- 
cians were employed to make exposures and develop films 
while readings generally were made by the attending 
physician, a member of the staff with special training in 
this type of work. In some hospitals the films were inter- 
preted by authorities in Baltimore or elsewhere. 
Deep therapy X-ray equipment was installed in the 
Memorial Hospital (Cumberland), the only hospital which 
possessed this type of equipment. 
8. Dietetics 
All of the larger and a few of the smaller hospitals had 
a Department of Dietetics under the supervision of a trained General Hospitals 
31 
Police who operated nine ambulances from sub-stations in 
various parts of the State, and rendered constant, valuable 
service. In several counties automobiles of public health 
nurses and welfare workers were not infrequently used for 
transportation of the sick. In other counties local fire or 
police departments provided ambulance service. In a few 
instances, ambulances were maintained by public sub- 
scription. 
In emergencies, it was declared that in every county it 
was always possible to find some one who was willing to 
transport a patient to a hospital, even though the distance 
may be great. Serious delay, however, was sometimes 
occasioned while arrangements were being completed, 
since there was no recognized channel, except the State 
Police, through which ambulance service might be quickly 
obtained. Furthermore, while some ambulances were 
well-equipped and even luxurious, other vehicles used for 
the purpose, particularly the “family car”, were quite 
unsuitable, caused considerable suffering en route and, at 
times, reduced the patient’s chances of recovery or pro- 
longed the period of hospitalization. 
To overcome the difficulties which have been mentioned, 
it is suggested that a State-wide organization be selected 
to integrate existing ambulance services and supplement 
them whenever necessary, so that patients may be trans- 
ported to the hospital safely, comfortably and without 
undue delay. It would, of course, be necessary to appropriate 
funds for this coordinating service, but it is believed that 
the amount need not be large. 
In Table 26, page 31, a partial list is presented of the 
ambulance services in the counties of Maryland in the 
year 1941, indicating the owners or operators, the number 
of vehicles and their total capacity. 
Types of Construction 
Many hospitals, particularly those having a capacity of 
more than 100 beds, were constructed of stone or brick 
and were well-equipped institutions of which the com- 
munity had every right to be proud. In nearly all hospitals 
there was evidence of sacrifice on the part of local citizens 
in order to provide the best possible buildings and equip- 
ment. Several of the smaller hospitals were converted 
residences. 
Financial Resources 
Hospitals derived their chief sources of revenue from 
patients, interest on investments, bequests and other 
special gifts, as well as appropriations from State, county 
and city governments. 
With one exception, all hospitals received annual ap- 
propriations from the State of Maryland. Frederick Emer- 
gency Hospital was maintained solely by the County 
Commissioners of Frederick County, at a cost, it was said 
of about $0.60 per patient day. 
In 1941, Miners Hospital, owned and maintained by the 
State of Maryland, was allowed $15,500 from the general 
fund, $12,500 from a special fund, and $4,705 from the 
receipts of the institution. 
During the fiscal year 1939-40, the amount of $184,795 
was allocated by the State to 17 hospitals; and $19,000 
to 3 counties for hospitalization of free cases; in addition, 
$57,038 was appropriated by county and city to 14 hospitals, 
making a total of $260,833- 
table 26 
PARTIAL LIST OF AMBULANCE SERVICES IN THE COUNTIES OF 
MARYLAND IN 1941, INDICATING THE OWNERS OR OPERATORS, 
THE NUMBER AND TOTAL CAPACITY OF VEHICLES 
Number of 
Total 
Area 
Owners or Operators 
Ambulances 
Capacity 
All Counties 
Maryland State Police 
9 
20 
ANNE ARUNDEL 
Annapolis 
Fire Department 
1 
1 
Eastport 
" ft 
1 
1 
West Annapolis 
»» ft 
1 
1 
Brooklyn 
" ft 
1 
1 
Riviera Beach 
1 
1 
BALTIMORE 
Towson 
County Commissioners* 
1 
3 
Catonsville 
99 99 
1 
3 
Essex 
” ” 
1 
3 
Sparrows Point 
Volunteer Fire Dept. 
1 
2 
Violetville 
" ” ” 
1 
2 
Cockeysville 
99 ft ft 
1 
2 
Pikes ville 
ft ft ft 
1 
2 
Arbutus 
1 
2 
MONTGOMERY 
Silver Springs 
Funeral Directors 
3 
3 
Bethesda 
2 
2 
Rockville 
1 
1 
Damascus 
1 
1 
Gaithersburg 
1 
1 
Barnesville 
1 
1 
PRINCE GEORGE’S 
Glendale 
Volunteer Fire Dept. 
1 
2 
Brentwood 
1 
2 
Bladensburg 
3 
6 
Branch ville 
2 
4 
Bowie 
1 
2 
Upper Marlboro 
2 
4 
Forestville 
1 
2 
TALBOT 
Easton 
Easton Emergency Hospital 
1 
2 
WASHINGTON 
Hagerstown 
Community Association 
1 
2 
99 
Funeral Directors 
3 
6 
Police Department 
1 
2 
WICOMICO 
Salisbury 
Red Cross 
1 
4 
»» 
County Commissioners* 
1 
4 
TOTAL 
50 
95 
*Operated by Fire Department. 32 
Medical Care in the Counties of Maryland 
STATE AND LOCAL APPROPRIATIONS TO HOSPITALS IN COUNTIES OF MARYLAND, 1939-40. 
TABLE 27 
County 
Name of Hospital 
Sources and 
State 
Total Appropriation 
County and City 
(1940) 
Total 
Allegany 
Allegany County 
$ 14,000 
$ 6,000 
$ 20,000 
Memorial 
17,000 
* 
17,000 
Miners 
23,295 
— 
23,295 
Anne Arundel 
Annapolis Emergency 
11,000 
1,400 
12,400 
Calvert 
Calvert County 
4,000 
— 
4,000 
Cecil 
Union Hospital of Cecil County 
8,000 
6,000 
14,000 
Charles 
Physicians Memorial 
2,000 
3,500 
5,500 
Dorchester 
Cambridge-Maryland 
15,000 
4,500 
19,500 
Frederick 
Emergency 
— 
— 
— 
Frederick City 
15,000 
800 
15,800 
Harford 
Harford Memorial 
8,500 
6,000 
14,500 
Kent 
Kent and Upper Queen Anne’s General 
2,500 
750 
3,250 
Montgomery 
Montgomery County General 
7,500 
7,755 
15,255 
St. Mary’s 
St. Mary’s 
3,500 
2,333 
5,833 
Somerset 
E. W. McCready Memorial 
8,000 
750 
8,750 
Talbot 
Easton Emergency 
15,500 
3,250 
18,750 
Washington 
Washington County 
10,000 
12,500 
22,500 
Wicomico 
Peninsula General 
20,000 
1,500 
21,500 
T ot al 
$184,795 
$57,038 
$241,833 
♦This hospital received financial assistance from the County Commissioners of Allegany County in the form of capital expenditures and 
maintenance. 
TABLE 28 
NUMBER AND PERCENT OF PAY AND FREE PATIENTS IN HOSPITALS IN THE COUNTIES OF MARYLAND, 1939-40* 
County 
Name of Hospital 
Total 
Patients 
Pay Patients 
Free Patients 
Number 
Percent 
Number 
Percent 
Allegany 
Allegany County 
3,298 
2,175 
65.9 
1,123 
34.1 
Memorial 
4,365 
2,801 
64.2 
1,564 
35.8 
Miners 
— 
— 
— 
— 
— 
Anne Arundel 
Annapolis Emergency 
2,213 
1,615 
73.0 
598 
27.0 
Calvert 
Calvert County 
576 
185 
32.1 
391 
67.9 
Cecil 
Union of Cecil County 
1,279 
538 
42.1 
741 
57.9 
Charles 
Physicians Memorial 
448 
288 
64.3 
160 
35.7 
Dorchester 
Cambridge-Maryland 
1,226 
647 
52.8 
579 
47.2 
Frederick 
Emergency 
— 
— 
— 
— 
100.0 
Frederick City 
2,063 
539 
26.1 
1,524 
73.9 
Harford 
Harford Memorial 
880 
339 
38.5 
541 
61.5 
Kent 
Kent and Upper Queen Anne’s 
433 
292 
67.4 
141 
32.6 
Montgomery 
Montgomery County General 
1,538 
926 
60.2 
612 
39.8 
St. Mary’s 
St. Mary’s 
492 
374 
76.0 
118 
24.0 
Somerset 
E. W. McCready Memorial 
611 
50 
8.2 
561 
91.8 
Talbot 
Easton Emergency 
2,236 
594 
26.6 
1,642 
73.4 
Washington 
Washington County 
3,500 
2,593 
74.1 
907 
25.9 
Wicomico 
Peninsula General 
3,180 
1,753 
55.1 
1,427 
44.9 
Total 
28,338 
15,709 
55.4 
12,629 
44.6 
*The numbers and percentages of free patients shown here are not comparable between hospitals since there was a lack of uniformity in 
the interpretation of the term “free patient”. General Hospitals 
33 
Attempts were made to determine (a) the basis upon 
which these funds were allocated, and (b) the extent to 
which they met the cost of hospital care for the indigent. 
1. Allocations of State and Local Funds in 1940 
The amounts of State and local funds allocated to all 
hospitals in the fiscal year 1939-40 are listed in Table 27, 
page 32, while the number and percent of pay and free 
patients and hospital days are shown in Table 28, page 32, 
and Table 29, page 33, respectively. 
During the year under review, the percentage of free 
cases ranged from 24.0 in St. Mary’s County to 91.8 in 
the E. W. McCready Memorial Hospital as shown in 
Table 28, page 32. These extremes were both small hos- 
pitals. Among the larger institutions, 25-9 percent of 
patients admitted to Washington County Hospital were 
free, in contrast with 73-9 percent in Frederick City 
Hospital. 
The percent of free hospital days in the small hospitals 
varied between 33-1 in St. Mary’s and 91.7 in the E. W. 
McCready Memorial Hospital, as indicated in Table 29, 
page 33- In the larger institutions the extremes were 31.1 
in Washington County and 72.0 in Easton Emergency 
Hospital. 
In accordance with a State law, hospitals should be paid 
at the rate of $2.50 for each free patient day. In Table 30, 
page 34, it appears that the amount actually received by 
the hospitals from the State for each free patient day 
equals $2.50 only in the case of St. Mary’s Hospital. In 
all other hospitals the amount received was less than $2.50 
per free patient day. In the case of Memorial Hospital in 
Cumberland, it appears to have been as low as $.60 per 
free patient day but this hospital also received financial 
aid in the form of capital investments and maintenance 
from the Allegany County Commissioners. 
The amounts received by each hospital from State and 
local sources for each free hospital day, and the estimated 
cost per patient per hospital day are listed in Table 30. 
It would appear that appropriations received from State 
and local sources fell short of compensating the hospitals 
in amounts varying from $.88 in the case of Montgomery 
General Hospital to as much as $3-88 per hospital day for 
Frederick City Hospital. In Physicians Memorial and St. 
Mary’s hospitals amounts received in excess of the cost 
per hospital day appeared to be $.34 and $.22, respectively. 
The average difference for 16 hospitals was $1.86 per free 
hospital day. 
Unfortunately, however, so many variations in methods 
of administration and accounting were observed that the 
figures can not be considered comparable. 
The following differences in administrative practice were 
observed: 
(a) Interpretation of the terms “free case’’ and “free 
hospital day” varied widely. 
NUMBER AND PERCENT OF PAY AND FREE HOSPITAL DAYS IN HOSPITALS IN THE COUNTIES OF MARYLAND. 
1939-40* 
TABLE 29 
County 
Name of Hospital 
Total 
Hospital 
Days 
Pay Days 
Free Days 
Number 
Percent 
Number 
Percent 
Allegany 
Allegany County 
38,007 
23,582 
62.0 
14,425 
38.0 
Memorial 
49,761 
21,218 
42.6 
28,543 
57.4 
Miners 
— 
— 
— 
— 
— 
Anne Arundel 
Annapolis Emergency 
15,898 
10,604 
66.7 
5,294 
33.3 
Calvert 
Calvert County 
5,154 
1,475 
28.6 
3,679 
71.4 
Cecil 
Union of Cecil County 
10,825 
3,058 
28.2 
7,767 
71.8 
Charles 
Physicians Memorial 
3,843 
2,226 
57.9 
1,617 
42.1 
Dorchester 
Cambridge-Maryland 
14,230 
6,903 
48.5 
7,327 
51.5 
Frederick 
Emergency 
— 
— 
— 
— 
100.0 
Frederick City 
21,231 
6,636 
31.3 
14,595 
68.7 
Harford 
Harford Memorial 
12,448 
4,478 
36.0 
7,970 
64.0 
Kent 
Kent and Upper Queen Anne’s 
4,320 
2,472 
57.2 
1,848 
42.8 
Montgomery 
Montgomery County General 
14,415 
8,360 
58.0 
6,055 
42.0 
St. Mary’s 
St. Mary’s 
4,110 
2,750 
66.9 
1,360 
33.1 
Somerset 
E. W. McCready Memorial 
6,495 
542 
8.3 
5,953 
91.7 
Talbot 
Easton Emergency 
23,059 
6,445 
28.0 
16,614 
72.0 
Washington 
Washington County 
37,394 
25,762 
68.9 
11,632 
31.1 
Wicomico 
Peninsula General 
31,321 
15,847 
50.6 
15,474 
49.4 
Total 
292,511 
142,358 
48.7 
150,153 
51.3 
♦The numbers and percentages of free hospital days in this table are not comparable, one hospital with the other, since the term “free 
hospital day” was not uniformly interpreted. 34 
Medical Care in the Counties of Maryland 
TOTAL FREE HOSPITAL DAYS, 1939-40, THE AMOUNT RECEIVED PER 
FREE HOSPITAL DAY FROM STATE AND STATE AND LOCAL 
SOURCES, TOGETHER WITH THE ESTIMATED COST 
PER PATIENT PER HOSPITAL DAY 
TABLE 30 
cies, either directly or in the form of capital expendi- 
tures and maintenance. In some cases local funds 
were designated for the maintenance of free beds. 
In others, appropriations were placed in the “general 
fund” of the hospital. In only a few cities and coun- 
ties did it appear necessary for hospitals to render 
an accounting of the manner in which the funds 
were expended, or to submit a list of free patients 
hospitalized. 
2. State Appropriations to Certain Counties 
Although Garrett and Prince George’s counties had no 
hospitals, the County Commissioners received in 1939-40 
appropriations from the State of $6,000 and $8,000, respec- 
tively, for hospitalization of the medically indigent. The 
County Commissioners of Montgomery County, which 
possessed a hospital to which a State appropriation also 
was made, received a grant of $5,000 from the State for 
hospitalization of indigent patients. 
The appropriations to these counties, as well as the 
number of hospital days for which payment was made1, 
and the amount paid per free hospital day are as follows: 
Name of Hospital 
Total “Free” 
Hospital Days 
Amount Received 
Per “Free” Hospital Day 
Cost per Patient 
per Hospital 
Day 
(1939-1940) 
(1939-1940) 
State 
State and Local 
Allegany County 
14,425 
$ .97 
$1.39 
$3.16 
Memorial 
28,543 
.60 
.60** 
3.96 
Miners 
— 
— 
— 
— 
Annapolis Emergency 
5,294 
2.08 
2.34 
5.19 
Calvert County 
3,679 
1.09 
1.09 
2.38 
Union of Cecil County 
7,765 
1.03 
1.80 
3.84 
Physicians Memorial 
1,617 
1.24 
3.40 
3.06 
Cambridge-Maryland 
7,327 
2.05 
2.66 
3.99 
Emergency 
— 
— 
— 
— 
Frederick City 
14,595 
1.03 
1.08 
4.96 
Harford Memorial 
7,970 
1.07 
1.82 
2.90 
Kent and Upper 
Queen Anne’s 
1,848 
1.35 
1.76 
3.40 
Montgomery County 
General 
6,055 
1.24 
2.52 
3.40 
St. Mary’s 
1,360 
2.57 
4.29 
4.07 
E. W. McCready 
Memorial 
5,953 
1.34 
1.47 
4.05 
Easton Emergency 
16,614 
0.93 
1.13 
3.90 
Washington County 
11,632 
0.86 
1.93 
4.44 
Peninsula General 
15,474 
1.29 
1.39 
3.82 
Total (16 hospitals) 
150,153 
$1.30* 
$1.92* 
$3.78* 
County 
State 
Appropriation 
Free Hospital 
Days Paid For 
Rate Per Free 
Hospital Day 
Garrett 
$6,000 
4,350 
$1.38 
Montgomery 
5,000 
4,671 
1.07 
Prince George’s 
8,000 
3,929 
2.04 
Total 
$19,000 
12,950 
$1.47 
for 16 hospitals in counties of Maryland. 
**This hospital also received financial assistance from the County Commissioners 
of Allegany County in the form of capital expenditures and maintenance. 
Apparently, the definition of these terms has not 
been standardized. For example, in ten hospitals a 
case was classified as “free” so long as the patient 
did not pay full ward rates. Partial payments in 
some cases were credited to the “general expense 
fund” and the patient carried as a “free” State case. 
(b) There was little uniformity of standards for de- 
termining the financial status of applicants for free 
hospitalization. 
In some hospitals the physicians’ statement was the 
basis for classifying the patient. In others, the 
superintendent investigated each applicant, unless 
the financial status of the prospective patient was 
definitely known. In still others, the county com- 
missioners, welfare or health departments were 
asked to make a decision. 
(c) Local appropriations, presumably allocated for the 
care of the indigent, were utilized in a variety of 
ways. 
In addition to State allocations, nearly every hos- 
pital received funds from local appropriating agen- 
Summary 
Contending that State appropriations were grossly in- 
adequate and that the allocation of funds was more or less 
arbitrary, more than one superintendent expressed the 
opinion, that unless an adverse balance could be shown 
by him, the State, for the subsequent biennium would 
reduce the appropriation. 
From the figures that have been presented it seems clear 
that neither the State nor local governments adhered to a 
uniform standard in the allocation of funds for the treat- 
ment of free cases. 
Important Deficiencies 
While the majority of hospitals were well constructed, 
equipped and staffed by competent medical and other 
personnel, the following important deficiencies were 
noted; 
]State of Maryland, Department of Public Welfare, Twentieth Biennial 
Report, 1939-40, Pages 47 and 51. 
1. There were no hospitals in 8 counties. General Hospitals 
35 
2. In a number of instances inadequate buildings and 
equipment were seen. 
3. All hospitals lacked adequate facilities for the care 
of (a) chronic disease, (b) psychotic patients awaiting 
removal to State institutions, and (c) units for isola- 
tion and treatment of communicable disease. 
1. Counties without Hospitals 
Of the eight counties previously listed in which there 
was no hospital, there were four in which the need ap- 
peared to be more urgent than in others, namely, Baltimore, 
Prince George’s, Carroll and Garrett counties. 
(a) Baltimore County 
For many years, Baltimore, the county with the largest 
area and population, has been without a hospital, de- 
pending upon the institutions in Baltimore City and in 
Pennsylvania. The recent rapid increase in population in 
areas which were not readily accessible to the hospitals 
of Baltimore City, revived the movement to construct an 
institution in the county. A detailed survey of the situation 
was made by the Committee on Medical Care, and a special 
report presented to the County Commissioners of Baltimore 
County. From this report it was evident that Baltimore 
County can not long continue to rely upon the charitable 
resources of the hospitals of Baltimore City. 
From the data assembled, it is perfectly clear, in the 
opinion of the Executive Committee, that Baltimore 
County either will have to make provisions within its own 
borders for hospitalization of its citizens, or adequately 
compensate the hospitals of Baltimore City. 
(b) Prince George's County 
A rapidly increasing population, particularly in areas 
adjoining the District of Columbia, and constant difficulty 
in securing admission to overcrowded institutions in the 
District, stimulated the formation of organized groups of 
citizens intent upon the construction of a hospital in 
Prince George’s County, with the aid of the Federal 
Government*. While protracted negotiations were pro- 
ceeding, a 50 bed hospital was built at Riverdale by private 
interests, which may assist in relieving conditions some- 
what, but by no means will solve the problem. 
(c) Carroll County 
Conditions in Carroll County were comparable with 
those in Baltimore County. Possessing no hospital, it was 
necessary to transport patients either to the City of Balti- 
more or to an adjoining county in Pennsylvania. At the 
time of the survey, there did not appear to be the slightest 
interest in the construction of a local hospital, either 
among the medical profession or citizens. Executives in 
the county welfare department expressed the need for the 
establishment of medical and surgical clinics. 
(d) Garrett County 
Oakland, the county seat of Garrett County, and popu- 
lated areas in the vicinity were at least 75 miles from the 
nearest hospital in Maryland. In winter, travel is often 
difficult—if not impossible, and serious delays in trans- 
porting patients to hospitals were reported. Intense interest 
in the construction of a new hospital was manifested 
especially among the physicians in Oakland. For many 
years, and continuing until about 1933, a privately owned 
hospital of about 25 beds was operated successfully in that 
town. 
2. Inadequate Buildings and Equipment 
Inadequate buildings and equipment existed in Harford 
Memorial and in the Union Hospital of Cecil County. 
These hospitals not only were overcrowded, but were 
serious fire hazards. In fact, fire hazard is absent in only a 
few of the smaller institutions. 
3. General Deficiencies 
(a) Lack of Facilities for the Care of the Chronically 111 
The general lack of provisions for the care of patients 
suffering from chronic disease was keenly felt by all hos- 
pitals. It was emphasized that because beds were occupied 
by the chronically ill, admission of acute cases sometimes 
had to be delayed or even refused. One superintendent 
stated that one patient had occupied a bed in his hospital 
for over 15 years, and repeated efforts to have him removed 
had failed. 
It was estimated that hospital care for a chronic case 
costs at least $1,200 per year. As soon as a new State 
appropriation was received, it was asserted, it was neces- 
sary immediately to discount that amount or at least a 
portion thereof, for each chronic case occupying a bed. 
It was also stated that, as a rule, such a patient did not 
need the relatively expensive facilities of a general hospital. 
(b) Inadequate Facilities for Care of Psychotic Patients 
Awaiting Removal to State Institutions 
Hospital superintendents asserted that psychotic patients 
usually were unmanageable, disturbed other patients and 
required the services of at least one day and one night nurse. 
Psychiatrists, on the other hand, maintained that with 
proper management, mentally disturbed persons need not 
annoy other patients. At present, most psychotic patients 
who can not be controlled in the home are confined to the 
county jail until a bed can be found in a State institution. 
While in jail, these patients are under the care of individuals 
who are absolutely without training or experience in 
dealing with the sick. 
*In Mongtomery County which also adjoins the District of Columbia, and 
which has one 40 bed hospital, groups of citizens organized in 1941 to urge 
the construction of another hospital. 36 
Medical Care in the Counties of Maryland 
(c) Lack of Isolation Units for Communicable Disease 
As a result of education of the public by the medical 
profession and health departments, together with the 
increased efficiency of control methods, the fear of com- 
municable disease, so intense for centuries, has been di- 
minished. Beliefs that all infections are airborn, and that 
epidemics could be controlled only by confining the sick 
to “pest houses’’ miles from other dwellings, have been 
radically changed. Most communities now are aware that 
the placement of cases of communicable disease on the 
“poor farm” is an unwarranted and often cruel solution 
of the problem, and that a patient may now be treated, 
with safety to others, in a communicable disease unit 
of a general hospital—although the institution may be 
located in the center of a city. 
If educational efforts are intensified, every county in 
Maryland will discontinue the use of the “pest house’’, 
and citizens will insist that each county establish a com- 
municable disease unit in connection with the local hos- 
pital, even if minor changes in construction may be 
necessary. 
A unit of from four to six beds probably would be 
sufficient to meet the ordinary requirements even in the 
larger hospitals. It is believed that these units could be 
maintained more economically than two or three large 
communicable disease hospitals located in various parts of 
the State, which appears to be the only alternative. 
When these units have been established, the spread of 
communicable disease may be controlled more promptly 
and hospitals in the counties of Maryland will then fulfill 
more completely their responsibilities to the communities 
they are striving to serve. 
Residents of Counties Hospitalized Elsewhere 
With eight counties possessing no hospitals, and others 
having institutions of insufficient capacity, inadequate 
equipment or personnel, many county residents were 
hospitalized each year in the City of Baltimore, the District 
of Columbia, Pennsylvania, West Virginia and Delaware. 
County Patients Admitted to Hospitals in the City 
of Baltimore 
In 1940 a total of 16,582 county residents were admitted 
to hospitals in the City of Baltimore in which are located 
several large medical centers and a number of the most 
distinguished physicians and surgeons in the field of 
medicine. It should be added, however, that patients also 
were sent to Baltimore occasionally because it was known 
that the State of Maryland made appropriations each year 
for the care of free patients in all general hospitals in that 
City as well as in the counties. It apparently was not known, 
or not fully appreciated, as will be pointed out later, that 
these contributions were not sufficient to pay for hos- 
pitalization for free cases from the City of Baltimore, much 
less for those from the counties. 
In Table 31, page 38, the number of hospital admissions 
of county residents in the City of Baltimore in 1940 has 
been shown, as well as the total patient days and the 
admissions per 1,000 population in the county of residence. 
A total of 16,582 county patients were admitted for 225,340 
patient-days, or an average of 13-6 days per patient, with 
17-3 admissions per 1,000 in the total counties.The number 
of admissions per 1,000 in the county of residence was 
highest in Howard County (58.2), Baltimore County (50.6), 
and Carroll County (34.9). None of these counties had 
general hospitals. In other counties the proportion of 
admissions per 1,000 population decreased, in general, with 
the distance from Baltimore City, as is shown graphically 
on Chart III, page 37. 
1. Pay Status of County Patients 
In Table 32, page 38, the number of county patients 
admitted to hospitals in Baltimore City in 1940 are pre- 
sented with the number per 1,000 population in the county 
of residence and the pay status—pay, part-pay, and free. 
Of the 16,582 admissions, 7,306, or 44.1 percent, were pay 
patients; 4,194 or 25-3 percent, were part-pay; and 5,082, 
or 30.6 percent, were classified as free patients. 
