INTRODUCTION
EVOLUTION OF THE MILITARY HOSPITAL
ANCIENT PERIOD
Of those who, during the World War, were patients in any of our large, especially constructed military hospitals there were probably few who reflected that they were having the unique experience of being the first soldiers in the history of the world so favored as to receive treatment in a military hospital, the perfections of which rivaled the refinements of the best contemporary civil institutions for the care of the sick. That this is irrefutable a rapid survey of medico-military history and an examination of the data set forth in this volume will substantiate.
HOSPITAL CARE OF ANCIENT WARRIORS
Turning back the leaves of history to the records of the earliest times we find that, throughout, it has been customary to remove wounded soldiers from the field of battle and to place them in temporary shelters where they were given such crude treatment (`wound surgery`) as the times afforded. Even in the more remote period, or the domain of unauthenticated history, as related by Homer, the wounded were transported by hand or chariot to the tents or `black ships` to the rear.1There was, as might be expected, no organized effort to either rescue or care for the wounded in these early times; nor was such the case until a comparatively late period. Since the improvised shelters were extremely temporary, it was the custom among the Greeks and Romans to call into use houses, temples, even stables wherein the soldiers were refreshed and their wounds builded up.2 It was not until after the beginning of the Christian Era that organized effort was made to rescue and adequately care for the wounded in permanent buildings which had been especially constructed for that purpose.
STATIONARY MILITARY HOSPITALS
In republican Rome private hospitals and the homes of the wealthy had been utilized for the care of wounded Roman soldiers, so long as military activities remained confined to the vicinity of Rome.3With the extension of conquest to unknown lands, and the establishment of standing armies in occupied territories, it became necessary to provide special hospitals for the Roman soldiery there. Some of these hospitals, constructed of stone during the latter part of the first century or beginning of the second century of the Christian Era,3 suggest a striking resemblance to the military hospitals planned and erected by the British and French about 17 centuries later. They consisted of series of wards built about a quadrangle and opening on both sides of longitudinal corridors; each ward only sufficiently large to accommodate approximately a dozen patients. There were such refinements as sewers, water piping, a heat-
14
ing plant, kitchen, and apothecary`s shop. This surprisingly excellent arrangement for caring for the sick and wounded continued throughout the Byzantine period (476 to 732 A. D.), but ceased with the decline of Romaninfluence.4
MEDIEVAL PERIOD
Modern hospitals had their incipiency during that part of the Middle Ages when the great waves of the Crusades, breaking on the deserts of the East, carried back in their ebb a flotsam of the lame, the halt, and the blind to the cities of medieval Europe. To care for these and the plague of lepers introduced at the same time, the charitable orders of the church founded places of shelter for the poor andhelpless.5 These institutions, called hospitals, were designed merely to house their helpless inmates, and had little resemblance to the scientifically constructed and administered hospitals of the present day.
The revival of the direct hospital care of warriors is credited to Isabella Queen of Spain, who, during the siege of Alora (1184), sent to the camps six large tents and their furniture, together with physicians, surgeons, medicines, and attendants. These tents were called the `Queen`s Hospital.`6
The influence of Queen Isabella on the establishment of military hospitals was afterwards seen at the siege of Metz (1552), when, under Emperor Charles the Fifth, there were included the organizations of both field and garrison hospitals.7
EIGHTEENTH-CENTURY HOSPITALS
Toward the close of the eighteenth century, widespread attention was directed to the wretched general condition of the hospitals throughout Europe.8 In the Hotel Dieu, at Paris, at that time a veritable hot bed of disease, there were approximately 1,220 beds, the most of which contained from four to six patients. In larger halls there were patients crowded on pallets or often lying about miserably on heaps of straw, which was in vile condition. Vermin and filth abounded and the ventilation was often so abominable that the attendants an inspectors would not enter in the morning without a sponge dipped in vinegar held to their faces. Although the Hotel Dieu was not a military hospital, its condition reflected the general lack of knowledge of hospital construction and management, and especially the high value of the basic principles of sanitation in connection therewith-the provision of adequate airspace, and means for ventilation and the admission of sunlight.
The true principle of hospital construction was at first discussed by committee of the French Academy of Sciences,9which in 1788 made a final report as to conditions which a model hospital should fulfill, specifying that the wards should be in isolated pavilions; that each ward should be 24 feet wide, from 14 to 15 feet high and 115 feet long; and should contain from 34 to 36 beds; and that the windows should extend to the ceilings. A part of the committee visited England,10 and along with the ideas of the English ward utilities, they were impressed with the necessity of limiting the beds in a ward to from 12 to 13, a custom entirely at variance with that which prevailed in the Hotel Dieu. They took ideas from the plan of the pavilion hospital at Stonehouse, England,10 in all probability the first pavilion hospital, which guided them preparing their famous report.
