Hospital Survey ™,i Plan for the State of Wlaryland Wlaryland State Planning Hpnl-IQOS Hospital Survey and jP for the State of Maryland Prepared by the HOSPITAL SURVEY COMMITTEE of the COMMITTEE ON MEDICAL CARE / / larylanclState Planning April - "By no other token or index is contemporary society better measured than through its willingness to see that every useful resource of the medical sciences for the accurate and helpful diagnosis and treatment of disease is made available to those who need it." Haven Emerson, M.D. MARYLAND STATE PLANNING COMMISSION PUBLICATION No. 53 For sale by the Maryland State Planning Commission 100 Equitable Building Baltimore 2, Maryland Price $1.00 MARYLAND STATE PLANNING COMMISSION Henry P. Irr, Chairman Member at Large Joseph R. Byrnes Legislative Council John B. Funk Department of Public Improvements William L. Galvin State Board of Public Welfare Robert M. Reindollar State Roads Commission Robert H. Riley State Department of Health Thomas B. Symons Member at Large I. Alvin Pasarew, Director COMMITTEE ON MEDICAL CARE *Maurice C. Pincoffs, M.D., Chairman *J. Douglas Colman, Secretary George M. Anderson, D.D.S. *Charles R. Austrian, M.D. F. V. Beitler, M.D. James W. Bird, M.D. Frank L. Black, M.D. T. Roy Brookes B. Lucien Brun, D.D.S. James D. Carr, M.D. Alan M. Chesney, M.D. Louis H. Douglass, M.D. Allen W. Freeman, M.D. Frank J. Geraghty, M.D. *Harry Greenstein R. C. Lamb Carroll Lockard, M.D. Mrs. George V. Dottier George M. Moffett Leslie W. Moses Walter H. Oakes Thomas W. Pangborn I. Alvin Pasarew J. Milton Patterson George H. Preston, M.D. Robert H. Riley, M.D. Henry E. Sigerist, M.D. *Winford H. Smith, M.D. Walter Sondheim Harvey B, Stone, M.D. Mrs. Thomas J. Tingley Ralph P. Truitt, M.D. Thomas J. S. Waxter Huntington Williams, M.D. *C. E. Wise, Jr. Samuel Wolman, M.D. Member of Executive Committee HOSPITAL SURVEY COMMITTEE D. Wise, M.D., Chairman *J. Douglas Colman, Secretary J. David Cordle W. D. Noble, M.D. Maurice C. Pincoffs, M.D. George H. Preston, M.D. Robert H. Riley, M.D. *Winford H. Smith, M.D. *Ernest L. Stebbins, M.D. Harvey B. Stone, M.D. Huntington Williams, M.D. C. E. Wise, Jr. Benjamin W. Wright Peregrine E. Wroth, Jr., M.D Edwin P. Young, Jr. Ralph Young, M.D. G. Fritz, Director * Member of Steering Committee MARYLAND STATE PLANNING COMMISSION JOSEPH R. BYRNES JOHN B. FUNK WILLIAM L. GALVIN ROBERT M. REINDOLLAR ROBERT H. RILEY THOMAS B. SYMONS HENRY P. IRR Chairman 104 EQUITABLE BUILDING BALTIMORE 2, MARYLAND I. Alvin Pasarew Director April 1, 1948 Honorable Wm. Preston Lane, Jr. Governor of Maryland Annapolis, Maryland Dear Governor Lane: I take great pleasure in transmitting herewith the “Hospital Survey and Plan for the State of Maryland,” which was prepared by the Hospital Survey Committee of the State Planning Commission. Under date of March 26, 1948, Dr. Thomas Parran, the Surgeon General of the United States Public Health Service, announced that “the Maryland State Plan meets the requirements of Section 623(a) of the Hospital Survey and Construction Act and is hereby approved.” Accordingly, the State of Maryland is entitled to a Federal allotment of $870,800 annually for five years, which will be used for the construction of public and other nonprofit hospitals included in the State Plan. One third of the expenditures for each approved project will be provided by these Federal funds and two thirds by the local hospital sponsors. Pursuant to Chapter 810 of the Acts of 1947, the State Board of Health has been charged with the responsibility of administering the Plan. Applications are currently being received for high-priority projects, and before long some of the State’s most urgent needs for hospital and public health facilities should be realized. In behalf of the Commission, I should like to make grateful acknowledgment of the valuable services rendered by the members of the Hospital Survey Committee, who contributed so generously of their time and experience in the consummation of the Plan. By surveying the hospital and public health needs of the State and proposing a long-term plan of construction and improvements, they have made a lasting contri- bution to the health and welfare of the people of Maryland. I should like also to take the opportunity to thank you for the warm encouragement and cooperation you have given to the State Planning Commission in every step of this important undertaking. Respectfully yours, Henry P. Irr, Chairman MARYLAND STATE PLANNING COMMISSION JOSEPH H. BYRNES JOHN B. FUNK WILLIAM L. GALVIN ROBERT M. REINDOLLAR ROBERT H. RILEY THOMAS B. SYMONS HENRY P. IRR Chairman 104 EQUITABLE BUILDING BALTIMORE 2, MARYLAND I. Alvin Pasarew Director December 18, 1947 Mr. Henry P. Irr, Chairman Maryland State Planning Commission 104 Equitable Building Baltimore 2, Maryland Dear Mr. Irr: In accordance with your recent request, the Committee on Medical Care has studied and reviewed the Report of the Hospital Survey Committee. As required by the provisions of the Hospital Survey and Construction Act, a public hearing was held on December 4, 1947, notice of which appeared in most of the newspapers of the State. In addition, notices of the hearing were mailed to all existing hospitals, all persons known to be interested in developing new hospitals, county health officers, members of the Legislature, and other interested and representative groups. Before a large and interested audience, the important phases of the hospital con- struction program outlined in the Report of the Hospital Survey Committee were explained in detail. In the discussions which followed the presentation of the various sections of the Report no new ideas were presented, nor were any objections made to the provisions of the Report, which, in the opinion of the Committee on Medical Care, necessitated any reconsideration of the Report. Therefore, as authorized by the Committee on Medical Care at its meeting on November 6, 1947, I hereby reccmmend to the Maryland State Planning Commission the acceptance of the Report of the Hospital Survey Committee and its transmission to the State Department of Health and the Surgeon General of the United States Public Health Service. Very truly yours, Maurice C. Pincoffs, M.D., Chairman Committee on Medical Care MARYLAND STATE PLANNING COMMISSION JOSEPH R. BYRNES JOHN B. FUNK WILLIAM L. GALVIN ROBERT M. REINDOLLAR ROBERT H. RILEY THOMAS B. SYMONS HENRY P. IRR Chairman 104 EQUITABLE BUILDING BALTIMORE 2, MARYLAND I. Alvin Pasarew Director Mr. Henry P. Irr, Chairman Maryland State Planning Commission 104 Equitable Building Baltimore 2, Maryland September 19, 1947 Dear Mr. Irr: The report of the Hospital Survey Committee, including the Hospital Survey and Plan for development of hospital facilities within the State of Maryland, is submitted herewith. The survey was completed late in 1946 and its preliminary findings and recommenda- tions were published as the Interim Report of the Committee. On the basis of the findings of the survey, combined with geographic, economic, and other factors, a long-range plan was developed for the construction and distribu- tion of facilities felt to be needed to bring the total of such facilities in line with the need in each of the fields of hospital service. In its work the Committee used as a guide the stipulations of the Hill-Burton Bill (Public Law 725-79th Congress) and the regulations promulgated thereunder by the United States Public Health Service. It is felt that the Plan fully complies with all Federal requirements and is in such form that it should receive the approval of the Surgeon General. Approval by the Surgeon General will qualify for aid from Federal funds such hospital construction done in accordance with the Plan up to the limits of such funds available. Throughout the period of the work, we have had the assistance and cooperation of various State and private agencies. This assistance has been of great value and is appreciated. The report does not purport to recommend solutions for all important problems. It is expected that further study and refinement of the plan will be made by the Depart- ment of Health and its Advisory Council on Hospital Construction, which is the agency responsible for the execution of the Plan. However, the Plan, as presented, does sup- ply a program for development of the State and will have many other uses if it re- ceives the careful attention of the various interests concerned. Respectfully yours, Walter D. Wise, M.D., Chairman Hospital Survey Committee CONTENTS Page FOREWORD XV SUMMARY xvii PART 1 hospital survey and construction program Chapter 1. Hospital Survey and Construction Act 1 Chapter 2. Hospital Survey Committee.. 2 PART II THE field survey Chapter 3. Hospitals, Nursing Homes, and Pub- lic Health Facilities. 4 Chapter 4. Classification of Institutions 6 PART III PLANNING Chapter 5. Introduction 14 Chapter 6. General Hospitals 16 Section 1: Allocation of beds and establish- ment of priorities 20 Section 2: Service areas 21 Allegany County 21 Baltimore Base Area 25 Anne Arundel County 28 Baltimore City 30 Baltimore County, 35 Page Carroll County. .. 36 Harford County 38 Howard County... 40 Calvert County 41 Cecil County 43 Charles County 45 Dorchester County 47 Frederick County 49 Garrett County . 52 Kent and Queen Anne’s Counties 54 Montgomery and Prince George’s Counties 57 St. Mary’s County.. 62 Somerset County. 64 Talbot and Caroline Counties 66 Washington County 68 Wicomico County 71 Worcester County. 73 Section 3. Regional integration of facilities ... 75 Chapter 7. Tuberculosis Hospitals 78 Chapter 8. Facilities for Chronic or Long-Term Patients 86 Chapter 9. Mental Hospitals 91 Chapter 10. Public Health Facilities 99 PART IV priorities Chapter 11. Priorities System 103 Chapter 12. Allocation of Priorities by Category 107 Appendices. 110 LIST OF TABLES AND ILLUSTRATIONS TABLES Page table A. Institutions by Type of Ownership or Control and by County - 4 table B. Institutions by Type of Service and County 6 table c. Bed Complement by County, Type of Institution, and Racial Assignment 7 table D. Bed Complement of Institutions Re- grouped According to Broad Classifica- tion 7 table E. Bed Complement and Normal Bed Capacity of Institutions after Reclassi- fication and Exclusions .. 8 table F. Normal Bed Capacity by County, Type of Ownership, Type of Institution, and Racial Assignment 9 table G. General Hospitals, Bed Complement and Normal Bed Capacity by Racial Assignment . ..... 10 table H. Tuberculosis Hospitals, Bed Comple- ment and Normal Bed Capacity by Racial Assignment 11 table I. Nursing Homes and Institutions for Chronics, Bed Complement .. .12 table J. Mental Hospitals, Bed Complement and Normal Bed Capacity by Racial Assignment 13 table K. Special Hospitals, Bed Complement and Normal Bed Capacity by Racial Assignment 13 table L. General Hospitals, Comparison of Ex- isting Normal Bed Capacities with Standards Established by Public Law 725 for Base, Intermediate, and Rural Areas 15 table M. Utilization of General Hospital Beds. .. 18 table N. Geographic Distribution of Patients Discharged from General Hospitals, Based on Sample Studies— between 18 and 19 Page table o. Baltimore Base Area, Population Trends, 1920-1945 ... 26 table P. General and Special Hospitals of Bal- timore City, Bed Complement by Type of Service ... . ... ..... 32 table Q. Proposed Construction at Nonprofit General Hospitals Available to Non- white Patients, Baltimore City .... . 33 table R. Distance from Population Centers to Nearest Available State Tuberculosis Sanitorium 81 table s. Beds Needed for Tuberculous Patients by County, Region, and Race, Accord- ing to 1945 Tuberculosis Deaths 83 table T. Per Cent Distribution of Population of Maryland by Age, 1900-1940 86 table u. Allocation of Proposed Additional Beds for Mental Patients 96 table V. Priority Points for General Hospitals, Met Need Adjusted by Utilization of Existing Facilities 103 table w. Schedule of Priorities . 108 ILLUSTRATIONS map 1. Hospital Service Areas 17 MAP 2. Population Distribution Related to General Hospital Service Areas of 12.5- Mile Radius 19 map 3. County Residents Admitted to Hospi- tals in Baltimore City, 1940 27 map 4. Regional Integration of Services 76 map 5. Tuberculosis Hospital Facilities 79 map 6. Mental Hospital Facilities 92 map 7. Public Health Facilities 100 chart 1. Occupancy Rates for General Hospi- tals, United States and Maryland..... . 104 FOREWORD Health consciousness, manifest as an active public interest in the personnel, services, and facilities available for the restoration and preservation of health, has grown remarkably since the turn of the century. Adequacy of health services and facilities and the means to make them available geographically and financially are now vital public issues. With the development of medical practice from empiric tenets to a scientific art, the doctor’s satchel and office equipment combined with his training and experience have ceased to be his total armamentarium. As his accessories, research and discovery have added therapeutic and diagnostic equipment, ranging from light globes the size of a grain of wheat to the million- volt X-ray apparatus and the electronic microscope. As a result, the scope of medical knowledge has grown so broad and the complexity of the equipment so great that specialists within the profession and expert technicians are now required. This broadening of medical knowledge has caused the financial investment necessary to grow beyond the capacity of individual physicians. The hospital was the natural place for the installation of this equipment and the employment of the personnel needed for its effec- tive use. Prior to the introduction of diagnostic and thera- peutic measures and equipment, the discovery of anesthesia had made surgery possible and the develop- ment of aseptic techniques had made it safe. The oper- ating room with its equipment became a most important part of the hospital. The hospital gradually advanced from its limited utility of offering only domiciliary care, for which the indigent were referred because of lack of home facili- ties. It ceased to be the place of last resort. Instead, it became the place of first resort for the care of the sick and injured. With patients available for clinical study and with equipment and trained personnel, staff research became an important function. The need for additional trained personnel made necessary programs for the training of doctors, nurses, and technicians, thus placing the hospital in the educational field. The newly found medical skills have resulted in the discovery of many diseases and pathological conditions and the development of techniques for their treat- ment. Conditions formerly thought to be hopeless have been brought within the field of curable diseases. The duration of illness has been reduced. This factor has been offset by care of patients with conditions which formerly had gone unrecognized or had been considered incurable. The percentage of births in hospitals has increased significantly. It is expected that this trend will continue until practically all births occur within hospitals, provided hospital capacities keep pace with the increased demand. As a result of the multiplicity of techniques necessary for treatment of the different types of patients, general hospitals have classified their service into depart- ments, such as surgical, medical, obstetric, pediatric, isolation, and others. Specialized hospitals have also been established for the care of limited types of patients, such as mental, tuberculosis, children, women, and those having diseases requiring isolation. The investment in materials, buildings, and equip- ment and the accompanying payrolls for highly skilled personnel have created financial problems, mounting in direct proportion to the broadening of the field. The financial side of medical care now presents two dis- tinct phases. Securing funds for the original invest- ment in construction and equipment is the first. The continuing operation of the hospital, which now en- tails annual operating costs equivalent to approximately one third to one half of the capital investment, is the day-to-day problem. Local and State subsidies and community funds have been established in order to make services available to all. During the last decade Blue Cross plans were developed as a means of budgeting for hospital needs. By this method, the large class of employed individuals were removed from the marginal group who were usually able to finance the ordinary costs of living but to whom medical expenses were frequently a financial catas- trophe. These persons were formerly part of the group known as the medically indigent. Motivated by a desire for the preservation of life and by the realization that means were known to approach this end, a universal demand has developed for the installation of hospital facilities within reasonable traveling distance of every home. Labor organizations have bargained with employers for the creation of funds to establish medical facilities and for the pay- ment of services rendered their members and depend- ents. Some employers voluntarily have included health programs with the perquisites offered their employees. By these means much has been accomplished toward making hospital services physically and financially available to greater numbers. Demand has in most communities exceeded the avail- able facilities. Due to variations in community educa- tion in the use of hospitals and financial resources, the establishment of hospitals has not been uniform. Some communities have what would appear to be an ade- quacy, but in large areas there are serious deficiencies. The inequity of area facilities is generally paralleled by a similar maldistribution of doctors, nurses, and trained personnel. The progress in hospital programs and the con- comitant health consciousness have created a mounting demand for adequate facilities until it has become a nation-wide issue. A variety of legislation has been proposed to provide anything from isolated phases of medical care to broad programs intended to cover every need “from the cradle to the grave.” Some of these have been enacted. The Hill-Burton Bill, under which state and national surveys of hospital facilities are being conducted, was passed by Congress and signed by the President (see Appendix A, Public Law 725). Under the Law, Federal FOREWORD—Continued funds are provided to assist the States with the cost of surveying their medical facilities. Congress is also authorized to appropriate funds to be allocated to the States as grants toward the construction of needed facilities. Health consciousness of the public, therefore, has culminated in the enactment of a Federal law which is intended to measure existing facilities against needs and to aid in providing the facilities necessary to correct the inequalities. Acknowledgments The Hospital Survey Committee is indebted to many individuals and private and government agencies for their valuable assistance. The following is a partial list of those to whom credit is due: AMERICAN COLLEGE OF SURGEONS AMERICAN HOSPITAL ASSOCIATION AMERICAN MEDICAL ASSOCIATION BALTIMORE ASSOCIATION OF COMMERCE BALTIMORE CITY HEALTH DEPARTMENT BOARD OF MENTAL HYGIENE DR. W. ROSS CAMERON DEPARTMENT OF LEGISLATIVE REFERENCE DEPUTY STATE HEALTH OFFICERS HOSPITAL ADMINISTRATORS MARYLAND-DISTRICT OF COLUMBIA HOSPITAL ASSOCIATION MARYLAND HOSPITAL SERVICE, INC. MARYLAND STATE DEPARTMENT OF HEALTH BUREAU OF MEDICAL SERVICES BUREAU OF VITAL STATISTICS MARYLAND STATE NURSES’ ASSOCIATION MARYLAND TUBERCULOSIS ASSOCIATION SALES MANAGEMENT MAGAZINE STATE BOARD OF NURSES’ EXAMINERS STATE ROADS COMMISSION UNITED STATES BUREAU OF THE CENSUS UNITED STATES PUBLIC HEALTH SERVICE To those whose names are not included, the Com- mittee extends its sincere thanks. SUMMARY The charges under which the project was con- ducted were1: 1. To survey existing institutional facilities for the care of the sick and for the rendering of public health service. 2. To analyze the facts governing the availability and use of these facilities. 3. To define the need for additional facilities. 4. To develop a long-range program whereby exist- ing facilities and such additional facilities as are recommended may operate to provide a compre- hensive and integrated hospital service for the citizens of Maryland. Recommendations of the Commission on Hospital Care and the provisions of the proposed Hospital Sur- vey and Construction Act were used as a guide and adapted to local conditions and thinking. Enactment of the Hospital Survey and Construction Act (Public Law 725 of the 79th Congress) was urged by many groups and became law on August 13, 1946. The Law authorizes Federal funds to be made avail- able equal to one third of the cost of the survey and planning program and one third of the cost of construc- tion under the program. The allotment of survey and planning funds to states is based on population. Allot- ment of construction funds takes into consideration population and per capita income. Maryland’s share of the funds for survey and planning is $46,158, plus $870,300 annually for a period of five years for con- struction. Grants are limited to governmental and nonprofit organizations. Hospitals were grouped and studied under the fol- lowing classifications: 1. General hospitals {{pp. 16-77) 2. Tuberculosis hospitals {pp. 78-85) 3. Chronic disease hospitals {pp. 86-90) 4. Mental hospitals {pp. 91-98) 5. Public health facilities {pp. 99-102) It is emphasized that these classifications are not at all independent of each other. Their services should be integrated and their physical structures closely re- lated and, if possible, joined. The priority schedule was purposely designed to promote such integration. General hospitals General hospitals will become general in fact when they include departments for mental, tuberculosis, chronic, and convalescent patients and establish out- patient services in these fields. Existing hospitals are reasonably well distributed, but at no point in the State is there an adequacy of beds {Map 2, p. 19; Map 3, p. 27). Their utilization varies from 30.6% to 122.8% of capacity {Table M, p. 18). This factor was used in establishing the priority schedule. General hospitals were treated on an area basis. Logical service areas for hospitals were established, taking into consideration population, geographic boundaries, transportation, and trade patterns. The areas range in size from single counties to the base area which includes Baltimore City and the five surrounding counties (Map 1, p. 17). The areas were later consolidated into regions for the purpose of demonstrating where facilities could be found if they were not available locally (Map 4., p. 76). General hospitals are conveniently located through- out the State, with the exception of four areas: Garrett, Carroll, Caroline, and Worcester counties. Projects are being actively planned by sponsoring groups in each of these areas. Groups in Garrett and Worcester counties are plan- ning general hospitals. In Caroline and Carroll coun- ties, groups are planning public health centers. Worces- ter, Caroline, and Carroll counties are served by general hospitals in communities located at reasonable dis- tances. Many of the existing hospitals are utilizing structures, all or part of which could be justifiably recommended for replacement. Most of them need to expand their capacity to meet the existing need. Few general hospitals conduct organized outpatient clinics, but practically all render diagnostic service to both inpatients and outpatients. While such programs are in a high state of development at a few hospitals, principally in Baltimore City, they are available to a limited extent throughout the State. Educational programs in the form of postgraduate training for nurses and physicians, schools for student nurses, internes, and resident training are conducted in Baltimore City. Outside of Baltimore City, educa- tional programs are largely limited to schools of nursing. In the field of medical education in general hospitals, all phases are covered at some point in the State, but there is again the problem of adequacy and distribution. Research is carried on quite extensively in Baltimore City, but no general hospitals in the balance of the State are engaged in active formal research programs. Tuberculosis hospitals Maryland has made limited provisions for tuber- culosis patients at its State-owned institutions. These are supplemented by nonprofit institutions. Tuberculosis hospitals are not satisfactorily distri- buted geographically (Map 5, p. 79). Assignment of their beds by race is not in equitable ratio to existing needs. Inadequacy of beds and improper geographic distri- bution is defeating educational programs in this field 1Interim Report of Committee on Medical Care, Maryland State Planning Commission, January 1947, pp. 19-38. and causing infected persons and their families to forego the benefits and protection of institutional care. The need for additional facilities was based on a standard of 2.5 beds per tuberculosis death per year. The allocation of facilities was based on regions estab- lished in the study of general hospitals. Changes in thinking with regard to tuberculosis facili- ties make it appear that the State-owned hospitals con- structed in an earlier day are not altogether proper as to design and location. Until the time when new con- struction can be undertaken, the existing institutions will have to be utilized. When the increased capacity approaches the need, changes can be made, such as the elimination of open-air pavilions. Clinics held in the counties and Baltimore City and the mass X-ray program being conducted in conjunc- tion with the Maryland Tuberculosis Association are fulfilling to a degree the case-finding phase of the pro- posed program. Educational programs for the public are being conducted by the State Department of Health, the Health Department of the City of Bal- timore, and the Maryland Tuberculosis Association. Transfer of the State-owned institutions to the De- partment of Health is a step toward integration of the entire program under one State office and can be ex- pected to bring about an improvement in the program in all its phases. The greatest urgency in this field is related to the care of tuberculosis nonwhite persons. Chronic disease hospitals Official action on a State program in the field of chronic disease hospitals was taken only in recent years. The construction program is just getting under- way with the first new institution at Deers Head, near Salisbury. An arrangement has been made for the use of buildings at Camp Ritchie as a temporary chronic disease hospital until the one planned for Hagerstown can be built. Even though the chronic disease hospital program has not yet started to function, it is to the credit of the State that it has officially recognized the need and has taken concrete steps toward meeting it. The projected State construction program should be expedited. Conditions existing in many nursing homes in which such patients are accepted are forceful testi- mony to the need. Chronic disease hospitals must include departments for chronic, convalescent, and incurable patients. They must maintain an active program of rehabilitation, or otherwise they will become merely domiciliary institu- tions. Grants to welfare clients should be supplemented in cases where a disabling illness exists, for the purpose of making possible the purchase of necessary services and medication. Mental hospitals Mental hospital capacities are seriously short of the need. Their geographic distribution is unsatisfactory (Map 6, p. 92). They have grown to the point where further ex- pansion is of doubtful advantage when weighed against a program for the construction of new facilities at new locations. Psychiatric departments of general hospitals are an important need and have been given high priority for the purpose of encouraging their establishment. The situation in the case of the acutely mentally ill is quite different from the tuberculous patients in that the condition is usually evident and the need for in- stitutional care is imperative rather than optional. As a result, the mental hospitals are crowded beyond their capacities in spite of the fact that personnel falls short of the needs of the normal capacity. The program enacted by the 1947 Legislature, authorizing construc- tion of housing for personnel, is a proper step toward alleviating the unsatisfactory conditions. A construc- tion program for the accommodation of more patients should be undertaken as early as possible. The mental health program which will have the benefit of Federal subsidization will broaden the service in this branch of the work. Public health facilities Public health facilities under the organizational ar- rangement by which Baltimore City and each of the counties has its own health department is very satis- factory (Map 7, p 100). The housing facilities for the centers are in most cases rented and unsatisfactory. A program for the construction of public health cen- ters is urged. Clinics operated outside of the centers usually require few specially designed facilities and can with some planning be adapted to rented places available. Personnel Every phase of the health program is impeded by shortage of personnel, both skilled and unskilled. The planned program of hospital construction will create an increased demand for all types of trained personnel. Educational programs for the training of laboratory, X-ray, and other types of technicians are in effect, but the number of graduates is short of the need. The same condition applies to the field of nursing. In recent years, many positions have been created for nurses in fields other than hospitals and bedside nurs- ing. Industry, commercial aviation, government, and other employers have established positions with train- ing in nursing as a basic qualification. Because of the competition for the services of trained personnel, hospitals are faced with the conflict between meeting the higher salary costs and the limitations of the patients’ ability to pay for the services. The entire field of trained personnel is one which should be studied further for the purpose of increasing recruitments and training to meet the growing de- mands. The establishment of salaries should be based on the value of services rendered and the ability of the public to purchase such services. xviii Physicians Study should be given to a program by which the services of specialists can be made routinely available for consultation with other physicians throughout the State. In line with the planned expansion of hospital facilities, it is important that formal action be taken to assure availability of competent professional persons. Veterans' facilities Federal-owned institutions were not included in the survey since these facilities are not available to the general public. However, with a significant number of residents qualifying for admission to such hospitals, the demand on other institutions is lessened. Con- versely, competition for personnel is increased. The Federal Government operates eight institutions in the State of Maryland: Type of Hospital Location Bed Capacity General Aberdeen Proving Ground 12 General Annapolis 275 General Bainbridge 1,601 General Baltimore 563 General Fort Meade 113 General Edgewood 56 General Fort Howard 364 Mental Perry Point 1,633 Priorities The need for additional facilities in all categories is far in excess of the amount that can be provided for with the present allotment of Federal funds. Ac- cordingly, considerable construction will have to be undertaken without the benefit of such assistance. For the purpose of allocating the limited Federal funds available to the points of greatest need, a sys- tem of priorities was developed (Table V, p. 103, and Table W. p. 108). The method devised will encourage the establishment of facilities in the order of the degree of public need for them. In determining the extent of need, such factors as population density and trends, geographic and racial distribution of population, per capita income and the ability of the community to support added facilities, transportation, industry, and commerce, were considered in relation to the existing hospital facilities. Further study needed This survey and the plan which it projects reveal the need for further study. They indicate not only the degree to which the problem of the care of the ill in Maryland has grown but also the discrepancy between existing facilities and present needs. As the concept is reoriented from one of meeting local needs in specific fields to considering current and projected needs in all the categories of medical services, new problems become apparent. The need for correla- tion of programs between institutions and fields of service is parelleled by the need for planning in the education of nurses, physicians, and other technical personnel. Serious consideration should be given to the integration of medical services for the purpose of making specialized services broadly available. These problems rest with the responsible authorities of the institutions and with the representatives of the various fields, working with the Committee on Medical Care of the State Planning Commission. The Plan as projected fully complies with the re- quirements of the Hospital Survey and Construction Act (Public Law 725 of the 79th Congress) and, sub- ject to the approval of the Surgeon General of the United States Public Health Service, should qualify the State of Maryland to receive Federal funds for hospital construction.1 xThe Maryland State Plan was approved by the Surgeon General of the United States Public Health Service on March 26, 1948. XIX PART I HOSPITAL SURVEY AND CONSTRUCTION PROGRAM1 Chapter 1. HOSPITAL SURVEY AND CONSTRUCTION ACT Congress passed the Hill-Burton Bill, known as Senate Bill 191, or the Hospital Survey and Con- struction Act, as one of the last acts of the 2nd Session of the 79th Congress. President Truman signed it on August 13, 1946, and it became known as Public Law 725. Under the Law, the work is divided into two phases, named in the title. The first phase is the survey and preparation of a plan. The second is the administra- tion of the construction of facilities under the plan. The Law is written so that this work may be done as two separate efforts, or as one continuous project. It is required that a “single State agency” be respon- sible for the survey and planning and that a “single State agency” be responsible for the administration of construction. These may be the same or different agencies. The present Hospital Survey Committee under its charge limited its work to the first phase of the Law and has completed its assignment with the preparation of the State Plan. Under legislation enacted by the 1947 Legislature, the State Board of Health is des- ignated as the agency to administer the construction program. Public Law 725 authorizes the appropriation of $3,000,000 to be allotted to the States as grants to be expended for surveys, to the extent of one third of the total expenditures for such purposes by the individual States. It also authorizes the appropriation of $75,000,000 annually for a period of five years for the construction of medical facilities. Grants for con- struction are applicable to projects which are within the scope of the approved State Plan and are based on one third of the total cost of such projects. Funds were appropriated for the survey; but, while authorized to be appropriated, no funds were appropriated for construction. The funds to be appropriated will be allotted to the various States on the basis of a formula contained in the Law. On the basis of the formula, the State of Maryland is entitled to a sum of $46,158 for survey purposes and an annual allotment of $870,300 for a period of five years for construction. If all of the funds available were utilized, it would be necessary that Maryland set up $92,316 for survey purposes, making a total of $138,474 available. Such sums were not necessary for the work of the present Committee. However, the State agency designated for the administration of the construction program prob- ably will find it necessary to review the program from time to time and no doubt will utilize some of this money. If all of the Federal construction funds available are utilized and if these funds are limited to the amounts now stipulated in the Law, the construction program will entail expenditures of $2,610,900 per year, or $13,054,500 for the five-year period. It is required that each State wishing to participate in this program make formal application for such part of the Federal funds allotted to it as it may need for carrying out the purposes of the Act. The State Planning Commission, on October 24, 1946, filed with the United States Public Health Service an application for $4,991 based on an estimated total expenditure of $14,973. The application was supported by such docu- ments as were required to establish the statutory authority for the State Planning Commission to function as the “single State agency” for the making of the survey and the preparation of the State Plan. The application was approved by the Surgeon General of the United States Public Health Service. Under the Law, certain bed maxima for the State are established in the various categories of medical facilities. Under the Regulations promulgated by the United States Public Health Service (Appendix B), hospital areas are defined and classified on the basis of population content. Graduated bed maxima are estab- lished for the various types of areas. The State Plan is intended to determine the dif- ferential between existing facilities and those estab- lished as needed. As a part of this plan, these needs are established on a priority basis according to their urgency. The plan is designed for the integration of the various types of facilities between the areas so that adequate services will be established in or be available to every part of the State. The completed plan will be submitted to the State Department of Health for the administration of grants for construction. Prior to initiating the program, the Department of Health will submit the plan to the Surgeon General of the United States Public Health Service for approval. It is expected the Department of Health will adopt the plan as presented. However, it has authority to modify the plan to meet changing conditions. xThe information appearing in Chapters 1 through 4 was originally presented as part of the Interim Report of_ Committee on Medical Care, Maryland State Planning Commission, January 1947, pp. 19-38. I Chapter 2. HOSPITAL SURVEY COMMITTEE ON November 2, 1945, the Executive Committee of the Committee on Medical Care of the State Planning Commission met to discuss the activities of the Commission on Hospital Care and the advisability of instituting a State-wide survey of hospital facilities. It was pointed out that the Commission had been established under the auspices of the American Hospital Association to stimulate state-wide hospital surveys, with the objective to make a complete survey of hospital and public health facilities in the United States. The contents of Senate Bill 191, as then written, were discussed. Under the provisions of the Bill, funds would be made available to states for surveys and for hospital construction after completion of the survey and plans for the expansion of needed hospital and public health facilities. A resolution was passed to the effect that the Execu- tive Committee would advise the entire Committee on Medical Care of this development for the purpose of securing authority to form and appoint a Hospital Survey Committee. Dr. Victor F. Cullen, Acting Chairman of the Com- mittee on Medical Care, addressed a letter to this group, as follows: In accordance with the responsibilities of the Committee on Medical Care of the Maryland State Planning Commission, “to keep under constant survey the problems of medical care for the citizens of this State, and to formulate recommenda- tions for better utilization and for extension of existing facilities and for the institution of such new facilities as are required,” and in view of the physical additions presently contemplated by many of our Maryland hospitals, the establishment of a Hospital Survey Committee has been con- sidered imperative. The following persons have been selected as members of the Committee: upon its completion, a report of its findings and recommenda- tions presented to the Committee on Medical Care of the Maryland State Planning Commission. Any interim re- ports which may seem indicated will, of course, be welcomed- Through the interests of Governor Herbert R. O’Conor, funds have been made available to the State Planning Com- mission, which should provide for the technical assistance necessary for the Committee effectively to perform its func- tions. Dr. Walter D. Wise was unanimously elected Chair- man of the Committee at a meeting held on February 22, 1946. The Hospital Survey Committee, at the outset, rec- ognized in its assignment three definable phases and several limiting factors. The initial phase would be the inventory of existing medical facilities. The second stage of the work would entail the compilation of the data thus gathered and an analysis of the recorded facilities quantitatively, qualitatively, geographically, and in relation to population trends. The third phase would consist of: establishing the actual need for the various types of facilities; determining the differential between existing facilities and those considered ade- quate to meet the need; and preparing a long-range plan for the construction of the facilities required to meet the established need, giving special consideration to the urgency of the need from the standpoint of type of service and location. The limiting factors were funds and time. The fund of $8,500 made available by the Board of Public Works was sufficient for the employment of only a small staff and for the payment of only minimum incidental expenses. The time element imposed a need for expeditious action. There was a generally recognized immediate need for additional medical facilities in all categories. The Hospital Survey and Construction Act, then pend- ing in Congress, contained clauses stipulating that grants would be made for hospital construction, but required that a State Plan for such expansions must have been completed and approved by the Surgeon General be- fore funds for construction could be released. The limited personnel which could be employed with the modest appropriation for this purpose would be re- quired to work with dispatch to complete the work be- fore the survey funds were exhausted. At its meeting on April 16, 1946, the Survey Com- mittee adopted a working program, as follows: 1. Hospital Schedule of Information to cover hospi- tals, and Public Health Department Facilities Schedule of Information to cover public health facilities, as prepared by the Commission on Hospital Care, will be used. 2. Schedules will be completed by the local health officers and hospital administrators. 3. The health officers will be requested to complete and return their schedules. The hospital ad- ministrators will be requested to hold their schedules until representatives of this Committee audit them. J. Douglas Colman W. D. Noble, M.D. George H. Preston, M.D. Robert H. Riley, M.D. Winford H. Smith, M.D. Harvey B. Stone, M.D. Huntington Williams, M.D. C. E. Wise, Jr. Walter D. Wise, M.D. Benjamin W. Wright Peregrine E. Wroth, M.D. Ralph Young, M.D. The Committee shall elect its own chairman. Hospitals do not achieve their fullest usefulness if their interests are limited to their primary function of restoring to health those disabled by illness or injury. In addition, hospi- tals have opportunities to maintain and improve health; to provide educational opportunities and encouragement for the members of the medical, dental, nursing and allied pro- fessions; contribute to the advancements of science through research; and to serve more actively in the education of the public in matters pertaining to the maintaining of health Therefore, the functions of the Committee are: 1. To survey existing institutional facilities for the care of the sick and for the rendering of public health service. 2. To analyze the facts governing the availability and use of these facilities. 3. To define the need for additional facilities. 4. To develop a long-range program whereby existing facilities and such additional facilities as are recommended may operate to provide a comprehensive and integrated hospital service for the citizens of Maryland. In performing its function, the Committee should recognize the provisions of the several contemplated federal public works programs, under which, funds may be available for hospital construction. It is imperative that the work of this Committee should be pursued with all possible dispatch and 2 Hospital Survey Committee 3 4. One copy of the completed Schedules will be held for study and the other submitted to the Commission on Hospital Care for tabulation. The Commission will return this copy along with a set of punch cards when the tabulations are completed. 5. One copy of the Hospital Schedules will be re- turned to the administrators. 6. At the completion of the work, the files, includ- ing the Schedules, with the deletion of Section G, entitled “Financial Data,” will be turned over to the State Department of Health. 7. Since the Bureau of Medical Services of the State Department of Health is seeking the same in- formation as the basis for licensing medical in- stitutions, cooperation will be accepted from and given to this Bureau. To give the Committee broader representation and to have the benefit of their own thinking and the thinking of the groups they represent, the following were nominated for membership on the Hospital Sur- vey Committee: Dr. Ernest L. Stebbins, Director of the School of Hygiene and Public Health of the Johns Hopkins University. Mr. J. David Cordle, Secretary-Treasurer of the Brotherhood of Railway Clerks of the Baltimore and Ohio Railroad. Mr. Edwin P. Young, Jr., City Editor of The Evening Sun. These nominations were presented to the Committee on Medical Care for approval. On November 25, 1946, the Governor announced these appointments. Thus membership of the Committee was increased to six- teen, including Dr. Maurice C. Pincoffs, Chairman of the Committee on Medical Care. PART II THE FIELD SURVEY Chapter 3. HOSPITALS, NURSING HOMES, AND PUBLIC HEALTH FACILITIES The f eld survey was undertaken for the purpose of compiling data as to the total number of medical institutions, including bed capacity and ancillary de- partments, and public health facilities available in the State. The f rst work done was the compilation of a complete list of institutions in the State maintaining facilities for the care of bed patients. This was simplified by the fact that the Legislature had already enacted a hospital licensing law, Chapter 210, Acts of 1945 (Appendix F), and the Bureau of Medical Services of the State Department of Health had already compiled such a list. A copy of this list was made available to the Hospital Survey Committee. Since the Bureau of Medical Services had planned to use for its basic files on the licensed institutions data similar to those required for the completion of the Schedules of Information, the survey work was com- plementary to the field work necessary for State li- censing purposes. The Bureau of Medical Services, in line with its work of inspection prior to licensing hospitals, made its facilities and personnel available to assist with the survey work. The hospital consultant of the Bureau, at the time of inspecting institutions for licensing purposes, on numerous occasions completed the Hospital Schedule of Information for the survey. This cooperation was very valuable to the survey throughout the period of its field work. Additions and deletions were made to the list as new institutions were found and others discontinued in service. These changes were almost entirely in the category of nursing homes. The original list, along with additions made during the period of the field work, included 231 institutions. Of those listed, 31 either had not followed through with their plans to open or had closed. The balance of 200 institutions were included in the survey. Institutions owned and operated by the Federal Government were not considered by this survey even though they are an increasingly important part of the Nation’s hospital service. A tabulation of the institutions by type of owner- ship or control and by county is given in Table A. Two copies of the Schedule of Information were mailed to every institution on the list. These Schedules contained forty pages of questions covering the follow- ing subjects: A. General data B. Area served C. Physical plant D. Patient service data E. Medical staff F. Administration G. Financial data H. Educational activities J. Research activities The recipients of the Schedules were requested to complete them and keep them available pending the TABLE A: INSTITUTIONS BY TYPE OF OWNERSHIP OR CONTROL AND BY COUNTY Goveri* MENTAL1 N ONGO VERNMENTAl Nonprofit County Proprietary Totals State City County City-County Church Nonprofit Allegany 1 2 1 1 4 9 Anne Arundel 1 — — — — 1 2 4 Baltimore 3 — — — 3 5 14 25 — — — — — i — i Caroline — — — — — — 1 i Carroll 2 — — — 1 — 4 7 Cecil — — — — — i 2 3 Charles — — — — — i — 1 Dorchester 1 — — — — i 2 4 Frederick 1 — 2 — — 3 2 8 Garrett — — — — — — 1 1 Harford — — — — — 1 2 3 Howard — — — — — — 2 2 Kent — — — — — 1 2 3 Montgomery — — — — 2 3 19 24 Prince George’s — — — — 1 1 5 7 Queen Anne’s — — — — — — 4 4 St. Mary’s — — — — — 1 — 1 Somerset — — — — — 1 — 1 Talbot — — — — — 2 3 5 Washington — — 1 — 2 2 4 9 Wicomico 1 — — — — 2 2 5 Worcester — — — — — — — — County totals 10 5 1 10 27 75 128 Baltimore City 1 2 — — 16 21 32 72 State Totals 11 2 5 1 26 48 107 200 1 Federal institutions not included. 4 Hospitals, Nursing Homes, and Public Health Facilities 5 visit of a field worker. Because of the comprehensive- ness of the questionnaire and the recognized difficulty in preparing the statistics required for its completion at a time when most medical institutions were very busy and experiencing personnel shortages, a period of thirty days was allowed between the mailing of the Schedule and the visit of the field worker. Preceding the mailing of the Schedules, a letter was sent by Dr. Merrill L. Stout, Director of the Hospital for the Women of Maryland, who was Presi- dent of the Maryland-District of Columbia Hospital Association. This letter portrayed the survey as some- thing apart from the usual questionnaire, received in such abundance by hospital administrators. Accompanying each Hospital Schedule was a letter from Dr. Walter D. Wise, Chairman of the Hospital Survey Committee, requesting that the information be entered promptly in preparation for the later visit by the field worker. Visits were made to the 200 institutions and to some of those which were later deleted from the list when they were found to have discontinued their work. The administrators of the institutions, with few ex- ceptions, were willing to cooperate with the survey effort but were universally seriously handicapped by a num- ber of operational problems. Few Schedules were completed at the time of the field worker’s first visit. In some cases, even though notice had been sent of the planned visit, a single entry had not been made prior to the arrival of the field worker. Some Schedules, especially in the cases of nursing homes, were completed by the field worker from the meager records available. In the larger institutions, where considerable time was required to prepare the statistical data, the administrator was assisted with the factual data and urged to complete the balance of the work by the time of a later visit. Many institutions had to be visited more than once and, in some cases, as many as four visits were necessary before the Schedule was completed and ready for audit. Public Health Department Facilities Schedules of Information were sent to the health officers in each of the counties and Baltimore City. Dr. Robert H. Riley, Director of the State Department of Health, and Dr. Huntington Williams, Commissioner of Health of Bal- timore City, urged their respective staffs to complete and return these Schedules promptly. The responsible persons performed this duty and re- turned the Schedules completed, with the result that this phase of the survey was completed with a minimum of effort on the part of the survey staff. The field work was started in April 1946, and com- pleted in October of the same year. Chapter 4. CLASSIFICATION OF INSTITUTIONS The Hospital Survey and Construction Act was intended to include general, tuberculosis, chronic disease, and mental hospitals. Because of the State chronic disease hospital program, the survey in- cluded, in addition, nursing homes, homes for the aged, and other special institutions. This was done for the purpose of gathering data on the number of patients being cared for in places other than their homes, and for estimating the potential load which would fall on in- stitutions of the various types once they became avail- able. Owing to the inclusive nature of the survey, it was necessary to group the types of institutions under twelve headings. The original grouping included the follow- ing categories of hospitals: 1. General 2. Nervous and Mental 3. Tuberculosis 4. Contagious 5. Obstetric 6. Pediatric 7. Orthopedic 8. Eye, Ear, Nose, and Throat 9. Convalescent 10. Skin and Cancer 11. Chronic Disease 12. Others, Including Aged In Table B the institutions are shown by type of service and county. The institutions were requested to report their bed complement, that is, the number of beds actually set up and in use for inpatients, excluding bassinets for newborn infants. They were also asked to report their normal bed capacity, that is, the number of beds for which the institution was designed or, in lieu of this information, the number of beds which could be set up allowing 80 square feet of floor space per bed. A positive differential between the bed complement and the normal bed capacity indicates the expansion of capacity, or crowding, which the institution per- mitted without adding space for beds. The original tabulation of the bed complement by county, by type of institution, and racial assignment is shown in Table C. For this tabulation, the institutions were grouped under the four main headings referred to in the Hospital Survey and Construction Act, that is, general, tuber- culosis, chronic disease, and mental hospitals. The Act specifically excludes institutions giving only domiciliary care. General hospitals included those institutions offer- ing medical care, surgery, and obstetrics. Hospitals admitting patients having conditions which fall in the category known as the specialties were grouped sepa- rately, but later included with general hospitals. In this group were contagious disease, obstetric, pediatric, orthopedic, and eye, ear, nose, and throat hospitals. Tuberculosis hospitals included those institutions where admissions are limited to patients having tuberculosis. One hundred beds maintained at Springfield State Hospital for the care of mental patients having tuber- culosis were counted as beds for mental patients. TABLE B: INSTITUTIONS BY TYPE OF SERVICE AND COUNTY County 1 General 1 Nervous and Mental Tuberculosis Contagious Obstetric Pediatric Orthopedic Eye, Ear, Nose, and Throat Convalescent Skin and Cancer Chronic 1 - Others, Including Aged Totals Allegany 3 1 1 1 3 9 Anne Arundel 1 1 1 — — — 1 4 Baltimore 9 3 — — — — 5 5 3 25 Calvert 1 — — — 1 Caroline 1 1 Carroll — 1 1 — — — — — 2 — 3 7 Cecil 1 — — — 1 — — — — — 1 3 Charles 1 — — — — — — 1 Dorchester 1 1 2 4 Frederick 3 1 1 3 8 Garrett 1 1 Harford 2 1 3 Howard 2 2 Kent 1 O 3 Montgomery 3 2 — — — — 12 7 24 Prince George’s 3 2 — — — — — 2 Queen Anne’s 4 4 St. Mary’s 1 — i Somerset 1 1 Talbot 1 2 * 2 5 Washington 1 1 — 1 2 3 i 9 Wicomico 1 1 2 1 5 Worcester — — — — — — — — County totals 25 20 6 7 2 24 27 17 128 Baltimore City 18 2 — 1 1 — 2 2 16 1 23 6 72 State Totals 43 22 6 1 8 — 2 4 40 1 50 23 200 6 Classification of Institutions 7 TABLE C: BED COMPLEMENT BY COUNTY, TYPE OF INSTITUTION. AND RACIAL ASSIGNMENT County General Nervous and Mental Tuberculosis Contagious Obstetric Pediatric Orthopedic Eye, Ear, Nose, and Throat ' onvalescent Skin and Cancer Chronic Others, Including Aged Totals By Race Totals w NW W NW w NW W NW w NW w NW w NW W NW W NW w NW w NW w NW w NW Allegany 391 2 96 — 6 17 — — — — — 48 — — — 558 2 560 Anne Arundel.... 70 — — 1,234 — — — — — 3 — — — — — — — — 9 — — — 79 1,237 1,316 Baltimore — — 4,112 — 463 11 — — — — — — — — 126 — — — 89 — 182 — 4,962 11 4,973 Calvert 15 11 15 11 26 Caroline 8 8 — 8 Carroll — — 3,011 — — 357 — — — — — — — — 11 — — — — — 37 — 3,059 357 3,416 Cecil 62 10 4 13 79 10 89 Charles 23 8 23 8 31 Dorchester 57 18 492 — 22 — 571 18 589 Frederick 175 33 30 — 523 234 22 962 55 1,017 Garrett 24 24 — 24 Harford 78 11 20 — 98 11 109 Howard 51 — 51 — 51 Kent 25 6 — — — — — — — — — — — — 13 — — — 38 6 44 Montgomery 323 20 100 — 141 — 141 705 20 725 Prince George’s , 206 — 97 — — — — — — — — — — — — — — — 114 — 417 — 417 Queen Anne’s . 31 31 — 31 St. Mary’s 35 10 35 10 45 Somerset 30 8 30 8 38 Talbot 83 25 — — — — 8 6 — — — — — — — — 26 — 117 31 148 Washington 185 — — — — — 4 — — — — — 26 — 54 — — — 54 — 22 — 345 — 345 Wicomico 147 30 60 39 — 64 — 310 30 340 Worcester County totals.... 1,905 192 7,989 1,234 1,036 368 30 9 43 — 391 — — — 422 — 701 22 12,517 1,825 14,342 Baltimore City . . . 5,730 514 425 — — — 100 — 8 — — — 172 47 79 26 343 — 21 — 884 18 566 32 8,328 637 8,965 State Totals ... 7,635 706 8,414 1,234 1,036 368 100 — 38 9 — — 172 47 122 26 734 — 21 — 1,306 18 1,267 54 20,845 2,462 23,307 Chronic disease hospitals included nursing homes, in- stitutions for the care of convalescent patients, chronics, incurables, and aged. Mental hospitals included primarily those established for the diagnosis and treatment of the mentally ill. The inclusive totals under the four broad headings, plus special institutions combined, are shown in Table D. More detailed analyses of the institutions and their constituent departments were made to determine which institutions should be excluded from the survey and which categories would be credited with certain groups of beds. During the period of the survey, Dr. Schnauffer’s Hospital at Brunswick in Frederick County closed. The Johns Hopkins Hospital included in its total 87 beds in the Phipps Psychiatric Clinic, which were credited to the mental hospital bed total. The Baltimore City Hospitals included 280 beds for tuberculous patients, 451 beds for chronics, and 705 beds for ambulatory aged, which were removed from the general hospital bed total. There were no deletions from the number of beds available for tuberculous patients; however, the beds for tuberculous patients at the Baltimore City Hospitals were added. The groups included in the category giving care to chronics, convalescents, and others including aged ranged from institutions bordering on the luxurious to places operated under conditions not fit for human habitation. At this point, institutions caring for aged persons and those giving only domiciliary care were excluded. In the final analysis this group was sharply discounted because few were found to offer more than domiciliary care. Rosewood State Training School for Feebleminded was removed from the category of mental hospitals. Also excluded were the Bowditch Hospital School and the Silver Cross Home, both institutions for epileptics, and the Marine Home for Retarded Children. The results of this reclassit cation of institutions and departments within institutions and after certain ex- clusions are shown in Table E. The normal bed capacities, determined from the reports, are also shown in Table E. TABLE D: BED COMPLEMENT OF INSTITUTIONS REGROUPED ACCORDING TO BROAD CLASSIFICATION Type of Institution Number of Bed Institutions Complement General hospitals 43 8,341 Tuberculosis hospitals 61 1,4042 Chronic disease hospitals Including institutions limiting admissions to: Chronics and convalescents 90 Aged and others 24 1141 3,4002 Mental hospitals Including institutions limiting admissions to: Epileptics Feebleminded Mental 221 9,6482 Special hospitals Including institutions limiting admissions to: Contagious 1 Obstetric 8 Orthopedic 2 Eye, ear, nose, and throat 4 15 514 Totals 200 23,307 'Not including departments of general hospitals. 2Including bed complements of departments of general hospitals. 8 Hospital Survey and Plan for Maryland-Part II TABLE E: BED COMPLEMENT AND NORMAL BED CAPACITY OF INSTITUTIONS AFTER RECLASSIFICATION AND EXCLUSIONS Type of Institution Number of Institu- tions Bed Comple- ment Normal Bed Capacity Standard under Public Law 7251 Differential Between Normal and Standard in Public Law 725 General 42 6,874 6,566 8,923 —2,357 Tuberculosis. . . . 62 1,684s 1,883s 3,177 —1,294 Chronic 902 2,391s 2,391s 3,966 —1,575 Mental 182 8,292s 7,453s 9,915 —2,462 7 300 300 300 Totals 163 19,541 18,593 25,981 —7,388 1 Based on population of 1,982,947, United States Bureau of the Census, Esti- mated Civilian Population, 1943. The population total used in the final analysis was 2,017,917, United States Bureau of the Census, Estimated Civilian Popu- lation, 1945. 2Not including departments of general hospitals. 3 Including bed complements of departments of general hospitals. category as set up in the Hospital Survey and Con- struction Act. The standards in Public Law 725 are as follows: General hospital beds... .....4.5 per 1,000 population Tuberculosis hospital beds 2.5 times the average an- nual deaths from tuber- culosis in the State for the five-year period from 1940 to 1944. i Chronic disease hospital beds 2.0 per 1,000 population Mental hospital beds .5.0 per 1,000 population The standards in each of the categories were com- pared with the existing normal bed capacities in Table E. It was found that the over-all shortage of beds in all categories, when compared with the stand- ards set up in Public Law 725, was 7,388. Detailed tabulations for each of the categories are shown in Tables G, H, I, J, and K. During the later study of the individual institutions, deletions for unsuitable construction and other reasons were made, with the result that the acceptable bed total was reduced and the number of beds needed increased to 9,208. An analysis of normal bed capacity by type of owner- ship, type of hospital, and racial assignment is given in Table F, Having established the net normal bed capacities, comparisons were made with the maximum for each 1 Deaths from tuberculosis in Maryland for this period were: 1940, 1,302; 1941, 1,256; 1942, 1,263; 1943, 1,250; 1944, 1,285. Classification of Institutions y TABLE F: NORMAL BED CAPACITY BY COUNTY , TYPE OF OWNERSHIP, TYPE OF INSTITUTION, AND RACIAL ASSIGNMENT Gene RAL Tuberculosi 3 C iHRONIC Mental Spec I L County1 Volun Proprie- County1 Volun- County1 Volun- Proprie- County1 Volun- Proprie- Volun- Proprie- Stale and/or City2 tary tary Stale and /or tary and /or tary tary State and /or tary tary tary tary County City* City2 City2 w NW w NW w NW W NW w NW W NW W NW W NW W NW W NW w NW W NW W NW w NW W NW W NW Allegany 49 2 2181/2 a 124 a 15 — 52i a 17 — Anne Arundel .... — — — — 58 12 — — — —, — — — — — — — 9 — — 1,044 — — — — — — Baltimore — — — — 199 ii — 254 — 206 — 2,013 — 238 — 99 — — — Calvert — 15 11 Caroline — — Cecil 62 10 13 — Charles — — — — 25 8 Dorchester — — — — 47 18 — — — — — — — — — 3 — 466 — — — — — Frederick — — 33i 22i 100 11 — — 523 — — — — — — — — — 55 — — — Garrett — 24 — Harford — — — — 61 11 17 — 20 — Howard — — — — 51 Montgomery CtO 310 20 195 — Prince George’s. . — — 1021 a — — 104 — — — — — — — — — 31 — — — 85 — — Queen Anne’s — 31 — St. Mary’s — — — — 35 10 Somerset — — — — 30 8 Talbot — — — — 67 20 Washington — — — — 132 10 — — — — — — 14 62 — — — — — — — 26 — Wicomico — — — — 147 30 Worcester — County totals .... 49 2 353 22 1,238 179 121 — 800 549 254 — 14 — 682 — 5,167 1,044 52 a 238 — 390 — — — 43 — Baltimore City . . . 354 81 1002 a 3,650 417 — — — — 14021402 — — 4512 — 610 — 634 — — — — — 483 — 79 — 216 41 State Totals .... 403 83 453 22 4 888 596 121 — 800 549 140 140 254 — 451 — 624 — 1,316 — 5,167 1,044 52 a 721 — 469 - 216 41 43 — Totals for White Patients 5,865 1,194 2,391 6,409 259 Totals for Non- white Patients 701 689 — 1,044 41 Totals 6,566 1,883 2,391 7,453 300 oSix extra beds set up for nonwhite patients. 6No racial assignment. 10 Hospital Survey and Plan for Maryland—Part II TABLE G: GENERAL HOSPITALS, BED COMPLEMENT AND NORMAL BED CAPACITY BY RACIAL ASSIGNMENT Name of Institution Location Bed Complemi 3NT Norm al Bed Capacity While Nonwhite Total White Nonwhite Total Allegany County 124 124 124 Cumberland 124 a a Cumberland 218 a 218 218 a 218 Frostburg 49 2 51 49 2 51 Anne Arundel County 58 12 70 Annapolis 58 12 70 Calvert County 15 11 26 Prince Frederick 15 11 26 Cecil County 62 10 72 Elkton 62 10 72 Charles County 31 25 8 33 La Plata 23 8 Dorchester County 47 18 65 57 18 75 Frederick County 100 11 111 Frederick 114 11 125 31 22 53 33 22 55 Harford County 17 17 17 17 Bel Air — — Havre de Grace 61 11 72 61 11 72 Kent County 31 25 25 Chestertown 25 6 — Montgomery County 30 10 40 30 10 40 Bethesda 92 10 102 92 10 102 201 — 201 188 — 188 Prince George’s County 87 87 87 b 87 b Cheverly 102 b 102 102 b 102 Laurel 17 — 17 17 — 17 St. Mary’s County 45 35 10 45 Leonardtown 35 10 Somerset County 38 30 8 38 30 8 Talbot County 67 20 87 Easton 83 25 108 Washington County 132 10 142 Hagerstown 175 10 185 Wicomico County 30 177 147 30 177 147 County totals 1,853 214 2,067 1,761 203 1,964 Baltimore City 513 513 4940 Eastern Avenue 513 a 513 a 2025 West Fayette Street .... 142 — 142 142 — 142 Broadway and Fairmount 165 — 165 165 — 165 110 N. Calhoun Street 177 25 202 158 15 173 Lafayette Avenue and John Street 124 — 124 124 — 124 Johns Hopkins Hospital Broadway and Monument.... 767 217 984 656 217 873 Maryland General Hospital Linden Avenue and Madison 233 9 242 228 7 235 Calvert and Saratoga Streets . 262 25 287 256 25 281 1514 Division Street — 125 125 — 125 125 Wilkens and Caton Avenues. . 221 — 221 184 — 184 1400 North Caroline Street. . , 230 20 250 230 20 250 1714 East Monument Street . . 300 — 300 300 — 300 South Baltimore General Hospital 1211 Light Street 138 12 150 127 8 135 Harford Road and Herring 100 a 100 100 a 100 33rd and Calvert Streets 341 — 341 341 — 341 418 West Lexington Street . . . 40 — 40 40 — 40 Rayner Avenue and Dukeland Street 186 b 186 186 b 186 Redwood and Greene Streets , 354 81 435 354 81 435 4,293 514 4,807 4,104 498 4,602 6,146 728 6,874 5,865 701 6,566 aNonwhite patients admitted. bNonwhite patients admitted on]emergency. Classification of Institutions 11 TABLE H: TUBERCULOSIS HOSPITALS, BED COMPLEMENT AND NORMAL BED CAPACITY BY RACIAL ASSIGNMENT Bed Complement Normal Bed Capa city White Nonwhite Total While Nonwhite Total Baltimore County Eudowood Sanatorium 194 — 194 194 194 Maryland Tuberculosis Sanatorium Mt. Wilson 199 11 210 199 11 210 Mt. Pleasant Hospital 60 60 60 60 Carroll County Maryland Tuberculosis Sanatorium Henryton — 357 357 — 538 538 Frederick County Maryland Tuberculosis Sanatorium 523 — 523 523 523 Wicom co County Maryland Tuberculosis Sanatorium Salisbury 60 — 60 78 — 78 County totals 1,036 368 1,404 1,054 549 1,603 Baltimore City Baltimore City Hospitals, Department 4940 Eastern Avenue 140 140 280 140 140 280 Baltimore City totals 140 140 280 140 140 280 State Totals 1,176 508 1,684 1,194 689 1,883 12 Hospital Survey and Plan for Maryland—Part 11 TABLE I: NURSING HOMES AND INSTITUTIONS FOR CHRONICS, BED COMPLEMENT Name of Institution Location Bed Name of Institution Location Bed Complement Complement Nursing Homes Allegany County Cumberland Wicomico County 15 Collins Nursing Home 6 Sallie Wright Nursing Home for Salisbury Crump Convalescent Home Cumberland 9 Welfare Patients 24 Anne Arundel County 658 „ A -VT • TT Baltimore County Baltimore City Catonsville 5 Alberta Convalescing Home 4013 Liberty Heights Avenue 14 14 Anderson Rest and Convalescent Home 3605 Hillsdale Road 22 25 3520 North Hilton Road. . . 35 6 6028 Old Harford Road. . 12 57 3502 Clifton Avenue 8 House in the Pines Nursing Home . . . 26 2101 West Cold Spring Lane 55 13 Colonial Nursing and Convalescent 7 4506 Frederick Avenue.... 9 29 2117 Denison Street 21 55 Carroll County Elmhurst Nursing Home 1708 Eutaw Place 34 5 1701 Ellamont Street 17 5 2601 Roslyn Avenue 16 5 Garrison Nursing Home 2803 Garrison Boulevard. . 10 Union Bridge 6 4700 Harford Road 47 Haven Nursing Home 4514 Garrison Boulevard. . . 16 Cecil County Home of Our Lady 1302 West Lexington Street 18 13 Jewish Convalescent Home Society. . . 4601 Pall Mall Road 11 Parkmont Nursing Home 4212 Parkmont Avenue. . . . 10 Dorchester County 4703 Hampnett Avenue. . . . 19 3 4112 Edmondson Avenue . . 5 The Wayne 3203 Brightwood Avenue . . 5 Garrett County Twilight Rest and Nursing Home .... 1913 Eutaw Place 14 24 Opitz Home for Aged and Invalids.... Edmondson Avenue and Nunnery Lane 41 Harford County 4 20 132 West Lafayette Avenue 8 Agnes McKenna Memorial Clinic .... The Misses Gaddis 21 Kent County 218 Ridgewood Road 11 7 2476 Shirley Avenue 22 6 526 South Chapelgate Lane 23 Mrs. Virginia Lewis 4203 Springdale Avenue . . . 4 Montgomery County 27 Wheeler Nursing Home 1700 Park Avenue 15 602 Cur Lu Rest Home Takoma Park 5 George Convalescent and Rest Home Jolliffe Nursing Home for Aged Takoma Park Silver Spring 14 14 1,260 17 Institutions for Chronics Mercy Villa Nursing Home St. Gabriel’s Home for Convalescent Girls Mrs. Lillie B. Melton Oak Drive Nursing Home Resthaven Convalescent Home Mrs. Louis Moody Sandridge Rest Home Silver Spring Silver Spring Takoma Park Takoma Park Rockville ‘I 5 6 10 Baltimore County Bellona Avenue, Govans . . . Catonsville 24 24 Sinclair Convalescent Home Kensington 5 Washington County Hagerstown Spring Villa Convalescent Home Waverly Sanitarium Takoma Park Rockville 13 24 Infant and Child Health Center, Inc. 14 Witzke Nursing Home Takoma Park Rockville 4 13 62 Woodlawn Sanatorium Mrs. Olive Wright Takoma Park 5 Baltimore City 4940 Eastern Avenue Youngerman’s Nursing Home Rockville 5 Baltimore City Hospitals, Department 451 Prince George’s County James Lawrence Kernan Hospital.... Windsor Mill Road 89 31 Happy Hills Convalescent Home for Mother Jones Rest Home Hyattsville Children 1708 West Rogers Avenue. . 68 Queen Anne’s County Home for Incurables 700 West 40th Street 166 Levindale Hebrew Home and Mrs. Legg’s Home for Welfare Infirmary Belvedere and Greenspring 6 175 88 Melvin Nursing Home Millington 3 Jenkins Memorial, Inc 1000 Caton Avenue Palmatory Nursing Home Millington 10 Aged Women’s and Aged Men’s Home 1400 West Lexington Street 32 12 1,069 Washington County Eshlman’s Nursing Home Maugansville 4 State Total, Institutions for 1,131 Gateway Nursing Home Hillcrest 18 Chronics Hagerstown 40 2,391 — Classification of Institutions 13 TABLE J: MENTAL HOSPITALS, BED COMPLEMENT AND NORMAL BED CAPACITY BY RACIAL ASSIGNMENT Bed Complement Normal Bed Capacity Name of Institution Location White Nonwhite Total While Nonwhite Total Allegany County 96 96 52 52 Anne Arundel County 1,234 1.2341 1,044 1,044' Baltimore County 22 22 22 22 69 69 42 42 35 35 35 35 300 300 238 238 2,214 2,214 2,013 2,013 Carroll County 3,011 3,011 2,688 2,688 Dorchester County 492 492 466 466 Frederick County 30 30 55 — 55 Howard County 33 33 33 — 33 18 18 18 18 Montgomery County 50 50 50 — 50 50 50 50 50 Prince George’s County Laurel Sanatorium Laurel 85 — 85 85 — 85 County totals 6,505 1,234 7,739 5,847 1,044 6,891 Baltimore City Gundry Sanatorium Athol and Frederick Road . . . 41 — 41 51 — 51 396 396 396 — 396 Phipps Psychiatric Clinic (Johns Hopkins Hospital) Broadway and Monument.... Street 87 — 87 87 — 87 Pinecrest Sanatorium 600 South Chapelgate Lane. . . 29 — 29 28 — 28 Baltimore City totals 553 — 553 562 — 562 State Totals 7,058 1,234 8,292 6,409 1,044 7,453 aNonwhite patients admitted. 1 Space for 164 additional beds when help is available. 