In Table 33, page 39, the total hospital days and the 
number of pay, part-pay and free patient days of county 
residents admitted to hospitals in the City of Baltimore in 
1940 are tabulated. Of the 225,340 hospital days, 83,018, 
or 36.8 percent, were pay patients; 54,381, or 24.1 percent, 
were part-pay; 76,474, or 33-9 percent were free patients; 
and for 11,467 hospital days, or 5-2 percent, the pay status 
of the patient was not known. 
The total pay patients, the number of free patients from 
Baltimore City and the counties admitted to 15 hospitals 
in that City in the fiscal year 1939-40, as reported to the 
State Department of Public Welfare, together with the 
number of hospital days of city and county patients have 
been tabulated as follows: 
Fifteen Hospitals 
in Baltimore City 
Pay 
Patients 
Free Patients 
Total 
City 
County 
Total 
Number of Patients 
46,262 
23,437 
7,740 
31,177 
77,439 
Percent 
59.7 
75.2 
24.8 
40.3 
100.0 
100.0 
Of the 77,439 patients, 46,262, or 59.7 percent were pay, 
and 31,177, or 40.3 percent were free patients. Of the 31,177 General Hospitals 
37 
MARYLAND STATE PLANNIN9 COMMliSION ] 
CHART IE 
PER CAPITA RATE 
COUNTY RESIDENTS ADMITTED 
TO 
HOSPITALS IN BALTIMORE CITY 
1940 
O i 2 3 
INCHES 
SCALE FOR WIDTH OF LINEt I INCH ■ 590 PATIENTS PER 10,000 POPULATION 38 
Medical Care in the Counties of Maryland 
free patients, 23,437, or 75-2 percent, were residents of 
Baltimore City while 7,740, or 24.8 percent, were county 
residents. 
It was also reported to the State Department of Public 
Welfare that 23,437 Baltimore patients were hospitalized 
for 321,507 days, or 13-7 days per patient, and 7,740 county 
residents remained a total of 134,120 days in these in- 
stitutions, or an average of 17-3 days per patient. For all 
of the 31,177 free patients the number of days’ hospitaliza- 
tion was 455,627, or 14.6 days per patient. 
County Patients Hospitalized in the District of 
Columbia 
Quite naturally, the hospitals of the District of Columbia 
were reluctant to admit patients from other political units 
in the absence of assurance that charges would be paid 
either by the patient or by a public or private agency in 
the city or county of residence. It has been found, however, 
that in the year 1940 the District of Columbia hospitalized 
415 free patients for a total of 7,448 hospital days who 
were residents of Maryland, particularly the adjoining 
counties, Montgomery and Prince George’s. 
Data on the number of county residents admitted to the 
hospitals in the District of Columbia were obtained from 
the Health Security Administration, a private agency to 
which applicants for admission to District hospitals were 
referred for credit rating and, if necessary, for financing 
of hospital charges. This organization also was utilized 
by the Community Chest of the District of Columbia 
which included among its beneficiaries persons living in 
the suburban areas in Montgomery and Prince George’s 
counties. It was stated that the purpose of the credit 
investigation was the determination of the extent to which 
the Community Chest was justified in assuming responsi- 
bility for hospital expenses. In addition to patients referred 
by hospitals to the Health Security Administration, it was 
said that other individuals, residents of the counties of 
Maryland, were hospitalized without reference to that 
organization, presumably because their credit rating was 
known to be satisfactory. 
The data provided by the Health Security Administra- 
tion, with the permission of the hospitals of the District, 
and by the Department of Health of the District of Columbia 
which administers Gallinger Hospital, have been sum- 
marized in the tables which follow. 
TABLE 32 
COUNTY RESIDENTS ADMITTED TO HOSPITALS IN CITY OF 
BALTIMORE IN 1940. THE TOTAL NUMBER OF PATIENTS, 
THE NUMBER PER 1,000 POPULATION IN THE COUNTY 
OF RESIDENCE AND THE PAY STATUS. 
TABLE 31 
NUMBER OF ADMISSIONS OF COUNTY RESIDENTS TO HOSPITALS 
IN THE CITY OF BALTIMORE IN 1940, TOGETHER WITH THE 
TOTAL PATIENT-DAYS AND ADMISSIONS PER 1,000 POPULA- 
TION IN THE COUNTY OF RESIDENCE. 
County of 
Residence 
Total 
Patients 
Number 
per 1,000 
Population 
Pay 
Pay 
Status of Patients 
Part-Pay } Free 
Howard 
1,000 
58.2 
361 
267 
372 
Baltimore 
7,886 
50.6 
3,631 
2,149 
2,106 
Carroll 
1,362 
34.9 
605 
307 
450 
Harford 
1,148 
32.7 
458 
368 
322 
Anne Arundel 
1,771 
25.9 
755 
418 
598 
St. Mary’s 
210 
14.4 
38 
32 
140 
Cecil 
325 
12.3 
115 
107 
103 
Calvert 
126 
12.0 
48 
18 
60 
Queen Anne’s 
153 
10.6 
61 
22 
70 
Kent 
140 
10.4 
43 
31 
66 
Charles 
141 
8.0 
30 
16 
95 
Frederick 
424 
7.4 
181 
102 
141 
Prince George’s 
499 
5.6 
244 
130 
125 
Somerset 
117 
5.6 
53 
19 
45 
Talbot 
99 
5.3 
58 
13 
28 
Caroline 
92 
5.2 
42 
11 
39 
Worcester 
107 
5.0 
49 
15 
43 
Dorchester 
130 
4.6 
54 
39 
37 
Wicomico 
145 
4.2 
71 
18 
56 
Washington 
225 
3.3 
145 
31 
49 
Garrett 
68 
3.1 
22 
16 
30 
Montgomery 
190 
2.3 
116 
27 
47 
Allegany 
157 
1.8 
96 
18 
43 
County not Specified 
67 
30 
20 
17 
Total 
16,582 
17.3* 
7,306 
4,194 
5,082 
Percent 
44.1 
25.3 
30.6 
County of Residence 
Total 
Patients 
Admitted 
Total 
Patient Days 
Admissions 
per 1,000 
Population 
Howard 
1,000 
13,299 
58.2 
Baltimore 
7,886 
95,658 
50.6 
Carroll 
1,362 
18,031 
34.9 
Harford 
1,148 
15,012 
32.7 
Anne Arundel 
1,771 
26,974 
25.9 
St. Mary’s 
210 
2,955 
14.4 
Cecil 
325 
3,853 
12.3 
Calvert 
126 
2,628 
12.0 
Queen Anne’s 
153 
2,977 
10.6 
Kent 
140 
2,345 
10.4 
Charles 
141 
2,808 
8.0 
Frederick 
424 
7,233 
7.4 
Prince George’s 
499 
7,445 
5.6 
Somerset 
117 
2,535 
5.6 
Talbot 
99 
1,780 
5.3 
Caroline 
92 
1,426 
5.2 
Worcester 
107 
1,958 
5.0 
Dorchester 
130 
1,918 
4.6 
Wicomico 
145 
2,879 
4.2 
Washington 
225 
3,195 
3.3 
Garrett 
68 
1,407 
3.1 
Montgomery 
190 
3,717 
2.3 
Allegany 
157 
2,660 
1.8 
County not Specified 
67 
647 
Total 
16,582 
225,340 
17.3* 
♦Admissions per 1,000 population in the total counties of Maryland 
♦Admissions per 1,000 population in the total counties of Maryland. General Hospitals 
39 
In Table 34, page 40, the county residents hospitalized 
in nine hospitals in the District of Columbia in 1940 are 
shown, as well as the total patients by color and pay 
status. Of the 1,243 patients, 1,084, or 87.2 percent, were 
white, and 159, or 12.8 percent, were colored. A total of 
290, or 23-3 percent, were pay; 538, or 43-3 percent, were 
part-pay; and 415, or 33-4 percent, were free patients. In 
Table 35, page 40, the distribution is given by county of 
residence and pay status. Of the 1,243 patients, 197, or 
15-8 percent, were residents of Montgomery County; 
999, or 80.4 percent, resided in Prince George’s County; 
and 47, or 3-8 percent, were residents of other counties. 
In Table 36, page 41, the days spent by residents of the 
counties of Maryland in twelve hospitals of the District 
of Columbia in 1940 are shown together with their pay 
status. Of a total of 17,226 hospital days, 2,203, or 12.8 
percent, were pay; 7,575, or 44.0 percent, were part-pay; 
and 7,448, or 43-2 percent, were free hospital days. In 
Table 37, page 41, the hospital days for the same patients 
are shown by pay status and by county of residence. It 
will be noted that 3,138 hospital days, or 18.1 percent, 
were residents of Montgomery County; 13,195, or 76.6 
percent, resided in Prince George’s County; and 893, or 
5-3 percent, were residents of other counties in Maryland. 
In Table 38, page 41, a summary is presented of the 
number of patients, hospital days and the average stay of 
pay, part-pay and free patients in hospitals in the counties 
of Maryland for the fiscal year 1939-40, and for county 
residents hospitalized in Baltimore City and in the District 
of Columbia in 1940. 
Of the total of 46,163 patients, 23,305, or 50.5 percent, 
were pay; while 4,732, or 10.3 percent, were part-pay; 
and 18,126, or 39.2 percent, were free patients. It also will 
be observed that there were no part-pay patients in the 
hospitals in the counties, as reported to the State Depart- 
ment of Welfare. If the percent of pay and part-pay patients 
are added, the total is 69.4 percent for county patients 
admitted to hospitals in the City of Baltimore, and for 
those hospitalized in the District of Columbia it was 
66.6 percent. 
Of the 46,163 patients, 28,338, or 61.4 percent, were 
admitted to 16 hospitals in the counties of Maryland; 
16,582, or 35-9 percent, to 15 hospitals in Baltimore City; 
and 1,243, or 2.7 percent, to 9 hospitals in the District of 
Columbia. 
County Residents Hospitalized in Other States 
In the counties bordering Pennsylvania, West Virginia 
and Delaware, it was reported that it was not unusual for 
local residents to be hospitalized in adjoining states. In 
other counties, it was declared that residents from neigh- 
boring states not infrequently were admitted to hospitals 
in the counties of Maryland. Complete figures could not 
be obtained readily. It was our impression that the number 
of county residents hospitalized in other states probably 
approximated that of residents of adjoining States admitted 
to hospitals in the counties of Maryland. 
Summary 
Eighteen hospitals with a total of 1,331 beds, excluding 
bassinets, were located in 15 of the 23 counties. There were 
no hospitals in 8 counties. Six institutions had more than 
100 beds, 3 had from 50 to 99 beds, and there were 9 with 
less than 50 beds. 
Fifteen hospitals were operated by non-profit corpora- 
tions, 1 by the State, 1 by Frederick County Commissioners, 
and 1 by the Sisters of Charity. In 15 hospitals the business 
of each was administered by a Board of Directors and a 
superintendent. 
In 14 hospitals the superintendent was a graduate nurse, 
while in 3 of the largest a layman, experienced in hospital 
administration, served in that capacity. 
Fadies auxiliaries were active in nearly every hospital. 
TABLE 33 
PATIENT-DAYS HOSPITALIZATION OF COUNTY RESIDENTS IN 
HOSPITALS IN THE CITY OF BALTIMORE IN 1940. 
County 
Total 
Hospital 
Days 
Hospital Days 
Pay 
Patients 
Part-Pay 
Patients 
Free 
Patients 
Unknown 
Pay Status 
Howard 
13,299 
4,205 
2,452 
5,473 
1,169 
Baltimore 
95,658 
38,318 
25,836 
25,442 
6,062 
Carroll 
18,031 
6,372 
4,277 
6,846 
536 
Harford 
15,012 
4,670 
4,668 
4,660 
1,014 
Anne Arundel 
26,974 
11,322 
5,746 
8,849 
1,057 
St. Mary’s 
2,955 
438 
362 
1,796 
359 
Cecil 
3,853 
560 
1,447 
1,669 
177 
Calvert 
2,628 
666 
309 
1,628 
25 
Queen Anne’s 
2,977 
754 
344 
1,805 
74 
Kent 
2,345 
476 
309 
1,530 
30 
Charles 
2,808 
272 
246 
2,256 
34 
Frederick 
7,233 
2,538 
1,746 
2,547 
402 
Prince George’s 
7,445 
3,165 
2,189 
1,972 
119 
Somerset 
2,535 
692 
240 
1,603 
— 
Talbot 
1,780 
596 
354 
777 
53 
Caroline 
1,426 
641 
174 
611 
— 
Worcester 
1,958 
475 
252 
1,229 
2 
Dorchester 
1,918 
605 
572 
740 
1 
Wicomico 
2,879 
990 
513 
1,327 
49 
Washington 
3,195 
1,636 
744 
759 
56 
Garrett 
1,407 
314 
327 
757 
9 
Montgomery 
3,717 
1,736 
633 
1,180 
168 
Allegany 
2,660 
1,357 
486 
779 
38 
County not Specified 
647 
220 
155 
239 
33 
Total 
225,340 
83,018 
54,381 
76,474 
11,467 
Percent 
— 
36.8 
24.1 
33.9 
5.2 Medical Care in the Counties of Maryland 
As a rule, surgical, anesthesia and emergency services 
were well-equipped. Outpatient departments were almost 
entirely lacking, although 6 hospitals provided space for 
clinics conducted by the county health department to which 
certain types of patients were referred upon discharge from 
the hospital. 
In general, obstetrical departments were adequately 
staffed and equipped. 
Clinical laboratories of variable capacities were main- 
tained in 14 hospitals. A combined clinical and public 
health laboratory had commenced to function in Charles, 
Calvert and St. Mary’s counties. 
X-ray services were found in all hospitals, 4 of which 
were in charge of full-time Roentgenologists. 
Dietetic services were functioning in most hospitals, 
pharmacies in 3, and a department of physiotherapy in 
1 hospital. Medical social services were lacking. 
Medical record rooms varied widely in efficiency of 
maintenance. 
Ambulance services were maintained in 2 hospitals. In 
other counties this service was operated by morticians, the 
State Police, local fire departments, county commissioners 
and associations of citizens. It is suggested that a State-wide 
agency be assigned the task of coordinating and, when 
necessary, supplementing existing ambulance services. 
In the year 1939-40, 17 hospitals received a total of 
$241,833 of which $184,795 was allocated by the State and 
$57,038 by county and city governments. In addition, 
$19,000 was appropriated by the State for hospitalization 
of the indigent in 3 counties. 
A total of 28,338 patients were admitted to 15 hospitals, 
of whom 15,709, or 55-4 percent, were classified as pay, 
and 12,629, or 44.6 percent, as free patients, according to 
reports received by the State Department of Welfare. 
TABLE 34 
COUNTY RESIDENTS HOSPITALIZED IN THE DISTRICT OF COLUMBIA IN 1940, THEIR COLOR AND PAY STATUS, 
BY HOSPITALS. 
Hospital 
Full Pay 
Part-Pay 
Free 
Total Patients 
W 
C 
W 
C 
W 
C 
W 
C 
T 
Children’s 
35 
4 
100 
12 
21 
14 
156 
30 
186 
Columbia 
30 
1 
81 
7 
9 
— 
120 
8 
128 
Emergency 
21 
1 
16 
2 
14 
— 
51 
3 
54 
Episcopal 
14 
5 
28 
4 
15 
6 
57 
15 
72 
Gallinger 
— 
— 
— 
— 
194 
48 
194 
48 
242 
Garfield 
28 
6 
33 
16 
6 
5 
67 
27 
94 
Georgetown 
9 
— 
20 
10 
14 
6 
43 
16 
59 
George Washington 
12 
— 
21 
— 
6 
— 
39 
— 
39 
Providence 
104 
6 
186 
2 
49 
4 
339 
12 
351 
Others 
14 
4 
18 
18 
Totals 
267 
23 
485 
53 
332 
83 
1,084 
159 
1,243 
Percent 
23.3 
43.3 
33.4 
100.0 
TABLE 35 
COUNTY RESIDENTS, BOTH WHITE AND COLORED, HOSPITALIZED IN THE DISTRICT OF COLUMBIA IN 1940, THEIR 
COUNTY OF RESIDENCE AND PAY STATUS 
County of 
Residence 
Pay 
Part-Pay 
Free 
Total Patients 
Percent 
of Total 
Montgomery 
55 
90 
52 
197 
15.8 
Prince George’s 
224 
442 
333 
999 
80.4 
Other Counties 
11 
6 
30 
47 
3.8 
Total 
290 
538 
415 
1,243 
100.0 General Hospitals 
41 
It appears that 16 hospitals receive an average of $1.30 
from the State, and $1.92 from State and local government 
sources for each free hospital day, the average cost of 
which was estimated as $3-78. It would appear, therefore, 
that State and local appropriations should be approximately 
doubled in order to compensate hospitals for the care of 
the indigent. 
There did not appear to be standard stipulations for the 
expenditure of the $19,000 appropriated annually for hos- 
pitalization of the indigent in 3 counties. 
Neither State nor local governments adhered to a uniform 
standard in the allocation of funds for the hospitalization 
of free cases. 
Differences in administrative practice among hospitals 
included variations in (a) interpretation of terms such as 
“free case” and “free hospital day”, (b) standards for 
determining the financial status of applicants for free 
hospitalization, and (c) the utilization of local funds 
presumably intended for payment for free cases. 
On account of the above variations, many of the figures 
presented in tables in this chapter can not be considered 
comparable, one hospital with the other. 
Other important deficiencies included (a) 8 counties were 
without hospitals, (b) inadequate buildings and equipment 
were found in at least 2 institutions, and (c) there was a 
State-wide lack of facilities for care of (i) chronic disease, 
(ii) psychotic patients awaiting removal to State institu- 
tions, and (iii) patients with communicable disease. It is 
suggested that facilities be provided in hospitals for care 
of psychotic patients and for the isolation and treatment 
of cases of communicable disease. 
TABLE 36 
RESIDENTS OF THE COUNTIES OF MARYLAND HOSPITALIZED IN 
DISTRICT OF COLUMBIA HOSPITALS IN 1940, INDICATING THE 
TOTAL HOSPITAL DAYS AND PAY STATUS, BY HOSPITALS 
In 1940, a total of 16,582 county residents was admitted 
to hospitals in Baltimore City for 225,340 hospital days, 
or an average of 13-6 days per patient. Of the 16,582 ad- 
missions, 7,306, or 44.1 percent were pay; 4,194, or 25.3 
percent were part-pay; and 5,082, or 30.6 percent were 
free patients. 
In 1940, a total of 1,243 county patients was hospitalized 
in 9 hospitals in the District of Columbia, of whom 290, 
Hospital 
Pay 
Part-Pay 
Free 
Total 
Children’s 
314 
1,540 
1,215 
3,069 
Columbia 
297 
994 
164 
1,455 
Emergency 
190 
280 
365 
835 
Episcopal 
99 
194 
194 
487 
Garfield 
481 
1,215 
606 
2,302 
Gallinger 
— 
— 
2,954 
2,954 
Georgetown 
16 
395 
448 
859 
George Washington 
202 
345 
209 
756 
Providence 
535 
2,452 
1,241 
4,228 
Florence Crittenton 
44 
— 
48 
92 
Casualty 
25 
— 
4 
29 
Prince George’s 
— 
160 
— 
160 
Health Center 
Total 
2,203 
7,575 
7,448 
17,226 
Percent 
12.8 
44.0 
43.2 
100 
TABLE 38 
THE NUMBER OF PATIENTS, TOTAL PATIENT DAYS AND AVERAGE 
STAY IN HOSPITAL OF PAY, PART-PAY AND FREE PATIENTS 
IN INSTITUTIONS IN THE COUNTIES OF MARYLAND IN 1939- 
40, AND FOR COUNTY RESIDENTS HOSPITALIZED IN 
THE CITY OF BALTIMORE AND IN THE DISTRICT 
OF COLUMBIA IN 1940 
Financial 
Status of 
Patients 
County Residents Hospitalized in 
Total 
Counties of 
Maryland 
City of 
Baltimore 
District of 
Columbia 
Pay 
Patients 
Hospital Days 
Average Stay 
55.4% 
15,709 
142,538 
9.1 
44.0% 
7,306 
82,018 
11.2 
23.3% 
290 
2,203 
7.6 
50.5% 
23,305 
226,759 
9.7 
Part-Pay 
Patients 
Hospital Days 
Average Stay 
— 
25.4% 
4,194 
53,381 
12.7 
43.3% 
538 
7,575 
14.1 
10.3% 
4,732 
60,956 
12.9 
Free 
Patients 
Hospital Days 
Average Stay 
44.6% 
12,629 
150,153 
11.9 
30.6% 
5,082 
76,474 
15.0 
33.4% 
415 
7,448 
17.9 
39.2% 
18,126 
234,075 
12.9 
Total 
Patients 
Hospital Days 
Average Stay 
100.0% 
28,338 
292,511 
10.3 
100.0% 
16,582 
225,340 
13.6 
100.0% 
1,243 
17,226 
13.8 
100.0% 
46,163 
535,077 
11.6 
TABLE 37 
HOSPITAL DAYS PROVIDED COUNTY RESIDENTS IN THE DISTRICT 
OF COLUMBIA IN 1940, INDICATING PAY STATUS AND COUNTY 
OF RESIDENCE, TOGETHER WITH THE PERCENT OF TOTAL 
HOSPITAL DAYS 
County of 
Residence 
Pay 
Part-Pay 
Free 
Total 
Percent 
of Total 
Montgomery 
518 
1,349 
1,271 
3,138 
18.1 
Prince George’s 
1,619 
6,173 
5,403 
13,195 
76.6 
Other Counties 
66 
53 
774 
893 
5.3 
Total 
2,203 
7,575 
7,448 
17,226 
100.0 42 
Medical Care in the Counties of Maryland 
or 23-3 percent were pay; 538, or 43-3 percent were part-pay; 
and 413, or 33-4 percent were free patients. Of the 1,243 
admissions, 197, or 15-8 percent were residents of Mont- 
gomery County; 999, or 80.4 percent, resided in Prince 
George’s County; and 47, or 3-8 percent, were residents 
of other counties. 
Of the 46,163 county residents hospitalized in one year, 
28,338, or 61.4 percent, were admitted to 16 hospitals in 
the counties of Maryland; 16,582, or 35-9 percent, to 
15 hospitals in Baltimore City; and 1,243, or 2.7 percent, 
to 9 hospitals in the District of Columbia. Of the 46,163 
patients, 23,305, or 50.5 percent, were pay; 4,732, or 
10.3 percent were part-pay; and 18,126, or 39.2 percent, 
were free patients. The average stay in hospital was 11.6 
days per patient; 9.7 days for pay, 12.9 for part-pay, and 
12.9 for free cases. Chapter VII 
HEALTH DEPARTMENT SERVICES 
Introduction 
Tn 1938 a comprehensive appraisal of the public health 
facilities of the State and counties of Maryland was 
made by Dr. John F. Kendrick and Dr. W. A. McIntosh 
of the staff of the International Division of the Rocke- 
feller Foundation. A report of the study, "Public Health 
Administration in Maryland", was published in 1939 by 
the Maryland State Planning Commission. Since the data 
assembled therein were of such recent origin, the Com- 
mittee on Medical Care decided to devote its attention 
chiefly to those phases of activity of the State and county 
health departments directly related to medical care. 
Full-Time County Health Service 
Maryland has the distinction of having been the first 
State in the United States to organize county-wide health 
service with full-time trained health personnel in each 
county. 
Full-time service throughout the counties was started 
in 1914 by the division of the State, outside of Baltimore 
City, into ten sanitary districts, each consisting of two or 
three counties under the direction of a full-time deputy 
State health officer. More intensive service in individual 
counties was started by Allegany County in 1922. The 
other counties followed one by one, and at the close of 
1934 each of the 23 counties was on a full-time basis. The 
headquarters of each unit is at the county seat. 
The personnel of each county health department in 1940 
included the county health officer, an assistant health 
officer in certain of the larger counties, two or more public 
health nurses, a sanitarian, other technical personnel 
including dentists and medical social workers, and one or 
more clerks. A tabulation of the personnel will be found 
in Table 39, page 44, which also includes the full-time 
personnel: population ratios. It will be seen that the latter 
varied between 1:2,244 in Kent and 1:13,018 in Carroll 
County. In contrast with the distribution of physicians, 
nurses, dentists, and hospital beds, the public health 
personnel was, in general, higher in the counties in the 
lower economic levels. 
The maintenance of county health departments is financed 
jointly by the State Department of Health and city and 
county governments. The personnel is appointed on a 
merit basis, regardless of whether the salaries are paid 
with State or local funds or both. 
The Program of County Health Departments 
In 1940 the county health departments conducted a 
generalized public health program, under the direction of 
the county health officer, of which the principal activities 
were: (1) communicable disease control including im- 
munization, venereal disease and tuberculosis clinics; 
(2) public health nursing; (3) clinics for expectant mothers, 
child health conferences and health services for school 
children; (4) services for crippled children; (5) mental 
hygiene clinics; (6) bacteriological laboratory service in 
eight counties; (?) dental clinics; (8) public health educa- 
tion and information services; (9) sanitation including 
milk, water and food control, as well as sewerage disposal 
and other types of community hygiene. 
1. Communicable Disease Control in 1940 
(a) General 
There were 13,837 cases of notifiable diseases reported 
to the State Department of Health from the counties of 
Maryland in 1940, and nearly 7,900 home visits were made 
by the health officers and public health nurses to discover 
sources of infection or to take measures to prevent the 
spread of disease1. Over 17,000 young children were im- 
munized against diphtheria; 5,500 persons were protected 
against typhoid fever and over 6,000 were vaccinated 
against smallpox. These protective measures were carried 
out with the cooperation of county medical societies. 
(b) Tuberculosis 
Over 5,700 persons were examined at the monthly chest 
clinics held in cooperation with the Maryland Tuberculosis 
Association, 581 were admitted to sanatoria and 12,275 
home visits were made to persons who were suffering from 
tuberculosis or who had been in contact with that infection. 
(c) Venereal Diseases 
Venereal disease clinics were held in every section of the 
State with over 9,000 persons admitted for diagnosis or 
treatment. Over 83,000 treatments were given and over 8,800 
follow-up visits were made to the homes of patients. 
2. Public Health Nursing 
There has been a constant increase in the number of 
public health nurses. In 1922, there were 22 nurses, and at 
the close of 1940 there was a total of 110. In addition to 
kinnual Report of the State Board of Health of Maryland, 1940. Medical Care in the Counties of Maryland 
the nurses on duty in the counties, the public health 
nursing staff of the State Department of Health included 
a nurse instructor and assistant instructor, nurse consultant 
in maternal and child hygiene, three nurse midwives, and 
two orthopedic nurses connected with the services for 
crippled children. With the exception of those assigned 
to special services, the county nurses carried on a generalized 
program under the direction of the county health officer. 