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EARLY AMERICAN HOSPITALS
In America, the first account of a hospital in the territory now known as the United States was of the one established on ManhattanIsland11 in 1658, for sick soldiers-who had previously been billeted in private families-and for West India Co.`s negroes. In 1679 this hospital consisted of five houses.
During the American Revolution, General Washington evinced the kindest interest in the sick and wounded; but there was much suffering on account of the poverty of the Government and the meager resources of the country, pre.
FIG. 1.-Tilton`s Log Hut Hospital, New Jersey, 1780. (From an old wood cut.)
venting the possibility of building and conducting hospitals. Consequently, it was a necessity to make use of all kinds of houses for the purpose of locating the sick and wounded; and we find but little recorded as adding to the development of hospitals.12
During the winter of 1779-80, Dr. James Tilton, of Delaware, was in charge of the general hospital at Trenton, N. J., and to him is to be accorded the credit of endeavoring to diminish the sickness, resulting from crowd poisoning, by a new system of hospital construction.13 He did away with the hospital tents and private houses then in use; and caused to be constructed a large number of log
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huts, built roughly, so that air could penetrate the crevices. These huts were without wooden floors, the ground being hardened or baked by heat, and each hut was intended to accommodate about 8 to 12 men.
During the War of 1812 the general hospital, established at Burlington, Vt.,14 consisted of 40 wards containing between 700 and 800 patients. Wards were appropriated to infectious or contagious diseases, surgical cases had rooms separate from the febrile, and venereal and itch patients were assigned to their separate wards and not intermixed with men of different diseases. In an adjoining house the surgeons were accommodated with comfortable rooms where one or more always remained.
INFLUENCE OF THE CRIMEAN WAR ON HOSPITALS
The next progressive step after the report of the French Academy`s committee, in the development of hospitals, was brought about by the fearful death rate of the English and French armies in the beginning of the Crimean War. So great was the mortality that the English people as a whole were aroused to the necessity of better provision being made for the sick and wounded. Miss Florence Nightingale, who had had training as a nurse at Kaiserworth, and a selected band of 37 nurses were sent to the seat of the war, on October 24, 1854.15 In 1855, the British Government appointed a sanitary commission to proceed at once to Crimea and Scutari.15 Miss Nightingale and the commission succeeded in introducing many valuable sanitary reforms in the British army in the East.16
In 1855 the sanitary inspectors of the British army in Crimea suggested the use of wooden huts or barracks for hospitals,17 and at the same time proposed a permanent tent hospital. It was found by experience that simple wooden huts raised from the ground, with double walls to protect from the heat in summer and cold in winter, made with ridge ventilation, and heated by means of open fires or stoves, gave far better results than any other kind of building.
The practical results of the interest in hospitals brought about by the Crimean War were the building of the famous Herbert Hospital at Woolwich,18 and establishing on a sure basis the detached plan of hospital construction which had been proposed and a small one erected (Plymouth Naval Hospital), just 100 years before. The Herbert Hospital was an improvement on the Lariboisiore, in Paris, finished in 1854; but like it was modeled after the plan proposed by the French Academy`s committee in 1786-the improvements being mainly in the details of internal arrangements.10
Until the building of the Herbert Hospital, the Lariboisiore was the model hospital of the world.10 The influence of the Crimean experience did not do so much for France; nothing better than the Lariboisiore was proposed.
Before the interest in sanitary and hospital reform, caused by the Crimean War, had quieted down, the American people had the opportunity offered them to make use of the valuable suggestions published in the reports of the English commission, and in doing so succeeded in developing the most perfect system of army hospitals ever known to the world.
17
HERBERT HOSPITAL
FIG. 2.-Herbert Hospital, Woolwich, England
FIG. 3.-Lariboisiore Hospital, Paris
18
CIVIL WAR HOSPITALSa
Prior to the Civil War the troops composing the United States Army were chiefly distributed at garrisons of the various units of the general system of our coast defense, or for the protection of the Indian frontier. Each of these stations was provided with a small post hospital in which serious cases of illness were treated.