307 patients (on date of survey) were in hospital in temporary beds not counted in complement. Normal at State mental hospitals is based on 45 square feet to bed plus 25 square feet per patient in day rooms. For infirmary and criminally insane patients the beds are at 50 square feet. TABLE K: SPECIAL HOSPITALS, BED COMPLEMENT AND NORMAL BED CAPACITY BY RACIAL ASSIGNMENT Name of Institution Location Bed Complemei sIT Normal Bed Capacity White Nonwhite Total While Nonwhite Total Allegany County 17 17 17 17 Washington County 26 26 26 26 43 43 43 43 Baltimore City 51 14 65 51 14 65 Beck Diagnostic Clinic 100 East 23rd Street 14 115 15 14 130 14 115 15 14 130 876 Washington Boulevard. . . 1017 East Baltimore Street. . . 8 8 8 8 28 12 40 28 12 40 216 41 257 216 41 257 State Totals 259 41 300 259 41 300 PART III PLANNING Chapter 5. INTRODUCTION The field work completed, the Hospital Survey Committee embarked on the second phase of its work, which consisted of an analysis of existing facilities and related economic, sociologic, geographic, and other factors for the purpose of preparing a comprehensive long-range State Plan. It was recognized both by the authors of Public Law 725 and the members of the Hospital Survey Com- mittee that, with the number of factors influencing the establishment and utilization of hospital facilities, no exact formula could be established for use in plan- ning hospital facilities for communities. In the Act, broad basic standards are established. Section 622 of the Act requires that the Surgeon General of the United States Public Health Service, within a period of six months, prescribe general regulations covering the interpretation and operation of the Act. A tentative set of these regulations, released on November 20, 1946, was discussed with the survey di- rectors of all the States at a meeting held in Washington on December 6, 1946. The purpose of this meeting was to explain the proposed regulations and, at the same time, obtain the benefit of the thinking of the directors for use in the final draft. Final regulations were is- sued on February 11,1947, and amended June 10,1947. Since the regulations define and interpret the mean- ing of the Act and are of basic importance in the preparation of the State Plan, they have been included in this report as Appendix B. Throughout the Act and the Regulations, standards have been established, but it is clear that the intention was to leave the application of the standards to the discretion of the State agency as much as possible. Where it was found that the regulations were not sufficiently specific for the purpose of making a de- termination of relative need or priority of a project, the Committee established its own policies or applied its own judgment. The final plan projects a system of integrated facili- ties which will provide adequacy of service in all the categories. As an approach to this end, the individual categories were considered separately (Chapters 6 through 10). Having made a determination of the needs, it was necessary to set up a priority system based on the urgency between and within the categories. Priorities and the methods and reasoning used in their determination are discussed in Part IV. Population data Population statistics were basic factors throughout this program. The allotment of funds to States was calculated by means of a formula in which the popula- tion of the State was a factor. The classification of areas as base, intermediate, or rural within the State was based in part on population. The determination of beds needed in the areas was related to population. The United States Public Health Service Regula- tions, Subpart A 53.1 (o) (Appendix B) require that “the latest figure of civilian population certified by the Federal Department of Commerce” be used. The latest actual count of inhabitants was the Sixteenth Census of the United States, taken in 1940 (Appendix I). As of that date, the population of the State was certified as 1,821,244. As of November 1, 1943, the United States Bureau of the Census estimated the civilian population of Maryland as 1,982,947.1 This figure was based on registrations for War Ration Book Four (Appendix I). As of July 1, 1945, the United States Bureau of the Census issued estimates for the States, crediting Mary- land with a civilian population of 2,017,971. This figure established an increase of 35,024 above the November 1, 1943 figure, which originally was used in making the determinations in this study. The Bureau of Vital Statistics of the Maryland State Department of Health, on November 1,1945, re- leased an estimate on population for 1945 in which the total for the State was given at 1,999,477. This esti- mate, based largely on the 1943 data of the United States Bureau of the Census, was not used in final analysis. No attempt was made to reconcile the November 1, 1943 figures for political subdivisions with the State total estimated by United States Bureau of the Census for 1945, because it would involve questionable assump- tions. A pro rata distribution would not give a true result. A projection of a population curve for each county would be unsatisfactory because of the effects of the war. Some areas exhibited extraordinary popula- tion increases between 1940 and 1943, while others which had previously shown a consistent increase ex- perienced a decrease for that period. Since the 1943 civilian population estimates of the United States Bureau of the Census were the latest certified figures for the political subdivisions, they were used for the classification of areas and the allocation of hospital beds. The State Department of Health, as the agency responsible for the hospital construction program, will be vested with authority to revise the State Plan in line with changed conditions. Since the program will be operative over a period of at least five years, later estimates by subdivisions may call for modification of the allocations. In the meantime, the additional beds to which the State is entitled as a result of the certified increase of civilian population of 35,024 between November 1, 1 United States Bureau of the Census, Population—Special Re- ports. Series P-44, No. 3, February 15, 1944. 14 Introd uction 15 1943 and July 1, 1945 were placed in the pool,1 which was allocated on the basis of unusual need. Since the pool is the one point at which the allocation of beds is flexible, it was the logical place to put them. On the State ratio of 4.5 beds per 1,000 population, this re- sulted in an increase of 158 beds being placed in the pool. Allocation by way of the pool allowed for as much consideration as any method which might be devised for the apportionment of the differential between the two certified population estimates. Allotment of the total number of pool beds is shown in Table L. 1 The pool is described further in Chapter 11. TABLE L: GENERAL HOSPITALS. COMPARISON OF EXISTING NORMAL BED CAPACITIES WITH STANDARDS ESTABLISHED BY PUBLIC LAW 725 FOR BASE, INTERMEDIATE, AND RURAL AREAS1 Beds Needed Acceptable Beds Needed Deficiencies Beds According To Normal Bed According To Between Area Allotted Total Area2 Population* State Capacity Area Standard and To Area Beds Standard Standards Existing Beds From Pool N eeded U.5 per 1,000 lt.5 per 1,000 Baltimore Base Area (B-l) Baltimore City 927,941 4,176 4,568 Baltimore County 202,425 911 — Anne Arundel County 77,070 347 70 Harford County 42,890 193 72 Howard County 18,481 83 — Carroll County 39,399 177 — Base Area Totals 1,308,206 5,887 4,710 5,887 1,177 385 6,272 It.5 per 1,000 U-0 per 1,000 Intermediate Areas Allegany County (1-1) 81,302 366 410 325 — 75 485 Washington County (1-2) 69,890 314 1684 280 112 — 280 Frederick County {1-3) 51,774 234 166 207 41 — 207 Montgomery and Prince George’s Counties {1-4) 221,780 998 519 887 368 — 887 Cecil County {1-5) 32,055 144 72 128 56 — 128 Talbot and Caroline Counties {1-6).... 32,237 145 87 129 42 50 179 Dorchester County (1-7) 24,264 109 65 97 32 15 112 Wicomico County {1-8) 32,960 148 177 132 — 70 247 Intermediate Area Totals 546,262 2,458 1,664 2,185 651 210 2,525 Jt-5 per 1,000 2.5 per 1,000 Rural Areas Garrett County {R-l) 18,534 83 — 46 46 — 46 Calvert County {R-2) 10,549 48 — 26 26 — 26 Charles County {R-3) 19,784 89 33 49 16 — 49 St. Mary’s County {R-U) 17,877 80 45 45 — 25 70 Kent and Queen Anne’s Counties (R-5) 25,265 114 25 63 38 — 63 Worcester County {R-6) 19,201 86 — 48 48 12 60 Somerset County {R-7) 17,269 78 38 43 5 43 Rural Area Totals 128,479 578 141 320 179 37 357 Population differential from 11/1/43 to 7/1/455 35,024 158 State Totals 2,017,971 9,081 6,5156 8,392 2,007’ 632 8 9,154 1 Includes acceptable general and special hospital beds. 2Area number given in parentheses. 3United States Bureau of the Census, Estimated Civilian Population, 1943. 4Includes 26 beds in Fleming Eye, Ear, Nose and Throat Hospital, which closed after survey was completed. 5United States Bureau of the Census. Estimated Civilian Population, 1945. 6Includes 44 beds in Allegany County and 29 beds in Wicomico County which are in excess of the State standard for the area. This total of 16 beds accounts for the discrepancy between the standard number of beds at 4.5 per 1,000 (9,081) and the final total number of beds needed(9,154). ’Beds in Allevanv and Wicomico counties not included. 8Pool beds include adjustments both for the difference between the State and area standards, as established by the United States Public Health Service, ana for the population increase between 1943 and 1945. Chapter 6. GENERAL HOSPITALS The general hospital is difficult to define concisely. An institution is classified as a general hospital when it admits more than one type of patient. The maintenance of service for medical, surgical, and ob- stetric cases is usually considered the minimal scope of a hospital so classified. As its field is broadened to include departments rendering services in psychiatry, tuberculosis, specialized surgery, and other fields of medicine, it continues to be classified as a general hospital. The basic program of a general hospital is considered: 1. Treatment of the sick and injured 2. Education of medical and nursing personnel 3, Prevention of illness, or conversely, the preser- vation of health 4. Research The degree to which the full program is executed varies with the size of the hospital, its location, and the availability of personnel. Included in the category of general hospitals are in- stitutions ranging in size from those maintaining only a few beds and a limited program to large institutions having in excess of 1,000 beds and carrying on the full program. In spite of the sameness of title and purpose, the utilization of the institutions as to area served and efficiency of operation varies with the size of the hospital, its relation to other institutions, and the type of patients treated. Because of these variables, two basic factors were necessarily considered in determining an adequacy of service for all communities. Of first importance was the determination of the location and size of the hospital which might be rela- tively accessible and which could be maintained and utilized efficiently by the people for whose service it was intended. The second consideration was to develop a plan of integration, by which services which could not be duplicated in every community would be made avail- able generally. The standards issued by the United States Public Health Service, in which variables in bed ratios to population were established, were based on detailed studies (Appendix B, Subpart A 53.1 (a), (b), (c), and (d)). These standards for base, intermediate, and rural areas, 4.5, 4.0, and 2.5 beds per 1,000 population, respectively, were used in classifying the areas of the State and determining the number of general hospital beds needed. Since the State standard of beds was established at 4.5 per 1,000 population, the beds in excess of area standards were considered pool beds. A regional plan of services was drawn up to indicate the points to which communities might turn for serv- ices not locally available (Chapter 6, Section 3). The institutions classified as general hospitals in Maryland range in complement from 17 beds to 984 beds (Table G). Most of the smaller hospitals serve their local communities, whereas the Johns Hopkins Hospital, the largest general hospital in the State, serves the world. Most small hospitals maintain services for medical and uncomplicated surgical and obstetric cases. As the size of the hospital increases, there is a proportionate broadening of its fields of work. After a study of the population distribution and the existing facilities, including some reclassifications and deletions because of unsatisfactory structures, the areas in the three classifications were set up as defined in the Regulations (Table L and Map 1). It will be noted in Table L that 632 beds remained for allocation as pool beds, after all areas were assigned the maximum number of beds according to area stand- ards. Only one district, Baltimore City and the surround- ing counties, qualified as a base area. There are eight areas classified as intermediate and seven as rural. The areas and the reasoning behind their establish- ment are contained in later sections where the general hospital service areas are discussed individually. No hospital communities were designated as area centers because, in most instances, hospital service areas are served by facilities in one community within the area. The base and district hospitals in the regional centers are considered to serve as centers. Where more than one community exists in a service area, it was felt that the institutions were of comparable status; hence they were not expected to serve as con- sultation centers. It is expected that such services will be available to all institutions in the State, flowing from the base or district hospitals. Table M analyzes the utilization of hospitals beds in relation to population. Having the number of ad- missions, and the number of patient days, it was pos- sible to calculate the average length of stay per patient. Table N, which lists the origin, or place of residence, of patients discharged from general hospitals, gives a basis for determining the area served by each institu- tion. The information contained in this table was based on sample studies by the hospitals, since such data are not maintained as a regular hospital procedure. Territorial coverage The general hospitals of the State were plotted on Map 2, which shows the distribution of population according to the 1940 Census. An area with a radius of 12% miles was circumscribed around each hospital location. With transportation highly developed, in the absence of natural barriers, the services of a hospital are readily accessible within a radius of 12 miles. It is not a hardship for a patient to travel as far as 25 miles to get care, if facilities are available at the end of the trip. 16 General Hospitals 17 MARYLAND STATE PLANNING COMMISSION 1947 MAP I HOSPITAL SERVICE AREAS LEGEND BASE AREA INTERMEDIATE AREA RURAL AREA AREA BOUNDARIES PROPOSED FACILITIES HOSPITAL COMMUNITIES AREA POPULATION DATA BASED ON 1943 US. BUREAU OF THE CENSUS ESTIMATE 18 Hospital Survey and Plan for Maryland—Part III TABLE M: UTILIZATION OF GENERAL HOSPITAL BEDS Patient Bed Normal Bed Beds Per Patient Per Cent Days Name of Institution Admissions Days Complement Capacity 1,000 Days Bed Occupancy1 Average Population1 Per Year1 Stay Allegany County (.81,302) Allegany Hospital 3,418 28,038 124 124 226,1 61.9 8.2 Memorial Hospital 6,064 60,774 218 218 278.8 76 4 10.0 Miners Hospital 1,162 11,042 51 51 216.5 59.3 9.5 Reeves Clinic (special) 400 835 17 17 49,1 13.5 2.1 Totals 11,044 100,689 410 410 5.0 245.6 67.3 9.1 Anne Arundel County (77,070) Annapolis Emergency Hospital 2,103 15,841 70 70 0.9 226.3 62.0 7.5 Calvert County (10,51,9) Calvert County Hospital 698 4,251 26 26 2,5 163.5 44,8 6.1 Cecil County (32,055) Union Hospital 1,457 16,504 72 72 2.2 229.2 62.8 11.3 Charles County (19,781,) Physicians Memorial Hospital 830 4,425 31 33 1.7 134.1 36.7 5.3 Dorchester County (24,264) Cambridge-Maryland Hospital 1,634 14,110 75 65 2.7 217.1 59.5 8.6 Frederick County (51,771,) Frederick City Hospital 3,157 30,195 125 111 272.0 74.5 9.6 Frederick County Emergency Hospital 550 13,140 53 55 238.9 65.5 23.9 Totals 3,707 43,335 178 166 3,2 261.1 71.5 11.7 Harford County (1,2,890) Fountain Green Hospital 215 2,457 17 17 144.5 39.6 11.4 Harford Memorial Hospital 2,847 20,990 72 72 291.5 79.9 7.4 Totals 3,062 23,447 89 89 2.1 263.4 72.2 7.7 Kent County (13,071) Kent and Queen Anne’s General Hospital 1,074 6,313 31 25 1.9 252.5 69.2 5,9 Montgomery County (101,,! 55) Montgomery County General Hospital 1,327 12,025 40 40 300,6 82.4 9.1 Suburban Hospital 2,208 19,985 102 102 195.9 53.7 9.1 Washington Sanitarium and Hospital 3,511 61,931 201 188 329.4 90.3 17.6 Totals 7,046 93,941 343 330 3.2 284.7 78.0 13.3 Prince George’s County (117,625) Eugene Leland Memorial Hospital 1,730 14,042 87 87 161.4 44.2 8.1 Prince George’s General Hospital 3,349 26,390 102 102 258,7 70.9 7.9 Warren Hospital 479 5,856 17 17 344.5 94.4 12.2 Totals 5,558 46,288 206 206 1.8 224.7 61.6 8.3 St. Mary’s Hospital (17,877) St. Mary’s Hospital 1,046 9,447 45 45 2.5 209.9 57.5 9.0 Somerset County (17,269) Edward W. McCready Memorial Hospital 769 7,914 38 38 2.2 208.3 57.1 10.3 Talbot County (16,190) Easton Memorial Hospital 2,940 28,692 108 87 5,4 329.8 90.4 9.8 Washington County (69,890) Washington County Hospital 6,149 63,640 185 142 2.0 448.2 122.8 10.3 Wicomico County (32,960) Peninsula General Hospital 5,955 47,947 177 177 5.4 270.9 74.2 8.1 (1,055,006) County totals 55,072 526,784 2,084 1,981 1.9 265.9 72.9 9.6 Baltimore City (927,91,1) Baltimore City Hospitals 4,828 57,242 513 513 111.6 30.62 11.9 Bon Secours Hospitals 4,823 39,000 142 142 274.6 75.2 8.1 Church Home and Hospital 5,831 48,761 165 165 295.5 81.0 8.4 Franklin Square Hospital 4,156 36,429 202 173 210.6 57.7 8.8 Hospital for Women of Maryland 3,981 37,421 124 124 301,8 82.7 9.4 Johns Hopkins Hospital 17,850 244,303 984 873 279.8 76.7 13.7 Maryland General Hospital 5,213 71,173 242 235 302.9 83.0 13.7 Mercy Hospital 7,460 87,736 287 281 312.2 85.5 11.8 Provident Hospital 2,793 35,628 125 125 285.0 78.1 12.8 St. Agnes Hospital 6,280 66,416 221 184 361.0 98.9 10.6 St. Joseph’s Hospital 7,847 74,680 250 250 298.7 81.8 9.5 Sinai Hospital 6,126 83,706 300 300 279.0 76.4 13.7 South Baltimore General Hospital 4,473 43,057 150 135 318.9 87.4 9.6 Sydenham Hospital 1,219 18,180 100 100 181.8 49.8 14.9 Union Memorial Hospital 7,914 104,832 341 341 307.4 84.2 13.2 Volunteers of America Hospital 480 5,101 40 40 127.5 34.9 10.6 West Baltimore General Hospital 4,271 49,042 186 186 263.7 72.2 11.5 University Hospital 10,179 143,538 435 435 330.0 90.4 14.1 Baltimore City totals 105,724 1,246,245 4,807 4.602 5,0 270.8 74.2 11.8 (1,982,91,7) State Totals 160,796 1,773,029 6,891 6,583 3.3 269,3 73.8 11.0 1 Based on normal bed capacity and 1943 estimated civilian population (given in parentheses). 2 Low occupancy rate attributable to closing of part of hospital because of shortage of personnel TABLE N: GEOGRAPHIC DISTRIBUTION OF PATIENTS DISCHARGED FROM GENERAL HOSPITALS, BASED ON SAMPLE STUDIES Name of Institution Total 1 Baltimore City Allegany County | Anne Arundel County Baltimore County ) I Calvert County Caroline County Carroll County Cecil County Charles County Dorchester County Frederick County Garrett County Harford County Howard County Kent County Montgomery County Prince George’s County Queen Anne’s County JH H z D O o m < a H CO Somerset County Talbot County Washington County Wicomico County Worcester County O g z o 53 cr < Z C )UT OF State 1 Foreign Pennsylvania Virginia West Virginia I Delaware District op Columbia Other States Allegany County Allegany Hospital 3,405 2,750 51 12 ii 581 Memorial Hospital 6,059 3,601 574 78 548 1,258 Miners Hospital 1,154 1,019 135 Anne Arundel County Annapolis Emergency Hospital 2,118 2,037 8 9 4 24 36 Calvert County Calvert County Hospital 691 19 629 1 6 17 19 Cecil County Union Hospital 1,449 1,376 58 15 — Charles County Physicians Memorial Hospital 826 752 35 35 4 Dorchester County Cambridge-Maryland Hospital 1,618 1,560 58 Frederick County Frederick City Hospital 3,760 506 2,784 6 293 33 60 78 Frederick County Emergency Hospital . . 550 550 Harford County Fountain Green Hospital 188 188 Harford Memorial Hospital 2,841 439 2,290 112 Kent County Kent and Queen Anne’s General Hospital 1,073 801 249 23 Montgomery County Montgomery County General Hospital . . Suburban Hospital 1,304 136 1,056 41 22 49 2,151 1,676 45 44 386 Washington Sanitarium and Hospital.... 3,507 1,753 1,754 Prince George’s County Eugene Leland Memorial Hospital 1,748 40 1,345 136 227 Prince George’s General Hospital 3,338 3,205 67 66 Warren Hospital 479 479 St. Mary’s County St. Mary’s Hospital 1,061 1,061 Somerset County Edward W. McCready Memorial Hospital 762 602 120 40 Talbot County Easton Memorial Hospital 3,334 709 156 24 450 1,551 444 Washington County Washington County Hospital 5,377 4,613 40 550 130 44 Wicomico County Peninsula County Hospital 5,912 512 3,270 1,186 135 a a 809 County totals 54,705 7,370 2,056 637 709 506 1,815 753 1,716 3,334 760 2,478 142 825 4,818 5,120 699 1,100 1,114 1,551 4,658 3,270 1,306 1,199 1,098 84 1,388 386 3,813 Baltimore City Baltimore City Hospitals 5,154 4,683 24 289 121 37 Bon Secours Hospital 4,796 4,796 Church Home and Hospital 5,841 3,194 2,325 322 Franklin Square Hospital 4,163 3,667 65 297 1 68 1 2 21 18 4 2 2 1 2 2 10 Hospital for Women of Maryland 4,006 2,581 1,425 Johns Hopkins Hospital 17,864 9,732 3,666 4,231 235 Maryland General Hospital 5,158 4,642 516 Mercy Hospital 7,500 6,855 491 154 Provident Hospital 2,773 2,718 55 St. Agnes Hospital 6,290 3,537 71 1,959 44 36 63 419 27 17 10 35 72 St. Joseph’s Hospital 7,881 5,911 1,572 398 a Sinai Hospital 6,114 5,811 a 303 a South Baltimore General Hospital 4,485 4,058 398 29 Sydenham Hospital 1,219 990 229 Union Memorial Hospital 7,915 5,310 2,605 Volunteers of America Hospital 479 300 119 60 West Baltimore General Hospital 4,272 3,204 a a a a a 1,068 University Hospital 10,179 6,315 3,512 352 Baltimore City Totals 106,089 78,304 160 4,117 1 112 1 38 84 437 31 2 19 11 2 2 17,266 5,267 235 State Iotals 160,794 78,304 7,370 2,216 4,117 638 709 618 1,816 753 1,716 3,372 760 2,562 579 856 4,820 5,139 699 1,111 1,114 1,553 4,658 3,272 1,306 18,465 1,098 84 1,388 386 9,080 235 a Included in total. General Hospitals 19 MARYLAND STATE PLANNING COMMISSION 1947 MAP 2 POPULATION DISTRIBUTION RELATED TO GENERAL HOSPITAL SERVICE AREAS OF 12.5-MILE RADIUS BASED ON 1940 US. CENSUS LEGEND 50 persons I 00 250 1,000 5.000 I 0,000 25.000 500.000 ond over 20 Hospital Survey and Plan for Maryland—Part III When Map 2 was originally prepared by the Mary- land State Planning Commission, different size dots were used to indicate varying numbers of people residing in the areas. After the hospitals were spotted on the map and circles of radius drawn, the dots outside the circles were counted. The adjoining tabula- tion discloses the number of persons estimated to be living outside the radii. From this study, it is apparent that four counties have important segments of population residing more than 12p2 miles from a general hospital: Caroline, Carroll, Garrett, and Worcester counties. When areas with a 25-mile radius were described on the map, which distance is not too great for patients to travel to suitable medical facilities, the State was prac- tically covered in its entirety. The only exception was the western half of Garrett County and a portion of Worcester County. It was therefore concluded that, with few exceptions, the hospitals of the State are well distributed and that most of the new construction should be as additions to existing hospitals, unless hospitals are of such con- struction that they should be condemned. County Population 19401 Outside 12 y2- Mile Radius2 Inside Mile Radius Allegany 86,973 5,400 81,573 Anne Arundel 68,375 200 68,175 Baltimore 155,825 9,200 146,625 Calvert 10,484 550 9,934 Caroline 17,549 13,850 3,699 Carroll 39,054 36,454 2,600 Cecil 26,407 1,400 25,007 Charles 17,612 1,150 S 750 W 15,712 Dorchester 28,006 5,550 22,456 Frederick 57,312 3,800 S 50,312 3,200 N, E Garrett 21,981 18,681 3,300 Harford 35,060 12,400 22,660 Howard 17,175 17,175 Kent 13,465 2,300 11,165 Montgomery 83,912 3,000 80,912 Prince George’s 89,490 1,600 87,890 Queen Anne’s 14,476 8,150 6,326 St. Mary’s 14,626 3,500 11,126 Somerset 20,965 4,600 16,365 Talbot 18,784 — 18,784 Washington 68,838 4,850 W 4,150 S 250 E 59,588 Wicomico 34,530 1,150 E 3,900 W 29,480 Worcester 21,245 21,245 — County totals 962,144 171,280 790,864 Baltimore City 859,100 —■ 859,100 State Totals 1,821,244 171,280 1,649,964 1United States Bureau of the Census, 16th Census of the United States, 1940. 2N, S, E, and W indicate the direction in which the excluded population groups are located. Section 1. Allocation of Beds and Establishment of Priorities The allocation of facilities and the establishment of priorities in the category of general hospitals pre- sent some problems not common to other groups. Some questions which arise in planning of all categories are more complex in the case of general hospitals. The planning for tuberculosis, chronic disease, and mental hospitals, and public health facilities is simpli- fied. With the exception of public health facilities, those institutions are few in number and serve large areas of the State. In the case of general hospitals, the areas are smaller and, in most instances, the institutions are autonomous. Distribution In Appendix B, Subpart A 53.1 of the Regulations gives the over-all general directions and standards for the different types of areas. In areas where general hospital beds exist in excess of the State standard for that area, such excess beds are not counted against the State standard of 4.5 (Subpart B 53.12). The primary consideration for the allocation of gen- eral hospital beds by areas is population. Left to the discretion of the Committee for assignment are those beds in the pool created by the differentials between area standards and the over-all State standard of 4.5 beds per 1,000 population (Subpart B 53.13). Priority of projects The determination of priority ratings between the categories and between projects within the categories is a more complex procedure. In the Regulations, Sub- part E 53.43 and 53.44, general principles for this part of the planning are set down, but some interpreta- tions and detailed policies are left the State agency. New installations are granted first priority, except where replacements are of a minor character or where a public hazard is to be replaced. Priority of public health center facilities is dependent on certification by the State Department of Health that existing facilities are unsuitable for use. The relative priority of projects is based on urgency, special consideration being given to rural areas with relatively small financial resources. Projects intended to provide a balancing of facilities available for racial groups are considered. Priorities are discussed in de- tail in Part IV. Determining distribution of general hospital beds While the basic consideration in the allocation of general hospital beds is the ratio of existing and pro- posed beds to population, modifying factors are geo- graphic barriers and location, socio-economic factors, availability of professional and lay personnel, and past experiences of existing hospitals in the area. The basic intent of Public Law 725 is to provide financial aid toward the construction of hospital facili- ties at points of determined need. Studies have shown that hospital facilities now exist in direct ratio to per capita income and not according to population (Ap- pendix P). This program is designed to correct this inbalance of beds to population. The first step, there- fore, is the relating of population to beds. As previously stated, only four areas in the entire General Hospitals 21 State have important segments of population living more than miles from a general hospital. The residents of Caroline County are largely depend- ent upon the Memorial Hospital at Easton for service. Carroll County residents use primarily the hospital facilities of Baltimore, but some use the facilities in Frederick City and Hanover, Pennsylvania. Garrett County is served by the Miners Hospital at Frostburg, and the Memorial Hospital and Allegany Hospital in Cumberland. Worcester County residents go to the Peninsula General Hospital at Salisbury. A detailed study of the needs of each county and Bal- timore City is contained in Section 2 of this Chapter. Policies established as a guide The policies listed below were established as a guide in the allocation of beds. 1. Proprietary hospitals are eliminated. 2. Institutions having buildings which are con- sidered hazards are also excluded, except for consideration on a replacement basis. 3. Hospitals whose ancillary departments have sufficient capacity to meet the needs imposed by additional beds are given precedence over in- stitutions whose departments are already taxed by service to the existing beds. 4. Hospitals having more than 100 beds will have priority over small hospitals within the area, unless the additional beds would result in a capacity of more than 100 beds. 5. Since the training of hospital personnel is of such importance to the over-all program of medical care, special consideration will be given to hospitals whose training program would be im- proved or enlarged by the additional facilities. 6. No application will be approved under this Plan unless the applicant includes therein the follow- ing statement: The applicant hereby assures the State agency that it will make its facilities avail- able to all persons residing in the area to be served without discrimination on account of race, creed, or color; provided, however, such statements will not be required from applicants in any specific area for which PHS-8 (HF) is sub- sequently submitted as an amendment to this Plan. (Note: PHS-8 (HF) provides for a specific statement of the number of beds assigned to each race.) 7. Reasonable evidence should be available to show that the hospital is in a position financially to maintain and operate the facilities. 8. A hospital must be in a detached building, no part of which is used for other than hospital pur- poses, in order to be considered an acceptable hospital. 9. Institutions considered unacceptable are not to be identified, and where more than one such in- stitution exists in an area only their total bed capacity is to be shown. Policies established as a guide Section 2. Service Areas1 ALLEGANY COUNTY Intermediate Area Number 1 Population Change from previous period Change over 1920 1943: 81,302 5,671 decrease 16.2% increase 1940: 86,973 7,875 increase 24.3% increase 1930: 79,098 9,160 increase 13.1 % increase 1920: 69,938 Nonwhite population Per cent nonwhite Per capita income 1945: 1,220 1.5 1945: $1,280.74 1940: 1,322 1.5 1940: $ 600.16 Classification of residents, 1940 Urban Rural nonfarm Rural farm 58.3% 34.6% 7.1% Land area: 426 square miles Population per square mile, 1943: 190.8 County seat: Cumberland Population 1940: 39,483 1930: 37,747 Births in hospitals as per cent of total births, 1945 Total White Nonwhite 82.4 82.6 72.7 General hospital facilities Institution Location Beds Allegany Hospital Cumberland 124 Memorial Hospital Cumberland 218 Miners Hospital Frostburg 51 Reeves Clinic (special) Westernport 17 1Sources of statistical data used herein are given in Appendices I through O. 22 Hospital Survey and Plan for Maryland—Part III Geographic considerations Allegany County lies in the mountainous part of Western Maryland, west of Washington County and east of Garrett County. It is bounded by Pennsylvania on the north and is separated from West Virginia on the south by the Potomac River. The County has 426 square miles of area, being the twelfth county in the State in size. Most of the surface is mountainous. The mountain ridges run generally north and south. Therefore, the western section is somewhat isolated from the eastern portion of the County. Population The population of Allegany County was 81,302 in 1943. A steady increase in population was experienced from 1920 to 1940, but a decrease took place between 1940 and 1943. This reversal of trend was construed as being due largely to the war and not to a change of industrial character. The area already had made important strides toward converting from coal mining to manu- facturing before the war period. It can be assumed that with the end of the war, the normal trend will be re- established, but at a less rapid rate of increase than was experienced in previous decades. The over-all net in- crease in population between 1920 and 1943 was 11,364, or 16.2%. The density of population in 1943 was 190.8 persons per square mile, which places Allegany County as the fourth county in the State in this respect. The population is concentrated in and around Cum- berland which had 45.4% of the total population of the County in 1940. Cumberland, with a population of 39,483 in 1940, is located near the center of the County. The eastern half of the County is thinly populated along Route 40, leading to Hancock and Hagerstown, and along Route 51, which skirts the southern boundary to the southeast. The western half of the County is more densely populated, having approximately 94% of the population when Cumberland is included. Other smaller communities are located along Route 36, which parallels and runs close to the western boundary. The population by election districts in 1940 was as follows: District 1, Orleans 804 District 2, Oldtown 987 District 3, Flintstone 1,284 District 4, Cumberland Canal 14,840 District 5, Wills Creek 7,925 District 6, Cumberland River 8,351 District 7, Rawlings 2,820 District 8, Westernport 5,658 District 9, Barton 1,673 District 10, Lonaconing 1,846 District 11, Frostburg 1,148 Dirstict 12, Frostburg 1,456 District 13, Mount Savage 3,245 District 14 1,944 District 15, Lonaconing 2,450 District 16, North Branch 1,670 District 17, Vale Summit , 390 District 18, Midland 1,954 District 19, Shaft 949 District 20, Ellerslie 1,569 District 21, Gross 969 District 22, Union Street 4,875 District 23, Dacatur Street 4,755 District 24, Eckhart 1,955 District 25, Pekin 711 District 26, Frostburg 2,061 District 27, Gilmore 662 District 28, Frostburg 1,872 District 29, La Vale 3,088 District 30, Zihlman 589 District 31, McCool 905 District 32, Frostburg 1,215 District 33, Kifer 353 The nonwhite population, numbering 1,220, made up 1.5% of the population of the County in 1945. As of 1940, the residents were 58.3% urban, 34.6% rural nonfarm, and 7.1% rural farm. Transportation Allegany County is adequately served by highways running to all parts of the County from Cumberland and extending into Pennsylvania and West Virginia. The Western Maryland and Baltimore and Ohio rail- roads cross the County from east to west, passing through Cumberland. Routes 40 and 51 cross the County east and west. Two other highways, Routes 220 and 36, run north and south through the western half of the County. Local and long-distance bus lines supplement the railroad service, Cumberland, the industrial, commercial, and medical center of the County, therefore, is accessible to all resi- dents of the County by means of public and private transportation. Industry and commerce The eastern half of Allegany County between Cum- berland and the Washington County line is devoted largely to horticulture. The economy of the western half, including Cumberland and extending to the western and southern extremities, is based on coal mining, manufacturing, and transportation. Large employers are the Baltimore and Ohio Railroad, Western Mary- land Railroad, Celanese Corporation, West Virginia Pulp and Paper Company, and Kelly Springfield Tire Company. There are also many small manufacturing plants in the area. The decline in the production and employment at the coal mines, due to the depletion of the coal supply, has been offset to some degree by the establishment of manufacturing industries, such as the Celanese Corpora- tion just west of Cumberland. This area has been suc- cessfully undergoing a transition in its economic structure for a period of twenty years. The income per capita for Allegany County was $600.16 in 1940, and rose to $1,280.74 in 1945. The per capita income for the State of Maryland for 1945 was $1,291.61. Physicians Seventy physicians practice in Allegany County, making a ratio of one physician to each 1,161 persons. They are distributed as follows: Cumberland 57 Lonaconing 2 Frostburg 4 Mount Savage 1 Piney Grove 1 Westernport 3 Barton 1 Luke 1 General Hospitals 28 Sixty of the 70 physicians have hospital affiliations. Their fields of practice are: General 38 Pediatrics 2 X-ray 2 Surgery 9 Genitourinary 1 Public health 2 Eye, ear, nose, and throat .8 Obstetrics 2 Gynecology 1 GENERAL HOSPITAL FACILITIES ALLEGANY HOSPITAL The Allegany Hospital, located in Cumberland, is owned and operated by the Daughters of Charity of St. Vincent de Paul. It was established by a board of laymen in 1906 and taken over by the Catholic Order in 1911. It is a general hospital and has special departments for obstetrics and pediatrics. It holds full approval by the American College of Surgeons. The school of nursing has State-approval. The directing board is made up of four Sisters who serve for a period of one year. The administrator is appointed by the Board on recommendation of the Superior. A group known as the Ladies’Aid devotes its efforts to sewing and raising funds for the hospital. Area served: During 1946, 3,405 patients were dis- charged, accounting for 33,960 days of service. The patients were largely from the local area, 50% being from Cumberland, and 31% from Allegany County outside of Cumberland. Buildings: The original buildings and several added wings which are of brick construction are classed as fire-resistant. Bed capacity: The present capacity is 124 beds. No beds are set aside for nonwhite patients because the demand for service by this group is not great enough to warrant such an arrangement. Utilization: The rate of occupancy of its beds was 61.9%. The average length of stay per patient was 8.2 days. Patients discharged were in the following classifica- tions: Personnel: The personnel consists of 200.5 full-time and 19.5 part-time employees, making a ratio of 1.7 employees per bed. Part-time employees were calcu- lated on the basis of 50% employment. Educational activities: The educational program in- cludes a State-approved school of nursing. There were 100 students in training as of the date of the survey. Building plans: At the present time, there are no plans for the expansion of this hospital. MEMORIAL HOSPITAL The Memorial Hospital, located in Cumberland, is the largest general hospital in the State outside of the City of Baltimore. It is owned jointly by the City of Cumberland and Allegany County. The original man- aging board of seven members was appointed by the Governor of the State, but from that point forward it has been self-perpetuating. This hospital is the successor to the Western Mary- land Hospital of Cumberland, which it absorbed in 1929. It has special departments set up in the fields of ob- stetrics, pediatrics, and eye, ear, nose, and throat. The American College of Surgeons has given its full approval. The nursing school has State-approval. The Women’s Auxiliary supports the cancer clinic and nursing school. This group has a membership of 500. Area served: Approximately 38% of the patients served in 1945 were from Cumberland and 21% from the rest of Allegany County, Garrett County residents accounted for 9% of the total number of patients treated; West Virginia, 21%; and Pennsylvania, 9%. Buildings: The buildings are fire-resistant. They were constructed in 1929. Bed capacity: The capacity is 218 beds. Utilization: The rate of occupancy for 1945 was 76.4% and the average stay per patient, 10 days. The patients discharged were classified as follows: Number of patients Per cent Medical 1,163 19.2 Surgical 2,351 38.8 Obstetric 842 13.9 Pediatric 1,479 24.4 Other 224 3.7 Totals 6,059 100.0 Number of Per cent patients Medical 725 21 .3 Surgical 1,723 50.6 Obstetric 249 7.3 Pediatric 616 18.1 Other 92 2.7 Totals 3,405 100.0 Medical staff: The Medical Staff is organized, hav- ing elected officers and standing committees which assist with medical problems and standards. The privilege of doing surgery is granted after four years of residency. Privileges are granted in the various special- ties on the basis of demonstrated ability in the field. There are 26 physicians on the Active Staff, 26 on the Courtesy Staff, and four on the Consulting Staff. Four dentists are on call. Personnel: The personnel is made up of 268 full-time employees. This establishes a ratio of 1.2 employees per bed. Educational activities: A State-approved school of nursing is maintained. As of the date of the survey, 119 students were in training. Medical staff: The Medical Staff is organized. Its officers and committees assist with the establishment of medical standards and analyses of quality of service. Specialized divisions are set up in medicine, surgery, obstetrics, urology, eye, ear, nose, and throat, anesthesia, pathology, and dentistry. Chiefs are ap- pointed for each type of service. Two dentists are on call. The privilege to work in surgery and the specialties is granted on recommendation of the Credentials Com- mittee. 24 Hospital Survey and Plan for Maryland—Part III Building plans: At present there are no projected construction plans. MINERS HOSPITAL The Miners Hospital at Frostburg, 11 miles west of Cumberland, is owned and operated by the State of Maryland. It was built by the State in 1913. It is a general hospital and has set up a separate ob- stetric department. It holds provisional approval by the American College of Surgeons. It is managed by a board of seven members, four of whom are appointed by the Governor and three elected by the Board. Area served: Eighty-eight per cent of the patients ad- mitted to this hospital were residents of Allegany County. Twelve per cent were residents of Garrett County. Buildings: The building is of brick construction, but the floors are wood and inflammable. Bed capacity: The capacity is 51 beds, two of which are reserved for nonwhite patients. Utilization: The occupancy rate is 59.3%, and the average length of stay is 9.5 days. A classification of discharged patients according to diagnosis resulted in the following groups: of from time to time. The rate of occupancy was 13.5% and the length of stay per patient was 2.1 days. Personnel: The personnel consists of 10 employees, making a ratio of 0.6 employee per bed. Building plans: No projected building program was reported. Conclusions Allegany County, containing Cumberland, which is the second largest city in the State, has had developed within its bounds the four hospitals described. None is located in the eastern half of the County. Only 5,400 of its residents live more than 12 miles from the Cum- berland and Frostburg hospitals. This figure is reduced further when taking into consideration the proprietary hospital at Westernport. On the basis of the 393 beds in the three nonprofit general hospitals there are 4.83 beds per 1,000 popula- tion. Taking into consideration the additional 17 beds in the hospital at Westernport, the ratio is 5.0 beds per 1,000 population. This is above the standard of 4.0 beds per 1,000 population for an intermediate area and also above the standard for the State of 4.5 beds per 1,000 population. In spite of this apparent excess of beds, the hospitals in Allegany County operate at an average occupancy rate of 67.3% with an average length of stay per patient of 9.1 days. These hospitals reported a total of 11,044 admissions for the year, accounting for 100,689 patient days of service. All of these factors indicate a high utilization of the facilities. The utilization of the apparent excess number of beds is attributed to the fact that the residents of large areas of southern Pennsylvania and northern West Virginia depend on these hospitals for service. Other factors are the education of the public to the use of the hospitals, the preference of the physicians to do their work in the hospitals, and the distance to other hospitals with comparable facilities. An indication of the acceptance of the hospitals by the public is the fact that 82.4% of all births in the County occurred in hospitals. Of the total number of births recorded per race, 82.6% to white parents and 72.7% to nonwhite parents oc- curred in hospitals. The County is reasonably stable economically, be- ing a trading and railroad center and having a diversity of industries and is, therefore, able to support its hospitals. In view of these considerations, it was concluded that the utilization of the hospital facilities will con- tinue at a high rate and probably increase. The existing hospitals are operating close to the highest point of occupancy at which satisfactory service can be maintained. There are a sufficient number of physicians practicing in the area to assure adequate medical service. With two schools training nurses, personnel of this type is reasonably available. Allegany County qualifies as an intermediate area. Recommendations It is recommended that Allegany County be classi- fied as an intermediate area. patients Medical 122 10.6 Surgical 754 65.3 Obstetric 278 24.1 Totals 1,154 100.0 Medical staff: The Medical Staff is not organized. Any physician holding a Maryland State license to practice is permitted to attend patients. Four local physicians make up the Staff. Personnel: The personnel includes 24 full-time and three part-time employees, making a ratio of 0.5 em- ployee per bed. Part-time employees were calculated on the basis of 50% employment. Educational activities: There is no educational pro- gram. Building plans: The State has set up a fund of $80,000 for the addition of 20 beds and general renovation of the hospital. REEVES CLINIC The Reeves Clinic, located at Westernport in the southwestern corner of Allegany County, was estab- lished in 1938 by Doctors R. W. and J. N. Reeves. They operate it as a partnership. Area served: Patients are admitted from all parts of western Maryland and northern West Virginia. Building: The building is of modern construction and includes the owners’ offices. Bed capacity: The capacity is 17 beds. Utilization: Work is limited largely to the field of eye, ear, nose, and throat. Emergencies are taken care General Hospitals 25 In spite of the fact that the existing beds in this County are already in excess of the United States Public Health Service standards for the State, it is recommended that 75 beds be allocated to this area out of the pool, to be established as additions to either the Allegany Hospital or the Memorial Hospital, or di- vided between these hospitals. The State has already set up funds for the addition of 20 beds at the Miners Hospital. When these beds are constructed, they will be supplemental to the 75 rec- ommended. The Miners Hospital at Frostburg is the only State- owned general hospital in the State. It is recommended that after the building and renovation program is completed, a local nonprofit association be organized and that the title and responsibility for the operation of the hospital be transferred to it. Baltimore City has for many years enjoyed the status of being the medical center for the State of Maryland and a large portion of the eastern United States. Due to the fact that medical facilities and personnel of preeminent caliber are available within Baltimore City, few hospitals have been established in the five counties near the City. These counties, Anne Arundel, Baltimore, Carroll, Howard, and Harford, are practically dependent on Baltimore City for hospital facilities with the exception of the Annapolis Emer- gency Hospital at Annapolis and the Harford Memorial Hospital at Havre de Grace; and since it fulfills the requirements for a base area as defined by the United States Public Health Service, the area consisting of Baltimore and the five counties has been classified as a base area. Geographic considerations The entire area comprises a logical single unit. It is free of travel barriers, such as mountains and rivers, which might obstruct a free flow of traffic to and from the City. The bodies of water which are located in the area have been spanned at convenient points by highway and railroad bridges. All parts of the area are within a 25-mile radius of Baltimore City, with the exception of distant sections of the counties. Population The population of this area increased from 931,413 in 1920 to 1,310,265 in 1945, or 40.7%. Table O shows the population at five dates for which data are available. Population figures supplied by the Bureau of Vital Statistics of the Maryland State Department of Health, for November 1, 1945, are identical with the estimates made by the United States Bureau of the Census on November 1, 1943, the only differential being in Bal- timore City and St. Mary’s County. For Baltimore, the population as of November 1, 1943 was reported as 927,941, and as of November 1, 1945 as 930,000. All subdivisions included in the Baltimore Base Area experienced steady increases in population, betwen 1920 and 1945, Baltimore County leading with a 170.6% increase. The most recent population statistics available on the distribution of the population within the subdivisions is contained in the 1940 U. S. Census. In an area where the population is static, these figures might be ac- BALTIMORE BASE AREA cepted;but with an 11.6% increase in population from 1940 to 1945 for the Area as a whole, some further study is necessary. The greatest concentration of population outside Baltimore City is in those election districts contiguous to the City. No statistical records since 1940 are available to indicate where the population increases have occurred. It was assumed that most of the new residents settled in the industrial areas. There is a great concentration of people in the Sparrows Point- Essex-Middle River area. The next largest center is in the Catonsville area. Other concentrations exist in the neighborhoods of Towson, Havre de Grace, Bel Air, and Annapolis. On the basis of the 1943 estimate, the population per square mile was calculated as follows: Land Area in Square Miles Population per Square Mile 191+3 Baltimore City 79 11,746.1 Anne Arundel County 417 184.8 Baltimore County 610 331.8 Carroll County 456 86.4 Harford County 448 95.7 Howard County 251 73.6 Baltimore Base Area 2,261 578.6 The distribution of population by race in 1940 and 1945 was noted as follows: 19 hO Total White Nonwhite Baltimore City 859,100 692,705 166,395 Anne Arundel County .... 68,375 50,524 17,851 Baltimore County 155,825 145,295 10,530 Carroll County 39,054 36,973 2,081 Harford County 35,060 31,076 3,984 Howard County 17,175 15,369 2,806 Baltimore Base Area 1,174,589 970,942 203,647 19J+5 Total White Nonwhite Baltimore City 930,000 751,000 179,000 Anne Arundel County .... 77,070 56,955 20,115 Baltimore County 202,425 188,660 13,765 Carroll County 39,399 37,311 2,088 Harford County 42,890 38,001 4,889 Howard County 18,481 15,469 3,012 Baltimore Base Area 1,310,365 1,087,396 222,869 According to these data 17.0% of the population of the Baltimore Base Area was nonwhite, as of 1945. Transportation, commerce, and industry Baltimore is the most important city in the State and is, therefore, the commercial and industrial center of the Baltimore Base Area. 26 Hospital Survey and Plan for Maryland—Part III TABLE O : BALTIMORE BASE AREA, POPULATION TRENDS, 1920-1945 County 19451 19432 1940s 1930s 1920s Per Cent Change 1943-1945 Per Cent Change 1940-1943 Per Cent Change 1930-1940 Per Cent Change 1920-1930 Per Cent Change 1920-1945 Baltimore City 930,000 927,941 859,100 804,874 733,826 0.2 8.0 6.7 9.7 26.7 Anne Arundel 77,070 77,070 68,375 55,167 43,408 — 12,7 23.9 27.1 77.5 Baltimore 202,425 202,425 155,825 124,565 74,817 — 29.9 25.1 66.5 170.6 Carroll 39,399 39,399 39,054 35,978 34,245 — 0.9 8.5 5,1 15.1 Harford 42,890 42,890 35,060 31,603 29,291 - 22.3 10,9 7.9 46.4 Howard 18,481 18,481 17,175 16,169 15,826 — 7.6 6.2 2.2 16.8 Area Totals 1,310,265 1,308,206 1,174,589 1,068,356 931,413 0.2 11.4 9.9 14.7 40.7 1 Maryland State Department of Health, Bureau of Vital Statistics. These population estimates are the same as the 1943 Bureau of the Census estimates except for Baltimore City. 2United States Bureau of the Census 3United States Bureau of the Census Estimated Civilian Population, 1943. 16th Census of the United States, 1940. Most of the industries of the area are located in Greater Baltimore, which includes portions of the ad- joining counties. The majority of people are employed in manufacturing, commerce, transportation, and ship- ping occupations. While large numbers of residents of the area commute between their homes and their place of employment, many of those in the outlying districts engage in farming. Baltimore serves as an important marketing and export and import center for a large portion of the eastern United States. With the industrial and commercial importance of the City, there has been developed a network of highways and railroads which converge in Baltimore. The diversity of the types of employment available differentiates this area from one where the economic welfare of the community is dependent on one industry, with the prosperity of the community rising and falling with the rate of operation of that industry. GENERAL HOSPITAL FACILITIES The general hospitals of the State are listed in Table G. Those located in the Baltimore Base Area are as follows: Table M shows that the per cent occupancy for the hospitals in Baltimore City is 74.2%. The occupancy rate is high in all except the Baltimore City Hospitals, Franklin Square Hospital, Sydenham Hospital, and the Volunteers of America Hospital. At the time of the survey, Baltimore City Hospitals and Franklin Square Hospital had some departments closed due to short- ages of personnel. Flow of patients to hospitals in Baltimore City Table N, showing the distribution of patients by place of residence, is a tabulation of data supplied by the hospitals. Unfortunately, few hospitals keep a routine record of these data. Some ran test studies or estimated the distribution, while others supplied no information on the question. The distribution in Table N, therefore, cannot be considered complete. It did supply a sufficient amount of information to indicate the trends or direction of travel of people seeking hospital care. This compilation is given weight because of its con- sistency with the data compiled during the survey of medical care in the counties.1 The information, with relation to travel of people to Baltimore City for hospital care, gathered during the previous survey was illustrated on a map which is reproduced herein (Map 3). It is quite apparent from Table N and Map 3 that patients travel from all parts of the State to Baltimore City for hospital care and that the people of Anne Arundel, Baltimore, Carroll, Harford, and Howard counties are especially dependent in this way. Normal Bed Capacity White Nonwhite Total Anne Arundel County Annapolis Emergency Hospital 58 12 70 Baltimore County No general hospitals 0 0 0 Carroll County No general hospitals 0 0 0 Harford County Fountain Green Hospital, Bel Air. .. 17 0 17 Harford Memorial Hospital, Havre de Grace 61 11 72 Howard County No general hospitals 0 0 0 Baltimore City 18 institutions 4,104 498 4,602 Totals 4,240 521 4,761 1Medical Care in the Counties of Maryland, Maryland State Planning Commission, April 1944. General Hospitals 27 MARYLAND STATE PLANNING COMMISSION 1947 MAP 3 COUNTY RESIDENTS ADMITTED TO HOSPITALS IN BALTIMORE CITY 1940 LEGEND 28 Hospital Survey and Plan for Maryland—Part III ANNE ARUNDEL COUNTY BALTIMORE BASE AREA Population Change from previous period Change over 1920 1943: 77,070 8,695 increase 77.5% increase 1940: 68,375 13,208 increase 57.5% increase 1930: 55,167 11,759 increase 27.1 % increase 1920: 43,408 Nonwhite population Per cent nonwhite Per capita income 1945: 20,115 26.1 1945: $852.67 1940: 17,851 26.1 1940: $472.06 Classification of residents, 1940 Urban Rural nonfarm Rural farm 19.1% 63.5% 17.3% Land area: 417 square miles Population per square mile, 1943; 184.8 County seat: Annapolis Population 1940; 13,069 1930: 12,531 Births in hospitals as per cent of total births, 1945 Total White Nonwhite 66.7 78.6 27.9 General hospital facilities Institution Location Beds Annapolis Emergency Hospital Annapolis 70 Geographic considerations Anne Arundel County lies south of Baltimore City, It is bounded on the north by Baltimore City and Balti- more County, on the west by Howard and Prince George’s counties, on the south by Calvert County, and on the east by the Chesapeake Bay. It has 417 square miles of land area, making it the thirteenth county in the State in size. The land is gen- erally flat with some rolling hills. There are numerous rivers and bays opening into the Chesapeake Bay, which are the base of the resort and fishing industries. Population Its population in 1943 was 77,070. On this basis, the density of the population was 184.8 persons per square mile, placing it fifth among the counties of the State in this respect. The County experienced a population increase of 77.5% between 1920 and 1943. In 1945 there were 20,115 nonwhite residents of the County, representing 26.1% of the County’s popula- tion. The election districts, as of 1940, had the following populations: District 1 4,304 District 2 13,168 District 3 10,938 District 4 10,932 District 5 11,735 District 6 13,069 District 7 1,895 District 8 2,334 Districts 2, 3, 4, 5, and 6, located in the area between Baltimore and Annapolis, account for approximately 88% of the County’s population. As of 1940, the County’s population was 19.1% urban, 63.5% rural nonfarm, and 17.3% rural farm. Transportation Highways traverse the County in all directions. The Governor Ritchie Highway, a modern dual highway between Annapolis and Baltimore City, places the two cities within easy traveling distance of each other. The ferry to the Eastern Shore has its western terminus at Sandy Point, near Annapolis. This ferry is one of the main links between the Eastern and Western Shores. Railroad service is available to practically all parts of the County. Industry and commerce The State Capital and the United States Naval Academy are located at Annapolis, both of which con- tribute to its commercial importance. The County is largely dependent on farming, fishing, and summer resort trade. Some residents are engaged in shipbuilding, while others are employed at a fertilizer plant and a lumber company. The per capita income in 1940 was $472.06, making it the fifteenth county in the State in this respect. In 1945 the per capita income was $852.67, again mak- ing it fifteenth in the State. Physicians There are 42 physicians practicing in Anne Arundel County. This establishes a ratio of one physician to every 1,835 people. General Hospitals 29 They are distributed as follows: Annapolis 18 Crownsville 1 Glen Burnie 6 Lothian 1 East Port 2 Gambrills 1 Linthicum Heights 2 West River 1 Pasadena 3 Millersville 1 Elkridge 1 Odenton 1 Brooklyn 4 They are engaged in the following types of practice: General 37 Eye, ear, nose, and Surgery 1 throat 2 Pediatrics 1 Psychiatry 1 GENERAL HOSPITAL FACILITIES ANNAPOLIS EMERGENCY HOSPITAL The Annapolis Emergency Hospital, located in Annapolis, is operated by a nonprofit association. The Board of Trustees is made up of local citizens who are elected to membership for terms of three years. The hospital has full approval of the American College of Surgeons. Area served: Forty-six per cent of the patients treated are from Annapolis and 50% are from the rest of Anne Arundel County. Buildings: The buildings are of fire-resistant con- struction. The original buildings were constructed in 1902. The newest addition was constructed in 1929. Bed capacity: This hospital has a normal capacity of 70 beds, 12 of which are reserved for non white patients. Utilization: Its beds are used at 62.0% of capacity, furnishing 226.3 days of service per bed per year. The average length of stay per patient is 7.5 days. An analysis of service rendered shows the following: more beds were made available and nonwhite patients admitted for obstetric care. Educational activities: There is no organized educa- tional program in any of the branches of training. UNITED STATES NAVAL HOSPITAL The United States Naval Hospital, located on the grounds of the United States Naval Academy, renders service to Naval personnel and their families in the vicinity. Although it is not generally available to the population, it reduces the patient load at the Annapolis Emergency Hospital. Conclusions If Annapolis were located in an isolated area, it would be in urgent need of more beds; but with its proximity to Baltimore City, its need, while existent, is not acute. Because of its relative position to Baltimore City and Washington, Anne Arundel County hospital needs were determined to be comparable to those of a rural area. On this basis, 2.5 beds per 1,000 popula- tion, as of 1943, would require an allocation of 193 beds to Anne Arundel County. The Annapolis Emergency Hospital has not reported any planned expansion. However, in light of the popula- tion served, more beds are needed. The need calculated above would furnish more beds than are necessary. An addition of approximately 40 beds, bringing the total to 110, would meet the needs as now projected. The Annapolis Emergency Hospital does not admit nonwhite obstetric patients. The only facilities for such care are those maintained by Dr. Johnson in a three-bed private hospital in Annapolis. Birth records show that 66.7% of all births in this County occur in hospitals: 78.6% of all white births take place in hospitals; whereas, only 27.9% of all nonwhite births are in hospitals. Recommendations Because of its geographic relationship to Baltimore City and the dependence of its residents on the City’s hospital facilities, it is recommended that Anne Arundel County be included in the Baltimore Base Area. It is recommended that, when beds are allocated to specific institutions within the Baltimore Base Area, a construction program for the addition of 40 beds to the Annapolis Emergency Hospital be given favorable con- sideration. Number of 'patients Per cent Medical 459 21.7 Surgical 878 41.5 Obstetric 471 22.2 Pediatric 184 8.7 Other 126 5.9 Totals 2,118 100.0 These proportions show a satisfactory balance be- tween services; however, the number of medical and obstetric patients might be expected to increase if 30 Hospital Survey and Plan for Marylnad—Part 111 BALTIMORE CITY BALTIMORE BASE AREA Population Change from previous period Change over 1920 1945: 930,000 2,059 increase 26.7% increase 1943: 927,941 68,841 increase 26.5% increase 1940: 859,100 54,226 increase 17.1% increase 1930: 804,874 71,048 increase 9.7% increase 1920: 733,826 Per capita income for Baltimore Nonwhite population Per cent nonwhite City and Baltimore County 1945: 179,000 19.2 1945: $1,548.12 1940: 166,395 19.4 1940: $ 725.02 Land area: 79 square miles Population per square mile, 1943: 11,746.1 Births in hospitals as per cent of total births, 1945 Total White Nonwhite 81.9 88.2 63.5 General hospital facilities: 23 institutions (See Table P) Geographic considerations Baltimore City is bounded by Baltimore County on three sides. A small portion of its southern boundary is common with Anne Arundel County. It fronts on the Patapsco River, which opens into the Chesapeake Bay. Its land area is 79 square miles. Almost the entire area is improved, being occupied by residences, com- mercial institutions, and industries. The state is generally divided into three large sec- tions: the Eastern Shore; the Western Shore, which includes Southern Maryland and the Baltimore Metro- politan Area; and Western Maryland. Baltimore City is located at the focus of these areas. Washington lies forty miles to the southwest and Philadelphia ninety miles to the northeast. Population Between 1920 and 1945 the population of Baltimore City increased by 196,174, or 26.7%. Consideration must be given the increase in population in the counties surrounding the City in order to make a determination of the increase in demand on the facilities within the City. It is for this reason that the five surrounding counties have been included with Baltimore City in the Baltimore Base Area. The nonwhite population of Baltimore City, num- bering 179,000, was 19.2% of the total in 1945. In 1940 it represented 19.4% of the total. Transportation Baltimore City, being an important seaport and commercial and industrial center, is accessible by every type of transportation from not only the surrounding counties but the entire State. Industry and commerce The data available on the per capita income for Baltimore City was combined with that of Baltimore County. It was $1,548.12 in 1945 as compared with $725.02 in 1940. The following is excerpted from a release by the Baltimore Association of Commerce, May 1947. Baltimore, the country’s sixth city in population and second seaport in foreign-trade tonnage, is one of the principal industrial and maritime centers of the United States. With a metropolitan population of over 1,200,000 persons, Baltimore also handles a large volume of wholesale and retail trade. In addition to its industrial, shipping, and commercial activities, Baltimore is an important banking and financial community and is a recognized leader in the writing of casualty insurance and fidelity and surety bonds. As the metropolis of Maryland, Baltimore is the principal factor in the business life of the State. By virtue of its central position on the Atlantic sea- board, Baltimore is conveniently situated with respect to the principal world markets and sources of raw materials. These fundamental advantages, together with the development of Baltimore’s great natural harbor, the availability of superior transportation facili- ties, and the existence of short-line rail connections to the interior of the United States, established the basis for the city’s remarkable business expansion during the last three or four decades. Baltimore has a highly diversified industrial structure with no one industry or single group of industries occupy- ing a dominant position. As a result of the city’s growth along many different lines, general business conditions in Baltimore have been relatively more stable than those in almost any other large industrial city in America. Practically all types of consumers’ goods, including foodstuffs, clothing and accessories, shoes, hats, furni- ture, housefurnishings, silverware, books and magazines, handbags, luggage, cosmetics, jewelry, and umbrellas, are made in Baltimore. In addition, the community pro- duces a large number of basic and specialized products, such as chemicals, colors and pigments, fertilizers, re- fined petroleum, iron and steel products, soaps, insulated wire and cable, aircraft, ships and yachts, motor vehicles, refined copper, biological and pharmaceutical products, meteorological and scientific instruments, portable electric tools, radios, bottle closures, textile-mill products, metal and glass containers, and numerous others. Of the 280 separate industries listed for Maryland in the 1939 Census of Manufactures, all but 31 were rep- General Hospitals 31 resented in Baltimore and vicinity. A total of 145 in- dustries, or slightly over half the number given for the State were concentrated entirely in the Baltimore area. The localization of a very large part of Maryland's manufacturing industry in and around Baltimore is due primarily to the community’s outstanding advan- tages as a location for many different kinds of industrial operations. In December 1946, the approximately 2,000 manufactur- ing establishments in the Baltimore Industrial Area (Baltimore City and Baltimore County) employed a total of 188,215 workers, and the aggregate value of their production last year was estimated at around two billion dollars. The combined expenditures for mater- ials, fuel, power and supplies for use in manufacture were well over a billion dollars, while the total outlay for wages and salaries exceeded four hundred million dollars. For over two hundred years Baltimore has served as an international seaport. Its great natural harbor, which has about forty miles of deep water frontage, is the city’s chief commercial asset. The development of the port also has been an important factor in the growth of the community’s manufacturing industry. Many large concerns which require waterside factory sites operate extensive facilities along the Baltimore water- front, making it one of the most important industrial harbors in the United States. The banks and investment houses of Baltimore have played an important part in the community’s economic progress. From the beginning of the city’s export and im- port trade, early in the eighteenth century, to the found- ing of the Baltimore and Ohio Railroad in 1827, and ever since, the business leaders of Baltimore have demonstrated their resourcefulness in financing sound business enterprises. Many important manufacturing, merchandising, transportation, and mining concerns have been organized and financed here. Baltimore’s location, favorable with respect to econo- mic land and water transportation, has enabled the city to become one of the principal wholesaling and jobbing markets in the country. In 1939, the most recent year for which official records are obtainable, the city had a total of 1,664 wholesale establishments, including full- and limited-function wholesalers, manufacturers’ branch- es, agents, brokers, etc. The estimated volume of sales in 1945, according to the magazine “Sales Management,” amounted to $1,440,671,000. The local wholesale houses at the close of 1946 afforded employment to approxi- mately 25,000 workers. The principal commodities distributed by Baltimore wholesalers include automotive parts and equipment; clothing and furnishings; electrical goods; farm prod- ucts; groceries and food specialities; lumber and con- struction materials: dry goods and general merchandise; beer, wines, and liquors; paper and paper products; machinery and supplies; and tobacco products. The approximately 15,000 retail stores located in Bal- timore had an aggregate sales volume in 1945 of $870,147,000 according to an estimate prepared by “Sales Management.” This figure was more than double the dollar value reported by the U. S. Census Bureau for the year 1939. Concentrated largely in the central business district and in some 70 neighborhood shopping centers, the city’s retail outlets in December 1946 em- ployed about 75,000 workers. Due to its great economic importance, as well as to its central location with respect to other parts of the State, Baltimore has developed close business and social ties with every section of Maryland. Not only do many of the industrial and commercial establishments of Balti- more market their products throughout the State, but the city is, in turn, a large consumer of the products of Mary- land’s farms, mines, forests, and fisheries. Many manu- facturing concerns in the counties, likewise, market a part of their production in Baltimore. In addition, the county areas send considerable volume of merchandise and other commodities to Baltimore for transshipment. The city’s relationship to the rest of the State is further strengthened by the fact that many Federal and State Bureaus and departments with jurisdiction throughout Maryland maintain their headquarters in Baltimore. GENERAL HOSPITAL FACILITIES Twenty-one general hospitals are located in the Baltimore Base Area, and eighteen are within the City (Table G). Only one of the general hospitals within the City has less than 100 beds. Their total normal bed capacity is 4,104 for white patients and 498 for nonwhite patients. The Baltimore City Hospitals, with 513 general hospital beds, admits nonwhite patients but does not reserve separate facilities for them. While the population of Baltimore City has increased by 196,174 persons, or 26.7% since 1920, and the entire area is highly developed, it cannot be assumed that the medical service needs are approaching a static level. The important increment in population, in the areas surrounding the City, is almost entirely dependent upon the facilities of the City for such service. The combined bed facilities of all the hospitals in- clude every type of service (Table P). HOSPITAL FACILITIES EXISTING AND PROPOSED Combining the general hospitals with the acute special hospitals, Baltimore City has 4,320 general hospital beds for white patients and 539 for nonwhite patients, or a total normal bed capacity of 4,859 beds. At 4.5 beds per 1,000 population as of 1943, Baltimore City should have 4,176 general hospital beds. If Baltimore City were considered as an independent area, it would have an excess of 683 beds above the United States Public Health Service standards. How- ever this excess in Baltimore City is utilized by the residents of Howard, Harford, Carroll, Baltimore, and Anne Arundel counties who depend largely on Balti- more City for hospital service. The existing and recommended facilities of the coun- ties included in the Baltimore Base Area are treated 32 Hospital Survey and Plan for Maryland—Part III TABLE P: GENERAL AND SPECIAL HOSPITALS OF BALTIMORE CITY, BED COMPLEMENT BY TYPE OF SERVICE Name op Institution Medical i u o xn Obstetric Pediatric W S O 3 < z o o Tuberculosis 1 Nervous and Ment l o 2 o « w o Convalescent Orthopedic Eye, Ear, Nose, and Throat Skin and Cancer Venereal Disease Aged 1 Other Totals Baltimore City Hospitals 117 178 98 60 280 451 60 705 1,949 Baltimore Eye, Ear, and Throat Charity — — — — — — — 65 65 Beck Diagnostic Clinic 14 — — — — — 14 Bon Secours Hospital — — 25 21 — — — 96 142 Children’s Hospital School — — — — — — — 130 130 Church Home and Hospital — — 25 — — — — 140 165 Doctor’s Hospital — — 8 — — — 8 Franklin Square Hospital 30 65 50 8 — — 10 10 29 202 Hospital for Women of Maryland — — 38 — — — — 86 124 Johns Hopkins Hospital 245 310 144 121 16 — 87 — 80 60 8 1,071 Maryland General Hospital — — 26 29 — — — — 187 242 Mercy Hospital 62 91 45 35 3 — 17 34 287 Presbyterian Eye, Ear, and Throat, Hospital . . — — — — — — — — 40 40 Provident Hospital 22 37 20 14 — — 32 125 St. Agnes Hospital — — 31 22 — — 168 221 St. Joseph’s Hospital 20 52 32 33 — — 10 3 100 250 Sinai Hospital 31 40 48 28 — — 153 300 South Baltimore General Hospital 8 97 24 21 — 1 50 Sydenham Hospital — — — — 100 — 100 Union Memorial Hospital — — 35 51 — 255 341 Volunteers of America Hospital — — — — — 40 40 West Baltimore General Hospital — — 35 20 — — 131 186 University Hospital 70 104 66 34 — — — — — — — — — — 161 435 Totals 619‘ 974 7501 497 119 2802 878 4514 — 1501 2151 — 120 7055 1,620 6,587 Number of Institutions Having Departments 10 9 17 14 3 1 1 1 — 3 6 — 2 1 15 1Some of these were placed in totals with special hospitals. aPlaced in totals with tuberculosis hospitals. 