3. Pre-natal Clinics, Child Health Conferences, and Health 
Services for School Children 
Nearly 2,500 expectant mothers were enrolled at the 
pre-natal clinics; 13,568 young children were examined at 
the child health conferences; and more than 46,000 home 
visits were made by the public health nurses in connection 
with these services. 
Health supervision of the older children included the 
physical examination of over 41,500 school children, and 
131,115 inspections were made in connection with the 
control of communicable disease in the schools. Dental 
clinics were also a part of the school health services, as 
has been indicated elsewhere in this report, and over 
12,000 children had some type of dental attention. 
4. Services for Crippled Children 
Over 2,300 physically handicapped children had the 
benefit of supervision and treatment in the Services for 
Crippled Children. A total of 252 children was hospitalized, 
12,446 physio-therapy treatments were given, and 5,764 
home nursing visits were made to the children for followup 
care. 
5. Mental Hygiene Clinics 
Over 800 persons—670 of whom were under 21—were 
examined at the mental hygiene clinics conducted under 
the joint auspices of the Bureau of Child Hygiene of the 
State Department of Health, the State Commissioner of 
Mental Hygiene, the State Mental Hygiene Society, the 
county departments of health and the school authorities. 
The examinations were given by psychiatrists connected 
with the State, Baltimore City or local hospitals or in- 
stitutions. A total of 101 clinics was held in 21 counties. 
6. Bacteriological Laboratories 
The Bureau of Bacteriology of the State Department of 
Health, with a central laboratory in Baltimore and eight 
branch laboratories throughout the State, has developed 
an extensive laboratory service. The total examinations 
increased from 15,600 in 1920 to 82,909 in 1930, and 278,919 
in 1940. The prodigious growth of this service is obvious. 
A high proportion of the increase during the past several 
years has been attributed to syphilis serology. 
The number and type of personnel engaged in laboratory 
work in the central laboratory in Baltimore and in each 
of the branch laboratories are as follows: 
TABLE 39 
ORGANIZATION OF THE COUNTY HEALTH DEPARTMENTS IN 1940, 
INDICATING THE NUMBER OF FULL-TIME COUNTY HEALTH 
OFFICERS, PUBLIC HEALTH NURSES, SANITARY 
OFFICERS AND DENTISTS, TOGETHER WITH 
THE PERSONNEL: POPULATION RATIO. 
County 
Public 
Health 
Officers 
Public 
Health 
Nurses 
Sanitary 
Inspectors 
Dentists 
Total* 
Personnel: 
Population 
Ratio 
Kent 
1 
4 
1 
6 
1:2,244 
Queen Anne’s 
1 
4 
1 
— 
6 
1:2,413 
Calvert 
1 
2 
1 
— 
4 
1:2,621 
Anne Arundel 
2 
19** 
2 
— 
23 
1:2,973 
Caroline 
1 
3 
1 
— 
5 
1:3,510 
Charles 
1 
3 
1 
— 
5 
1:3,522 
Worcester 
1 
4 
1 
— 
6 
1:3,541 
St. Mary’s 
1 
2 
1 
— 
4 
1:3,656 
Garrett 
1 
4 
1 
— 
6 
1:3,663 
Talbot 
1 
3 
1 
— 
5 
1:3,757 
Somerset 
1 
3 
1 
— 
5 
1:4,193 
Wicomico 
1 
6 
1 
— 
8 
1:4,316 
Cecil 
1 
3 
1 
— 
5 
1:5,281 
Allegany 
2 
10 
4 
— 
16 
1:5,425 
Dorchester 
1 
3 
1 
— 
5 
1:5,601 
Howard 
1 
2 
— 
— 
3 
1:5,725 
Montgomery 
1 
8 
3 
— 
12 
1:6,993 
Washington 
1 
5 
2 
1 
9 
1:7,649 
Frederick 
1 
4 
2 
— 
7 
1:8,187 
Harford 
1 
2 
1 
— 
4 
1:8,765 
Prince George’s 
2 
5 
2 
— 
9 
1:9,943 
Baltimore 
2 
9 
1 
— 
12 
1:12,985 
Carroll 
1 
2 
3 
1:13,018 
Total Counties 
27 
110 
30 
1 
168 
1:5,727 
Bacteriologists 
and Assistant 
Bacteriologists 
Laboratory 
Assistants 
and Helpers 
Clerks 
and Sten- 
ographers 
Central Laboratory 
Branch Laboratories: 
13 
14 
7 
Cumberland 
2 
1 
— 
Hagerstown 
1 
1 
1 
Hurlock 
2 
1 
1 
Frederick 
1 
1 
1 
Rockville 
1 
2 
— 
Salisbury 
1 
1 
1 
Elkton 
1 
1 
1 
Annapolis 
1 
1 
1 
Total 
23 
23 
13 
Maintenance Costs 
The budget for the State Department of Health for the 
year 1940-41 has been summarized in Table 40, page 45- 
The total for the year was $1,978,221, of which $782,669 
*ln addition to those listed, other technical personnel and one or more clerks were 
employed in each county. 
**ln this county, there was an intensive development of maternal and child hygiene 
services, necessitating an increase in the staff. Health Department Services 
45 
were the estimated expenditures for the Health Department 
of Baltimore City; $661,587 were allocated for adminis- 
trative costs, and $333,965 for the county health depart- 
ments. Administrative costs included the maintenance of 
the many services in the central office of the State Depart- 
ment of Health in Baltimore, all of which benefited the 
counties directly, but the total could not be equally dis- 
tributed among them. 
The source of funds for the maintenance of county health 
departments included $212,259 from State and/or Federal 
sources, $196,783 from city and county governments, and 
$124,923 from other agencies. 
In Table 41, page 46, the budgets of the county health 
departments are shown for the year 1940-41, together with 
the expenditures per capita, the local appropriations and 
the percentages of the budgets appropriated locally. The 
counties have been arranged in order of the per capita 
expenditures. 
Budgets ranged from $74,520 in Anne Arundel County, 
in which an intensive maternal and child health program 
was being developed, to $9,572 in Carroll County. For the 
total counties the average budget was $23,216. The per 
capita costs varied from $1.51 in Queen Anne’s to $0.25 in 
Carroll County, with an average expenditure of $0.58 per 
person. 
Since there was comparatively little variation in the 
number of employees of county health departments, it is 
not surprising to find that the cost per capita was larger in 
the counties with relatively small populations. 
The local appropriations, totalling $196,783, varied from 
$34,544 in Allegany to $1,486 in St. Mary’s, with an 
average of $8,556 per county. The proportion of the budgets 
contributed locally extended from 70.0 percent in Allegany 
to 11.3 percent in St. Mary’s County, with a mean of 
35-5 percent. It will be noted that, as a rule, the highest 
local appropriations were made by the largest counties and 
by those in the higher economic levels. 
Interviews with County Health Officers 
Each county health officer was interviewed at length, 
and each county health department was inspected, par- 
ticular attention being given to those facilities which 
provided for examination and treatment of patients. 
The typical county health officer, in addition to a degree 
in medicine, possessed a degree or certificate in public 
health. The majority had been serving in their county 
for at least ten years. 
Increase Reported in Requests for Medical Care 
Each county health officer reported that during the past 
four or five years it had become necessary to assume, in 
addition to his usual activities, an ever increasing re- 
sponsibility in arranging for medical care for the indigent 
and the medically indigent. 
The majority of health officers agreed that very few 
patients who were able to visit the physician’s office ever 
went untreated, and that many physicians devoted a great 
deal of time and effort during office hours to care of the 
indigent. Difficulties in securing medical care, they believed, 
were confined largely to those requesting home visits, 
particularly the chronically ill, and patients requiring a 
diagnostic study. 
Health officers expressed the belief that those unable 
to secure medical attention might be divided into two 
general classes, (a) recipients of relief, particularly residents 
of counties in which arrangements for payment of phy- 
sicians had not been completed, and (b) those indebted to 
physicians who habitually made no serious effort to dis- 
charge their obligations. 
The indigent or medically indigent individual, failing to 
obtain continued services from the family physician, 
applied for aid either to another practitioner, to the county 
health department, the local hospital, the county welfare 
department, or the county commissioners, usually in this 
sequence. 
In procuring medical care for such individuals, county 
health officers generally proceeded as follows: 
After it had been determined that the patient actually 
needed medical attention and a tentative diagnosis was 
made, an attempt was made to ascertain the patient’s 
financial status. This sometimes involved a telephone call 
TABLE 40 
BUDGET OF STATE DEPARTMENT OF HEALTH IN 1940-41 SHOWING 
TOTAL EXPENDITURES FOR THE COUNTIES OF MARYLAND, 
BALTIMORE CITY AND FOR ADMINISTRATIVE 
PURPOSES 
Source of Funds 
Total 
State &/or 
Federal 
Local 
Other 
Agencies 
Total Counties 
$ 533,965 
$ 212,259 
$ 196,783 
$ 124,923 
Baltimore City 
782,669 
27,059 
755,610 
Total Counties and 
$1,316,634 
$ 239,318 
$ 952,393 
$ 124,923 
Baltimore City 
Administrative Costs 
661,587 
586,906 
5,730 
68,951 
Total 
$1,978,221 
$ 826,224 
$ 958,123 
$ 193,874 
Percent 
100.0% 
41.8% 
48.4% 
9.8% 46 
Medical Care in the Counties of Maryland 
to the county welfare department. If the patient were 
indigent and the condition a relatively simple one, the 
county health officer might risk the accusation of engaging 
in the private practice of medicine and give such treatment 
or advice as was indicated. As a rule, however, the health 
officer either attempted to persuade the doctor named as 
the family physician to accept responsibility for the case, 
or called another physician who was known usually to be 
willing to assist those in need. Even the latter occasionally 
tires of receiving constant appeals, or, after a few such calls, 
the county health officer hesitates to impose further on 
good nature. If it seemed certain that the applicant was a 
hospital case, the local hospital was asked to admit the 
patient. If the request was granted, the hospital would then 
assume responsibility for procuring a physician. It was not 
unusual for the health officer to ask that the patient be 
admitted to a local hospital if the individual lived more 
than a few miles from the nearest physician’s office. This 
would enable the patient to receive medical attention, and 
make it unnecessary to ask a physician to drive a number 
of miles each day to treat the case. 
Analysis of Requests for Medical Care Received by 
County Health Departments 
It has been noted that, in addition to their usual func- 
tions, county health officers almost unanimously declared 
that they had been obliged to assume an ever increasing 
responsibility for arranging for medical care of the indigent 
or for those who claimed to be in that status. Activities 
of this kind were not regarded as a part of their official 
duties and reports of this work, therefore, were not sub- 
mitted either to county commissioners or to the State 
Department of Health. To obtain estimates of the volume 
and character of these unmet needs, county health officers 
were requested to submit each month to the Committee 
on Medical Care the following information: 
1. The age, sex, race and economic status of each in- 
dividual applying for medical care. 
2. The name of the person or agency from whom the 
request was received. 
3. The reason for applying to the county health 
department. 
4. The disposition of the case. 
Eight counties sent the Committee information regularly 
in sufficient detail to warrant its use. These were Anne 
Arundel, Baltimore, Cecil, Charles, Harford, Howard, 
Talbot, Worcester counties. The period covered by each 
varied from four to eight months, with an average of seven 
months. In all cases the late winter and spring of 1940 
were included. 
In Table 42, page 47, the reports received from these 
eight county health departments are tabulated, together 
with estimates of the annual number of requests and of the 
rates per 1,000 population. The latter ranged from 2 in 
Anne Arundel, Harford and Worcester Counties to 10 per 
1,000 in Cecil County. While considerable variation from 
county to county was expected, the extremes noted are 
believed to be the result of incomplete reporting. 
Characteristics of Applicants 
Persons applying to county health departments for 
medical care exhibited the following characteristics. 
1. Sex 
In five of the eight counties, males constituted less than 
50 percent of the applicants. In three counties the propor- 
tion was less than 35 percent. It has long been established 
that women seek medical attention more frequently than 
men. 
2. Race 
The frequency of Negro applications varied considerably 
from county to county. When each percentage was com- 
THE BUDGETS OF THE COUNTY HEALTH DEPARTMENTS FOR THE 
YEAR 1940-41, INDICATING THE EXPENDITURES PER CAPITA, 
THE TOTAL LOCAL APPROPRIATIONS, AND THE PERCENT- 
AGE OF THE TOTAL BUDGET APPROPRIATED LOCALLY, 
IN ORDER OF THE PER CAPITA EXPENDITURES. 
TABLE 41 
County 
Total 
Budget 
Expendi- 
tures per 
Capita 
Local Appropriations 
Rank 
Percent 
of Total 
Budget 
Total 
Queen Anne’s 
$ 21,868 
$1.51 
21 
13.0 
$ 2,836 
Kent 
17,716 
1.32 
13 
28.9 
5,114 
Calvert 
11,569 
1.10 
16 
24.6 
2,847 
Anne Arundel 
74,520 
1.09 
22 
11.6 
8,650 
Somerset 
17,873 
.95 
18 
22.6 
4,047 
Charles 
16,642 
.94 
20 
14.0 
2,328 
St. Mary’s 
13,081 
.89 
23 
11.3 
1,486 
Worcester 
18,506 
.87 
11 
30.1 
5,577 
Caroline 
13,607 
.78 
14 
27.1 
3,681 
Garrett 
16,096 
.73 
12 
29.5 
4,743 
Wicomico 
24,637 
.71 
17 
23.5 
5,789 
Talbot 
12,803 
.68 
15 
25.2 
3,223 
Howard 
10,178 
.59 
6 
47.8 
4,869 
Dorchester 
15,931 
.57 
19 
16.1 
2,574 
Allegany 
49,312 
.57 
1 
70.0 
34,544 
Cecil 
12,739 
.48 
10 
37.5 
4,781 
Montgomery 
40,633 
.48 
3 
58.9 
23,919 
Washington 
29,804 
.43 
4 
51.5 
15,360 
Frederick 
21,903 
.38 
8 
38.9 
8,512 
Harford 
13,398 
.38 
7 
43.2 
5,791 
Prince George’s 
28,983 
.32 
5 
51.1 
14,799 
Baltimore 
42,557 
.27 
2 
65.0 
27,657 
Carroll 
9,572 
.25 
9 
38.2 
3,654 
Total Counties 
$533,965* 
$0.58 
— 
35.5 
$196,783* 
*The average budget was $23,216, with a mean appropriation of $8,556 per county. Health Department Services 
pared with that of the Negroes in the total county popula- 
tion, it was apparent in all counties that the proportions 
in this sample were higher than the percentage of Negroes 
in the total population. 
3. Age 
In all counties except Worcester, which reported only 
21 applications, the percentage of applicants under 15 years 
of age was greater than the percentage of persons in this 
age group in the total population of their respective 
counties. The percentage of applicants over 45 was lower 
than the corresponding percentage for the total population. 
These findings are, in general, in agreement with established 
figures on the general morbidity in relation to age. 
4. Economic Status 
Information on the economic or occupational status of 
applicants or their parents was not as complete as was 
expected. However, taking into account those cases in 
which this information was recorded, it is clear that those 
“on relief” were in the minority, ranging from zero to 
38 percent. Conversely, those not “on relief”, comprised 
from 62 to 100 percent of the total. It is clear, therefore, 
that a high proportion of applicants for medical care were 
not recipients of relief and presumably self-supporting. 
Origin of Requests 
The majority of applications were made by the patients, 
their relatives or neighbors. The cases referred by the 
county welfare departments did not exceed 50 percent of 
the total in any of the counties, the majority of appeals 
were made directly to the county health departments. 
A small number of persons were referred to the Health 
Department by physicians. 
The majority of applicants claimed that they had a 
family physician. Among those who asserted that an 
appeal for medical care had been made to other persons or 
agencies before coming to the Health Department, about 
70 percent stated that a physician previously had been 
called upon. 
TABLE 42 
REQUESTS FOR MEDICAL CARE RECEIVED IN EIGHT COUNTY HEALTH DEPARTMENTS IN MARYLAND IN THE 
LATE WINTER AND SPRING MONTHS OF 1940 
County Health Departments 
Anne Arundel 
Baltimore 
Cecil 
Charles 
Harford 
Howard 
Talbot 
j Worcester 
Period Covered, Months 
8 
8 
8 
5 
8 
7 
4 
7 
Total Requests Received 
98 
303 
205 
52 
52 
55 
27 
21 
Total Estimated Requests per Year 
131 
404 
273 
143 
77 
94 
81 
36 
Total Estimated Requests per Year, per 1,000 Population 
2 
3 
10 
7 
2 
6 
4 
2 
Characteristics of Applicants 
(1) Sex—Percent Males 
34 
33 
34 
42 
55 
45 
50 
53 
(2) Color—Percent White 
41 
78 
78 
30 
81 
75 
31 
63 
(3) Age-(Percent) 0-14 years 
48 
38 
34 
45 
43 
37 
31 
13 
15-44 years 
41 
43 
54 
45 
33 
32 
40 
52 
45 years and over 
11 
20 
11 
10 
24 
31 
29 
35 
(4) Economic Status Total “on relief” 
5 
41 
14 
6 
11 
13 
1 
0 
Total not “on relief” 
49 
242 
116 
46 
30 
21 
5 
7 
Unknown status 
44 
20 
75 
0 
17 
21 
21 
14 
Applicants of Known Percent“on relief” 
9 
14 
11 
11 
27 
38 
17 
0 
Status Not “on relief” 
91 
85 
89 
89 
73 
62 
23 
100 
Requests Made By: Patient or Relative 
29 
62 
83 
74 
65 
31 
83 
83 
(percent) Welfare Department 
41 
22 
9 
8 
15 
45 
11 
17 
Physician 
25 
10 
6 
13 
15 
20 
0 
0 
Other Agency 
6 
1 
2 
5 
4 
4 
6 
0 
Applicants Claiming a Family Physician (Percent) 
84 
67 
52 
92 
72 
83 
18 
43 
Applicants Claiming Request First Made to 
Family Physician (Percent) 
64 
50 
68 
67 
0 
93 
0 
92 
Disposition: Treated by Health Department 
13 
15 
1 
52 
12 
11 
89 
48 
(Percent) Treated by Private Physician at Request 
of Health Department 
20 
9 
11 
25 
5 
2 
0 
19 
Hospitalized 
67 
76 
88 
23 
83 
87 
11 
33 48 
Medical Care in the Counties of Maryland 
Disposition of Requests 
About 60 percent of those who applied to the Health 
Department were subsequently hospitalized. This might be 
interpreted as indicating that many of the applicants were 
acutely ill. However, there were other deciding factors. 
For example, in some cases home conditions were so 
insanitary that there was little hope of successful treatment 
there; or bedside nursing, even of the most elementary 
type, was not available; and distance from the nearest 
doctor’s office was an important consideration in some 
instances. 
About 30 percent of individuals were treated by the staff 
of the county health department, although the type of 
service rendered was not an official responsibility of that 
agency. Approximately 10 percent were referred to physi- 
cians, usually friends of the county health officer or public 
health nurses, because “no means, other than appeal to 
one’s friends, has yet been provided for the treatment of 
‘charity’ patients living in the counties of Maryland”. 
Data Inadequate for Accurate Estimate of Number 
of Medically Indigent 
From these data it was expected that an estimate of the 
number of medically indigent in the counties of Maryland 
could have been made, but the information at hand does 
not appear to be sufficiently complete for this purpose. 
The number of requests received, however, served to confirm 
reports of health officers and others that persons in signifi- 
cant numbers were daily seeking medical care in or through 
the county health department. 
Health Departments Prevent Unnecessary 
Hospitalization 
The county health officer not only secured the hos- 
pitalization of patients but also assisted in reducing the 
number of hospital admissions. For example, at the request 
of the superintendent, the health officer or one of his 
nurses visited the homes of individuals who are without 
a physician and whose families, neighbors or friends ur- 
gently requested hospitalization. In a high proportion of 
such cases it was found that the patient required only 
simple treatment and that admission to hospital was not 
often necessary. By such visits, particularly among those 
living in rural areas and those known to be indigent, the 
number of hospital admissions has been decreased, and 
hospital beds reserved for those who really need that type 
of care. 
County Medical Care Programs in Depression Years 
Almost in despair during the dark days of financial 
depression, several health officers developed medical care 
programs for the indigent in their counties. For example, 
in Washington County, the County Medical Society, in 
conjunction with the County Health Department, operated 
the following plan: 
If an indigent individual or a member of his family 
requested a physician, the call was referred to the office 
of the county health department by day, or to the local 
hospital by night. In either case a public health nurse was 
sent to the home. Upon arrival, the nurse took the tem- 
perature, pulse, respiration and otherwise formed an 
opinion as to the necessity for summoning a physician. 
If that need was apparent, a physician was summoned 
from a list of those who had agreed to respond to such 
calls. If the first physician could not be reached or was not 
available, the next on the list was called. In the meantime 
the nurse was authorized to render first aid, if necessary. 
If a patient were a member of a family known to be re- 
ceiving relief and his condition did not require the im- 
mediate attention of a physician, the nurse was permitted 
to administer such simple remedies or give such advice 
as was indicated. If the nurse found it advisable to summon 
a physician, the latter, upon arrival, assumed full respon- 
sibility for the subsequent management of the case. 
Discussion of Program 
Although physicians in Washington County received no 
compensation for care of indigent patients, the program 
functioned reasonably well for about one year. 
Before the plan was adopted, several objections were 
raised. For example, it was thought that a nurse should 
not be asked to assume responsibility for deciding whether 
a physician should be called, and it was questioned whether 
a nurse should be permitted to administer any kind of 
treatment. In practice, however, it was found that the 
nurses did not fail, so far as is known, to call a physician 
when needed. 
Objections to the plan which subsequently developed 
included (a) the absence of payment for services while 
physicians in other counties and states were being com- 
pensated for the treatment of the indigent, (b) emergency 
treatment only was provided, and the difficulties of se- 
curing medical care for the chronically ill and the less 
emergent cases continued as usual, and (c) physicians 
reported that there was a tendency for indigent patients 
to adopt as the “family” physician, the practitioner who 
answered the emergency call. On the other hand, the plan 
made it possible to reduce the number of unnecessary calls 
of physicians to the homes of the indigent. When a physi- 
cian was summoned by a public health nurse, he answered 
the call willingly, even at night, because he knew that his 
services were really necessary. 
In nearly every county the health officer expressed 
profound regret that a State-wide plan for providing 
medical care for the indigent had not yet been developed. Health Department Services 
49 
Clinics ami Equipment in the County Health 
Department 
In each county health department it was found that 
activities of various types including orthopedic, venereal 
disease, tuberculosis, immunization and dental clinics were 
conducted routinely. It was also learned that the health 
department was the only public agency, other than the 
hospital, which was staffed and equipped for these pur- 
poses. If it should subsequently be decided to establish 
county centers for treatment of the indigent, it would seem 
logical, in the interests of economy and efficiency, to 
utilize these established agencies. Additional space, 
equipment and personnel would be required to expand these 
facilities in order to treat the indigent and to serve as a 
center for the reception of calls and their referral to local 
physicians. 
With the above potentialities in mind, estimates were 
made of the capacity of the present facilities and of the 
probable costs of expansion of each department. The present 
quarters, with comparatively few changes would probably 
serve the purpose in Anne Arundel, Baltimore, Caroline, 
Charles, Dorchester, Harford, Howard, Kent, Somerset, 
Talbot, Washington, and Wicomico Counties. At least one 
room should be added in Calvert, Carroll, Cecil, Frederick, 
Garrett, Prince George’s, Queen Anne’s, St. Mary’s and 
Worcester counties, and a minimum of two rooms would 
be required in Allegany and Montgomery counties. 
In all counties additional equipment would be needed, 
the amount varying with the size of the county. The 
following personnel also would be required, (a) a county 
director, with an assistant director in the larger counties, 
(b) one or more nurses, (c) a medical social worker in most 
of the counties, (d) an additional laboratory worker in the 
branch laboratories and (e) one or more clerks. The em- 
ployment of part-time clinicians would, of course, be 
essential to conduct the clinics. 
Estimates of the costs of additional space, equipment 
and personnel will be found in Chapter IX. 
Summary 
In 1940, a total of 27 public health officers, 100 public 
health nurses, 30 sanitary inspectors and 35 clerks, as well 
as other personnel, were full-time employees in the county 
health departments. 
The staff of a typical county health department was 
composed of the county health officer, two or more public 
health nurses, a sanitarian, and one or more clerks. Each 
department conducted a generalized public health program 
including communicable disease control, public health 
nursing, preschool and school health service, maternal and 
child hygiene, services for crippled children, mental 
hygiene clinics and other activities. In addition, a bac- 
teriological laboratory service is provided in eight counties 
covering the entire State. 
The maintenance of the county health departments was 
financed jointly by the State Department of Health and 
city and county governments and other agencies. Personnel 
were appointed on a merit basis, regardless of whether the 
salaries were provided from State or local funds, or both. 
The budget of the State Department of Health in 1940-41 
totalled $1,978,221 of which $533,965, or 27.0 percent, was 
expended in the 23 counties. Of the latter amount, the 
sum of $212,259, or 39-8 percent, was received from State 
and/or Federal sources, while $196,783, or 36.8 percent, 
was appropriated by city and county governments, and 
$124,923, or 23-4 percent, was obtained from other agencies. 
Of the total for all counties, $533,965, the average budget 
was $23,216 per county. The average cost for all counties 
was $0.58 per capita, and the local appropriations totalled 
$196,783, or an average of $8,556 per county. 
Since the number of personnel in the county health 
departments did not vary greatly, the cost per capita was 
larger in the counties having relatively small populations. 
In general, the appropriations by local agencies were 
larger in the most populous counties and in those in the 
higher economic levels. 
The typical county health officer possessed degrees both 
in medicine and in public health, and had served in the 
county for at least ten years. 
A number of county health officers reported that a 
proportion of the population had difficulty in securing 
medical attention, the percentage varying in magnitude 
with fluctuations in economic conditions. 
The indigent or medically indigent individual seeking 
medical care, usually applied first to private practitioners, 
then to the county health department, the local hospital, 
the county welfare department, or the county commis- 
sioners in the sequence indicated. 