When the troops began to go into camp, at the commencement of war, each regiment established a regimental hospital on the same general plan. Hospital tents or buildings, temporarily occupied, afforded shelter for the more serious cases. When small regiments were grouped together as brigades it was often found convenient to establish a congeries of regimental hospitals at one point, and this led to their consolidation in many instances as brigade hospitals. At a later period, the same tendency to consolidation led to the union of the several brigade hospitals of a division, forming thus a division hospital. The division hospital was sometimes a mere aggregation of a regimental or brigade hospital; but in its highest development, in connection with large armies in which troops were maneuvered by divisions, it formed a single unit having the same relation to the division that the regimental hospital had to the regiment.
Very soon after the mobilization of troops was begun in 1861 it was found that the system of post and regimental hospitals was inadequate to provide for all the sick. Difficulty was especially experienced when a regiment changed station. It became necessary, therefore, to organize near the bases of operations independent hospitals to receive and care for the sick necessarily left behind when troops moved, as well as those for whom regimental hospitals were inadequate, and the wounded after battles. Such establishments, known as general hospitals, being of a more or less permanent character, it was possible to provide more conveniences and comforts for the care of the sick and wounded than could be furnished in the field, and hence it became the custom to send the more serious cases, especially those requiring protracted treatment, to a general hospital. When, in the course of events, the general hospitals near the several bases of operations became encumbered with sick and wounded, others were established throughout the North, and the hospitals near the bases of operations were evacuated upon the more distant establishments, from time to time, to make room for the continual stream of diseased and disabled which constantly flowed from the scene of active operations.
At the beginning of the War of the Rebellion this country knew nothing practically of large military hospitals. It was, therefore, not surprising that existing buildings were used. Hotels, churches, seminaries, dwellings, warehouses, and factory buildings were used at the various places in the North and Middle West as extemporized hospitals.
Frequently, when the ground in the vicinity of a building taken for hospital purposes was of a suitable character, the demand for increased accommodation was supplied by hospital tents pitched so as to form a series of elongated pavilions, which in some instances were replaced later by long wooden pavilions.
aAbstracted from Medical and Surgical History of the War of the Rebellion.19Illustrations used in this connection are slightly reduced from the originals, consequently scales on the reproductions do not apply.
19
The prototype of the pavilion hospitals of the Civil War was erected in West Virginia. This was before the need of specially constructed hospitals in the large cities had received a practical recognition, and was due to the movements of large bodies of troops in West Virginia as well as the absence of adaptable buildings. This was a series of ridge ventilated wooden sheds, 130 by 25 by 14 feet to the eaves, each divided by transversal partitions into four wards of 20 beds each. The wards were roughly constructed, were well adapted for use in warm weather, but, because of the lack of shutters on the ridge ventilators, permitted the cold winds and snow to penetrate in the winter to an extent unbearable to the patients.
The inauguration of the peninsular campaign in 1862 filled the hospitals of Washington with sick men of the moving army. It occasioned also the vaca-
tion of a number of barracks buildings near Washington and Baltimore, which were acquired by the Medical Department, and though intended to be used for makeshift hospitals, many retained the status of general hospitals to the end of the war.
To adapt this type of dormitories to hospital purposes, they were generally repaired; additional windows were inserted; and ridges were laid open for ventilation in summer and louvered exits were provided for winter use. The lower rooms of two-storied barracks were connected with the ridge by ventilating shafts.
The greatest defect in the barrack buildings was their arrangement or relative position on the camp ground, which was seldom the most appropriate
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for the aggregation of hospital pavilions. They were either so detached as to greatly augment the difficulties of administration, or so massed around a central point as to materially interfere with ventilation.
The difficulties encountered in the use of illy adapted buildings for hospitals led the United States Sanitary Commission, early in the winter of 1861, to urge upon the Government the importance of building hospitals on the pavilion principle. The first of the hospitals constructed in accordance with this suggestion were the Judiciary Square and Mount Pleasant hospitals, Washington, D. C.
The most grievous fault in the plan of these hospitals lay in the common atmosphere which the single roof and the screen partitions gave to all the rooms occupied by the sick, including even those assigned for the purpose of isolation. Although nominally built upon the pavilion principle, they were wanting in the very point which was the leading idea of the system. A central corridor with a double row of attached pavilions, five on each side, does not
FIG. 5.-Judiciary Square Hospital, Washington, D. C.
appear to have met with favor, after recognized failure of attempts of this kind on the Mount Pleasant type.