8 Placed in totals with mental hospitals. 4Placed in totals with chronic disease hospitals and nursing homes. 5Only domiciliary care provided. in the discussion of the individual counties. With the addition of these facilities to the Baltimore City totals, the resultant figures for the Baltimore Base Area are: PROVIDENT HOSPITAL Provident Hospital, which is organized, operated, and staffed by nonwhite persons, was considered the logical beginning point for racial assignment of beds. This hospital holds approval by the American College o f Surgeons. It is approved for interne training and residencies in surgery and obstetrics, as well as for a general residency. It has an approved school of nurs- ing, the only one in Maryland for training of Negro nurses for State registration. It is well organized in all departments, including an outpatient service. The physicians in charge of the X-ray department and clinical laboratory do not limit their practice to these fields; but with a larger hospital these deficiencies might be corrected. Other departments, such as dietary, pharmacy, medical records, medical social service, and nursing school, are under the supervision of well-trained people. Con- sulting service is utilized in most of the specialties. In addition to the main hospital building, which was originally used by what is now the Union Memorial Hospital, several adjoining row houses have been re- modeled and are utilized for nurses’ quarters, teach- ing areas, and the outpatient department. The land area, occupied by the hospital and other buildings owned by the hospital, is 30,756 square feet, which with the necessary demolition of some of the row houses and the acquisition of a plot now proposed would supply minimal space for additional buildings. Baltimore City Anne Arundel County Carroll County (Westminster) Harford County White 4,104 88 50 108 Nonwhite 498 22 0 11 Total 4,602 1101 50i 1191 Total general hospital beds Special (acute) hospitals2 4,350 101 531 26 4,881 127 Less beds in nonacceptable hospitals ., 4,451 144 557 34 5,008 178 Total beds 4,307 523 4,830 Applying the standard of 4.5 beds per 1,000 popula- tion to the combined population for the Baltimore Base Area, which was 1,308,206 as of 1943, 5,887 general hospital beds are established as the need. In the light of the dependence of the entire State on Bal- timore City, the Committee allocated to the Baltimore Base Area 385 additional beds from the pool, bringing the quota for the Area to 6,272. With 4,830 acceptable beds in existence and recommended, there is a de- ficiency of 1,442 beds in Baltimore City. ALLOTMENT OF BEDS Having established the need at 1,442 after rec- ommendation for the counties included in the area, the next problem was the allotting of these beds. 1 Includes recommended beds. 2The Children’s Hospital School, listed with special hospitals in Table K, was transferred to the category of chronic disease hospitals. General Hospitals 33 The hospital is located in one of the two areas of Negro population concentration. Its normal capacity is 125 beds. The utilization rate of these beds is 78.1%, which is relatively high. Present projected plans include modernization of the existing hospital, a new nurses’ home, and re- placements and increased capacity in the laundry and power house, along with the addition of 50 to 75 beds. The beds are planned to be used for pediatric, obstetric, and general service. With the acute need for beds for the care of nonwhite patients specifications should call for a capacity of 250 beds. It can be expected that this hospital event- ually will need more than the 50 additional beds now projected. If funds can be located sufficient to meet two thirds of the cost of construction and necessary replacements, allocation of matching Federal funds is recommended for the project under consideration which will add 50 beds to the present capacity. BUILDING PLANS OF OTHER HOSPITALS In making plans for the expansion of hospital facilities, proposed building plans were weighed against the established needs. Reports by the general hospitals of Baltimore on their projected building plans were reviewed. Seven nonprofit general hospitals, which admit white and nonwhite patients, have under consideration plans for expansion. The Franklin Square Hospital project is located in the western area; Johns Hopkins Hospital is in the eastern area; South Baltimore Gen- eral Hospital is in the southern district. St. Joseph’s new location in Loch Raven will be in the north and convenient to Towson. Maryland General Hospital, University Hospital, and Mercy Hospital are in the center of the City. If construction follows figures being considered at present, 857 new general hospital beds will be added within Baltimore City, including the new St. Joseph’s Hospital. If ratios of 17% for nonwhite patients are observed, 744 of these beds will be assigned for white patients and 113 for nonwhite patients (Table Q). Within the Baltimore Base Area, several planned expansions were reported which, for various reasons, were not considered as being eligible for financial assistance at this time under the general hospitals phase of the program. West Baltimore General Hospital plans remodeling and expansion of its operating rooms suite, X-ray de- partment, and an addition of 20 beds. The hospital is strategically located, serving the West Baltimore residential area and Catonsville. This expansion is a continuation of a program under which a new wing to the hospital and a new nurses’ home have already been added. It is set up well organizationally and has well-qualified heads in most departments. While it holds an important place in the hospital picture, it cannot be considered for a grant under the Hospital Survey and Construction Act because of its policy against the admission of nonwhite patients. If its policy is changed to comply with the Act, the Hospital could be included in the program. The Baltimore Eye, Ear, and Throat Charity Hospi- tal, located at 1214 Eutaw Place, has under considera- tion plans for an addition to its laboratories, X-ray department, laundry, and hospital records area. This hospital is rendering valuable service to inpatients and clinic patients. Its present buildings are remodeled row houses which do not lend themselves well to hospital purposes. They present a fire hazard which would be increased with the addition of more space. In line with the established policy of excluding from the program any institution maintaining a building which is partially used for other than hospital or clinic purposes, this institution is excluded. Also, in line with the present generally accepted policy of concentrating all types of service in large general hospitals, this hospital is eliminated on account of its size. This decision is no reflection on the quality of work done nor the ability of the medical staff, but is made in the interest of safety and efficiency. St. Agnes Hospital, located at Wilkens and Caton Avenues, on the western edge of the City, plans to add 100 beds to its obstetric and pediatric depart- ments. It also plans an addition to its nurses’ home. TABLE Q: PROPOSED CONSTRUCTION AT NONPROFIT GENERAL HOSPITALS AVAILABLE TO NONWHITE PATIENTS, BALTIMORE CITY Racial Assignment of Beds To Normal Bed Capacity Be Added (17% Nonwhite) Name of Institution Estimated Cost Funds On Hand White Nonwhite Total White Nonwhite Total 158 15 173 75 15 90 $1,000,000 Johns Hopkins Hospital 656 217 873 2002 02 2002 3,000,000 to $1,750,000 5,000,000 Maryland General Hospital 228 7 235 76 16 92 1,000,000 900,000 256 25 281 124 26 150 1,000,000 230 20 250 124 26 150 in Loch Raven district South Baltimore General Hospital 127 8 135 21 4 25 250,000 100,000 354 81 435 124 26 150 800,000 Total Beds 2,009 373 2,382 744 113 857 1Present plans at St. Joseph’s Hospital call for erection of a 400-bed hospital at new location, making net increase 150. 2Johns Hopkins Hospital already has 24.9% of its beds reserved for nonwhite patients. The addition of 200 beds would reduce this percentage to 20.2%. 34 Hospital Survey and Plan for Maryland Part III This hospital in recent years has completed remodel- ing and renovating projects in its dispensary and acci- dent division, operating rooms, and pediatric depart- ment. The buildings are old but well constructed and have been kept in a good state of repair. Its bed complement is 37 beds in excess of its normal capacity. The per cent of occupancy based on normal capacity is 98.9%. In line with industrial development in this section, extensive home building operations are in progress in the area served by the hospital. It can be expected that St. Agnes Hospital, being located nearest this development, will be utilized to a great extent by the new residents. With its present high rate of occupancy and the expected increase in the population of the service area, need for more beds is indicated clearly. However, owing to its policy of not admitting nonwhite patients, this hospital cannot be considered for a grant under the Hospital Survey and Construction Act. This hospital is of more than ordinary importance to the community because of its proximity to and ad- ministrative and functional coalition with the Jenkins Memorial, whose function is the care of chronic and incurable patients. It is an important part of the hospital facilities of the City and should be encouraged to expand its facilities to meet the present and the apparent future increased demand. The Church Home and Hospital, located at Broad- way and Fairmount Avenue, has under consideration a project for the addition of 90 beds. This hospital is located in a densely populated area and is operating at a rate of occupancy of 81.0%. Some parts of the institution are quite old, but newer additions are fairly modern. Operating under a policy which does not permit the admission of nonwhite patients, this hospital cannot qualify for a grant of Federal funds under this program. Located as it is in an area with a large Negro population, it would seem logical that this hospital make some service available for Negroes. However, this body has no authority with regard to policies of the in- dividual hospitals; these prerogatives rest with the boards of the hospitals. The observation made above is rendered in the light of existing conditions which might be used as justif cation of a change in policy, and which in turn would bring the projected expansion program within the scope of the Hospital Survey and Construction Act. The Presbyterian Eye, Ear and Throat Hospital, located at 1017 East Baltimore Street, has a normal capacity of 40 beds. It conducts outpatient clinics in its specialties. A letter from the President of the Board states that plans for a new hospital of the same bed capacity are under consideration, but are quite nebulous. Because of the age of the buildings now used and the inflammable nature of their construction, the opinion expressed by the President of the Board is correct in that an entirely new building is the only program which should be considered. Because of its limited field and its size, and since the plans are not at all crystallized nor funds yet available, this project was not recommended for con- sideration under the program. The Sinai Hospital is in the process of preparing a construction program which, it is understood, will en- tail the vacating of the present building and the con- struction of a new hospital at a new site. It was re- ported by the Administrator that the new building will have a greater capacity than the present one. He also reported that the present policy opposed to the admission of nonwhite patients will be changed when the new hospital is put into service. Under the new policy, the Sinai Hospital would be included in this program. The bed capacity of the new hospital has not yet been determined. The importance of the West Baltimore General Hospital, St. Agnes Hospital, Church Home and Hospital, and Sinai Hospital is emphasized because they conduct schools of nursing. With the present critical shortage of nurses, hospitals operating schools of nursing should be aided in every possible way be- cause of their contribution to the over-all medical program. This is an additional reason for giving favor- able consideration to their construction programs should they see fit to change their policies to qualify for assistance. The completion of the seven programs, summarized in Table Q, along with the recommended additions at Provident Hospital, would leave the area 535 beds short of the allotted number. These beds would be assigned to othdr hospitals in the area as they develop construction programs in conformity with the reg- ulations. Conclusions Baltimore City, with its hospitals serving not only its own residents but those of a large area surrounding it, is in need of more general hospital beds. Building plans reported to be under consideration by hospitals in Baltimore City approximate the num- ber considered to be needed. Table Q lists the projects reported by hospitals which meet the basic requirements of the program. They are reasonable and could be favorably considered for grants of funds under this program; however, their listing does not constitute approval nor the granting of a specific priority. Recom men dot ion s It is recommended that Baltimore City, together with Anne Arundel, Baltimore, Carroll, Harford, and Howard counties, be considered as a base area. It is recommended that hospitals in the Baltimore Base Area which have building programs under con- sideration be encouraged to crystallize their plans and to raise the necessary funds. General Hospitals 35 BALTIMORE COUNTY BALTIMORE BASE AREA Population Change from previous period Change over 1920 1943: 202,425 46,600 increase 170.6% increase 1940: 155,825 31,260 increase 108.3% increase 1930: 124,565 49,748 increase 66.5% increase 1920: 74,817 Per capita income for Baltimore Nonwhite population Per cent nonwhite City and Baltimore County 1945: 13,765 6.8 1945: $1,548.12 1940: 10,530 6.8 1940: $ 725.02 Classification of residents for Baltimore City and Baltimore County, 1940 Urban Rural nonfarm Rural farm 87.5% 10.1% 2.4% Land area: 610 square miles Population per square mile, 1943: 331.8 County seat; Towson Population 1940: 3,623 Births in hospitals as per cent of total births, 1945 Total White Nonwhite 80.3 82.6 54.8 Geographic considerations Baltimore County is bounded by Pennsylvania on the north, by Carroll, Howard, and Anne Arundel counties and Baltimore City on the south, and by Harford County on the east. It has 610 square miles of area, making it the third largest county in the State. Population The population of Baltimore County, as of 1943, was 202,425, which places it first among the counties in population. The phenomenal population increase of 170.6% within 23 years is attributed to the growth of industries in the City of Baltimore and the surrounding areas. The population density increased from 255.5 per square mile in 1940 to 331.8 per square mile in 1943. The most recent data available on population dis- tribution by election districts, as of 1940, are as follows: District 1 21,221 District 8 6,736 District 2 7,501 District 9 21,641 District 3 7,150 District 10 2,448 District 4 7,596 District 11 7,225 District 5 2,121 District 12 15,436 District 6 1,177 District 13 13,366 District 7 3,385 District 14 10,420 District 15 28,402 It will be noted that the population is concentrated in Election Districts 1 and 13, which lie southwest of the City of Baltimore, and Election Districts 9, 11, 12, 14, and 15, which lie east and north of the City. It was assumed that the bulk of the 46,600 new residents since 1940 have taken up residence in these areas. Non white persons, numbering 13,765, made up 6.8% of the County population in 1945. Residents of Baltimore County, along with the residents of Baltimore City are 87.5% urban, 10.1% rural nonfarm, and 2.4% rural farm. Transportation The main lines of the Baltimore and Ohio Railroad and the Pennsylvania Railroad cross the southwest section of the County. Other railroads run north and northwest through the County. A network of roads makes travel to Baltimore City convenient. Industry and commerce Heavy industries are located in the Sparrows Point, Dundalk, and Middle River areas, offering employ- ment to a large part of the population in these areas. Since many residents of the County are employed in Baltimore City, both have been considered in the examination of per capita income. In 1940 the per capita income for the combined area was $725.02. In 1945 it was $1,548.12. In each of the years cited, this area had the highest income per capita in Maryland. The per capita income for the State in 1945 was $1,291.61. Physicians There are 167 physicians residing in Baltimore County. The distribution of these physicians is as follows: 36 Hospital Survey and Plan for Maryland—Part III Catonsville 24 Towson 33 Dundalk 13 Woodlawn 1 Parkville 4 Essex 7 Raspsburg 4 Middle River 5 Halethorpe 5 Overlea 2 Baltimore (suburbs) 12 White Hall 1 Sparrows Point 8 Reisterstown 6 Ruxton 2 Pikesville 11 Cockeysville 3 Arcadia (Upperco) .. .1 Parkton 1 Arbutus 2 Baldwin 2 Riderwood 1 Fork 1 Timonium 1 Randallstown 2 Relay 1 Granite 1 Garrison 2 Stoneleigh 2 Lutherville 1 Sparks 6 Owings Mills 1 Lansdowne 1 vicinity of Towson, Middle River, and Sparrows Point merit consideration only if the facilities of Baltimore are not increased to a sizable degree. If application is made for a project in this area, sup- ported by evidence of funds available for construction and demonstrated ability to support the hospital, it will be approved. If such application is approved, beds now allotted in Baltimore City will be assigned to such project. A hospital in this area should include quarters for the County Health Department. Recommendations St. Joseph’s Hospital now owns land in the Loch Raven area and plans to erect a 400-bed hospital. This project is recommended. At the completion of this project, Towson will have access to adequate hospital facilities conveniently located. A group of citizens in the Middle River area is giving serious consideration to the establishment of a hospital. Should their plans crystallize and sufficient funds be raised, their project will be considered for Federal funds in view of the population as shown in 1940 by election districts and the apparent increase in the in- tervening years. Any hospital in this area should in- clude quarters for the County Health Department. Due to its position as almost surrounding Baltimore City and the total dependence of its residents on the hospitals of Baltimore City for service, Baltimore County was included in the Baltimore Base Area. According to the County’s population in 1943, this establishes a ratio of one resident physician to every 1,212 persons. GENERAL HOSPITAL FACILITIES Baltimore County does not have a general hospital. The residents depend upon the hospitals in Baltimore City. Conclusions With transportation highly developed and with medical facilities and personnel of high caliber in Baltimore City, the continued dependence of Balti- more County on the City would be satisfactory if hospital facilities in the City are increased in propor- tion to the demand. Community hospitals in the CARROLL COUNTY BALTIMORE BASE AREA Population Change from previous period Change over 1920 1943; 39,399 345 increase 15.1% increase 1940; 39,054 3,076 increase 14.0% increase 1930: 35,978 1,733 increase 5.1% increase 1920: 34,245 Nonwhite Per cent nonwhite Per capita income 1945: 2,088 5.3 1945: $1,049.95 1940: 2,081 5.3 1940: $ 520.25 Classification of residents, 1940 Urban Rural nonfarm Rural farm 12.0% 50.7% 37.3% Land area: 456 square miles Population per square mile, 1943: 86.4 County seat: Westminster Population 1940: 4,692 1930: 4,463 Births in hospitals as per cent of total births, 1945 Total White Nonwhite 53.4 55.4 21,4 General Hospitals 37 Geographic considerations Carroll County is bounded on the north by Pennsyl- vania, on the west by Frederick County, on the south by Howard County, and on the east by Baltimore County. In this location, it makes up the northwestern section of the Baltimore Base Area. It has 456 square miles of land area, making it the tenth county in the State in size. The land is hilly, but most of it is tillable. Population The population of Carroll County, as of 1943, was 39,399. There has been a continuous but not very great increase in population from 1920 to 1943. During the 23-year period, it amounted to 15.1%. The pop- ulation density in 1943 was 86.4 persons per square mile, making it tenth county in the State in this respect. The population distribution, given by election dis- tricts for 1940, shows a rather even spread: District 1, Taneytown 2,894 District 2, Uniontown 1,960 District 3, Myers 1,705 District 4, Woolerys 3,072 District 5, Freedom 6,538 District 6, Manchester 3,210 District 7, Westminster 8,588 District 8, Hampstead 2,529 District 9, Franklin 1,041 District 10, Middleburg 982 District 11, New Windsor 1,876 District 12, Union Bridge 1,446 District 13, Mount Airy 1,625 District 14, Berrett 1,588 The only incorporated communities with popula- tions of more than 1,000 persons, as of 1940, are Westminster with 4,692 and Taneytown with 1,208. In 1940, only 12.0% of the population was rated as urban, 50.7% was rural nonfarm, and 37.3% rural farm. Non white persons, numbering 2,088, made up 5.3% of the County’s population in 1945. Transportation The County is bisected by one main highway. Route 140, which runs northwest from Baltimore City, through Westminster to Emmitsburg. Other secondary roads converge at Westminster, furnishing access to all points in the County and to Gettysburg and Han- over in Pennsylvania. The southern portion of the County is served by two highways, one running from Thurmont to Baltimore and the other from Frederick to Baltimore. Bus service into Westminster is maintained by the Greyhound Lines, All-American Lines, and Blue Ridge Lines. The lines emanate from Baltimore City and serve the communities beyond Westminster. The Western Maryland Railroad has three passenger trains into Westminster daily. These trains run into Hagerstown and Cumberland and make connections with the Pennsylvania Railroad into Frederick. Three trains make trips in the opposite direction daily. Industry and commerce There are no large industries in Carroll County. A number of small industries exist, including a cement plant, a shoe manufacturing plant, a floor-covering factory, a rubber manufacturing plant, and a machine factory. The per capita income in 1940 was $520.25. At that time, Carroll County was the tenth in the State from the standpoint of income. The per capita income amounted to $1,049.95 in 1945, and Carroll County fell to eleventh place among the counties of the State. Physicians Twenty-seven physicians are practicing in Carroll County and are distributed as follows: Westminster 9 Hampstead 4 Sykesville 3 Taneytown 3 Union Bridge 3 New Windsor 2 Mount Airy 2 Manchester 1 On the basis of the County’s population in 1943, this establishes a ratio of one physician to every 1,459 residents. Three of these physicians have the privilege of treat- ing patients in the Frederick City Hospital and one has such privilege in the hospital at Gettysburg, Pennsylvania. GENERAL HOSPITAL FACILITIES There are no general hospitals in Carroll County. Studies of patients in the hospitals of Frederick City and Baltimore City (Table N) indicate that residents of Carroll County use the hospitals in these two cities. It is reported by local people that some residents of the County travel to Hanover and York in Pennsylvania for hospital care. At present a community group in Westminster is promoting actively a project for the establishment of a community health center. According to their plans, it is to be primarily a diagnostic center. Conclusions Carroll County has need for a general hospital. It should be located at Westminster, which is the County Seat, and is located at the approximate center of the County. It is accessible to all parts of the County and is the largest community in the County. On the basis of United States Public Health Service standards for rural areas, of which Carroll County is typical, there is a need for a 100-bed general hospital. Because of the established practice of the residents to go outside the County for hospital care, a 100-bed hospital would exceed the current need until such time as the hospital is established definitely as the medical center for the County. The development of this hospital and staff will no doubt be slow because of its proximity to the specialists and facilities in Baltimore. 38 Hospital Survey and Plan for Maryland Part III Recommendations It is recommended that a hospital of at least 50-bed capacity be established in Carroll County. This hospital should be planned so that two later additions of 25 beds each can be made as the need develops. With the small number of nonwhite residents in the County, it is not recommended that special facilities be set up for their care. On occasions, if the manage- ment chooses to practice segregation, they may do so by providing private or semiprivate rooms. In the absence of local hospital facilities and with a past record of dependence on the hospital facilities of Baltimore City, Carroll County was made a part of the Baltimore Base Area. Should the contemplated diagnostic center be con- structed prior to the construction of a general hospital, it us recommended that the center be designed so that it will serve as the nucleus for a hospital. HARFORD COUNTY BALTIMORE BASE AREA Population Change from previous period Change over 1920 1943: 42,890 7,830 increase 46.4% increase 1940: 35,060 3,457 increase 19.7% increase 1930: 31,603 2,312 increase 7.9% increase 1920: 29,291 Nonwhite population Per cent nonwhite Per capita income 1945: 4,889 11.4 1945: $818.82 1940: 3,984 11.4 1940: $492.07 Classification of residents, 1940 Urban Rural nonfarm Rural farm 14.2% 44.9% 41.0% Land area: 448 square miles Population per square mile, 1943: 95.7 County seat: Bel Air Population 1940: 1,885 Births in hospitals as per cent of total births, 1945 Total White Nonwhite 79.5 82.9 54.2 General hospital facilities Institution Location Beds Fountain Green Hospital Bel Air 17 Harford Memorial Hospital Havre de Grace 72 Geographic considerations Harford County is bounded on the north by Pennsyl- vania, on the west by Baltimore County, on the south by Baltimore County and the Chesapeake Bay, and on the east by the Chesapeake Bay and the Susque- hanna River. Across the River to the east is Cecil County. A portion of Baltimore County, approximately 10 miles wide, lies between the City of Baltimore and Harford County. Harford County, with 448 square miles of land area, is the eleventh county in the State from this standpoint. The surface in the eastern portion is generally flat, but becomes hilly on the west and north. Population As of 1943, the County’s population was 42,890. With 95.7 residents to the square mile, it stood seventh among the counties of the State. The nonwhite population, 4,889 in 1945, constituted 11.4% of the County’s population. The population distribution by election districts, as 1940, was as follows: District 1, Abington 5,782 District 2, Halls Cross Roads 6,828 District 3, Bel Air 7,800 District 4, Marshall 4,489 District 5, Dublin 5,194 District 6, Havre de Grace 4,967 As of 1940, the population was 14.2% urban, 44.9% rural nonfarm, and 41.0% rural farm. Transportation The main lines of the Baltimore and Ohio Railroad and the Pennsylvania Railroad, running between Washington, Baltimore, Philadelphia, and New York, cross Harford County. Main highways between these cities also traverse the County. There are numerous secondary roads which give all parts of the County convenient access to Baltimore and Havre de Grace. General Hospitals Industry and commerce There are no large industries located in Harford County. The only manufacturing plant is located in Belcamp, where shoes and rubber overshoes are manu- factured. Farming is practiced by a large segment of the population. Many residents are employed in Balti- more City and in the industries surrounding Baltimore. The two trading centers are Bel Air and Havre de Grace. In 1940 Harford County ranked eleventh county in the State in per capita income, which was $492.07. As of 1945, the per capita income was $818.82, making it the sixteenth county in the State in this respect. Physicians There are 28 physicians practicing in the County. They are distributed as follows: County, their distribution being 28.4%, 52.2%, and 15.5%, respectively. The out-of-state patients (3.9%) are accounted for by the fact that important highways connecting Washington, Baltimore, Philadelphia, and New York cross the Susquehanna River at this point. Thus there are people from all parts of the Nation tunneling through this area. Bed capacity: The normal capacity is 72 beds, of which 11 are set aside for nonwhite patients. On the basis of 1943 population in Harford County, the Harford Memorial Hospital has 1.7 beds per 1,000 population. Utilization: This hospital operated at a rate of oc- cupancy of 79.9%, rendering 291.5 days of service per bed at the time of the survey. The average length of stay per patient was 7.4 days. An analysis of services by diagnosis showed the following: Number of patients Per cent Medical 1,368 48.1 Surgical 428 15.1 Obstetric 608 21.4 Pediatric 321 11.3 Other ‘116 4.1 Totals 2,841 100.0 Medical staff: The Medical Staff is organized, having officers and standing committees. There are chiefs of service in obstetrics; surgery; pediatrics; anesthesia; ear, nose, and throat; and medicine. The Active Staff has a membership of 15 physicians. Their ages range from 29 to 62 years, the average age being 40 years. Six of these men live in Havre de Grace. The others are located in near-by communities. The membership of the Courtesy Staff includes seven physicians, whose ages range from 32 to 72 years. The average age is 47 years. The Consulting Staff is made up of 21 specialists from Baltimore City. Qualifications for surgery and obstetrics are high. Educational activities: The hospital has no educational program in effect. Building plans: Active consideration is being given to plans for an addition which will increase the capacity by 20 beds. Conclusions The analysis of patients by diagnosis shows a broad acceptance of the Harford Memorial Hospital. A hospital where the work is preponderately surgical would indicate that only emergency cases and those which cannot possibly be taken care of in the home apply for care. This conclusion must be tempered with the fact that some of the major surgical work is re- ferred to the hospitals of Baltimore. The high occupancy rate and comparatively short average stay indicate a rapid turnover of patients due to an urgent need for beds. In spite of this eccentric location on the east-central boundary of the County, most of the residents of the County travel to this hospital for care. Its construc- tion was partially financed out of County tax funds, Forest Hill 2 Havre de Grace 6 Cardiff 2 Aberdeen 6 Darlington 2 Churchville 1 Street 1 Fallston 1 Edgewood 1 Bel Air 6 This establishes a ratio of one physician to every 1,532 persons, based on the County’s population in 1943. GENERAL HOSPITAL FACILITIES FOUNTAIN GREEN HOSPITAL The Fountain Green Hospital, located near Bel Air, is a privately-owned institution with a capacity of 17 beds. The building was constructed fifty years ago and was originally used as a tavern. It is of frame construction. Most of the patients are obstetric cases. A few medical and some ear, nose, and throat cases are ad- mitted. The occupancy rate is 39.6%. During the reporting year 144.5 days of service per bed were rendered. The average length of stay per patient was 9.9 days. The physician who owns this hospital has the bulk of the patients as his private cases. Five other physi- cians have hospital privileges. One doctor travels from Baltimore to do ear, nose, and throat work. Bel Air would be a logical geographic location for a hospital, being the center of the County. Since the Fountain Green Hospital is a privately-owned institu- tion, no assistance can be given under the program. Even if it were operated as a nonprofit institution, no additional construction could be recommended owing to the inflammable nature of its construction. HARFORD MEMORIAL HOSPITAL The Harford Memorial Hospital is located at Havre de Grace. It is community-owned and operated on a nonprofit basis. This is a modern hospital, having been put into service in 1942, at which time the original hospital of frame construction was vacated. The hospi- tal has provisional approval by the American College of Surgeons. Area served: The patients are largely from the local community, the rest of Harford County, and Cecil 40 Hospital Survey and Plan for Maryland—Part III making it a “County” hospital. There are no hospitals located west except Fountain Green Hospital. The three election districts of Cecil County, across the Susquehanna River, look somewhat to this hospital for care, as indicated by the fact that 15.45% of the patients are residents of Cecil County. When calculating the need, the residents of Cecil County were balanced off against those residents who it was assumed turned to Baltimore City for service. Although Harford County was considered in this study as a part of the Baltimore Base Area, the stand- ards for a rural area (2.5 beds per 1,000 population) were used in determining the number of beds necessary. On this basis its need was set at 107 beds. Proposed plans call for the addition of 20 beds, which would bring the total to 92. This additional number of beds is conservative in view of the present rate of occupancy. The addition of 30 beds instead would relieve the present excessive percentage of occupancy, and allow for some future increase in the utilization of the hospi- tal. Unless new industries locate in the area or other changes occur affecting the population, it is assumed that the 102 beds will be adequate for some time in the future. As of 1945, Harford County’s nonwhite population was 11.4%. On this basis ten beds must be assigned to nonwhite patients, in order to keep beds available in proportion to population groups. Since there are al- ready 11 beds reserved for non white patients, all of the additional beds may be used for white patients. Since Bel Air is located approximately halfway be- tween Baltimore and Havre de Grace, about 16 miles away, and with adequate highways, it is felt that the facilities of Baltimore and Havre de Grace can serve the needs of this area. Should more than the present limited funds become available and should the residents of Bel Air and the surrounding area become interested in financing a hospital, the project should be given serious considera- tion. Recommendations Because of its proximity to Baltimore City and its dependence to a large degree on the physicians of Baltimore City for medical care, Harford County was made a part of the Baltimore Base Area. It is recommended that an addition of 30 beds be approved for the Harford Memorial Hospital at Havre de Grace. HOWARD COUNTY BALTIMORE BASE AREA Population Change from previous period Change over 1920 1943: 18,481 1,306 increase 16.8% increase 1940: 17,175 1,006 increase 8.5% increase 1930: 16,169 343 increase 2.2% increase 1920: 15,826 Nonwhite population Per cent nonwhite Per capita income 1945; 3,012 16.3 1945: $861.70 1940: 2,806 16.3 1940: $455.08 Classification of residents, 1940 Urban Rural nonfarm Rural farm 0.0% 61.3% 38.7% Land area: 251 square miles Population per square mile, 1943: 73.6 County seat: Ellicott City Population 1940: 1,216 Births in hospitals as per cent of total births, 1945 Total White Nonwhite 55.6 61.2 28.1 General Hospitals 41 Geographic considerations Howard County lies west and southwest of Balti- more, with a small segment of Baltimore County about four miles in width separating the County from the City. It is bounded by Baltimore County and Carroll County on the north, Frederick, Montgomery, and Prince George’s counties on the west and south, and Anne Arundel and Baltimore counties on the east. It is next to the smallest county in the State, having 251 square miles of area. The surface is largely rolling in nature and lends itself to farming. Population The population of Howard County, as of 1943, was 18,481. With 73.6 persons per square mile, it ranks twelfth among the counties of the State. The population growth experienced has been small, amounting to 16.8% within 23 years, whereas the over- all increase for the Baltimore Base Area, including Howard County, was 40.5% for the same period. The nonwhite population, as of 1945, was 3,012, or 16.3% of the total. There are no incorporated municipalities in the County. The population distribution by election dis- tricts, as of 1940, was as follows: District 1, Elkridge 3,229 District 2, Ellicott City 3,778 District 3, West Friendship 1,974 District 4, Lisbon 2,410 District 5, Clarksville 2,304 District 6, Guilford 3,480 For 1940, the residents of the County were classified as 61.3% rural nonfarm and 38.7% rural farm. Transportation Highways cross the County in all directions, with several leading into Baltimore City. The Baltimore and Ohio Railroad has a line going into Ellicott City, the County Seat, Busses and trolleys furnish trans- portation between Ellicott City and Baltimore City. Industry and commerce There are no large industries in Howard County. Many residents travel to Baltimore City for employ- ment. The per capita income of this County was $455.08 in 1940, making it the sixteenth county in the State in this respect. In 1945, with a per capita income of $861.70, the County was thirteenth in the State. Physicians There are 12 physicians practicing in Howard County. Nine of these physicians have hospital affiliations. Their average age is 45 years, the young- est being 31 years of age and the oldest 70 years. They are distributed throughout the County as follows: Elkridge 2 Ellicott City 8 Savage 1 Clarksville 1 On the basis of the County’s population in 1943, there was one physician for every 1,540 residents. GENERAL HOSPITAL FACILITIES There are no general hospitals in Howard County and no municipalities which might support one. The majority of the residents travel to Baltimore City for hospital service. Some residents use the institutions in Mongtomery County. Conclusions No hospital is recommended for this County. Its population was taken into consideration in establishing the needed beds for Baltimore City. It was made, therefore, a part of the Baltimore Base Area. CALVERT COUNTY RURAL AREA NUMBER 2 Population 1943: 10,549 1940: 10,484 1930: 9,528 1920: 9,744 Change from previous period 65 increase 956 increase 216 decrease Change over 1920 8.3% increase 7.6% increase 2.2% decrease Nonwhite population 1945: 4,916 1940: 4,880 Per cent nonwhite 46.6 46.5 Per capita income 1945: $743.39 1940: $367.61 Urban 0.0% Classification of residents, 1940 Rural nonfarm 34.2% Rural farm 65.8% Land area: 219 square miles Population per square mile, 1943: 48.2 County seat: Prince Frederick Population 1940: 200 Births in hospitals as per cent of total births, 1945 Total White Nonwhite 58.3 76.9 39.7 General hospital facilities Institution Location Beds Calvert County Hospital Prince Frederick 26 42 Hospital Survey and Plan for Maryland—Part III Geographic considerations Calvert County is a peninsula which extends south from its common boundary with Anne Arundel County. It has the Patuxent River for its western boundary and the Chesapeake Bay for its eastern boundary. It is generally level and contains 219 square miles, being the smallest county in the State. Population The population of this County was 10,549 in 1943. During the 23-year period from 1920 to 1943, the increase amounted to 805 people, or 8.3%. Distri- bution of the County’s population is fairly even. With a density of 48.2 persons per square mile in 1943, the County ranked seventeenth in this respect. In 1940 the population distribution according to election districts, was as follows: District 1, Solomons Island 3,513 District 2, Prince Frederick 3,092 District 3, Sunderland 3,879 For the same year the residents were classified as 34.2% rural nonfarm and 65.8% rural farm. Nonwhite persons, numbering 4,916, made up 46.6% of the population in 1945. Transportation A highway extends the length of the County from north to south and has branches extending to numerous points on the eastern and western shores. Small ferries connect Calvert County with St. Mary’s County in the extreme south and with Charles County at ap- proximately the middle of Calvert County. Prince Frederick, the County Seat, is the location of the Calvert County Hospital. It lies 35 miles south of Annapolis, 39 miles southeast of Washington, and 60 miles south of Baltimore. Highways connect these communities. Industry and commerce There are no large industries in this County. The only manufacturing plant listed by the Baltimore Association of Commerce is a shipbuilding firm at Solomons in the southern extremity of the County. Most residents are engaged in fishing and farming. The per capita income for the County was $367.61 in 1940, the County being nineteenth in the State in this respect. In 1945, with a per capita income of $743.39, the County ranked twenty-first in the State. Physicians There are five physicians practicing in Calvert County. They are distributed as follows: GENERAL HOSPITAL FACILITIES CALVERT COUNTY HOSPITAL The Calvert County Hospital, located in Prince PTederick, is owned by a nonprofit corporation. The Board of Directors, with a membership of 13, serves for three-year terms. The Board is self-perpetuating. A Ladies’ Auxiliary, with a membership of 35, furnishes linens and helps with other expenses of the hospital. Area served: Of the patients treated, 91% are residents of Calvert County. A few residents of Anne Arundel, Charles, and Prince George’s counties have been patients. Building: The building is a frame structure. The interior and exterior construction is inflammable. Bed capacity: The capacity is 26 beds, of which 11, or 42.3%, are reserved for nonwhite patients. Utilization: The rate of occupancy of this hospital is 44.8% and the average length of stay per patient is 6.1 days. During the year for which the report was made, the patients fell into the following categories: Number of patients Per cent Medical 196 28.4 Surgical 177 25.6 Obstetric 188 27.2 Pediatric 126 18.2 Other 4 0.6 Totals 691 100.0 Medical staff: The Medical Staff is not organized. Privileges are granted by the Board of Directors to licensed physicians upon application. Four physicians make up the total staff. On occasions, physicians from Baltimore City are called in for surgery or consultation. Personnel: The personnel consists of 12 full-time and two part-time employees, making a ratio of 0.5 em- ployee per bed. Five of the employees are furnished living quarters within the hospital. Educational program: There is no educational program in effect at this hospital. Building plans: The Board of Directors recognizes the fact that this building is not suitable as a hospital and presents a hazard. The Board feels that it cannot raise sufficient funds to build a new hospital, but is making an effort to raise funds locally and to obtain an appro- priation from the State to modernize the present building. Conclusions Calvert County, with a population of 10,549, quali- fies as a rural area. On the basis of the standard for rural areas, this County is allotted 26 beds. On ac- count of the hazard presented and the very unsatis- factory physical condition of the existing hospital, it was considered unacceptable, thus qualifying the area for the allocation of its full quota of 26 new beds. While it is considered inefficient to construct hospi- tals with a capacity of less than 50 beds, in view of the low occupancy rate reported, there is no justification for the installation of more than 26 beds in this area. Prince Frederick 2 Solomons 1 Huntington 1 O wings 1 All of these men are general practitioners. Their average age is 47 years. On the basis of the County’s 1943 population, there was one physician to every 2,110 residents. General Hospitals 43 Recommendations It is recommended that this area be classified as a rural area. It is further recommended that the present hospital be replaced with a new structure of the same bed capacity. In order to justify the expenditure of funds necessary for such program and in order to make as efficient use of the personnel as possible, it is further recommended that provision be made in this new structure for the housing of the County Health De- partment. A cooperative arrangement should be set up for the use of the facilities and personnel by both the County Health Department and the hospital, similar to the arrangement which has been in force for some time at the Physicians Memorial Hospital in La Plata, Charles County. Because of the hazard presented by the unsatisfactory structure in which the hospital is now housed, it is urged that this replacement be made as soon as pos- sible. CECIL COUNTY INTERMEDIATE AREA NUMBER 5 Population Change from previous period Change over 1920 1943; 32,055 5,648 increase 35.8% increase 1940: 26,407 580 increase 11.8% increase 1930: 25,827 2,215 increase 9.4% increase 1920; 23,612 Nonwhite population Per cent nonwhite Per capita income 1945: 2,885 9.0 1945: $804.02 1940: 2,356 8.9 1940: $479.38 Classification of residents, 1940 Urban Rural nonfarm Rural farm 13.3% 55.2% 31,5% Land area: 352 square miles Population per square mile, 1943; 91.1 County seat: Elkton Population 1940: 3,518 1930: 3,331 Births in hospitals as per cent of total births, 1945 Total White Nonwhite 78.1 78.8 68.0 General hospital facilities Institution Location Beds Union Hospital Elkton 72 Geographic considerations Cecil County is located in the northeast corner of the State. It is bounded by Delaware on the east, Pennsyl- vania on the north, the Susquehanna River and Chesa- peake Bay on the west, and Kent County on the south. On the opposite side of the Susquehanna River is Harford County. It has 352 square miles of land area, making it the seventeenth county in the State in size. The Elk River, which appears as an extension of the Chesapeake Bay, almost divides Cecil County into two parts. The area between the Elk River and the Maryland-Delaware state line is typical of the Eastern Shore, being rather level. The remainder of the County north and west of Elkton is hilly. crease exceeded that of the previous 20 years, due largely to war industries located at Elkton. The density was 91.1 persons per square mile in 1943, making it the eighth county in the State in this respect. The largest community is Elkton, which had a population of 3,518 in 1940. » There is a population concentration in the extreme west-central area on the opposite side of the Susque- hanna River from Havre de Grace. The area south of Elkton and east of the Elk River is sparsely popu- lated. Non white persons, numbering 2,885, made up 9% of the population of the County in 1945. With the exception of a few residents in the southern extremity of the County, all residents live within a radius of miles of a hospital. The residents of the western portion are within the service area of the hospital at Havre de Grace. Population The population of the County increased at a moder- ate rate until 1940. Between 1940 and 1943, the in- 44 Hospital Survey and Plan for Maryland—Part III The popu1ation distribution in 1940, according to election districts was as follows: District 1, Cecilton 2,182 District 2, Chesapeake City 2,301 District 3, Elkton 5,890 District 4, Fair Hill 1,759 District 5, Northeast 3,693 District 6, Rising Sun 2,562 District 7, Port Deposit 6,058 District 8, Oakwood (Mount Pleasant) 889 District 9, Calvert (Brick Meeting House) 1,073 In the same year the residents of Cecil County were classified as 13.3% urban, 55.2% rural nonfarm, and 31.5% rural farm. Transportation The main lines of the Baltimore and Ohio Railroad and the Pennsylvania Railroad between Baltimore and Philadelphia cross Cecil County. Main highways between these cities also cross the County. Several highways intersect at Elkton, making it readily accessible from all parts of the County by bus or rail transportation or other conveyances. Industry and commerce Elkton is the trading center for the central and south- ern portions of the County. The residents of the western portion use Havre de Grace as their trading center. Highway and rail transportation make Newark and Wilmington, Delaware, convenient of access, with the result that some Cecil County residents travel to these communities to shop. The per capita income for the residents in 1940 was $479.38, making it the thirteenth county in this respect. In 1945, with a per capita income of $804.02, the County dropped to eighteenth place in the State. During the war, a large industry for the production of explosives was located at Elkton. This establishment has since been closed. There are two paper manufacturing plants, an iron works company, and a fabricated steel plant located in the County. Physicians Eighteen physicians practice in the area. This establishes a ratio of one physician to every 1,781 per- sons. They are distributed as follows: Elkton 8 Perry ville 2 Chesapeake City 2 Port Deposit 2 North East 3 Rising Sun 1 These physicians practice in the following fields: Medicine 11 Obstetrics 2 Surgery 4 X-ray 1 GENERAL HOSPITAL FACILITIES UNION HOSPITAL The Union Hospital, located in Elkton, was estab- lished in 1921. It is owned by the community and is under the direction of a Board of Directors. The Board consists of 11 members, who elect new members to fill vacancies as they occur. This hospital holds pro- visional approval by the American College of Surgeons. A Ladies’ Auxiliary, with a membership of 1,004, sup- plies linens and purchases equipment. Area served: Ninety-five per cent of the patients treated are residents of Elkton and the immediately surround- ing area. Buildings: In 1944 the hospital vacated its old location in a frame structure and was established in a new modern building. At the time of this change, the first floor of the old building was turned over to the com- munity for the use of the State health clinics. The re- mainder of the old hospital is used as a nurses’ resi- dence. Bed capacity: The capacity is 72 beds and 25 bassinets. Ten beds and nine bassinets are reserved for nonwhite patients. Utilization: The rate of occupancy for the year was 62.8%. The average length of stay per patient was 11.3 days. During the year for which the report was made, the patients fell into the following categories according to diagnosis: Number of patients Per cent Medical 292 20.2 Surgical 623 42.9 Obstetric 368 25.4 Pediatric 166 11.5 Totals 1,449 100.0 Medical staff: The Medical Staff is organized, having elected officers. The Executive Committee of the Staff functions as liaison between the Administration and the Staff. Appointment to membership is made by the Board upon recommendation of the Medical Staff. Privilege to do major surgery or work in the specialties is granted on the basis of recognized ability and certifica- tion by the Specialty Board or Fellowship in the American College of Surgeons. Personnel: The personnel of the hospital consists of 41 full-time employees and five part-time employees, which establishes a ratio of 0.6 employee per bed. Educational activities: There is no educational program in operation at this hospital. Conclusions Cecil County, with a population in excess of 25,000, qualifies as an intermediate area. At the rate of 4.0 beds per 1,000 population, the County should have 128 beds. The present rate of occupancy of 62.4% at the Union Hospital, which is centrally located, is as high as can reasonably be expected in a hospital of 72 beds. The hospital at Havre de Grace reported having had residents of Cecil County as patients equivalent to 31.9% of the total number of patients treated in the Elkton Hospital. Recom mendations It is recommended that Cecil County be classified as an intermediate area. To bring the normal bed capacity of Cecil County up to area standards, it is recommended that 56 beds be added to the Union Hospital at such time as the utiliza- tion indicates the need and funds are available. General Hospitals 45 CHARLES COUNTY RURAL AREA NUMBER 3 Population Change from previous period Change over 1920 1943: 19,784 2,172 increase 11.7% increase 1940: 17,612 1,446 increase 0.5% decrease 1930: 16,166 1,539 decrease 8.7% decrease 1920: 17,705 Nonwhite population Per cent nonwhite Per capita income 1945; 8,111 1945: 41.0 1945 $579.36 1940: 7,228 1940: 41.0 1940: $319.90 Classification of residents, 1940 Urban Rural nonfarm Rural farm 0.0% 45.0% 55.0% Land area: 458 square miles Population per square mile, 1943: 43.2 County seat: La Plata Population 1940; 488 1930: 332 Births in hospitals as per cent of total births, 1945 Total White Nonwhite 52.1 86.2 17.6 General hospital facilities Institution Location Beds Physicians Memorial Hospital La Plata 33 Geographic considerations Charles County is bounded on the west and south by the Potomac River, across which lies Virginia. Its eastern boundary is made up of the Wicomico River and by a line which is the common boundary with St. Mary’s County. A small area extends to the Patuxent River on the east. It has a common boundary with Prince George’s County on the north. With a land area of 458 square miles, Charles County was ninth among the counties of the State. Population The population of Charles County, as of 1943, was 19,784. La Plata, the County Seat, was credited with having a population of 488 in 1940. Indian Head to the west had a population of 1,104 in the same year. The balance of the population is evenly distributed across the County. On the basis of the County’s population in 1943, there were 43.2 persons per square mile. In this respect Charles County ranked nine- teenth in the State. In 1945, the nonwhite population, numbering 8,111, comprised 41.0% of the County’s total. The population of Charles County according to elec- tion districts, as of 1940, was as follows: District 1, La Plata 1,957 District 2, Hill Top 800 District 3, Cross Roads 1,251 District 4, Allens Fresh 1,708 District 5, Harris Lot 1,897 District 6, White Plains 2,215 District 7, Pomonkey 3,142 District 8, Bryantown 1,948 District 9, Patuxent 1,142 District 10, Marbury 1,552 In the same year the residents were classified as 45.0% rural nonfarm and 55.0% rural farm. The population decreased between 1920 and 1930. From 1930 to 1940, however, the population increased, and an even greater increase occurred between 1940 and 1943. The total population increase from 1920 to 1943 was 2,079, or 11.2% over the 1920 level. Transportation All parts of the County are served by a network of secondary roads which join the primary highways, Routes 301 and 5, which cross the County from north to south. Access to La Plata, where Physicians Memor- ial Hospital is located, is convenient from all parts of the County. A branch of the Pennsylvania Railroad crosses the County from south to north and continues into Balti- more. Industry and commerce No manufacturers are listed in Charles County by the Baltimore Association of Commerce. The majority of the residents are engaged in agricultural pursuits. The per capita income in 1940 was $319.90, making Charles County the twentieth county in the State in this respect. In 1945, it was $579.36, dropping the County to twenty-second place in the State. Physicians Eleven physicians are residing and practicing in Charles County, Three other physicians from sur- 46 Hospital Survey and Plan for Maryland—Part III rounding areas have patients in the County. They are distributed as follows: Number of patients Per cent Medical 470 56.9 Surgical 95 11.5 Obstetric 216 26.2 Pediatric 26 3.1 Other 19 2.3 Totals 826 100.0 Medical staff: The Medical Staff is not organized. All members of the Charles County Medical Society are privileged to treat patients in the hospital. In addi- tion, four physicians from the District of Columbia treat patients in this hospital. Privilege to do major surgery is granted to applicants who have had one year of approved residency in surgery and who have performed under supervision or assisted with one hundred major operations during the previous two years. Personnel: The personnel of this hospital is made up of ten full-time and five part-time employees. Con- sidering the part-time employees as being on a one-half- time basis, this establishes a ratio of 0.4 employee per bed. Five employees are given quarters at the hospital. Educational activities: There is no educational program in effect. Building plans: No building plans are under considera- tion at present. Conclusions Charles County, with a population of less than 25,000, qualifies as a rural area. The population is practically constant. On the basis of the standard for rural areas, this area would be entitled to 49 beds. The normal capacity at the Physicians Memorial Hospital at present is 33 beds, indicating an unmet need of 16 beds. Since the present occupancy rate is only 39.0% and the average length of stay per patient is 5.3 days, the present existing beds are not being overtaxed. Recommendations It is recommended that Charles County be classified as a rural area and that 16 additional beds be allocated to this area to bring it up to the standard for rural areas. On account of the low utilization being made of the existing facilities, this allotment is not considered urgent. La Plata 3 Hughesville 3 Marbury 1 Wayside 1 Indian Head 1 Waldorf 1 Bel Alton 1 Four of these physicians are surgeons and ten are general practitioners. On the basis of its 1943 population, Charles County had a ratio of one resident physician to every 1,413 persons. GENERAL HOSPITAL FACILITIES PHYSICIANS MEMORIAL HOSPITAL The Physicians Memorial Hospital, located in La Plata, was opened in 1938. It is owned by a nonprofit association. Its Board of Directors consists of 12 mem- bers who serve for terms of one year. Vacancies are filled by election by the Board, except in the case of one member who is appointed by the County Com- missioners. A Ladies’ Auxiliary engages in fund-raising efforts to purchase equipment for the hospital. Area served: Residents of Charles County make up 91% of the patients treated at this hospital. Some patients are admitted from St. Mary’s and Prince George’s counties. Buildings: The buildings are brick structures, but the interior is constructed of inflammable materials. Bed capacity: The normal capacity is 33 beds, two of which are temporarily out of service to make room for a business office. Eight of these beds are reserved for nonwhite patients. Utilization: The rate of occupancy is 39.0% based on the number of beds in use, but 36.7% based on the normal capacity. The average length of stay per patient is 5.3 days. During the year for which the report was made, the patients fell into the following categories: General Hospitals 47 DORCHESTER COUNTY INTERMEDIATE AREA NUMBER 7 Population Change from previous period Change over 1920 1943: 24,264 3,742 decrease 13.0% decrease 1940: 28,006 1,193 increase 0.4% increase 1930: 26,813 1,082 decrease 3.9% decrease 1920: 27,895 Nonwhite population Per cent nonwhite Per capita income 1945: 7,012 28.9 1945: $1,063.84 1940: 8,089 28.9 1940: $ 452.83 Classification of residents, 1940 Urban Rural nonfarm Rural farm 36.1% 34.1% 29.9% Land area: 580 square miles Population per square mile, 1943: 41.8 County seat: Cambridge Population 1940: 10,102 1930: 8,544 Births in hospitals as per cent of total births, 1945 Total White Nonwhite 66.7 83.9 35.4 General hospital facilities Institution Location Beds Cambridge-Maryland Hospital Cambridge 65 Geographic con sideralion s Dorchester County is the largest of the nine counties making up the Eastern Shore. It lies south of Talbot and Caroline counties. It is separated from Talbot County by the Choptank River. It lies northwest of Somerset County and Wicomico County and is sepa- rated from them by the Nanticoke River. It is bounded by the Chesapeake Bay on the west and southwest. The eastern boundary is common with the State of Delaware. The 580 square miles of surface is generally flat and is cut by many rivers which empty into the Chesa- peake Bay. Population The population of this County is concentrated in the northern third of the area with 36.1% of the entire County population being residents of Cambridge, the shopping center and County Seat. The southern por- tion of the County is very thinly populated, with large areas having no residents. The population was almost constant during the two decades between 1920 and 1940. The decrease in population between 1940 and 1943 is attributable to the fact that no war industries were located in the area. It is assumed that this loss is only transitory. During the period 1930-1940 the population of Cam- bridge increased from 8,544 to 10,102. The population density, as of 1943, was 41.8 persons per square mile, making it the twentieth county in the State in this respect. Nonwhite persons, numbering 7,012, made up 28.9% of the population in 1945. The population is concentrated largely within a radius of 12 Yi miles of Cambridge, there being only 5,550 residents living outside such radius. Most of these are in the eastern section of the County. The largest incorporated community in the County outside of Cambridge is Hurlock, which had a population of 800 in 1940. The election districts of Dorchester County, as of 1940, had the following populations: District 1, Fork 1,565 District 2, East New Market 1,891 District 3, Vienna 1,281 District 4, Taylors Island 599 District 5, Lakes 975 District 6, Hooper Island 1,033 District 7, Cambridge 11,945 District 8, Neck 881 District 9, Church Creek 988 District 10, Straits 1,089 District 11, Drawbridge 294 District 12, Williamsburg 646 District 13, Bucktown 721 District 14, Linkwood 880 District 15, Hurlock 2,091 District 16, Madison 408 District 17, Salem 507 District 18, Elliott 230 48 Hospital Survey and Plan for Maryland—Part III In the same year the population was classified as 36.1% urban, 34.1% rural nonfarm, and 29.9% rural farm. Transportation Highways extend from Cambridge to the populated areas of the County. A principal highway between the Chesapeake ferries, Easton, Salisbury, and the south passes through Cambridge, The bridge across the Chop- tank River at Cambridge brought Cambridge within fifteen miles of Easton; whereas, formerly, it was neces- sary to travel a circuitous route in order to go from one of these communities to the other. The Pennsylvania Railroad maintains service into Cambridge and through the eastern part of the County to Salisbury in the south. Industry and commerce The principal employers in the County are the can- ning factories at Cambridge and Hurlock. Several manufacturers of men’s shirts are located in Cam- bridge. The remainder of the population are engaged in retail trade and service industries, including employ- ment in the County offices. The residents of the County outside of Cambridge are principally engaged in farming and fishing. The per capita income in 1940 was $452.93,placing Dorchester County seventeenth in the State in this respect. In 1945, it rose to ninth place in the State, with a per capita income of $1,063.84. Physicians There are 21 physicians practicing in the area. They are distributed as follows: Cambridge 16 East New Market 1 Hurlock 2 Vienna 1 Fishing Creek 1 Their average age is 50 years. According to the County’s 1943 population, there was one physician to every 1,155 residents. GENERAL HOSPITAL FACILITIES CAMBRIDGE-MARYLAND HOSPITAL The Cambridge-Maryland Hospital, located in Cam- bridge, was founded in 1899 by a nonprofit association. It is controlled by a Board of Directors with a member- ship of 12, with an indeterminate term of office. A Women’s Auxiliary, with a membership of 50, engages in activities for the support of the hospital. This hospital has full approval of the American Col- lege of Surgeons. Its nursing school is State-approved. Area served: A rough estimate of the place of residence of patients served showed 96.4% as residents of Dorchester County. Bed capacity: The normal capacity of this hospital is 65 beds. However, 75 beds were in use at the time of the survey. Eleven bassinets are the normal capacity; how- ever, 15 were in use at the time of the survey. Of these facilities, 18 beds and four bassinets are reserved for nonwhite patients. Utilization: An analysis of patients by diagnosis showed the following classifications: Number of patients Per cent Medical 551 34.1 Surgical 517 31.9 Obstetric 283 17.5 Other 267 16.5 Totals 1,618 100.0 The rate of occupancy, based on the bed complement, was 51.5%. Based on the normal bed capacity, it was 59.5%. The average length of stay per patient was 8.6 days. In 1945, 66.7% of all births in the County occurred in hospitals. Of these, 83.9% of the births to white mothers occurred in hospitals and 35.4% of births to nonwhite mothers occurred in hospitals. Medical staff: The Medical Staff is organized, having elected officers. Staff committees function under the titles of Credentials Committee, Medical Records Committee, and Membership Committee. Member- ship is granted by the Board of Directors on rec- ommendation of the Staff, following approval of the Credentials Committee. The Active Staff is comprised of 28 members. The Consulting Staff has nine members, and the Visiting Staff two members. Privilege to do major surgery is granted on the basis of resident training and demonstrated ability, or Fel- lowship in the American College of Surgeons, or certi- fication by a Specialty Board. In the specialities, privilege to do major work is granted on the basis of special training and demonstrated ability. Personnel: The personnel consists of 46 full-time and five part-time employees. This establishes a ratio of 0.8 employee per bed, based on normal bed capacity. There are also six volunteer workers. Educational activities: A nursing school is conducted. At the time of the survey, there were 14 students in training. Affiliations are maintained for training in pediatrics at the Children’s Hospital in Washington, D, C., and for medicine and dietetics in the Baltimore City Hospitals. Building plans: This hospital has under consideration plans for an addition which will include in the neigh- borhood of 30 new beds, along with a boiler house, elevator, and new dietary department. Conclusions Cambridge, being the political, commercial, and in- dustrial center of the County, is the logical point at which to have the medical center for the area. The Cambridge-Maryland Hospital, located in Cam- bridge, and operating at an occupancy rate of 51.5%, ordinarily would not be considered overtaxed. This hospital is not in urgent need of additional beds. How- ever, the planned elevator and dietary department renovation and equipment are considered necessary. General Hospitals 49 This hospital recently has gone through a reorganiza- tion which, it is expected, will create a greater com- munity interest in the hospital and result in greater utilization. Under a long-range program, this com- munity will have need for 112 beds. This conclusion is based on the increase of population expected to result from postwar adjustment1 and increased utilization of xAs of July 1, 1946, the estimated population of Dorchester County was 28,791, according to the Maryland State Depart- ment of Health, Bureau of Vital Statistics. the hospital under its new administration. Recommendations Because its population for the period 1920-1940 exceeded 25,000 people, and as of 1943 was only slightly under 25,000, it is recommended that Dorches- ter County be classified as an intermediate area. It is recommended that 47 additional beds be allocated to this area: that is, 32 to bring the area up to its standard of 97 beds, plus 15 from pool beds. FREDERICK COUNTY INTERMEDIATE AREA NUMBER 3 Population Change from previous period Change over 1920 1943: 51,774 5,538 decrease 1.5% decrease 1940: 57,312 2,872 increase 9.1% increase 1930: 54,440 1,899 increase 3.6% increase 1920: 52,541 Nonwhite population Per cent nonwhite Per capita income 1945: 4,245 8.2 1945: $1,177.27 1940; 4,705 8.2 1940: $ 582.62 Classification of residents, 1940 Urban Rural nonfarm Rural farm 34.3% 32.2% 33.5% Land area: 664 square miles Population per square mile, 1943: 78.0 County seat: Frederick Population 1940: 15,802 1930: 14,434 Births in hospitals as per cent of total births, 1945 Total White Nonwhite 69.9 68.8 80.4 General hospital facilities Institution Location Beds Frederick City Hospital Frederick 111 Frederick County Emergency Hospital Frederick 55 Geographic considerations Frederick County is bounded on the north by Pennsylvania, on the west by Washington County, on the south by the Potomac River which separates it from the State of Virginia and Montgomery County, and on the east by Howard and Carroll counties. The western boundary, common to Frederick and Wash- ington counties, is located on the ridge of a mountain. The line between Carroll and Frederick counties is a surveyed line in hilly country. The boundary between Carroll and Frederick counties runs along the Mono- cacy River. The area of the County is 664 square miles, making it the second county in the State in size. Mountains run north and south covering most of the western third of the County. A rolling terrain characterizes the eastern third. This is 5,538 less than was reported in 1940 and 767 less than reported in 1920. The population density in 1943 was 78.0 persons per square mile, making Fred- erick County the eleventh in the State in this respect. The mountainous area in the northwest corner of the County is not populated, but otherwise the County is developed for residences and farming. Frederick City is the principal community of the County. It had a population of 15,802 in 1940. It is the County Seat and is located to the south of the cen- ter. Brunswick, the second largest community of the County, is located in the southwest corner. Its popula- tion in 1940 was 3,856. The nonwhite population, numbering 4,245 in 1945, constituted 8.2% of the County’s residents. The population of Frederick County according to election districts, as of 1940, was as follows: Population The population of the County, as of 1943, was 51,774. 