County health officers asserted that they have been 
obliged to assume an ever increasing responsibility in 
arranging for medical care for the indigent and the near 
indigent. 
In an analysis of 813 requests for medical care received 
by eight county health departments, the findings were 
as follows: 
1. Females constituted a slightly higher proportion of 
applicants than males. 50 
Medical Care in the Counties of Maryland 
2. There was a higher proportion of children than 
adults. 
3. About 20 percent were “on relief”, while the re- 
maining 80 percent were not beneficiaries of county 
welfare departments. 
4. The majority of applications were made by patients, 
their relatives or neighbors, only a small proportion 
was referred by county welfare departments. 
5. A high percentage of applicants claimed that they 
had a family physician and asserted that he had been 
called upon before application was made to the 
health department. 
6. Approximately 60 percent of the applicants were 
hospitalized, 30 percent were treated by the county 
health department, and 10 percent were referred to 
private physicians, who as a rule, were friends of 
the county health officers or nurses. 
7- An accurate estimate of the number of medically 
indigent in all the counties of Maryland could not 
be made from the data available. The number of 
requests for medical care received, however, sub- 
stantiated reports that a significant number of in- 
dividuals were constantly requesting county health 
departments to provide medical care. 
The county health departments appear to have pre- 
vented a number of unnecessary admissions to hospitals. 
The need for a plan for medical care of the indigent 
was frequently expressed by county health officers. 
A variety of clinical activities was conducted routinely 
in the county health departments. It is suggested that it 
seems logical to utilize these established agencies, if it 
should subsequently be decided to organize county facilities 
for the medical care of the indigent. Additional space, 
equipment, and personnel that would be required have 
been listed. Chapter VIII 
WELFARE DEPARTMENT SERVICES 
Types of Assistance 
Tn the relief program administered by the State and 
county departments of welfare, there were provisions 
for two types of assistance*, (1) classified and (2) general. 
1. Classified assistance included the following categories: 
(a) Aid to Dependent Children 
(b) Old Age Assistance 
(c) Public Aid to Needy Blind 
In these categories the operating funds were derived 
from "matched” Federal and State sources. 
2. General assistance included but one category: 
(a) General Public Assistance. 
In this category funds were obtained from State and 
local sources. 
The conditions under which assistance could be granted 
in the various categories were defined by law. A summary 
of these terms is presented below. 
1. Classified Assistance: 
(a) Aid to Dependent Children 
This category provided care for children whose wage 
earning parents were temporarily or permanently inca- 
pacitated. Medical certification of physical disability of 
the parent was required. 
In Garrett County, and occasionally in other counties, 
a certificate of physical disability was obtained from the 
county health department. In the majority of counties, 
however, this statement was secured from the attending 
physician. 
In Cecil and Kent counties, the county welfare depart- 
ments compensated the physicians directly for making 
these examinations. In other counties the disabled parent 
was expected to pay the physician. The' cost of the exa- 
mination was usually $1.00. Few individuals, however, 
could pay even this small amount, otherwise they would 
not have found it necessary to apply for assistance. In 
some cases this fee was paid by the family with the proceeds 
of the first check received from the county welfare de- 
partment. 
In all counties re-examination was required every six 
months, except when the continued existence of the 
disability was obvious to the casual observer. 
(b) Old Age Assistance 
To be admitted to this category, a person must have 
been 63 years of age, a citizen of the United States, and a 
resident for at least one year in the county in which his 
application was filed. He must have demonstrated the need 
for financial assistance. As a rule, no physical examination 
was necessary, except in Allegany, Calvert, Harford, 
St. Mary’s and Washington counties in which the applicant 
was required to present a certificate of physical disability 
as proof of need if it appeared that he was employable or 
employed. As a rule, the county welfare department 
assumed no obligation for payment for this examination, 
the applicant being expected to compensate his family 
physician. 
(c) Public Aid to Needy Blind 
An opthamological examination was a prerequisite for 
admission to this category. In twenty-one counties these 
examinations were made at the Wilmer Clinic of the 
Johns Hopkins Hospital in Baltimore. The county welfare 
departments usually provided transportation while the 
State Welfare Department paid the cost of examinations. 
In Montgomery and Prince George’s counties this service 
was rendered by the Episcopal Eye, Ear, Nose and Throat 
Hospital in Washington, D. C. 
2. General Assistance 
(a) General Public Assistance 
This category was provided for persons who were 
temporarily or permanently incapacitated, but who were 
not eligible for admission to any other classification. As 
a rule, a medical certificate was not required, since ap- 
plicants either were under the care of a physician, or 
application for assistance had been made in order to obtain 
medical attention. In certain counties, it was possible for 
persons in this category to receive medical care since 
provisions were made for direct compensation of both 
physicians and hospitals. These counties included Allegany, 
Anne Arundel, Worcester, Frederick, Kent, Wicomico and 
possibly others. 
Usual Procedures for Securing Assistance and 
Medical Care 
The financial resources of each household were studied 
by the county welfare department, and a budget prepared 
in which the family income, if any, was augmented each 
*Persons in financial distress in the counties of Maryland were described 
in various terms “those on relief”, “relief clients”, “welfare cases”, and 
“those receiving assistance”. The latter was most frequently used by county 
welfare departments. 52 
Medical Care in the Counties of Maryland 
month by an amount necessary to maintain life at a level 
“compatible with decency and health’’. The standards 
varied from county to county. In some areas which were 
more “relief minded’’ and in those in which the cost of 
living was higher, the families received a larger monthly 
check. 
The procedure for securing medical care for recipients of 
assistance varied with the type of medical service required: 
(1) in the home, (2) nursing care, (3) hospitalization, 
(4) obstetrical care, (5) clinic service, and (6) dental care. 
1. In the home 
The source of medical care in the home was, of course, 
the family physician. In some indigent families, particu- 
larly those who had recently taken up residence in the 
county, a family physician had not been selected. In such 
families difficulty in securing a physician frequently was 
reported. In a number of counties public health nurses were 
called to the home to investigate reports of illness when a 
physician was not available. 
2. Nursing Care 
It was unanimously agreed by county welfare executives 
that the services of a registered nurse rarely, if ever, could 
be obtained for indigent patients because of the cost. In 
many of the counties there was no provision for any kind 
of bedside nursing. In Caroline, Garrett, Howard, Kent, 
Queen Anne’s, St. Mary’s, Talbot, and Worcester counties 
the county welfare department secured the services of a 
“practical” nurse, if such a person and the funds were 
obtainable. The urgent need for the organization of a 
bedside nursing service for recipients of relief was em- 
phasized by every county welfare executive. 
3. Hospitalisation 
When an indigent individual required hospitalization, 
welfare department workers followed one of the pro- 
cedures outlined below: 
(a) Arrangements were made directly with the local 
hospital or with an institution in the City of Balti- 
more. This was the routine practice in Calvert, 
Caroline, Frederick, Kent, Prince George’s, and 
Talbot counties. 
(b) Certification of the need for hospitalization and 
indigency of a patient was made to the county 
commissioners or other official agency that con- 
tracted with the hospital. This was the procedure 
in Allegany, Garrett, Montgomery, St. Mary’s, 
Somerset and Worcester counties. 
(c) The county health departments were requested to 
make the necessary arrangements in Anne Arundel, 
Baltimore, Charles, Harford, Howard, Queen Anne’s 
and Washington counties. 
It was pointed out by welfare executives that the county 
welfare departments were usually without funds for 
hospitalization and that individuals almost invariably 
were referred to hospitals with the implied understanding 
that the cost would be met by appropriations for the 
treatment of free patients received from the State and/or 
local governments. Occasionally, payments were made to 
hospitals in the form of checks payable to recipients of 
old age assistance. The amounts usually were small and 
were regarded as payment for board and lodging. If such 
an arrangement could not have been made in at least one 
hospital, it would not have been possible to secure the 
admission of these patients. 
In attempting to hospitalize indigent persons in in- 
stitutions in the City of Baltimore, both county welfare 
and county health departments declared that it was not 
unusual to be compelled to make four or five long distance 
calls before accommodations could be found. The need for 
a central hospital admitting service was emphasized. 
4. Obstetrical Care 
In a few counties in which arrangements had been made 
for payment of physicians, little difficulty was experienced 
in obtaining obstetrical care for indigent patients in the 
home. In other counties this was a serious and constant 
problem. 
In nearly every hospital, except Frederick Emergency, 
it was almost impossible to hospitalize a normal free 
obstetrical case. In a few counties, it was asserted, the 
patient had to be “almost dead’’ before admission could 
be obtained even for an abnormal case. According to 
welfare executives, it was contended by hospitals that if 
a single normal case were admitted, it would be necessary 
to accept every normal case, and the “entire hospital soon 
would be filled with obstetrical patients.’’ 
In all counties a small proportion of mothers postponed 
application for medical care until delivery was imminent 
or had already taken place. In instances of this kind the 
greatest difficulties were encountered. In some cases it was 
impossible, according to welfare executives, to induce a 
physician to assume responsibility for care of the case and, 
if the patient could not be hospitalized, public health 
nurses not infrequently were called upon to render as- 
sistance. 
5. Clinic Service 
The clinics conducted by the county health departments 
were reported by county welfare executives to have been 
of great assistance in obtaining diagnoses or treatment 
for such conditions as tuberculosis, syphilis, the psychoses 
and deformities. Welfare executives expressed keen regret 
that general medical and surgical clinic services were not 
provided. Health Department Services 
53 
6. Dental Care 
The procedures for securing dental care for recipients of 
relief differed little from those employed in obtaining 
medical care. 
In the school dental clinics which were conducted in 
several of the more wealthy counties, the children of 
medically indigent parents received certain types of dental 
service. In Washington County, and to a very limited 
extent in several other counties, the county health de- 
partments maintained dental service for indigent adults. 
In Montgomery County the County Commissioners as- 
sumed responsibility for paying for this service. 
The county welfare departments undertook to secure 
dental care for those receiving assistance in the same 
manner as that utilized in obtaining medical attention in 
Allegany, Anne Arundel, Caroline, Carroll, Cecil, Dor- 
chester, Frederick, Garrett, Howard, and Prince George’s 
counties. 
Individuals made their own arrangements for dental 
care in Baltimore, Charles, Howard, Kent, Queen Anne’s, 
St. Mary’s, Somerset, Talbot, Wicomico and Worcester 
counties. 
Except in the school clinics, the dental care of indigent 
persons was almost exclusively limited to the emergency 
type. 
Selection of Physicians and Authorization of Service 
In all counties recipients of assistance had full freedom 
of choice of physicians. Any individual who applied to 
the county welfare department for medical care, was urged 
to call his family physician. Only after it was found that 
a physician could not be reached, or that none could be 
induced to accept the case, did the welfare department 
endeavor to secure medical care from other sources, it 
was asserted. 
In the few counties in which plans for payment of 
physicians were operating*, the heads of households were 
expected to receive authorization from the county welfare 
department before calling a physician. In emergencies 
occurring on Sundays and holidays, the head of the house- 
hold was permitted to call the physician directly. 
Financial Provisions for Medical Care 
The budget of the State and county welfare departments 
for the year 1942 will be found in Table 43, page 53- The 
total, which included expenditures both in the counties 
and in Baltimore City, was $10,880,783- Of this amount, 
$3,048,913, or 28.0 percent, was allocated for Aid to 
Dependent Children; $4,192,636, or 38.5 percent, for Old 
Age Assistance; $193,676, or 1.8 percent, for Public Aid 
to Needy Blind; $2,202,422, or 20.2 percent, for General 
Public Assistance; while $1,243,136, or 11.4 percent, was 
estimated as administrative costs. 
The number of households receiving assistance from the 
various categories of assistance in the counties of Maryland 
has been shown in Table 44, page 54. The total households 
assisted in Baltimore City was 15,313, while in the total 
counties, it was 14,303- It will be observed that in Baltimore 
City the number in General Public Assistance alone and 
in combination with other categories was 6,745, or more 
than three times greater than in the total counties in 
which there was a total of 1,903- On the other hand, the 
number of households in the total counties was signifi- 
cantly greater in the categories of Old Age Assistance and 
in Aid to Dependent Children. 
Expenditures for Medical Care 
Since a tabulation of expenditures for medical care for 
the year 1940 was not available, attempts were made in 
several county welfare departments to determine the 
proportion devoted to that purpose. At least one hundred 
records were studied only to find that in about one quarter 
of the cases the expenditures for medical care were not 
itemized, but combined with other items. It was also 
found that it would be exceedingly difficult, if not im- 
possible, to obtain precise information upon this point, 
which was regarded as a very important one in relation 
to the subject of this report. 
BUDGET OF THE STATE AND COUNTY WELFARE DEPARTMENTS 
FOR THE STATE OF MARYLAND FOR THE YEAR 1942. 
TABLE 43 
Categories of Assistance 
Total 
Percent 
of 
Total 
(a) Classified (i) Aid to Dependent 
Children 
$ 3,048,913 
28.0 
(ii) Old Age Assistance 
4,192,636 
38.5 
(iii) Public Aid to Needy 
Blind 
193,676 
1.8 
(b) General (i) General Public 
Assistance 
2,202,422 
20.2 
(c) Administration 
(i) State Department 
160,357 
1.5 
(ii) Local Units 
1,082,779 
9.9 
Total 
$10,880,783 
100.0 
The financial provisions for medical care for recipients 
of relief were said to be limited by the Federal Social 
Security Law, which charged the State and county welfare 
departments with the duty of providing the “minimum 
subsistence compatible with decency and health’’. Because 
*A11 specific authorization for medical care has since been discontinued in 
Social Security categories, because of Federal objection. Medical Care in the Counties of Maryland 
of legal and financial limitations, welfare executives were 
forced to regard medical care as one of the necessities of 
life beyond the purview of their program. 
Agreements for Procuring Medical Care 
So far as could be determined, no clearly defined State- 
wide policy had been formulated for securing medical care. 
Responsibility for establishing procedures was placed on 
the shoulders of the county welfare departments. As a 
preliminary step most county welfare executives attempted 
to secure a formal agreement with the county medical 
society and the county health department. The extent to 
which such arrangements could be reached depended in no 
small measure upon the usual working relationships with 
these organizations. In Anne Arundel, Garrett and Wash- 
ington counties agreements were effected. In Anne Arundel 
County the county medical and dental societies and the 
local hospital participated as well as the county health 
department. In these counties a committee representing 
each participating group met at appropriate intervals and, 
whenever possible, adjusted difficulties arising in connec- 
tion with the operation of the agreements. In one of the 
counties the plan functioned for about three months, in 
another for approximately six months, and in Anne Arundel 
County the agreement was still in operation at the con- 
clusion of the field survey on September 15, 1941. 
The county welfare executives in twenty counties 
declared that after it was found that formal agreements 
with the organized medical profession and other health 
agencies could not be obtained, informal arrangements 
were sometimes made with individual physicians. Welfare 
executives stated that, in general, they relied principally 
upon the cooperation of a relatively small number of 
physicians and dentists who always could be depended 
upon to respond to calls for assistance. 
Plans for Payment 
A summary of plans developed by the county welfare 
departments to compensate physicians for medical care in 
the home will be found in Table 45, page 56. It will be 
noted that two general methods of financing medical care 
were employed, either singly or in combination: 
(1) A fixed sum, varying from 50c to $3-50 per family 
was allotted each month for medical service. 
TABLE 44 
UNDUPLICATED NUMBER OF HOUSEHOLDS RECEIVING ASSISTANCE FROM THE VARIOUS CATEGORIES OF 
ASSISTANCE IN THE COUNTIES OF MARYLAND IN JUNE, 1940. 
County 
Total 
OAA 
Only 
ADC 
Only 
PANE 
Only 
GPA 
Only 
Various 
Combina- 
tions of 
OAA, ADC 
and PANE 
GPA 
and 
Other 
State of Maryland 
29,616 
16,097 
3,978 
579 
5,598 
314 
3,050 
Baltimore City 
15,313 
6,871 
1,243 
348 
4,113 
106 
2,632 
Total Counties 
14,303 
9,226 
2,735 
231 
1,485 
208 
418 
Percent 
100% 
64.5% 
19.1% 
1.6% 
10.4% 
1-5% 
2-9% 
Allegany 
1,288 
696 
244 
24 
184 
18 
122 
Anne Arundel 
605 
369 
126 
14 
71 
10 
15 
Baltimore 
1,049 
768 
136 
20 
44 
10 
71 
Calvert 
229 
149 
44 
2 
31 
2 
1 
Caroline 
464 
341 
73 
8 
35 
6 
1 
Carroll 
468 
345 
46 
6 
59 
3 
9 
Cecil 
554 
339 
118 
10 
54 
9 
24 
Charles 
335 
227 
76 
5 
24 
3 
— 
Dorchester 
717 
541 
91 
13 
54 
13 
5 
Frederick 
745 
445 
201 
12 
70 
8 
9 
Garrett 
583 
336 
105 
7 
124 
5 
6 
Harford 
523 
361 
62 
5 
80 
4 
11 
Howard 
307 
219 
53 
2 
28 
4 
1 
Kent 
281 
209 
29 
11 
24 
3 
5 
Montgomery 
709 
420 
148 
14 
96 
14 
17 
Prince George’s 
749 
408 
144 
9 
117 
18 
53 
Queen Anne’s 
400 
287 
69 
8 
23 
9 
4 
Saint Mary’s 
384 
222 
122 
2 
34 
4 
— 
Somerset 
637 
397 
182 
13 
38 
3 
4 
Talbot 
412 
343 
38 
7 
21 
3 
— 
Washington 
1,378 
773 
316 
25 
191 
21 
52 
Wicomico 
1,000 
657 
224 
7 
82 
22 
8 
Worcester 
486 
374 
88 
7 
1 
16 
— Health Department Services 
The amount was added to the monthly check 
received from the welfare department. It was ex- 
pected that each monthly allotment would be saved 
for use in a medical emergency. 
(2) The monthly check of the family was supplemented 
by the amount of a specified medical obligation 
incurred within the month. If the total were more 
than was available in the surplus funds of the county 
welfare department for that month, payment of the 
obligation was pro-rated over a number of months. 
The first method was used in Allegany County where 
$1.00 per month was allocated to the family and no other 
funds were available. It also constituted the principal form 
of payment in St. Mary’s County. With some variations 
this procedure formerly was used in Calvert, Cecil and 
Worcester counties. 
In St. Mary’s County a “pool’’ was organized by the 
county welfare department. One dollar was collected each 
month from recipients of relief. These amounts were pooled 
and physicians paid therefrom for services rendered the 
participating families. This plan operated for a few months 
and, it was reported, seemed to be going well when it was 
found the county welfare departments were not permitted 
to conduct such an activity and, therefore, it was dis- 
continued. 
In the remaining counties the second method of financing 
medical care, that of supplementing the monthly check, 
was employed. 
Financial Arrangements with Physicians 
The head of the household was encouraged to make 
arrangements for medical care directly with the physicians, 
because it was desired that the former should learn to 
manage his own financial affairs and also because it was 
found that an indigent individual usually was able to 
make a “better bargain’’ with physicians than the county 
welfare department. When agreement as to the probable 
cost of treatment had been reached between the head of 
the household and the physician, the county welfare de- 
partment was so informed. If the expense involved was 
found to be greater than the amount that might “properly 
be allocated’’ for the purpose, or if the funds of the county 
welfare department were low, the physician was requested 
by the welfare executive to reduce his fee. The limit of the 
amount that might “properly be allocated’’ seemed to be 
left to the discretion of the welfare worker since, so far as 
could be determined, no standard had been set. 
In several counties when the monthly check was increased 
to provide for settlement of a specific medical obligation, 
the physician was informed, as a matter of courtesy. This 
was as far as county welfare departments appeared to have 
gone in aiding in the payment of bills. Many executives 
stoutly maintained that a county welfare department was 
not a collecting agency. Welfare executives also expressed 
the belief that physicians seldom had difficulty in making 
collections if serious attempts were made to do so, and 
that among those receiving assistance the proportion of 
persons who paid their bills was no less than among the 
general population. 
Physicians’ Fees 
Physicians’ fees were practically the same in all rural 
areas; office visits, $1.00; home calls $2.00 within three 
miles of the office, and a minimum of $3-00 when the 
distance was greater. In towns over 10,000 population, the 
fees were higher. The cost of obstetrical services varied from 
$10.00 to $25-00 and included, as a rule, delivery and one 
or two post-natal calls. 
Opinions on the Availability of Medical Care 
Each executive was asked the question, “Are there 
persons in the county who, because of lack of sufficient 
funds, are unable at times to obtain medical care?’’ In the 
twenty counties the answer was “Yes”. In twelve of these 
the executives asserted that many persons with chronic 
illnesses were at time unable to obtain medical care, while 
more than a few with acute illnesses also were in that 
category. In eight counties the executives were of the 
opinion that only a relatively small number of persons 
were unable eventually to secure medical attention. 
In all of the twenty-three counties the welfare executives 
expressed the opinion that there was a considerable number 
of persons who, because of lack of money or credit, some- 
times delayed calling a physician even past the danger 
point. 
Medical Care Problems Outlined by Welfare 
Executives 
All welfare executives declared that the problem of 
securing adequate medical care for those receiving assistance 
was one of the most difficult and important extant. The 
following specific deficiencies were presented, with sug- 
gestions as to their correction: 
1. A general lack of understanding of relief problems on the part 
of local physicians and a few county health departments. 
Most executives agreed that, so far as the physicians 
were concerned, adjustment of fees and a change in the 
method of paying them undoubtedly would go far in reach- 
ing a solution of this problem. 
2. A lack of adequate diagnostic and treatment facilities in the 
county health departments. 
In twelve counties this defect was repeatedly mentioned. 
Services specifically requested included general medical and 
surgical clinics, mental hygiene clinics and dental clinics— 
particularly for dental treatment of adults. Medical Care in the Counties of Maryland 
56 
3. The absence of hospital facilities for treatment of the 
chronically ill. 
The erection of a hospital or, if necessary, a number of 
institutions for treatment of the chronically ill was strongly 
advocated. 
4. The absence of any kind of bedside nursing service. 
In six of the counties, executives pointed out that the 
lack of visiting nurses and “practical” nurses for home care 
of patients was a serious deficiency. If such services were 
available, suffering of many patients, in the opinion of the 
executives would be alleviated and recovery hastened. 
5. A lack of adequate medical care for the low income group. 
Many executives expressed the belief that in addition to 
those now receiving assistance, there were numerous others 
in the low income group who were suffering for lack of 
adequate medical care. Particular reference was made to 
those who were “too proud to accept anything that might 
be regarded as charity and preferred to continue to suffer 
in relative silence”. In several counties, a fairly large 
proportion of the population—sharecroppers, farmhands, 
fishermen and the like—received wages that barely were 
sufficient to purchase the absolute necessities of life. The 
welfare departments were not permitted to assist persons 
TABLE 45 
SUMMARY OF PROCEDURES USED BY COUNTY WELFARE DEPARTMENTS TO COMPENSATE PHYSICIANS FOR 
MEDICAL CARE IN THE HOME 
Counties 
of 
Maryland 
Amounts Added Each 
Month to Family Check 
Amounts Added to Family 
Check Only After Illness 
Developed 
Talbot 
$0.50 per person in family to maximum of $3.50 
Amount agreed upon by physician, patient, and 
welfare executive.* 
St. Mary’s 
$1.00 Minimum and $2.00 maximum depending 
on size of family 
None 
Garrett 
$1.00 
Amount agreed upon by physician, patient, and 
welfare executive.* 
Frederick 
$0.50 
Amount agreed upon by physician, patient, and 
welfare executive.* 
Allegany 
$1.00 
None 
Anne Arundel 
Calvert 
Caroline 
Carroll 
Dorchester 
Queen Anne’s 
Somerset 
Wicomico 
Worcester 
None 
Amount agreed upon by physician, patient, and 
welfare executive.* 
Cecil 
Charles 
Harford 
Howard 
Prince George’s 
Kent* 
None 
In acute case, amount agreed upon by physician, 
patient, and welfare executive.* 
In chronic cases, amount varied with doctor’s 
statement of need. 
Baltimore 
None 
None 
*In most counties the total amount of the bill was pro-rated over a period of months so that the “legal limits” of the clients, budget would 
not be exceeded Health Department Services 
57 
in this class since their incomes were regarded as being 
slightly above “the minimum compatible with decency 
and health”. 
Suggested Solutions for Problems 
In thirteen counties welfare executives favored the 
development of a “well-controlled plan” for public pay- 
ment for medical care. In four counties, it was felt that the 
present plan was operating satisfactorily. In the remainder, 
no comments were elicited. Of those who ventured an 
opinion on this subject, twelve favored a cooperative 
program between the county welfare and county health 
departments. One suggested the formation of a new or- 
ganization. All except two expressed the belief that the 
benefits of such a plan also should be extended to families 
in the low income brackets. Under any plan, welfare 
executives believed that those receiving assistance should 
always, “within reason”, have the right to choose their 
own physician. 
All except two of the twenty-three executives believed 
that physicians should receive the same fees for the treat- 
ment of recipients of relief as for private patients. 
Summary 
The categories of assistance for indigent persons included: 
Aid to Dependent Children, Old Age Assistance, Public 
Aid to Needy Blind, and General Public Assistance. Except 
for Public Aid to Needy Blind, there were no uniform 
provisions for physical examinations for determination of 
eligibility for relief or for compensation of the examiners. 
Important and urgent needs outlined by county welfare 
executives included: an organized bedside visiting nurses 
service, a central hospital admitting service, a larger 
number of hospital beds for normal obstetrical cases, 
general medical and surgical clinics in county health 
departments, dental clinics for indigent adults. 
It was found that recipients of relief had free choice of 
physicians. 
For the year 1942, the total budget of the State and 
county welfare departments was $10,880,783, of which 
28.0 percent was allocated for Aid to Dependent Children, 
38.5 percent for Old Age Assistance, 1.8 percent for Public 
Aid to the Needy Blind, 20.2 percent for General Public 
Assistance, and 11.4 percent for Administration. 
An accurate estimate of the proportion spent for medical 
care could not be obtained. 
A total of 14,303 households received assistance of which 
64-5 percent were in Old Age Assistance, 19.1 percent were 
in Aid to Dependent Children, 1.6 percent in Public Aid to 
Needy Blind, 10.4 percent in General Public Assistance, 
and 2.9 percent in a combination of General Public As- 
sistance and other categories. 
