A Modern Field Hospital
By Colonel Dion Williams, U.S. Marine Corps
The effectiveness of any military force may be measured as to questions of personnel by the percentage of the total personnel that is available for use on the front lines in the theater of operations; the higher this percentage can be maintained the greater will be the effective striking energy of the force assigned to carry out any specific military mission. To maintain any given fighting force in the theater of operations it is necessary to have a corresponding force of men back of the lines in the service of supply and in the training stations and camps where they will be constantly available to furnish the replacements to make good the unavoidable drainage from the front forces due to a variety of causes.
Experience teaches us that the greatest contribution to this constant drainage of manpower from the effective front line strength is made up of the sick and wounded who require hospitalization and that the conservation of manpower resulting from efficient hospitalization far exceeds the conservation resulting from all other means employed. The sick or wounded man not only reduces the effective strength during the time that he is on the sick list but the effective strength is also reduced by the number of men required to evacuate the sick and wounded from the front lines to the hospitals and to care for them while they are undergoing treatment in the hospitals. Hence, everything that can be done to increase the efficiency of the evacuation of the sick and wounded and to reduce the total number of sick days by increasing the efficiency of the hospital service results in a direct proportionate gain in the military effectiveness of any force.
At all of the permanent naval stations in the United States and the outlying possessions permanent naval hospitals are provided having every facility and convenience for the proper treatment of the sick and wounded, and where the sick and wounded can be quickly evacuated to these hospitals from their regular posts of duty the solution of the problem is easy. However, when circumstances require that naval forces operate at a distance from the permanent bases and stations the problem becomes more difficult. Especially is this true of the expeditionary forces of the Marine Corps operating in foreign countries for the suppression of minor revolutions and disorders, the maintenance of treaty obligations, or the support of established state policies.
As a rule the theaters of operation for such expeditions are in countries where the development of sanitation and modern hospital facilities are particularly backward, and in many cases the climatic conditions are such as to cause an increase in the normal sick rate as experienced at the home stations of the troops.
The Navy, and the Marine Corps as the main landing force reliance of the Navy, have ever been proud of their constant state of readiness for any service they may be called upon to perform and of their mobility in carrying out the missions assigned to them in peace and war. Having in view the maintenance of the highest efficiency in readiness for any required service, the greatest mobility attainable, and the most efficient conservation of the trained manpower of the naval services, a system of hospitalization should be provided for the naval landing forces which will meet the probable requirements.
Considering the requirements of the Marine Corps expeditionary forces there are several possible methods for meeting the hospital needs and a consideration of these methods will show which one will best meet the requirements under varying conditions of service and mission. To accomplish this, the methods employed in the past will be enumerated and discussed.
First; reliance may be placed upon hospital ships anchored at the base ports, to which the sick and wounded may be evacuated from the posts occupied by the landing forces. Hospital ships are primarily designed to transport sick and wounded from the theater of operations by sea routes to the permanent hospitals at the home stations or bases, and to anchor them in the base harbors of an expeditionary force and use them as stationary hospitals diverts them from their proper mission and from an economic standpoint results in a disproportionate overhead expense.
Second; existing hospital facilities in the country to be occupied may be taken over and operated as military hospitals. As a rule the existing hospitals in localities where landing forces are called upon to operate are inadequate for the requirements of the civil population which they are designed to serve, and to place upon them the additional burden of caring for the personnel of an invading force would divert these institutions from their normal function, would deprive the civil population of the facilities which have been provided for their use, and would cause a natural feeling of resentment throughout the communities so imposed upon just at a time when every effort should be made to secure all possible co-operation between the members of the force of occupation and the local inhabitants.
In addition, the hospitals in the countries usually occupied by our landing forces areas a rule poorly constructed, insufficiently equipped, and are lacking in proper sanitary arrangements to make them fit places for the proper treatment of military personnel whose stay in the hospital should be made as short as possible by the provision of every possible means of efficient medical treatment and service.
Third; buildings may be commandeered or rented and fitted up as extemporized military hospitals. For this purpose very few suitable buildings are available, rentals would be high, the cost and time elements in refitting them for hospital use would be excessive and would violate the general rule that it is not advisable to expend large sums in repairs to rented buildings for government use. In practice it has been demonstrated that such buildings even with a considerable expenditure of money and time make indifferent hospitals, and that the same energy and money expended in other ways would secure far better results.