50 Hospital Survey and Plan for Maryland—Part III District 1, Buckeystown 2,439 District 2, Frederick 17,637 District 3, Middletown 2,051 District 4, Creagerstown 909 District 5, Emmitsburg 3,343 District 6, Catoctin 1,054 District 7, Urbana 1,879 District 8, Liberty 1,211 District 9, New Market 2,653 District 10, Hauvers 1,491 District 11, Woodsboro 1,862 District 12, Petersville 1,375 District 13, Mount Pleasant 884 District 14, Jefferson 1,266 District 15, Thurmont 2,944 District 16, Jackson 1,242 District 17, Johnsville 1,185 District 18, Woodville 1,055 District 19, Linganore 822 District 20, Lewistown 1,265 District 21, Tuscarora 1,026 District 22, Burkittsville 996 District 23, Ballenger 636 District 24, Braddock 863 District 25, Brunswick 3,856 District 26, Walkersville 1,368 In 1940, the population was classified as 34.3% urban, 32.2% rural nonfarm, and 33.5% rural farm. Transportation Frederick has railroad service by the Baltimore and Ohio Railroad, Pennsylvania Railroad, and Western Maryland Railroad. Local and long-distance bus service runs through Frederick City and to most parts of the County. High- ways radiate from Frederick City to all parts of the County, the City being readily accessible to all resi- dents of the County. Industry and commerce A large per cent of the residents of the County are engaged in farming. Other residents are employed at the canneries, manufacturing plants, and clothing factories. The per capita income for Frederick County in 1940 was ?582.62, making it the sixth county in the State in this respect. In 1945, with a per capita income of $1,177.27, it ranked seventh in the State. Physicians Forty-nine physicians have their homes in Frederick County and practice there. Five other physicians from surrounding areas have patients in the County. The distribution of physicians by residence is as follows: Public health 1 Pediatrics 1 Eye, ear, nose, and throat 3 X-ray 1 Internal medicine 1 Surgery 3 Psychiatry 1 The average age of the physicians based on the forty- seven ages reported was 57 years. Forty-seven per cent were 60 years of age or over. Thirty-eight per cent were between the ages of 40 and 61 years. Fifteen per cent were 40 years of age or under. On the basis of 1943 population there was one resi- dent physician for every 1,057 residents. GENERAL HOSPITAL FACILITIES FREDERICK CITY HOSPITAL The Frederick City Hospital, located in Frederick, is owned and operated by a nonprofit association known as the Frederick City Hospital Association. It was opened in 1902. It is a general hospital and maintains separate departments for pediatrics and obstetrics. It has full approval by the American College of Surgeons. Its nursing school has State-approval. A Board of Managers with a membership of 30 is responsible for the hospital. Members are elected for life. Vacancies are filled by election by the Board. Area served: An analysis of patients by residence, based on a study of four months’ experience, shows the following: Frederick City 44.2% Frederick County (outside of Frederick City) 29.8 Carroll County 13.5 Montgomery County 7.8 Others 4.7 100.0% Buildings: The original buildings have had additions built from time to time. Interior construction of the older buildings is not fire-resistant. Bed capacity: The normal bed capacity of this hospital is 111, but because of the excessive demand for service additional beds have been put into use. At the date of the survey, 125 beds were in service. Twenty-four bassinets are in use. Eleven beds are reserved for non- white patients. Utilization: The rate of occupancy based on the normal bed capacity was 74.5%. The average length of stay per patient was 9.6 days. An analysis of patients by diagnosis showed the following: Number of patients Per cent Medical 825 21.9 Surgical 1,738 46.2 Obstetric 855 22.7 Pediatric 90 2.3 Orthopedic 222 5.9 Other 30 1.0 Totals 3,760 100.0 Medical staff: The Medical Staff is organized and has elected officers. Privileges to do surgery and work in specialized fields are granted on the basis of rec- ommendation by the Staff. Personnel: Ninety-one full-time employees and 18 part-time employees make up the personnel. This Frederick City 29 Thurmont 3 Jefferson 1 Emmitsburg 2 Walkersville 2 Liberty town 3 Middletown 1 Brunswick 4 Johnsville 1 New Market 2 Ijamsville 1 Forty-one physicians have affiliations with the Frederick City Hospital. Thirty-eight physicians are general practitioners. Eleven others limit their practice to the specialties as follows: General Hospitals 51 establishes a ratio of 0.9 employee per bed, based on normal bed capacity. There are also 22 volunteer workers. Educational activities: A nursing school is conducted. Forty-seven students were in training, as of the date of the survey. Building plans: The Frederick City Hospital has some funds accumulated for building purposes. A campaign is planned to raise additional funds for adding a wing, which will include a delivery room, nursery, and service room, and increase the capacity by 25 beds. FREDERICK COUNTY EMERGENCY HOSPITAL The Frederick County Emergency Hospital at Frederick is operated by the County Commissioners. It was built in 1934 and is located on the grounds of the County Home. Area served: As a County-owned institution, admis- sions are limited to residents of the County. Buildings: The exterior walls are of brick construc- tion, but the interior is constructed of inflammable materials. Bed capacity: The normal capacity is 55 beds, of which 22 are reserved for nonwhite patients. Ten bassinets are in use. Utilization: The rate of occupancy is 65.5%. The average length of stay per patient is 23.9 days. It is understood that the patients are largely indigent. The length of stay is unusually long due to the fact that this is used as the infirmary for the County Home and most of the patients from this source are aged. During the year for which the report was made there were 550 patients discharged. No records are available as to the types of service rendered. Medical staff: There is no organized Medical Staff. A physician appointed by the County Commissioners functions as Medical Director. Personnel: Fourteen employees make up the personnel, representing a ratio of 0.3 employee per bed. This ratio is low because maintenance, heat, and food service are supplied by the County Home. Educational activities: No educational program is in operation. Building plans: No building program is under con- sideration at the present time. SCHNAUFFER HOSPITAL The Schnauffer Hospital, located at Brunswick, in the southwestern corner of the County, was serving the local community and the surrounding area at the time of the survey. Residents of Virginia patronized this hospital It is owned by Doctor Schnauffer, who has since closed it. The owner stated the reason for closing the hospital was ill health. The building is in the process of being remodeled for use as an apartment building. Conclusions Frederick City, located near the center of the area and accessible to all parts of the County, is the trad- ing and medical center. That it is the medical center is established by the existence of two general hospitals and 29 resident physicians there. Eighty-seven and eight-tenths per cent of the popula- tion of the County live within miles of Frederick. Approximately 3,800 residents of the southern ex- tremity and 3,200 residents of the northeastern corner of the County live outside the radius. There is an apparent need for additional hospital beds in the area. These beds should be installed as an addition to the Frederick City Hospital. On the basis of population and existing facilities, Frederick County qualifies as an intermediate area. A ratio of 4.0 beds per 1,000 population, the standard for intermediate areas, entitles this area to 207 beds, based on the County’s population in 1943. Since there are already 166 beds in service, 41 beds are needed to bring the existing beds to the standard for the area. Recommendations It is recommended that Frederick County be classi- fied as an intermediate area. It is further recommended that an addition of 41 beds be programmed for the Frederick City Hospital. 52 Hospital Survey and Plan for Maryland—Part III GARRETT COUNTY RURAL AREA NUMBER 1 Population Change from previous period Change over 1920 1943: 18,534 3,447 decrease 5.8% decrease 1940: 21,981 2,073 increase 11.7% increase 1930: 19,908 230 increase 1.2% increase 1920: 19,678 Nonwhite population Per cent nonwhite Per capita income 1945: 0 0.0 1945: $752.62 1940: 5 0.0 1940: $311.72 Classification of residents, 1940 Urban Rural nonfarm Rural farm 0.0% 49.9% 50.1% Land area: 668 square miles Population per square mile, 1943: 27.7 County seat: Oakland Population 1940: 1,587 1930: 1,583 Births in hospitals as per cent of total births, 1945 Total White Nonwhite 38.9 38.9 0.0 Geographic considerations Garrett County is the westernmost county of Mary- land. It is bounded by Pennsylvania on the north, by West Virginia on the west and south, and by Alle- gany County on the east. It is the first county of the State in area, having 668 square miles. Most of the surface is mountainous; however, numerous farms have been developed where the land is flat or rolling. Population In 1943 the population of Garrett County was 18,534. From 1940 to 1943, there was a loss in popula- tion amounting to 3,447 people, or 15.7%, This can be attributed to the fact that there were no war industries in the County. During the previous decade, 1930 to 1940, an increase of 10.4% was recorded. From 1920 to 1930, the change amounted to 1.2%. The net change for the 23-year period was a decrease of 5.8%, or a loss of 1,144 people. As of 1945, no nonwhite persons were residing in the County. With its large area and sparse population, Garrett County ranks lowest in the State in population density, with 27.7 persons per square mile. As of 1940, the residents were classified as 49.9% rural nonfarm and 50.1% rural farm. The population according to election districts was as follows: District 1, Swanton 1,233 District 2, Friendsville and Selbysport 1,954 District 3, Grantsville 2,407 District 4, Bloomington 817 District 5, Accident 1,219 District 6, Sang Run 923 District 7, East Oakland 1,187 District 8, Ryans Glade 2,343 District 9, Johnsons 861 District 10, Deer Park 950 District 11, The Elbow 292 District 12, Bittinger 674 District 13, Kitzmillersville 2,028 District 14, West Oakland 3,125 District 15, Avilton 471 District 16, Mountain Lake Park 1,497 Transportation Access to the County is possible by two highways: one running from Frostburg to Westernport in Alle- gany County and into Oakland; and the other running directly west from Frostburg to Keyser Ridge, from which point Route 219 furnishes access to the area between Keyser Ridge and Oakland. Other highways lead to Oakland from West Virginia on the south and west. It was reported that severe winters are experienced frequently, making highway travel difficult at that time of the year. The Baltimore and Ohio Railroad has several trains stopping at Oakland daily. Three of these trains pass through Cumberland. A Western Maryland Railroad line runs through daily with four passenger trains to Cumberland and Elkins, West Virginia. Blue Ridge busses go into Oakland from Keyser Ridge, and from Red House on Route 50. Local busses furnish trans- portation from the near-by communities to Oakland. Industry and commerce The County is divided into two districts, the northern General Hospitals 53 district which lies along Route 40, and the southern district which centers around Oakland. Both districts look largely to Cumberland for supplying needs which cannot be procured locally. Recently publicity has been given to a projected plan for the establishment of a $10,000,000 recreation center near Oakland. Oakland is reported to be the only shopping center in the entire County. One bank in Oakland reported having accounts from every part of the County. There are several large mines in the area which, along with the railroads, provide employment. Several paper mills at Luke, in Allegany County, give some employment to residents. Some residents commute to Frostburg and Cumberland to work. Others work on farms. In 1940 the income per capita was $311.72, making it the twenty-first county in the State in this respect. For 1945 the per capita income in Garrett County rose to $752.62, placing it twentieth in the State in this respect. For the same year, the per capita income for the State was estimated at $1,291.61. Physicians Seven physicians practice in Garrett County as follows: annual cost of maintenance and operation is quite high, averaging in the neighborhood of one third to one half of the equivalent of the capital invested. The an- nual operating cost of a $500,000 hospital would be in the neighborhood of $166,000. Recognition should be taken of the fact that, if the community commits itself to the construction of a hospital, the income of the persons who will use the hospital must be adequate to support it or the County must stand ready to subsidize the free patients. The State has in operation its hospital care program, but under the present limitations, it does not cover the full cost, leaving part to be covered with local funds. It is accepted generally that hospitals having less than 50 beds cannot be operated efficiently. Neverthe- less, many hospitals of less than 50 beds are being operated. This factor should be weighed against the cost of maintaining empty beds and the inconvenience of travel to hospital facilities if the hospital community is not large enough to support a 50-bed hospital. Public Law 725 (Appendix A) states in part that the maximum ratio between general hospital beds and population is 4.5 per 1,000 persons. This would vary upward in communities where there are outstanding physicians and facilities and downward where there is a lack of physicians and facilities, especially in areas located in close proximity to well-supplied centers. According to the standards set forth, Garrett County would rate as a rural area. With Garrett County and Oakland situated as they are with relation to Cumberland, Baltimore, and Washington, consideration should be given this fact in determining the hospital beds required. On the basis of 2.5 general hospital beds per 1,000 population, a 46- bed hospital will supply the needs of Garrett County. The residents of the northern district along Route 40 will continue to travel to the existing hospitals in Frostburg and Cumberland. This will be offset by residents of West Virginia who will come into Oakland for hospitalization. The establishment of a hospital in the area should at- tract doctors and nurses and will give to those practi- tioners already in the area the opportunity to practice medicine more nearly to the extent of their ability and knowledge. The basic services which will bs maintained in an area such as Oakland are general medicine, uncompli- cated surgery, and uncomplicated obstetrics. It is not expected that there will be a need for enough of the other types of service to support highly skilled special- ists. Patients needing such services will be referred to other areas where the need is great enough to attract specialists. A relationship must be established and maintained between the local hospital staff and the medical groups in Cumberland and Baltimore, so that specialists will be on call for special occasions. These consultants should from time to time visit the area and conduct clinics for educational purposes. Some thought must be given to making an arrange- ment with other small hospitals of comparable status Oakland 4 Friendsville 1 Grantsville 1 Kitzmillersville 1 Only one of these physicians is affiliated with the Memorial Hospital in Cumberland. The youngest is 32 and the oldest is 66, their average age being 45. On the basis of the County's 1943 population, this establishes a ratio of one physician to every 2,648 resi- dents. GENERAL HOSPITAL FACILITIES In Garrett County three nursing homes were listed, but only one was in operation at the time of the survey. There are no general hospitals. PROPOSED HOSPITAL CONSTRUCTION Funds available: Mr. George W. Loar of Oakland, in his will, bequeathed $170,000 for the construction of a memorial hospital in Oakland. Under the terms of the will, the County Commissioners may accept these funds and proceed with the erection of a hospital with the understanding that the direct management of the hospital will be turned over to a Board, consisting of the County Commissioners and five other persons des- ignated under the will. Because of the limited time allowed for the acceptance of this gift, the Commis- sioners took formal action accepting the gift and have committed the County to the erection of a hospital. Site: A site has been made available for the hospital. It lies above the level of the center of town but is easy of access, having a highway running along one side. The land is comprised of about 15 acres. Public service facilities are available to the site. The proposed hospital appears to be entirely satisfactory from the standpoint of facilities and access, and quite adequate in size. Considerations: While a hospital is a very desirable facility in a community, it must be recognized that the 54 Hospital Survey and Plan for Maryland—Part III in the area for the sharing of the services of a roentgeno- logist and pathologist. Conclusions Oakland, now without any medical facilities, should have a hospital and medical center. The center should include facilities for the public health clinics and the County Health Department in addition to hospital beds and ancillary departments. By a cooperative arrangement with the State Health Department, X-ray and laboratory equipment and personnel can be made available to the County. Three new physicians have located in the area, re- placing older men who died or moved away, bring- ing the total to seven. The influx of young physicians gives some assurance that a medical staff can be or- ganized. Even though a hospital or health center is established at Oakland, some people in the northern part of the County would continue to travel to Frostburg and Cumberland for hospitalization. This factor will be offset by requests for care of cases now taken care of in homes; applications for service on elective surgery which, due to lack of facilities, is not done at the present time; and patients coming in from near-by towns in West Virginia. If less than 50 beds are provided in the original struc- ture, it should be so planned that a later addition can be made conveniently to bring the capacity up to 50 beds. The County must be ready to underwrite deficits which may be large at first but should become smaller as the utilization of the hospital increases. With a total absence of hospital facilities in this County and with approximately 18,000 of its 21,000 population in 1940 living more than 12 miles from a general hospital, this hospital project should be given a high priority. There is an immediate need for better quarters for the clinics being conducted by the County Health De- partment. Therefore, public health facilities definitely should be included in the proposed hospital. Recommendations It is recommended that Garrett County be classified as a rural area, and that a hospital with a capacity of 46 beds be constructed at Oakland. It is further rec- ommended that quarters for the County Health De- partment be included in this hospital, and that this project be given a high priority. KENT AND QUEEN ANNE’S COUNTIES RURAL AREA NUMBER 5 Population 1943: 25,265 1940: 27,941 1930: 28,813 1920: 31,027 Kent County Queen Anne’s County Combined Change from previous period 2,676 decrease 872 decrease 2,214 decrease Nonwhite population 1945 1940 3,947 4,061 3,670 4,347 7,617 8,408 Change over 1920 18.6% decrease 9.9% decrease 7.1% decrease Per cent nonwhite 1945 1940 30.2 30.2 30.1 30.0 30.1 30.1 Kent County Queen Anne’s County Per capita 1945 $1,209.85 $ 901.34 income 1940 $577.27 $372.82 Classification of residents, 1940 Urban Rural nonfarm Rural farm Kent County 20.5% 48.3% 31.2% Queen Anne’s County 0.0% 50.8% 49.2% Combined 9.9% 49.6% 40.6% Kent County Queen Anne’s County Combined Land area Population per square mile, 1943 284 square miles 46.0 373 square miles 32.7 657 square miles 38.5 County seat Kent County: Chestertown Queen Anne’s County: Centreville Population 1940 1930 2,760 2,809 1,141 1,291 Births in hospitals as per cent of total births, 1945 Kent County Queen Anne’s County Combined Total White 63.4 81.9 42.3 59.5 52.6 70.3 Nonwhite 25.0 4.9 14.8 General hospital facilities Institution Location Kent and Queen Anne’s General Hospital Chestertown Beds 25 General Hospitals 55 Geographic considerations Kent County lies immediately south of Cecil County with the Sassafras River making up about four fifths of the common boundary. It is bounded on the west by the Chesapeake Bay, on the south by the Chester River, which serves as about thre< fourths of a common boundary of Kent and Queen Anne’s counties, and on the east by the State of Delaware. The County, with a land area of 284 square miles, ranks twentieth in the State in this respect. Queen Anne’s County, lying south of Kent County, has the Chesapeake Bay to the west, Talbot County to the south, and Caroline County and the State of Delaware to the east. With a land area of 373 square miles, it ranks fifteenth among the counties of the State. The boundaries between Queen Anne’s and Talbot counties and between Queen Anne’s and Caroline counties do not appear to have a physiographic basis. The surface of Kent and Queen Anne’s counties is generally fiat. Population The population of Kent County was 13,071 and of Queen Anne’s County 12,194 in 1943, making a total of 25,265. The distribution of the population of the area according to election districts, as of 1940, was as follows: Kent County District 1, Masseys 2,295 District 2, Kennedyville 1,854 District 3, Worton (Betterton) 1,671 District 4, Chestertown 2,920 District 5, Edesville 2,738 District 6, Fairlee 1,067 District 7, Pomona 920 Queen Anne’s County District 1, Dixon 2,034 District 2, Church Hill 1,809 District 3, Centreville 3,287 District 4, Kent Island 2,094 District 5, Queenstown 2,813 District 6, Ruthsburg 1,163 District 7, Crumpton 1,276 As of 1943, Kent County had a density of 46 persons per square mile and Queen Anne’s County had 32.7 persons per square mile, the counties ranking eighteenth and twentieth, respectively, in the State. The density for the entire area, 38.5 persons per square mile, in- dicates this area is sparsely populated. There are no large communities in either county, Chestertown, the County Seat of Kent County, has the largest popula- tion concentration in the area. In 1940 its population was 2,760. Centreville, the County Seat of Queen Anne’s County, had a population of 1,141 in 1940. Nonwhite persons, numbering 7,617, made up 30.1% of the total population of the area in 1940. There was no change in this percentage between 1940 and 1945. Within a radius of miles around Chestertown, the location of the Kent and Queen Anne’s General Hospital, all but 2,300 residents of Kent County are located. The latter live in the eastern extremity of the County. More than one half of the residents of Queen Anne’s County live within the radius of the hospital. The residents of the southern and eastern portions of the County, totaling 8,150 people, live out- side the radius. The residents of Kent County were classified in 1940 as 20.5% urban, 48.3% rural nonfarm, and 31.2% rural farm. The residents of Queen Anne’s County were class- ified as being 50.8% rural nonfarm and 49.2% rural farm. For the two counties combined the classification was 9.9% urban, 49.6% rural nonfarm, and 40.6% rural farm. Transportation The entire area is served by highways which make access to Chestertown convenient. The Pennsylvania Railroad maintains service into both counties. This service is supplemented by bus lines. Industry and commerce Farming is one of the principal sources of income. There are no large industries in the entire area. A manufacturer of detonators and fuses and three can- ning factories offer employment in this area. The per capita income of Kent County in 1940 was $577.27, making it the eighth county in the State from this standpoint. In 1945 the per capita income was $1,209.85, raising the County’s rank to sixth in the State. Queen Anne’s County in 1940 had a per capita income of $372.82, making it the eighteenth county in the State. In 1945 the per capita income was $901.34, the County climbing to twelfth place in this respect. Physicians There are 18 physicians practicing in Kent County and eight in Queen Anne’s County. They are distri- buted follows: Kent County Chestertown 11 Still Pond 1 Millington 3 Rock Hall 1 Betterton 1 Galena 1 Queen Anne’s County Centreville 3 Stevensville 2 Church Hill 1 Sudlersville 1 Queenstown 1 On the basis of Riair 1943 population, Kent County had one physician for every 726 residents and Queen Anne’s County, one physician for every 1,524 residents. Combining the populations of the two counties there was one physician for every 972 persons. GENERAL HOSPITAL FACILITIES KENT AND QUEEN ANNE’S GENERAL HOSPITAL The Kent and Queen Anne’s General Hospital, lo- cated in Chestertown, is the only general hospital in the area. Centrally located in the area, it was built with funds supplied by residents of both counties and put into service in 1935. A Board of Directors, consisting of 15 members, is in charge of the institution. The members of this Board serve for a term of one year. The Board is self-perpetu- ating. The Kent and Queen Anne’s Hospital Auxiliary, an organization of several hundred women members, en- gages in enterprises to raise money for equipment and supplies. 56 Hospital Survey and Plan for Maryland—Part III Area served: Ninety-seven and nine-tenths of the patients served by this hospital are residents of the two counties. Bed capacity: At the time of the survey, 31 beds were in use. The normal bed capacity of the hospital is 25. The six extra beds are reserved for nonwhite patients. Ten bassinets are in use. Utilization: A classification of the discharged patients by diagnosis was as follows: Number of patients Per cent Medical 130 12.1 Surgical 693 64.6 Obstetric 208 19.4 Orthopedic 16 1.5 Pediatric 26 2.4 Totals 1,073 100.0 The occupancy rate, based on the normal bed capac- ity, was 69.2%. Based on the bed complement, it was 55.8%. The average length of stay per patient was 5.9 days. Medical staff: The Medical Staff is organized, having elected officers. Appointment to the Staff is made by the Board of Directors on recommendation of the Staff. Privilege to do major surgery is granted on the same qualification required for Fellowship in the American College of Surgeons, or on the basis of certification by the Surgical Specialty Board, or equivalent training in postgraduate work. Personnel: Twenty-one full-time employees make up the personnel of the hospital. This establishes a ratio of 0.8 employee per bed. Educational activities: No educational program is be- ing conducted by this hospital. Conclusions This area has sufficient population to qualify as an intermediate area. On the basis of United States Public Health Service standards, 100 beds would be needed. There is no apparent need for a hospital of 100 beds. It was considered, therefore, as a rural area. The length of stay of patients in the Kent and Queen Anne’s General Hospital is short, being only 5.9 days. The rate of occupancy, based on the number of beds in use, is 55.8% which is not high. It was reported that at times there is a list of patients waiting for admission to the hospital. In the light of the moderate occupancy rate, occasions when there are waiting lists are apparently at peaks throughout the year. However, they are not indicative of a steady de- mand for beds in excess of the capacity of the hospital. On the basis of 2.5 beds per 1,000 population, this area would be entitled to 63 beds, or 38 more than the present normal bed capacity. The addition of these 38 beds would relieve the recurring periods of crowding. Recommendations It is recommended that Kent and Queen Anne’s counties be classified as a single rural area. It is recommended also that 38 beds be allocated to this area. General Hospitals 57 MONTGOMERY AND PRINCE GEORGE’S COUNTIES INTERMEDIATE AREA NUMBER 4 Population < ,f , j Change from previous period Change over 1920 1943; 221,780 48,378 increase 183.4% increase 1940; 173,402 64,101 increase 121.5% increase 1930: 109,301 31,033 increase 39.6% increase 1920: 78,268 Nonwhite population Per cent nonwhite 1945 x 1940 1945 1940 Montgomery County 11,040 8,926 10.6 10.6 Prince George’s County 21,408 16,273 18 2 18 2 Combined 32,448 25,199 14.6 14.5 Per capita income 1945 1940 Montgomery County $860.57 $524.67 Prince George’s County $789.90 $487.99 Classification of residents, 1940 Urban Rural nonfarm Rural farm County 9.1% 74.1% 16.8% Prince George’s County 20.5% 62.4% 17 1% Combined 15.0% 68.0% 17.0% Land area Population per square mile, 1943 Montgomery County 494 square miles 210.8 Prince George’s County 485 square miles 242.5 Combined 979 square miles 226.5 Population County seat 1940 1930 Montgomery County: Rockville 2,047 1,460 Prince George’s County: Upper Marlboro 565 *420 Births in hospitals as per cent of total births, 1945 Total White Nonwhite Montgomery County 91.2 93.7 64.5 Prince George’s County 89.4 94.6 60 9 Combined 90.3 94.2 62.1 General hospital facilities Institution Location Beds Montgomery County General Hospital Olney 40 Suburban Hospital Bethesda 102 Washington Sanitarium and Hospital Takoma Park 188 Eugene Leland Memorial Hospital Riverdale 87 Prince George’s General Hospital Cheverly 102 Warren Hospital Laurel 17 Geographic considerations Montgomery and Prince George’s counties encircle the District of Columbia. Montgomery County is the westernmost of the two counties. It is bounded by Howard and Frederick counties on the north and by the Potomac River on the west and south. The eastern boundary is common to the District of Columbia and Prince George’s County. Prince George’s County is bounded by Montgomery County, the District of Columbia, and the Potomac River on the west, by Charles County on the south, and Anne Arundel and Calvert counties on the east and northeast. It touches Howard County for a short dis- tance on the north. The surface of both counties is uneven and ranges from moderately high hills in the west where Mont- gomery County joins Frederick County to low rolling hills in the eastern and southern parts of Prince George’s County. The area of Montgomery County is 494 square miles, making it the fifth county in the State in size. Prince George’s County has an area of 485 square miles, making it the sixth county in the State in size. Population The population of Montgomery County was 104,155 in 1943. With a density of 210.8 persons per square mile, it ranked third among the counties of the State. Prince George’s County had a population of 117,625 in 1943. With a density of 242.5 persons per square mile, the County ranked sixth in the State. Both counties are populated throughout, but the majority of people make up communities on the peri- phery of the District of Columbia. In the 23-year Hospital Survey and Plan for Maryland—Part III period between 1920 and 1943, the population cf the area increased 183.4%. The population as of 1940 of Montgomery County was divided according to election districts as follows: District 1, Laytonsville 1,813 District 2, Clarksburg 1,558 District 3, Poolesv.'lle 1,724 District 4, Rockvilla ...5,995 District 5, Coiesville 4,045 District 6, Darnestown 1,682 District 7, Bethesda 26,114 District 8, Olney 2,601 District 9, Gaithersburg 3,861 District 10, Potomac 1,828 District 11, Barnesville 1,735 District 12, Damascus 2,079 District 13, Wheaton 28,877 The population as of 1940 of Prince George’s County was divided according to election districts as follows; District 1, Vansville 1,923 District 2, Bladensburg 6,103 District 3, Marlboro 2,081 District 4, Nottingham 1,626 District 5, Piscataway 2,666 District 6, Spalding 7,605 District 7, Queen Anne 2,199 District 8, Aquasco 1,120 District 9, Surratts 2,200 District 10, Laurel 3,691 District 11, Brandywine 2,427 District 12, Oxon Hill 2,802 District 13, Kent 2,264 District 14, Bowie 3,600 District 15, M ell wood 1,960 District 16, Hyattsville 6,926 District 17, Chillum 10,864 District 18, Seat Pleasant 10,750 District 19, Riverdale 7,184 District 20, Lanham 1,758 District 21, Berwyn 7,711 The population for the area as a whole was classified in 1940 as 15.0% urban, 68.0% rural nonfarm, and 17.0% rural farm. It is assumed that the 48,378 new residents entering the area between 1940 and 1943 were largely attracted by employment in and around Wash- ington. They were considered, therefore, to be pre- ponderantly urban. With this addition to the urban population, the distribution is 33.5% urban, 53.2% rural nonfarm, and 13.3% rural farm. The nonwhite population of the area was 32,448 in 1945, amounting to 14.6% of the total residents in the two counties. Approximately 2,300 residents of Montgomery Coun- ty and 1,600 residents of Prince George’s County live more than 12p2 miles from a hospital. Most residents, however, live within 12 miles of more than one hospital. Transportation The entire area is covered by a network of highways which extend to all points of the counties. Railroad and bus service offer convenient public transportation throughout the area. Both transporta- tion and highway systems radiate from Washington, which is the trading and medical center and the place of employment for a large segment of the population. Industry and commerce Employment is largely in government work and service industries. No large basic industries are located in the area. The per capita income for Montgomery County as of 1940 was $524.67 and $860.57 in 1945. Its position in the State was ninth in 1940 and fourteenth in 1945. Prince George’s County residents had a per capita income of $487.99 in 1940 and $789.90 in 1945. It was the twelfth county in the State in this respect in 1940 and nineteenth in 1945. Physicians There are 97 physicians residing in Montgomery County and 37 physicians in Prince George’s County. Four out-of-state physicians practice in Montgomery County and seven in Prince George’s County. The resident physicians are distributed as follows: Montgomery County Silver Spring 31 Kensington 2 Bethesda 19 Takoma Park 18 Damascus 2 Gaithersburg 3 Rockville 7 Chevy Chase 6 Glen Echo 2 Dawsonville 1 Poolesville 2 Sandy Spring 3 Laytonsville 1 Prince George’s County Laurel 4 Mt. Rainier 7 Berwyn 2 Upper Marlboro 3 Greenbelt 3 Hyattsville 6 Cottage City 2 Riverdale 1 Bowie 1 Brentwood 1 College Park 2 District Heights 1 Fairmont Heights 1 Capital Heights 1 Bladensburg 1 Takoma Park 1 Using the 1943 population figures for the two-county area, this establishes a ratio of one resident physician to every 1,655 persons. Taking the counties separately, Montgomery County has one resident physician for every 1,074 persons, whereas Prince George’s County has one for every 3,179 persons. GENERAL HOSPITAL FACILITIES Six hospitals serve the residents of this area. Three are located in each county. Four are located just out- side the District of Columbia and one in Olney and one in Laurel. A community group in Silver Spring holds title to a plot of land and is engaged in efforts to raise funds for the construction of a hospital. MONTGOMERY COUNTY GENERAL HOSPITAL The Montgomery County General Hospital, located at Olney, was established in 1920. It is owned by a nonprofit corporation and operated by a Board of Di- rectors. The Board consists of 18 members who are elected annually. Special departments are set up, rendering service to obstetric, orthopedic, eye, ear, nose, and throat, and skin and cancer cases. The Women’s Board, with a membership of 100, assists the institution financially and from time to time makes gifts of equipment and supplies. Area served: For the period reported, 81.0% of the patients treated were from Montgomery County, 10.4% General Hospitals 59 from Howard County, 3.1% from Prince George’s County, and 5.5% from other areas and out of the State. Buildings: The buildings are not fire-resistant. Bed capacity: The present capacity is 40 beds, ten of which are reserved for nonwhite patients. Fourteen bassinets are maintained. Utilization: The rate of occupancy is 82.4%, and the average length of stay is 9.1 days. For the period reported, patients fell into the fol- lowing classifications, according to diagnosis: Number of patients Per cent Medical 275 21.1 Surgical 703 53.9 Obstetric 287 22.0 Orthopedic 39 3.0 Totals 1,304 100.0 Medical staff: The Staff consists of three physicians. In addition, 20 physicians are available for consulta- tion and 25 others make up a Visiting Staff. Personnel: The personnel consists of 29 employees, which establishes a ratio of 0.7 employee per bed. Educational activities: There is no educational pro- gram in effect. Building plans: This hospital has just completed a building program which included the enlargement of the dietary department. A recent drive for funds pro- duced approximately $60,000 for a new maternity de- partment. SUBURBAN HOSPITAL The Suburban Hospital, located at Bethesda, was put into service in December, 1943. It was built under the Lanham Act. It is operated by the Suburban Hospital Association, which is a nonprofit corporation. Title is held by the United States Government. The Managing Board consists of 15 members whose term of office is three years. A Women’s Auxiliary of 322 members assists the hospital with voluntary services and makes purchases of necessary supplies and equip- ment. It has full approval of the American College of Surgeons. Area served: For the period reported, 77.9% of the patients were residents of Montgomery County, 43.5% of whom were residents of Bethesda and Chevy Chase. Seventeen and nine-tenths per cent were residents of Washington, D. C. The remainder were from other areas. Buildings: The buildings are of brick and stone, but the hospital is not classified as fire-resistant because of the inflammable interior construction. Bed capacity: The present capacity is 102 beds and 22 bassinets. Ten of the beds are reserved for nonwhite patients. Utilization: The rate of occupancy is 53.7%, and the average stay is 9.1 days per patient. The patients classified according to diagnosis, for the period re- ported, were as follows: Number of patients Per cent Medical 729 33.9 Surgical 741 34.4 Obstetric 480 22.3 Pediatric 74 3.5 Orthopedic 103 4.8 Contagious 24 1.1 Totals 2,151 100.0 Medical staff: The Medical Staff is organized and elects its own officers annually. Standing committees are Executive, Medical Records, Program, Library, Cre- dentials, Internes and Residencies, Laboratory, Nutri- tion, and Outpatient. Membership on the Staff is granted by the Board of Trustees on recommendation of the Executive Committee of the Staff. Recommenda- tion is based on demonstrated ability and some degree of limiting of practice to the specialty for which applica- tion is made. Sixty-nine physicians make up the Senior and Associate Staffs, while 128 physicians make up the Courtesy and Consulting Staffs. Staff services are set up in the various specialties. Twenty-eight members of the Staff hold Specialty Board certification. Personnel: One hundred thirty-three employees make up the personnel, establishing a ratio of 1.3 employees per bed. Educational activities: This hospital is approved for three mixed residencies. No other educational program is in operation. Building plans: No building program is under con- sideration. WASHINGTON SANITARIUM AND HOSPITAL The Washington Sanitarium and Hospital, located at Takoma Park, was opened in 1907. It is owned by the General Conference of the Seventh Day Adventist Church and is operated by the Washington Sanitarium Association, Incorporated. The Managing Board has a membership of 12. Their term of office is two years. It is approved for interne training. The nurses’ school is State-approved. Area served: Of the patients treated, 50% were from Montgomery County. It was reported that patients are admitted from a broad area, including points as far south as South Carolina and as far north as Pennsyl- vania. Buildings: Buildings have been added from time to time, with the result that some are constructed of brick and stone, while others are of frame construction. The buildings are not considered fire-resistant. Bed capacity: The normal capacity is 188 beds, but as of the date of the report 201 beds were in service, plus 30 bassinets. None of these beds is available for non- white patients. Utilization: For the period reported, the classification of service by diagnosis was as follows: 60 Hospital Survey and Plan for Maryland—Part III Number of patients Per cent Medical 1,268 36.1 Surgical 911 26.0 Obstetric 710 20.2 Pediatric 21 0.6 Orthopedic 242 6.9 Nervous and Mental 244 7.0 Other 111 3.2 Totals 3,507 100.0 The rate of occupancy based on normal bed capacity was 90.3%. Based on bed complement it was 84.4%. The average length of stay per patient was 17.6 days. Medical staff: The Medical Staff is organized, having staff officers and committees on Internes, Library, Pro- gram, and Membership. Appointments to the Active Staff are made by the Board of Trustees, The Active Staff is made up of eight members, all of whom are on a full-time salary basis. Appointments to the Courtesy Staff are made by the Board on recommendation of the Staff. The Courtesy Staff consists of 40 members and the Consulting Staff of ten members. Staff services are set up in medicine, surgery, obstetrics, radiology, and eye, ear, nose, and throat. The privilege to do major surgery is granted on the same basis as qualifica- tions for Fellowship in the American College of Sur- geons. Personnel: Two hundred and seventy full-time and 73 part-time employees make up the personnel. Con- sidering the part-time employees as being on half-time duty, this establishes a ratio of 1.6 employees per bed, on the basis of normal bed capacity. Educational activities: As of the date of the survey, three internes were on duty; there were no residents. The nursing school had a student body of 84. The nursing school is affiliated with the Johns Hopkins Hospital for instruction in surgery and with the Child- ren’s Hospital in Washington, D. C., for instruction in pediatrics. Building plans: This hospital reported a planned building program of $900,000.00, which would result in the addition of 75 beds. EUGENE LELAND MEMORIAL HOSPITAL The Eugene Leland Memorial Hospital, located in Riverdale, is owned and operated by a proprietary corporation. Its activities are under the direction of a Board of five members whose terms of office are for one year. The hospital was established in 1942. A group known as the Workers’ Auxiliary of the Eugene Leland Memorial Hospital assists the hospital in social, educational, and spiritual activities. Special departments are maintained for obstetric and pediatric services. This hospital has provisional approval of the Ameri- can College of Surgeons. Area served: For the period reported, 76.9% of the patients were residents of Prince George’s County. The remainder of the patients were from other areas, including Montgomery County and the District of Columbia. Buildings: The exterior construction of the buildings is of brick, but the interior construction is wood. The buildings are, therefore, not considered fire-resistant. Bed capacity: This hospital reported a capacity of 87 beds.1 None of these is available for nonwhite patients. Twenty-one bassinets are maintained. Utilization: The rate of occupancy is 44.2%. The average length of stay per patient is 8.1 days. For the year reported, the patients fell into the following categories: Number of patients Per cent Medical 550 31.4 Surgical 510 29.2 Obstetric 521 29.8 Pediatric 80 4.6 Orthopedic 75 4.3 Other 12 0.7 Totals 1,748 100.0 Medical staff: The Medical Staff of this hospital is a closed organization, consisting of the Malin Medical Group. This group of physicians render outpatient services and treat patients in the hospital. One of the physicians functions as Chief of Staff, in lieu of having elected staff officers. Personnel: Eighty full-time employees and six part- time employees make up the personnel of this institu- tion, establishing a ratio of 0.95 employee per bed. Educational activities: No educational program is in operation at this hospital. Building plans: Plans are under consideration for the construction of an outpatient department which will be under the direction of the Malin Medical Group. PRINCE GEORGE’S GENERAL HOSPITAL The Prince George’s General Hospital, located in Cheverly, was opened in 1944. Built under the Lanham Act, it is leased from the Federal Government and operated by Prince George’s County. Special depart- ments are maintained for obstetric, pediatric, ortho- pedic, and eye, ear, nose, and throat services. A Board of 15 members directs the affairs of the hospital. These members serve for a period of three years. They are appointed by the Board of County Commissioners. The Prince George’s General Hospital Guild, with a membership of 1,500, assists the hospital through fund- raising projects for the purchase of supplies. Area served: It was reported that 96% of the patients are residents of Prince George’s County, Buildings: The buildings, which are new and modern, are considered fire-resistant. Bed capacity: The normal capacity is 102 beds and 18 bassinets. This hospital reports that it does not have a policy opposed to the admission of nonwhite patients, but that, to date, it has been impossible to set aside beds for this purpose. Under a construction program which is planned, facilities will be made available for such patients. Utilization: For the year reported this hospital’s occupancy rate was 70.9%. The average length of stay iSince the completion of the survey, 21 beds in a separate building of the hospital and ten beds which had been assigned to children have been taken out of service. General Hospitals 61 per patient was 7.9 days. For the last seven months of operation the hospital’s occupancy rate increased to 79.0%. Classification of patients for the year reported, according to diagnosis, was as follows: Number of patients Per cent Medical 713 21.4 Surgical 1,079 32.3 Obstetric 685 20.5 Orthopedic 153 4.6 Other 708 21.2 Totals 3,338 100.0 Medical staff: The Medical Staff is organized and has elected officers. Committees of the Staff function under the following titles: Executive, Credentials, Medical Records, Program, Clinical, Pathological, and Audit. Appointment to membership on the Staff is made by the Board of Directors upon recommendation of the Med- ical Staff. There are 40 physicians on the Active Staff, 102 on the Courtesy Staff, four on the Consulting Staff, and four on the Honorary Staff. By type of practice and staff position held, these men fall in the following categories: Medicine 77 Otolaryngology 2 Surgery 36 Genito-urinary 2 Obstetrics 24 Neurosurgery 2 Pediatrics 4 Orthopedics 2 Anesthesia 4 Opthalmology 2 Privilege to work in the specialties is limited to physicians meeting the high qualifications established. Personnel: The personnel of this hospital is made up of 109 full-time employees and 31 part-time em- ployees. This establishes a ratio of 1.2 employees per bed. There are also 27 volunteer workers. Educational activities: Residents are employed in medicine, surgery, and obstetrics. Building plans: Plans are under consideration to add 110 beds to this hospital. The County Medical Society, the Hospital Administration, and the County author- ities are cooperating in this effort. The ultimate plan calls for the establishment of this hospital as the medical center for the entire County. WARREN HOSPITAL The Warren Hospital, located at Laurel, is owned and operated by two physicians. It was opened in 1940. Area served: All of the patients are residents of the immediately surrounding area. Buildings: The buildings, which are 46 years old, are of frame construction. Bed capacity: Seventeen beds make up the normal capacity. No beds are reserved for nonwhite patients. Utilization: For the period reported, the hospital had an occupancy rate of 94.4% and had an average length of stay per patient of 12.2 days. The patients fell into the following classifications according to diagnosis: Number of patients Per cent Medical 103 21.5 Surgical 218 45.5 Obstetric 158 33.0 Totals 479 100.0 Building plans: The owners reported that at some future time they plan to replace the present buildings with a modern structure which will have a capacity cf approximately 40 beds. Because of its type of structure, this hospital was not considered acceptable. Conclusions Montgomery and Prince George’s counties, being homogeneous and lacking a clear line of demarcation for purposes of defining hospital service areas, were treated as one area. Located around the District of Columbia, with a combined population of 221,780, they qualify as an intermediate area. Most of the area’s employment is in government work and in service industries, which can be expected to be reasonably steady. No significant changes in the area’s population are anticipated. The six hospitals in this area maintain 536 beds, or a ratio of 2.4 beds per 1,000 population. Seventeen of these beds, located in the Warren Hospital at Laurel, are considered unacceptable because of the type of building and the material of which it is constructed. Twenty-one beds at the Eugene Leland Memorial Hospital were taken out of service after the survey was completed. The area should be allowed 21 beds as replacements. The net number of beds considered acceptable was, therefore, 519. On the basis of the standard for intermediate areas of 4.0 beds per 1,000 population, this area is entitled to 887 beds. The differential of 368 beds is considered the normal need. The Montgomery County Hospital at Olney has plans for a construction program to include the addition of 16 beds. This hospital reported an occupancy rate of 82.4%, which is abnormally high for a hospital of its size. The 16 beds planned, therefore, are considered justified. The Prince George’s General Hospital at Cheverly is planning an addition which will increase its capacity by 110 beds to a total of 212. The hospital reported an occupancy rate of 70.9%, which is about normal for a hospital of its present capacity. Since this hospital was put into service in 1944 and the figures reported were for a part of its first two years of service, it is assumed that the utilization for that period was lower than will be expected in the future. The Administration is in the process of working out a plan to establish this hospital as the medical center for the entire County and to include public health facili- ties. Arrangements have been made with specialists from the District of Columbia to serve on the Staff. Doubling the capacity is an unusually ambitious pro- gram, but it is considered practical in this case in view of its location in a growing suburb of Washington. Plans for its establishment as a medical center for the area, the cooperative interest of the County Medical Society, and the availability of specialists who are already a part of the Visiting Staff, along with the rapid rate of utilization of the hospital from the date of its opening, weigh in favor of the proposed addition. This hospital reported that it had no policy opposed 62 Hospital Survey and Plan for Maryland—Part III to the admission of nonwhite patients, maintaining that when adequate facilities are available, beds will be reserved for them. In the light of this report, it must be required that as a condition of participation in this program, at least 14.6% of the beds be reserved for nonwhite patients. The Eugene Leland Memorial Hospital at Riverdale has a program for the establishment of an outpatient department, but no construction is contemplated which would increase the bed capacity. Being a pro- prietary hospital, it would not qualify for assistance under the Act. The Washington Sanitarium and Hospital, located at Takoma Park, has projected plans for an addition which would increase its bed capacity by 75 beds. While this hospital would qualify otherwise, its policy of not admitting nonwhite patients eliminates it from participation in the program. Should this policy be changed before the ratio of existing beds for the area is reached, consideration may be given an application for a grant. The Suburban Hospital at Bethesda did not report any projected building program. Its rate of occupancy, for the year reported, was 53.7%. Warren Hospital at Laurel was considered unac- ceptable owing to its frame construction. Because of the geographic position of this community and its population, a modern hospital is considered a necessity. A community group in Silver Spring has acquired a site and accumulated some funds for the construction of a hospital. This is a densely populated area on the edge of the District of Columbia. The head of the community group stated that plans call for the construc- tion of a hospital of 200 beds when the funds are avail- able. If funds in the amount needed for a 200-bed hospital cannot be raised within a reasonable period of time, it is planned to construct a hospital of as many beds as can be financed. This hospital will not be less than 100 beds. Plans for the hospital at Silver Spring should be integrated with the Suburban Hospital at Bethesda, if at all possible. Recommendations It is recommended that Montgomery and Prince George’s counties be classified as an intermediate area. It is recommended that 368 general hospital beds, necessary to bring the number in existence up to the ratio of 4.0 beds per 1,000 population, be allocated to this area. The reported construction programs are reasonable and their combined total falls within the number of additional beds allocated. As plans materialize, sup- ported by sufficient construction funds, these programs should be considered for approval. ST. MARY’S COUNTY RURAL AREA NUMBER 4 Population Change from previous period Change over 1920 1943: 17,877 3,251 increase 11.1% increase 1940: 14,626 563 decrease 9.2% decrease 1930: 15,189 [923 decrease 5.7% decrease 1920: 16,112 Nonwhite population Per cent nonwhite Per capita income 1945: 5,524 17.1 1945: $255.06 1940: 4,725 32.3 1940: $277.11 Classification of residents, 1940 Urban Rural nonfarm Rural farm 0.0% 44.0% 56.0% Land area: 367 square miles Population per square mile, 1943: 48.7 County seat: Leonardtown Population 1940: 668 1930: 697 Births in hospitals as per cent of total births, 1945 Total White Nonwhite 65.0 81.9 10.7 General hospital facilities Institution Location Beds St. Mary’s Hospital Leonardtown 45 General Hospitals 63 Geographic considerations St. Mary’s County is the southernmost county of the Western Shore of Maryland. It is surrounded by water, with the exception of its northern boundary which is common with Charles County, The Wicomico River, which has the same name as a river on the Eastern Shore, and the Potomac River bound St. Mary’s County on the west and south and separate it from Charles County on the west and Virginia on the south. The Chesapeake Bay makes up the eastern boundary and the Patuxent River is the northeastern boundary, separating it from Calvert County. The surface is 367 square miles of flat land. It is the sixteenth county in size. Population The population, which was 17,877 as of 1943, is evenly distributed over the County with one concentra- tion at Leonardtown. The population of Leonardtown was 668 as of 1940. The population of the County decreased during the period from 1920 to 1940 by 9.2%. The 20-year loss was more than offset between 1940 and 1943, during which time a net increase of 11.1% over 1920 took place. This increase was due to military installations in the County, which are considered permanent. The population density as of 1943 was 48.7 persons per square mile, placing the County sixteenth in the State. Nonwhite persons, numbering 5,524, made up 17.1% of the population in 1945. In 1940 the residents were classified as 44,0% rural nonfarm and 56.0% rural farm. The population in 1940 according to election districts was as follows: District 1, St. Inigoes. 1,880 District 2, Valley Lee 1,201 District 3, Leonardtown 2,704 District 4, Chaptico 1,645 District 5, Mechanicsville 1,778 District 6, Hillville 1,736 District 7, Milestown 2,110 District 8, Bay 1,287 District 9, St. George Island 285 Transportation Highways run the length of the County from the southeast point of the land to the northwest. Branch roads extend to numerous points on the shores. There is one spur railroad extending into the north of the County for a short distance. Bus service is maintained to Leonardtown, the County Seat, which is west of the approximate center of the County. Travel is convenient to Leonardtown, the location of St. Mary’s Hospital. Surrounded by water, land travel out of the area is limited to the northwesterly direction to Charles County. Leonardtown is 56 miles southeast of Washington and 86 miles south of Baltimore. In this respect it is quite isolated. Industry and commerce The Baltimore Association of Commerce does not list any manufacturers in this area. The residents work primarily at farming and fishing. Others are employed in the service industries. The Patuxent Naval Air Test Center located at Cedar Point, which lies east of Leonardtown at the junction of the Patuxent River with the Chesapeake Bay, is considered a permanent installation. A community has developed there. This is resulting in an improve- ment in the commercial life of St. Mary’s County. The Naval personnel are served by government-owned medi- cal facilities. The per capita income in 1940 was $277.11, making it the twenty-second county in the State in this respect. In 1945 it was $255.06, making it the twenty-third county in the State in this respect.1 Physicians There are 12 physicians practicing in St. Mary’s County. They are distributed as follows: Leonardtown 4 Pearson 1 Great Mills 1 Charlotte Hall 1 Morganza 1 Drayden 1 Avenue 1 Chaptico 1 Oakley 1 On the basis of its population in 1943, the County has one physician to every 1,490 persons. GENERAL HOSPITAL FACILITIES ST. MARY’S HOSPITAL St. Mary’s Hospital, located in Leonardtown, was opened in 1913. It is owned by a nonprofit corporation. The Board of Directors consists of eight members, seven of whom serve terms of three years. The Presi- dent of the Women’s Auxiliary is the eighth member and serves during her term of office, which is one year. Election of Board members is by vote at a community meeting of all persons having paid a minimum mem- bership fee of $2.00. A Ladies’ Auxiliary has a member- ship of approximately 50. This organization gives general financial assistance to the hospital. Area served: All patients served during the period covered by the report were residents of St. Mary’s County, Buildings: The original building, constructed in 1913 was built of inflammable material. In 1944, under the Lanham Act, a new building was erected as an at- tachment to the old building. Nonwhite patients are cared for in the latter building. Bed capacity: The capacity of the combined buildings is 45 beds. Ten of these beds are reserved for nonwhite patients. Utilization: The hospital is operating at an occupancy rate of 57.5%, The average length of stay per patient is 9 days. For the period reported, the patients were diagnosed as follows: Number of patients Per cent Medical 627 59.1 Surgical 192 18.1 Pediatric 242 22.8 Totals 1,061 100.0 1See Appendix L, footnote 5. 64 Hospital Survey and Plan for Maryland—Part III Medical staff: The Medical Staff is not organized. Privilege to practice in the hospital is granted to all reputable medical doctors in the area. Seven have patients in this hospital regularly. Personnel: The personnel is made up of 22 full-time employees, establishing a ratio of 0.5 employee per bed. Fourteen of these employees are furnished quarters in the hospital. Educational activities: There is no educational program in effect at this hospital. Conclusions St. Mary’s County, with a population of 17,877, qualifies as a rural area. The new wing at the St. Mary’s Hospital was con- structed in 1944, but the old wing, which was of frame construction, was not vacated. The two units are at- tached. Nonwhite patients are cared for in the old build- ing.This unit should be razed because it is unsatisfactory and a fire hazard. Non white obstetric patients are not admitted. While 65.0% of all births of St. Mary’s County in 1945 oc- curred in hospitals, 81.9% of births to white mothers were in hospitals, whereas only 10.7% of births to nonwhite mothers were in hospitals. St. Mary’s Hospital is operating at 57.5% of capacity, with periods when it is crowded. A change of policy which would allow the admission of nonwhite obstetric patients would require additional beds. On the basis of the standard for rural areas, 45 beds are needed. This is the present capacity of the St. Mary’s Hospital. Since some of the present bed capacity would be lost with the demolition of the old building, 25 new beds should be allocated from the pool on condition that nonwhite obstetric patients be granted admission. Recommendations It is recommended that St. Mary’s County be classi- fied as a rural area and that 25 beds be allocated as an addition to the existing hospital. SOMERSET COUNTY RURAL AREA NUMBER 7 Population Change from previous period Change over 1920 1943: 17,269 3,696 decrease 29.8% decrease 1940: 20,965 2,417 decrease 14.8% decrease 1930: 23,382 1,220 decrease 5.0% decrease 1920: 24,602 Nonwhite population Per cent nonwhite Per capita income 1945: 5,820 33.7 1945: $816.49 1940: 7,061 33.7 1940: $260.15 Classification of residents, 1940 Urban Rural nonfarm Rural farm 18.6% 51.1% 30.2% Land area: 332 square miles Population per square mile, 1943: 52.0 County seat: Princess Anne Population 1940: 942 1930: 975 Births in hospitals as per cent of total births, 1945 Total White Nonwhite 48.5 76.4 13.3 General hospital facilities Institution Location Beds Edward W. McCready Memorial Hospital Crisfield 38 GeogJ'aphic considerations Somerset County is the southernmost county of the Eastern Shore. It is bounded on the north by Wicomico County, from which it is separated partially by the Wicomico River. Extensions of the Chesapeake Bay make up its western boundary. The Pocomoke River, the southern boundary, separates the County from Virginia. Worcester County bounds it on the east. It has 332 square miles of surface, making it the eighteenth county in the State in size. Its surface is flat. Population The population of Somerset County was 17,269 in 1943. This was 7,333 less than its 1920 population. The decrease in population has been continuous during General Hospitals 65 the 23-year period. With a population density in 1943 of 52 persons per square mile, the County ranked fourteenth in the State. The largest community in the County is Crisfield, which had a population of 3,908 in 1940. The County Seat is Princess Anne, which had a population of 942 in 1940. There are no large unpopulated areas, the residents being distributed throughout the County. The largest concentration in 1940 was in the southern extremity around Crisfield. In 1940, the residents were classified as 18.6% urban, 51.1% rural nonfarm, and 30.2% rural farm. The distribution by election districts, as of 1940, was as follows: District 1, West Princess Anne 2,046 District 2, St. Peters 747 District 3, Brinkleys 2,030 District 4, Dublin 1,396 District 5, Mount Vernon 1,058 District 6, Fairmount 908 District 7, Crisfield 4,208 District 8, Lawsons 1,810 District 9, Tangier 510 District 10, Smith Island 680 District 11, Dames Quarter 347 District 12, Asbury 1,454 District 13, Westover 973 District 14, Deal Island 1,048 District 15, East Princess Anne 1,750 In 1945 there were 5,820 non white residents in the County, amounting to 33.7% of the total population. Transportation A main highway runs north and south the length of the County, connecting Crisfield and Princess Anne with Salisbury to the north. Lateral highways connect with Pocomoke City in the southern part of Wicomico County. Other secondary roads run to points on the Bay. The Pennsylvania Railroad has a line running into Crisfield paralleling the main highway to Salis- bury. A branch of this railroad extends to Pocomoke City. Bus services are maintained daily to Crisfield and Princess Anne. Industry and commerce The principal occupations are fishing, farming, and canning. There are four canning factories, two clothing manufacturers, and one seafood equipment manu- facturer in the County. The residents of the northern portion of the County use Salisbury as their trading center, while the resi- dents of the central section use Princess Anne, and of the southern section, Crisfield. The per capita income in 1940 was $260.15, making it the twenty-third county in the State in this respect. In 1945, it was $816.49, placing the County seven- teenth in the State. Physicians There are 17 physicians practicing in this County, and they are distributed as follows: Of these, 15 are in general practice, one in surgery, and one in anesthesia. Their average age is 56 years. On the basis of the County’s 1943 population, there was one physician for every 1,016 residents. GENERAL HOSPITAL FACILITIES EDWARD W. MCCREADY MEMORIAL HOSPITAL The Edward W. McCready Memorial Hospital, located in Crisfield, was founded in 1923. It is a non- profit association, operated by a Board of Directors with a membership of 14. The members of the Board serve for life. Vacancies are filled by vote of the re- maining members. A Junior Auxiliary Board and a Senior Auxiliary Board, each with a membership of 20, engage in fund-raising efforts for the benefit of the hospital. Area served: For the period reported, 79.0% of the patients treated were residents of Somerset County, 15.7% were from Worcester County, and 5.2% were principally from the eastern shore of Virginia and Tangiers Island. Building: The building is a two-story brick and stone structure. The interior is not fire-resistant. Bed capacity: The normal bed capacity of this hospital is 38 beds and eight bassinets. Eight beds are reserved for nonwhite patients. Utilization: The rate of occupancy for the period re- ported was 57.1%. The average length of stay per patient was 10.3 days. Of the County’s total births, 76.4% of births to white mothers and 13.3% of births to nonwhite mothers were in hospitals. For the year reported, the patients were diagnosed as follows: Number of patients Per cent Medical 162 21.3 Surgical 398 52.2 Obstetric 104 13.6 Pediatric 98 12.9 Totals 762 100.0 Medical staff: The Medical Staff is not organized. Privileges to work in the hospital are granted by action of the Board of Directors, after investigation of the applicant. Privileges to do surgery are granted by the Board of Directors upon presentation of satisfactory proof of experience and training. Personnel: The personnel consists of 19 employees, making a ratio of 0.5 employee per bed. Eight em- ployees are given quarters in the hospital. Educational activities: There is no educational pro- gram in effect. Building plans: The management of the hospital re- ported that building plans are under consideration for an addition which will include ten beds, along with laboratory and X-ray facilities. Conclusions Somerset County qualifies as a rural area. Its popula- tion has decreased over a period of 23 years. As of Marion Station 1 Crisfield 8 Ewell 2 Princess Anne 5 Deal Island 1 66 Hospital Survey and Plan for Maryland—Part III 1943 its population was 17,269. On the basis of the standard of 2.5 beds per 1,000 population for rural areas, this County would be entitled to 43 beds. Since the utilization of the existing hospital is largely by residents of the County and facilities are available at the Salisbury hospital just north of the northern boundary of this County, it is apparent that there is no urgent need for additional beds. This is especially true in the light of the fact that the rate of occupancy of the existing hospital is 57.1%. A project which will bring about an improvement of service to the exist- ing beds should be considered. Recommen dations It is recommended that Somerset County be classi- fied as a rural area. It is recommended also that five additional beds be allocated to this area in order to bring it up to the standard for rural areas, but that the project be placed low on the priority schedule. TALBOT AND CAROLINE COUNTIES INTERMEDIATE AREA NUMBER 6 Population Change from previous period Change over 1920 1943: 32,237 4,096 decrease 12.4% decrease 1940: 36,333 363 increase 1.7% decrease 1930: 35,970 988 decrease 2.7% decrease 1920; 36,958 Nonwhite population Per cent nonwhite 1945 1940 1945 1940 Caroline County 3,161 3,447 19.7 19.6 Talbot County 4,938 5,736 30.5 30.5 Combined 8,099 9,183 25.1 25.3 Per capita income 1945 1940 Caroline County $1,054.28 $473.42 Talbot County $1,380.67 $584.75 Classification of residents, 1940 Urban Rural nonfarm Rural farm Caroline County 0.0% 53.4% 46.6% Talbot County 24.1% 40.1% 35.8% Combined 12.5% 46.6% 41.0% Land area Population per square mile, 1943 Caroline County 320 square miles 50.1 Talbot County 279 square miles 58.0 Combined 599 square miles 53.8 Population County seat 1940 1930 Caroline County: Denton 1,572 1,604 Talbot County: Easton 4,528 4,092 Births in hospitals as per cent of total births, 1945 Total White Nonwhite Caroline County 54.4 70.2 6,2 Talbot County 62.4 90.0 6.3 Combined 58,4 79.5 6.8 General hospital facilities Institution Location Beds Easton Memorial Hospital Easton 87 Geographic considerations Talbot and Caroline counties lie between Delaware on the east and the Chesapeake Bay on the west, with Queen Anne’s County bounding the area on the north and Dorchester County on the south. No geographic barriers have been used for the northern boundaries. Talbot County, which is the western portion of the area, is separated from Dorchester County by the Choptank River, which is bridged at Cambridge. The River continues north and makes up about one half of the southern boundary between Caroline and Talbot counties. The general contour of the surface of the two counties is flat. Caroline County has a land area of 320 square miles and ranks nineteenth in the State in this respect. With a land area of 279 square miles, Talbot County ranks twenty-first. Population The population of Caroline County was 16,047 in 1943. Talbot County had a population of 16,190 in the same year. Caroline County had 50.1 persons per square mile and Talbot County had 58.0 persons per General Hospitals 67 square mile in 1943, their respective ranks being fifteenth and thirteenth in the State. Both counties are thinly populated throughout. The population of Caroline County according to election districts, as of 1940, was as follows: District 1, Henderson 1,568 District 2, Greensboro 2,445 District 3, Denton 3,255 District 4, Preston 2,241 District 5, Federalsburg 3,348 District 6, Hillsboro 1,515 District 7, Ridgely 1,786 District 8, American Corner 1,391 The population of Talbot County according to elec- tion districts, as of 1940, was as follows: District 1, Easton 7,733 District 2, St. Michaels 3,370 District 3, Trappe 3,034 District 4, Chapel 2,614 District 5, Bay Hundred 2,033 Easton is the largest community in the area with a population of 4,528 in 1940. Smaller concentrations of population occur at Federalsburg and Denton in Caroline County. The population for this area was almost static for the 20-year period between 1920 and 1940. A significant loss of population was experi- enced between 1940 and 1943, probably due to the fact that no war industries were located in the area. In 1940, the residents of Caroline County were 53.4% rural nonfarm and 