There did not appear to be a well-defined State-wide 
policy for procuring medical care for those receiving • 
assistance. 
In each of three counties, formal agreements for pro- 
viding medical care for indigent patients were reached 
between the county welfare department, the county medical 
and county dental societies and the county health depart- 
ment. In only one of these did the agreement continue 
to function for more than six months. In other counties 
the county welfare executives sometimes made informal 
agreements with individual physicians. 
Two general methods of financing medical care were 
employed either alone or in combination (a) an amount 
ranging from $0.50 to $3-50 per family was added to the 
monthly check, with the expectation that it would be 
“saved” to pay for emergency medical services, and (b) 
the monthly check was augmented, whenever sufficient 
funds were on hand, to pay for a specific medical obligation. 
Heads of households were encouraged to make their own 
financial arrangements with physicians. 
In rural areas, physicians’ fees, as a rule, were $1.00 for 
office calls, $2.00 for home calls under 3 miles, and a 
minimum of $3-00 for greater distances. Charges for ob- 
stetrical cases varied between $10.00 and $25-00 per case. 
Twenty welfare executives stated that there were persons 
in their respective counties who, because of lack of sufficient 
funds, were unable at times to obtain medical care. Twelve 
executives asserted that many persons with chronic illness 
were at times unable to obtain medical services. 
In all 23 counties, welfare executives believed that there 
was a considerable number of persons who, because of lack 
of money or credit, sometimes delayed calling a physician 
even past the danger point. 
Welfare executives, cognizant of the need for expanding 
medical services not only for the benefit of those receiving 
assistance, but for the marginal income group, suggested 
the following procedures (a) the adjustment of physicians’ 
and dentists’ fees and a change in the method of paying 
them, (b) expansion of the diagnostic and treatment 
facilities in the county health department, especially the 
establishment of general medical and surgical clinics and 
dental clinics, particularly for the treatment of adults, 
(c) the erection of chronic disease hospitals, (d) the or- 
ganization of a bedside nursing service. 
Twenty-one executives expressed the opinion that 
physicians should receive the same fees for treatment of 
recipients of relief as for private patients. 
Welfare executives favored the retention of the right of 
those receiving assistance to select their own physician, 
and to negotiate with him directly both in seeking and 
paying for professional services. Chapter IX 
THE SCOPE AND COSTS OF A MEDICAL CARE PROGRAM 
In a program for medical care the following are basic 
considerations: 
1. The number of beneficiaries 
2. The frequency of illness and the volume of medical 
care 
3. The character of the medical services 
4. The costs of operation 
1. THE NUMBER OF BENEFICIARIES 
{a) The Number of Indigent in the Counties in 1940 
(i) The number receiving assistance 
The households receiving assistance from the county 
welfare departments in 1940 included only those in which 
none was employable, that is to say, that there was no 
individual who was physically fit and between 17 and 65 
years of age. 
In Table 46, page 59, it will be noted that there were 
14,303 households and 50,060 individuals receiving as- 
sistance, assuming that there was an average of 3-5 persons 
per household. The number of individuals varied from 
801 in Calvert to 4,823 in Washington County, with a 
rate of 23-6 per 1,000 population in Baltimore and 106.4 
in Somerset County. For the total counties the rate was 
52.0 persons per 1,000 population. 
(li) The number employed by the W. P. A. 
In 1940 in indigent families in which there were one or 
more employable persons, work was usually provided for 
at least one of them by the Works Projects Administration, 
a Federal works agency, in which the worker received 
approximately $45-00 per month. From this amount the 
family was expected to pay all living expenses, including 
those for medical care. With a total income of about 
$540 per year, such medical care as could have been paid 
for, if any, must have been strictly limited to acute 
emergencies. 
In the total counties the number of persons employed 
and awaiting employment in the W.P.A. during the week 
of June 19, 1940, was 9,333, representing an estimated total 
of 32,666 individuals. In Kent and Calvert counties there 
were no persons in this group, as shown in Table 47, page 
60. In Baltimore and Talbot counties 98 individuals were 
represented, while there were as high as 8,694 persons in 
Allegany County. The rate per 1,000 population, except 
in Kent and Calvert counties, ranged from 0.6 in Baltimore 
to 124.7 in Garrett County. For the total counties the rate 
was 33-9 persons per 1,000 population. 
(iii) The total receiving assistance and employed by the 
W.P.A. 
For all counties a total of 82,726 individuals received 
assistance and were represented in the W.P.A. group, of 
whom 801 were in Calvert and 13,202 in Allegany County, 
as will be seen in Table 48, page 61. The rate was 24.2 
in Baltimore and 217-5 per 1,000 population in Garrett 
County. For the total counties the rate was 86.0 per 1,000 
population. The above data may be summarized as follows: 
Households 
Individuals 
Number 
Per 1,000 
Population 
Direct relief 
14,303 
50,060 
52.0 
W. P. A. employees 
9,333 
32,666 
34.0 
Total 
23,636 
82,726 
86.0 
In estimating the total number of individuals that should 
be provided for in a partly or wholly tax-supported program 
for medical care, it is taken for granted that both the 
above groups should be included1. 
Classification of Counties 
The proportion of the population which has been 
supported wholly or partially by tax funds has varied from 
year to year, reaching a peak in 1940. The distribution of 
82,726 individuals in this class in that year is shown in 
Table 49, page 61, by counties arranged in order of magni- 
tude. It will be observed that the counties have been 
divided into three groups in which the total indigent 
varies from (a) 0-2,499, (b) 2,500 to 4,999, and (c) 5,000 
individuals or more. It is obvious that the frequency of 
illness and the volume of medical care as well as other 
factors vary with the number of persons involved. In the 
remainder of this Chapter, therefore, the counties will be 
classified in these three groups. 
JIn 1940, the Civilian Conservation Corps, another Federal works agency, 
provided employment in a number of counties of Maryland for 2,427 youths 
from 17 to 23 years of age. A large proportion of the wages of these youths 
augmented the income of a family receiving assistance or one in which 
another member was employed by the W.P.A. These individuals were not 
included in the total for whom medical care should be provided, because 
in most instances, if not all, they had already been counted. The Scope and Costs of a Medical Care Program 
59 
The Medically Indigent Not Included in 
Calculations 
An indigent person has been defined as a member of a 
household receiving or eligible to receive assistance from 
a county welfare department, while a medically indigent 
individual is one who is able to pay the cost of occasional 
minor illness, but unable to pay expenses involved in a 
severe or prolonged disability. 
It has been repeatedly brought to the attention of the 
Committee by many persons in the counties of Maryland 
that in any plan for medical care provision should be made 
for assisting not only the indigent, but also the medically 
indigent ... “a good, hard-working man with a family 
who ordinarily pays his bills but who is overwhelmed 
when overtaken by illness in himself or in his family.” 
In calculating the number of beneficiaries in a medical 
care program for the Counties of Maryland, persons of this 
type have not been included because no acceptable estimate 
of their number is at present available. 
The Committee believes that information of this type 
for the counties of Maryland could best be obtained by 
a more detailed survey, or by trial of a program including 
provisions for the medically indigent in one or more 
counties or even on a State-wide basis. 
Calculations upon which the program is based included 
the estimated medical needs of an entire population. In 
Maryland it is proposed that only the indigent would be 
served. At first, the latter might not and probably would 
not use all services for which provision has been made. 
Furthermore, it would be impracticable to set up a complete 
system within a year or two. If the total recommended 
appropriations were made, the balance during the first 
biennium could be utilized for care of the medically in- 
digent, or at least for obtaining estimates of their 
distribution. 
I 
2. THE FREQUENCY OF ILLNESS AND VOLUME OF 
MEDICAL CARE 
The frequency of illness and the volume of medical care 
were recorded by Collins1 for a twelve-month period 
between 1928 and 1931 by periodic canvasses of 8,758 
white families in 130 localities in 18 states. Illnesses causing 
symptoms that lasted one day or longer were recorded, 
together with the number of doctor’s calls on the case. 
The surveyed families included representation from all 
geographic sections, from rural, urban, and metropolitan 
areas, from all income classes, and both native and foreign 
born persons. 
The recorded illness from all causes amounted to 829 
cases per 1,000 persons. Of the total cases, 79 percent were 
attended by some type of practitioner, a rate of 647 at- 
tended cases per 1,000 population. On this basis, among the- 
82,726 individuals in the counties of Maryland for whom 
a medical care program is outlined, there would have been 
68,580 cases of recorded illness, of which 53,524 would 
have been attended by some type of physician. 
In Collins’ series, 526 attended cases per 1,000 were 
treated by physicians in general practice. In the Maryland 
group, therefore, a total of 43,514 cases would have been 
attended by general practitioners, assuming that the 
indigent patients would request and receive all the medical 
care for which the majority of the population were able 
to pay. The distribution of the theoretical number of 
attended cases in the counties of Maryland is shown in 
Table 50, page 62. 
Collins found that there were 4.6 calls by all practitioners 
per attended case with a total of 2,949 calls during the year 
per 1,000 canvassed population. It was observed that the 
volume of medical care in terms of doctors’ calls per 1,000 
population was greater in large cities than in small towns 
and rural areas. In calculating the theoretical number of 
TABLE 46 
TOTAL HOUSEHOLDS AND ESTIMATED NUMBER OF INDIVIDUALS 
RECEIVING ASSISTANCE ASSUMING THAT THE AVERAGE WAS 
3.5 PERSONS PER FAMILY; AND THE NUMBER PER 1,000 
POPULATION IN THE COUNTY OF RESIDENCE IN 
JUNE, 1940 
County 
Total 
Households 
Receiving 
Assistance 
Estimated 
Number of 
Persons Receiv- 
ing Assistance 
(1) x 3.5 
Number 
per 1,000 
Population 
in County 
of Residence 
Baltimore 
1,049 
3,672 
23.6 
Prince George’s 
749 
2,621 
29.3 
Montgomery 
709 
2,482 
29.6 
Anne Arundel 
605 
2,117 
31.0 
Carroll 
468 
1,638 
42.0 
Frederick 
745 
2,608 
45.5 
Allegany 
1,288 
4,508 
51.9 
Harford 
523 
1,830 
52.2 
Howard 
307 
1,075 
62.6 
Charles 
335 
1,172 
66.6 
Washington 
1,378 
4,823 
70.1 
Kent 
281 
984 
73.1 
Cecil 
554 
1,939 
73.4 
Calvert 
229 
801 
76.5 
Talbot 
412 
1,442 
76.8 
Worcester 
486 
1,701 
80.1 
Dorchester 
717 
2,510 
89.6 
Saint Mary’s 
384 
1,344 
91.9 
Caroline 
464 
1,624 
92.5 
Garrett 
583 
2,040 
92.9 
Queen Anne’s 
400 
1,400 
96.7 
Wicomico 
1,000 
3,500 
101.4 
Somerset 
637 
2,229 
106.4 
Total Counties 
14,303 
50,060 
52.0 
Collins, Selwyn D.: Frequence and Volume of Doctors’ Calls Among 
Males and Females in 9,000 Families Based on Nation-wide Periodic Can- 
vasses, 1928-31, Pub. Health Rep., 55:1977-2020 (Nov. 1, 1940) (Reprint 
2205). 60 
Medical Care in the Counties of Maryland 
calls per case in the counties of Maryland, the figure 4.0 
rather than 4.6 calls per attended case was used, since there 
were no large cities in that area. It is thought that the use 
of even a smaller ratio might be justifiable. 
With the estimated total of 43,514 cases attended by 
private practitioners, the total number of calls, therefore, 
would have been 174,056. In Table 50, page 62, the 
number of calls by private practitioners has been calculated 
by counties. 
Distribution of Calls 
In a study by Ciocco and Altman1 the average weekly 
patient load of white male practitioners was indicated for 
Maryland, exclusive of Baltimore City. From these data, 
it was estimated that the physicians’ services were dis- 
tributed as follows: 
Office calls -73% 
Hospital calls 5% 
Home calls 22% 
In Table 51, page 63, the distribution of 174,056 calls 
of general practitioners has been calculated on the above 
basis. It will be noted that 127,059 are office calls, 8,704 
are hospital calls, and 38,293 are home calls. 
Cases Attending Clinics 
Of the 53,524 cases that would be attended by some type 
of medical practitioner, it was estimated that 43,514 cases 
would receive treatment from general practitioners. In the 
suggested plan it is contemplated that clinics would be 
staffed by specialists, and that treatment by physicians 
not general practitioners would be limited to that received 
in clinics and in hospitals. It is clear, therefore, that the 
remainder, 10,010 cases, represents the number that, under 
the plan, would be expected to attend clinics. With an 
estimated average of 5 clinic calls per case, there would 
be a total of 50,050 clinic calls per year. In Table 52 
page 64, the distribution of the estimated clinic cases and 
calls has been shown by counties. 
3. THE CHARACTER OF MEDICAL SERVICES 
NEEDED 
The following medical and dental services and equipment 
are regarded as the minimum essential to the mainte- 
nance of a program of medical care for the indigent in the 
counties of Maryland; 
1. Private Physicians 
(a) General Practitioners 
(b) Clinicians 
(c) Consultants 
2. Hospitals 
(a) General 
(b) Chronic Disease 
3. Health Departments 
(a) Clinic Space and Equipment 
(b) Visiting Nurses 
(c) Dentists 
(d) Clinical Laboratories 
4. Administration 
(a) State 
(b) County 
1. Private Practitioners Services 
(a) General Practitioners 
In a number of cities and counties throughout the United 
States full and part-time physicians are employed by local 
governments to treat the indigent in their homes and in 
offices—usually located in the city or county health de- 
TABLE 47 
TOTAL PERSONS EMPLOYED AND AWAITING EMPLOYMENT IN THE 
WORKS PROJECTS ADMINISTRATION IN THE COUNTIES OF 
MARYLAND FOR THE WEEK ENDING JUNE 19, 1940, THE 
ESTIMATED NUMBER OF INDIVIDUALS IN THE HOUSE- 
HOLDS—ASSUMING THAT FOR EACH PERSON EM- 
PLOYED THE NUMBER IN EACH HOUSEHOLD 
AVERAGE 3.5 PERSONS; AND THE NUMBER 
PER 1,000 POPULATION IN COUNTY OF 
RESIDENCE, BY RANK. 
County 
Total Employed 
and Awaiting 
Employment in 
in the W.P.A. 
(Week of 
June 19, 1940) 
Total Individuals 
Represented 
(Average 3.5 Per 
Person 
Employed) 
Number per 
1,000 Popula- 
tion in County 
of Residence 
Kent 
None 
Calvert 
None 
— 
— 
Baltimore 
28 
98 
.6 
Montgomery 
<•' 130 
455 
5.4 
Talbot 
28 
98 
5.2 
Carroll 
142 
497 
12.7 
Cecil 
127 
444 
16.8 
Charles 
85 
298 
16.9 
Prince George’s 
496 
1,736 
19.4 
Anne Arundel 
390 
1,365 
20.0 
Howard 
134 
469 
27.3 
Dorchester 
220 
770 
27.5 
Harford 
290 
1,015 
29.0 
Caroline 
146 
511 
29.1 
Worcester 
177 
620 
29.2 
Queen Anne’s 
122 
427 
29.5 
Saint Mary’s 
128 
448 
30.6 
Somerset 
213 
746 
35.6 
Wicomico 
367 
1,285 
37.2 
Frederick 
1,140 
3,990 
69.6 
Washington 
1,703 
5,960 
86.6 
Allegany 
2,484 
8,694 
100.2 
Garrett 
783 
2,740 
124.7 
TOTAL 
9,333 
32,666 
33.9 
Antonio and Altman, Isador: Statistics on the Patient Load of 
Physicians in Private Practice, J. A.M.A. 121:506-513 (February 13) 1943- The Scope and Costs of a Medical Care Program 
61 
partment. In areas in this vicinity1 in which this type of 
service was investigated a full-time physician seemed to 
be able to serve fairly adequately the emergency medical 
needs of the indigent. If, however, the population were 
large and the area extensive, one physician or even several 
physicians were unable at times to provide adequate 
emergency service. Moreover, the special services which 
occupy such an important place in modern medical practice, 
were not provided except to a very limited extent. We have 
not found a single instance in which a part-time physician 
has been able to render a significant amount of medical 
care for the indigent and at the same time earn a livelihood 
in the private practice of medicine. To provide adequate 
treatment, particularly in rural and semi-rural areas which 
predominate in the counties of Maryland, it seems essential 
that all or nearly all physicians in private practice should 
participate in the program. 
It is held that each family should have the privilege of 
selecting its own physician, and conversely, that practi- 
tioners should be privileged to decide whether or not they 
will accept a case. 
(b} Clinicians 
Under the suggested plan, the large majority of patients 
would receive medical care in their own homes and in the 
doctors’ offices. For ambulatory patients, and particularly 
for obscure and difficult cases, clinics, staffed by specialists, 
should be established in the county seat, and possibly in 
other locations. In these clinics physical examinations of 
applicants for relief and other activities related to the 
medical care program might also be conducted. 
It is essential that these physicians in charge of clinics 
should be specialists in their field and that they be selected 
with the greatest care by competent medical authorities. 
Whenever properly qualified clinicians are available 
locally their services should be utilized, otherwise it would 
be necessary to obtain clinicians from the nearest medical 
center. 
TABLE 49 
THE TOTAL NUMBER OF INDIVIDUALS RECEIVING ASSISTANCE 
FROM COUNTY WELFARE DEPARTMENTS AND THOSE IN FAM- 
ILIES IN WHICH THE HEAD OF HOUSEHOLD OR ONE OF ITS 
MEMBERS WAS EMPLOYED IN THE W.P.A.; AND THE 
NUMBER PER 1,000 POPULATION IN THE COUNTY 
OF RESIDENCE. 
TABLE 48 
ESTIMATED NUMBER OF INDIVIDUALS RECEIVING ASSISTANCE 
FROM COUNTY WELFARE DEPARTMENTS AND PERSONS IN 
HOUSEHOLDS IN WHICH ONE OF THE MEMBERS WAS EM- 
PLOYED BY THE W.P.A., TOGETHER WITH THE TOTAL 
AND NUMBER PER 1,000 POPULATION IN THE COUN- 
TIES OF RESIDENCE. 
Total 
Indigent 
Persons 
County 
Persons Receiving 
Assistance and in 
Households in Which Head 
or Other Member was 
Employed by the W.P.A. 
(June 19, 1940) 
Number 
Per 1,000 
Population 
Calvert 
801 
76.5 
Kent 
984 
73.1 
Charles 
1,470 
83.5 
Talbot 
1,540 
82.0 
Howard 
1,544 
89.9 
0-2,499 
Saint Mary’s 
1,792 
122.5 
Queen Anne’s 
1,827 
126.2 
Caroline 
2,135 
121.7 
Carroll 
2,135 
54.7 
Worcester 
2,321 
109.2 
Cecil 
2,383 
90.2 
Harford 
2,845 
81.2 
Montgomery 
2,937 
35.0 
Somerset 
2,975 
141.9 
Dorchester 
3,280 
117.1 
2,500-4,999 
Anne Arundel 
3,482 
50.9 
Baltimore 
3,770 
24.2 
Prince George’s 
4,357 
48.9 
Garrett 
4,780 
217.5 
Wicomico 
4,785 
138.6 
Frederick 
6,598 
115.1 
5,000 & Over 
Washington 
10,783 
156.6 
Allegany 
13,202 
152.1 
Total 
82,726 
86.0 
County 
Estimated 
Number of 
Individuals 
Receiving 
Assistance 
(1940) 
Estimated 
Number of 
Individuals 
in WPA 
Households 
(1940) 
Total 
Individuals 
Number 
Per 
1,000 
Population 
Baltimore 
3,672 
98 
3,770 
24.2 
Montgomery 
2,482 
455 
2,937 
35.0 
Prince George’s 
2,621 
1,736 
4,357 
48.9 
Anne Arundel 
2,117 
1,365 
3,482 
50.9 
Carroll 
1,638 
497 
2,135 
54.7 
Kent 
984 
None 
984 
73.1 
Calvert 
801 
None 
801 
76.5 
Harford 
1,830 
1,015 
2,845 
81.2 
Talbot 
1,442 
98 
1,540 
82.0 
Charles 
1,172 
298 
1,470 
83.5 
Howard 
1,075 
469 
1,544 
89.9 
Cecil 
1,939 
444 
2,383 
90.2 
Worcester 
1,701 
620 
2,321 
109.2 
Frederick 
2,608 
3,990 
6,598 
115.1 
Dorchester 
2,510 
770 
3,280 
117.1 
Caroline 
1,624 
511 
2,135 
121.7 
Saint Mary’s 
1,344 
448 
1,792 
122.5 
Queen Anne’s 
1,400 
427 
1,827 
126.2 
Wicomico 
3,500 
1,285 
4,785 
138.6 
Somerset 
2,229 
746 
2,975 
141.9 
Allegany 
4,508 
8,694 
13,202 
152.1 
Washington 
4,823 
5,960 
10,783 
156.6 
Garrett 
2.040 
2,740 
4,780 
217.5 
Total 
50,060 
32,666 
82,726 
86.0 
JIn the States of Virginia and North Carolina Medical Care in the Counties of Maryland 
Department of Health. In 23 counties in 1940 a total of 
68 clinics, or an average of 3 per county, was operated at 
least once each week. These clinics were staffed by 62 
physicians, almost all of whom were private practitioners 
who had taken a special interest in the treatment of this 
type of disease. Approximately 9,000 persons were admitted 
for diagnosis and/or treatment, and over 83,000 treatments 
were given. 
(ii) Orthopedic Clinics were conducted by the State 
Department of Health in nearly every county. Over 2,300 
physically handicapped children were treated in 1940. 
(iii) Tuberculosis Clinics conducted in most of the counties 
by the Maryland Tuberculosis Association, in cooperation 
with the State and County Health Departments. In 1940 
over 5,700 persons were examined at the monthly chest 
clinics. 
Types of Clinics 
The following types of clinics should be provided in 
each county: 
(i) Internal Medicine 
(ii) Surgery 
(iii) Obstetrics and Gynecology 
(iv) Pediatrics 
(v) Ophthalmology and Otorhinolaryngology 
Clinic Services Now Functioning 
It is taken for granted that the following clinics, estab- 
lished and maintained by the State Department of Health 
and other agencies would be continued: 
(i) Venereal Disease Clinics conducted by the State 
TABLE 50 
THE TOTAL INDIVIDUALS RECEIVING ASSISTANCE AND THOSE IN FAMILIES IN WHICH AT LEAST ONE MEMBER 
WAS EMPLOYED BY THE W.P.A.; THE ESTIMATED NUMBER OF CASES ATTENDED BY A GENERAL PRACTI- 
TIONER ANNUALLY, ON THE ASSUMPTION THAT THERE WERE 526 CASES PER 1,000 POPULATION; 
AND THE ESTIMATED NUMBER OF CALLS MADE BY PHYSICIANS IN GENERAL PRACTICE, 
ASSUMING THAT THERE WERE 4.0 CALLS PER CASE. 
County 
Total Persons 
Receiving 
Assistance 
and Those in 
Families in 
Which One 
Member was 
Employed by 
the W. P. A. 
Estimated 
Number of 
Cases 
Attended 
by General 
Practitioners 
(526 Cases 
per 1,000 
Population) 
Estimated 
Number of 
Calls by 
General 
Practitioners 
(4.0 Calls 
per Attended 
Case) 
Calvert 
801 
421 
1,684 
Kent 
984 
518 
2,072 
Charles 
1,470 
773 
3,092 
Talbot 
1,540 
810 
3,240 
Howard 
1,544 
812 
3,248 
0-2,499 
Saint Mary’s 
1,792 
943 
3,772 
Queen Anne’s 
1,827 
961 
3,844 
Caroline 
2,135 
1,123 
4,492 
Carroll 
2,135 
1,123 
4,492 
Worcester 
2,321 
1,220 
4,880 
Cecil 
2,383 
1,253 
5,012 
Harford 
2,845 
1,496 
5,984 
Montgomery 
2,937 
1,546 
6,184 
Somerset 
2,975 
1,565 
6,260 
Dorchester 
3,280 
1,725 
6,900 
2,500-4,999 
Anne Arundel 
3,482 
1,832 
7,328 
Baltimore 
3,770 
1,983 
7,932 
Prince George’s 
4,357 
2,293 
9,172 
Garrett 
4,780 
2,514 
10,056 
Wicomico 
4,785 
2,516 
10,064 
Frederick 
6,598 
3,471 
13,884 
5,000 & Over 
Washington 
10,783 
5,672 
22,688 
Allegany 
13,202 
6,944 
27,776 
Total 
82,726 
43,514 
174,056 The Scope and Costs of a Medical Care Program 
63 
(iv) Mental Hygiene Clinics conducted under the joint 
auspices of the Bureau of Child Hygiene of the State 
Department of Health, the State Commissioner of Mental 
Hygiene, the State Hygiene Society, County Health 
Departments and Boards of Education. Clinicians were 
selected from the State, Baltimore City or local hospitals 
and institutions. In 1940 over 800 persons—670 under 
21 years of age—were examined at 101 clinics in 21 counties. 
(c) Consultants 
At all times competent consultants, carefully selected 
by impartial medical authorities, should be procurable by 
a private practitioner attending indigent cases. 
In most counties the clinicians might also serve as 
consultants. Other physicians should be appointed to serve 
in this capacity when clinicians are not available. 
2. Hospitalisation 
(a) General 
In Collins series1 there were during the year 61.6 hospital 
cases and 886 hospital days per 1,000 persons under ob- 
servation, exclusive of cases in institutions throughout the 
year. Among 82,726 persons, the estimated number of 
indigent in the counties of Maryland in 1940, there would, 
therefore, have been 5,095 hospital cases and 73,295 hospital 
days. 
During the year 1940 a total of 228,346 free hospital days 
were reported as having been provided for county residents 
by hospitals in the counties and in Baltimore City for 
which at least partial compensation was received from the 
State and local governments. 
From the above data the following deductions are 
possible: 
Either the data furnished the Committee were inaccurate, 
or, indigent patients were provided with more than three 
times the number of hospital days than were calculated 
to have been needed, or, a proportion and perhaps a fairly 
large proportion of the group defined as the medically 
indigent received free hospitalization. The last of these 
deductions seems the most likely. 