The improvements which were made in each succeeding hospital erected during the Civil War had reference to the character of the construction of the wards, their lighting and ventilation, the attachment of their bathrooms and toilets, and their arrangement as a whole, including their connection one with another and with the administration and executive departments of the hospital. Structural refinements replaced the former coarse joining and rough finishing. The pavilions were gradually reduced in length from those of 248 feet with transversal partitions, giving four wards, to a clear ward length of 150 feet in each building. The width and height of the wards became increased to 24 or 25 feet and 12 or 14 feet, respectively. The open ridge, which admitted driving rains and snows, received protection, and other means of ventilation connected with the heating of the wards were introduced. Lastly, faults of aggregation were recognized and avoided.
21
FIG. 6.-Sedgwick Hospital, Greenville, La.
22
The experience of the war was decidedly in favor of the pavilion system, each pavilion constituting a single ward isolated from adjacent buildings by somewhat more than its own width and connected by a covered walk with the other buildings of the hospital. In an aggregation this separation was effected without removing any of the wards to an inconvenient distance from the admin.
FIG. 7.-Mower Hospital, Chestnut Hill, Pa.
istration and executive buildings, by radiating them around some central point in a form determined by the configuration of the ground available for building.
The force of medical officers indicated a decided preference for a pavilion length affording space for not more than 50 beds. The experience of the British in Crimea with similar pavilions was in favor of a ward containing from 26 to
23
FIG. 8.-Satterlee Hospital, West Philadelphia, Pa.
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30 patients as giving better ventilation and greater comfort and economy of labor than one of larger capacity.
From the foregoing progressive stages through which general hospital construction passed during the War of the Rebellion, it would seem that the United States Army slowly and independently arrived at conclusions similar to those drawn by the British and French. Billings, in his report on barracks and hospitals, states, in referring to the pavilion type of hospital recommended by the British, `The experience gained during the late war * * * contributed greatly to the recognition of its value in this country.`9
AMERICAN MILITARY HOSPITALS IN THE INTERIM BETWEEN THE CIVIL AND WORLD WARS
Of the large especially constructed Civil War hospitals none has survived the ravages of time. Of the many post hospitals of that period-some of which were used as general hospitals-many remain, in name at least, for by alteration or new construction their original appearance is no longer recognizable. This alteration in the post hospitals was largely due to the publication of Billings` `Report on Barracks and Hospitals,`9 which forms a classic treatment of military hospitals in general.
During the Spanish-American War nothing in the way of general hospital construction was accomplished which would add to the developed plan of the Civil War. Of the general hospitals established, the majority were extemporized by the use of tents, vacant barracks or other existing buildings-hotels or school buildings-post hospitals, etc. Where increased capacity was requisite, when existing buildings were used, tent wards were erected.20
Several semi permanent general hospitals were constructed shortly after this period, three arrangements of the pavilion wards being used.21 One consisted in locating the wards on the outer side of a covered way, shaped like an inverted V; in the establishment of them on two sides of a central square; and in arranging them in two parallel lines on each side of a covered passageway.
The 1,000-bed hospital at Fort Monroe was built in the form of an inverted V, similar to the plans of the Lincoln and McClellan Hospitals of the Civil War, and the hospitals used by the French at Metz in 1870-71. The administrative portion of the hospital was located between two covered corridors; the entrance standing obliquely away from the latter in such a manner as to receive the full benefit of wind and sun without interference from each other. The chief disadvantages of this hospital were difficulty of administration and a too great size of the individual ward.
The general hospital at Savannah, also having a capacity of 1,000 beds, was well planned and arranged for purposes of administration; the beds being closely placed at right angles to along central corridor. The long axes of the pavilions, however, extended north and south-an undesirable arrangement in hospital buildings in such a southern latitude. The buildings were also too compactly placed, seriously interfering with each other in respect to air currents.
The general hospital at San Francisco had 10 general wards, each with an inside length of 153 feet and, including lavatory and administrative rooms of 180 feet. The width of the ward was 25 feet; the space between wards was 35 feet. These buildings were located in parallel lines on each side of a central square in which was placed the operating rooms and mess halls. The square
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was partially closed in at one end by the administrative building and was bordered by a covered passageway connecting all the wards ,the block plan resembling very closely that of the Lariboisiore except that the latter had three-storied wards.
This adaptation of the pavilion ward has proven, in its grouping of buildings, to be very convenient and easily administered; and, as will be seen later, materially influenced the block plans for the hospitals constructed at the large camps during the World War.