46.6% rural farm. At the same time, the residents of Talbot County were classified as 24.1% urban, 40.1% rural nonfarm, and 35.8% rural farm. Nonwhite persons, numbering 8,099, made up 25.1% of the population of the two counties in 1945. The hospital at Easton is the only facility in this area. Within a radius of miles from Easton the entire population of Talbot County and a portion of Caroline County are located. Outside the radius there are approximately 13,850 residents of Caroline County, on the basis of its population. Transportation Highways from Caroline County run into Easton or are connected with roads which do. The highways of Talbot County radiate from Easton, which is located at the approximate center of the County. The Pennsyl- vania Railroad has lines serving the two counties. Most of the traffic from the ferries at Matapeake and Love Point to the southern part of the Eastern Shore moves through Easton. Industry and commerce There are no heavy industries in this area. A high percentage of the residents are engaged in farming. The Baltimore Association of Commerce listed a milk company, several manufacturers of buttons, and several canning companies as offering employment. The income per capita of the residents of Caroline County for 1940 was $473.42, making it the fourteenth county in the State in this respect. In 1945, the income per capita rose to $1,054.28, making it the tenth county in the State in this respect. The per capita income of the residents of Talbot County was $584.75 in 1940, ranking it fifth in the State. Per capita income in- creased to $1,380.67 in 1945, raising it to second county in the State in this respect. Physicians There are 13 physicians practicing in Caroline Coun- ty. They are distributed as follows: Federalsburg 2 Denton 5 Preston 1 Goldsboro 1 Greensboro 1 Ridgely 3 Their average age is 43 years. On the basis of the County’s population in 1943, there was one physician for every 1,234 persons. There are 21 physicians residing in Talbot County. In addition, five physicians whose residence is outside the County practice at the Easton Memorial Hospital. The physicians are distributed as follows: Easton 11 Queen Anne 1 St. Michaels 5 Royal Oak 3 Trappe 2 Tilghman 1 On the basis of the County’s 1943 population, there was one resident physician for every 771 persons. Combining the populations and physicians of the two counties, a ratio of one physician to every 948 residents is established. GENERAL HOSPITAL FACILITIES EASTON MEMORIAL HOSPITAL The Easton Memorial Hospital was established in 1916. It is owned and operated by a nonprofit associa- tion. The Board of Trustees consists of 14 members whose terms are for one year. The Board is self- perpetuating. It has full approval of the American College of Surgeons. Its nursing school has State-ap- proval. Area served: An analysis of patients served shows the following: 46.5% reside in Talbot County, 21.3% in Caroline County, 13.5% in Queen Anne’s County, and 4.7% in Dorchester County. Other areas account for the remaining 14%. Buildings: The buildings have been in service for 30 years and are not considered fire-resistant. Bed capacity: The normal capacity of this hospital is 87 beds and 16 bassinets. At the time of the survey, there were 108 beds and 25 bassinets in service. Nor- mally 20 beds are reserved for nonwhite patients, but at the time of the survey 25 beds were in use. Utilization: The rate of occupancy based on normal bed capacity was 90.4%; based on the bed comple- ment it was 72.8%. The average length of stay per patient was 9.8 days. A breakdown of patients by diag- nosis revealed the following: 68 Hospital Survey and Plan for Maryland—Part III Number of patients Per cent Medicine 790 23.7 Surgery 644 19.3 Obstetrics 420 12.6 Pediatrics 552 16.6 Orthopedics 218 6.5 Gynecology 244 7.3 Urology 242 7.3 Eye, ear, nose, and throat 224 6.7 Totals 3,334 100.0 Medical staff: The Medical Staff is organized, having elected officers. Appointment to the Medical Staff is made by the Board of Directors on the recommendation of the Staff. Privilege to do major surgery is granted on the basis of the candidate’s having had residency in surgery and a minimum of one year of experience. Personnel: The personnel consists of 121 full-time employees and five part-time employees. On the basis of normal capacity, this establishes a ratio of 1.4 em- ployees per bed. In addition, there are five volunteer workers. Educational activities: A nursing school is conducted. The director of the training school is also the director of nursing services. At the time of the survey, 23 stu- dents were in training. Affiliations are established at the Johns Hopkins Hospital for training in pediatrics and at the Delaware State Hospital for training in psychia- try. Building plans: This hospital reported a projected building program under which the addition of 100 beds is contemplated. Conclusions The area of Talbot and Caroline counties has suffi- cient population and income to support its own hospital facilities. The Easton Memorial Hospital, which now uses 108 beds, although its normal capacity is 87 beds, has under consideration plans to add 100 beds. The area qualifies as an intermediate area on the basis of the projected hospital construction and the popula- tion of the combined counties. The large segment of residents of Caroline County that lives more than miles from the nearest hospital is in need of a facility. The Caroline County Medical Society has committed itself to the support of a com- munity health center to be located at Denton. The projected plan includes space for the public health facility and a small unit of approximately 15 beds. Recommendations It is recommended that Talbot and Caroline counties be classified together as an intermediate area. It should have 129 beds, in order to establish a ratio of 4.0 beds per 1,000 population. However, on account of its strategic location with relation to not only the immediate area but also the entire central portion of the Eastern Shore, it is recommended that 50 additional beds be allocated to this area from the pool, bringing the total allocation to 179 beds. Considering the normal bed capacity at the Easton Memorial Hospital against the allotment of 179 beds, there exists an unmet need of 92 beds. The Easton Memorial Hospital has reserved 23% of its beds for nonwhite patients. Since the nonwhite population made up 25.1% of the total population of the area, as of 1945, it is required that this propor- tion be maintained in the apportionment of new beds. It is recommended that a public health center be constructed at Denton, but that no hospital unit be included. This is in line with the opinion that a small facility is inefficient to operate, cannot easily secure qualified personnel, and frequently has difficulty in screening patients for the purpose of limiting admis- sions according to its limited facilities. Ambulance service from Caroline County to the hospital at Easton will bring the residents within a safe time limit of adequate facilities. WASHINGTON COUNTY INTERMEDIATE AREA NUMBER 2 Population Change from previous period Change over 1920 1943: 69,890 1,052 increase 17.1% increase 1940: 68,838 2,956 increase 15.3% increase 1930: 65,882 6,188 increase 10,4% increase 1920: 59,694 Nonwhite population Per cent nonwhite Per capita income 1945: 1,817 2.6 1945: $1,160.51 1940: 1,790 2.6 1940: $ 578.71 Classification of residents, 1940 Urban Rural nonfarm Rural farm 47.2% 34.6% 18.2% Land area: 462 square miles Population per square mile, 1943: 151.3 County seat: Hagerstown Population 1940: 32,491 1930: 30,861 Births in hospitals as per cent of total births, 1945 Total White Nonwhite 71.6 71.7 62.5 General hospital facilities Institution Location Beds Washington County Hospital Hagerstown 142 Fleming Eye, Ear, Nose and Throat Hospital (special) Williamsport 26 General Hospitals 69 Geographic considerations Washington County lies between Pennsylvania on the north and West Virginia on the south, with Alle- gany County on the west and Frederick County on the east. The eastern and western boundaries have been established along mountain ridges which, while they are crossed by highways, are natural barriers to con- venient travel. Its land area is 462 square miles, which makes it the eighth county in the State in size. Some portions of the County are hilly. The balance is suitable for farming. Large areas are used for agriculture and dairy farming. Population The population was 69,890 in 1943, which represented an increase of 17.1% over the County’s population in 1920. With a density of 151.3 persons per square mile, the County ranks sixth in the State. In 1940, the population of Hagerstown was 32,491, or 47.2% of the total for the County. It is the County Seat and is located at the approximate center of the County. In addition to Hagerstown, there were eight communities in the County having populations ranging from 404 to 1,772 in 1940. The largest of these was Williamsport, located southwest of Hagerstown on the Potomac River. The entire County is populated, there being no large areas without inhabitants. As the distance from Hagerstown increases, however, the density of popula- tion decreases. Map 2 shows that 60,000 people re- side within a radius of Hagerstown. Ap- proximately 5,000 residents in the western extremity and 4,000 in the southern portion live beyond the 12 Ve- nule radius. Nonwhite persons, numbering 1,817, made up 2.6% of the population in 1945. The population of Washington County according to election districts, as of 1940, was as follows: District 1, Sharpsburg 1,813 District 2, Williamsport 3,127 District 3, Hagerstown 6,125 District 4, Clear Spring 1,735 District 5, Hancock 2,988 District 6, Boonsboro 2,339 District 7, Cavetown 2,044 District 8, Rohrersville 1,366 District 9, Leitersburg 1,288 District 10, Funkstown 1,889 District 11, Sandy Hook 1,428 District 12, Tilghmanton 1,618 District 13, Conococheague 1,729 District 14, Ringgold 1,662 District 15, Indian Spring 1,566 District 16, Beaver Creek 1,085 District 17, Hagerstown 4,932 District 18, Chewsville 1,230 District 19, Keedysville 945 District 20, Downsville 856 District 21, Hagerstown 5,702 District 22, Hagerstown 6,102 District 23, Wilsons 1,074 District 24, Hagerstown 4,687 District 25, Hagerstown 7,739 District 26, Halfway 1,769 In 1940, the residents were classified as 47.2% urban, 34.6% rural nonfarm, and 18.2% rural farm. Transportation Highways and railroads converge in Hagerstown from all parts of the County. The Baltimore and Ohio Rail- road, the Western Maryland Railroad, the Pennsyl- vania Railroad, and the Norfolk-Western Railroad furnish rail service to Hagerstown. Local and long- distance bus lines furnish transportation to Hagerstown from all parts of the County and State. Industry and commerce There are numerous industries in Hagerstown. Manufactured products range from aircraft and pipe organs to clothing, machinery, and mineral products. The only industries located outside of Hagerstown are two in Williamsport. Other communities are small trading centers for the farm population. The per capita income for Washington County was $578.71 in 1940 and $1,160.51 in 1945. In 1940 it ranked seventh among the counties of the State with respect to per capita income. In 1945 it was eighth in the State. Physicians The residents of Washington County have available the services of 65 physicians. They are distributed as follows: Hagerstown 52 Smithsburg 1 Funkstown 1 Sharpsburg 2 Clear Spring 2 Boonsboro 2 Hancock 3 Williamsport 2 Their average age is 50 years. On the basis of 1943 population, the County had one resident physician for every 1,075 persons. The Washington County Hospital reported a staff membership of 66. Three staff members live in Pennsyl- vania and one in Baltimore. The remaining 62 are from Washington County, which would indicate that all but three of the physicians of the County are affiliated with the hospital. Twelve physicians hold Specialty Board certification. Classification of staff physicians by type of practice is as follows: Medicine 41 Pediatrics 4 Pathology 1 Dentistry 1 Genito-urinary 1 Anesthesia 1 Orthopedics 1 Gynecology and obstetrics 1 Surgery 6 Roentgenology 2 Eye, ear, nose, and throat 7 From the standpoint of medical services, Washington County is adequately supplied. GENERAL HOSPITAL FACILITIES WASHINGTON COUNTY HOSPITAL The Washington County Hospital, located in Hagers- town, is owned and operated by the Washington Coun- ty Hospital Association, a nonprofit association. It was organized in 1905. 70 Hospital Survey and Plan for Maryland—Part III It has specialized departments for obstetric, pedia- tric, orthopedic, eye, ear, nose, and throat, and skin and cancer services. The American College of Surgeons has given this hospital full approval. Its nursing school has State- approval. The Board of Trustees is made up of nine members whose terms are unlimited. When vacancies occur, due to resignation or death, the remaining members elect a successor. A group of 120 women, known as the Ladies’ Aux- iliary, supplies linens and assists with the school of nursing. Area served: During the year reported, 88.0% of the patients discharged were residents of Washington County, 8.7% were from Pennsylvania, and 2.0% from West Virginia. The remaining patients were from other counties and states. Buildings: The buildings are of brick, stone, and steel construction. The most recent construction was com- pleted in 1935. Bed capacity: The normal capacity is 142 beds, but additional beds were installed as the demand occurred, until at present there are 185 beds in use. Ten beds are reserved for nonwhite patients. Forty-eight bassi- nets are in use. Utilization: The rate of occupancy, based on the normal bed capacity, is 123.6%. For the period reported, the average length of stay per patient is 10.35 days. Patients discharged were in the following classifica- tions: Number of patients Per cent Medical 1,145 21.3 Surgical 2,292 42.6 Obstetric 990 18.4 Pediatric 576 10.7 Other 374 7.0 Totals 5,377 100.0 Medical staff: The Medical Staff is organized. Officers are elected annually. Standing committees function in the divisions of Medical Records, Internes, Resi- dents, Laboratories, Surgery, and Obstetrics. There is also an Executive Committee which acts on Staff problems and a Joint Conference Committee which serves as liaison between the Staff and the Administra- tion. Appointment to membership on the Staff is made annually by the Board of Trustees on rec- ommendation of the Staff. Privileges to do surgery or to work in the specialties are granted on the basis of Specialty Board certifica- tion, Fellowship in the American College of Surgeons, or three years of postgraduate work in the field. Personnel: Two hundred and fifty-five full-time em- ployees and two part-time employees make up the personnel. This is a ratio of 1.8 employees per bed, on the basis of the normal bed capacity. Educational activities: At the time of the field survey, efforts were underway to obtain approval for training internes and residents. It was reported later that such approval had been granted as of December 8,1946. The nursing school has full State-approval. Fifty- two students are now in training. Affiliation is main- tained with Sheppard and Enoch Pratt Hospital in Baltimore for training in psychiatry. While there is no formal course offered, students have been accepted in the laboratories. Some of these students were certified later as registered laboratory technicians. Building plans: The administrator reported the fol- lowing building program considered as desirable and practical: 1. One-story addition to third floor Administration Building, south extension, for a modern pediatric unit with solarium above serving the fourth floor. 2. One-story addition to third floor Administration Building, north extension, to provide expansion of laboratory and X-ray facilities, solarium above serving the fourth floor. 3. Nurses’ residence and education building, 100 to 125 beds. 4. Power house and equipment with capacity for long-range plan. 5. An addition with a capacity of 100 hospital beds. Items 1 and 2 would release areas which could pro- vide about 25 additional beds, making a total increase of 125 beds. Additional space would be provided for the operating room suite by relocating delivery and labor rooms in the 100-bed addition. This would provide a better emergency room, physical therapy facilities, and administrative offices. The Hospital rents to the County Health Depart- ment a building adjoining the Administration Building. This building contains only about one half of the space needed. Sufficient land owned by the Hospital is available for all of the present and long-range planning. When practicable, the Hospital will acquire residences in the area to meet the needs of employees. Lack of these facilities has hampered the recruitment of employees. FLEMING EYE, EAR, NOSE AND THROAT HOSPITAL This hospital had a capacity of 26 beds and was privately owned and operated. It was established in 1943. Work was limited to the field of eye, ear, nose, and throat. Since completion of the field survey, this hospital has been closed. Considerable work had been done originally in converting it from a dwelling to a hospital, and it is probable that it will be reopened as a hospital. Because of this potentiality, some details are included herein. Area served: Sixty per cent of the patients were resi- dents of the local area. Approximately 5% were resi- dents of Maryland outside the local area. Thirty-five per cent were residents of West Virginia and Pennsyl- vania. Some physicians from Pennsylvania and West Virginia, who referred cases to this hospital, assisted Dr. Fleming with the work. For the period reported, General Hospitals 71 the occupancy rate was 35.8% and the average length of stay per patient was 4 days. Building: While the construction is of inflammable materials, and the original building quite old, the hospital has been renovated and is modern in appear- ance. Conclusions Hagerstown is the trading and medical center of the County. It is easy of access from all points. The County meets all qualifications as an inter- mediate area. The standard for intermediate areas of 4.0 beds per 1,000 population justifies a total of 280 general hospital beds in the County. The differential between the normal bed capacity and the standard requirements is 112 beds. With 26 beds at the Fleming Eye, Ear, Nose and Throat Hospital out of service and 43 extra beds already in use in the Washington County Hospital, this area must be given a high priority. Should the Fleming Hospital be converted to other uses, the allotment to this area will be increased by 26 beds if sufficient local matching funds are made avail- able. Because of its diversity of industries balanced with a large population of farmers, the economy of the area is believed stable. Seventy-one and six-tenths per cent of all births in the County were in hospitals, indicating a general acceptance of hospitals by the public. Seventy-one and seven-tenths per cent of births to white mothers were in hospitals and 62.5% of births to nonwhite mothers were in hospitals. Recommendations It is recommended that Washington County be classi- fied as an intermediate area. It is recommended also that 112 beds be installed as an addition to the Washington Hospital. Since nonwhites make up 2.6% of the population of this County, it would be required that three of the new beds be reserved for the use of nonwhite patients. Inasmuch as ten beds already are reserved for non- whites the new beds need not be specifically assigned. WICOMICO COUNTY INTERMEDIATE AREA NUMBER 8 Population Change from previous period Change over 1920 1943: 32,960 1,570 decrease 17.0% increase 1940; 34,530 3,301 increase 22.6% increase 1930: 31,229 3,064 increase 10.9% increase 1920: 28,165 Nonwhite population Per cent nonwhite Per capita income 1945; 7,152 21.7 1945: $1,316.20 1940: 7,495 21.7 1940: $ 617.09 Classification of residents, 1940 Urban Rural nonfarm Rural farm 38.6% 32.1% 29.4% Land area: 380 square miles Population per square mile, 1943: 86.7 County seat: Salisbury Population 1940: 13,313 1930: 10,997 Births in hospitals as per cent of total births, 1945 Total White Nonwhite 69.8 82.4 33.9 General hospital facilities Institution Location Beds Peninsula General Hospital Salisbury 177 Geographic considerations Wicomico County lies around the southwest corner of the State of Delaware. Its entire northern boundary is common with Delaware. A small projection of the County runs north between the western boundary of Delaware and the eastern boundary of Dorchester County. Almost the entire western boundary of the County is made up of the Nanticoke River, which separates it from Dorchester County. Wicomico Coun- ty lies north of Somerset County and is partially separated from it by the Wicomico River. The County’s surface is generally flat. With a land area of 380 square 72 Hospital Survey and Plan for Maryland—Part III miles, it ranks fourteenth among the counties of the State. Population The population of this County in 1943 was 32,960. An increase of 22.6% was experienced between 1920 and 1940; however, a reversal of trend was experienced between 1940 and 1943, when a loss of 4.5% was re- corded. The population is concentrated largely in and around Salisbury, which is the County Seat. It serves as the principal trading center for this and the surrounding counties, and for a part of the State of Delaware. The entire County is populated, there being no large vacant areas. The population density in 1943 was 86.7 persons per square mile, making it the ninth county in the State in this respect. Nonwhite persons, numbering 7,152, made up 21.7% of the population in 1945. The population distribution in the County by election districts was reported in 1940 as follows: District 1, Barren Creek 1,595 District 2, Quantico 931 District 3, Tyaskin 1,263 District 4, Pittsburg 1,478 District 5, Parsons 6,861 District 6, Dennis 737 District 7, Trappe 940 District 8, Nutters 1,094 District 9, Salisbury 5,106 District 10, Sharptown 1,173 District 11, Delmar 2,009 District 12, Nanticoke 1,485 District 13, Camden 5,585 District 14, Willards 1,234 District 15, Hebron 1,385 District 16, Fruitland 1,654 In the same year the residents were classified as 38.6% urban, 32.1% rural nonfarm, and 29.4% rural farm. Transportation Salisbury is the hub of the highways and railroads of this part of the State. From Salisbury they radiate to the principal communities in Worcester, Somerset, and Dorchester counties and run north to Philadelphia. Bus service is maintained to most of the surrounding com- munities. Industry and commerce Eighteen manufacturing plants are located in this County, principally in Salisbury. Six of these manu- facture shirts and four operate canneries. Salisbury is the center of the large poultry-raising and vegetable-growing businesses. In 1940 its popula- tion was recorded as 13,313. Physicians There are 36 physicians residing in Wicomico Coun- ty. They are distributed as follows: Their types of practice are as follows: General medicine ....18 Eye, ear, nose, Obstetrics 4 and throat 4 Pediatrics 3 Surgery 6 Tuberculosis 1 Their average age is 43 years. On the basis of the County’s population in 1943, there was one resident physician for every 916 patients. In addition, one physician from Delmar, Delaware, practices in the County. GENERAL HOSPITAL FACILITIES PENINSULA GENERAL HOSPITAL The Peninsula General Hospital, located in Salis- bury, was founded in 1903. It is operated by a non- profit association. Its Board of Directors has a member- ship of 18, whose term of office is one year. Election to membership on the Board is by means of a public meeting held annually. The Junior and Senior Auxiliary Boards, with a total membership in the neighborhood of 90, are engaged in enterprises for the raising of funds which are used for the purchase of new equipment. Support is also given this hospital by the Kiwanis, Rotary, Lions, and Elks Clubs. From time to time, other clubs and church organizations throughout the County make contributions. This hospital is fully approved by the American College of Surgeons. It conducts a State-approved school of nursing. Area served: On the basis of the period reported, 55.3% of the patients treated were from Salisbury and Wicomico County; 20.0% from Worcester County; 8.7% from Somerset County; and the remainder from other states, including Delaware and Virginia. Building: The building is constructed of brick and stone and is classified as fire-resistant. Additions to the building were made in 1920 and 1938. Bed capacity: The normal capacity is 177 beds. Thirty beds are reserved for nonwhite patients. Utilization: The rate of occupancy was 74.2%, and the average length of stay per patient was 8.1 days. Of the births occurring in this County, 69.8% were in hospitals; 82.4% of births to white mothers and 33.9% of births to non white mothers occurred in hospitals. For the year reported, the patients were diagnosed as follows: Number of patients Per cent Medical 903 15.3 Surgical 1,819 30.8 Obstetric 1,929 32.6 Pediatric 856 14.5 Other 405 6.8 Totals 5,912 100.0 Medical staff: The Medical Staff is organized and has elected officers. Membership to the Staff is granted by the Board of Directors on recommendation of the Staff. Privilege to do major surgery is granted by the Board on the basis of Specialty Board certification, or a minimum of two years of postgraduate training at an approved institution. Salisbury 29 Fruitland 2 Delmar 1 Sharptown 1 Mardela 1 Hebron 1 Willards 1 General Hospitals 73 Personnel: The personnel is made up of 172 full-time and three part-time employees, establishing a ratio of 0.98 employee per bed. Educational activities: At the time of the survey, two internes and two residents were employed on a one- year rotating basis. As of the date of the survey, 38 students were in training. The school affiliates with Johns Hopkins Hospital for training in pediatrics and with Sheppard and Enoch Pratt Hospital for training in psychiatry. Building plans: This hospital reports a projected build- ing program which would include the addition of 100 new beds, a new boiler house and a nurses’ home. The estimated cost at the time of reporting was $800,000. Conclusions On the basis of a population of 32,960 and with a hospital having more than 100 beds, this area fully qualifies as an intermediate area. The standard of 4.0 beds per 1,000 population for intermediate areas would qualify this area for 132 beds. It already has 177 beds. However, the official population of this County does not reflect the true picture of the population served by the Peninsula General Hospital. Salisbury is the marketing center for Wicomico and the surrounding counties and for the southern portion of Delaware. Travel and freight hauling through this area contributes to the need for hospital facilities. In spite of the fact that the number of existing beds is already in excess of not only the standard for an inter- mediate area, but also of the State standard of 4.5 beds per 1,000 population, the rate of occupancy in Peninsula General Hospital is high. This is a reflection of the number of people who depend on this hospital for service. The short length of stay reported is in- dicative of the rapid turnover of patients resulting from pressure to get other patients admitted. There- fore, it was concluded that the need for beds in this area is greater than normal and that an allocation of beds must be made from the pool. Recommen dation s It is recommended that this area be classified as an intermediate area and that 70 beds be allocated from the pool, bringing the bed capacity to 247. In order to maintain an equitable assignment of beds on the basis of the County’s nonwhite population in 1945, it will be necessary that 15 of the new beds be reserved for nonwhite patients. WORCESTER COUNTY RURAL AREA NUMBER 6 Population Change from previous period Change over 1920 1943: 19,201 2,044 decrease 13.9% decrease 1940: 21,245 379 decrease 4.8% decrease 1930; 21,624 685 decrease 3.1% decrease 1920: 22,309 Nonwhite population Per cent nonwhile Per capita income 1945: 6,029 31.4 1945: $1,347.48 1940: 6,670 31.4 1940: $ 598.45 Classification of residents, 1940 Urban Rural nonfarm Rural farm 12.9% 48.3% 38.8% Land area: 483 square miles Population per square mile, 1943: 39.8 County seat: Snow Hill Population 1940: 1,926 1930: 1,604 Births of hospitals as per cent of total births, 1945 Total White Nonwhite 39.1 61.9 9.1 Geographic considerations Worcester County is located in the southeastern corner of the State. In the east it fronts on the Atlantic Ocean. Its northern extremity is bounded by the State of Delaware on the north and Wicomico County on the west. The western extension is bounded on the north by Wicomico County and on the west by Somerset County. On the south the boundary is common to Virginia. The surface is fat and lends itself to farming. It is the seventh county in size in the State, having 483 square miles of land area. 74 Hospital Survey and Plan for Maryland—Part III Population In 1943, Worcester County had a population of 19,201. This was the lowest point since 1920 when the population was recorded as 22,309. Since 1920 there has been a small decrease recorded in each decennial census, the total loss between 1920 and 1943 being 3,108, or 13.9%. The nonwhite population, numbering 6,029, con- stituted 31.4% of the County’s population, in 1945. In 1943 the population density was 39.8 persons per square mile. In this respect, this County ranked twenty- first in the State. As of 1940, the residents were classified as 12.9% urban, 48.3% rural nonfarm, and 38.8% rural farm. The population was distributed in 1940, according to election districts, as follows: District 1, Costens 4,311 District 2, Snow Hill 3,674 District 3, East Berlin 2,888 District 4, Newark 1,056 District 5, St. Martin 1,451 District 6, Colbourne 583 District 7, Atkinsons 704 District 8, Stockton 2,209 District 9, West Berlin 2,332 District 10, Ocean City 2,037 Transportation A main highway, Route 113, crosses the County from the southwest to the northeast through Pocomoke City in the south, Snow Hill in the center, and Berlin in the north. Other highways, running from points on the coast and from Virginia in the south, cross the main highway at Pocomoke City, Snow Hill, and Berlin and extend to Salisbury in Wicomico County. Bus and rail lines supply service between the com- munities in the County and to Salisbury. Industry and commerce Farming is the principal occupation, which includes poultry raising, fruit growing, and truck farming. Some residents find employment in canning factories. The summer resort business centered around Ocean City is a source of income and employment. During the harvest season transient labor is im- ported, supplying a source of business for the local merchants, but at the same time presenting social problems such as need for medical care and hospital facilities. With a per capita income of $598.45 in 1940, the County ranked fourth in the State. In 1945 the per capita income was $1,347.48, making it the third county in the State in this respect. Physicians Fourteen physicians are located in the County. Their ages range from 28 to 68, with seven being 40 years of age or less. They are distributed as follows: Ocean City 3 Berlin 4 Snow Hill 3 Pocomoke City 3 Stockton 1 One physician specializes in eye, ear, nose, and throat, and another in chests. All others are general practi- tioners. The ratio of physicians to population is one to every 1,372 persons. GENERAL HOSPITAL FACILITIES At present there are no hospitals located in Worcester County. The Peninsula General Hospital at Salisbury reported that 1,186, or 20%, of its patients are resi- dents of Worcester County. Related to the total population of the County, this shows that one out of every 16 residents was a patient in the Salisbury hospital during the year. This ratio indicates a rather general education to the use of hospital facilities. The relative distances between the principal com- munities in Worcester County and their distances from near-by hospitals are as follows: Salisbury to Berlin 24 miles Salisbury to Snow Hill 18 miles Salisbury to Pocomoke City 26 miles Pocomoke City to Snow Hill 13 miles Snow Hill to Berlin 16 miles Pocomoke City to Berlin 29 miles Ocean City to Berlin 8 miles Pocomoke City to Crisfield 26 miles None of the residents of this County live within a 12p2-mile radius of the hospitals at Salisbury or Cris- field. Conclusions With a population of nearly 20,000, Worcester County qualifies as a rural area. Ranking third in the State in per capita income, Worcester County should be able to support a hospital. This support will de- pend on the quality of service maintained as compared with service available at the hospital in Salisbury. The distances to hospitals in Crisfield and Salisbury are not too great to travel for medical care since there are no difficult natural barriers, and highways are usually passable throughout the year. The hospital at Salisbury is very busy, with an occupancy rate of 74.2% and an average length of stay per patient of 8.1 days, serving its local area and parts of the surrounding counties and part of the State of Delaware. It has projected an expansion program, which contemplates the addition of 100 beds which will relieve the present problems. A hospital located at either Snow Hill or Berlin would furnish some relief to the crowding at the Salisbury hospital. The location of a hospital in Snow Hill would have the advantage of being almost midway between Berlin and Pocomoke City. Located at Berlin it would serve Ocean City and Snow Hill, but it would be 29 miles from Pocomoke City. Snow Hill, therefore, would be the logical location for a hospital for Worcester County if funds and physicians and other personnel are available and if local support is given. General Hospitals 75 A committee of local citizens has organized for the purpose of building a hospital in Berlin. It is reported that some funds already have been raised for this purpose. Some difficulty might be experienced in organizing a staff. It should be organized around the physicians now practicing in Snow Hill, Berlin, and Ocean City, with privileges extended to those in Pocomoke City. Some dependence would have to be placed on con- sultants coming from Salisbury. Recommendation s It is recommended that Worcester County be classi- fied as a rural area. On the basis of a rural area ratio of 2.5 beds per 1,000 population, it should have 48 beds. On account of the influx of summer vacationists and transient farm labor, it is recommended that 12 beds be allocated from the pool. It is recommended that the hospital be located at Snow Hill. If sufficient funds cannot be raised to pay two thirds of the cost of the hospital at Snow Hill, there is no serious objection to locating it at Berlin. The whole proposition of whether or not a hospital should be constructed in this County with the ac- companying problems of staff and personnel should be weighed against the advantages of supporting the pro- jected expansion at the Salisbury hospital. Section 3. Regional Integration of Facilities Hospitals generally have two spheres of service. The first sphere is the local community comprised of the town or city in which it is located and the in- habitants of near-by residential areas. The extent of this immediate hospital service area is affected prin- cipally by the nearness of other communities which maintain hospitals with comparable facilities and medical staffs. The second sphere extends beyond the immediate service area to include other communities whose hospital facilities and medical staff are limited to a narrower field. This broader field of service for the purposes of this survey was termed the “region” of service. The nucleus of a region is the principal hospital in the area which meets the standards for a hospital in a dis- trict or base area. The designation as a base or district hospital may be given one or more hospitals fulfilling the requirements in a community. A district hospital is one having more than 100 beds, departmental physical and staff organization, and effective standards sufficient to assure a high quality of service. A base hospital is defined as one having a teaching program approved by the American Medical Associa- tion’s Council on Medical Education and Hospitals, functioning in conjunction with a medical school, or one having a minimum of 200 general hospital beds, and offering at least two or more approved residencies. The object of delineating regions was to establish a plan of integration of hospital facilities so that com- munities with limited service would know where to look for services not available locally. After a study of the existing facilities along with geographical factors and trading and travel habits, the service areas were grouped into what were considered logical regions. Each region was given the name of the community in which the base or district hospital facilities for the region were located. Map 4 shows the regions as established. Cumberland Region The Cumberland Region includes Garrett and Alle- gany counties. At present, there are no hospitals located in Garrett County, but one is planned to be established in Oakland. This hospital cannot be expected to care for more than medical, obstetric, and uncomplicated surgical cases. Services for X-ray interpretations and pathological diagnoses will have to be arranged either on a part-time basis or by reference. Such services are available at the Memorial and the Allegany Hospitals in Cumberland. The Reeves Clinic at Westernport limits its work to the field of eye, ear, nose, and throat. Residents from this area who require other services will travel to Oakland or to Cumberland, depending on the serious- ness of their condition. Miners Hospital at Frostburg has limited facilities, and the practice of going into Cumberland for major work already has been established. Residents of the southern portions of Somerset and Bedford counties in Pennsylvania in the past have traveled to Cumberland for services outside the scope of their local hospitals. Records of the Cumberland hospitals show that many residents of northern West Virginia use the Cumberland hospitals. Residents of the eastern section of Washington County use their local hospital at Hagerstown and travel to Baltimore for service not available locally, so this area was not placed in the Cumberland Region. Allegany Hospital and Memorial Hospital, each having more than 100 beds, qualify as district hospitals. It was concluded, therefore, that the Cumberland Region, consisting of Garrett and Allegany counties, logically and practically would constitute a region. It is expected, however, that there will be occasions when it will be necessary to refer patients to the base hospitals 76 Hospital Survey and Plan for Maryland—Part III MARYLAND STATE PLANNING COMMISSION 1947 REGIONAL INTEGRATION OF SERVICES LEGEND - REGIONAL BOUNDARY • AREA BOUNDARY BASE HOSPITAL DISTRICT HOSPITAL COMMUNITY HOSPITAL CENTER PROPOSED FACILITIES MAP 4 General Hospitals 77 in Baltimore for facilities and service of specialists not available in Cumberland. Baltimore City Region The Baltimore City Region, with Baltimore City as the regional base, was designed to include those areas which are totally dependent upon the hospital facilities of Baltimore City for service and those which look largely to Baltimore City for services which are not available locally. Included in the region, therefore, are the areas of Washington County, Frederick County, Cecil County, Calvert County, St. Mary’s County, and the counties making up the Baltimore Base Area. Each of the counties included in the region, but out- side the Baltimore Base Area, has a hospital facility of limited service, making it necessary that certain types of cases be referred elsewhere. In Baltimore City, the teaching hospitals, along with the other hospitals which are highly organized from the standpoint of physical arrangement, facilities, and medical staff, are in a position to render services not available in the outlying portions of the region. The transportation and trading patterns for this area center in Baltimore, making it an integrated region. For these reasons, the Baltimore City Region was delineated as described above. District of Columbia Region The District of Columbia Region includes the three counties of Maryland which lie in a semicircle around the District of Columbia. They are Montgomery, Prince George’s, and Charles counties. There is one hospital at La Plata in Charles County. Prince George’s County has three hospitals and Mont- gomery County has three. The largest of these hospitals is the Washington Sanitarium and Hospital at Takoma Park. This entire area has become densely populated primarily by reason of its proximity to the District of Columbia. Its travel and trading patterns radiate from the District of Columbia, and practically all endeavors are secondary to and dependent on activities in Washington. In the District of Columbia there are several large hospitals with complete facilities which are in a position to fill the needs not available in the three counties. Be- cause of the close relationship between the counties and the District of Columbia, they have been included in the District of Columbia Region as defined above. Easton Region The Easton Region was designed to include Kent, Queen Anne’s, Talbot, Caroline, and Dorchester counties. There are three hospitals in this region, the largest of which is the Easton Memorial Hospital, which is at the approximate center of this region. While the Easton Memorial Hospital at present has 87 beds, the addi- tional facilities which are now contemplated by the hospital management will increase its capacity to 187 beds. Highways and rail service connect Easton with the other communities in the region. It is the nearest com- munity of importance to the eastern terminal of the Chesapeake Ferry lines. It was concluded, therefore, that Easton is the logical point to designate as the location for the district hospital for the region. Salisbury Region The Salisbury Region consists of Somerset, Worces- ter, and Wicomico counties. Almost all travel from these counties and from the southern extremity of the peninsula moves toward and through Salisbury. The hospital at Salisbury, with 177 beds, is well organized. It has physicians practicing in the various specialties. A building program is contemplated which would increase its bed capacity. Salisbury is the trading center of the area, which also includes the southern portion of Delaware. For these reasons, the Salisbury Region was estab- lished as described above. Chapter 7. TUBERCULOSIS HOSPITALS SIX institutions in the State maintain services for the treatment of patients with a primary diagnosis of tuberculosis. Four of these are State-owned, and two are owned and operated by nonprofit organizations. In addition, one general hospital maintains a depart- ment for the treatment of tuberculous patients (Table H and Map 5). These institutions maintain a total of 1,883 beds. The tuberculosis section of the Baltimore City Hospitals has a capacity of 280 beds. Of these, 140 reserved for non white patients are not considered acceptable,1 and therefore, have been excluded from the total. Of the 1,743 acceptable normal bed capacity, 1,194 beds are for white patients and 549 for nonwhite patients. Summary of existing facilities The State Sanatorium at Henryton, which is reserved for nonwhite patients, has space for 181 beds not in use. This total resulted from a count of beds actually out of service plus areas which were not previously used as bed space. Sixty-five of the beds out of service were in a new wing which is equipped and will be put into use when personnel can be found. A building which was constructed some years ago for child patients is out of service. If this building is remodeled for use as a children’s hospital, it will have a capacity of about 40 beds. The balance of the space not in use is not equipped. The State Sanatorium at Sahillasville, with a capacity of 523 beds, has only 442 beds in service. Due to a shortage of personnel, three pavilions were closed in April 1947, accounting for 60 of the beds out of service. Twenty-one beds in a section of the new hospital were also not in use. Admission is limited to white residents of Maryland. Convalescent patients are being housed in the hospital which is equipped for acutely ill patients, because sufficient staff is not available for service required by acutely ill patients. Additional personnel would make it possible to transfer to the pavilions the patients who are able to wait on themselves, thereby providing beds in the hospital for the acutely ill patients on the waiting list. The pavilions are wood structures which were built at a time when unheated open shelters were considered proper facilities for tuberculous patients. Their bed capacity was included with the total for the Sanatorium, but they are not considered satisfactory. They should be taken out of service as soon as beds in better struc- tures can be established. The State Sanatorium at Mt. Wilson, ten miles from Baltimore, has a capacity of 210 beds. Admission is limited to white residents of Maryland, except in the surgical section. Eleven surgical beds are reserved for nonwhite patients. The surgical section containing a total of 23 beds is closed, due to shortage of personnel. The State Sanatorium at Salisbury has a capacity of 78 beds which are intended for the use of white resi- dents of the Eastern Shore. A cottage containing space for 18 beds is out of use, reducing the number of beds in service to 60. The Mt. Pleasant Hospital, located at Reisterstown, is a member agency of the Associated Jewish Charities. Its capacity is 50 beds. Admissions are limited to white patients. Eudowood Sanatorium (Hospital for Consumptives of Maryland), located at Towson, has a capacity of 194 beds and accepts only white patients. The summary of normal bed capacity and beds in use is as follows: Normal Beds In Service Institution Bed Ca- - PACITY Total White Nonwhite State Sanatoria: Henry ton . 538 357 — 357 Sabillasville 523 442 442 — Mt. Wilson 210 187 187 — Salisbury 78 60 60 — Mt. Pleasant Hospital 60 60 60 — Eudowood Sanatorium 194 194 194 — Baltimore City Hospitals 280* 280 140 140* Total beds . 1,883 1,580 1,083 497 *Less unacceptable beds at Baltimore City Hospitals . 140 140 — 140 Total acceptable beds . 1,743 1,440 1,083 357 A department containing 100 beds for white tuber- culous mental patients is maintained at the Springfield State Hospital at Sykesville. At the Crownsville State Hospital, for nonwhite mental patients, a section con- taining 38 beds for tuberculous patients is in use. In a new building at Crownsville, original plans called for the reservation of 80 additional beds for tuberculous patients. This building will be put into service in the near future, but the 80 beds will not be used as originally planned because the need does not justify such action. Tuberculosis beds in mental hospitals were not con- sidered as a part of the total available in this category since their use is limited to patients from the mental hospitals and not available to the general public. The Veterans’ Administration has purchased a site in Baltimore on which it plans to construct a 300-bed tuberculosis hospital for veterans. While the admission of patients to this facility will not be limited to resi- dents of Maryland, it can be expected that, because of its availability, it will be used by veterans who are residents of Maryland. It will relieve to some degree the demand on the existing hospitals. Bed standards based on tuberculosis deaths The United States Public Health Service set up in its regulations the generally accepted maximum stand- ard of 2.5 tuberculosis beds per average annual death from tuberculosis over a five-year period. This is the minimum standard established by the American Trudeau Society, a national association of physicians specializing in tuberculosis, and by the Medical Section of the National Tuberculosis Association. In a report on the Maryland Tuberculosis Sanitoria, xThe classification as unacceptable refers to the structure in which the patients are housed and not to the service. With the acute need for beds in this category, this unit is indispensable until replacements are made available. Tuberculosis Hospitals 79 MARYLAND STATE PLANNING COMMISSION 1947 TUBERCULOSIS HOSPITAL FACILITIES I- A DEPARTMENT OF BALTIMORE CITY HOSPITALS ( includes beds for nonwhites ) 2 - RESERVED FOR NONWHITES SEE TABLE H LEGEND STATE- OWNED CITY - OWNED NONPROFIT MAP 5 80 Hospital Survey and Plan for Maryland—Part III contained in the Capital Improvement Program for Maryland,1 it is stated: With the recognized minimum of one bed per death per year, it is apparent that the present capacity . . . totals a figure which would seem sufficient to meet the needs. Inasmuch, however, as the ratio between the negro and white cases is not in the same ratio as the facilities pro- vided, more beds for colored patients are required. The white population is apparently cared for adequately. It is apparent that the former State standard, upon which an impression of adequacy of existing facilities had been based, is only 40% of the present accepted standard. Deaths in Maryland from tuberculosis for the period 1940 to 1944, inclusive, were as follows: Total White Nonwhite 1940 1,302 683 619 1941 1,256 635 621 1942 1,263 654 609 1943 1,250 667 583 1944 1,285 686 599 Total 6,356 3,325 3,031 Annual Average 1,271 665 606 Per Cent by Race 52.3% 47.7% On the basis of 2.5 beds per annual death from tuber- culosis, the need was computed as follows: Total White Nonwhite Total beds needed 3,177 1,662 1,515 Existing acceptable beds 1,743 1,194 549 Additional beds needed 1,434 468 966 On the basis of normal bed capacities, considering only the beds in acceptable buildings, the standard of 2.5 beds per tuberculosis death is met only to the extent of 54.9%. Classified according to their avail- ability by race, the standard is met up to 71.8% for white patients and 36.2% for non white patients. Tuberculosis deaths by place of occurrence A compilation of deaths from respiratory tuber- culosis during 1943 and 1944, published in Hospitals, August 1946, revealed that in Maryland the distribu- tion was as follows: in general hospitals, 26.1%; tuberculosis hospitals, 37.1%; homes, 29.5%. With the exception of the Baltimore City Hospitals, no general hospital in the State admits known tuber- culosis patients. It must, therefore, be concluded that the deaths from tuberculosis reported by general hospitals were largely cases admitted undiagnosed or under circumstances justifying the setting aside of the hospital rules. It is interesting to note the close relationship of the previous Maryland standard of one bed per tuberculosis death at 40% of the United States Public Health Serv- ice standard and the number of deaths occurring in tuberculosis hospitals at 37.1% of the total deaths from tuberculosis. Case finding The fact that only 37.1% of the deaths from tuber- culosis occurred in tuberculosis hospitals in 1943 and 1944 strongly indicates a failure in case finding, in- adequacy of facilities, and a lack of public education to the benefits and safety of institutional isolation. The organizational arrangement under which all counties and the City of Baltimore have functioning health departments provides the means by which cases can be found. County health officers disclosed that a total of 486 clinics were held during the year reported. This is an average of 21 clinics per county per year. The aver- age number of visits per clinic was 18, the total being 8,399. These figures do not include community surveys by mass chest X-ray. The clinics conducted by the Department of Health of Baltimore City reported 11,980 visits during 1945. Records of the Department of Health show that re- ports of cases found come from clinics, private physi- cians, and other institutions in approximately equal numbers. Waiting lists With the shortage of beds in this category, it was surprising to find that lists of patients waiting for ad- mission were small. On the basis of the number of names on the waiting lists, the number of additional beds needed would not be justified. It was learned from people actively engaged in this field that two factors account for the small waiting lists and both are direct results of inadequate facilities. The general knowledge that there is a long wait until admission to a hospital is possible causes many people to despair of obtaining such service in a reasonable length of time. As a result, many do not file applica- tions. The sequel to this attitude is that those who do ap- ply wait long periods for admission during which time their conditions deteriorate with the result that death frequently occurs shortly after admission. This gives weight to the very prevalent impression that people go to tuberculosis hospitals only to die. Efforts to educate the public to the viewpoint that tuberculosis is curable under proper treatment and care are thus defeated. If adequate case-finding measures could be instituted and sufficient beds made available, cases found could be admitted promptly rather than in the terminal stage of the disease. Patients would file applications and waiting lists would turn over rapidly. At the same time, the public impression with regard to hospitalization for tuberculosis would change. Unfortunately, the existing facilities are put to the least effective use when admissions are largely limited to patients who are beyond reasonable expectation of recovery. The only benefit of a limited program is the isolation of the infected person. Admission procedures Admission to the three State-owned tuberculosis hospitals for white patients is arranged through clinics 1 “Six-year Capital Improvement Program for Maryland,” Maryland State Planning Commission and Department of Budget and Procurement, January, 1941. Tuberculosis Hospitals 81 conducted throughout the State. Private physicians may certify patients for admission. Assignment of white patients to the institutions is done through the office of the General Superintendent at Sabillasville. Nonwhite patients are certified for admission in the same manner. Their applications are directed to the Superintendent of the Henry ton Branch. None of the hospitals has medical-social service workers. When patients are discharged, they are re- ported to the local health district whose personnel follow up the cases. State building plans In reply to an inquiry with regard to building plans, the following reports were obtained: Location Plans Henryton Kitchen and quarters for employees Sabillasville 1 building to house employees and service departments; 1 wing for 120 beds Mt. Wilson None Salisbury 50 additional beds During the 1947 session of the General Assembly, no applications for construction funds were filed by any of the State Tuberculosis Sanatoria. A request was made for maintenance funds in the amount of $18,000 for renovation at the State Sanatorium at Sabillasville. These were the only funds appropriated for the Mary- land Tuberculosis Sanatoria, aside from the regular operational budgets. Administration of State Sanatoria The four State-owned tuberculosis hospitals until recently have been under the direction of a Board of Managers of ten members. The Governor, Comptroller, and Treasurer were ex-officio members. The remaining seven nonsalaried members were appointed biennially for terms of six years. The Superintendent of the State Sanatorium at Sabillasville functioned as general superintendent of the other three institutions, each of which was under the immediate direction of a medical superintendent. Recently, with the retirement of the General Super- intendent, the Board adopted a resolution requesting that the institutions be placed under the jurisdiction of the State Department of Health, and that the Board of Managers be discharged. The Legislature took the recommended action. Area served The use of all beds for tuberculous patients in the State are limited to residents of the State, with the ex- ception of a few at Eudowood. Nonwhite patients from all parts of the State must travel to Henryton for hospitalization. Non white resi- dents of Baltimore City are admitted to the tuber- culosis section of the Baltimore City Hospitals, where 140 beds are reserved for them in a building which, be- cause of its condition, should be taken out of service as soon as replacements can be constructed. It was found that white residents from all parts of the State were admitted to the three State-owned hospi- TABLE R: DISTANCE FROM POPULATION CENTERS TO AVAILABLE STATE TUBERCULOSIS SANATORIUM NEAREST County Starting Point Distance (Mileis)* ML Wilson1 Sabillas- ville1 Salis- bury1 Henry Ion2 Allegany 82 120 53 35 26 81 88s 17 83 86 1033 27 177 53 17 92s 25 60 76s 109 149 3 883 53 1363 1543 Anne Arundel . 36 Baltimore 20 Baltimore City Center 15 60 70 Caroline 41 Carroll 40 Cecil 92 Charles 82 Dorchester. . . . 33 Frederick 24 Garrett 139 Harford 36 Howard 16 Kent 80 Montgomery . . Prince George’s Queen Anne’s. . St. Mary’s .... 41 Upper Marlboro. . . Centerville........ 47 105 64 Somerset 13 48 Washington . . . 15 0 Worcester 18 1For white patients. 2 For non white patients. 3Exeluding bay-crossing distance. tals in spite of the fact that the branch at Salisbury is primarily intended for white residents of the Eastern Shore. A study was made of the distance between the hospi- tals and the centers of the counties and Baltimore City. The findings are shown on Table R. Patients from St. Mary’s County, for whom the hospital at Mt. Wilson is the nearest, must travel 105 miles between their homes and the institution. Those from Oakland in Garrett County, for whom the hospital at Sabillasville is nearest, must travel 139 miles. Nonwhite residents are forced to travel even greater distances to the hospital at Henryton. From Cumber- land, the distance is 120 miles. Residents of Worces- ter County on the Eastern Shore must travel 154 miles in addition to the bay crossing. These distances indicate a very definite need for a better distribution of facilities. Such improved distri- bution will reduce expense of travel, add to the con- venience of visitors, and as a result increase the num- ber of patients who will accept institutional care when recommended. At the same time, it will probably re- duce the number of patients leaving the institutions against advice. Types of facilities and priorities Under Priorities, Part IV, precedence is given con- struction of tuberculosis facilities planned as additions to general hospitals. One important illustration of the desirability of such procedure is the utilization of beds for nonwhite tuberculous patients. There are 357 beds in service for nonwhite tuber- culous patients in the entire State outside the Baltimore City Hospitals. In spite of this fact, the waiting list at Henryton contained only 45 names on April 9, 1947. In contrast to this situation, the administration of 82 Hospital Survey for Maryland—Part III the Baltimore City Hospitals found it necessary to allocate beds for tuberculous patients between white and nonwhite patients. It was explained that other- wise all of the beds would be occupied constantly by nonwhite patients. It seems likely that because of convenience and possibly greater confidence attached to a general hospital, the applicants more readily ac- cept hospitalization in a department of a general hospi- tal located in an urban area than in an isolated institu- tion limited only to the care of tuberculous patients. Tuberculosis is now recognized as a preventable and curable disease. Under recently developed mass X-ray programs, cases are found in their incipiency and may be treated at home, or at hospitals for reasonably short periods. Surgical treatment has reduced the period of hospitalization. There is the possibility that the need for facilities in this category may be reduced to the point where the sections of hospitals constructed for this purpose may eventually be converted to other uses. This is an important factor in constructing tuberculosis facilities as additions to general hospitals. General hospitals have operating rooms and personnel available for the surgical procedure now used in treat- ing tuberculosis. Tuberculous patients are subject also to acute illness and accidents, which require general hospital care. Duplication of ancillary facilities can be avoided by a close relationship between the two types of institutions. The disruption of the life of the patient and of his family when institutional care is required, on which is superimposed the fact that facilities are only available at an inconvenient distance, are deterrents to accepting hospitalization. These factors were given consideration in determin- ing that additions to general hospitals be awarded “A” priority and new installations at new locations “B” priority. It is expected that better geographic distribution of facilities will thus be established. Apprehension is held by some people with respect to establishing tuberculosis facilities in general hospi- tals. They feel that the tuberculosis department will be treated as a stepchild. This feeling is based on the fact that in the past the tuberculous patient was avoided by the general hospital. Like the mental patient, when found within the hospital, the tuber- culous patient was discharged promptly. This attitude is attributable to the fact that proper facilities for such patients were not a part of the hospital. Personnel was not trained in this field. The doctors largely shared the viewpoint of the hospital administration, looking at the tuberculous patient as a case to be referred to the State Sanatorium. As a re- sult, training and experience in the field of tuberculosis have been very limited. The establishment of a department for tuberculosis in a general hospital and the inclusion of training and experience for nurses and internes and staff members, coupled with the newer more positive techniques, in- cluding surgery, would be insurance against a stepchild attitude toward the department in a general hospital. Distribution of new tuberculosis hospital beds Having concluded that a better distribution of facilities for the care of tuberculous patients was needed, efforts were directed to devising a plan for the allocation of beds to locations which would bring about such better distribution. It was concluded that the factors which were con- sidered when consolidating the general hospital service areas into the regions, such as, convenience of travel, absence of natural barriers, and trading habits, would be of equal importance in locating new tuberculosis facilities and determining regions to be served by such facilities. The same regions and regional centers were therefore designated (Map 4). Since deaths from tuberculosis were used as the base for determining the need for facilities, the distribution of new beds was made on the same basis. A report of deaths from tuberculosis by county and by race was obtained from the Bureau of Vital Statis- tics of the State Department of Health. A tabulation of these data by counties, grouped by regions, is shown in Table S. The existing acceptable beds are equivalent to 54.9% of the total number considered to be necessary. As stated previously, the determined need for white patients is met up to 71.8%; whereas, for nonwhite patients, only 36.2% of the need is fulfilled. The priority schedule, discussed in Chapter 12, pro- vides for construction of tuberculosis facilities. Over a period of time the schedule should equalize the existing facilities and needs, the only limiting factor being avail- ability of funds. TUBERCULOSIS HOSPITALS MARYLAND TUBERCULOSIS SANATORIUM, SABILLASVILLE The Maryland Tuberculosis Sanatorium at Sabillas- ville is situated in the northwestern corner of Frederick County, close to the Maryland-Pennsylvania state line. It was opened in 1908 and was the first State-owned sanatorium for the care of tuberculous patients. It is 65 miles from Baltimore, 18 miles from Hagers- town, and 23 miles from Frederick. Area served: Admission is limited to white patients who are residents of Maryland. White residents of all parts of the State are admitted to this institution. For the year ending June 30, 1945, 46.6% of the patients admitted were residents of Baltimore City. Bed capacity: The institution has a normal capacity of 523 beds. Utilization: During the period for which the report was submitted, 444 patients were discharged and 89 died, making a total of 533. This indicates a turnover of slightly more than one patient per bed per year. The 533 patients discharged or died received an average of 252 days of service. On the basis of normal bed capacity, the occupancy rate was 94.2% for the year reported. Medical staff: The Medical Staff consists of the Super- intendent and five full-time resident physicians, on a salary basis. Personnel: The total personnel includes 158 full-time employees and two part-time employees, establishing a Tuberculosis Hospitals TABLE S: BEDS NEEDED FOR TUBERCULOUS PATIENTS BY COUNTY, REGION, AND RACE, ACCORDING TO 1945 TUBERCULOSIS DEATHS1 Total White Nonw fHITE Region Beds Needed Beds Needed Beds Needed Deaths at 2.5 Deaths at 2.5 Deaths at 2.5 1945 Per Death 1945 Per Death 1945 Per Death Cumberland Garrett 3 7.5 3 7.5 0 0.0 Allegany 16 40.0 15 37.5 1 2.5 Regional Totals 19 47.5 18 45.0 1 2.5 Baltimore City Washington 20 50.0 18 45.0 2 5.0 Frederick 18 45.0 14 35.0 4 10.0 12 30.0 10 25.0 2 5.0 8 20.0 3 7.5 5 12.5 St. Mary’s 18 45.0 8 20.0 10 25.0 Anne Arundel 38 95.0 21 52.5 17 42.5 Baltimore 64 160.0 43 107.5 21 52.5 Howard 12 30.0 4 10.0 8 20.0 Harford 16 40.0 13 32.5 3 7.5 13 32.5 8 20.0 5 12.5 Baltimore City 773 1,932.5 349 872.5 424 1,060.0 Regional Totals 992 2,480.0 491 1,227.5 501 1,252.5 District of Columbia Montgomery 32 80.0 20 50.0 12 30.0 Prince George’s 41 102.5 27 67.5 14 35.0 Charles 12 30.0 5 12.5 7 17.5 Regional Totals 85 212.5 52 130.0 33 82.5 6 15.0 1 2.5 5 12.5 Queen Anne’s 12 30,0 5 12.5 7 17.5 12 30.0 4 10.0 8 20.0 12 30.0 8 20.0 4 10.0 Dorchester 19 47,5 8 20.0 11 27.5 Regional Totals 61 152.5 26 65.0 35 87.5 Salisbury Wicomico 23 57.5 13 32.5 10 25.0 Somerset 14 35.0 6 15.0 8 20.0 Worcester 24 60.0 11 27.5 13 32.5 Regional Totals 61 152.5 30 75.0 31 77.5 State Totals 1,218 3,045.0 617 1,542.5 601 1,502.5 1 Maryland State Department of Health, Bureau of Vital Statistics. ratio of 0.3 employee per bed. One hundred and eleven employees are quartered in the institution. Educational activities: A school for practical nurses is in operation. The course covers two years’ training and qualifies the student for a State license in practical nursing limited to the care of tubercular patients. At the time of the survey, there were only two students in training. The school is set up for 20 students. In 1941, 20 students were graduated. In 1944 only one student completed the two-year course. MARYLAND TUBERCULOSIS SANATORIUM, MT. WILSON The Mt. Wilson Branch of the Maryland Tuberculo- sis Sanatorium was opened in 1925. It is owned and operated by the State of Maryland and is located in Baltimore County near Pikesville, ten miles from Bal- timore City. Area served: Admissions are limited to white residents of the State of Maryland, except in the surgical section where eleven beds are reserved for nonwhite tubercular patients needing surgical care. Records show that patients are admitted from all parts of the State. Residents of Baltimore City make up 51.5% of all admissions. Residents of Baltimore County account for 10.8% of all admissions. Bed capacity: The normal bed capacity of this in- stitution is 210 beds. Utilization: Patients in other State tuberculosis hospi- tals who are in need of surgical care are supposed to be transferred to this institution. Due to lack of personnel, the surgical department is closed. During the year ending June 30, 1945, 256 patients were discharged and 33 died, making a total of 289. This is a turnover of 1.4 patients per bed per year. On the basis of normal bed capacity, the occupancy rate for the year was 91.1%. The average stay of patients discharged or died was 242 days. Medical staff: The Medical Staff consists of the Super- intendent and two full-time salaried resident physicians. Three thoracic surgeons make up the Visiting Staff. They are on a salary basis. Personnel: The personnel consists of 104 full-time and seven part-time employees. Considering the part- time employees on a 50% basis, this is a ratio of 0.5 employee per bed. Educational activities: There is no educational program. MARYLAND TUBERCULOSIS SANATORIUM AT HENRYTON The Maryland Tuberculosis Sanatorium at Henryton is owned and operated by the State of Maryland. It was opened in 1923. It is located in Carroll County, approximately 26 miles from Baltimore City. Area served: Admission is limited to nonwhite resi- dents from the entire State. 