(b) Chronic Disease 
In addition to hospitalization, it is of the utmost im- 
portance that institutions for the treatment of chronic 
disease be constructed. Further reference to this subject 
will be found in Chapter X. 
3. Health Department Services 
(a) Clinic and Office Space 
Under the proposed program the county health de- 
partment would provide the following facilities and 
equipment: 
(i) A center for the reception of calls for physicians and 
for the hospitalization of indigent patients. 
(ii) Quarters for clinics located whenever practicable 
in local hospitals. 
(iii) Offices for visiting nurses and medical social 
workers. 
(iv) Offices for records and accounting. 
(h) Visiting Nurses Service 
Visiting nurses should be attached to the staff of the 
county health department with the following duties: 
1. Bedside nursing service in the homes. 
2. Service in clinics. 
3. Public health nursing service when not otherwise 
engaged. 
Serving under the direct supervision of the county 
health officer in such matters as hours of work and office 
TABLE 51 
ESTIMATED NUMBER OF CALLS BY GENERAL PRACTITIONERS BY 
COUNTIES, ASSUMING THAT 73 PERCENT WERE OFFICE, 5 PER- 
CENT HOSPITAL AND 22 PERCENT HOME CALLS 
County 
Total 
Estimated 
Calls 
Theoretical Distribution of Calls 
Office 
73% 
Hospital 
5% 
Patient’s Home 
22% 
Calvert 
1,684 
1,229 
84 
371 
Kent 
2,072 
1,513 
103 
456 
Charles 
3,092 
2,257 
155 
680 
Talbot 
3,240 
2,365 
162 
713 
Howard 
3,248 
2,371 
162 
715 
Saint Mary’s 
3,772 
2,754 
189 
829 
Queen Anne’s 
3,844 
2,806 
192 
846 
Caroline 
4,492 
3,279 
225 
988 
Carroll 
4,492 
3,279 
225 
988 
Worcester 
4,880 
3,562 
244 
1,074 
Cecil 
5,012 
3,658 
251 
1,103 
Harford 
5,984 
4,368 
299 
1,317 
Montgomery 
6,184 
4,514 
309 
1,361 
Somerset 
6,260 
4,570 
313 
1,377 
Dorchester 
6,900 
5,037 
345 
1,518 
Anne Arundel 
7,328 
5,350 
366 
1,612 
Baltimore 
7,932 
5,790 
397 
1,745 
Prince George’s 
9,172 
6,696 
459 
2,017 
Garrett 
10,056 
7,341 
503 
2,212 
Wicomico 
10,064 
7,347 
503 
2,214 
Frederick 
13,884 
10,135 
694 
3,055 
Washington 
22,688 
16,562 
1,135 
4,991 
Allegany 
27,776 
20,276 
1,389 
6,111 
Total 
174,056 
127,059 
8,704 
38,293 
1Collins, Selwyn D.: Frequency and Volume of Hospital Care for Specific 
Disease in Relation to All Illnesses Among 9,000 Families Based on Nation- 
wide Periodic Canvasses, 1928-31, Pub. Health Rep., 57:1399-1428 (Sept. 18, 
1942) and 57:1439-1460 (Sept. 25, 1942) Reprint 2405- 64 
Medical Care in the Counties of Maryland 
routine, the visiting nurse would also be responsible to 
the physician in charge of each case under her care. 
(c) Dental Services 
Dental clinics have been established in a number of 
counties, as indicated in Chapter V, and it has been shown 
that this service is seriously handicapped by inadequate 
funds. 
Under normal conditions, it should be made possible to 
establish and maintain in every county a dental program 
for the care of the indigent under the leadership of a 
full-time dentist on the staff of the county health de- 
partment. In the smaller counties, it is believed that one 
dentist could conduct the school health program and give 
a reasonable amount of emergency dental care to adults. 
In the counties having a larger number of indigent patients, 
however, there should be at least two dentists, one con- 
ducting the school dental health program and the other 
giving dental care to indigent adults. 
Cd) Clinical Laboratory Service 
To provide clinical laboratory service for physicians 
attending indigent patients in their home and offices, and 
for patients attending clinics, it would be necessary to 
procure additional laboratory personnel and equipment. 
In the interests of economy and efficiency other than 
operation and administration, it is suggested that this 
personnel be attached to the staff of the branch laboratories 
of the State Department of Health, or that arrangements 
for clinical laboratory service such as are now operative 
in Charles, St. Mary’s and Calvert counties be extended 
to other sections of the State. 
It would be expected that the clinical laboratories in 
hospitals continue to provide services for the indigent 
patients in their respective institutions. 
4. Administration 
(a) State 
To advise in the formulation of policies for the ad- 
ministration of the medical care program, it is suggested 
that the State Board of Health establish a Council on 
Medical Care composed of representatives of all major 
organizations concerned with the problem. 
TABLE 53 
COST OF CALLS BY GENERAL PRACTITIONERS IN THE OFFICE, 
HOSPITAL AND THE PATIENT’S HOME, AT $1.50, $1.50 AND $2.50 
PER CALL, RESPECTIVELY. 
TABLE 52 
THE TOTAL BENEFICIARIES WITH ESTIMATED TOTAL CLINIC 
CASES, AND THE ESTIMATED TOTAL CLINIC VISITS PER YEAR, 
ASSUMING AN AVERAGE OF 5.0 CLINIC CALLS PER CASE. 
County 
Total 
Beneficiaries 
Estimated 
Total Clinic 
Cases 
Estimated 
Total Clinic 
Visits per Year 
Calvert 
801 
97 
485 
Kent 
984 
119 
595 
Charles 
1,470 
178 
890 
Talbot 
1,540 
186 
930 
Howard 
1,544 
187 
935 
Saint Mary’s 
1,792 
217 
1,085 
Queen Anne’s 
1,827 
221 
1,102 
Caroline 
2,135 
258 
1,290 
Carroll 
2,135 
258 
1,290 
Worcester 
2,321 
281 
1,405 
Cecil 
2,383 
288 
1,440 
Harford 
2,845 
344 
1,720 
Montgomery 
2,937 
356 
1,780 
Somerset 
2,975 
360 
1,800 
Dorchester 
3,280 
397 
1,985 
Anne Arundel 
3,482 
421 
2,105 
Baltimore 
3,770 
456 
2,280 
Prince George’s 
4,357 
527 
2,635 
Garrett 
4,780 
579 
2,895 
Wicomico 
4,785 
579 
2,895 
Frederick 
Washington 
Allegany 
6,598 
10,783 
13,202 
798 
1,305 
1,598 
3.990 
6,525 
7.990 
Total 
82,726 
10,010 
50,050 
County 
General Practitioners 
Office Calls 
at $1.50 
Hospital* 
Calls 
at $1.50 
Home Calls 
at $2.50 
Total Cost 
Calvert 
$ 1,843.50 
$ 126.00 
$ 927.50 
$ 2,897.00 
Kent 
2,269.50 
154.50 
1,140.00 
3,564.00 
Charles 
3,385.50 
232.50 
1,700.00 
5,318.00 
Talbot 
3,547.50 
243.00 
1,782.50 
5,573.00 
Howard 
3,556.50 
243.00 
1,787.50 
5,587.00 
Saint Mary’s 
4,131.00 
283.50 
2,072.50 
6,487.00 
Queen Anne’s 
4,209.00 
288.00 
2,115.00 
6,612.00 
Caroline 
4,918.50 
337.50 
2,470.00 
7,726.00 
Carroll 
4,918.50 
337.50 
2,470.00 
7,726.00 
Worcester 
5,343.00 
366.00 
2,685.00 
8,394.00 
Cecil 
5,487.00 
376.50 
2,757.50 
8,621.00 
Harford 
6,552.00 
448.50 
3,292.50 
10,293.00 
Montgomery 
6,771.00 
463.50 
3,402.50 
10,637.00 
Somerset 
6,855.00 
469.50 
3,442.50 
10,767.00 
Dorchester 
7,555.50 
517.50 
3,795.00 
11,868.00 
Anne Arundel 
8,025.00 
549.00 
4,030.00 
12,604.00 
Baltimore 
8,685.00 
595.50 
4,362.50 
13,643.00 
Prince George’s 
10,044.00 
688.50 
5,042.50 
15,775.00 
Garrett 
11,011.50 
754.50 
5,530.00 
17,296.00 
Wicomico 
11,020.50 
754.50 
5,535.00 
17,310.00 
Frederick 
15,202.50 
1,041.00 
7,637.50 
23,881.00 
Washington 
24,843.00 
1,702.50 
12,477.50 
39,023.00 
Allegany 
30,414.00 
2,083.50 
15,277.50 
47,775.00 
Total 
$190,588.50 
$ 13,056.00 
$ 95,732.50 
$299,377.00 
♦Hospital calls are included in eight counties in which there was no hospital. 
In these counties a proportion of potential hospital patients is treated in the 
home, hence these costs have not been deducted. The Scope and Costs ot a Medical Care Program 
65 
To administer the program developed by the State Board 
of Health with the advice of the Council on Medical Care, 
a Bureau should be established within the State Department 
of Health. The full-time Chief of this Bureau should be 
a physician, experienced in the field of medical care, 
appointed by the Director of the State Department of 
Health and should serve under his direction. 
(b) County 
In the interests of economy and efficiency, it is suggested 
that the county health officer, at present the director of 
the county department of health, should administer the 
local functions of the program. In the larger counties the 
health officer would be unable to attend to all details of 
the program in addition to his usual public health duties, 
therefore, it would be necessary to employ an assistant to 
the health officer who need not be a physician. 
Medical Social Workers 
It is suggested that a medical social worker be employed 
in each county health department whose duties would 
include the investigation and classification of all applicants 
for free medical care. It would be expected that this em- 
ployee would work in the closest possible cooperation 
with the county welfare department and that the case 
records of the latter would be available at all times. 
Clerks 
In the larger counties it would be necessary to employ 
additional clerical assistance, while in some of the smaller 
counties the present personnel might reasonably be ex- 
pected to do this work along with their usual duties. 
County Advisory Council 
To act in an advisory capacity to the county health 
officer in the administration of the local program, it is 
suggested that a County Council on Medical Care be 
established which should be composed of one or more 
representatives of (a) the county medical society (b) the 
county dental society (c) the county welfare department, 
(d) the local hospital and (e) the general public. 
4. THE COSTS OF OPERATION 
It is difficult, if not impossible, to predict accurately the 
cost of a program for medical care for a given population. 
In presenting the estimates which follow, it is emphasized 
that the amounts of fees for service, salaries and other 
emoluments should not be regarded as an attempt to 
establish a standard, but merely as an effort to ascertain 
the probable costs of such a program if it had been in 
operation during the year 1940. 
In the suggested program appropriations for the fol- 
lowing services and equipment should be made; 
1. Private Physicians 
(a) General Practitioners 
Fees for office, hospital calls and deliveries, travel 
for home calls. 
(b) Surgeons and Anesthetists 
Payments for service. 
(c) Clinicians 
Fees for clinics and travel expenses when 
necessary. 
(d) Consultants 
Payments per consultation and travel, if required. 
2. Hospitals 
Compensation for all hospital service to eligible persons. 
3. Health Departments 
Salaries of visiting nurses, dentists and laboratory 
personnel. 
4. Administration 
(a) State 
Salaries of bureau chief, statistician and clerks. 
TABLE 54 
THE TOTAL INDIGENT AND THE RESIDENT BIRTH RATE IN THE 
COUNTIES OF MARYLAND IN 1940, TOGETHER WITH THE ESTI- 
MATED NUMBER OP BIRTHS AND THE TOTAL FEES FOR 
OBSTETRICAL CARE DURING LABOR, DELIVERY AND 
THE IMMEDIATE PUERPERIUM AT $25 PER CASE. 
County 
Total Indigent 
in 1940 
Resident 
Birth Rate 
in 1940 
Estimated 
Number 
of Births 
Total Delivery 
Fees at $25 
per Case 
Calvert 
801 
24.4 
20 
$ 500 
Kent 
984 
19.3 
19 
475 
Charles 
1,470 
26.3 
39 
975 
Talbot 
1,540 
18.2 
28 
700 
Howard 
1,544 
22.1 
34 
850 
Saint Mary’s 
1,792 
26.9 
48 
1,200 
Queen Anne’s 
1,827 
16.8 
31 
775 
Caroline 
2,135 
19.1 
41 
1,025 
Carroll 
2,135 
17.7 
38 
950 
Worcester 
2,321 
17.5 
41 
1,025 
Cecil 
2,383 
18.6 
45 
1,125 
Harford 
2,845 
18.7 
53 
1,325 
Montgomery 
2,937 
20.9 
61 
1,525 
Somerset 
2,975 
19.0 
57 
1,425 
Dorchester 
3,280 
17.4 
57 
1,425 
Anne Arundel 
3,482 
19.4 
67 
1,675 
Baltimore 
3,770 
19.0 
72 
1,800 
Prince George’s 
4,357 
20.6 
90 
2,250 
Garrett 
4,780 
24.1 
115 
2,875 
Wicomico 
4,785 
17.7 
85 
2,125 
Frederick 
6,598 
17.5 
116 
2,900 
Washington 
10,783 
18.5 
199 
4,975 
Allegany 
13,202 
20.1 
265 
6,625 
Total 
82,726 
19.6 
1,621 
$40,525 66 
Medical Care in the Counties of Maryland 
(b) County 
Salaries of health officers, assistants, medical 
social workers and clerks. 
General clinic equipment, supplies, drugs and 
biologicals. 
Dental laboratory, X-ray and other special 
equipment. 
Remodeling and rentals. 
1. Private Practitioners 
(a) General Practitioners 
(i) Fees for office, hospital and home calls 
In Table 53, page 64, the fees of general practitioners for 
office, hospital and home calls have been calculated by 
counties in accordance with the following scale: office 
calls, $1.50; hospital calls, $1.50; and home calls, $2.50. 
The total estimated cost for these services is $299,377 of 
which $190,588.50, $13,056.00 and $93,732.50, are the costs 
for office, hospital and home calls, respectively. 
(ii) Fees for deliveries 
In 1940 in the counties of Maryland the resident birth 
rate was 19.6 per 1,000 population. Among 82,726 in- 
dividuals, therefore, there would have been approximately 
1,621 births. The theoretical distribution of births by 
counties is shown in Table 54, page 65- If the fee for 
complete care during labor, delivery and the immediate 
puerperium were $25, the total payments for 1,621 births 
would be $40,525- The estimated costs by counties are 
included in the same Table. Calls for obstetrical care, 
other than those for labor, delivery and the immediate 
puerperium, have been included in the office, hospital, 
and home visits. 
(iii) Travel for home calls 
For 43,514 attended cases it has been calculated that 
there would be 6,112 home calls. Of the latter it is estimated 
that 3,056, or 50 percent, would be distributed within a 
radius of less than 3 miles from the physician’s residence; 
1,834, or 30 percent, from 3 to 5 miles; and 1,222, or 20 
percent, over 5 miles. 
For services requiring travel in excess of 3 miles, but 
not more than 5 (one way) from the physician’s residence, 
$2.50 is used as the travel allowance in addition to the 
usual fee, and $5 for distances in excess of 5 miles. 
For 1,834 calls, at $2.50 per call, the payments for travel 
would be $4,585; for 1,222 calls, at $5, they would amount 
to $6,110. The total estimated travel costs for general 
practitioners, therefore, is $10,695- 
(b) Surgeons' and Anesthetists' Fees 
Since physicians would be paid for the care of indigent 
patients, it seems reasonable and proper that surgeons also 
should be compensated for their services. 
Of all hospital cases, it has been estimated1 that 62 
percent were surgical and 38 percent non-surgical patients. 
Since it is estimated that there would have been 5,095 
hospital cases in 82,726 persons, the surgical patients 
would total 3,090 cases. Five specific conditions were 
listed as extremely frequent in hospital practice, namely, 
tonsillectomies, deliveries, accidental injuries, acute ap- 
pendicitis and female genital diseases. 
If 75 percent of the 3,090 surgical cases, or 2,318 patients, 
were operated upon, and if the average fee for major and 
minor surgery were placed at $25, the total payments 
would be $57,950. 
At an estimated fee of $10 per operation for anesthetists, 
the payments would total $23,180. 
(c) Clinicians 
It is suggested that clinicians be compensated on a fee 
per clinic basis, with travel allowance when necessary. 
A fee of $10 is used in the calculations with an average 
travel allowance of $20 per clinic. The latter involves 
inter-county travel and is a rate somewhat less than that 
of the Maryland Tuberculosis Association, which however, 
uses fewer clinicians covering the same area with a resultant 
higher average distance per clinician. 
Five types of clinics in addition to those now being 
conducted in each county are believed to be necessary— 
TABLE 55 
THE TOTAL CLINICS PER YEAR IN EACH COUNTY AND IN EACH 
GROUP OF WITH TOTAL CLINICIANS FEES AT $10 
PER CLINIC AND TRAVEL AT $20 PER CLINIC. 
Total Clinics Per Year 
Clinicians Payments 
County 
Group* 
In Each 
County 
In Each 
Group 
Fees 
at 
$10 
Travel 
at 
$20 
Total 
I 
(11 counties) 
60 
660 
$6,600 
$13,200 
$19,800 
II 
(9 counties) 
120 
1,080 
10,800 
21,600 
34,400 
III 
(3 counties) 
240 
720 
7,200 
** 
7,200 
Total 
— 
2,460 
$24,600 
$34,800 
$59,400 
♦Group I—Calvert, Kent, Charles, Talbot, Howard, St. Mary’s, Queen Anne’s, 
Caroline, Carroll, Worcester and Cecil counties. 
Group II—Harford, Montgomery, Somerset, Dorchester, Anne Arundel, Baltimore, 
Prince George’s, Garrett and Wicomico counties. 
Group III—Frederick, Washington and Allegany counties. 
♦♦Travel allowances are not included for these counties, since it is assumed that 
clinicians would be available locally. 
Collins, Selwyn D.: Frequency and Volume of Hospital Care for Specific 
Diseases in Relation to all Illness Among 9,000 Families, Based on Nation- 
wide Periodic Canvasses, 1928-31, Pub. Health Rep., 57:1399-1428 (Sept. 18, 
1942) and 57:1439-1460 (Sept. 25, 1942) Reprint No. 2405- The Scope and Costs of a Medical Care Program 
67 
Internal Medicine, Surgery, Obstetrics and Gynecology, 
Pediatrics and Ophthalmology and Otolaryngology—-the 
frequency varying from one to four of each per month, 
depending upon the estimated total indigent in the county. 
The total costs are summarized in Table 35, page 66. 
For all of the five types of clinics in all counties, there 
would be 2,460 clinics per year, while the total estimated 
cost of this service is $39,400, which includes $24,600 for 
clinicians’ services and $34,800 for travel. 
(d) Consultants 
For all counties, it is felt that there should be a minimum 
of 10 consultants; 2 each in internal medicine, surgery, 
obstetrics and gynecology, pediatrics, and ophthalmology 
and otolaryngology. 
As a basis for estimating the total cost, a consultation 
fee of $10 has been used with an average travel allowance 
of $20. The latter is based on the assumption that the 
majority of the consultants would reside in Baltimore City 
and that inter-county travel would be involved. 
For 43,514 attended cases it is estimated that 433, or 
1 percent, would require consultants’ services in addition 
to those which would be available in the clinics. The 
cost, therefore, for fees would approximate $4,350 while 
the travel payments would amount to about $8,700, or a 
total cost of $13,050. 
2. Hospitals 
In all counties a total of 152,111 free hospital days was 
reported by 16 general hospitals which received allocations 
totalling $219,038 from State and local governments in 
1939-40, or an average of $1.82 per free hospital day. In 
these hospitals the average cost was reported to be $3-80 
per hospital day. In order to compensate the hospitals 
adequately, therefore, the allocations should be increased 
from $219,038 to $457,332, or by about 109 percent. Of 
the former amount the State of Maryland contributed 
$162,000, or 72.9 percent. The augmented State allocation, 
therefore, should approximate $337,968, or $175,968 in 
new funds. At the same time the local government ap- 
propriations should be increased from $57,038 to $119,363 
in order to attain the total from all sources of $457,332. 
In 1940, 7,296 county patients were treated in hospitals 
in Baltimore City for a total of 76,235 hospital days. These 
hospitals were allocated $221,000 by the State of Maryland 
for care of free patients of which the county residents 
comprised about 25 percent. At $3-80 per hospital day, the 
estimated cost, the Baltimore hospitals would have re- 
ceived $289,693- Of the State allocation of $221,000, it is 
estimated that approximately $55,250 was expended for 
county residents. It is clear, therefore, that in order to 
compensate the hospitals in Baltimore City for hospitali- 
zation of free county cases a total of $231,443 should be 
added to the allocation of the State of Maryland. 
Future State Appropriations for Hospitalisation 
It has been indicated that current methods for allocating 
State funds for general hospitals are unsatisfactory in several 
important respects. In order to establish a more equitable 
distribution, and concurrently with any increase in ap- 
propriations, it is suggested that the following steps be 
taken: 
1. A “free hospital day’’ should be clearly defined and 
a basis of payment for it be established. 
2. A medical social worker, attached to the staff of the 
county health department, should determine the 
eligibility of applicants for free hospitalization. 
3. Hospitals should be licensed by the State Board of 
Health, after conforming with minimum standards 
which should be established by that Board, and these 
should include (a) the installation of a uniform 
system of accounting, (b) the maintenance of ap- 
propriate professional standards, and (c) periodic 
inspections to determine the extent to which licensing 
standards are maintained. 
3- Health Departments 
(a) Visiting Nurses 
As a basis for estimating the cost of visiting nurses 
service, the minimum salary has been placed at $1,500 with 
a travel allowance of $600 per year. These rates are in 
accordance with the current standards for public health 
nurses. 
The suggested distribution of visiting nurses, in ac- 
cordance with the estimated number of indigent in 1940, 
and the costs are found in Table 56, on page 67. 
TABLE 56 
THE NUMBER OF NURSES SUGGESTED FOR EACH COUNTY AND IN 
EACH GROUP OF COUNTIES, TOGETHER WITH ESTIMATES 
OF THE COSTS. 
Number of Nurses 
Salaries and Travel per Year 
County 
Group 
In Each 
County 
In Each 
Group 
Salaries 
at 
$1,500 
Travel 
at 
$600 
Total 
I 
(11 counties) 
2 
22 
$33,000 
$13,200 
$46,200 
II 
(9 counties) 
3 
27 
40,500 
16,200 
56,700 
III 
(3 counties) 
4 
12 
18,000 
7,200 
25,200 
Total 
— 
61 
$91,500 
$36,600 
$128,100 68 
Medical Care in the Counties of Maryland 
(b) Dentists 
The number of dentists recommended for each county 
and the travel allowances are shown in the Table below. 
It will be observed that a minimum annual salary of $3,000 
has been suggested, with a travel allowance of $600 per 
year. 
bility for such functions of the Bureau of Medical Care as 
the payment of accounts, which the former is now per- 
forming for other Bureaus of the State Department. 
(b) Counties 
(i) The County Health Officers 
Since administration of the medical care program by 
health officers would impose additional responsibilities 
upon them, it seems both appropriate and necessary that 
the salaries of health officers should be increased. The 
amounts suggested are set forth in the following Table: 
TABLE 57 
THE NUMBER OP DENTISTS SUGGESTED FOR EACH COUNTY AND 
EACH GROUP OF COUNTIES, TOGETHER WITH THE SALARIES 
AND TRAVEL. 
County 
Group 
Number of Dentists 
Salaries and Travel Per Year 
In Each 
County 
In Each 
Group 
Salaries 
at $3,000 
Travel 
at $600 
Total 
I 
(11 counties) 
1 
11 
$33,000 
$ 6,600 
$39,600 
II 
(9 counties) 
1 
9 
27,000 
5,400 
32,400 
III 
(3 counties) 
2 
6 
18,000 
3,600 
21,600 
Total 
— 
26 
$78,000 
$15,600 
$93,600 
TABLE 58 
THE NUMBER OF COUNTY HEALTH OFFICERS WITH SUGGESTED 
MINIMUM INCREASES IN SALARY FOR ADMINISTERING THE 
PROGRAM OF MEDICAL CARE 
Number of Officers 
Salary Increases Per Year 
County 
Group 
In Each 
County 
In Each 
Group 
Salaries 
Increases 
Total 
Increases 
I 
(11 counties) 
1 
11 
$ 500 
$5,500 
II 
(9 counties) 
1 
9 
750 
6,750 
III 
(3 counties) 
1 
3 
1,000 
3,000 
Total 
— 
23 
— 
$15,250 
It will be observed that for 26 dentists the sum of $78,000 
is allocated for salaries and $15,600 for travel allowances, 
a total of $93,600. From this amount, however, should be 
deducted the sum of $19,801 which was the amount ex- 
pended in 1940, giving a final estimate of $73,779 for 
augmented dental services. 
(c) Clinical Laboratory Personnel 
It is estimated that a minimum of 12 additional bac- 
teriologists would be needed—3 in the central laboratory 
in Baltimore and one in each of the 9 branch laboratories. 
The salaries are estimated on a basis of an average of 
$1,800 per year or a total of $21,600. 
4. Administration 
(a) State 
The following minimum salaries and expenses should 
be provided for the proposed Bureau of Medical Care of the 
State Department of Health: 
It is suggested that assistants to the county health 
officers be provided in Frederick, Washington and Allegany 
counties at an annual salary of $2,400 or a total cost of 
$7,200. 
(ii) Medical Social Workers 
If one worker in each county received an average salary 
of $1,800 per annum with a travel allowance of $600, the 
cost of medical social service workers’ salaries would total 
$41,400 and the travel $13,800. A total expenditure of 
$55,200 would be involved. 
(hi) Clerks 
With one additional clerk in each of the 20 county 
health departments in Groups I and II at an average salary 
of $1,200, the total salaries would be $24,000. For two 
clerks in each county in Group III, the salaries would 
amount to $7,200. The total expenditures for clerical 
assistance would be $31,200. 