HOSPITAL SITUATION AT THE TIME OF OUR ENTRANCE INTO THE WORLD WAR
In April, 1917, the number of beds in hospitals of the Army was 9,530, distributed among 131 post hospitals, 4 general hospitals, and 5 base hospitals.22
The usual type of our post hospital differed materially from the military hospitals in use in foreign countries.23 In our service, the small number of troops located at any one place made our Army hospital buildings of correspondingly small size. Considerations of economy also forced the building of post hospitals of such a compact nature that they naturally and unavoidably presented many defects incident to all activities being present within the same structure. Among these faults may be mentioned the crowding together and close connection of the administrative portion, wards, kitchen, lavatories, etc., which should be separated one from another. Exceptionally, there were large post hospitals, to which, by special and successive appropriations, additions were made until the faults mentioned above were partially eliminated.
The character of the construction of the general hospitals was very similar to that of the post hospitals, the difference being mainly in size, in the aggregation of buildings, and in the more elaborate installation of surgical and medical appliances for the recognized specialties in general hospitals. Though designated general hospitals, but two served for general cases-the Letterman General Hospital at San Francisco, Calif., and the Walter Reed General Hospital, Takoma Park, District of Columbia. The genera hospital, Fort Bayard, N.Mex., was used solely for the treatment of pulmonarytuberculosis,24 and the Army and Navy General Hospital, Hot Springs, Ark., cared for those cases for which the hot springs of Arkansas had a high reputation for benefiting.25
The post and general hospitals were, usually, of permanent brick and stone construction. Some were of wood, some partly of stone, or brick and wood: a few were built of concrete. They contained central heating plants-hot-water systems usually-had range cooking facilities, and were rarely more than two-storied. The size of their wards varied, containing from 6 to 36 beds, dependent upon the size of the hospital. As a rule, the permanent hospitals were well constructed, durable, well lighted, and had ample porches.
During the concentration of troops along the Mexican border in 1916, semi permanent hospitals were erected at various places for their care and treatment.26 The two existing base hospitals at Fort Sam Houston, Tex., and at Fort Bliss, Tex., of about 200 beds each, were enlarged by the addition of pavilion wards, and increased to the capacity of 750 and 900 beds, respectively.
26
REFERENCES
(1) Eleventh Iliad.
(2) Withington, E. T.: Medical History from the Earliest Times. The Scientific Press, (Ltd.), London, 1894, 69-70.
(3) Garrison, F. H.: Notes on the History of Military Medicine. The Military Surgeon, Washington, D. C., 1921, 1, No. 1, 22.
(4) Withington: Op. cit., 117.
(5) Garrison, F. H.: An Introduction to the History of Medicine. W. B. Saunders & Co. Philadelphia., 1913, 120.
(6) Withington: Op. cit., 224.
(7) Heizman, C. L.: Military Sanitation in the Sixteenth, Seventeenth, and Eighteenth Centuries. Journal of the Military Service Institution of the United States, Governors Island, N. Y., 1893, xiv, No. 64, 711.
(8) Garrison, F. H.: An Introduction to the History of Medicine, 332.
(9) Circular No. 4, War Department, Surgeon General`s Office, Washington, Dec. 5, 1870. A Report on Barracks and Hospitals.
(10) Wylie, W. G.: Hospitals: History of Their Origin. New York Academy of Medicine Transactions, 1874-1876, 264.
(11) Wylie: Op. cit., 266.
(12) Wylie: Op. cit., 272.
(13) Brown, H. E.: Medical Department of the United States Army, 1775-1873. Washington, D. C., Surgeon General`s Office, 1873, 52-53.
(14) Brown: Op. cit., 89-90-91.
(15) Report: Hospitals of the British Army in Crimea and Scutari. Eyre and Spottiswoode, London, 1855.
(16) Wylie: Op. cit., 278.
(17) Report of the Proceedings of the Sanitary Commission Dispatched to the Seat of War in the East. Harrison & Sons, London, 1855-1856.
(18) Burdette, H. C.: Hospitals and Asylums of the World. J. and S. Churchill, London, Vol. IX, 34.
(19) Medical and Surgical History of the War of the Rebellion, Part III. Medical volume, Chap. XII.
(20) Annual Report of the Surgeon General, U. S. Army, 1898, 128-131.
(21) Munson, E. L.: Military Hygiene. Wm. Wood & Co., New York, 1901, 439-442.
(22) Hospitalization Program for the United States. On file, Record Room, S. G. O., Correspondence File, 632.1.
(23) Munson: Op. cit., 434-436.
(24) A. R. 1445, 1913.
(25) A. R. 1441-42, 1913.
(26) Annual Report of the Surgeon General, U. S. Army, 1917, 142.