84 Hospital Survey and Plan for Maryland—Part III Bed capacity: The institution has a normal capacity of 538 beds. Utilization: For the year ending June 30, 1945, 248 patients were discharged and 189 died, making a total of 437. On the basis of the normal bed capacity, the occupancy rate was 62.5% for the year reported. The average length of stay of patients discharged or died was 319 days. Medical staff: The Medical Staff consists of the Super- intendent and two full-time resident physicians along with three part-time physicians and a dentist, all of whom are on a salary basis. Personnel: The personnel, as of the date of the survey, was 146 full-time and 14 part-time employees. Con- sidering the part-time employees as being on duty 50% of the time, this establishes a ratio of 0.3 employee per bed. One hundred and twenty-six of the personnel are furnished quarters by the institution. Educational activities: A school for the training of prac- tical nurses in the f eld of tuberculosis is in operation. There were seven students in training at the time of the survey. Facilities are available for the training of a class of nine. MARYLAND TUBERCULOSIS SANATORIUM, SALISBURY Maryland Tuberculosis Sanatorium, located at Salis- bury in Wicomico County, is owned and operated by the State of Maryland. It was opened in 1912. Area served: Admission is limited to white residents of Maryland, primarily for residents of the nine counties making up the Eastern Shore. For the fiscal year 1944, 69.3% of the patients were from Wicomico, Worcester, Somerset, and Dorchester counties. Bed capacity: The institution’s normal capacity is 78 beds. Utilization: During the fiscal year 1944, 54 patients were discharged and 21 died, making a total of 75. This represents a turnover of approximately one person per bed per year. Based on the normal bed capacity, the rate of occupancy was 65.5% for the year reported. Medical staff: The Superintendent is the only physician employed at this institution. He is on a salary basis. Personnel: There are 27 full-time employees, making a ratio of 0.35 employee per bed. Educational activities: There is no educational program at the institution. EUDOWOOD SANATORIUM HOSPITAL FOR THE CONSUMPTIVES OF MARYLAND Eudowood Sanatorium, located at Towson in Balti- more County, was opened in 1896. It is a nonprofit corporation, managed by a Board of Directors. The Board consists of 18 members, six of whom are ap- pointed by the Governor and 12 are self-perpetu- ating. A Women’s Board, with 60 members, en- gages in projects for the purpose of raising funds for supplying equipment to the institution. The institution is assisted also by the Baltimore Tuberculosis Aid Society, American Legion Auxiliary, Rotary Club, Kiwanis Club, and others. Area served: Admission is largely limited to residents of Maryland except in very unusual circumstances. Ad- missions are limited to white patients. A small de- partment made up of private rooms is open for the ad- mission of paying patients without restrictions as to residence. Patients for the year reported were largely residents of Maryland, 76.1% being from Baltimore City and Baltimore County and 21.5% from the other counties of Maryland. Bed capacity: The normal bed capacity is 194, 48 of which are for children. Utilization: During the year reported, 143 patients were discharged and 33 died, making a total of 176. The average length of stay of patients discharged and died was 132 days. The occupancy rate was 80.3%. Medical staff: The Medical Staff is made up of the Superintendent and three part-time physicians, all of whom are on a salary basis. Patients are permitted to employ private physicians. Personnel: Eighty-nine full-time and 49 part-time em- ployees make up the personnel. Considering the part- time employees as being employed 50% of the time, this is a ratio of 0.6 employee per bed. Educational activities: The institution does not engage in any educational program. MT. PLEASANT HOSPITAL The Mt. Pleasant Hospital, located at Reisterstown, is a member agency of the Associated Jewish Charities. It was founded in 1908 as a nonprofit association. It is managed by a Board of Directors, consisting of 15 members whose terms of office run for two years. The Board is self-perpetuating. Area served: Admissions are limited to white residents of the State of Maryland. Most patients are residents of Baltimore City. Bed capacity: It has a capacity of 60 beds. Utilization: The rate of occupancy was 86.5% for the year reported. The average length of stay was 107 days. Medical staff: The Medical Staff is not organized. The Chief of Staff is appointed by the Board of Directors. He selects his own associates. Physicians other than the Resident Staff may treat private patients. The Con- sulting Staff includes specialists in genito-urology, roentgenology, dermatology, laryngology, and gastro- enterology. Personnel: The personnel consists of 22 employees, establishing a ratio of 0.4 employee per bed. Educational activities: There is no educational program in force. Building plans: The Associated Jewish Charities, of which this institution is a member agency, is planning a large medical center to be located in the suburbs of Baltimore. This medical center will include facilities for the care of tuberculous patients. It is planned that at such time as the projected program materializes, the Mt. Pleasant Hospital will be converted to a con- valescent home. Tuberculosis Hospitals 85 Conclusions There is a serious deficiency of beds for the care of tuberculous patients, especially in facilities for non- white patients. The isolated locations of the existing hospitals have the disadvantages of being remote from the labor and supply sources and inconvenient for patients and visi- tors. New facilities should be distributed so that con- venient access would be possible from all parts of the State. Tuberculosis institutions with a capacity of less than 200 beds ideally should be built close to or as parts of general hospitals. Those with capacities of more than 200 beds may well be built as separate units. In either situation, they should include or have immediate access to general hospital facilities, both for the surgical treatment of the tuberculosis conditions and for the treatment of other conditions arising which require general hospital care. While surgery in the treatment of tuberculosis is not usually of an emergency nature, it is an important phase of the program and facilities and services must be readily available. Outpatient clinics are a necessary part of the pro- gram and should be a required part of an institution which admits tuberculous patients. The small lists of patients waiting for admission cannot be accepted as prima-facie evidence that there is no need for additional tuberculosis beds. The facts that existing facilities amount to only 54.9% of the standard, that important segments of those beds are not in use, that only 37.1% of the deaths in the State occur in tuberculosis hospitals, and that there are small waiting lists indicate: 1. Need for more active and effective case-finding methods. 2. Need for public education. 3. Need for facilities sufficient to give assurance that the wait on the list will be short. The percentage of deaths from tuberculosis which occur outside the tuberculosis hospitals, 62.9%, in- dicates a high potential for the spread of the disease. The transfer of the tuberculosis hospitals to the State Department of Health should revitalize the program by bringing together under one department: 1. Case findings. 2. Medical care at the hospitals. 3. Follow-up care and rehabilitation by close align- ment between the institutions and the public health nurses and medical-social workers. 4. Health education. Equipment and renovation are need in all State tuberculosis hospitals. A program for the utilization of existing beds now out of service and for the construction of additional facilities should be coordinated with the case-finding program. An intensified case-finding program would be largely wasted effort if facilities are not made available for the care of found cases. Recommendations It is recommended that steps be taken immediately to do whatever is necessary to put into service existing beds which are not now in use. This means construction of quarters and higher salaries for employees. A program of renovation and modernization should be instituted where the cost of such procedure is not outweighed by advantages of total replacement. Funds should be appropriated for the construction of tuberculosis facilities, especially for nonwhite patients. Construction should be at locations close to com- munities from which personnel can be secured. Where tuberculosis departments are set up as parts of general hospitals, the State should assume the finan- cial responsibility for the operation of those depart- ments. Since a special committee of the State Planning Commission is now intensively surveying the tuber- culosis program in Maryland, the needed facilities and suggested distribution are considered tentative. It is expected that the report of the special committee will have considered the material contained in this re- port and that their findings and recommendations will be the basis for some significant revision in the alloca- tions of beds as developed on Table S. Chapter 8. FACILITIES FOR CHRONIC OR LONG-TERM PATIENTS IN true conformity with the laws of compensation, medical science is creating a problem by solving one. Man’s success in obtaining longevity creates the probr- lem of caring for the chronically ill, most of whom are in the higher age groups, and of caring for those under- going a prolonged convalescence. In the last 60 years, man’s life expectancy has been increased from 34 years to 64.4 years, i This lengthening of the span of life has increased the number of people in the higher age brackets (Table T) problems are those who have survived the diseases and dangers of an active life and have come to the later years of that life with the disabilities of old age. Many aged persons enjoy good health and the re- wards of a hard-earned rest by living off their pensions or savings. But a visit to homes for the care of the aged and to other types of nursing and convalescent homes, or a talk with the representatives of the Department of Welfare who assist in finding shelter for their chroni- cally ill and aged clients, supplies vivid testimony to the fact that man’s success in one endeavor is offset to a degree by his apparent failure in another. Some pro- gress has been made toward solving the problem of the care of the aged and chronics, but even a casual in- spection of the medical institutions of Maryland em- phasizes the inadequacy of facilities for their care. Today’s overwhelming demand for beds and services in all categories of medical institutions raises the ques- tion: Where shall provisions be made for the chroni- cally ill, the incurables, those having conditions re- quiring long periods of convalescence and rehabilitation, individuals with congenital disabling conditions, and those who are disabled by advanced age, all of whom may be grouped as patients with long-term illnesses? It is generally accepted that county homes or alms- houses are not proper places for these patients. Institutional care for patients with a long-term ill- ness only in recent years has been recognized as a dis- tinct medical field. Thinking in this respect has not yet produced a generally accepted solution. General hospitals today cannot admit the aged or those who have long-term illnesses. This is not a matter of option. There are not enough beds available in gen- eral hospitals to meet the demands of the short-term acutely ill cases applying. The inadequacy of general hospital facilities is documented earlier in this report. It is true that now techniques and drugs have ex- pedited diagnosis and shortened the period of hospital stay, but not nearly enough to offset the added loads otherwise imposed. Existing facilities There are 114 institutions in the State classified as chronic disease hospitals, nursing homes, and homes for the aged. Excluding institutions offering only domi- ciliary care, these were found to have in use 2,391 beds. Most of the nursing homes included were converted dwellings. Those offering insufficient nursing service or located in unsuitable structures were later eliminated. The final list of institutions considered acceptable num- bered only 35, with a total of 1,713 beds. Nursing homes The pressure to have convalescent patients discharged from general hospitals and dearth of facilities prevent- ing the admission of patients with diagnoses indicating TABLE T: PER CENT DISTRIBUTION OF POPULATION OF MARYLAND BY AGE, 1900-1940* Age Groups Per Ce NT DlSTR IBUTION 1940 1930 1920 1910 1900 Under 15 15-44 45-64 23,8 49.7 19.7 6.8 28.2 47.8 18.1 5.7 0.2 29.7 47.9 17.3 5.0 0.1 31.0 48.5 15.8 4.7 0.1 33.1 47.9 14.4 4.2 0.3 Total 100.0 100.0 100.0 100.0 100.0 ♦United States Bureau of the Census, 16th Census of the United States, 1940. and, hence, the number having long-term illnesses. The full impact of this trend has not yet been felt. Science has accomplished this by devising improved means of piloting individuals through birth, childhood diseases, adolescence, reproduction, and some of the degenerative diseases of middle and advanced age. Preventive programs have reduced to a minimum the incidence and, hence, the hazard of diseases, such as malaria, typhoid fever, and small pox. With modern medicine and surgery and techniques for the control of living habits and body functions, many diseases which formerly were considered incurable or fatal, or left to the whims of nature, are now curable or at least not fatal. In an increasing number of illnesses, such as appen- dicitis and pneumonia, surgery and medicine usually can provide a prompt and definite cure. However, some conditions, such as diseases of the heart and arteries or kidneys, cancer, diabetes, asthma, and arth- ritis, while controlled to the point where they are not immediately fatal, frequently are not curable. The result often is a long period of convalescence or in- validism. The chronic or long-term diseases are those which are incurable or of long duration, limiting to varying de- grees the activities of the patient or causing total dis- ability. As a result of the successes in medical science, in which the law of the survival of the fittest has been modified, society now faces the problem of providing for those whom science has preserved without curing. In the same category and presenting many of the same bulletin of the Metropolitan Life Insurance Company, October 1945. Facilities for Chronic or Long-term Patients 87 a probable long-term illness have resulted in the mush- rooming of nursing homes. Most nursing homes are proprietary and operated for profit. Some are beautiful structures with an air of luxurious cleanliness and refinement. From this degree of elegance, they range down the scale to a point where several “boarders” were found occupying cots in small buildings within the back yard chicken enclosure, with the chickens occupying the surrounding shanties. These conditions are a disgraceful indictment of the State of Maryland. Nursing homes can be classified in three groups. In the first group are fine structures, well equipped and with adequate service maintained. The second group is comprised of those which, with some remodeling and additional equipment and personnel, can eventually attain satisfactory standards of service. In the third group are those which are so limited as to structure and other features that there is no prospect of their ever attaining satisfactory minimum standards. These should be taken out of service as rapidly as other ac- commodations can be found. Under the licensing pro- gram, some have been eliminated but many are still in operation. The State Department of Health refuses to dignify institutions in this group by issuing even a temporary license to them. The Department is in the paradoxical position of having to permit such institutions to operate and, in so doing, to condone their services and facilities, while it is quite apparent that they are not fit places for the care of patients. To institutions in the second group, licenses are being issued on a temporary basis with stated conditions which must be met before the expira- tion of the limited period for which the license is termed. Until such time as suitable institutions are available to provide adequately for all those needing this type of institutional care, the Department of Health will not be able to close all of the unfit places. As the situation stands, some operators of private homes ask in defiance or in desperation, “Where will these patients go if we close and turn them out?” Being unable to suggest an alternative, the State reluctantly allows them to con- tinue with the hope that adequate facilities will event- ually come into being. The derogatory comments about nursing homes are statements of facts, as they were found to exist and are not intended to depreciate their importance. The nurs- ing homes, both proprietary and nonprofit, can play a most important role in supplying service in the field of chronic disease and convalescent care. Suitable institutions from the standpoint of structure, service, and facilities should be encouraged as a supplement to such service in the home, in the larger chronic disease hospitals, and in the special departments of general hospitals. Their place in a complete integrated plan for the care of long-term illnesses should be fully assessed. The vastness of the construction program required to bring the number of chronic disease hospital beds into some relationship with the number needed presents a financial problem which will require some time to be met. The opening of suitable nursing homes presents a more immediate partial solution to the problem. Suitable nursing homes are those which are located in proper environment and which fully comply with the standards set up for licensing, with adequate medi- cal and nursing service, physical and occupational therapy, and space for recreation. STATE PROGRAM Official cognizance was taken of the need for institu- tions for the care of chronically ill when the Legislature enacted laws in 1943 and 1945, committing the State to the construction of three chronic disease hospitals (Appendices G and H). These enactments followed the survey of the alms- houses of Maryland made by the State Department of Welfare for the Legislative Council in 1940,1 and the report prepared by the Almshouse Commission.2 The three hospitals were intended at that time to have capacities as follows: Salisbury, 300; near Balti- more, 500; near Hagerstown, 500. Responsibility of these institutions was placed with the State Depart- ment of Health. The original appropriation for the three institutions was $2,500,000. When bids were taken for the con- struction of the first building to be erected at Salisbury, it was found that this one institution would entail an expenditure of $1,798,860 for construction. The con- struction of the other two hospitals was held up pend- ing the appropriation of additional funds. The Department of Health submitted to the 1947 Legislature an application for appropriations for the construction of the two additional hospitals to be located at Hagerstown and Baltimore, but no construc- tion funds were made available. A sum of $45,000 was appropriated for engineering and architectural services on the Hagerstown project. In the application for appropriations, the estimated construction costs of the 500-bed Hagerstown hospital was set at $4,670,000. This is based on a construction cost of $9,340 per bed. In addition, it was estimated that the cost of construction of housing facilities for personnel would amount to $290,000, The operating cost was estimated at $1,500,000 for a two-year period, or $1,500 per bed per year. The estimated cost of the hospital to be located in Baltimore was $5,440,000 for 600 beds, or $9,007 per bed. The estimated operating cost was set at $1,800,000 for a two-year period, or $1,500 per bed per year. The United States Army Hospital at Camp Ritchie, in Frederick County, has been turned over to the State for use as a temporary chronic disease hospital until the permanent hospital can be constructed in Hagerstown. Problems of personnel and equipment delayed the opening of the Camp Ritchie Hospital until Septem- ber 8, 1947. on the Almshouses in Maryland, Maryland Legislative Council, April 1940. 2Report of the Almshouse Commission, November 22, 1940. 88 Hospital Survey and Plan for Maryland—Part III Long-term patients and general hospitals The shortage of general hospital beds for acutely ill patients makes it impossible to assign any of the existing general hospital beds to the use of patients with long- term illnesses. General hospitals are geared to render intensive service for short-stay patients, which requires a high ratio of personnel, and results in a high cost per patient day. However, a hospital for the care of chronic disease patients must maintain facilities and personnel sufficient to meet all medical needs of its patients, which include acute illnesses and injuries resulting from accidents. If it is to fulfill its purpose it must have a planned re- habilitation program with sufficient facilities and trained personnel to insure maximum results. The establishment of such services will result in a propor- tionately high cost per patient day. This apparent paradox can be resolved and the duplication of ancillary services, such as X-ray, oper- ating rooms, laboratories, physical and occupational therapy, and administration, can be avoided if the chronic disease hospitals are established as a part of or convenient to existing general hospitals. Under such an arrangement the elimination of the facilities which are maintained already by the general hospital will result in a lower average cost per patient day in the chronic disease department. The chronic disease department will be available for use by patients having a long convalescence. Such patients can be transferred promptly from the general hospital, thus making general hospital beds, with their intensive services, available more quickly for other patients with acute illnesses. The care of convalescent patients in the chronic disease hospital has many advantages over present practice by which they are frequently discharged to their homes where inadequate help and facilities are available. This practice often results in a longer con- valescence, incomplete recovery, and at times, a relapse necessitating a return to the general hospital. Chronic disease hospitals should therefore be con- structed as additions or closely related to general hospitals. This plan has the reciprocal benefit of better care for the patients because of availability of facilities and medical personnel, while the physicians and nurses gain experience with this type of patient and have an opportunity for research in the field. Such a plan obviates the administrative costs of a separate institution. A procedure could be set up by which payment for services rendered patients who would otherwise qualify for admission to State-owned chronic disease hospitals could be made to the general hospital, based on the cost of services calculated sepa- rately for the chronic disease department. Hospitalization in a general hospital would be free of the stigma of charity usually attached to State institutions. Patients able to pay for their care could be admitted. State chronic disease hospitals are primarily intended to care for those unable to pay for services. As additions to general hospitals, the facilities will have a better distribution across the State, making them more accessible and more readily acceptable by patients and their relatives. Located in communities with general hospitals, problems of securing personnel will be reduced. Convalescent care The term convalescent care is usually applied to the period between the acute exacerbation and recovery, whereas the term chronic has, in the past, not usually carried the connotation of recovery. With newer techniques, some chronic conditions which were for- merly considered permanent and incurable are now con- sidered curable or controllable, with prospects of the patient’s being returned to society on a rehabilitated basis, adjusted to the residual disability or limitations imposed by the disease. Many chronic patients are, therefore, looked upon today as being in the process of a long convalescence. Institutions for the care of convalescents are an apparent need at present. Such institutions or de- partments of general hospitals need not be geared to the intensive regime maintained where patients in the acute stages of illness are served. They would serve that group of patients whose home environments do not lend themselves to the required conditions. Patients whose period of convalescence is expected to be long can be provided for in nursing homes for convalescents. However, because long periods of con- valescence frequently deplete financial resources and most nursing homes are operated on a proprietary basis with a profit motive, most patients with a prog- nosis of slow recovery, of necessity, must look to public- owned institutions for care. The need for chronic dis- ease hospitals for the care of chronically ill patients is, therefore, amplified by the need for facilities for con- valescent patients. When institutions are constructed, chronic disease hospitals should therefore include departments for chronics, incurables, and convalescents. Welfare patients In the absence of chronic disease hospitals, the De- partment of Public Welfare has made allotments to clients and assisted them in making arrangements for care in nursing homes. The limited sums allowed are reflected in the services rendered. In the course of the survey, it was found that nurs- ing homes which admitted any appreciable per cent of “welfare cases,” that is, persons dependent upon allotments from the Department of Welfare, were generally of very low standard. The charges to Wel- fare Department clients were usually limited to the amounts of their allotments and were consistently low. The service was of proportionately low quality. Taking into consideration the economic value of rehabilitated persons as compared with the liability of an inmate of an institution, it would be economically sound to allot, for these patients, sufficient public funds to command adequate medical, nursing, and ancillary services to insure as high a per cent as pos- sible of rehabilitation. Such arrangement with con- valescent nursing homes would have value as a con- Facilities for Chronic or Long-term Patients 89 tinning program for the better distribution of this type of service. It would be a semblance of a program in this field until institutions can be built out of public money. The Welfare Department, in making allotments to clients who use these funds for the purchase of care in homes which are below the licensing standards, is indirectly subsidizing such places and defeating the purposes of the licensing program. It would seem logical to have the Department of Health,under which the licensing program is conducted, reach an understanding with the Welfare Department whereby it would recommend and encourage its clients needing bedside or medical care to purchase service only in licensed institutions. DISTRIBUTION OF FACILITIES Facilities for chronic disease patients should be so distributed as to be of easy access from all parts of the State. The general hospitals regions (Map 4) were, therefore, used as a basis for the geographic allocation of beds. The ratio of 2.0 beds per 1,000 population was used to determine the number of beds allocated to each region. The resultant figure was adjusted by the num- ber of acceptable beds in each region, with the following result: The District of Columbia Region is allocated 437 beds. In order to have better accessibility, it was felt that a chronic disease hospital should be built in Easton. On the basis of the population of the area, it should have a capacity of 163 beds. Another installation should be made at Salisbury. This should contain 139 beds. Since a contract already has been let by the State for a 300-bed unit to be con- structed in Salisbury, the beds needed for the two regions are considered to be included in this institution. It is understood that chronic disease hospitals will admit members of all races. It is expected that beds will be allocated as needs arise. Conclusions There is an acute need for facilities for chronic, in- curable, and convalescent patients. Based on the accepted standard of 2.0 beds per 1,000 population, there is a need for 4,036 beds in this category. The existing acceptable beds total 1,713, leaving a shortage of 2,323. With the steady increase in the span of life, the potential number of patients in this category can be expected to increase. Unless active steps are taken to put in operation known methods of rehabilitating as many as possible of such patients, the number requir- ing institutional care will increase cumulatively. The potential gain which could result from the re- habilitation of such patients justifies an investment in facilities for this purpose, without taking into con- sideration the return in human happiness. Availability of beds for this purpose would result in a saving to paying patients against the higher cost of care in a general hospital. More efficient use could be made of general hospital beds if facilities were conveniently available for con- valescent and chronic patients. Assurance of complete services would be greater if chronic disease hospitals were closely integrated with general hospitals. This arrangement would bring into direct contact with the field the specialists on the staffs of the general hospitals. At the same time, their services would be made available to the chronic disease patient. Furthermore, opportunities would be created for train- ing and research in this field. Allotments of welfare funds are too small to allow the recipients to purchase satisfactory services. Recommendations It is recommended that: 1. Efforts be made to have the State program for the construction of chronic disease hospitals executed at the earliest possible time. 2. These hospitals be constructed as additions to or as close as possible to general hospitals. 3. Additional facilities for this purpose be constructed at the regional centers as designated under the general hospital program. Region Population 191+3 Bed Quota Acceptable Additional Bed Beds Capacity Needed Cumberland 99,836 200 9 191 Baltimore City .... 1,490,351 2,981 1,581 1,400 District of Columbia 241,564 553 116 437 Easton 81,766 163; — I — 1 Salisbury 69,430 139 \ A 295 \ Totals 1,982,9471 4,036 1,713 2,323 Allegany County was authorized by the 1947 Gen- eral Assembly to issue bonds in the amount of $250,000, for the erection of an Infirmary and Nursing Home (Chapter 769, Laws of Maryland 1947). This will expedite the program for the installation of the 191 chronic disease beds assigned to that area. The Allegany County project will reduce the demand for such facilities in the Hagerstown area. In the light of this development, the chronic disease hospital planned for Hagerstown should be reduced propor- tionately. Frederick and Washington counties, which will be served by a hospital located in Hagerstown, have a total population of 121,664. They will require 243 beds, on the basis of 2.0 beds per 1,000 population. The chronic disease hospital for this area should, therefore, be designed to have a capacity of 250 beds. This leaves 1,150 beds to be located elsewhere in the Baltimore City Region. This remainder should be con- structed in and around Baltimore City. iThe United States Bureau of the Census reported the estimated population, as of July 1, 1945, as 35,024 greater than the estimate of November 1, 1943. Since the increase was not reported by counties, distribution was made on the basis of the 1943 figure, and the 70 additional beds by which the State quota was in- creased were added to the District of Columbia Region. 90 Hospital Survey and Plan for Maryland—Part III 4. The plan projected at present for the construc- tion of chronic disease hospitals be reconsidered from the standpoint of better geographic distribution. 5. Nursing homes be encouraged if they establish high standards and render therapeutic and rehabilita- tive services. 6. Public health nursing service supplemented by medical and housekeeping service be made available in the homes of patients in this category. 7. Allotments of funds to welfare clients requiring bed care be supplemented by an amount sufficient to allow the purchase of care in institutions maintaining sufficient services and facilities to give a reasonable assurance of recovery and rehabilitation. 8. Where chronic disease hospitals are an integrated part of the general hospital, the State pay for services rendered patients who qualify for assistance, at a rate based on costs calculated separately for the chronic disease department. Chapter 9. MENTAL HOSPITALS A mental hygiene program includes services and facilities for the prevention and treatment of con- ditions, existing and potential, which are inimical to mental health. The scope of such program encompasses: 1. Programs for the prevention of mental illness. 2. Case finding. 3. Facilities for treatment of ambulatory persons mentally ill. 4. Institutional facilities. 5. Program for follow-up care of patients discharged or paroled from institutions. 6. Training of physicians, nurses, and other per- sonnel. 7. Research. The mental hospital is a unit in this program; how- ever, its maximum effectiveness can be obtained only if the other phases of the program are in effect. The mental hospital of today is the successor to the insane asylum of yesterday. Both titles are appropriate. In the hospital one expects constructive therapy, resulting in improvement or cure; whereas, in the asylum, as the title denotes, little more than custodial care is available. From the austere fortress-type of institution with cupolas housing armed guards, the mental hospital has evolved with divisions for the segregation of patients by type of illness, containing departments of physical and occupational therapy and other services. With this transition, progress has been made in converting public attitude toward patients from one of resignation to one of confidence and expectation of recovery. The changes have not been in attitude alone. The development of treatments, such as shock therapy, has placed some types of mental illness in the category of curable diseases. Consequently, the treatment of some types of mental illness has been placed within the scope of the general hospital. Psychiatric service in general hospitals for inpatients and outpatients has therefore become an essential part of a mental health program. The psychiatric department of the general hospital, located within the community, serves as the diagnostic, therapeutic, research, and personnel training center. It serves the patients who, after short, intensive treat- ment, can recover sufficiently to return to society. Such psychiatric departments, supplemented by outpatient clinics, broaden the scope of the hospital’s program and are complementary to the mental hospital in supplying diagnostic and postinstitutional care. Patients admitted to such psychiatric sections of general hospitals have available the services of the specialists in other fields on the staff of the hospitals. Through this arrangement, opportunities for research are established. The value of personnel training and of experience gained by nurses, resident physicians, and auxiliary workers is inestimable. Psychiatric departments of general hospitals are free of the stigma which, while unjustified, still prevails with regard to State institutions limited to the care of mental disease. The former are not located in isolated places as is the case of most existing mental hospitals. Located near urban communities, they are near sources of labor supply. The purpose of this study is to determine the differ- ential between the currently existing acceptable facili- ties and those needed to establish a state of adequacy, and to project a long-range plan for the construction of the additional facilities needed. The existing facilities were determined through the survey (Table J and Map 6). The determination of adequacy in mental health facilities is not as simple as implied in the Hospital Sur- vey and Construction Act, which states that the total number of beds for mental patients shall not exceed 5.0 per 1,000 population.1 Mentally ill persons are heir to all the illnesses to which normal people are subject, so that the incidence of other ailments adds to the complexity of the prob- lem. Arrangements must be made for the segregation at least by age and sex within each of the divisions. There are classifications of mental diseases which present different problems and, preferably, are cared for separately. These include the mentally ill, the de- linquent, the feebleminded, the epileptic, and the criminally insane. Not segregated are some less defined groups, such as senile patients, the adult feebleminded, and others. The acuteness of the problem presented by these groups is growing. Often there are no clear lines of demarcation among these types of patients. It is necessary that policies be established to govern the manner in which existing institutions are expanded and utilized to meet these growing needs. The ad- visability of new institutions for special types of patients also will be affected by such policies. Until this is done, no orderly approach can be made to a plan of expansion which will result in the meeting of all recognized needs. The ratio of 5.0 beds per 1,000 population is con- sidered as the need for mentally ill patients exclusive of feebleminded and epileptics. Mental hygiene in Maryland is under the supervision of the State Board of Mental Hygiene. Its duties and operations are described as follows;2 The Board of Mental Hygiene was established in 1922 as the successor to the State Lunacy Commission which was established by Chapter 487 of the Laws of 1886. The primary duty of the Board is to supervise the care given mental patients in public and private hospitals in xAppendix A, Public Law 725, Section 622(b). 2 The Maryland State Budget for the Fiscal Years Ending June 30, 191,6 and June 30, 191,7, issued January 1945, p. 185. 92 Hospital Survey and Plan for Maryland—Part III MARYLAND STATE PLANNING COMMISSION 1947 1- RESERVED FOR NONWHITES 2- PHIPPS PSYCHIATRIC CLINIC, A DEPARTMENT OF JOHNS HOPKINS HOSPITAL SEE TABLE J MENTAL HOSPITAL FACILITIES LEGEND STATE-OWNED NONPROFIT PROPRIETARY CHURCH-OWNED MAP 6 Mental Hospitals 93 Maryland. The Board of Mental Hygiene consists of six members and the Commissioner of Mental Hygiene who is a member of the Board.1 A central record is kept of all patients who are admitted to any institution for mental patients, either public or private, in Maryland and a similar record is made of all discharges, so that information is readily available as to all institutional mental patients in the State. The office maintains a service by which non-resident patients admitted on an emergency basis to public mental hospitals in Maryland are returned to their State of residence and by which residents of Maryland are likewise returned from other States. The office employs an Inspector of Nursing who visits all the public and private hospitals for mental patients, inspects the nursing conditions, investigates the general operation of the institutions, and reports to the Commis- sioner. The office in cooperation with the County Commissioners of the various counties and the County Boards of Welfare arranges for an investigation of the ability of relatives to pay for the care of patients in the State hospitals and sees to it that this money is collected and turned over to the State. In cooperation with the Superintendents of the State hospitals, because of the overcrowding at Spring Grove and Springfield, this office arranges for the assignment of beds at these two institutions for all patients applying for admission. This service requires the handling of about 1,700 applications a year. This office has organized and supervises a plan by which mental patients are boarded in private homes. At present there are approximately 220 such patients on boarding care outside the hospitals. Under the present public health program of the State, with Deputy State Health Officers employed on a full-time basis in each of the counties, and with the City of Baltimore having a large well-organized health department, mental hygiene clinics can be organized and conducted for State-wide coverage. Mental health clinics should be established at points convenient to all residents. With public education and provisions made for attendance by qualified psychia- trists and nurses with special training in psychiatry, potential candidates for institutional care could be dis- covered and, in many instances, through follow-up service, be diverted from their current drift back to a state of normalcy. The costs of such program, while large, should be more than balanced by the cost of institutional care thus obviated. Public education, resulting in early case finding, well-staffed clinics, and treatment of potential in- stitutional patients, should materially affect the num- ber of admissions to mental hospitals and accelerate the discharge or parole of patients to the follow-up care of the clinics. Hence, the number of beds required for this type of patient will gradually be reduced. The 79th Congress enacted Public Law 487, known as the “National Mental Health Act.” Its purpose is “the improvement of the mental health of the people of the United States through the conducting of re- searches, investigations, experiments, and demonstra- tions relating to the cause, diagnosis, and treatment of psychiatric disorders; assisting and fostering such re- search activities by public and private agencies, and promoting the coordination of all such researches and activities and useful application of their results; train- ing personnel in matters relating to mental health; and developing, and assisting States in the use of the most effective methods of prevention, diagnosis, and treatment of psychiatric disorders.” Under this Act, $30,000,000 is made available to the Surgeon General of the United States Public Health Service for allotment to the States. The Surgeon Gen- eral is authorized to work with “the State Health authority except that in the case of any State in which there is a single State agency, other than the State health authority charged with responsibility for ad- ministering the mental health program of the State, it means such other State authority.” Under this stipulation, Federal funds for carrying out the purposes stated in the Act are made available. The 1947 General Assembly enacted Chapter 716, under which the State Board of Health is designated as the State agency to execute this program (Appendix E). INSTITUTIONS FOR THE CARE OF THE MENTALLY ILL Twenty-three institutions2 in the State maintain 9,648 beds for the care of patients with nervous and mental disorders and feeblemindedness. Five of the 23 institutions, maintaining a bed com- plement of 8,337, are owned and operated by the State and represent 86.4% of the total number of in beds use for patients of this category. STATE-OWNED INSTITUTIONS Crownsville State Hospital, located at Crownsville in Anne Arundel County, is devoted entirely to the care of nonwhite patients. The bed complement of this in- stitution is 1,234, which is 14.8% of all State-owned beds for mental patients, or 12.7% of the total number of beds in the State. Since this is the only facility in the State for the care of nonwhite mental patients, there are set up divisions for feebleminded, mental patients having tuberculosis, criminally insane, and mentally ill. Following is an excerpt from The Maryland State Budget;3 The Crownsville State Hospital is located at Crownsville, Anne Arundel County, Maryland. The institution is owned by the State and was created by Chapter 250, Laws of Maryland 1910, for the care and treatment of the colored insane and feebleminded. The property comprises 1,271 acres and the value of the land, buildings and equipment is $2,761,982.13. The average population during the 1944 fiscal year was 1,520 at a per capita cost of $272. Methods of Admission: All patients from Baltimore City and the County (excepting those having criminal charges) require certificates of two qualified physicians who have practiced five years or more, with an order from the Department of Public Welfare in case of city patients and an order from the County Commissioners of their native County, if a County charge. Cases appearing in the Criminal Court are committed on an order signed by the Judge of the Criminal Court. Patients are also transferred here from either the Maryland Penitentiary or House of Correction on order of the Commissioner of Mental Hygiene, in accordance with authority invested by Section 48, of Article 59, of the Annotated Code of Maryland. iThe 1947 General Assembly enacted Chapter 327 to add five advisory members to the Commission. including Phipps Psychiatric Clinic, Johns Hopkins Hospital. K>p. cit., p. 188. 94 Hospital Survey and Plan for Maryland—Part III Rosewood State Training School, another of the five State-owned institutions in this group, is located at Owings Mills in Baltimore County. Its admissions are limited exclusively to feebleminded white patients. Its present capacity is 1,386. While admission is limited to patients between the ages of six and 16 years, patients once admitted may remain for life or until discharged. The beds at Rosewood were in- cluded in this survey, but were eliminated from the tabulations of available beds for mental patients in the State when compared with the maximum established in Public Law 725. The following is an excerpt from The Maryland State Budget:1 The Rosewood State Training School, formerly known as the Maryland Asylum and Training School for the Feebleminded, but which name was changed by Chapter 187, Acts of 1912, is located at Owings Mills, Maryland. It was incorporated in 1888 and opened in February 1889 with the admission of seventeen patients. . . . There is a hospital building, thirteen cottages for children, two school buildings, an administration building, laundry, kitchen building, power house, water treatment plant, sewage disposal system and a number of farm or out buildings erected on the farm of 587 acres. The property has an inventory value of $2,442,176. The annual average population of children in 1944 was 1,165 and the per capita cost was $356.00.2 The function and purpose of the institution is the education, training, care and treatment of feebleminded children. Springfield State Hospital at Sykesville in Carroll County maintains 3,011 beds. This hospital is in- tended primarily to serve the Western counties, in- cluding Garrett, Allegany, Washington, Frederick, Montgomery, and Carroll counties. Its records show that residents from every county in the State and a large number from the City of Baltimore are accepted here. One department of 100 beds is reserved for the care of mental patients found to have tuberculosis. In this department there are 50 beds for female and 50 beds for male patients. Patients at Spring Grove State Hospi- tal and Eastern Shore State Hospital, who are found to have tuberculosis, are transferred to the tuberculosis section at Springfield. Psychiatric epileptic patients are centered also at Springfield. For this type of patient, there is a colony of 466 beds. The following is an excerpt from The Maryland State Budgets The Springfield State Hospital is located at Sykesville, Carroll County, Maryland. This State Institution for the care and treatment of the white insane was estab- lished by Chapter 231, Acts of 1894, The property consists of 1,391 acres. The inventory value of land, buildings and equipment is $3,726,161. The average population in the 1944 fiscal year was 2,959, at a per capita cost of $282.4 After authorization has been received from the Com- missioner of Mental Hygiene, patients are accepted for admission if accompanied by commitment certificates of two physicians and an order of the Department of Public Welfare of Baltimore City, or the County Commissioners of the County of which they are residents, or by Court order. All patients are first received at the Hubner Building, where they are routinely given thorough physical ex- aminations. Mental examinations are made by assigned physicians who present the cases with written abstracts before the entire staff within a month. The hospital has a well equipped operating room where minor surgery is done by the resident staff and major by competent consulting surgeons. The tubercular unit cares for all the white tuberculous insane for the entire state. An eye clinic is conducted at the hospital twice monthly by a specialist from Baltimore. Patient statistics for the 19-14 fiscal year are as follows: 591 admissions; 188 deaths; 423 discharges. . . . At the beginning of the fiscal year there were 615 on parole, or otherwise absent, and at the end 529. At the end of the fiscal year the total number of patients in the hospital was 2,984. Spring Grove State Hospital located at Catonsville, just outside the limits of Baltimore City, has 2,214 beds. Its service area includes: Howard, Baltimore, Harford, Anne Arundel, St. Mary’s, Charles, Calvert, and Prince George’s counties and Baltimore City. The white male and female criminally insane from the entire State are committed here. For this purpose, there are 61 beds for male and 60 for female patients. The following is an excerpt from The Maryland State Budget:5 The Spring Grove State Hospital is located at Catons- ville, Baltimore County, Maryland. This hospital is the third oldest hospital in the United States for the care and treatment of the mentally sick. It was founded in 1797. It was first incorporated as “The Maryland Hospital” and was located on the present site of the Administration Building of the Johns Hopkins Hospital. It was established by Article 44 of the Annotated Code of Maryland, and is devoted exclusively to the treatment of white, insane, male and female citizens of Maryland. The property consists of 637 acres; the inventory of land and buildings and equipment is $4,175,586.40. The average population for the fiscal year of 1944 is 2,156. The percapita cost in the fiscal year of 1944 is $294.6 Eastern Shore State Hospital, located at Cambridge in Dorchester County, has 492 beds. It was established to render service to the mentally ill of the Eastern Shore. Patients are admitted from Cecil, Kent, Queen Anne’s, Caroline, Talbot, Dorchester, Wicomico, Wor- cester, and Somerset counties. In line with the practice of grouping certain types of patients at the various institutions, this hospital is the center for alcoholic patients and drug addicts. The following is an excerpt from The Maryland State Budget:1 The Eastern Shore State Hospital is two and a half miles southeast of Cambridge, Dorchester County, on State Highway No. 16. It was established by Chapter 245, Acts of 1912, for the care of white mental defectives and mentally ill adults of the Eastern Shore. The buildings were accepted and first used in 1915. Since 1939 it has xOp. cit., p. 194. 2The per capita allowance for 1948 was set at $733.00. 3Op. cit., p. 197. 4The per capita allowance for 1948 was set at $580.00. 50p. cit., p. 201. 6The per capita allowance for 1948 was set at $600.00. 1Op. cit., p. 191. Mental Hospitals 95 received all white drug and alcoholic addicts court-com- mitted in the state. It now furnishes all psychiatric con- sultation and mental hygiene service requested by public agencies and practicing physicians of the nine Eastern Shore Counties. Emergency commitments are arranged by telephone dis- cussion with the personal physician or the proper county or state authority; court commitments are accepted on presentation of the court orders; all other admissions are arranged after direct field investigation by a member of social service or medical staff. The property consists of 395 acres of land and water, the necessary buildings and equipment, with a total inventory value of $981,337. During the fiscal year 1944 an average daily patient population of 459 was cared for at a per capita cost of $368d There were discharged as recovered 47% as many mentally ill as were admitted. PROPRIETARY INSTITUTIONS The proprietary hospitals offering service to the mentally ill average 40 beds per institution. One has a total of 85 beds and another 69 beds. The remainder have 50 beds or less with the smallest maintaining only 12 beds. There are three important nonprofit institutions for the care of the mentally ill. They are The Seton In- stitute, with 396 beds maintained and operated by a Catholic Order; the Sheppard and Enoch Pratt Hospi- tal, with 300 beds operated as a nonprofit corporation; and the Phipps Psychiatric Clinic, a part of the Johns Hopkins Hospital, with 87 beds. All of these are located in the vicinity of Baltimore City. One other institution for the care of mentally ill patients in the State is maintained by Allegany County at Cumberland. This is only a vestigial rem- nant of a county home. In this institution are 96 beds for the care of mental patients largely on a custodial basis. The Bowditch Hospital School, at Ruxton in Balti- more County, and the Silver Cross Home for Sane Female Epileptics, at Reisterstown in Baltimore County, both nonprofit institutions, were included in the survey; but because they limit their work to the care of epileptics, their bed totals were excluded from the tabulations of mental hospital beds. Acceptable beds The inventory of institutions rendering services to the mentally ill was reviewed for the purpose of re- ducing it to those caring only for psychotic patients. Institutions limiting admissions to feebleminded or epileptic patients were eliminated from the final tabulation. Beds in excess of normal capacity and those in institutions which had inadequate facilities and personnel or presented other hazards were also deleted. After such deletions were made, it was found that 7,278 acceptable beds were in service in the State. Standards On the basis of the United States Public Health Service standard for this category of 5.0 beds per 1,000 population, and a State-wide population of 2,017,971,2 there should be 10,090 mental hospital beds available in the State. The number of existing acceptable beds is, therefore, inadequate by 2,812 beds. This shortage is evidenced by the fact that the total number of beds in service for this type of patient ex- ceeds the total normal capacity of the institutions by 839 beds. This overcrowding is accomplished by reduc- ing the floor space per patient. In the State-owned in- stitutions, the standard floor space is 45 square feet per regular bed and 50 square feet per bed in the infirmary and in the section for the criminally insane, which is low compared with accepted standards of 80 square feet per bed. The unsatisfactory conditions resulting from over- crowding have been made more acute by the shortage of personnel. The isolated locations of the State-owned mental hospitals and the nature of the work have con- tributed to the personnel shortage. Maryland’s mental hygiene problem is today com- plicated by the cumulative effects of the war during which construction was prohibited and personnel com- mandeered for war service, and of the postwar period during which personnel for this type of service have been practically unobtainable. The State Board of Mental Hygiene is aware of the shortage of facilities, both for patients and for the hous- ing of employees. In its request to the 1947 General Assembly, it rated employees’ housing facilities as of first importance. This is logical in that proper housing is necessary in order to attract personnel to the isolated locations of the mental hospitals. Without qualified personnel in adequate numbers, therapeutic programs cannot be undertaken satisfactorily. The institutions then fail in the most important aspect of their programs, which is rehabilitation and return of their patients to society, and revert to the old program of merely ac- cumulating the mentally ill. The General Assembly recognized the urgency of the need and appropriated funds for employees’ quarters. A program for the construction of 2,812 additional beds would entail a large outlay of funds and should be planned over a period of years as such funds can be made available and used effectively. Since the State-owned mental hospitals are self- contained communities, the additions probably will re- quire the expansion of utilities. These may be expected to entail important expenditures and, hence, cause a slowing-up of the program. Psychiatric departments in general hospitals One of the most important phases of the program is the provision of psychiatric departments in general hospitals properly spaced across the State. These de- partments would supply a place locally for the person who suddenly has become disturbed and unmanageable. Such conditions are at time transitory episodes not due to actual mental illness. Other conditions which fall in the category of mental illness which would be of short duration could be cared for in such departments. These departments, having other staff specialists available in addition to a psychiatrist, could institute diagnostic and therapeutic services, and thereby screen xThe per capita allowance for 1948 was set at $778.00. 2United States Bureau of the Census, Estimated Civilian Population, 1945. 96 Hospital Survey and Plan for Maryland—Part III patients so that a minimum of time is lost. Only those patients unable to cooperate and requiring special facilities need be referred to the mental hospitals. Such psychiatric departments should be supple- mented by outpatient service, caring for patients who do not require institutional care and for postinstitutional patients. Allocation of beds For these reasons, construction of psychiatric units as additions to general hospitals was given “A” priority. To promote better distribution of services to mental patients, “B” priority was given new facilities at new locations. The allocation of facilities by race was calculated on the basis of estimates supplied by the Bureau of Vital Statistics of the State Department of Health (Appendix J). A conference was held with Dr. George H. Preston, Commissioner of Mental Hygiene, to integrate the planning of the Bureau of Mental Hygiene and of the Hospital Survey Committee. As a result of this con- ference 2,812 additional beds, sufficient to bring the ratio up to 5.0 beds per 1,000 population, were tenta- tively allocated according to the schedule shown in Table U. The Hospital Survey Committee, having reviewed this program with the Board of Mental Hygiene, con- siders the additional facilities to be needed for the care of the mentally ill, and is of the opinion that the quickest way to get relief in this field is to build addi- tions to existing hospitals. However, it seriously ques- tions the desirability of continuing to build to the already huge institutions. Consideration should be given to the establishment of one or more new in- stitutions according to the geographic needs of the State. It is understood that expansion of utilities at exist- ing institutions is already necessary and that, before additional patient facilities can be added, many of the utilities in these institutions require great expansion. Now would seem to be the time to make a decision as to future policy. If these additions are made, anticipating any such growth as herein contemplated, it would tend to estab- lish as policy the indefinite expansion at these locations. If a change of policy were adopted, namely, the estab- lishment of facilities at new locations, it would seem necessary to restudy the grouping of types of patients within all of the institutions. The Committee is not satisfied that the values of concentrating this construction at a new location have been fully explored. The restudy of this possibility is such a protracted process that this Committee does not feel justified in delaying the publication of the report to pursue in- quiries. It takes no stand as between the two pos- sibilities, but refers the questions to the State Board of Health and its Advisory Council on Hospital Construc- tion for consultation with the Board of Mental Hygiene for final determination. If construction follows these allocations listed, the number of beds for mentally ill patients will be on the ratio of 5.0 beds per 1,000 population; the number of beds allocated for nonwhites will be in the same pro- portion as the nonwhite population is to the total population; and psychiatric units will be reasonably available to all residents of the State. It will be noted that all of the beds required to bring the total up to the United States Public Health Service standard were allocated to State-owned hospitals with the exception of the psychiatric beds. Should any pro- jects be initiated for the construction of additions to existing nonprofit institutions, or for the establishment of new nonprofit mental hospitals, allotments of beds should be taken from the number now allocated to the State-owned institutions which would be relieved by such construction. Senile patients It is an established fact that active disturbed mental patients and those who present a danger to themselves and others can be cared for more properly in the en- vironment of the specialized facilities in mental or psychiatric hospitals. However, there are those, such as the senile patient, whose requirements are primarily domiciliary and hygienic care, and some question might be raised as to their proper placement in mental hospitals. If left alone, they frequently deteriorate into a state of mental, physical, and environmental in- difference. For their physical well being, they need considerable help and attention to maintain standards TABLE U: ALLOCATION OF PROPOSED ADDITIONAL BEDS FOR MENTAL PATIENTS Name of Institution Normal Bed Ca- pacity Additionai Beds Springfield State Hospital, Sykesville Spring Grove State Hospital, Catonsville Crownsville State Hospital, Crownsville1 2,688 2,013 1,044 Male disturbed patients Female disturbed patients Infirmary Convalescent patients Senile patients Relief of overcrowding Female admissions build- ing and convalescent section Criminally insane and psychopaths Relief of overcrowding Relief of overcrowding 100 planned 100 planned 100 planned 100 planned 300 needed 159 needed 250 planned '350 planned 300 needed 591 needed Eastern Shore State Hospital, Cambridge 466 Increased capacity 221 needed University Hospital, Baltimore City 0 Psychiatric unit 125 recommended Memorial Hospital, Cumberland 0 Psychiatric unit 31 recommended Union Hospital, Elkton 0 Psychiatric unit 15 recommended Peninsula General Hospital, Salisbury 0 Psychiatric unit 20 recommended Frederick City Hospital; Frederick 0 Psychiatric unit 20 recommended Prince George’s General Hospital, Cheverly 0 Psychiatric unit 10 recommended Washington County Hospital, Hagerstown 0 Psychiatric unit Total 20 recommended 2,812 1 Reserved for non white patients. Mental'Hospitals 97 of health and cleanliness. For their mental well being, they need more than food and a bed in an attic or a converted storage room. With the present inadequacy of mental hospital beds, the question presents itself: Should the capacities of mental hospitals be expanded to include the senile type of patient, or should they be placed in another type of institution, or can they be cared for in subsidized private homes? The institutions for the care of the nervous and mental patients are all operating far beyond their rated capacities. Because of their isolated locations, the nature of their work, to which not all persons are suited, and because of salaries offered, their problems are made more acute by the shortage of personnel. Buildings which can be manned are in operation and universally crowded. While efforts are being made to solve the facilities and personnel problems, continuing shortages have in- fluenced policies resulting in a selection of cases for admission to mental hospitals. The senile type of patient has been practically eliminated. Such elimina- tion is not necessarily dictated by written policy. It is an outgrowth of the repeated failure to have such patients admitted for care. Also, physicians familiar with the problems of the mental hospitals hesitate to recommend commitment of senile patients, suggesting instead care in the home with the employment of some help, or transfer of the patient to a nursing home. Since senile patients already are practically elimi- nated from admission to overcrowded mental hospitals, they should be cared for in new facilities. It is quite apparent that the chronic disease hospitals now planned will fall far short of the needs of the chronically ill. The construction of additional separate facilities for the senile patients at the existing State mental hospi- tals also runs counter to the hope that these institu- tions will not continue to expand in size. In either approach to a solution, new facilities are required for senile patients and the policy must be established for their care either under the mental health or chronic disease program. Further study is recom- mended, in which serious consideration should be given to the construction of facilities specifically for senile patients. Such new facilities may be either independent hospitals, or additions to mental or chrome disease hospitals. A more immediate partial solution to the problem can be accomplished by encouraging nursing homes and foster homes to accept such patients. Feebleminded patients Feebleminded children already have been provided for at the Rosewood State Training School. The isolation and protection provided these patients ap- pear to be a proper procedure. The child handicapped through lack of mental faculties presents dangerous potentialities in a community and, if kept at home, is demoralizing to the other members of the family. This type of patient in an institution for the care of feebleminded patients is in an environment compatible with his capabilities. Training programs geared to his capacity can usually develop the patient to the maxi- mum extent of his mental limitations. While admissions to Rosewood are limited to patients between the ages of six and 16 years, once admitted, they are continued as patients until discharge or death. As a result, there is an accumulation of older patients to the point where, of 1,386 patients, 216 are between the ages of 16 and 21 years, and 660 are over 21 years of age. Since there is a waiting list of those needing the type of service offered at Rosewood, it is desirable to pro- vide other or additional facilities to which patients can be transferred once they have attained the pre- determined age for transfer, such as 21 years. Unless some such program is undertaken, candidates for ad- mission may remain on the waiting list through the entire period when some progress might be made under a training program. Others may be forced to wait until they are 16 years of age, beyond which admission is not permitted. It is illogical to place the older feebleminded patients in chronic disease hospitals. Most of the regular patients who will qualify for admission to such in- stitutions will be disabled or physically feeble but will have their mental faculties. The feebleminded patients would be largely incompatible with the cardiacs, hypertensives, arthritics, and others having long- term illnesses. It is recommended, therefore, that separate facilities for older feebleminded patients be erected at places other than in conjunction with the chronic disease hospitals. Such additional facilities for feebleminded patients placed at one of the established State mental hospitals would have some advantages. The patients are not too unlike those already cared for in these institutions. There is sufficient acreage already owned. However, Spring Grove State Hospital and Spring- field State Hospital already are very large institutions and both are faced with an acute need for additional facilities for their present patient load. The feeble- minded patients at the time of transfer would present the problem of accommodating themselves to the new environment and might become difficult to manage. The period of adjustment may be long. The disad- vantages to the institutions and the patients would weigh against establishing facilities for the older feeble- minded at the present mental hospitals. It is more logical to place such additional facilities at Rosewood. The Rosewood personnel is trained in handling this type of patient. The patients themselves would not be retarded by the need to become acclimated in an entirely new environment. Instead, their transi- tion from the division of younger patients to the facili- ties for overage patients would be gradual. Rosewood has sufficient acreage for such additional buildings, but its utilities would need to be expanded. Conclusions There is a serious need for additional mental hospital facilities. 98 Hospital Survey and Plan for Maryland—Part III These additional facilities should include psychiatric departments in general hospitals. Personnel housing facilities are needed at the State- owned mental hospitals. Such construction is essential to the establishment of proper service to the patients in the existing beds. There is a need for facilities for the care of senile patients. The chronic disease hospitals now planned will fall short of the needs of the chronically ill and, therefore, will not allow for the inclusion of senile patients; nor is this desirable. Facilities are needed for the care of feebleminded above the age of 16 years. The mental health program under Federal aid and the establishment of outpatient departments at hospi- tals in conjunction with psychiatric departments are needed for case finding and preventive work and am- bulatory treatment. Psychiatric departments in general hospitals will furnish educational and training opportunities to physicians, nurses, and auxiliary personnel and, at the same time, establish this type of case as one with potentialities for recovery rather than one of hopeless outlook. Recommendations It is recommended that: 1. Construction of mental hospital facilities be in- stituted as rapidly as possible to bring the total to a ratio of 5.0 beds per 1,000 population. 2. Construction of psychiatric departments of gen- eral hospitals be encouraged. 3. Additional facilities be constructed to permit segregation by age of patients otherwise now cared for at Rosewood. 4. Facilities for the care of senile patients be con- structed as separate departments of the State hospitals, or at new locations. 