(iv) Clinical Equipment, Supplies, Drugs and 
Biologicals 
The minimum clinical equipment, supplies, drugs and 
biologicals with estimated costs have been tabulated 
below: 
Chief of Bureau, Salary $ 5,000 
Travel 1,200 
Statistician 2,500 
Clerks, three 5,500 
Office expenses 2,500 
Total $16,700 
It is assumed that the Bureau of Personnel and Accounts 
of the State Department of Health would accept responsi- The Scope and Costs of a Medical Care Program 
69 
Equipment Estimated Cost 
Examination tables $ 50 
Cabinets and shelves 75 
Instruments 200 
Desks, tables and chairs 150 
Filing cabinet 50 
Miscellaneous 75 
Total $ 600 
Supplies Estimated Cost 
Stationery $ 50 
Linens 75 
Dressings and bandages 50 
Miscellaneous 75 
Total $ 250 
Drugs and Biologicals Estimated Cost 
Prescriptions (local pharmacists) $ 500 
Emergency drugs (clinics) 250 
Emergency biologicals (clinic) 250 
Total $1,000 
(iii) X-ray 
It is suggested chat provisions be made for the installation 
of X-ray and other special diagnostic facilities in the county 
health departments for which the initial amount of $15,000 
should be allocated. 
(c} Remodelling and Rentals 
In most county health departments it would be necessary 
to remodel, make additions to present quarters, or to rent 
more space. 
It has been estimated that the following costs would be 
involved: 
Remodelling $7,500 
Rentals 1,400 
It is known that in a number of county health depart- 
ments additional rooms could be obtained without cost, 
since they are located in public buildings. 
Cost of the above minimum equipment, supplies, drugs 
and biologicals totals $1,850. For larger counties additional 
amounts should be provided in accordance with the scale 
in the following Table. 
SUMMARY OF ESTIMATED ANNUAL COSTS OF MEDICAL CARE 
PROGRAM FOR 82,726 INDIVIDUALS IN THE COUNTIES OF MARYLAND 
TABLE 59 
THE ESTIMATED COST OF EQUIPMENT, SUPPLIES, DRUGS AND 
BIOLOGICALS 
Percent of 
1. 
Services of private Physicians 
Total Expenditures 
Total 
(a) General Practitioners 
Office Calls 
$190,588 
Hospital Visits 
13,056 
Home Visits 
95,733 
Deliveries 
40,525 
Travel for Home Visits 
10,695 
$350,597 
(b) Surgeons and Anesthetists 
Surgical Services 
57,950 
Anesthetists Services 
23,180 
$ 81,130 
(c) Clinicians 
Clinic Fees 
24,600 
Travel 
34,800 
$ 59,400 
(d) Consultants 
Consultations 
4,350 
Travel 
8,700 
$ 13,050 
$504,177 
36.7 
2. 
Hospitalization 
Increased payments to Hospitals in Counties 
175,968 
Hospitalization of County Residents in Haiti- 
more City in Addition to Current Ex- 
penditures 
231,443 
$407,411 
29.7 
3. 
Health Department Services 
Visiting Nurses, Salaries 
$ 91,500 
Visiting Nurses, Travel 
36,600 
Dentists, Salaries 
78,000 
Dentists, Travel 
15,600 
Clinical Laboratory Personnel 
21,600 
$243,300 
Less Dental Appropriations (1940) 
19,801 
$223,499 
16.3 
4. 
Administration 
(a) State Office 
16,700 
(b) County Offices: 
County Health Officers, Part Salaries 
15,250 
Administrative Assistants 
7,200 
Medical Social Workers, Salaries 
41,400 
Medical Social Workers, Travel 
13,800 
Clerks, Salaries 
31,200 
$125,550 
9.1 
5. 
Equipment 
Equipment, Supplies, Drugs and Biologicals 
53,050 
Dental Equipment and Supplies 
20,800 
Laboratory Equipment 
15,200 
X-ray and other Special Equipment 
15,000 
Remodelling and Rentals 
8,900 
$112,950 
8.2 
$238,500 
Total 
$1,373,587 
100.0 
County 
Group 
Cost of Equipment, Supplies 
In Each 
County 
In Each 
Group 
I 
(11 counties) 
$ 1,850 
$20,350 
II 
(9 counties) 
2,550 
22,950 
III 
(3 counties) 
3,250 
9,750 
Total 
— 
$53,050 
(v) Special Equipment 
(i) Dental 
With one dentist in each of the 20 counties in Groups I 
and II, the estimated cost of equipment and supplies is 
$800 per county, or $16,000 in all. With two dentists in 
the remaining 3 counties, it is estimated that the cost of 
equipment and supplies would be $1,600 in each county, 
or a total of $4,800. For all counties the costs of dental 
equipment and supplies would total $20,800. 
(ii) Laboratory 
For additional equipment and supplies for clinical 
laboratories operating in conjunction with existing bac- 
teriological laboratories of the State Department of Health, 
it is suggested that a total of $15,200 should be 
appropriated. Chapter X 
ACTIVITIES OF THE EXECUTIVE COMMITTEE 
Special Inquiries 
Quite apart from the field survey of the counties 
/o£ Maryland, the Executive Committee of the 
Committee on Medical Care conducted a series of special 
inquiries on a number of related subjects including; 
1. Medical Care Problems in the Counties and Their 
Relationship to Medical and Hospital Facilities in 
the City of Baltimore. 
2. Facilities for the Treatment of Chronic Disease. 
3. The Need for a Central Hospital Admitting Service. 
4. The Integration of Independent State Agencies 
Providing Medical Care. 
5- The Outpatient Medical Services in the City of 
Baltimore. 
1. Medical Care Problems in the Counties and Their Kelation- 
ship to Medical and Hospital Facilities in the City of 
Baltimore 
From the beginning, the Committee has considered that 
its function is State-wide. Indeed, from a practical point 
of view, it is impossible to separate medical care in Balti- 
more from medical care in the counties. Medical facilities 
in Baltimore are a part of the whole State’s equipment for 
medical care and are so used, as has been clearly shown in 
Chapter VI. A study of medical care in the counties of 
Maryland would be only partially completed if this rela- 
tionship to the medical facilities of Baltimore were not 
considered. 
Many of the economic difficulties which arise in pro- 
viding medical care for county residents relate to the cost 
of hospitalization in the city. Similarly, it is not possible 
to obtain an adequate view of the problems of Baltimore’s 
medical institutions and facilities without considering 
their use by county residents. This is particularly true of 
counties immediately surrounding the City, but to some 
extent applies to the whole State. 
The size of Baltimore and the multiplicity of the volun- 
tary, city, State and private institutions furnishing medical 
care are such as to demand most careful study before 
suggestions can be made for the more effective use of these 
facilities. 
As in the counties, certain data are obtainable. These 
relate chiefly to medical services which are alreadjr well 
performed. The interest of the Committee, however, is 
concerned chiefly with those medical needs which at 
present are less well met. Before a sound opinion can be 
formed as to the practicability of any remedial plan, it 
will be necessary to obtain quantitative data on many 
of these unmet needs—the necessary personnel, the costs, 
and the essential type of administration. 
Among the obvious unmet medical needs in Baltimore 
are some which are State-wide in character. For example, 
there is need for a solution of the problem of the care of 
the defective and delinquent child. This problem should 
certainly not be approached on either a county or a city 
basis, but as a State-wide problem demanding a State-wide 
solution. The State has long determined that mental 
defectives are a State problem whether they occur in the 
city or in the county. Similarly, the study of tuberculosis 
can not be approached without knowledge of both City 
and county needs. On the other hand, there are very im- 
portant unmet medical needs in Baltimore which have 
a distinctly local character, and they must be solved 
locally. These, however, are problems of such magnitude 
that the Committee feels that they should be the subject 
of a separate inquiry and report. 
2. Facilities for the Treatment of Chronic Disease 
(a) Evidence of Need 
Chronic disease is increasing in frequency as the average 
age of the population tends to advance. Maryland, with 
respect to meeting the need for medical care for the chronic 
patient, has not yet solved the problem. 
In Baltimore City, it is true, there has been a fairly rapid 
expansion of the size of the chronic hospital which is a 
part of the group of City Hospitals. In spite of this ex- 
pansion there usually exists a waiting list of approximately 
500 cases. The problem is an especially serious one since 
the City has at present no method of providing home care 
for those chronically ill patients for whom hospital beds 
are not available. 
In the counties of Maryland hardly a beginning has been 
made in the provision of hospital beds for chronic cases. 
In fifteen counties almshouses, or "county homes", still 
exist. In 1939, when a study of these institutions was 
made by the State Department of Public Welfare at the 
request of the Legislative Council, it was found that 556 
individuals resided in the almshouses. Of this number, 319 
were found to be handicapped physically or mentally to 
such a degree that they required chronic hospital care. 
It was clearly demonstrated that the almshouses contained 
many patients for whose care the necessary facilities were 
not available. Activities of the Executive Committee 
71 
(b) The Kind of Care Needed 
Certain facts must be considered in connection with the 
development of a State-wide program for the chronically 
disabled patient. The kind of care that is needed in an 
individual case depends not so much upon the nature of 
the chronic disease, as upon the character and degree of 
mental and physical disability which has resulted from it. 
All estimates of the number of patients needing chronic 
hospital care are untrustworthy—if they are based upon 
medical diagnoses, such as arthritis, arteriosclerosis, heart 
disease and the like. Patients with any of these conditions 
may come in one of the following categories: (i) those 
capable of self-support, (ii) those disabled to the extent 
that they need boarding-home care with occasional medical 
supervision, (iii) those sufficiently handicapped to require 
infirmary care with nursing attendance and regular medical 
supervision, or (iv) those who are bedridden and require 
chronic hospital care. During any of these stages these 
patients may have acute exacerbations or complications, 
placing them in group (v) those who require the type of 
medical care which can be given only in a general hospital. 
These types of service, namely, boarding-home, infirmary 
and chronic and general hospital care, increase in cost in 
the order named. 
A program for the care of the chronically ill should 
include provision for each category of care, and it is equally 
important that facilities should be provided for classifying 
the patients. Moreover, it is characteristic of most of the 
chronic diseases that the condition is progressive, so that 
an adequate system must include provision for the ready 
transfer of a patient from one class of care to another as 
his condition requires. Many older patients will do well 
in the infirmary section in summer, but in winter may have 
to be transferred into the chronic hospital. Similarly, the 
chronic hospital cases will develop such complications as 
urinary retention, pneumonia and coronary thrombosis, 
which would make it necessary to transfer them at once 
to a general hospital. On the other hand, patients at the 
end of a long, acute illness in the general hospital, may be 
permanently disabled and have to be transferred to the 
chronic hospital. This relationship makes it highly desira- 
ble that the infirmary, the chronic hospital and the general 
hospital be not far separated. If the chronic hospital is 
built near a general hospital, not only will these transfers 
be facilitated, but the medical services in the chronic 
hospital will be strengthened by the availability of pro- 
fessional consultant services from the general hospital. It 
would also be unnecessary to install in the chronic hospital 
those expensive medical facilities which would be ab- 
solutely necessary if a general hospital was not within 
easy reach. 
(c) Results to be Expected 
Though a large proportion of the cases admitted to 
infirmaries and chronic hospitals are incurable, there will 
be a definite percentage in which this will not be so. The 
chronic hospital will give a chance for life and for more 
or less complete recovery to many patients who, because 
of the great length of their illness, can seldom receive 
treatment over a sufficient length of time in the general 
hospitals. Many cases of arthritis fall into this group, and 
this disease is one of the leading causes of chronic total 
disability. Arthritis requires prolonged, persistent treat- 
ment, which is generally unobtainable in the general 
hospital or in the home. With adequate care the ultimate 
results are usually far less disabling in character. Certain 
types of paralyses are likewise susceptible to great im- 
provement in function if skilled care and nursing can be 
given for a sufficient length of time. 
It seems evident that great advantages would be gained 
if this complex system, comprising many varieties of 
medical care, were placed under unified direction. In order to 
function efficiently, it can not be administered in sections. 
(d) Provisions for Expansion 
The present magnitude of this problem cannot be de- 
termined. Only an extensive survey of the whole State, with 
classification of disabled individuals according to the type 
of care that they need, would produce really valuable 
estimates. On the other hand, such data as have been 
obtained seem to indicate that it is probably neither 
possible nor wise to attempt a complete solution of the 
problem in one step. Provision should certainly be made, 
however, in the selection of sites and in the architectural 
plans, for the construction of additions to the chronic 
hospitals and infirmaries, as the need for them is established. 
3. The Need for a Central Hospital Admitting Service 
There are a number of steps which are of necessity 
involved in the admission of a patient as a free case to 
a ward in one of the Baltimore hospitals. The first is the 
examination of the individual, which determines that his 
hospitalization is necessary. The second is the investigation 
which shows that his economic status is such that, without 
assistance, he can not pay for hospital care. Finally, a 
hospital must be found which will receive him. 
The first task is obviously that of a physician except in 
accidents or other emergencies, in which the need for 
hospitalization is evident. The task of determining the 
economic status is that of the department of welfare or of 
the hospital. This determination would precede admission 
if the patient’s condition permitted, otherwise it would 
follow. The third task, that of finding an institution that 
will admit the patient, is the duty of no specific person. 
It becomes, therefore, the task of whomever has the problem 72 
Medical Care in the Counties of Maryland 
on his hands, whether it be a physician, a nurse or an 
ambulance driver. For example, a patient enters the ac- 
cident room of a hospital, is obviously ill and requires 
immediate hospitalization. The interne who examines him 
finds that there are no vacant beds in the institution. It 
devolves upon him, or upon the nurse who assists him, to 
find a bed elsewhere for this patient. This must be done 
by calling the admitting office of other institutions in the 
city until one has agreed to take the patient. An ambulance 
is then called to transport the patient to that hospital. 
If, as sometimes happens, the interne is unable to hospitalize 
the patient, some way must be found to care for the patient 
at his home. If the patient resides in one of the counties, 
he must be returned to it. 
There are obvious disadvantages in this procedure. The 
interne is inexperienced in this type of work, not well 
acquainted with the resources of the city, and harassed in 
the performance of this duty by the demands of other 
cases needing his attention. The method is inefficient in 
a second particular in that failures to secure hospital 
accommodations are not recorded at a central office, so 
that unmet medical needs are not brought to the public 
attention. 
In the winter of 1939-1940, for example, when there 
was a high incidence of pneumonia among children, the 
number of hospital beds available for children was in- 
sufficient. A considerable number of children had to be 
treated in the home under the supervision of a dispensary 
physician. This unmet need, however, was not disclosed 
until a specific inquiry by this Committee brought it to 
light. 
It has already been pointed out in Chapters VII and VIII 
that in attempting to hospitalize indigent persons in 
Baltimore, county health and county welfare departments 
reported that it was frequently necessary to make four or 
five long distance calls to various hospitals before a hospital 
could be found which would accept the patient. 
It would seem that some agency should be provided 
with facilities for and charged with the responsibility of 
finding a bed for any indigent case whose need of hos- 
pitalization has been certified by a physician. A central 
admitting office would accomplish this task far more 
efficiently than a physician or nurse. Moreover, there 
would be accumulated in a very few years a record of the 
unmet needs for hospital care which would offer a much 
sounder basis for future hospital development than we now 
possess. 
4. Integration of Independent State Agencies Providing Medical 
Care 
The Executive Committee devoted several sessions to the 
study of the organization chart of the State Government. 
It was observed that a number of State agencies were 
concerned with various aspects of the problem of medical 
care. For example, many departments maintained services 
for the physical examination of their employees or candi- 
dates for employment, each with varying standards. 
Furthermore, it was noted that the administration of 
hospitals and other institutions having to do with medical 
care presented a complex picture. For example, overcrowd- 
ing of institutions for care of psychotic patients was 
reported, and a need for additional beds for patients suffer- 
ing from tuberculosis was indicated. 
In the interest of promoting economy and efficiency, the 
Committee suggested that the many agencies concerned 
should be integrated. It was also agreed that the manner 
in which they might be combined to effect the greatest 
economy should be the subject of further investigation. 
5. The Out-patient Medical Services in the City of Baltimore 
(a) The Problem Defined 
No extensive study of the outpatient facilities of Balti- 
more has as yet been possible, but certain problems relating 
to them have been discussed at meetings of the Executive 
Committee, and their nature is outlined in order to em- 
phasize the need of further study. 
A primary problem is the relative dissociation of the 
medical care given in an outpatient department from that 
received by the same patient in his home, in physicians’ 
offices, in other outpatient departments or in hospitals. 
The outpatient physician has no contact with the patients’ 
home environment, or with the manifestations of illness 
he has suffered there, or the treatment given for it. If the 
patient is admitted to a hospital the outpatient physician 
rarely has an opportunity to follow the patient’s illness 
on the wards, and often after discharge from a hospital 
the patient does not return to the same outpatient phy- 
sician. As a result, the typical outpatient has many physi- 
cians rather than one, and it is natural that he is often 
treated as a case of disease rather than as an individual 
whose disability may be due in part to other types of 
strain than the disease from which he is suffering. This 
handicap of the outpatient type of medical care seriously 
impairs its efficiency. 
Obstetrical departments have found it possible to offer 
a service combining home, outpatient and hospital care. 
The possibilities of organizing similar combined services 
in other branches of clinical medicine should be thoroughly 
explored. 
The outpatient departments in Baltimore vary greatly as 
to the completeness of the medical service which they are 
able to offer to their patients. Faithful attendance and 
interest on the part of the outpatient physicians influence 
greatly the number of patients visiting a clinic. A factor 
of even greater importance appears to be the prestige of 
the institution and the variety of departments and of Activities of the Executive Committee 
73 
facilities which it contains. The tendency to seek treatment 
in the larger clinics associated with the Johns Hopkins and 
the University of Maryland medical schools is overloading 
these clinics, while attendance in the smaller outpatient 
departments tends to remain stationary or even to diminish. 
The smaller institutions are similarly handicapped in 
attempting to provide medical personnel for outpatient 
service since they have no funds for this purpose, and the 
work has little attraction for the physician from an edu- 
cational standpoint. The patient is usually right in as- 
suming that in these institutions he will, if necessary, 
receive the most expert attention, but he is often wrong 
in believing that his particular condition requires more 
than can be well supplied by the smaller outpatient de- 
partment near his home. 
Only more careful consideration than has been possible 
can determine whether it is wiser to encourage the closing 
of some of the smaller clinics or whether it would be 
feasible to limit the intake of the larger clinics to those 
needing intensive study, referred by the less well-equipped 
clinics, or by private physicians. 
(b) Financing Outpatient Departments 
The financing of outpatient departments offers increasing 
difficulties to the institutions to which they are attached. 
In most instances the costs are not available, but in the 
larger institutions here and in other cities, they have been 
found to approximate $1.00 to $1.50 per patient visit, 
exclusive of professional service which is donated by the 
physician. In order to finance the heavy cost of their out- 
patient departments, the larger clinics have been forced to 
charge fees to patients who can pay. The remainder of the 
upkeep must be provided from general hospital funds. Thus 
the desire of the hospitals to maintain their charitable 
work often results in their using some of the income from 
pay patients for service for free and part-pay patients. 
The financial problem thus briefly outlined is not a simple 
one, but surely it deserves further study in the hope that 
some more equitable way of meeting outpatient costs can 
be found. 
In the opinion of the Committee, the principle should 
be adopted that the deficits incurred by non-profit medical 
institutions in giving medical care to free and part-pay 
patients should be met either by voluntary philanthropy, 
or from taxes upon the whole community, but adverse 
balances should not be met even in part by increased 
charges to the pay patients. 
The amount of money available from philanthropy which 
is available for the support of outpatient departments, or 
of hospitals generally, will vary according to the wealth 
of the community. It is of interest, however, that even 
throughout the depression years, certain cities found it 
possible to pay these deficits from their Community Funds. 
In Cleveland, for example, the voluntary hospitals running 
dispensaries, classified all individuals on admission as free, 
part-pay, or full-pay patients. The part-pay patients paid 
various fractions of the cost, according to their income and 
responsibilities. The full-pay patients paid full cost, but 
nothing in excess of cost. A bill was rendered to the Com- 
munity Fund for the deficit incurred in caring for the free 
and part-pay patients. 
In other cities a large proportion of the outpatient work 
is carried on in city dispensaries, in which the entire cost 
is supplied from tax funds. Occasional communities ap- 
propriate from the tax funds to assist in financing voluntary 
outpatient services. In Baltimore the bulk of the outpatient 
work which is done by the medical institutions of this 
city, is not supported by either philanthropy or tax funds. 
Moreover, the City of Baltimore does not conduct any 
large outpatient service in connection with the City 
Hospitals, and the amount of definitive medical care 
provided by the dispensaries maintained by the Baltimore 
City Department of Public Welfare is a small part of the 
whole. 
It should be pointed out that in any true estimate of the 
cost of outpatient medical care, approximately one-half 
would be the value of the services now donated free of 
cost by the physicians staffing these clinics. The com- 
munity has become so accustomed to accepting the medical 
profession’s disproportionate burden in the medical care 
of the indigent, that there is danger that it may assume, 
without justification, that these free services will always 
be available in sufficient amount to meet the needs. Chang- 
ing conditions, however, render it doubtful whether such 
an assumption is justified. 
A physician gives his time to an outpatient department 
partly, it is true, for purely philanthropic reasons, and 
because it is in the tradition of his profession, but also 
because he is influenced to a very considerable extent by 
the educational value to himself offered by this opportunity 
to study disease. 
The value of this educational opportunity in many 
clinics is steadily diminishing for a variety of reasons. 
Adequate study of a patient today is a far more complex 
process than it was a few decades ago. It requires more 
extensive laboratory studies, more X-ray investigation, 
more specialized types of diagnostic and therapeutic equip- 
ment. Many of the clinics, ill-supported as they are, are 
unable to supply these facilities. A physician is then apt 
to feel that he is doing no more advanced work than he 
could do in his own office, and to conclude that as far as 
his philanthropy goes, it will still have extensive applica- 
tion among the free patients in his private practice, and 
that he gains nothing by continuing his association with 
the outpatient clinic. This is one reason why outpatient 
clinics are finding it increasingly difficult to staff their 
departments with an adequate number of physicians. 74 
Medical Care in the Counties of Maryland 
Another difficulty in maintaining outpatient clinics is 
that when overcrowding of a clinic occurs, the patients 
have to be pushed through at such n rate of speed that 
careful work, the only type that has educational value, is 
quite impossible. The physician leaves the clinic often 
late to keep his own appointments, with the sense of 
dissatisfaction that goes with a hastily done task. 
(c) Physical Examination of Applicants for Relief 
To complicate the picture still further, in recent years 
there has been thrust upon outpatient departments by the 
relief agencies, the task of determining the employability 
of relief workers. That such examinations must be made is 
not questioned, but they certainly should be performed in 
places other than in outpatient departments. Those ex- 
aminations seldom provide any real interest to the dis- 
pensary physician, and interest in his work is the chief 
stimulus which impels him to continue to serve in an 
outpatient department. 
(d) Conclusion 
Many of those who have studied these problems feel that 
if the State and the community persist in being pennywise 
in furnishing support to the outpatient departments, they 
may awake to find that, through the need of having to 
pay physicians to staff these institutions, they have been 
pound foolish. 
If, in the discussion of certain aspects of our outpatient 
system in Baltimore, stress has been chiefly laid upon the 
problems which afflict them, and in some instances threaten 
their existence, it is because the chief purpose of the Com- 
mittee’s existence is to point out deficiencies, and to suggest 
remedies. Yet the discussion should not be discontinued 
without drawing attention to the tremendous value to the 
community of the outpatient system as a whole, and to 
the vast amount of medical care it furnishes to the indigent 
and medically indigent of Baltimore, its environs, and 
indeed to the State as a whole. Approximately half a 
million visits a year are paid to these institutions. A very 
high quality of care is given. Any threat to their existence 
or continuing service is of grave concern to all citizens of 
Maryland. 
Summary 
1. It was found that several medical care problems in the 
counties and in the City of Baltimore are inextricably 
interwoven, particularly those which have to do with 
hospitalization, the care of defective and delinquent 
children, mental defectives and tuberculosis, while some 
other problems have a distinctly local character and must 
be solved locally. 
2. The problem of the treatment of chronic disease has 
been discussed, and the urgency of the need for construction 
of hospital centers has been stressed. For medical and 
economic reasons it is suggested that patients be classified 
according to the type of care they require, and that pro- 
visions be made for treatment in the boarding home, 
infirmary, chronic hospital and general hospital, and that 
prompt transfer from one facility to another be made 
possible, as the condition of the patient indicates. It is 
urged that such facilities be localized, and that they be 
placed under unified direction. Until the magnitude of the 
problem is fully determined it is suggested that one or 
two such hospital centers be erected with ample pro- 
visions for expansion. 
3. The several steps necessary at present for securing 
admission of free cases to hospitals in the City of Baltimore 
were detailed, procedures involving loss of time on the 
part of physicians, nurses and others. County health and 
welfare departments both have reported that it was not 
unusual to make several long distance calls before a hospital 
bed could be secured. 
From the foregoing it is apparent that there is a need for 
a central admitting service, the creation of which should 
be one of the earliest concerns of the Council on Medical 
Care. 
4. In the interests of economy and efficiency it is sug- 
gested that efforts should be made to integrate the many 
State agencies now concerned with various phases of 
medical care. The organizations involved and the manner 
in which they should be combined are suggested as topics 
for further investigation. 
5. Problems related to outpatient facilities of Baltimore 
City include consideration of (a) the relative dissociation 
of the medical care given in an outpatient department 
from that received by the same patient in the home, in 
physicians’ offices, and in the outpatient departments of 
other hospitals, (b) the type and quality of medical services 
offered by the different clinics, (c) the source of payment 
for the service rendered; (in the opinion of the Committee 
deficits should not be met, even in part, by increased 
charges to pay patients. About one-half of the value of 
services rendered is donated by clinicians, a dispropor- 
tionate share). In many departments the value of the edu- 
cational opportunity to clinicians is steadily diminishing 
for a variety of reasons—one of which is that of routine 
examinations of applicants for relief. 
The outpatient departments in hospitals in Baltimore 
furnish more than 500,000 visits a year to indigent and 
medically indigent patients in Baltimore, its environs, and 
to a lesser degree in every county in the State. Any threat 
to their existence is of grave concern to all citizens of 
Maryland. Chapter XI 
FURTHER ACTIVITIES OF THE EXECUTIVE COMMITTEE 
Introduction 
T n many of its sessions the subject of medical care in 
rural areas has engaged the attention of the Executive 
Committee of the Committee on Medical Care and phy- 
sicians, dentists, county health officers and public welfare 
officials from rural districts were interviewed. Furthermore, 
as the field study progressed, the findings were reviewed 
and discussed. 