5. The mental health program for which Federal matching funds have been made available be instituted as early as possible. Chapter 10. PUBLIC HEALTH FACILITIES Public health facilities and services are supplemental to the services of physicians and medical institu- tions. They are an important part of a complete health program which envisions proper preventive and cura- tive medical and surgical services available financially and geographically to everyone. Health offices are established in every county and in Baltimore City (Map 7). Under this arrangement, geographic distribution is achieved. Joint financial participation by the State and local governments con- tributes to uniformity and integrationo of programs and policies. The problems in this field are those of adequate hous- ing, suitably located, containing sufficient space to carry on the program. At present, most health centers and clinic facilities throughout the State are located in rented buildings, or use space in public buildings by sufferance. In many instances, the quarters are inadequate or unsatisfactory. Because of the limited funds available for this pro- gram, consideration was given only to administrative centers, which include some clinic facilities. Auxiliary clinics were omitted for the present. The housing accommodations of each center were surveyed on the basis of visits and reports by health officers. The findings were reviewed with the Director of the State Department of Health and the Com- missioner of Health of Baltimore City. Each center was considered as to size, location, and structure. The areas in which new facilities were needed urgently were listed, with those least satisfactory being placed at the top of the list. At the conclusion of the review, the first seven centers listed were as follows: 1. Carroll County 2. St. Mary’s County 3. Calvert County 4. Southern Health District, Baltimore City 5. Caroline County 6. Worcester County 7. Frederick County Carroll County is at present without a general hospi- tal. The present interest of the community is in the establishment of a diagnostic health center. This diagnostic health center should be so designed and lo- cated that it will later serve as the nucleus for a hospital. The public health facilities of St. Mary’s County are located in entirely unsatisfactory quarters on the sec- ond floor of a frame commercial building. New quarters should be provided at the St. Mary’s Hospital, under a building program which would entail the replace- ment of the old hospital structure which is now at- tached to the new hospital. The new addition is pro- vided for under allocation of general hospital beds with which the funds for public health facilities could be combined. The public health department of Calvert County is in a very unsatisfactory location. Under “General Hospitals” (Chapter 6) it is recommended that the Calvert County Hospital be replaced. When this is done, space should be provided in the new hospital for the county health offices and clinics. Baltimore City is divided into eight health districts, shown on Map 7, as follows: The Southern Health District does not have any building at present. Some funds have been appro- priated by Baltimore City for construction of a facility. Since the Southern District is heavily populated and in urgent need of quarters, this project is recommended. The Eastern Health District is served by a building which has been adapted to the needs of a health center, but is inadequate. A new building constructed for the purpose is needed at this location and is considered urgent by the Health Commissioner. The Southeastern Health District headquarters is established in an old school building which, while meeting the need, is not satisfactory. The Western Health District is served by a facility at 617 West Lombard Street and by the Druid Health Center. The Commissioner of Health considers addi- tional space at the Druid Health Center as necessary. The Southwestern, Northwestern, Northern, and North- eastern Health Districts have no headquarters buildings at present. As the more urgent needs in other districts are met, plans should go forward for centers in these districts, so that eventually each health district will be serviced by a headquarters building located within the district. Caroline County is in need of a new public health center. There is local interest in the establishment of a community health center to include about 15 beds along with public health facilities. It is generally recognized that such a small funit is inefficient to operate. A false sense of security is developed around a hospital unit of such limited scope, with the result that patients requiring the services usually offered only in larger institutions receive in- adequate care. This results in delay in obtaining service or the hospitalization of cases beyond the scope of the institution. A public health center with ambulance service to Easton brings hospital care sufficiently close for safety. Plans are under consideration for an addi- tion to the Easton Hospital which would increase its capacity sufficiently to provide for the care of residents from Caroline and Talbot counties. The allotment of beds to this area has been made large enough to meet this need. A public health facility for Caroline County falls in the “A” priority bracket, whereas a hospital unit or community health center, such as is being considered locally, would fall in the “B ” bracket, if approved at all. Worcester County is in need of better quarters for its county health offices. At present the construction of a hospital is being considered by the residents of this area. Should the hospital materialize, quarters for the 100 Hospital Survey and Plan for Maryland—Part III MARYLAND STATE PLANNING COMMISSION 1947 LEGEND EXISTING ACCEPTABLE PUBLIC HEALTH CENTER PROGRAMMED PUBLIC HEALTH CENTER (EXISTING FACILITY UNSUITABLE) PUBLIC HEALTH FACILITIES O EXISTING ACCEPTABLE AUXILIARY FACILITY NOTE: EACH COUNTY CONSTITUTES A PUBLIC HEALTH DISTRICT SEE KEY FOR IDENTIFICATION MAP 7 Public Health Facilities 101 Key to Map 7 Allegany County A—Cumberland B—Mt. Savage C—Frostburg D—Zihlman E—Lonaconing F—W ester nport G—Cresaptown Anne Arundel County A—Annapolis B—Lothian C—Davidsonville D—Odenton E—Glen Burnie F—Linthicum G—Pasadena H—Parole Baltimore County A—Towson B—Essex C—Middle River D—Pikes ville E—Randallstown F—-Reisterstown G—Chase H—Catonsville I—Cockeysville J—Turners Station K—Sparrows Point L—Halethorpe M—Overlea N—Dundalk Calvert County A—Prince Frederick Caroline County A—Denton B—Greensboro C—Federalsburg Carroll County A—Westminster Cecil County A—Elkton B—Cecilton Charles County A—La Plata Dorchester County A—Cambridge Frederick County A—Frederick Garrett County A—Oakland B—Grantsville C—Friendsville D—Kitzmiller Harford County A—Belair B—Edgewood C—Aberdeen D—Havre de Grace Howard County A—Ellicott City Kent County A—Chestertown Montgomery County A—Rockville B—Poolesville C—Damascus D—Olney E—Gaithersburg F—Colesville G—Bethesda H—Silver Spring I—Takoma Park Prince George’s County A—Upper Marlboro B—Hyattsville C—Aquasco D—Laurel E—Fairmount Heights F—Lanham Queen Anne’s County A—Centerville St. Mary’s County A—Leonardtown Somerset County A—Princess Anne B—Crisfield Talbot County A—Easton Washington County A—Hagerstown Wicomico County A—Salisbury Worcester County A—Pocomoke City B—Snow Hill C—Berlin Baltimore City A—City Health Department Municipal Office Building (2) B—Western Health District 617 West Lombard Street (1) C—Druid Health Center 1313 Druid Hill Avenue (17) D—-Southeastern Health District 901 South Kenwood Avenue (24) E—Eastern Health District 1923 East Monument Street (5) F—Northeastern Health District G—Northern Health District H—Northwestern Health District I—Southwestern Health District J—Southern Health District 102 Hospital Survey and Plan for Maryland—Part III public health office should be included. If it does not, a separate public health facility should be developed. The county health office in Frederick is located in a very old structure which is unsatisfactory. The Fred- erick City Hospital is giving active consideration to plans for an additional wing. The quartering of the public health service in this wing would be a move toward efficient use of personnel and facilities. Both the State Department of Health and the De- partment of Health of Baltimore City are in urgent need of more adequate housing for their administrative headquarters. However, as presently contemplated, such construction probably would not qualify for assist- ance under the provisions of the Federal Act. Therefore,, no opinion is expressed on the degree of their urgency in relation to other projects mentioned herein. The needs of the other counties and of Baltimore City are generally only slightly less urgent then the seven centers listed. Some areas are making plans for new structures to house their public health departments. As funds become available and the more urgent needs are provided for, consideration should be given to the plans for new facilities in those areas. Conclusions The City of Baltimore is divided geographically into eight health districts. This is a satisfactory ar- rangement organizationally. There is a need for hous- ing for the headquarters office and clinic facilities in most of the districts. The arrangement by which each county has its own county health department, which is a part of the State Health Department organizationally and financially, is eminently satisfactory. In the counties, health centers should be located in hospitals wherever possible to make efficient use of personnel and equipment and for many other com- pelling reasons. Most of the health centers are located in structures which were not designed for this purpose and are un- satisfactory from the standpoint of function. The auxiliary clinic locations are, in most instances, in satisfactory locations geographically, but are in need of better housing and more space. Recommendations It is recommended that funds for construction of public health service facilities be allotted to the fol- lowing areas as local matching funds become available. They are arranged in order of urgency. 1. Carroll County 2. St. Mary’s County 3. Calvert County 4. Southern Health District, Baltimore City 5. Caroline County 6. Worcester County 7. Frederick County It is further recommended that where hospital con- struction is being planned in the counties, the public health facilities should be planned as a part of such construction. Federal funds up to 10% of the total funds available to the State should be allocated to public health facilities. PART IV PRIORITIES Chapter 11. PRIORITIES SYSTEM Important deficiences in each of the five categories of hospitals and limited funds available for grants- in-aid for the construction of the needed facilities made the establishment of priorities necessary. It was considered essential to formulate a method for the establishment of priorities within the categories as well as between them which would embody the principles enumerated in Subpart E, Sections 53.41 through 53.47 of the Regulations (Appendix B). Because of the autonomous character of general hospitals, a special method was used in determining priorities within that category. A different set of priority policies was applied to tuberculosis, chronic disease, and mental institutions, these being largely State-owned and generally available to all residents of the State. In the field of public health, an appraisal of existing facilities was used. Establishment of priorities between the categories was found to be a complex undertaking. However, a method was devised which gives reasonable compara- tive priority status to the projects in the different types of facilities. GENERAL HOSPITALS The State was divided into general hospital service areas. Each of these represented the delineation of the area served by the general hospital or hospitals within the area. In this category priorities were established between areas. On the basis of standards issued by the United States Public Health Service and the judgment of the Com- mittee, these areas were classified as base, intermediate, and rural. The minimum standard in each type of area was established as: Rural area—2.5 beds per 1,000 population Intermediate area—4.0 beds per 1,000 population Base area—4.5 beds per 1,000 population The over-all State standard was set at 4.5 beds per 1,000 population. The differential between the State standard and the rural area standard left 2.0 beds per 1,000 population, which were placed in what was termed the pool. The differential in the case of intermediate areas left 0.5 beds per 1,000 population for the pool. Assignments were made from the pool to areas which needed more beds than the minimum standards. In making allocations from the pool, such circumstances as high utilization of existing facilities, rapidly chang- ing population, and other factors were taken into con- sideration. The resultant figures, that is, the area standard supplemented by allocations from the pool, were considered the determined needs. The number of existing beds was established by the survey. The normal number of beds for which each hospital had been constructed was reduced by the number of beds located in buildings classified as un- acceptable, thus arriving at the acceptable normal bed capacity. The per cent to which the determined need was met was established by dividing the number of acceptable beds by the determined need. By this process, the per cent of met need was established (Table V). In this TABLE V: PRIORITY POINTS FOR GENERAL HOSPITALS, MET NEED ADJUSTED BY UTILIZATION OF EXISTING FACILITIES Total Accept- Per Cent Standard Differential Beds ABLE of Met Per Cent Per Cent Between Order of Needed Normal Need1 Occupancy Occupancy Actual and Priority Points2 Priority Area Bed R —60% Standard Per Capacity land B—70% Cent Capacity R-l, Garrett County 46 0.0 [ 1 R-2, Calvert County 26 — — — — — 0.0 i 2 R-6, Worcester County 60 — — — — — 0.0 / 3 1-2, Washington County 280 168 60.0 109.5 70 39.5 20.5 A \ 4 1-6, Talbot and Caroline Counties . . 179 87 48.6 90.4 70 20.4 28.2 1 5 R-5, Kent and Queen Anne’s Counties 63 25 39.7 69.2 60 9.2 30.5 ' 6 1-4, Montgomery and Prince George’s Counties 887 519 58.5 71.7 70 1.7 56.8 / 7 1-5, Cecil County 128 72 56.3 62.8 70 — 7.2 63.5 B ). 8 R-4, St. Mary’s County 70 45 64.3 57.5 60 — 2.5 66.8 1 9 1-8, Wicomico County 247 177 71.7 74.2 70 4.2 67.5 (.10 1-7, Dorchester County 112 65 58.0 59.5 70 —10.5 68.5 111 B-l, Baltimore Base Area 6,272 4,710 75.1 74.0 70 4.0 71.1 c I12 1-3, Frederick County 207 166 80.2 71.5 70 1.5 78.7 (13 1-1, Allegany County 485 410 84.5 67.3 70 — 2.7 87.2 114 R-3, Charles County 49 33 67.3 36.7 60 —23.3 90.6 D \ 1.5 R-7, Somerset County 43 38 88.4 57.1 60 — 2.9 91.3 (16 1 Acceptable normal bed capacity divided by total beds needed. 2Per cent of met need minus differential between actual and standard per cent occupancy. 104 Hospital Survey and Plan for Maryland—Part IV CHART I Occupancy rates for general hospitals UNITED STATES AND MARYLAND LEGEND UNITED STATES, 1940 UNITED STATES, 1945 MARYLAND SIZE GROUPS OF HOSPITALS UNITED STATES MARYLAND AVERAGE NUMBER OF BEDS PER HOSPITAL PER CENT OCCUPANCY AVERAGE NUMBER OF BEDS PER HOSPITAL PER CENT OCCUPANCY (BEDS) 1940 1945 1940 1945 1945-46 1945-46 under 20 13.3 14.0 46.4 57.7 1 7.0 49. 1 20 39 27.2 27.6 50.7 6 1.8 30.5 5 1 .4 40 59 47.5 48.0 57.2 67.9 46.2 6 1.7 60 79 68.1 67 .6 62.4 7 1.1 69.8 66.2 80 99 87.1 87 .7 66.3 73.1 8 7.0 67.3 1 00 139 1 14.6 I-15.4 68.6 76.4 1 1 5.4 70.9 1 40 199 164.7 1 65.2 7 1 .2 79.8 1 69.6 83.4 200 299 236.5 240.5 74.6 7 9.3 246.0 82.0 300 499 370.3 365.8 76.0 79.2 358.7 84.6 500 7 99 607.7 599.2 80.6 7 8.8 51 3.0 30.6 8 00 and over 1,5 44.2 1,725.6 79.8 70.3 873.0 76.7 MARYLAND STATE PLANNING COMMISSION 1947 Priorities System 105 manner, the factors which had been taken into con- sideration in allocating pool beds to individual areas were reflected in the resultant lower per cent of met needs for these areas. The use made of existing beds being an important index as to the urgency of need for additional facilities, the per cent of met need was modified to reflect the urgency. An institution with an abnormally high utilization or percentage of occupancy1 would indicate an immediate need for more facilities. Conversely, an institution with a lower than normal rate of oc- cupancy would not appear to be in urgent need of more beds. The degree of the urgency of the need is indi- cated by the extent of the differential between what is considered a normal rate of occupancy for the size of the institution and its actual rate. It has been demonstrated that the percentage of occupancy varies with the size of the hospital.2 In- stitutions with less than 100 beds normally operate at an occupancy rate near 60%, whereas large hospitals generally reach 70%, or higher (Chart 1). By this means, rural areas are given special consideration. Since small hospitals usually are located in the rural areas and larger ones in intermediate and base areas, 60% was established as the normal occupancy rate for hospitals in rural areas and 70% for those in inter- mediate and base areas. A comparison was made between the actual rate of occupancy as reported by the hospitals and the estab- lished normal. Where experience was higher than normal for the area, the differential of percentage points was subtracted from the percentage of met needs. By this procedure, the figure representing the per cent of met need was changed by the degree of differential between the actual -rate of occupancy and the estab- lished normal, thus giving the hospital with a high rate of occupancy a lower index and hence, a proportion- ately higher position on the priority schedule. The resultant figures were termed priority points and were tabulated in increasing order in Table V. They ranged from 0.0 to 91.3. The priority schedule was then divided into four groups, as follows: TUBERCULOSIS, CHRONIC DISEASE, AND MENTAL HOSPITALS Priorities within the categories of tuberculosis, chronic disease, and mental hospitals were set up on a State-wide basis. Within these categories, projects were considered to be of varying importance. Highest priority was given facilities constructed as additions to general hospitals. This is in line with current opinion that general hospitals should include facilities for tuberculous, chronic disease, and mental patients. Since general hospitals are located within urban areas, the problems of remoteness from home as a deterrent to patients accepting care, convenience of visitors, and supply of personnel and personnel hous- ing are more readily answered. Under such a program, the scope of service of general hospitals is broadened. At the same time, their educational activities become more inclusive. In the light of the proven fact that tuberculosis can be controlled and its incidence actually reduced, there is the probability that a point eventually might be reached when fewer beds will be needed, at which time those beds added to general hospitals for this purpose could be converted to other uses. Addi- tions to general hospitals for the care of tuberculous, chronic, or mental patients were, therefore, placed in “A” priority. Rated next in importance in these categories were new facilities at new locations. These should be located in or near population centers, thus overcoming the objections to the present isolated locations of most of the existing institutions. New facilities at new locations therefore were given “B” priority. Additions to existing facilities were given the lowest, or “C” and “D” priorities. An exception was allowed for the assignment of higher priority to service and personnel housing facili- ties. Although not increasing the number of beds for patients when added to or replacing facilities at exist- ing institutions, such improvements are considered imperative to the effective use of existing facilities. The criteria which will govern the granting of such higher priority will be based on the relative size of the project compared with the whole program and the rela- tionship between the cost of the projected construction and the demonstrated resultant increase in the effec- tiveness of the facilities. PUBLIC HEALTH FACILITIES Public health facilities exist in all of the counties and Baltimore City. Under the present system, the dis- tribution of facilities is satisfactory. While most of these facilities could be located in better buildings, with the limited funds available, the inclusion of pro- jects for such facilities was restricted to those which are least satisfactory. Through conference with the Di- rector of the State Department of Health and the Commissioner of Health of Baltimore City, these un- satisfactory facilities were arranged in the order of their urgency and divided as equally as possible among the four priority brackets. Priority Priority Number of Areas in Priority Group Group Points Rural Intermediate Base “A” 0.0— 40.0 4 2 0 “B” 40.1— 68.0 1 3 0 “C” 68.1— 80.0 0 2 1 “D” 80.1—100.0 2 1 0 The arrangement of general hospital service areas and the priority brackets were used later as a control for the establishment of quotas of beds in the priority brackets in the other categories.3 1 Utilization or percentage of occupancy is determined by mul- tiplying the normal bed capacity by 365 and dividing this figure jnto the days of service rendered in one year, multiplied by 100. 2“Hospitals Registered by the American Medical Association,” Journal of the American Medical Association, April 20, 1946, Hospital Number. 3See “Bed Quotas in Priority Brackets,” Chapter 12. 106 Hospital Survey and Plan for Maryland—Part IV Since the public health services are available through- out the State, the primary need in this category being for housing and not for the extension of services, Fed- eral funds allocated to this type of facility were limited to 10% of the amount of Federal funds available. First priority in this category will be given to facilities which will be constructed as parts of general hospitals. MET NEEDS BY CATEGORY The per cent of met need in each category was determined by using the State standards for the various categories and dividing them into the acceptable normal bod capacity in each category. The results are given in the adjoining tabulation. In the category of general hospitals, the adjusted met needs or priority points were used in the priority determinations on an area level rather than the per Category Total Beds Needed Acceptable Normal Bed Capacity Per Cent of Met Need General 9,154 3,177 6,515 1,743 71.2 Tuberculosis k4 oj white 71.8 nonwhite 36.2 Chronic disease .... 4,036 1,713 42.4 Mental 10,090 7,278 79 , /white 73.7 ' \ non white 63.5 cent of met need on a State level. When the per cent of met need was adjusted by the differential between the actual rate of occupancy of existing facilities and the established normal rate of occupancy, the resultant order of service areas was developed (Table V). Chapter 12. ALLOCATION OF PRIORITIES BY CATEGORIES Having thus determined priorities within the various categories of hospitals, it was then necessary to determine a relative priority for each of the various categories of hospitals. The “Schedule of Priorities” (Table W) is based on the method finally devised. Under the priority system, six general hospital serv- ice areas which have less than 40 priority points have “A” ratings. Four of these are rural and two interme- diate. Since the priority points for these areas range from 0.0 to 40.0, applications on these projects will be given first consideration for approval. After these areas have been given an opportunity to waive the right or to submit a project attesting their ability to supply their portion of the construction funds, along with assurance as to their ability to finance operation of the project, remaining Federal funds will be held available for projects in the “A” priority bracket in the other categories. Since the met need in the category of tuberculosis hospitals for nonwhite patients is 36.2% and lower than in the other categories, “A” priority projects will be considered next for tuberculosis facilities for these patients. In order to qualify for “A” priority, pro- jects must be additions to or parts of general hospitals. Chronic disease, mental, and tuberculosis facilities for white patients, as additions to or parts of general hospitals, will be next in line for approval. After projects which qualify for “A” priority have been allocated funds or have been eliminated by reason of failure to submit applications, the projects in the “B” bracket will be considered. Under the “B” bracket, general hospital projects, tuberculosis facili- ties for nonwhite patients, and chronic disease hospi- tal projects, which are new facilities at new locations, will be given equal consideration. Following these, projects for tuberculosis hospitals for white patients and mental hospitals, to be new facilities at new locations, will be considered. When all such projects have either been approved or set aside because of failure to submit applications, consideration will be given similarly to projects in the “C” and “D” brackets. BED QUOTAS IN PRIORITY BRACKETS In order to maintain an equitable balance in the number of beds which might be established in each category, the general hospital bed allocations were used as the control. The general hospital service areas were listed in the order of their priority points. The number of beds allo- cated to the six areas in the “A” priority bracket total 374, or 14.2% of the total unmet need in this category (Table W). This percentage of unmet need was estab- lished, therefore, as the limit of beds which might be added in the other categories under “A” priority pro- jects. This same procedure was applied under the other priority brackets with the following results: Beds to be Added Under “A” Priority 14.2% of Unmet Needs General Hospitals 374 Tuberculosis Hospitals: White 67 Nonwhite 137 Chronic Disease Hospitals., 330 Mental Hospitals: White 315 Nonwhite 84 Total 1,307 Applied to each priority bracket, the resultant totals for all categories are: “A” priority 1,307 beds “B” priority 1,815 beds “C” priority 5,756 beds “D” priority 330 beds Total Unmet Needs 9,208 beds As a precaution against the possible situation where one large project might absorb a disproportionate share of the funds available, no single project may he permitted to use more than 50% of an annual allotment of Federal funds if other acceptable applications are pending. TIME LIMITS ON APPLICATIONS In order to avoid a stagnation of the program by rea- son of the failure of groups with high priorities to exercise their rights to funds, time limits were estab- lished for the filing of projects. Projects which qualify under the “A” bracket will have until April 1, 1948, to file applications. If Federal funds available for the current period are not entirely exhausted by the approved applications, notice will be sent to other groups according to their priority positions, advising them of the opportunity to submit their project applications. Potential appli- cants so notified would have until May 1st of the fol- lowing year to submit their proposals. This procedure of considering projects semiannually will be followed throughout the life of the program ex- cept when available funds would be lost by waiting until the next filing date. In such case, the State agency will call for further project applications on shorter notice, PRIORITY ADJUSTMENTS When projects are approved for construction, the priority status of other projects will be reviewed for the purpose of determining the effect of the approved project on the need for other facilities. The priority position of remaining projects will then be adjusted to compensate for the change in urgency of need. APPEAL AND HEARING PROCEDURE The State Board of Health shall provide an oppor- tunity for a fair hearing to applicants who are dissatis- fied with the action taken on their applications by the State Department of Health. 108 Hospital Survey and Plan for Maryland—Part IV TABLE W: SCHEDULE OF PRIORITIES AREA BASIS STATE-WIDE BASIS Public Health Facilities Totals General Hospital Beds Tuber- culosis Hospital Beds Chronic Disease Hospital Beds Mental Hospital Beds White Non- white White Non- white Total beds needed Acceptable normal bed capacity Unmet need Per cent met need 9,154 6,515 2,639 By area—0.0% to 88.4% Beds Allotted 3,177 1,743 1,434 54.9% 71.8%|36 2% 4,036 1,713 2,323 42.4% 10,090 7,278 2,812 72.1% 73.7 %|63.5 % 26,457 17,249 9,208 “A” PRIORITY BRACKET “A” priority includes up to 14.2% of unmet need in each category R-l, Garrett County R-2, Calvert County R-6, Worcester County 1-2, Washington County 1-6, Talbot and Caroline Counties R-5, Kent and Queen Anne’s Counties 46 26 60 112 92 38 Faci dition ities to s to, or be constru iarts of, gen cted as eral hos ad- pitals Up to 10% of total funds available Beds which may be con- structed 374 67 137 330 315 84 1,307 Order of priority by category 1 4 2 3 4 “B” PRIORITY BRACKET “A” + “B” priorities include up to 33.8% of unmet need 1-4, Montgomery and Prince George’s Counties 1-5, Cecil County R-4, St. Mary’s County 1-8, Wicomico County 368 56 25 70 N sw faci ities at nev j locati ons Up to 10% of total funds available Beds which may be con- structed 519 92 190 460 438 116 1,815 Order of priority by category 1 2 1 1 2 2 “C” PRIORITY BRACKET “A” + “B” + “C” priorities include up tc 96.4% of unmet need B-l, Baltimore Base Area 1-7, Dorchester County 1-3, Frederick County 1,562 47 41 Additions to existing faciliti es Up to 10% of total funds available Beds which may be con- structed 1,650 292 604 1,452 1,389 369 5,756 Order of priority by category 1 1 1 1 1 1 “D” PRIORITY BRACKET “A” + “B” + “C” + “D” priorities include up to 100% of unmet need 1-1, Allegany County R-3, Charles County R-7, Somerset County 75 16 5 A( iditions to existing facilit ies Up to 10% of total funds available Beds which may be con- structed 96 17 35 81 80 21 330 Order of priority by category 1 1 1 1 1 1 Allocation of Priorities by Categories 109 Actions which entitle applicants to a hearing include the following: (1) Denial of opportunity to make formal application. (2) Rejection or disapproval of application. (3) Refusal to reconsider an application. Appeals from decisions or actions must be made by the applicant, in writing, within 30 days from the date of the decision by the State Department of Health. The appellant will be notified in writing of the time and place of hearing. The time and place of the hearing will be determined by the State Board of Health. The appellant is entitled to be represented by counsel. The appellant and other persons interested and con- cerned with the State Department of Health decision are entitled to present pertinent evidence in any way desired, subject to reasonable procedures of admissi- bility and methods of presentation. The appellant is entitled to examine all evidence and to question opposing witnesses. Such hearing will be held before the State Board of Health. The decision of the State Board of Health will be made in writing within 30 days from the date of the hearing, and will be based on the evidence presented at the hearing. A stenographic record of the hearing will be made and, upon the request and at the expense of the ap- pellant, will be transcribed and made available for examination. SUMMARY General hospital priorities between areas were based on the acceptable normal bed capacity divided by the total beds needed and adjusted by the differential between what was established as the normal per cent of occupancy for the area and the actual per cent of occupancy. The resultant figures, priority points, were broken into priority brackets as follows: Priority Group Priority Points “A” 0.0— 40.0 “B” 40.1— 68.0 “C” 68.1— 80.0 “D” 80.1—100.0 Tuberculosis, chronic disease, and mental hospitals were treated on a State-wide basis. “A” priority was given to facilities which will be additions to general hospitals. “B” priority was given to new facilities at new locations. “C” and “D” priorities were given to additions to existing facilities. Allowance was made for the granting of higher priority to projects for service facilities and personnel housing which would increase the effectiveness of existing facilities. Public health facilities were granted funds up to 10% of the total Federal funds available. The relative priority of projects in this group was established upon the recommendation of the Director of the State De- partment of Health and the Commissioner of Health of Baltimore City. The number of beds which may be added in each priority bracket in the categories of tuberculosis, chronic disease, and mental facilities are limited to a per cent of the unmet need equal to that allowed for general hospital beds in the same bracket. Applications for projects and approvals will be made at six-month intervals. Adjustment of priority positions will be made as projects affecting the urgency of other projects are ap- proved for construction. Under the above-described priority program, the projects in the various categories will be considered in the order of their need, based on a comparison be- tween the current met needs and the determined needs, along with the utilization of existing facilities. Rural projects will receive special consideration by reason of the lower normal per cent of occupancy standard. Groups having under consideration the construction of facilities will have equal opportunity to qualify under the program in proportion to the extent and urgency of the needs and the utilization of their exist- ing facilities. Provision is made for appeals and hearings in connection with applications submitted under the Hospital Construction Program. APPENDICES Laws and Regulations Page appendix A. Public Law 725, 79th Congress, and Amendments 111 appendix B. United States Public Health Service Regulations 115 appendix c. Chapter 810, Laws of Maryland, 1947 119 appendix D, Chapter 811, Laws of Maryland, 1947 — .120 appendix E. Chapter 716, Laws of Maryland, 1947 . ...120 appendix F. Chapter 210, Laws of Maryland, 1945.. ...121 APPENDIX G. Chapter 421, Laws of Maryland, 1945..... 122 appendix H. Chapter 170, Laws of Maryland, 1943 122 Tables appendix I. Population of Maryland by County, 1943, 1940, 1930, and 1920... 124 appendix J. Population of Maryland by Race and County, 1940 and 1945 .124 appendix K. Composition of Population in Maryland by County, Urban, Rural Nonfarm, and Rural Farm, 1940 125 appendix L. Per Capita Income in Maryland by County, 1940 and 1945 125 appendix M, Population Per Square Mile in Maryland by County, 1943 126 appendix N. Number of Physicians in Maryland by County, 1947 126 appendix 0. Total Births and Births in Hospitals in Maryland by Race and County, 1945 1 .126 appendix P. Per Capita Civilian Hospital Resources by State 127 APPENDIX A PUBLIC LAW 725—79th CONGRESS CHAPTER 958—2D SESSION (S 191) AN ACT To amend the Public Health Service Act to authorize grants to the States for surveying their hospitals and public health cen- ters and for planning construction of additional facilities, and to authorize grants to assist in such construction. Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That this Act may be cited as the “Hospital Survey and Construction Act.” Sec. 2. The Public Health Service Act (consisting of titles I to V, inclusive, of the Act of July 1, 1944, 58 Stat. 682) is hereby amended by adding at the end thereof the following new title: “TITLE VI—CONSTRUCTION OF HOSPITALS “Part A—Declaration of Purpose “Sec. 601. The purpose of this title is to assist the several States— “(a) to inventory their existing hospitals (as defined in section 631 (e), to survey the need for construction of hospitals, and to develop programs for construction of such public and other non- profit hospitals as will, in conjunction with existing facilities, afford the necessary physical facilities for furnishing adequate hospital, clinic, and similar services to all their people; and “(b) to construct public and other nonprofit hospitals in ac- cordance with such programs. “Part B—Surveys and Planning “Authorization of Appropriation “Sec. 611. In order to assist the States in carrying out the purposes of section 601 (a), there is hereby authorized to be appro- priated the sum of $3,000,000, to remain available until expended. The sums appropriated under this section shall be used for mak- ing payments to States which have submitted, and had approved by the Surgeon General, State applications for funds for carrying out such purposes. “State Applications “Sec. 612 (a) To be approved, a State application for funds for carrying out the purposes of section 601 (a) must— “(1) designate a single State agency as the sole agency for carrying out such purposes: Provided, That after a State plan has been approved under section 623, any further survey or pro- graming functions shall be carried out, pursuant to section 623 (a) (10), by the agency designated in accordance with section 623 (a) (1); “(2) provide for the designation of a State advisory council, which shall include representatives of nongovernment organiza- tions or groups, and of State agencies, concerned with the opera tion, construction, or utilization of hospitals, including rep- resentatives of the consumers of hospital services selected from among persons familiar with the need for such services in urban or rural areas, to consult with the State agency in carrying out such purposes; “(3) provide for making an inventory and survey in accordance with section 601 (a) containing all information required by the Surgeon General, and for developing a program in accordance with section 601 (a) and with regulations prescribed under section 622; and “(4) provide that the State agency will make such reports, in such form and containing such information, as the Surgeon Gen- eral may from time to time reasonably require, and give the Surgeon General, upon demand, access to the records on which such reports are based. “(b) The Surgeon General shall approve any application for funds which complies with the provisions of subsection (a). “Allotments To States “Sec. 613. (a) Each State for which a State application under section 612 has been approved shall be entitled to an allot- ment of such proportion of any appropriation made pursuant to section 611 as its population bears to the population of all the States, and with such allotment it shall be entitled to receive 33 1/3 per centum of its expenditures in carrying out the purposes of section 601 (a) in accordance with its application: Provided, That no such allotment to any State shall be less than $10,000. The Surgeon General shall from time to time estimate the sum to which each State will be entitled under this section, during such ensuing period as he may determine, and shall thereupon certify to the Secretary of the Treasury the amount so estimated, reduced or increased, as the case may be, by any sum by which the Surgeon General finds that his estimate for any prior period was greater or less than the amount to which the State was en- titled for such period. The Secretary of the Treasury shall there- upon, prior to audit or settlement by the General Accounting Office, pay to the State, at the time or times fixed by the Surgeon General, the amount so certified. “(b) Any funds paid to a State under this section and not ex- pended for the purposes for which paid shall be repaid to the Treasury of the United States. “Part C—Construction of Hospitals and Related Facilities “Authorization of Appropriations “Sec. 621. In order to assist the States in carrying out the purposes of section 601 (b) there is hereby authorized to be appro- priated for the fiscal year ending June 30, 1947, and for each of the four succeeding fiscal years, the sum of $75,000,000 for the con- struction of public and other nonprofit hospitals; and there are further authorized to be appropriated for such construction the sums provided in section 624. The sums appropriated pursuant to this section shall be used for making payments to States which have submitted, and had approved by the Surgeon General, State plans for carrying out the purposes of section 601 (b); and for making payments to political subdivisions of, and public or other nonprofit agencies in, such States. “General Regulations “Sec. 622. Within six months after the enactment of this title, the Surgeon General, with the approval of the Federal Hospital Council and the Administrator, shall by general regula- tion prescribe— “(a) The number of general hospital beds required to provide adequate hospital services to the people residing in a State, and the general method or methods by which such beds shall be distri- buted among base areas, intermediate areas, and rural areas: Provided, That for the purposes of this title, the total of such beds for any State shall not exceed four and one-half per thousand population, except that in States having less than twelve and more than six persons per square mile the limit shall be five beds per thousand population, and in States having six persons or less per square mile the limit shall be five and one-half beds per thousand population; but if, in any area (as defined in the regulations) within the State, there are more beds than required by the standards prescribed by the Surgeon General, the excess over such stand- ards may be eliminated in calculating this maximum allowance. “(b) The number of beds required to provide adequate hospi- tal services for tuberculous patients, mental patients, and chronic- disease patients in a State, and the general method or methods by which such beds shall be distributed throughout the State: Provided, That for the purposes of this title the total number of beds for tuberculous patients shall not exceed two and one-half times the average annual deaths from tuberculosis in the State over the five-year period from 1940 to 1944, inclusive, the total number of beds for mental patients shall not exceed five per thousand population, and the total number of beds for chronic- disease patients shall not exceed two per thousand population. “(c) The number of public health centers and the general method of distribution of such centers throughout the State, which for the purposes of this title, shall not exceed one per thirty thousand population, except that in States having less than twelve persons per square mile, it shall not exceed one per twenty thous- and population. 112 Hospital Survey and Plan for Maryland “(d) The general manner in which the State agency shall de- termine the priority of projects based on the relative need of different sections of the population and of different areas lacking adequate hospital facilities, giving special consideration to hospitals serving rural communities and areas with relatively small financial resources. “(e) General standards of construction and equipment for hospitals of different classes and in different types of location. “(f) That the State plan shall provide for adequate hospital facilities for the people residing in a State without discrimination on account of race, creed, or color, and shall provide for adequate hospital facilities for persons unable to pay therefor. Such regula- tion may require that before approval of any application for a hospital or addition to a hospital is recommended by a State agency, assurance shall be received by the State from the applicant that (1) such hospital or addition to a hospital will be made, available to all persons residing in the territorial area of the ap- plicant, without discrimination on account of race, creed, or color, but an exception shall be made in cases where separate hospital facilities are provided for separate population groups, if the plan makes equitable provision on the basis of need for facilities and services of like quality for each such group; and (2) there will be made available in each such hospital or addition to a hospital a reasonable volume of hospital services to persons unable to pay therefor, but an exception shall be made if such a requirement is not feasible from a financial standpoint. “(g) General methods of administration of the plan by the designated State agency, subject to the limitations set forth in section 623 (a) (6) and (8). “State Plans “Sec, 623. (a) After such regulations have been issued, any State desiring to take advantage of this part may submit a State plan for carrying out the purposes of section 601 (b). Such State plan must— “(1) designate a single State agency as the sole agency for the administration of the plan, or designate such agency as the sole agency for supervising the administration of the plan; “(2) contain satisfactory evidence that the State agency des- ignated in accordance with paragraph (1) hereof will have au- thority to carry out such plan in conformity with this part; “(3) provide for the designation of a State advisory council which shall include representatives of nongovernment organiza- tions or groups, and of State agencies, concerned with the operation, construction, or utilization of hospitals, including representatives of the consumers of hospital services selected from among persons familiar with the need for such services in urban or rural areas, to consult with the State agency in carry- ing out such plans; “(4) set forth a hospital construction program (A) which is based on a State-wide inventory of existing hospitals and sur- vey of need; (B) which conforms with the regulations prescribed by the Surgeon General under section 622 (a), (b), and (c); (C) which, in the case of a State which has developed a pro- gram under part B of this title, conforms to the program so developed except for any modification required in order to comply with regulations prescribed pursuant to section 622 (a), (b), and (c), and except for any modification recommended by the State agency designated pursuant to paragraph (1) of this subsection and approved by the Surgeon General; and (D) which meets the requirements as to lack of discrimination on account of race, creed, or color, and for furnishing needed hospital services to persons unable to pay therefor, required by regulations prescribed under section 622 (f); “(5) set forth the relative need determined in accordance with the regulations prescribed under section 622 (d) for the several projects included in such programs, and provide for the con- struction, insofar as financial resources available therefor and for maintenance and operation make possible, in the order of such relative need; “(6) provide such methods of administration of the State plan, including methods relating to the establishment and main- tenance of personnel standards on a merit basis (except that the Surgeon General shall exercise no authority with respect to the selection, tenure of office, or compensation of any individual employed in accordance with such methods), as the Surgeon General prescribes by regulation under section 622 (g); “(7) provide minimum standards (to be fixed in the discretion of the State) for the maintenance and operation of hospitals which receive Federal aid under this part; “(8) provide for affording to every applicant for a construc- tion project an opportunity for hearing before the State agency; “(9) provide that the State agency will make such reports in such form and containing such information as the Surgeon General may from time to time reasonably require, and give the Surgeon General, upon demand, access to the records upon which such information is based; and “(10) provide that the State agency will from time to time review its hospital construction program and submit to the Surgeon General any modifications thereof which it considers necessary. “ (b) The Surgeon General shall approve any State plan and any modification thereof which complies with the provisions of subsection (a). If any such plan or modification thereof shall have been disapproved by the Surgeon General for failure to comply with subsection (a), the Federal Hospital Council shall, upon request of the State agency, afford it an opportunity for hearing. If such Council determines that the plan or modification complies with the provisions of such subsection, the Surgeon General shall thereupon approve such plan or modification. “(c) No changes in a State plan shall be required within two years after initial approval thereof, or within two years after any change thereafter required therein, by reason of any change in the regulations prescribed pursuant to section 622, except with the consent of the State, or in accordance with further action by the Congress. “(d) If any State, prior to July 1, 1948, has not enacted legisla- tion providing that compliance with minimum standards of maintenance and operation shall be required in the case of hospitals which shall have received Federal aid under this title, such State shall not be entitled to any further allotments under section 624 “Allotments To States “Sec. 624. Each State for which a State plan has been ap- proved prior to or during a fiscal year shall be entitled for such year to an allotment of a sum bearing the same ratio to the sums authorized to be appropriated pursuant to section 621 for such year as the product of (a) the population of such State and (b) the square of its allotment percentage (as defined in section 631 (a) ) bears to the sum of the corresponding products for all of the States. The amount of the allotment to a State shall be avail- able in accordance with the provisions of this part, for payment of 33 1/3 per centum of the cost of approved projects within such State. The Surgeon General shall calculate the allotments to be made under this section and notify the Secretary of the Treasury of the amounts thereof. Sums allotted to a State for a fiscal year for construction and remaining unobligated at the end of such year shall remain available to such State for such purpose for the next fiscal year (and for such year only), in addition to the sums allotted for such State for such next fiscal year. Any amount of the gum authorized to be appropriated for a fiscal year which is not appropriated for such year, or which is not allotted in such year by reason of the failure of any State or States to have plans approved under this part, and any amount allotted to a State but remaining unobligated at the end of the period for which it is available to such State, is hereby authorized to be appropriated for the next fiscal year in addition to the sum otherwise authorized under section 621. “Approval of Projects and Payments for Construction “Sec. 625. (a) For each project for construction pursuant to a State plan approved under this part, there shall be submitted to the Surgeon General through the State agency an application by the State or a political subdivision thereof or by a public or other nonprofit agency. Such application shall set forth (1) a description of the site for such project, (2) plans and specifications therefor in accordance with the regulations prescribed by the Surgeon General under section 622 (e), (3) reasonable assurance that title to such site is or will be vested solely in the applicant, (4) reason- able assurance that adequate financial support will be available for the construction of the project and for its maintenance and operation when completed, and (5) reasonable assurance that the rates of pay for laborers and mechanics engaged in con- struction of the project will be not less than the prevailing local wage rates for similar work as determined in accordance with Public Law 403 of the Seventy-fourth Congress, approved August 30, 1935, as amended. The Surgeon General shall approve such application if sufficient funds to pay 33 1/3 per centum of the cost of construction of such project are available for the allotment to the State, and if the Surgeon General finds (A) that the applica- tion contains such reasonable assurance as to title, financial support, and payment of prevailing rates of wages, (B) that the plans and specifications are in accord with the regulations pre- scribed pursuant to section 622, (C) that the application is in conformity with the State plan approved under section 623 and Appendices 113 contains an assurance that the applicant will conform to the ap- plicable requirements of the State plan and of the regulations prescribed pursuant to section 622 (f) regarding the provision of facilities without discrimination on account of race, creed, or color, and for furnishing needed hospital facilities for persons unable to pay therefor, and an assurance that the applicant will conform to State standards for operation and maintenance, and (D) that it has been approved and recommended by the State agency and is entitled to priority over other projects within the State in accordance with the regulations prescribed pursuant to section 622 (d). No application shall be disapproved until the Surgeon General has afforded the State agency an opportunity for a hearing. “(b) Upon approving an application under this section, the Surgeon General shall certify to the Secretary of the Treasury an amount equal to 33 1/3 per centum of the estimated cost of con- struction of the project and designate the appropriation from which it is to be paid. Such certification shall provide for payment to the State, except that if the State is not authorized by law to make payments to the applicant the certification shall provide for payment direct to the applicant. Upon certification by the State agency, based upon inspection by it, that work has been per- formed upon a project, or purchases have been made, in accordance with the approved plans and specifications, and that payment of an installment is due to the applicant, the Surgeon General shall certify such installment for payment by the Secretary of the Treasury; except that if the Surgeon General, after investigation or otherwise, has ground to believe that a default has occurred requiring action pursuant to section 632 (a) he may, upon giving notice of hearing pursuant to such subsection, withhold certifica- tion pending action based on such hesring. “(c) Amendment of any approved application shall be subject to approval in the same manner as an original application. Certi- fication under subsection (b) may be amended, either upon ap- proval of an amendment of the application or upon revision of the estimated cost of a project. An amended certification may direct that any additional payment be made from the applicable allot- ment for the fiscal year in which such amended certification is made. “(d) The funds paid under this section for the construction of an approved project shall be used solely for carrying out such pro- ject as so approved. “(e) If any hospital for which funds have been paid under this section shall, at any time within twenty years after the completion of construction, (A) be sold or transferred to any person, agency, or organization, (1) which is not qualified to file an application under this section, or (2) which is not approved as a transferee by the State agency designated pursuant to section 623 (a) (1), or its successor, or (B) cease to be a nonprofit hospital as defined in section 631 (g), the United States shall be entitled to recover from either the transferor or the transferee (or, in the case of a hospital which has ceased to be a nonprofit hosital, from the owners thereof) 33 1/3 per centum of the then value of such hospital, as deter- mined by agreement of the parties or by action brought in the district court of the United States for the district in which such hospital is situated. “Part D—Miscellaneous “Definitions “Sec. 631. For the purposes of this title—- “(a) the allotment percentage for any State shall be 100 per centum less that percentage which bears the same ratio of 50 per centum as the per capita income of such State bears to the per capita income of the continental United States (excluding Alaska), except that (1) the allotment percentage shall in no case be more than 75 per centum or less than 33 1/3 per centum, and (2) the allotment percentage for Alaska and Hawaii shall be 50 per centum each, and the allotment percentage for Puerto Rico shall be 75 per centum; “(b) the allotment percentages shall be promulgated by the Surgeon General between July 1 and August 31 of each even- numbered year, on the basis of the average of the per capita in- comes of the States and of the continental United States for the three most recent consecutive years for which satisfactory data are available from the Department of Commerce. Such promulga- tion shall be conclusive for each of the two fiscal years in the period beginning July 1 next succeeding such promulgation: Provided, That the Surgeon General shall promulgate such per- centages as soon as possible after the enactment of this title, which promulgation shall be conclusive for the fiscal year ending June 30, 1947: “(c) the population of the several States shall be determined on the basis of the latest figures certified by the Department of Commerce; “(d) the term ‘State’ includes Alaska, Hawaii, Puerto Rico, and the District of Columbia; “(e) the term ‘hospital’ (except as used in section 622 (a) and (b) ) includes public health centers and general, tuberculosis, mental, chronic disease, and other types of hospitals, and related facilities, such as laboratories, out-patient departments, nurses’ home and training facilities, and central service facilities operated in connection with hospitals, but does not include any hospital furnishing primarily domiciliary care; “(f) the term ‘public health center’ means a publicly owned facil- ity for the provision of public health services, including related facilities such as laboratories, clinics, and administrative offices operated in connection with public health centers; “(g) the term ‘nonprofit hospital’ means any hospital owned and operated by a corporation or association, no part of the net earn- ings of which inures, or may lawfully inure, to the benefit of any private shareholder or individual; “(h) the term ‘construction’ includes construction of new buildings, expansion, remodeling, and alteration of existing build- ings, and initial equipment of any such buildings; including architects’ fees, but excluding the cost of off-site improvements and, except with respect to public health centers, the cost of the ac- quistion of land; and “(i) the term ‘cost of construction’ means the amount found by the Surgeon General to be necessary for the construction of a pro- ject. “Withholding of Certification “Sec. 632. (a) Whenever the Surgeon General, after reason- able notice and opportunity for hearing to the State agency des- ignated in accordance with section 612 (a) (1), finds that the State agency is not complying substantially with the provisions required by section 612 (a) to be contained in its application for funds under Part B, or after reasonable notice and opportunity for hearing to the State agency designated in accordance with section 623 (a) (1) finds (1) that the State agency is not complying substantially with the provisions required by section 623 (a), or by regulations prescribed pursuant to section 622, to be contained in its plan submitted under section 623 (a), or (2) that any funds have been diverted from the purposes for which they have been allotted or paid, or (3) that any assurance given in an application filed under section 625 is not being or cannot be carried out, or (4) that there is a substantial failure to carry out plans and specifications ap- proved by the Surgeon General under section 625, the Surgeon General may forthwith notify the Secretary of the Treasury and the State agency that no further certification will be made under part B or part C, as the case may be, or that no further certification will be made for any project or projects designated by the Surgeon General as being affected by the default, as the Surgeon General may determine to be appropriate under the circumstances; and, except with regard to any project for which the application has already been approved and which is not directly affected by such default, he may withhold further certifications until there is no longer any failure to comply, or, if compliance is impossible, until the State repays or arranges for the repayment of Federal moneys which have been diverted or improperly expended. “(b) (1) If the Surgeon General refuses to approve any applica- tion under section 62o, the State agency through which the applica- tion was submitted, or if any State is dissatisfied with the Surgeon General’s action under subsection (a) of this section, such State may appeal to the United States circuit court of appeals for the circuit in which such State is located. The summons and notice of appeal may be served at any place in the United States. The Surgeon General shall forthwith certify and file in the court the transcript of the proceedings and the record on which he based his action. “(2) The findings of fact by the Surgeon General, unless sub- stantially contrary to the weight of the evidence, shall be con- clusive; but the court, for good cause shown, may remand the case to the Surgeon General to take further evidence, and the Surgeon General may thereupon make new or modified findings of fact and may modify his previous action, and shall certify to the court the transcript and record of the further proceedings. Such new or modified findings of fact shall likewise be conclusive unless sub- stantially contrary to the weight of the evidence. “(3) The court shall have jurisdiction to affirm the action of the Surgeon General or to set it aside in whole or in part. The judgment of the court shall be subject to review by the Supreme Court of the United States upon certiorari or certification as pro- 114 JHospital Survey and Plan for Maryland vided in sections 239 and 240 of the Judicial Code, as amended. “Federal Hospital Council; Administration of Title “Sec. 633. (a) The Surgeon General is authorized to make such administrative regulations and perform such other functions as he finds necessary to carry out the provisions of this title. Any such regulations shall be subject to the approval of the Adminis- trator. “(b) In administering this title, the Surgeon General shall consult with a Federal Hospital Council consisting of the Surgeon General, who shall serve as Chairman ex officio, and eight mem- bers appointed by the Administrator. Four of the eight appointed members shall be persons who are outstanding in fields pertaining to hospital and health activities, three of whom shall be author- ities in matters relating to the operation of hospitals, and the other four members shall be appointed to represent the consumers of hospital services and shall be persons familiar with the need for hospital services in urban or rural areas. Each appointed member shall hold office for a term of four years, except that any member appointed to fill a vacancy occurring prior to the expiration of the term for which his predecessor was appointed shall be appointed for the remainder of such term, and the terms of office of the members first taking office shall expire, as designated by the Ad- ministrator at the time of appointment, two at the end of the first year, two at the end of the second year, two at the end of the third year, and two at the end of the fourth year after the date of appointment. An appointed member shall not be eligible to serve continuously for more than two terms but shall be eligible for reappointment if he has not served immediately preceding his re- appointment. The Council is authorized to appoint such special advisory and technical committees as may be useful in carrying out its functions. Appointed Council members and members of advisory or technical committees, while serving on business of the Council, shall receive compensation at rates fixed by the Ad- ministrator, but not exceeding $25 per day, and shall also be en- titled to receive an allowance for actual and necessary travel and subsistence expenses while so serving away from their places of residence. The Council shall meet as frequently as the Surgeon General deems necessary, but not less than once each year. Upon request by three or more members, it shall be the duly of the Surgeon General to call a meeting of the Council. “(c) In administering the provisions of this title, the Surgeon General, with the approval of the Administrator, is authorized to utilize the services and facilities of any executive department in accordance with an agreement with the head thereof. Pay- ment for such services and facilities shall be made in advance or by way of reimbursement, as may be agreed upon between the Administrator and the head of the executive department furnish- ing them. “Conferences of State Agencies “Sec. 634. Whenever in his opinion the purposes of this title would be promoted by a conference, the Surgeon General may invite representatives of as many State agencies, designated in accordance with section 612 (a) (1) or section 623 (a) (1), to confer as he deems necessary or proper. Upon the application of five or more of such State agencies, it shall be the duty of the Surgeon General to call a conference of representatives of all State agencies joining in the request. A conference of the representatives of all such State agencies shall be called annually by the Surgeon General. “State Control of Operations “Sec. 635. Except as otherwise specifically provided, nothing in this title shall be construed as conferring on any Federal officer or employee the right to exercise any supervision or control over the administration, personnel, maintenance, or operation of any hospital with respect to which any funds have been or may be expended under this title.” Sec. 3. Paragraph (2) of section 208 (b) of the Public Health Service Act, a£ amended, is amended by inserting “(A)” before the words “to assist”; by striking out the word “paragraph” and inserting in lieu thereof the word “clause”; and by striking out the period at the end of such paragraph and inserting in lieu thereof a comma and the following: “and (B) to assist in carrying out the purposes of title VI of this Act, but not more than twenty such officers appointed pursuant to this clause shall hold office at the same time.” Sec. 4. Section 1 of the Public Health Service Act is amended to read: “Section 1. Titles I to VI, inclusive, of this Act may be cited as the ‘Public Health Service Act’.” Sec. 5. The Act of July 1,1944 (58 Stat. 682), is hereby further amended by changing the number of title VI to title VII and by changing the numbers of sections 601 to 612, inclusive, and refer- ences thereto, to sections 701 to 712, respectively. Approved August 13, 1946. AMENDMENTS TO PUBLIC LAW 725~79th CONGRESS PUBLIC LAW 713—80th CONGRESS CHAPTER 544—2D SESSION (H.R. 5889) AN ACT To extend the provisions of title VI of the Public Health Service Act to the Virgin Islands. Be it enacted by the Senate and House Representatives of the United States of America in Congress assembled, That (a) para- graph (a) of section 631 of the Public Health Service Act, as amended, is amended by inserting after “Puerto Rico” the follow- ing: “and the Virgin Islands.” (b) Paragraph (d) of such section is amended to read as follows: “(d) the term ‘State’ includes Alaska, Hawaii, Puerto Rico, the Virgin Islands, and the District of Columbia;”. Approved June 19, 1948. PUBLIC LAW 723—80th CONGRESS CHAPTER 554—2D SESSION (H.R. 6339) AN ACT To amend the provisions of title VI of the Public Health Service Act relating to standards of maintenance and operation for hospi- tals receiving aid under that title. Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That subsection (d) of section 623 of the Public Health Service Act, as amended, is amended to read; “(d) If any State, prior to July 1,1948, has not enacted legisla- tion providing that compliance with minimum standards of maintenance and operation shall be required prior to that date (or, at the option of the State, required within such time after enactment of the legislation as the Surgeon General finds rea- sonable) in the case of hospitals which shall have received Federal aid under this title, such State shall not be entitled to any further allotments under section 624 until such time as such State has enacted such legislation. Upon enactment of such legislation after July 1, 1948, the prohibition in this subsection against further allotments to such State under this part shall no longer be effective and such State shall, subject to the other requirements of this part, be entitled to allotments under sec- tion 624 for the fiscal year in which such legislation is enacted and for the preceding fiscal year.” Approved June 19, 1948. Appendices 115 PUBLIC LAW 830—80th CONGRESS CHAPTER 728—2D SESSION (H R. 4816) AN ACT To amend section 624 of the Public Health Service Act so as to provide a minimum allotment of $100,000 to each State for the construction of hospitals. Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That the first sentence of section 624 of the Public Health Service Act, as amend- ed, is amended to read as follows: “Each State for which a State plan has been approved prior to or during a fiscal year shall be entitled for such year to an allotment of a sum bearing the same ratio to the sums authorized to be appropriated pursuant to sec- tion 621 for such year as the product of (a) the population of such State and (b) the square of its allotment percentage (as defined in section 61 (a)) bears to the sum of the corresponding products for all of the States: Provided, That no such allotment to any State shall be ess than $100,000 but for the purpose of this proviso the term State shall not include the Virgin Islands.” Sec. 2. There are hereby authorized to be appropriated for the fiscal year ending June 30, 1948, and for each of the three succeeding fiscal years, such sums as may be necessary to provide increased allotments for the construction of hospitals pursuant to the first sentence of section 624 of the Public Health Service Act, as amended by the first section of this Act. Approved June 29, 1948. APPENDIX B UNITED STATES PUBLIC HEALTH SERVICE REGULATIONS1 TITLE 42—PUBLIC HEALTH Chapter I—Public Health Service, Federal Security Agency Part 53—Grants for Survey, Planning and Construction of Hospitals Subpart A—Definitions Sec. 53.1 Definitions. Subpart B—Distribution of General Hospital Beds 53.11 Plan of distribution. 53.12 Maximum State allowance. 53.13 Standards for construction program. 53.14 Beds classified as general hospital beds. Subpart C—Distribution of Tuberculosis, Mental, and Chronic Disease Hospital Beds 53.21 Maximum State allowance. 53.22 Distribution. Subpart D—Distribution of Public Health Centers 53.31 Maximum State allowance. 53.32 Distribution. Subpart E—Priority of Projects 53.41 Manner of determination. 53.42 Balance among categories of facilities. 53.43 All categories of facilities; additional facilities as against replacements. 53.44 General hospital category. 53.45 Chronic disease category. 53.46 Public health centers. 53.47 Size and character. Subpart F—General Standards of Construction and Equipment 53.51 General. 53.52 Size of mental and psychiatric hospitals. 53.53 Size of tuberculosis hospitals. Subpart G—Non-Discrimination and Hospital Services for Persons Unable To Pay Therefor 53.61 General. 53.62 Non-discrimination. 53.63 Hospital services for persons unable to pay therefor. Subpart H—Methods of Administration of the State Plan 53.71 General. 53.72 Construction program. 53.73 Personnel administration. 53.74 Fair hearings. 53.75 Construction standards. 53.76 Publicizing the State plan. 53.77 Processing construction applications. 53.78 Requests for construction payments. 53.79 Fiscal and accounting requirements. Appendix A—General standards of construction and equipment. Appendix B—Merit System Policies of the United States Public Health Service. Authority; §§ 53.1 to 53.79, inclusive, issued under sec. 622, Pub. Law 725, 79th Cong., 60 Stat. 1042; 42 U. S. C. Supp. 291e. Derivation: §§ 53.1 to 53.79, inclusive, contained in Regula- tions, Acting Surgeon General, Jan. 24, 1947, approved Federal Hospital Council, Nov. 14, 1946, and Federal Security Adminis- trator, Feb. 4, 1947, as amended by Regulations, Surgeon General, approved Federal Hospital Council and Federal Security Ad- ministrator, June 5, 1947, 12 F. R. 980, 3308. Subpart A—Definitions § 53.1 Definitions. Except as otherwise stated, the following terms shall have the following meanings when used in the regula- tions in this part: (a) Area. A logical hospital service area, taking into account such factors as population, distribution, natural geographic boundaries, transportation, and trade patterns, all parts of which are reasonably accessible to existing or proposed hospital facilities and which has been designated by the State Agency as a base, intermediate, or rural area. Nothing in the regulations in this part shall preclude the formation of an interstate area with the mutual agreement of the States concerned. (b) Base area. Any area which is so designated by the State Agency and has the following characteristics: (1) Irrespective of the population of the area, it shall contain a teaching hospital of a medical school; this hospital must be suitable for use as a base hospital in a coordinated hospital system within the State; or (2) the area has a total population of at least 100,000 and con- tains or will contain on completion of the hospital construction program under the State plan at least one general hospital which has a complement of 200 or more beds for general use. This hospital must furnish internships and residencies in two or more specialties and must be suitable for use as a base hospital in a coordinated hospital system within the State. (c) Intermediate area. Any area so designated by the State Agency which: (1) Has a total population of at least 25,000 and (2) contains, or will contain on completion of the hospital con- struction program under the State plan, at least one general hospital which has a complement of 100 or more beds and which would be suitable for use as a district hospital in a coordinated hospital system within the State. (d) Rural area. Any area so designated by the State Agency which constitutes a unit, no part of which has been included in a base or intermediate area. (e) Coordinated hospital system. An interrelated network of gen- eral hospitals throughout a State in which one or more base hospi- tals provide district hospitals and the latter in turn provide rural and other small hospitals with such services relative to diagnosis, treatment, medical research and teaching as cannot be provided by the smaller hospitals individually. "(f) Hospital. Public health centers and general, tuberculosis, •mental, chronic disease, and other types of hospitals, and related 1 Reprint from Federal Register, October 22, 1947. 116 Hospital Survey and Plan for Maryland facilities, such as laboratories, out-patient departments, nurses’ home and training facilities, and central service facilities operated in connection with hospitals, but not institutions furnishing primarily domiciliary care. The term “hospital,” except as ap- plied generally to include public health centers, shall be restricted to institutions providing community service for in-patient medical or surgical care of the sick or injured; this includes obstetrics. It shall exclude Federal hospitals and institutions found to con- stitute a public hazard. (g) Allied special hospital. Cardiac, eye-ear-nose-throat, isola- tion, maternity, children’s orthopedic, and skin and cancer, as well as other hospitals providing similar specialized types of care commonly given in general hospitals. The term excludes mental, tuberculosis, and chronic disease hospitals. (h) Chronic disease hospital. A hospital, the primary purpose of which is medical treatment of chronic illness, including the de- generative diseases, and which furnishes hospital treatment and care, administered by or under the direction of persons licensed to practice medicine in the State. The term includes such convales- cent homes as meet the foregoing qualifications. It excludes tuber- culosis and mental hospitals, nursing homes, and also institutions, the primary purpose of which is domiciliary care. (i) General hospital. Any hospital for in-patient medical or surgical care of acute illness or injury and for obstetrics, of which not more than 50% of the total patient days during the year are customarily assignable to the following categories of cases: Chronic, convalescent and rest, drug and alcoholic, epileptic, mentally deficient, mental, nervous and mental, and tuberculosis. (j) Mental hospital. A hospital for the diagnosis and treat- ment of nervous and mental illness but excluding institutions for the feeble-minded and epileptics. (k) Nonprofit hospital. Any hospital owned and operated by a corporation or association, no part of the net earnings of which is applied, or may lawfully be applied, to the benefit of any private shareholder or individual. (l) Psychiatric hospital. A type of mental hospital where patients may receive intensive treatment and where only a minimum of continued treatment facilities will be afforded. (m) Tuberculosis hospital. A hospital for the diagnosis and treatment of tuberculosis, excluding preventoria. (n) Hospital bed. A bed for an adult or child patient. Bassinets for the new-born in a nursery, beds in labor rooms and in health centers, and other beds used exclusively for emergency purposes are not included in this definition. (o) Population. In computing the population of the State or any area thereof for purposes of the regulations in this part, the State Agency shall use the latest figures of civilian population certified by the Federal Department of Commerce with such ad- justments as may be necessary to reflect changing local conditions. Such adjustments shall not result in any increase in the total population of the State over the figures certified by the Depart- ment of Commerce. (p) Public health center. A publicly owned facility utilized by a local health unit for the provision of public health services, in- cluding related facilities such as laboratories, clinics, and adminis- trative offices operated in connection with public health centers. (q) Local health unit. A single county, city, county-city, or local district health unit, as well as a State health district unit where the primary function of the State district unit is the direct provision of public health services to the population under its jurisdiction. (r) Public health services. Services provided through organized community effort in the endeavor to prevent disease, prolong life, and maintain a high degree of physical and mental efficiency. In addition to the services which the community already provides as a matter of practice, the term shall include such additional services as the community from time to time may deem it desirable to provide. (s) State. The 48 States, Alaska, Hawaii, Puerto Rico, and the District of Columbia. (t) State agency. As the context may require, either the agency designated by the State pursuant to section 612 (a) (1) of the Federal Hospital Survey and Construction Act or the agency des- ignated to administer the State plan pursuant to section 623 (a) (1) of the Federal Act. (u) Surgeon General. The Surgeon General of the United States Public Health Service. (v) Federal Act. Title VI of the Public Health Service Act, as amended by the Hospital Survey and Construction Act (Public Law 725, 79th Congress, 60 Stat. 1042; 42 U. S. C. Supp. 291 (e) ), approved August 13, 1946. Subpart B—Distribution op General Hospital Beds § 53.11 Plan of distribution. It is the intention of the regula- tions in this part to provide for distribution of general hospital beds among the different areas of the State so as to provide com- prehensive and adequate types of hospital services to all sizes of communities. In accordance with this intent the general methods by which general hospital beds shall be distributed among base areas, intermediate areas, and rural areas, shall be as provided for in §§ 53.12 to 53.14, inclusive. § 53.12 Maximum State allowance. The number of general hospital beds required to provide adequate hospital services to the people residing in any State shall be: (a) In States having 12 or more persons per square mile, 4.5 beds per thousand population, (b) In States having less than 12 and more than 6 persons per square mile, 5 beds per thousand population; and (c) In States having 6 persons or less per square mile, 5.5 beds per thousand population. If in any area (base, intermediate, or rural), as determined by the State agency, there are more beds than required by these standards, such excess may be eliminated in calculating the maxi- mum allowance for the State as a whole. § 53.13 Standards for construction program. The construction program under the State plan shall provide for general hospital beds, existing and proposed, in each area within the State in accordance with the following standards: (a) In States having 12 or more persons per square mile, 2.5 beds per thousand population in rural areas, 4.0 beds per thousand in intermediate areas, and 4.5 beds per thousand in base areas; (b) In States having less than 12 but more than 6 persons per square mile, 3 beds per thousand population in rural areas, 4.5 beds per thousand in intermediate areas, and 5 beds per thousand in base areas; and (c) In States having 6 or less persons per square mile, 3.5 beds per thousand population in rural areas, 5.0 beds per thousand in intermediate areas, and 5.5 beds per thousand in base areas. In addition, the State agency shall subtract from the total number of beds permitted for each area under § 53.12 the total number of beds permitted for each area under this section or the number of beds in existence, whichever is greater. The total num- ber of beds so determined for all areas shall be distributed at the discretion of the State agency and without regard to standards specified in §§53.12 and 53.13. This shall be done in such a man- ner as to meet the special needs of any area and facilitate the co- ordination of hospital services. In allocating beds under this sec- tion, the State Agency shall give special consideration to hospitals serving persons in rural areas and communities with relatively small financial resources. § 53.14 Beds classified as general hospital beds. The count of existing general hospital beds shall include the beds in the hospitals of this category as defined above, and also: (a) Beds in allied special hospitals, and (b) beds in any tuberculosis, mental, or chronic disease hospital which are specifically assigned for the care of general patients, except where the beds so assigned in any institution number less than ten. Beds for persons hospitalized for the primary condition of tuberculosis, mental, or chronic disease shall be ex- cluded. Subfart C—Distribution of Tuberculosis, Mental, and Chronic Disease Hospital Beds § 53.21 Maximum State allowance. The number of beds re- quired to provide adequate hospital services for tuberculous patients, mental patients, and chronic disease patients in any State shall be: . _ J_. .. , (a) For tuberculous patients, 2.5 times the average annual deaths from tuberculosis in the State over the 5-year period from 1940 to 1944, inclusive; . (b) For mental patients, 5 per thousand population; and (c) For chronic disease patients, 2 per thousand population. The count of existing tuberculosis, mental, and chronic disease hospital beds shall include the beds in the hospitals of these respec- tive categories, as defined above, and also beds in any general hospital which are specifically assigned for the care of tuberculous, mental and chronic disease patients respectively, except where the beds so assigned in any institution number less than 10 in any category. § 53.22 Distribution. Whenever practicable, tuberculosis hospitals receiving grants under the Federal Act shall be built in centers of population and in proximity to general hospitals. Whenever practicable, mental hospitals receiving grants under the Federal Act shall be located in centers of population and in proximity to general hospitals. Whenever practicable, chronic disease hospitals shall be built in centers of population and in proximity to general hospitals. Appendices 117 Subpart D—Distribution of Public Health Centers § 53.31 Maximum State allowance. The number of public health centers in a State (counting those existing as well as those provided with aid under the act) shall not exceed one per 30,000 State population, except in States having less than 12 persons per square mile the number shall not exceed one per 20,000 popula- tion. The following shall be excluded from the count of public health centers: (a) Existing facilities which the State Agency, after consultation with the State health authority, has determined to be unsuitable for use as public health centers, and (b) Auxiliary facilities such as laboratories and clinics, whether existing or proposed, and whether they are located within the same structure as the health department office, or in a separate structure. § 53.32 Distribution. The general method of distribution of public health centers throughout the State shall conform to the plan of organization of local health units within the State. In in- stances where the State Health Department is not the State Agency designated under section 623 (a) (1) of the Federal Act, the method of distribution shall be determined after consulta- tion with the State health authority. Subpart E—Priority of Projects § 53.41 Manner of determination. The general manner in which the State Agency shall determine the priority of projects included in the State construction program shall conform with the prin- ciples set out in this subpart. § 53.42 Balance among categories of facilities. Insofar as prac- ticable the State Agency shall develop its construction program in relation to the proportionate need for each of the five categories of facilities (general, mental, tuberculosis, chronic, and health centers). In determining proportionate needs, consideration shall be given to existing facilities and those under construction with- out assistance under the Federal act. § 53.43 All categories of facilities; additional facilities as against replacements. Initial installations and additions to existing hospi- tals and health centers shall be given priority over replacements, except: (a) Where replacement is of minor character and necessary to the provision of needed additional facilities; (b) Where, in the case of a hospital, replacement is essential to eliminate an existing needed hospital which constitutes a public hazard; (c) Where, in the case of a public health center, the State health authority has certified that the existing facility is unsuitable for use as a public health center. § 53.44 General hospital category. The relative priority of these projects shall be determined after consideration of the following factors in the order of importance as given; (a) The relative need for beds in the area (base, intermediate, or rural) in which the project will be located, taking into account the utilization of existing general hospital beds in the area and giving special consideration to projects providing service for persons lo- cated in rural communities and areas with relatively small finan- cial resources; (b) The extent to which beds will be made available for groups of the population which by reason of race, creed, or color are less adequately served than other groups of the population. § 53.45 Chronic diseases category. Priority shall be given to those projects in which the chronic disease facilities will be operated as sub-units of general hospitals. § 53.46 Public health centers. Highest priority in this category shall be given to the provision of facilities for local health units serving rural communities and areas with relatively small financial resources. Where the agency designated to administer the State plan is not the State health authority, the State Agency shall de- termine the relative priorities to be established after consultation with the State health authority. § 53.47 Size and character. Insofar as practicable and without affecting the priority of hospitals serving rural communities and areas with relatively small financial resources, special consideration shall be given to applications for construction of projects of a size and character consistent with efficient and economical opera- tion. Subpart F—General Standards of Construction and Equipment § 53.51 General. Plans and specifications for each project sub- mitted to the Surgeon General for approval under the Federal Act shall be prepared in accordance with the “General Standards of Construction and Equipment” for hospitals of different classes and in different types of locations as prescribed by the Surgeon General set forth in Appendix A1 to this part. The Surgeon General may approve plans and specifications which contain deviations from the requirements prescribed, if he is satisfied that the pur- poses of such requirements have been fulfilled. The design and construction covered by the plans and specifica- tions must conform with the applicable State and local laws, codes, and ordinances and with the approved State plan. The plans and specifications must be complete and adequate for contract pur- poses and have the approval and recommendation of the State Agency. Equipment shall be provided in the kind and to the extent necessary for the proper functioning of the facility as planned. § 53.52 Size of mental and psychiatric hospitals. No application for construction of a psychiatric hospital with a capacity of more than 500 beds or of a mental hospital with a capacity of more than 3,000 beds shall be approved. This requirement shall not be construed to prevent approval of applications for improvements of psychiatric and mental hospitals with bed capacities equal to or greater than those specified above, if such improvements are de- signed to provide more intensive treatment facilities within such hospitals. § 53.53 Size of tuberculosis hospitals. No application for con- struction of a tuberculosis hospital with a capacity of less than 100 beds shall be approved, except that an application for con- struction of a tuberculosis hospital with a capacity from 50 to 100 beds may be approved where necessary to provide facilities for an isolated area too small to support a larger hospital. Subpart G—Non-Discrimination and Hospital Services for Persons Unable To Pay Therefor § 53.61 General. The State plan shall provide for adequate hospital facilities for the people residing in a State without dis- crimination on account of race, creed, or color and shall provide for adequate hospital facilities for persons unable to pay therefor. § 53.62 Non-discrimination. Before a construction application is recommended by a State Agency for approval, the State Agency shall obtain assurance from the applicant that the facilities to be built with aid under the act will be made available without discrimination on account of race, creed, or color to all persons residing in the area to be served by that hospital. However, in any area where separate hospital facilities are provided for separate population groups, the State Agency may waive the requirement of assurance from the construction applicant if (a) it finds that the plan otherwise makes equitable provision on the basis of need for facilities and services of like quality for each such population group in the area, and (b) such finding is subsequently approved by the Surgeon General. Facilities provided under the Federal Act will be considered as making equitable provision for separate population groups when the facilities to be built for the group less well provided for heretofore are equal to the proportion of such group in the total population of the area, except that the State plan shall not program facilities for a separate population group for construction beyond the level of adequacy for such group. § 53.63 Hospital services for persons unable to pay therefor. Be- fore a construction application is recommended by a State Agency for approval, the State Agency shall obtain assurance that the applicant will furnish a reasonable volume of free patient care. As used in this section, “free patient care” means hospital service offered below cost or free to persons unable to pay therefor, in- cluding under “persons unable to pay therefor, both the legally indigent and persons who are otherwise self-supporting but are unable to pay the full cost of needed hospital care. Such care may be paid for wholly or partly out of public funds or contri- butions of individuals and private and charitable organizations such as community chests or may be contributed at the expense of the hospital itself. In determining what constitutes a reason- able volume of free patient care, there shall be considered condi- tions in the area to be served by the applicant, including the amount of free care that may be available otherwise than through the applicant. The requirement of assurance from the applicant may be waived if the applicant demonstrates to the satisfaction of the State Agency, subject to subsequent approval by the Surgeon General, that furnishing such free patient care is not feasible financially. Subpart H—Methods of Administration of the State Plan § 53.71 General. The State plan shall provide for general methods of administration which are in accord with the principles set out in §§ 53.72 to 53.78, inclusive. , § 53.72 Construction program. The State hospital construction program shall be developed in the following manner: (a) The State Agency shall determine need for hospital facilities of all types and health center facilities by applying the ratios heretofore specified and deducting existing facilities, except those justifying replacement under priority regulations. *Not included herein. 118 Hospital Survey and Plan for Maryland (b) The State Agency shall determine through field investiga- tion, and otherwise, the approximate locations within each area at which needed beds or health centers should most appropriately be built. (c) After having determined hospital and public health center needs, the State Agency shall establish an overall construction program. This program shall set forth all such needs in accordance with the standards specified in §§ 53.12, 53.21, and 53.31 and shall show the relative need for each project included, irrespective of the availability of funds for construction and for maintenance and operation. (d) The State Agency shall, from time to time as necessary, but at least annually, review the overall hospital construction pro- gram. Annually, at a time fixed by the Surgeon General, the Agency shall submit to him a report, which shall contain such revisions of the construction program, as the Agency considers necessary. (e) The State Agency shall establish a separate construction schedule on such forms and for such periods as the Surgeon General may prescribe. Insofar as funds are available for construction and for maintenance and operation, construction shall be scheduled in the order of relative need. § 53.73 Personnel administration. A system of personnel ad- ministration on a merit basis shall be established and maintained with respect to the personnel employed in the administration of the State plan. Such a system shall include provision for: (a) Impartial administration of the merit system; (b) Operation on the basis of published rules or regulations; (c) Classification of all positions on the basis of duties and re- sponsibilities and establishment of qualifications necessary for the satisfactory performance of such duties and responsibilities; (d) Establishment of compensation schedules adjusted to the responsibility and difficulty of the work; (e) Selection of permanent appointees on the basis of examina- tions so constructed as to provide a genuine test of qualifications and so conducted as to afford all qualified applicants opportunity to compete; (f) Advancement on the basis of capacity and meritorious serv- ice; and (g) Tenure of permanent employees. Substantial compliance with the merit system policies of the Public Health Service as set forth in Appendix B1 will be deemed to meet the requirements of the regulations in this part. § 53.74 Fair hearings. The State Agency shall establish such rules and regulations as will provide an opportunity for an ap- peal to and a fair hearing before the State Agency to every appli- cant for a construction project who is dissatified with any action of the State Agency regarding its application. § 53.75 Construction standards. The State Agency shall adopt general standards of construction and equipment for the various types of hospitals and health centers assisted under this program. The standards adopted shall not be less than the general standards prescribed by the Surgeon General and set forth in Appendix A to this part. § 53.76 Publicizing the State plan, (a) Prior to submission of the State plan to the Surgeon General, the State Agency shall publish a general description of the provisions proposed to be in- cluded in the State plan and shall give reasonable notice of a public hearing at which all interested persons or organizations will be given an opportunity to be heard. (b) After the Surgeon General has approved the State plan, the State Agency shall publish a general description of its provisions in newspapers having general circulation throughout the State and shall make the approved State plan available for examination, upon request, to all interested persons or organizations. § 53.77 Processing construction applications—(a) Form of ap- plication. Construction applications, including a detailed estimate of the cost of the project, shall be submitted to the Surgeon Gen- eral through the State Agency and shall be executed on forms prescribed by the Surgeon General. (b) Order of processing applications. The State Agency shall pro- cess applications received in the order of priority, except that the State Agency may approve, recommend and forward to the Sur- geon General applications out of the order of priority if: (1) The State Agency has afforded reasonable opportunity for development and presentation of projects in the order of priority, and (2) If the State Agency certifies to the Surgeon General that financial resources for the construction, maintenance and opera- tion of projects of higher priority are not then available. The priority of a project under the State plan shall not be affected by the fact that other projects of lower priority have previously been approved and recommended by the State Agency. (c) Assurances from applicant. In addition to assurance other- wise required by the State Agency, before approving an applica- tion, the State Agency must have assurance from the applicant: (1) That actual construction work will be performed by the lump sum (fixed price) contract method, that adequate methods of obtaining competitive bidding will be or have been employed prior to awarding the construction contract, either by public ad- vertising or circularizing three or more bidders, and that the award of the contract will be or has been made to the responsible bidder submitting the lowest acceptable bid; (2) That the construction contracts will prescribe the minimum rates of pay for laborers and mechanics engaged in construction of the project as determined by the Secretary of Labor and that such minimum rates will be stated in the specifications advertised in the call for bids on the proposed project; (3) That the requirement that each contractor or subcontractor shall furnish a weekly sworn affidavit with respect to the wages paid each employee during the preceding week, as required by 48 Stat. 948 (40 Q. S. C. 276 (b) and 276 (c) ), and the regulations is- sued pursuant thereto, will be incorporated in the project speci- fications and made a part of the construction contract; (4) That the project will not be advertised or placed on the market for bidding until the final working drawings and specifica- tions have been approved by the Surgeon General and the ap- plicant has been so notified; (5) That no construction contract or contracts for the project or a part thereof, the cost of which is in excess of the estimated cost approved in the application for that portion of the work covered by the plans and specifications, will be entered into without the prior approval of the Surgeon General; (6) That the construction contract will require the contractor to furnish performance and payment bonds, the amount of which shall each be in an amount not less than fifty percentum (50%) of the contract price, and to maintain during the life of the con- tract adequate fire, workmen’s compensation, public liability and property damage insurance; (7) That any change or changes in the contract which (i) makes any major alteration in the work required by the plans and specifications, or (ii) raises the total contract price over the ap- proved estimate of cost of the work covered by the plans and specifications will be submitted to the Surgeon General for prior approval; (8) That the construction contract will provide that the Sur- geon General, the State Agency and their representatives will have access at all times to the work wherever it is in preparation or progress and that the contractor will provide proper facilities for such access and inspection; (9) That the applicant will provide and maintain competent and adequate architectural or engineering supervision and in- spection at the project to insure that the completed work conforms with the approved plans and specifications; and (10) That the hospital, when completed, will be operated and maintained in accordance with minimum standards prescribed by the State Agency for the maintenance and operation of hospitals aided under the Federal act. Provided: That the State Agency, with the prior approval of the Surgeon General, may waive technical compliance with any of the requirements of this paragraph except subparagraph (1) if it finds that the purpose of such requirement has been fulfilled. (d) Certification to the Surgeon General. After the State Agency has approved a construction application, it shall recommend it to the Surgeon General for approval and shall certify: (1) That the application contains reasonable assurance as to title, payment of prevailing rates of wages, and financial support for the non-Federal share of the cost of construction and the en- tire cost of maintenance and operation when completed; (i) Availability of funds for the non-Federal share of construc- tion costs shall mean (a) funds immediately available, placed in escrow, or acceptably pledged, or (b) funds or fund sources speci- fically earmaked in a sum sufficient for that purpose or (c) other assurances acceptable to the Surgeon General. (11) To assure the availability of funds for maintenance and operation, the application for the construction of a new project must include a proposed operating budget, on a form prescribed by the Surgeon General, for the two year period immediately following its completion. In the case of an addition to an existing facility, the application must include a statement showing that funds are or will be available to meet the difference between pro- posed expenditures and anticipated income from the operation of the constructed addition for the two year period immediately following its completion. iNot included herein. Appendices 119 (2) That the plans and specifications are in accord with Appen- dix A; (3) That the application is in conformity with the State plan approved by the Surgeon General and contains an assurance that the applicant will conform to the applicable requirements of the plan; (4) That the application contains an assurance that the ap- plicant will conform to the requirements of § § 53.61, 53.62, and 53.63 regarding the provision of facilities without discrimination on account of race, creed, or color, and for furnishing needed hospital facilities for persons unable to pay therefor; (5) That the application contains an assurance that the ap- plicant will conform to State standards for operation and main- tenance and to all applicable State laws and State and local codes, regulations, and ordinances: (6) That the application is entitled to priority over other pro- jects within the State and that in making this determination the State agency has complied with paragraph (b) of this section; and (7) That the State Agency has approved the application. (e) Amendments to application. An amendment to any applica- tion approved by the Surgeon General shall be processed in the same manner as an original application, except that the original application’s conformity with priority regulations shall suffice for the amendment. Minor changes not provided for under para- graph (c) (7) of this section are not considered amendments. § 53 78 Requests for construction payments—(a) Certification by Slate Agency. The State Agency shall certify to the Surgeon General the amount of payments due to an applicant for the cost of work performed and materials and equipment furnished. Requests for payment under the construction contract shall be submitted in each of three stages, as follows: (1) The first installment when not less than 25 percent of the work of construction of the building has been completed, (2) The second installment when the mechanical work has been substantially roughed in, and (3) The third installment when work under the construction contract is completed and final inspection made. Requests for payment of the Federal share of other allowable costs such as architect’s fee, inspection cost, and cost of equipment shall be included in requests for payments made at one or more of the stages indicated in this paragraph. All costs that have not been determined at the time the third payment for work performed under the construction contract is requested shall form the basis of a request for final payment of the Federal share of the entire project. With the consent of the Surgeon General, the State Agency may adopt a different schedule of payments, but in no case shall such payments be less frequent than those scheduled in this para- graph. (b) Inspection by State Agency. As a basis for certification by the State Agency that payment of an installment is due an ap- plicant, the State Agency, without expense to the Federal govern- ment, shall make adequate inspections to determine that the work has been performed upon a project, or purchases have been made, in accordance with the approved plans and specifications. § 53.79 Fiscal accounting requirements—(a) Construction allot- ments. The State Agency shall be responsible for establishing and maintaining accounts and fiscal controls of all Federal and State funds allotted for construction projects. Federal and State funds shall be separately identified by maintaining separate fund ac- counts for this purpose. The fiscal records shall be so designed as to show at any given time the Federal funds allotted, encumbered, and unencumbered balances. If State contributions are made for construction, sep- arate accounts, reflecting similar information, shall be maintained for State funds. (b) Construction payments. Where the State may receive Federal funds for applicants for construction project grants, or the State itself is an applicant, adequate records of account and fiscal con- trols shall be established and maintained by the State to assure proper accounting of all funds received and disbursed. Similar suitable accounts shall be maintained to show the receipt and dis- bursement of State, local or other funds used for matching pur- poses. The State Agency shall require that applicants receiving Federal funds establish and maintain adequate accounting and fiscal rec- ords to reflect the receipt and expenditure of funds allotted and paid for construction projects. Separate accounts by source shall be maintained of all funds received for construction projects. These records shall be maintained regardless of whether Federal funds are received through the State Agency or directly from the Federal government. The States which by law are authorized to make payments to applicants shall promptly pay such applicants funds certified for payment by the Surgeon General for approved construction pro- jects. [seal] Thomas Parran, Surgeon General. Approved: Thomas Parran, Chairman, Federal Hospital Council. Approved: October 17, 1947. Oscar R. Ewing, Federal Security Administrator. APPENDIX C CHAPTER 810 LAWS OF MARYLAND, 1947 AN ACT to add two new sections to Article 43 of the Annotated Code of Maryland (1939 Edition), title “Health”, sub-title “Hospitals”, said new sections to be known as Section 496L and 496M, and to follow immediately after Section 496K of said Article, as said section was enacted by Chapter 210 of the Acts of 1945, designating the State Board of Health as the sole agency to represent the State for the purpose of Part C, Public Law 725 of the 79th Congress of the United States authorizing grants to States for construction and re- construction of hospitals and health centers, and creating an Advisory Council on Hospital Construction to advise in con- nection therewith. Section 1. Be it enacted by the General Assembly of Maryland, That two new sections be and they are hereby added to Article 43 of the Annotated Code of Maryland (1939 Edition), title “Health”, sub-title “Hospitals”, said new sections to be known as Sections 496L and 496M to follow immediately after Section 496K of said Article, as said Section was enacted by Chapter 210 of the Acts of 1945, and to read as follows: 496L. The State Board of Health is hereby designated as the sole agency to represent the State of Maryland for the purposes of Part C, Title VI of the Public Health Service Act, as enacted by Public Law 725 of the 79th Congress of the United States, and all amendments thereof and additions thereto, providing grants to States for the construction and reconstruction of hospitals and related facilities. There is hereby conferred upon the State Board of Health the powers necessary for it to comply with the provisions relating to the sole State agency representing the State of Mary- land for the purposes stated in Part C of said Public Law 725 and all amendments thereof and additions thereto, and contained in any part of said Title VI of Public Law 725 and all amendments thereof and additions thereto. 496M. The Governor shall appoint eleven persons to an Advisory Council on Hospital Construction to consult with and advise the State Board of Health in its administration of a State plan for the construction and reconstruction of hospital facilities as pro- vided for in said Public Law 725 of the 79th Congress of the United States. The term of office of the appointed members of the Advisory Council on Hospital Construction shall be three years, but of those first appointed, three shall be appointed for a term of one year, four for a term of two years, and four for a term of three years, and, on the expiration of their respective terms, their successors shall be appointed for a term of three years. Three members of said Advisory Council on Hospital Con- struction shall be appointed from a list of names submitted by the 120 Hospital Survey and Plan for Maryland Medical and Chirurgical Faculty of Maryland; four members shall be appointed from a list of names submitted by the Mary- land-District of Columbia Hospital Association, at least two of whom shall be physicians; one member shall be a member of the faculty of a graduate school of Public Health in the State of Mary- land; and three members shall be representatives of consumers of hospital services selected from among persons familiar with the need for such services in urban and rural areas. In addition to the members so appointed, the persons holding the following positions shall also serve as members of said Ad- visory Council on Hospital Construction; the Director of the Department of Health of Maryland; the Commissioner of Mental Hygiene of Maryland; two members of the Committee on Medical Care of the Maryland State Planning Commission, designated by said Commission; and the Commissioner of Health of Baltimore City. Sec. 2. (Severability.) If any provision of this Act, or the application thereof to any person or circumstance shall be held invalid, such invalidity shall not affect the provisions or applica- tions of this Act which can be given effect without the invalid provision or application, and to this end the provisions of this Act are declared to be severable. Sec. 3. (Repeal.) All Acts, or parts of Acts, which are in- consistent with the provisions of this Act are hereby repealed. Sec. 4. And he it further enacted, That this Act shall take effect June 1, 1947. Approved, April 25, 1947. APPENDIX D CHAPTER 811 LAWS OF MARYLAND, 1947 AN ACT to repeal and re-enact with amendments, Section 20 of Article 31 of the Annotated Code of Maryland (1943 Supplement), title “Debt-Public”, sub-title “Public Works”, as said Section 20 was amended by Chapter 645 of the Acts of 1945, relating to the time during which bonds may be issued for public works by political sub-divisions of the State and the purposes for which said sub-divisions may accept assistance of any agency of the Federal Government. Section 1. Be it enacted by the General Assembly of Maryland, That Section 20 of Article 31 of the Annotated Code of Mary- land (1943 Supplement), title “Debt-Public”, sub-title “Public Works”, as said Section 20 was amended by Chapter 645 of the Acts of 1945, be and it is hereby repealed and re-enacted, with amendments, to read as follows: 20. The powers conferred by this sub-title shall be in addition and supplemental to the powers conferred by any other law, and bonds, interim certificates or other obligations may be issued hereunder for any project notwithstanding that any other law, may provide for the issuance of bonds, interim certificates or other obligations for like purposes and without regard to the require- ment, restrictions or other provisions contained in any other law. Bonds may be issued under this sub-title notwithstanding any debt, or other limitation prescribed by any other law, and the mode and method of procedure for issuance of bonds under this sub-title need not conform to the provisions of any other law. Any proceedings heretofore taken under any other law by any municipality relating to the subject matter of this sub-title, may be continued under such other law or under this sub-title, or at the option of the governing body may be discontinued and new proceedings instituted under this sub-title. Except in pursuance of any contract or agreement theretofore entered into by and between any municipality and any Federal agency, no municipal- ity shall borrow any money or issue any bonds pursuant to the provisions of this sub-title after June 1, 1949. It is the purpose of this sub-title to enable municipalities to secure the benefits of any agency of the Federal Government engaged in a works pro- gram, to encourage public works, to reduce unemployment and thereby to assist in the national recovery and promote the public welfare, and it is also the purpose of this sub-title to enable municipalities to accept and secure the assistance and benefits of any agency of the Federal Government given to encourage or to aid in the construction or acquisition of public works, made necessary by and connected with post-war reconstruction and to enable municipalities to accept and secure the benefits of any agency of the Federal Government given for or to aid in a program of public health, medical research or medical care, and to these ends municipalities shall have power to do all things necessary or convenient to carry out said purpose in addition to the express powers conferred in this sub-title. This sub-title is remedial in nature and the powers hereby granted shall be liberally construed. Sec. 2. And be it further enacted, That this Act shall take effect June 1, 1947. Approved, April 25, 1947. APPENDIX E CHAPTER 716 LAWS OF MARYLAND, 1947 AN ACT to add a new and additional section to Article 43 of the Annotated Code of Maryland (1939 Edition) title “Health”, sub-title ‘‘Miscellaneous Provisions”, to be known as Section 44B of said Article, to follow immediately after Section 44A of said Article, providing for the administration and super- vision by the State Board of Health, of a mental health pro- gram. Section 1. Be it enacted by the General Assembly of Maryland, That a new and additional section be and the same is hereby added to Article 43 of the Annotated Code of Maryland (1939 Edition), title “Health”, sub-title “Miscellaneous Provisions,” to be known as Section 44B of said Article, to follow immediately after Section 44A of said Article and to read as follows: 44B. The State Board of Health is hereby designated as the agency of the State to administer a program of non-institutional services for mentally ill or those who are suffering from conditions which may lead to mental illness and to coordinate and supervise the administration of those services included in the program which are not administered directly by it. The purpose of such program shall be to develop, extend and improve services for locating per- sons who are suffering from some mental illness and to provide facilities for diagnosis and corrective treatment of non-institutional cases. Isothing in this Act shall be construed to amend or alter in any way, the rights and powers conferred upon the Board of Mental Hygiene. The said State Board of Health is hereby authorized: (a) To formulate and administer a detailed plan or plans for Appendices 121 the purposes herein specified, and make such rules and regulations as may be necessary or desirable for the administration of such plans. (b) To receive and expend in accordance with such plans, all funds made available to such Board by the Federal Government, the State or its political subdivisions or from any other sources for such purposes. (c) To cooperate with the Federal Government, through its appropriate agency or instrumentality, and all other agencies, both public and private, in developing, extending and improving such services and in the administration of such plans. Sec 2. And be it further enacted, That all laws or parts of laws inconsistent herewith are hereby repealed to the extent of such inconsistencies. Sec. 3. And be it further enacted, That this Act shall become effective June 1, 1947. Approved April 25. 1947. APPENDIX F CHAPTER 210 LAWS OF MARYLAND, 1945 AN ACT to add a new sub-title and eleven new sections to Article 43 of the Annotated Code of Maryland (1939 Edition), title “Health”, said new sub-title to read “Hospitals”, said new sections to be known as Sections 496A to 436K, in- clusive, and to follow immediately after Section 496 of said Article, providing for the licensing of hospitals, authorizing the State Board of Health to promulgate rules and regulations prescribing certain minimum standards for hospitals and creating an Advisory Committee. Section 1. Be it enacted by the General Assembly of Maryland, That a new sub-title and eleven new sections be and they are hereby added to Article 43 of the Annotated Code of Maryland (1939 Edition), title “Health”, said new sub-title to be known as “Hospitals”, and said new sections to be known as Sections 496A to 496K, inclusive, to follow immediately after Section 496 of said Article, and to read as follows: HOSPITALS 496A. (Definitions.) The following terms used in this sub- title are hereby defined as follows: “Hospital” as herein used means any institution which main- tains and operates facilities for the care and/or treatment of two (2) or more non-related persons as patients suffering mental or physical ailments, but shall not be construed to include any dis- pensary or first-aid treatment facilities maintained by any com- mercial or industrial plant, educational institution or convent. “Person” shall include any person, partnership, association or corporation or any state, county or local governmental unit and any division, board or agency thereof. 496B. (Hospitals Must Obtain Licenses.) No person shall establish, conduct, maintain or operate in the State of Maryland any hospital without first having obtained a license therefor as hereinafter provided in this sub-title. 496C. (Existing Hospitals to Obtain Licenses.) No person may continue to operate an existing hospital unless such opera- tion shall be approved and legally licensed by the State Board of Health as hereinafter provided in this sub-title; provided, how- ever, that all hospitals in operation on the effective date of this sub-title shall be given a reasonable time to meet the minimum standards provided for in this sub-title and the rules and regula- tions issued thereunder. 496D. (Application for Licenses.) Any person desiring a license to open a hospital or to continue the operation of an existing hospital shall file with the State Board of Health a verified ap- plication setting forth the name of the applicant desiring such license, that the applicant is not less than twenty-one years of age and of reputable and responsible character, the class of hospital to be operated, the location thereof, the name of the person in charge thereof and such additional information as the State Board of Health may require. Applications on behalf of a corporation or association or a governmental unit or agency shall be made by any two officers thereof. Each application for a license to operate a hospital shall be ac- companied by a fee of ten dollars ($10.00). All licenses issued hereunder shall expire one year from date of issuance. No such fee shall be refunded and all fees received by the State Board of Health under the provisions of this sub-title shall be paid into the State Treasury to the credit of the State Board of Health for the purpose of carrying out the provisions of this sub-title. 496E. (Issuance of Licenses.) The State Board of Health is hereby authorized to issue licenses to open, maintain and operate hospitals which, after inspection, are found to comply with the provisions of this sub-title and the rules and regulations adopted thereunder by the State Board of Health. No license granted hereunder shall be assignable or transferable. 496F. (Inspections.) The State Board of Health shall cause each hospital in the State of Maryland to be periodically inspected under rules and regulations to be established by said Board of Health, as hereinafter provided. Any hospital desiring to make any alteration or addition to its buildings and plant or any change in any of its facilities may, before making such change, alteration or addition, request the State Board of Health to approve the same, provided, however, that nothing contained in this sub-title shall be construed as in any way superseding the provisions of any local building code now in existence or hereafter enacted. Thereupon, the State Board of Health shall investigate the change, alteration or addition so contemplated to be made and as soon thereafter as reasonably practical shall notify the licensee that said change, alteration or addition is approved or disapproved with such recommendations as said State Board of Health shall care to make. 496G. (Standards Established.) The State Board of Health shall have full power and authority to make and promulgate rea- sonable rules and regulations classifying hospitals and prescribing minimum standards of safety and sanitation in the physical plant of diagnostic, therapeutic and laboratory facilities and equipment of each class of hospitals, provided, however, that nothing contained in this sub-title shall affect the right of each institution to employ its own personnel and staff, and provided further that said rules and regulations are not in conflict with any provisions of this sub-title. The State Board of Health may modify, amend or rescind such regulations from time to time as may be in the public interest. 496H. (Appeals.) Any person aggrieved by the refusal of the State Board of Health to issue a license may, within ten (10) days after receipt of notice of such action or failure to act, take an ap- peal therefrom to a court having equity jurisdiction in the County or in the City of Baltimore where such hospital is located or contemplated and a copy of such appeal shall be filed with the State Board of Health. Within five (5) days after the receipt of such copy, the State Board of Health shall transmit to such court all the original papers pertaining to such application, and such appeal shall thereafter be heard by such court as promptly as circumstances will reasonably permit. Such hearing may be heard upon the record so transmitted, but the court may hear such additional evidence as it may deem proper, and upon the conclusion of such hearing, the court may affirm, vacate or modify the order appealed from. Any party to said proceeding may ap- peal from the decision of such court to the Court of Appeals of Maryland, the procedure therein to be the same as in appeals from the action of equity courts. 496-1. (Advisory Board.) An advisory Board of seven (7) mem- bers, each of whom shall hold office for a period of five (5) years, shall be appointed by the Governor to make recommendations to the State Board of Health and to assist in the establishment of minimum standards under the provisions of this sub-title and any amendments thereto. Three (3) members of paid Advisory Board shall be appointed from a list of names submitted by the Medical and Chirurgical Faculty of Maryland. Four (4) members of said 122 Hospital Survey and Plan for Maryland Advisory Board shall be appointed from a list of names submitted by the Maryland-District of Columbia Hospital Association of which two (2) shall be superintendents of Maryland hospitals and one (1) shall be a trustee of a Maryland hospital and at least one (1) of whom shall be a member of the Medical and Chirurgical Faculty of Maryland. At least four (4) members of the Advisory Board shall be doctors of medicine and members of the Medical and Chirurgical Faculty of Maryland. Of the original committee, one (1) member shall be appointed for a term of one (1) year, two (2) for a term of two (2) years, one (1) for a term of three (3) years, two (2) for a term of four (4) years, and one (1) for a term of five (5) years, from June 1, 1945 and thereafter their successors shall be appointed for a term of five (5) years. All members of said Advisory Board shall be citizens and residents of the State of Maryland for a period of at least one year immediately prior to appointment; at least two (2) shall be residents of the City of Baltimore; at least two (2) shall be residents of the counties; and all members shall serve without compensation. Meetings of said Advisory Board may be called by the State Board of Health or by any three members of the Advisory Board on proper notice. 496J. (Violations—Penalties.) Any person maintaining and operating a hospital without a license shall be guilty of a mis- demeanor, and upon conviction thereof shall be liable to a tine of not more than One Hundred Dollars ($100.00) for the first offense and not more than Five Hundred Dollars ($500.00) for each subsequent offense, and each day such hospital shall operate after a first conviction shall be considered a second offense. 496K. (Saving Section.) If any provision of this sub-title, or the application thereof to any person or circumstances, is held invalid, the remainder of this sub-title and the application of such provision to other persons or circumstances shall not be affected thereby. If any provision, clause, sentence or section of this sub- title shall be declared to be invalid or in violation of any pro- vision of the State or Federal Constitution, the remainder of this sub-title shall stand and be effective notwithstanding. Sec. 2. And he it further enacted, That this Act shall take effect June 1, 1945. Approved March 8, 1945. APPENDIX G CHAPTER 421 LAWS OF MARYLAND, 1945 AN ACT to repeal and re-enact with amendments Section 526 of Article 43 of the Annotated Code of Maryland (1943 Supp.), title “Health,” sub-title “Chronic Hospitals and Infirmaries,” increasing the number of chronic hospitals and infirmaries and specifying their location. Section 1. Be it enacted by the General Assembly of Maryland, That Section 526 of Article 43 of the Annotated Code of Mary- land (1943 Supp.), title “Health,” sub-title “Chronic Hospitals and Infirmaries,” be and the same is hereby repealed and re-en- acted with amendments so as to read as follows; 526. The State Board of Health is authorized to establish three institutions for needy persons from the various counties and Bal- timore City who require medical, nursing or custodial care by reason of chronic illness or infirmity; one of which shall be located in one of the nine counties on the Eastern Shore, one in the eastern part of the Western Shore convenient and accessible to Baltimore City, Baltimore, Anne Arundel, Carroll, Howard, and Harford Counties, and one on the Western Shore in Western Maryland, at points to be selected by said Board with the approval of the Board of Public Works. The cost of the erection and equipment of said in- stitutions (including the cost of acquiring appropriate sites) shall be paid out of appropriations in the budget, or in any bond issue bill making appropriations for the purpose. Each institution shall contain two sections, one of which shall be a chronic hospital and the other an infirmary, and proper provision for both the white and colored races shall be made. In selecting sites and making archi- tectural plans for each institution, provision shall be made for possible expansion and for the later addition of a unit for the treatment of chronic diseases of children. The State Board of Health shall appoint a superintendent and such other personnel as may be necessary, within the limits of the budgetary appropria- tions, for each institution. Sec. 2. And be it further enacted, That this Act shall take effect on June 1, 1945. Approved March 29, 1945. APPENDIX H CHAPTER 170 LAWS OF MARYLAND, 1943 AN ACT to add a new sub-title and five new sections to Article 43 of the Annotated Code of Maryland (1939 Edition), title “Health”, said new sub-title to read “Chronic Hospitals and Infirmaries”, and said new sections to be known as Sections 526 to 530, inclusive, and to follow immediately after Section 525 of said Article, providing for the establishment of Chronic Hospitals and Infirmaries and their management and main- tenance. Section 1. Be it enacted by the General Assembly of Maryland, That a new sub-title and five new sections be and they are hereby added to Article 43 of the Annotated Code of Maryland (1939 Edition), title “Health”, said new sub-title to be known as “Chronic Hospitals and Infirmaries”, and said new sections to be known as Sections 526 to 530, inclusive, to follow immediately after Section 525 of said Article, and to read as follows: CHRONIC HOSPITALS AND INFIRMARIES 526. The State Board of Health is authorized to establish two institutions for needy persons from the various counties and Baltimore City who require medical, nursing or custodial care by reason of chronic illness or infirmity; one of which shall be located in one of the nine counties on the Eastern Shore and one in one of the fourteen counties on the Western Shore, at points to be selected by said Board with the approval of the Board of Public Works. The cost of the erection and equipment of said in- stitutions (including the cost of acquiring appropriate sites) shall be paid out of appropriations in the budget, or in any bond issue bill making appropriations for the purpose. Each institution shall contain two sections, one of which shall be a chronic hospital and the other an infirmary, and proper provisions for both the white and colored races shall be made. In selecting sites and making architectural plans for each institution, provision shall be made for possible expansion and for the later addition of a unit for the treatment of chronic diseases of children. The State Board of Health shall appoint a superintendent and such other personnel as may be necessary, within the limits of the budgetary appro- priations, for each institution. 527. Admission to the chronic hospitals and infirmaries shall Appendices 123 be made on the basis of a statement by a physician who, after an examination, finds that the patient is in need of chronic hospital or infirmary care, and of a further statement by the local County Welfare Board or the Department of Welfare of Baltimore City that the patient is unable to pay for the cost of his care. Final arrangements for admission shall be made only after the County Commissioners of the County or the Department of Welfare of Baltimore City where the applicant resides have given their ap- proval. No patient shall be admitted who has tuberculosis in a transmissible form, mental disease of the type requiring care in a mental hospital, an orthopedic disease of a type admissible to the special orthopedic hospitals, or who is under the age of sixteen years. 528. No patient shall be admitted who is able to pay the cost of proper hospital care elsewhere. In all cases admitted, there shall be collected from the patient or his family as much of the actual cost of maintenance as is reasonably possible, but no case shall pay above the actual per diem cost calculated on the basis of the total cost of running the institutions. 529. For each patient admitted to either of the chronic hospitals and infirmaries from any county of the State or Baltimore City, the County Commissioners of said county and the Mayor and City Council of Baltimore shall pay into the State Treasury the sum of seventy-five cents per day, as long as said patient remains in such institution. The remaining cost of board, care and treatment, and the cost of operation shall be paid out of appropriations in the budget. Said charge of seventy-five cents per day shall be collectible by the State Comptroller in the same manner as in the case of patients admitted to the insane hospitals of the State, as provided in Section 49 of Article 59 of the Code and the Comptroller shall have the power to determine, in the event of any dispute as to residence, which .one of two or more counties may be responsible for such charge. 530. Each of the chronic hospitals and infirmaries shall have a Board of Visitors consisting of one member of the Board of County Commissioners for each County and the Director of the Department of Welfare of Baltimore City in the area served by such institution, said member to be selected by said Board of County Commissioners. The Board of Visitors shall make periodic visits to the institution and make suggestions to the State Board of Health concerning the conduct and maintenance of the chronic hospitals and infirmaries. Sec. 2. And he it further enacted, That this Act shall take effect June 1, 1943. Approved March 18, 1943. 124 Hospital Survey and Plan for Maryland APPENDIX I POPULATION OF MARYLAND BY COUNTY 1943, 1940, 1930, AND 1920 Per Cent Change County 19431 19402 19302 19202 1920-19302 1930-19402 1940-1943 Allegany 81,302 86,973 79,098 69,938 13.1 10.0 — 6.5 Anne Arundel 77,070 68,375 55,167 43,408 27.1 23.9 12.7 Baltimore 202,425 155,825 124,565 74,817 66.5 25.1 29.9 Calvert 10,549 10,484 9,528 9,744 -2.2 10.0 0.6 Caroline 16,047 17,549 17,387 18,652 —6.8 0.9 — 8.6 Carroll 39,399 39,054 35,978 34,245 5,1 8.5 0.9 Cecil 32,055 26,407 25,827 23,612 9.4 2.2 21.4 Charles 19,784 17,612 16,166 17,705 —8.7 8.9 12.3 Dorchester 24,264 28,006 26,813 27,895 —3.9 4.4 —13.4 Frederick 51,774 57,312 54,440 52,541 3.6 5.3 — 9.7 Garrett 18,534 21,981 19,908 19,678 1.2 10.4 —15.7 Harford 42,890 35,060 31,603 29,291 7.9 10.9 22.3 Howard 18,481 17,175 16,169 15,826 2.2 6.2 7.6 Kent 13,071 13,465 14,242 15,026 —5.2 — 5.5 — 2.9 Montgomery 104,155 83,912 49,206 34,921 40.9 70,5 24.1 Prince George’s 117,625 89,490 60,095 43,347 38.6 48.9 31.4 Queen Anne’s 12,194 14,476 14,571 16,001 —8.9 — 0.7 —15.8 St. Mary’s 17,877 14,626 15,189 16,112 —5.7 — 3.7 22.2 Somerset 17,269 20,965 23,382 24,602 —5.0 —10.3 —17.6 Talbot 16,190 18,784 18,583 18,306 1.5 1 1 ' —13.8 Washington 69,890 68,838 65,882 59,694 10.4 4.5 1.5 Wicomico 32,960 34,530 31,229 28,165 10.9 10.6 — 4.5 Worcester 19,201 21,245 21,624 22,309 —3.1 — 1.8 — 9.6 County totals 1,055,006 962,144 826,652 715,835 15.5 16.4 9.7 Baltimore City 927,941 859,100 804,874 733,826 9.7 6.7 8.0 State Totals 1,982,947 1,821,244 1,631,526 1,449,661 12.5 11.6 8.9 1United States Bureau of the Census, Estimated Civilian Population, 1943. 2United States Bureau of the Census, 16th Census of the United States, 1940. APPENDIX J POPULATION OF MARYLAND BY RACE AND COUNTY, 1910 AND 1913 19401 19452 County Total White Nonwhite Total White Nonwhile Allegany 86,973 85,651 1,322 81,302 80,082 1,220 Anne Arundel 68,375 50,524 17,851 77,070 56,955 20,115 Baltimore 155,825 145,295 10,530 202,425 188,660 13,765 Calvert 10,484 5,604 4,880 10,549 5,633 4,916 Caroline 17,549 14,102 3,447 16,047 12,886 3,161 Carroll 39,054 36,973 2,081 39,399 37,311 2,088 26,407 24,051 2,356 32,055 29,170 2,885 Charles 17,612 10,384 7,228 19,784 11,673 8,111 Dorchester 28,006 19,917 8,089 24,264 17,252 7,012 Frederick 57,312 52,607 4,705 51,774 47,529 4,245 Garrett 21,981 21,976 5 18,534 18,534 0 Harford 35,060 31,076 3,984 42,890 38,001 4,889 Howard 17,175 14,369 2,806 18,481 15,469 3,012 Kent 13,465 9,404 4,061 13,071 9,124 3,947 Montgomery 83,912 74,986 8,926 104,155 93,115 11,040 89,490 73,217 16,273 117,625 96,217 21,408 Queen Anne’s 14,476 10,129 4,347 12,194 8^524 3^670 St. Mary’s 14,626 9,901 4,725 32,318 26,794 5,524 Somerset 20,965 13,904 7,061 17,269 11,449 5,820 Talbot 18,784 13,048 5,736 16,190 11,252 4,938 Washington 68,838 67,048 1,790 69,890 68,073 1,817 Wicomico 34,530 27,035 7,495 32,960 25,808 7,152 Worcester 21,245 14,575 6,670 19,201 13,172 6,029 County totals 962,144 825,776 136,368 1,069,447 919,186 150,261 Baltimore City 859,100 692,705 166,395 930,000 751,000 179,000 State Totals 1,821,244 1,518,481 302,763 1,999,447 1,670,186 329,261 1 United States Bureau of the Census, 16th Census of the United States. 1940. 2 Maryland State Department of Health, Bureau of Vital Statistics. Appendices 125 COMPOSITION OF POPULATION IN MARYLAND BY APPENDIX K COUNTY, URBAN, RURAL NONFARM, AND RURAL FARM, 19401 Urban Rural Nonfarm Rural Farm 1940 Number Per Cent Number Per Cent Number Per Cent Allegany 86,973 50,707 58.3 30,054 34.6 6,212 7.1 Anne Arundel 68,375 13,069 19.1 43,451 63.5 11,855 17 3 Baltimore 155,825 \ 28,802 \ 102,167 \ [ Baltimore City 859,100 / 859,100 / 87.5 -] 10.1 2.4 Calvert 10,484 — — 3,586 34.2 6,898 1 65.8 Caroline 17,549 — 9,375 53.4 8,174 46.6 Carroll 39,054 4,692 12.0 19,784 50.7 14,578 37.3 Cecil 26,407 3,518 13.3 14,565 55,2 8,324 31.5 Charles 17,612 — — 7,929 45.0 9,683 55.0 Dorchester 28,006 10,102 36.1 9,541 34.1 8,363 29.9 Frederick 57,312 19,658 34.3 18,453 32.2 19,201 33,5 Garrett 21,981 — — 10,962 49.9 11,019 50.1 Harford 35,060 4,967 14.2 15,730 44.9 14,363 41.0 Howard 17,175 — — 10,522 61.3 6,653 38.7 Kent 13,465 2,760 20.5 6,501 48.3 4,204 31.2 Montgomery 83,912 7,650 9.1 62,170 74.1 14,092 16.8 Prince George’s 89,490 18,347 20.0 55,829 62.4 15,314 17.1 Queen Anne’s 14,476 — — 7,348 50.8 7,128 49.2 St. Mary’s 14,626 — — 6,433 44.0 8,193 56.0 Somerset 20,965 3,908 18.6 10,716 51.1 6,341 30.2 Talbot 18,784 4,528 24.1 7,539 40.1 6,717 35.8 Washington 68,838 32,491 47.2 23,842 34.6 12,505 18.2 Wicomico 34,530 13,313 38.6 11,069 32.1 10,148 29.4 Worcester 21,245 2,739 12.9 10,267 48.3 8,239 38.8 State of Maryland 1,821,244 1,080,351 59.3 497,833 27.3 243,060 13.3 1 United States Bureau of the Census, 16th Census of the United States, 1940. APPENDIX L PER CAPITA INCOME IN MARYLAND BY COUNTY, 1940 AND 945 Population Gross Income Per Capita Population Gross Income Per Capita County 19401 19402 Income, 1940 19453 19454 Income, 1945 Allegany 86,973 $52,198,000 $600.16 (s) 82,302 $104,127,000 $1,280.74 (5) Anne Arundel. . 68,375 32,277,000 472.06 (15) 77,070 65,715,000 852.67 (15) 155,825 \ 202,425 \ Baltimore City. 859,100 / 735,844,000 725.02 (1) 930,000 / 1,753,133,000 1,548.12 (1) Calvert 10,484 3,854,000 367.61 (19) 10,549 7,842,000 743.39 (21) Caroline 17,549 8,308,000 473.42 (H) 16,047 16,918,000 1,054.28 (10) Carroll 39,054 20,318,000 520.25 (10) 39,399 41,367,000 1,049.95 (11) Cecil 26,407 12,659,000 479.38 (13) 32,055 25,773,000 804.02 (18) Charles 17,612 5,634,000 319.90 (20) 19,784 11,462,000 579.36 (22) Dorchester 28,006 12,682,000 452.83 (17) 24,264 25,813,000 1,063.84 (9) Frederick 57,312 33,391,000 582.62 (6) 51,774 60,952,000 1,177.27 (7) Garrett 21,981 6,852,000 311.72 (21) 18,534 13,949,000 752.62 (20) Harford 35,060 17,262,000 492.07 (11) 42,890 35,119,000 818.82 (16) Howard 17,175 7,816,000 455.08 (16) 18,481 15,925,000 861.70 (13) Kent 13,465 7,773,000 577.27 (8) 13,071 15,814,000 1,209.85 (6) Montgomery, . . 83,912 44,026,000 524.67 (9) 104,155 89,633,000 860.57 (U) Prince George’s 89,490 43,670,000 487.99 (12) 117,625 92,912,000 789.90 (19) Queen Anne’s. . . 14,476 5,397,000 372.82 (18) 12,194 10,991,000 901.34 (12) St. Mary’s 14,626 4,053,000 277.11 (22) 32,318 8,243,000 255.06 (23)* Somerset 20,965 5,454,000 260.15 (23) 17,269 14,100,000 816.49 (17) Talbot 18,784 10,984,000 584.75 (5) 16,190 22,353,000 1,380,67 (2) Washington.... 68,838 39,837,000 578.71 (7) 69,890 81,108,000 1,160.51 (8) Wicomico 34,530 21,308,000 617.09 (2) 32,960 43,382,000 1,316.20 U) Worcester 21,245 12,714,000 598.45 U) 19,201 25,873,000 1,347.48 (3) State of Maryland . . 1,821,244 $1,144,301,000 $628.31 1,999,447 $2,582,504,000 $1,291.61 Note: Numbers in parentheses give relative position of county in State. 1 United States Bureau of the Census, 16th Census of the United States, 1940. 2“Gross effective buying income,” as used in Sales Management, April 10, 1941. 3 Maryland State Department of Health, Bureau of Vital Statistics. 4“Gross effective buying income,” as used in Sales Management, May 10, 1946. 5The 1945 population estimates of the State Department of Health are the same as the 1943 U. S. Bureau of the Census estimates for all the counties of Maryland, except St. Mary’s County. Therefore, it would be advisable to consider both the 1945 and 1943 figures for this County in order to arrive at a more valid pic- ture of its economic status. The 1945 per capita income of $255.06, given above, shows a decrease from the 1940 per capita income. However, on the basis of the lower estimated population of 17,877 for 1943, St. Mary’s 1945 per capita income rises to $461.10, thereby showing an increase over 1940. In either instance, its relative position among the counties of the State remains unchanged. 126 Hospital Survey and Plan for Maryland POPULATION PER APPENDIX M SQUARE MILE IN MARYLAND BY COUNTY , 1943 County Population 19431 Land Area In Square Miles2 Population Per Square Mile Allegany 81,302 426 (12) 190 8 U) Anne Arundel 77,070 417 (13) 184 8 (5) Baltimore 202,425 610 (3) 331 8 (1) Calvert 10,549 219 (23) 48 2 (17) Caroline 16,047 320 (19) 50 1 (15) Carroll 39,399 456 (10) 86 4 (10) Cecil 32,055 352 (17) 91 1 (8) Charles 19,784 458 (9) 43 2 (19) Dorchester 24,264 580 U) 41 8 (20) Frederick 51,774 664 (2) 78 0 (11) Garrett 18,534 668 (1) 27 7 (23) Harford 42,890 448 (11) 95 7 (7) Howard 18,481 251 (22) 73 6 (12) Kent 13,071 284 (20) 46 0 (18) Montgomery 104,155 494 (5) 210 8 (3) Prince George’s Queen Anne’s 117,625 485 (6) 242 5 (2) 12,194 373 (15) 32 7 (22) St. Mary’s 17,877 367 (16) 48 7 (16) Somerset 17,269 332 (18) 52 0 (U) Talbot 16,190 279 (21) 58 0 (13) Washington 69,890 462 (8) 151 3 (6) Wicomico 32,960 380 (U) 86 7 (•9) Worcester 19,201 483 (7) 39 8 (21) County totals Baltimore City 1,055,006 927,941 9,808 79 107 11,746 6 .1 State Totals. ... 1,982,947 9,887 200 6 Note: Numbers in parentheses give relative position of county in State. DJnited States Bureau of the Census, Estimated Civilian Population, 1943. 2United States Bureau of the Census, 16th Census of the United States, 1940. APPENDIX N NUMBER OF PHYSICIANS IN MARYLAND BY COUNTY, 1947 County Number op Resident Physicians1 Residents Per Physician2 70 1,161 1,835 1,212 2,110 1,234 1,459 1,781 1,799 42 167 5 13 27 18 11 21 1,155 49 1,057 2,648 1,532 1,540 726 7 28 12 18 97 1.074 3,179 1,524 1,490 1,016 771 1.075 916 37 8 12 17 Talbot , 21 65 36 14 1,372 County Totals 795 1,327 1 Reported by County Health Officers. 2According to United States Bureau of the Census, Estimated Civilian Popula tion, 1943. APPENDIX O TOTAL BIRTHS AND BIRTHS IN HOSPITALS IN MARYLAND BY RACE AND COUNTY, 1945' Births in Hospitals Number Per C ent Total Bi RTHS County Total White Nonwhite Total White Nonwhite Total White Nonwhite Allegany 1,724 1,691 33 1,421 1,397 24 82.4 82.6 72.7 Anne Arundel 1,819 1,392 427 1,213 1,094 119 66.7 78.6 27.9 Baltimore 5,174 4,751 423 4,155 3,923 232 80.3 82.6 54.8 Calvert 312 156 156 182 120 62 58.3 76.9 39.7 Caroline 329 248 81 179 174 5 54.4 70.2 6.2 Carroll 708 666 42 378 369 9 53.4 55.4 21.4 Cecil 702 652 50 548 514 34 78.1 78.8 68.0 Charles 605 304 301 315 262 53 52.1 86.2 17.6 Dorchester 462 298 164 308 250 58 66,7 83.9 35.4 Frederick 1,141 1,029 112 798 708 90 69.9 68.8 80.4 Garrett 424 424 0 165 165 0 38.9 38.9 0.0 Harford 1,090 994 96 867 815 52 79.5 82.0 54.2 Howard 381 317 64 212 194 18 55.6 61.2 28.1 Kent 246 166 80 156 136 20 63.4 81.9 25.0 Montgomery 2,694 2,463 231 2,457 2,308 149 91.2 93.7 64.5 Prince George’s 2,992 2,529 463 2,675 2,393 282 89.4 94.6 60.9 Oueen Anne’s 260 178 82 110 106 4 42.3 59.5 4.9 St. Mary’s 708 540 168 460 442 18 65.0 81.9 10.7 Somerset 357 199 158 173 152 21 48.5 76.4 13.3 Talbot 330 220 110 206 198 8 62.4 90.0 7.3 Washington 1,467 1,451 16 1,050 1,040 10 71.6 71.7 62.5 Wicomico 636 471 165 444 388 56 69.8 82.4 33.9 Worcester 407 231 176 159 143 16 39.1 61.9 9.1 County totals 24,968 21,370 3,598 18,631 17,291 1,340 74.6 80.9 37.2 Baltimore City 17,848 13,308 4,540 14,622 11,739 2,883 81.9 88.2 63.5 State Totals 42,816 34,678 8,138 33,253 29,030 4,223 77.7 83.7 51.9 1 Maryland State Department of Health, Bureau of Vital Statistics. Appendices 127 APPENDIX P PER CAPITA CIVILIAN HOSPITAL RESOURCES BY STATE1 Index of Beds Per 1,000 Beds Population Hospit al Hospital States Arranged By Per Population Per Per $100 Facilities Maintenance Per Capita Income Capita 1944 1,000 Average Income Valuation Expense Income Persons Per Person Per Capita Per Capita U) (2) (S) U) (5) (6) 1. Connecticut $1,431 1,776,807 12.54 .876 $47.01 $13.52 2. Nevada 1,372 156,445 7.52 .548 15.33 3,66 3. California 1,366 8,746,989 9.17 .671 22.50 11.13 4. New York 1,343 12,632,890 15.00 1.116 57.76 16.43 5. Washington 1,336 2,055,378 9.79 .733 21.14 9.31 6. Delaware 1,287 283,802 12.67 .984 47.78 11.85 7. New Jersey 1,261 4,167,840 11.02 .874 39.97 10.57 8. District of Columbia. . . 1,254 926,260 16.06 1.281 46.88 17.87 9. Oregon 1,204 1,214,226 10.17 .845 21.89 8.72 10. Rhode Island 1,198 778,972 10.40 .868 38.10 9.94 11. Michigan 1,183 5,429,641 10.88 .920 33.09 12.11 12. Massachusetts 1,177 4,162,815 14.68 1.247 42.24 14.58 13. Illinois 1,175 7,729,720 11.54 .982 32.36 11.53 14. Maryland 1,169 2,127,874 10.64 .910 36.34 10.90 15. Ohio 1,167 6,836,667 8.59 .736 27.86 9.05 16. Pennsylvania 1,048 9,247,088 10.96 1,046 40.73 9.44 17. Indiana 1,040 3,419,707 7.57 .728 30.27 8.45 18. Montana 1,008 464,999 9.81 .973 28.79 10.87 19. Utah 972 606,994 6.77 1.170 21.00 5.40 20. Maine 968 793,600 10.48 .699 27.17 10.42 21. Wisconsin 966 2,975,910 11.15 1.085 27.79 9.47 22. Kansas 961 1,174,447 8.70 .905 17.82 7.08 23. Iowa 936 2,269,759 9.32 .996 19.69 7.29 24. Colorado 935 1,147,259 11.88 1.271 30.66 10.56 25. Wyoming 934 257,108 14.91 1.596 30.90 15.95 930 531,573 7.21 .775 14.27 5.15 27. Nebraska 920 1,213,792 9.34 1.015 21.53 7.54 28. Missouri 885 3,589,538 9,63 1.088 30,49 7.87 29. Minnesota 876 2,508,663 11.69 1.334 30.51 10.54 30. North Dakota 872 528,071 11.88 1.362 24.03 9.05 31. Vermont 863 310,941 12.86 1.490 30.11 9.67 32. Arizona 833 638,412 8.90 1.068 25.62 8.71 33. Florida 828 2,367,217 6.02 .727 10.47 4.99 34. South Dakota 817 558,629 9.81 1.201 23.17 6.50 35. Virginia 814 3,199,115 7.35 .903 14.70 6.28 36. New Hampshire 804 457,231 12.49 1.553 31.02 10.11 37. Texas 791 6,876,248 6.60 .834 15.67 6.23 38. Oklahoma 720 2,064,679 8.04 1 117 13.64 4.36 39. 1 West Virginia 692 1,715,984 7.24 1.046 22.35 5.88 40. Louisiana 698 2,535,385 7.41 1.093 22.74 5.76 41. New Mexico 660 532,212 7.61 1.153 23.57 6.29 42. Tennessee 645 2,870,158 6,34 .983 15.47 4,98 43. Georgia 624 3,223,727 5.57 .893 11.33 4.11 44. North Carolina 606 3,534,545 6.17 1.018 18,11 5.26 45. Kentucky 589 2,630,194 6.14 1.042 13.22 4.40 46. Alabama 579 2,818,083 5.36 .926 10.38 4.82 47. South Carolina 560 1,923,354 5.65 1.009 13.79 4.29 48. Arkansas 522 1,776,446 7.53 1.443 14.76 5.07 49. Mississippi 468 2,175,877 4 56 1.026 7.89 2.72 50. Alaska — 72,524 10.62 — 21.38 14.47 51. Hawaii — 423,329 12.21 — 28.25 18.02 52. Puerto Rico 1,869,245 3.47 5.18 2.91 Col. 1—1942-44. Source: Survey of Current Business, August 1945. Col. 2—1944 Estimate: United States Bureau of the Census (excludes members of armed forces overseas). Col. 3—Source: 1945 American Hospital Directory estimate based on reports from civilian hospitals primarily recognized by the American Medical Association; includes all types of service—general, mental, tuberculosis, and special. Col. 4—Index obtained by dividing Col . 3 by Col. 2 expressed in $100 units of income. Cols. 5 and 6—Ibid: Estimate based on reports from hospitals representing 70.4 to 77.3 per cent of recognized bed capacity. Col. 6—Does not include contractual or corporate charges, e.g , taxes, insurance, interest. 1 Reprinted from Hospitals, March 1946.