The efforts of the Committee were by no means confined 
to making studies of existing medical care agencies and 
to forming estimates of the costs of such improvements 
as are obviously necessary. Much of the time of this Com- 
mittee and much of its resources were devoted to arranging 
conferences aimed to establish better integration of the 
work of existing agencies in this field. In particular, a 
solution was sought of the fundamental problem—/vW of 
determining the most desirable method of administering the -portion 
of the field of medical care which is partly or completely tax- 
supported. At present both in the City of Baltimore and in 
the counties neither the professional societies, the volun- 
tary health and welfare associations, the departments of 
health nor the departments of public welfare have any 
authorization or responsibility for developing or ad- 
ministering a unified program of medical care. Among 
all those concerned it was vital, therefore, to obtain 
agreement as to the type of administrative control which 
is to be recommended to the legislative bodies of the State. 
The individual members of the Committee have had 
many years intimate contact with the various aspects of 
this problem. Furthermore, in several instances, they have 
played a part in medical relief programs in this State and 
elsewhere. As a result of these experiences and the dis- 
cussions and other activities of the Executive Committee, 
its members have come to hold definite opinions as to the 
essentials which should be embodied in a program for 
medical care in the counties of Maryland. 
The Nature of the Problem of Medical Care in the 
Counties 
The term “medical care’’ signifies the total preventive, 
diagnostic and curative medical services furnished the 
population in their homes, in physicians’ and dentists’ 
offices, in clinics and in general and special hospitals. 
The subject of medical care has received an increasing 
amount of nation-wide attention in recent years. With the 
expenditure of vast sums of money for relief by Federal, 
State and local governments, medical care has come to be 
acknowledged as an integral part of the problem of main- 
taining, at public expense, those who lack financial means 
to support themselves. 
Moreover, for several decades the medical profession, 
those interested in social welfare, and the general public, 
have realized that modern developments of scientific 
medicine have so increased the cost of medical care that 
many of those financially able to provide themselves with 
other necessities are often unable to meet the monetary 
demands incident to serious illness or prolonged physical 
disability. 
Studies of the provisions for medical care for the indigent 
have demonstrated to the Committee on Medical Care that 
in many areas such medical services are, in general, re- 
stricted to bare emergency services, and that these de- 
ficiencies constitute a serious and urgent problem, particu- 
larly when it is clear that the lack of medical care and 
rehabilitation is frequently the basic cause of indigency. 
The nature of the problem varies in different areas, but 
some of its characteristics may be summarized as follows: 
1. The number of physicians in a rural area depends in 
part upon the number of people able to pay a physi- 
cian. In an impoverished area, therefore, with a 
large number of people dependent on free care, there 
are few physicians available. The distribution of 
physicians should be in proportion to the population. 
Instead, it is in inverse proportion to it if poverty 
is general. This situation will grow worse instead of 
better unless a solution can be found. 
2. Public funds for home, hospital and clinic care are 
inadequate in practically all counties. In the counties 
in the lower economic level, the amount of medical 
work which must be done without compensation is 
quite beyond the possible load for the number of 
available physicians and hence only emergency care 
can be given. 
3. Facilities such as consultant services, adequately 
equipped hospitals and clinical laboratories, dental 
and nursing services, were lacking in a number of 
areas, and the level of medical care available to the 
entire population suffered accordingly. 
4. The activities of the State and county departments 
of health in providing special clinics for certain types 
of disease have been very helpful, but they cannot 
be regarded as even a partial solution of the medical 
care problem. A great volume of acute and chronic 76 
Medical Care in the Counties of Maryland 
disease cannot be cared for by these special clinics 
nor was that the purpose for which they were estab- 
lished. The State and county health departments, 
however, aid the practicing physician by furnishing 
certain types of laboratory and X-ray service, drugs 
for the treatment of venereal disease and a variety 
of preventive and therapeutic biologicals. Within 
their legislative and budgetary limits, the State and 
County departments of welfare also played an im- 
portant part in the medical care program as it existed 
in the counties when the field survey was made. 
5. There is no governmental or voluntary agency in the 
counties of Maryland which has any legal responsi- 
bility for organizing medical care for the indigent and 
the medically indigent. In many states this is not the 
case. As a result, in Maryland, while many agencies 
are doing what they can through local agreement 
and friendly cooperation, the large majority deplore 
the existing confusion. This holds true of the medical, 
dental and nursing profession, the State Department 
of Health, the State Department of Welfare, the 
county commissioners and the voluntary health 
agencies. The confusion is illustrated by the fact that 
in most counties when an indigent patient is taken 
ill, he will apply indiscriminately for help to the 
nearest physician, the county health officer, a public 
health nurse, a welfare worker or the office of the 
county welfare department, or to the county com- 
missioners. Medical services are arranged for, if they 
are obtainable, by any expedient that will meet the 
situation, usually by personal requests to a neigh- 
boring physician to give free service, rather than in 
accordance with a definite plan or agreement. 
It has been observed by the Executive Committee that 
there is a widespread and increasing demand that some 
program be evolved to meet these needs, and to correlate 
the work of existing agencies. 
Essential Features in a Long Term Program for 
Medical Care in the Counties 
In any long term program for medical care in the counties 
of Maryland the following features, in the opinion of the 
Committee, are essential: 
1. That adequate medical care be ensured to all, and that the 
normal flow of physicians into these areas be maintained to 
replace those whom age, disability or death have removed from 
active practice. 
In recent years many programs for medical care of the 
indigent among the population are being carried out in 
various sections of this country and in Canada. The chief 
feature in the majority of these plans has been the assump- 
tion by the government of the responsibility of paying for 
certain types of medical care furnished to the indigent by 
physicians of the community. Such programs meet one 
great need, that of enabling communities which can no 
longer support a physician, to retain his services by fur- 
nishing him with an income for his work among the 
indigent. If there are sufficient physicians, the amount of 
medical care of certain types will be adequate. It is apparent 
to the Committee on Medical Care, however, that such 
programs have not touched many fundamental problems 
associated with medical care in rural districts. Emergency 
medical care may thus be provided, but the quality of 
medical care will not be significantly affected. To insure 
a satisfactory level of medical care for a term of years in 
a rural area, it is fundamental that there be a normal flow 
of physicians into that area to replace those whom age, 
disability or death have removed from active practice. 
2. That local facilities for a modern type of medical practice be 
provided. 
The question of assuring a renewal of supply of phy- 
sicians is intimately bound up with the question of enabling 
the local physicians to carry on a type of practice which is 
abreast of modern developments in medicine. A young 
physician considering a county practice will ask himself, 
not only whether he can earn a living in the county, but 
whether he will be able to utilize the skills he has acquired 
during his years of study and hospital training. As new 
developments in medicine occur, he will also be concerned 
as to whether he will be in position to learn of them and 
apply them in his practice, or whether he must find himself 
steadily retrogressing. 
Any program, therefore, which is to ensure adequate 
medical care for a long period, must include the provision 
of local facilities for a modern type of medical practice, 
and also a solution of the problem of providing such 
contacts between the local physician and the medical 
centers, as will enable the physician to give to his patients 
the advantages of the progressive advances in medicine. 
3. That such local facilities should include, among other es- 
sentials, certain types of laboratory and Koentgenological 
services. 
Elsewhere in this report are cited certain studies on the 
distribution of physicians, which indicate that young 
doctors are not entering the less prosperous areas in sufficient 
numbers, with a consequent impairment of medical services 
in rural areas. 
In connection with making diagnostic facilities available 
to the practicing physician, it should be pointed out that, 
even if it were possible for each physician individually to 
equip himself completely with such facilities, it would be 
highly uneconomical and his patients would have to pay 
in the long run for this economic fallacy. Certain types of 
laboratory and Roentgenological services requiring expen- Further Activities of the Executive Committee 
77 
sive primary outlays for equipment and trained personnel 
for their employment, are most economically used if they 
serve a considerable group of physicians or where there is 
an adequate clientele for their use. 
The State Department of Health has made considerable 
progress toward enabling county physicians to obtain 
such services. Its experience indicates that it is advisable 
that certain diagnostic tests be performed at branch labora- 
tories, whereas others are sent in from all over the State 
to the central laboratory, where mass production methods 
enable them to be performed most efficiently and economi- 
cally. An experiment initiated by the Committee on 
Medical Care and now in progress, involving a group of 
three county hospitals, has for its objectives the determina- 
tion of how the State Department of Health branch labora- 
tories may cooperate most efficiently and economically 
with local laboratories. It is hoped that by this arrangement 
the local laboratories will be enabled to give adequate 
laboratory services for the indigent under treatment in the 
clinics of the county health department, and that the 
branch laboratories of the State Department of Health will 
enable the local hospitals to maintain more efficient 
laboratories at less cost by furnishing them with consultant 
and supervisory personnel, and making available to them 
the resources of the State laboratories for tests which 
otherwise could not be performed. 
Further developments in this direction are certainly 
attainable if interest is focused on the objective of ob- 
taining for the practicing county physicians a maximum 
of diagnostic facilities by the most efficient and economic 
methods. 
4. That, in the interest of lowering the cost of medical care, 
serious efforts should he made to improve home care through 
home nursing, laboratory service and other facilities. 
Modern medical practice requires the utilization of the 
hospital for the care of patients with certain types of 
illness, or for the correction of certain handicapping 
physical conditions. Economy demands, however, that the 
patient should not be treated in hospitals unless the hospital 
has positive benefits to offer, which cannot be adequately 
supplied in the home. It appears to be quite feasible to 
improve home care through home nursing services, labora- 
tory service, and other facilities. There can be little doubt 
that the introduction of such services would influence the 
cost of illness. When adequate treatment can be given at 
lower cost than in the hospital, patients should be kept 
at home. Moreover, since hospitals vary in size and type 
of equipment, the hospital to which the patient is taken 
should be the nearest one which can adequately and 
economically furnish treatment for his case. 
3. That arrangements he effected for improving the flow to the 
larger, well equipped medical centers of those seriously ill 
patients requiring highly specialised and expensive diag- 
nostic procedures and treatment. 
A small rural hospital has a very important role to play 
in the community. It can save lives by furnishing near at 
hand emergency care in surgical and medical emergencies 
in which time is of great importance. It can furnish ob- 
stetrical care, medical care for many serious illnesses as 
well as a wide variety of types of surgery. 
On the other hand, there are diagnostic procedures, 
serious types of operations, and other therapeutic measures 
which are beyond the scope of the small rural hospital. 
Some of these conditions may well be handled in the 
larger hospitals in small cities; others may require all the 
resources available in the medical centers of a large city. 
Small rural hospitals have sometimes lost the confidence 
of their communities by permitting members of their staff 
to attempt procedures for which adequate experience and 
equipment were lacking. The transfer of complicated cases 
to the larger medical centers is at the present time hampered 
by transportation difficulties, lack of knowledge on the 
part of the physician of city medical resources, and by 
difficulties connected with the payment for hospitalization 
of indigent county patients. Moreover, in many instances 
when patients return to the counties no adequate record of 
what was done in the city, or what further treatment was 
advised, is made available. The better organization of this 
whole aspect of rural medical care is an important part 
of any future program. 
6. That the local hospital should he more adequately supported 
and equipped. 
Supported by adequate equipment and by consultant 
services, the local hospital will, in the performance of 
its natural function, greatly aid the young physician by 
enabling him to utilize his intensive training, and by 
making it possible for him to put into practice newer 
developments in the field of medicine. 
At present, many of the smaller rural hospitals in Mary- 
land have a low percentage of occupancy. This seems 
explainable in part by the fact that many of them lack the 
equipment and the personnel for certain categories of work 
which should naturally be included within their scope. 
Meanwhile, patients from these areas are compelled to 
make expensive trips to distant centers and the local 
physicians lose the opportunity of treating them. Such 
circumstances not only increase the cost of medical care 
to the citizens of the county, but an opportunity for 
raising the community level of medical care is lost. More- 
over, it discourages young, ambitious physicians from 
establishing themselves in such a community. 78 
Medical Care in the Counties of Maryland 
7. That a definite coordinated State-wide clinic program be 
adopted. 
The clinics for special types of disease which are operated 
at regular intervals in all of the counties of Maryland under 
the supervision of the State Board of Health, the Maryland 
Tuberculosis Association, the Maryland League for Crippled 
Children, and a number of other agencies, constitute an 
important element in medical care in the counties. Not 
only do they enable many indigent cases to receive spe- 
cialized care which they would not otherwise obtain, but 
through the visits of consultants, they give to local phy- 
sicians, who in many instances staff the clinics, a contact 
with newer methods of diagnosis and treatment. The 
clinic program, however, has developed rapidly, ap- 
parently with expediency as the guiding principle rather 
than systematic planning. In some instances local antago- 
nism has been aroused, in others the educational value of 
the clinics to the local physicians has not been developed. 
Both the medical profession and the State Department of 
Health feel that this valuable adjunct in the field of medical 
care of the indigent would be strengthened if a definite 
program could be adopted in the formation and admini- 
stration of which the medical profession, the State Depart- 
ment of Health and the State Department of Public Welfare 
had a voice. 
Summary 
A program of medical care in the counties of Maryland 
must involve a series of definite agreements between the 
practicing physicians, the State Department of Health, the 
State Department of Public Welfare, the voluntary health 
agencies, local and State-wide, and the county com- 
missioners as to what part each shall play and as to what 
classes of cases shall be served by different aspects of the 
program. 
The program must include medical care in the home, in 
the physician’s office, in clinics and also in general and 
special hospitals within and outside the county, according 
to available facilities and the nature of the patient’s 
condition. 
A continuing program must be such as to ensure a 
constant renewal of the supply of'physicians, and of other 
professional personnel. It must be based upon a recognition 
of the fact that such personnel will move into rural areas 
only when they offer a reasonable financial return for 
professional work, adequate diagnostic and therapeutic 
facilities, especially in the form of well equipped local 
hospitals, and some feasible method by which the physi- 
cians can maintain contact with new developments in 
medicine. 
In any long term program for medical care in the counties 
the following are essential features: 
1. That adequate medical care be ensured to all, and 
that the normal flow of physicians into these areas 
be maintained to replace those whom age, disability 
or death have removed from active practice. 
2. That local facilities for a modern type of medical 
practice be provided. 
3. That such facilities should include, among other 
essentials, certain types of Roentgenological service. 
4. That in the interest of lowering the cost of medical 
care, serious efforts should be made to improve home 
care through home nursing, laboratory service and 
other facilities. 
5- That arrangements be effected for improving the flow 
to the larger, well equipped medical centers of those 
seriously ill patients who require highly specialized 
and expensive diagnostic procedures and treatment. 
6. That the local hospital should be adequately sup- 
ported and equipped. 
7. That a definite coordinated State-wide clinic program 
be adopted. Chapter XII 
CONCLUSIONS AND RECOMMENDATIONS 
Conclusions 
Although Maryland is fortunate in her wealth of medical 
facilities and the general high level of medical care received 
by her citizens, and although the profession, on a voluntary 
basis, has unselfishly and untiringly given medical care to 
the indigent, the following important observations have 
been made: 
1. In some sections of the State certain essential medical 
services are not available to the indigent and medi- 
cally indigent. 
2. For many years the State and county health de- 
partments, in collaboration with the State and 
county medical societies, have furnished diagnostic 
and, in some cases, therapeutic services in tuber- 
culosis, venereal disease, orthopedics and mental 
disease. 
3. There has been a growing tendency for the indigent 
and medically indigent to request and receive medical 
care from State and county health departments. 
4. Except in the limited fields of medicine with which 
the State and county health departments are now 
concerned, there is at present no State or other 
agency legally responsible for providing medical care 
for those unable to pay for these services, and there 
is no clearly defined procedure by which such care 
may be obtained. 
The indigent sick may usually secure, without cost, 
a visit from a neighboring physician. As a rule, 
however, for cases of chronic disease, for those re- 
quiring intensive diagnostic study, and for persons 
needing hospitalization, medical care is available 
only when some individual or agency intervenes on 
behalf of the patient and secures the necessary service 
as a matter of charity. 
Recommendations 
The Committee on Medical Care presents the following 
recommendations: 
1. That a program providing medical care for the 
indigent and medically indigent in the counties be 
established by the State of Maryland. 
2. That this program be formulated and administered 
by the State Department of Health which shall be 
held responsible for the compensation of physicians 
and of institutions for services rendered to eligible 
persons. Should Federal legislation provide otherwise, 
it is assumed that this recommendation might be 
modified. 
3. That the State Department of Public Welfare shall 
have no responsibility for providing medical care 
but shall determine the financial eligibility of ap- 
plicants. 
4. That specific appropriations adequate to finance this 
program should be made by the State of Maryland 
to the State Department of Health and to the State 
Department of Public Welfare. 
(a) Appropriations to the State Department of 
Health should provide for payments to physicians, 
hospitals and county health departments for services 
to the indigent and medically indigent; for salaries 
and expenses involved in the administration of the 
program; for the purchase of equipment, supplies, 
drugs and biologicals; and for the provision of 
additional space necessary for the proper conduct of 
these services. 
(bj Appropriations to the State Department of 
Public Welfare should be adequate to provide for the 
discharge of the duties of this agency under the 
program. 
Course of Action Recommended 
To implement these recommendations, the following 
procedures are advocated; 
1. The State Board of Health should be authorized to 
establish a Council on Medical Care which shall act 
in an advisory capacity constituted as follows: 
Two members appointed by the Council of the 
Medical and Chirurgical Faculty of Maryland. 
Two members appointed by the State Board of 
Health, one of whom must be the Director of the 
State Department of Health. 
One member from the Faculty of the Medical School 
of Johns Hopkins University, and one from ihe 
Faculty of the Medical School of the University of 
Maryland, to be appointed by the governing body 
of the respective Medical Schools. 
One Maryland hospital administrator appointed by 
the Maryland-District of Columbia Hospital As- 
sociation. 80 
Medical Care in the Counties of Maryland 
The Director of the State Department of Welfare. 
One dentist appointed by the governing body of 
the Maryland Dental Association. 
One nurse, appointed by the Board of Directors of 
Maryland State Nurses Association. 
The Commissioner of Mental Hygiene. 
The superintendent of the tuberculosis sanatoria of 
Maryland. 
One member appointed by the Executive Board of 
the Maryland Medical Association. 
2. In the interest of economy and efficiency, the Council 
on Medical Care should seek to integrate the many 
agencies of the State Government which are now 
concerned with medical care. 
The organizations which should be included and 
the manner in which they should be combined to 
effect greatest economy should be the subjects of 
further study. 
3- With the advice of the Council of the Medical and 
Chirurgical Faculty of Maryland and of the Maryland 
State Dental Association, the Council on Medical 
Care should recommend to the State Board of Health 
the appointment of medical and dental consultants 
who shall, when requested by local physicians or 
dentists, through appropriate channels, perform the 
duties outlined elsewhere in this report. 
4. A Bureau of Medical Care should be established 
within the State Department of Health for the 
administration of the program. The Chief of this 
Bureau should be a physician who is experienced in 
the organization and distribution of medical care, 
and who serves on a full-time basis. This physician 
should be appointed by the Director of the State 
Department of Health and serve under his supervision. 
5- In cooperation with the county medical societies, the 
county health officers shall administer the local 
aspects of medical care program. 
6. Other phases and details of this program should, so 
far as practicable, follow the suggestions embodied 
in the text of this report. 
The Need for a Separate Study for Baltimore City 
is Indicated 
Although less urgent, it is recognized that a program 
to accomplish similar results must be developed for the 
City of Baltimore. Because of the differing problems, 
however, the Committee on Medical Care considers that 
the formulation of such a program for Baltimore City 
should be the subject of a separate inquiry and report. 
Hospitals for Treatment of Chronic Disease 
Shortly after the Committee began its survey, Governor 
Herbert R. O’Conor appointed a Commission to consider 
the advisability of establishing special institutional 
facilities for the care of the chronically ill. The Committee 
on Medical Care did not, therefore, feel justified in recom- 
mending any specific solution to this problem. It wishes 
to record, however, that all of the information assembled 
by its survey indicates an urgent need for such facilities, 
and in the discussions of the Committee with the medical 
profession, health and welfare department workers, and 
others concerned with the care of the sick, the immediate 
establishment of adequate facilities for the care of the 
chronically ill was considered by them to be of vital 
importance. The Committee urges, therefore, that the 
plans for the establishment of chronic hospitals be con- 
summated at the earliest possible date. APPENDIX Ilrmidrnt 
Dean Lewis. M. D. 
£rcrrtanj 
Walter D. Wise. m. D. 
ijrraaurrr 
J. Albert Chatard. M. D. 
Htfr-|lrralbrnta 
Victor f. Cullen, m. D., 
FIRST VICE-PRESIDENT 
ACTING PRESIDENT 
Frederic V. beitler, m. d. 
William D. Noble. M. D. 
f0riitral anil (Cfjtntrgtral 3Farullg 
of tljr &latr of fEarylaniu 
1211 CCatlfrif»ral &trrrt. 
Salttmurr. 
August 23, 1939 
Mr. AbeljWolman, Chairman 
State Planning Commission 
Baltimore, Maryland 
Dear Sir: 
The Medical and Chirurgical Faculty of Maryland desires to draw your attention to the advantages of con- 
stituting a new Section or Standing Committee of the State Planning Commission whose function it shall be to 
keep under constant survey the problems of medical care for the citizens of this State and to formulate from time 
to time recommendations for better utilization and for extension of existing medical facilities and for the in- 
stitution of such new facilities as are required. 
We are using the term “medical care’’ in an inclusive sense to cover all the agencies available in safeguarding 
and improving the health of the people and in the treatment of disease. It may be interpreted therefore as com- 
prising lay and professional medical education, sanitation, preventive medicine, curative medicine, dental and 
nursing care, and pharmacy. It is evident that there exist today, and, in view of the rapid advances in medical 
science, that there will always exist difficulties in making available to all the highest standard of medical care. 
It would be the function of such a committee as we propose to be constantly comparing what is available in the 
way of medical care in our State with what is known to be valuable and to plan systematically to repair the 
deficiencies in our present system. 
Though Maryland is fortunate as compared to the majority of States in her wealth of medical facilities and 
in the average high level of medical care which her citizens receive, yet this Committee will quickly become 
aware of many urgent needs for improvement. 
Among the deficiencies in the present system of medical care in Maryland the following may be cited as 
outstanding examples: 
(1) Lack of facilities for hospital care for Negro patients in the counties. 
(2) The lack of adequate support for the out-patient departments of city and county hospitals. 
(3) The lack of funds or organization for the medical care in their homes of those upon relief and for other 
classes of indigent patients. 
(4) The lack of facilities for postgraduate education for practicing physicians. 
(5) The inadequate buildings, equipment, and budget of certain county hospitals. 
(6) The lack of beds in the counties for the care of chronically disabled patients. 
(7) The lack of adequate accommodations for existing institutions for the feeble-minded, especially among 
the colored race. 
These urgent needs are cited merely as instances of some of the problems which demand solution. 
The needs just cited are well known to our Welfare Boards, to our Boards of Health, to this Faculty, and, 
in general, to social service workers, physicians, nurses and all those who devote themselves to the medical care 
of the population. Efforts have been made by all of these agencies to obtain improvements. There has, however, 
never existed an official warrant for any group to evolve a coordinated program in which all health agencies would 
play a part. The problems require such a cooperative effort for their solution and it is the opinion of this Faculty 
that only through the efforts of a Committee with official standing and in the membership of which the various 
health agencies are represented can such a cooperative program be achieved. The existing system of medical care is composed of many interrelated elements. It derives its support from the 
fees of private patients, from the philanthropic contributions of the general public to medical institutions, from 
the philanthropic donations of service by the medical profession and from tax funds devoted to public health and 
to the support of medical institutions. 
There is general agreement that an increase of the financial support derived from tax funds is a requisite to 
adequate development of medical care. It is vital, however, that the program for such State-supported improve- 
ments in our present system of medical care be devised so as to conserve all of the valuable assets we now possess 
and not be planned in a manner which would set one form of medical service in competition with another to their 
mutual disadvantage. 
Only a Committee which includes representatives from the agencies best acquainted with the different aspects 
of the present system of medical care can wisely devise a program for the most efficient development of this system. 
Further, it seems desirable that such representatives of the various health agencies should be selected from a list 
of nominees furnished by each agency, since the executive body of each agency is best acquainted with the special 
qualifications of its members. Moreover, since the public is to be on the one hand the chief beneficiary of improved 
medical care and on the other hand the chief source of financial support it seems evident that there should be lay 
representation. 
Upon the basis of these principles the Faculty suggests the following tentative composition of the proposed 
Committee: 
The State Welfare Board. ..... .. ... 1 member 
The Baltimore City Welfare Board 1 member 
The Maryland State Board of Health. 1 member 
The Baltimore City Health Department .1 member 
The Medical and Chirurgical Faculty 1 member 
The Baltimore City Medical Society 1 member 
The Maryland Medical, Dental and Pharmaceutical Association (Colored).. 1 member 
The Maryland Dental Association .......... .1 member 
The Maryland Mental Hygiene Society. ..... 1 member 
The Maryland Tuberculosis Association .1 member 
The Maryland State Nursing Association 1 member 
The Baltimore Hospital Conference. .. ..... 1 member 
The Maryland Conference of Social Welfare 1 member 
The Maryland Pharmaceutical Association.. .... 1 member 
The University of Maryland Medical School 1 member 
The Johns Hopkins Medical School .. 1 member 
The Johns Hopkins University School of Hygiene and Public Health 1 member 
From the lay community.. ... 3 members 
This list does not represent all aspects of medical care, but in the interest of compactness has been selected to 
cover the chief categories. 
It is evident that to work effectively such a Committee must have a salaried Executive Secretary and steno- 
graphic assistance. The funds for such services will have to be sought from the public, from the State or from the 
participating agencies. The Medical and Chirurgical Faculty has no funds available, but as a token of its sincere 
desire to forward the formation of this Committee, members of its Council will pledge themselves to raise the 
sum of five hundred dollars yearly for three years, by private subscription from the membership, to be applied 
to the expenses of the Committee. 
We trust that as Chairman of the Maryland Planning Commission you will give careful consideration to the 
advantages of forming such a Committee on Medical Care and will recommend to the Governor the steps towards 
its organization. 
Very sincerely yours, 
Victor F. Cullen, 
Acting President, The Medical and Chirurgical Faculty of Maryland.