Fourth; field hospitals sheltered under tentage may be provided for the use of expeditionary forces. Experience has demonstrated that the use of tentage for quartering the members of military forces, except in cases where frequent changes of site are necessary, and the stay in anyone locality is necessarily short, is a very expensive means as compared with temporary or even permanent buildings. For Use as hospitals tents must be provided with good flooring and with screens to exclude flies and other insects, they form unsatisfactory protection in rainy climates, and are difficult to heat in cold climates. Nevertheless, in cases where frequent moves are required by the nature of the military operations the use of tentage for hospitals appears to be the solution indicated.
Fifth; portable buildings especially designed for the purpose may be provided with all of the necessary equipment and held in readiness for use with expeditionary forces in cases where the occupation promises to be of such nature as to demand hospitalization of a comparatively lengthy tenure at a port of debarkation and supply or at the central headquarters station of the forces of occupation.
From a consideration of the above enumerated methods it would appear that the best solution of the problem presented would be, in the case of temporary landings and occupations, to use tentage for housing the field hospitals, locating such field hospitals at the port or ports which offer the most convenient facilities for the evacuation of the more serious cases to hospital ships for subsequent transportation to the naval hospitals at home stations. During such temporary occupations of foreign territory, the sick and wounded at small outlying stations and outposts would also be housed in tents, those cases which would require protracted treatment being transported by ambulance or boat to the main field hospitals for further treatment or evacuation to home stations.
However, if the occupation of the foreign territory promises to be of long duration, as in the cases of Haiti and Santo Domingo, the use of tentage for field hospitals at base ports and headquarters stations and for sick bays at the small stations and outposts will not afford the requisite facilities for the proper treatment of the sick and wounded, and more nearly permanent facilities must he provided.
The present occupation of Santo Domingo by the naval forces began in November, 1916, and the first requirements from the military standpoint were the subjugation of numerous revolutionary bands, commonly styled "bandits," and the re-establishment of law and order in order that the policies of the United States government might be carried out in the fulfillment of treaty obligations and with due regard to the lasting peace of the country.
The fulfillment of this mission was entrusted to a brigade of marines and the subsequent operations required the occupation of certain selected ports as bases of operation and supply, the occupation of interior cities and towns throughout the country, and the dispatch of small columns and patrols by railroad, road and trail wherever it was found necessary in the course of operations designed to carry out the main mission of establishing law and order and aiding the loyal civil authorities in the conduct of local government and a general disarmament of the inhabitants. During the early stages of the operations no intelligent estimate of the probable duration of the occupation could be made; it might require a few months or several years to accomplish the desired results; and the erection of even temporary buildings to house the various activities of the forces of occupation was apparently not justified.
In some of the cities and towns buildings which belonged to the Dominican Republic and which had formerly been used as barracks and storehouses for the Dominican army were adapted to the uses of the forces of occupation, but few of these buildings were in any way suitable for use as hospitals or sick bays. The Dominican cities and towns were lacking in hospital facilities to meet their own needs for the civilian population and it was not good policy to commandeer such facilities for military use at the expense of the civil population.
As a result, in some of the stations occupied buildings were leased and fitted up as temporary hospitals and at other stations tents were used for this purpose. In many cases very high rents were demanded and received for the buildings rented for military uses, and at best these buildings were but poorly suited to the needs of a hospital.
In the northern district of Santo Domingo, embracing about one-half the total area of the country, the headquarters was established at the principal city, Santiago de los Caballeros, a pleasant little city of 20,000 inhabitants located some forty miles inland from the well-known port of Puerto Plata at an elevation of about 1,000 feet above sea level. The climate of Santiago is of course tropical, but mild and salubrious and well suited as a site for a military hospital for the forces of occupation in the northern district.
In 1919 the military field hospital at Santiago was located in a rented building which had formerly been used as a bakery. This building was not suited for use as a hospital, but the expenditure of considerable money in addition to the high rent paid had made it as good for the purpose as was practicable. At this time the appropriations for the naval service, including the Marine Corps, were very much reduced in the general campaign for retrenchment and economy following the heavy expenditures for the World War, and it became apparent that practically all of the rented buildings in Santo Domingo used by the marine forces of occupation would have to be given up and other arrangements made to house the activities thus displaced, in order to prevent creating over-expenditures of funds.
In the northern district one battalion and the headquarters of the fourth regiment of marines were stationed at Santiago, and the remainder of the regiment was disposed in one-company posts at the towns of Monte Cristi, Puerto Plata, Moca, La Vega, San Francisco de Macoris and Sanchez. At all of these stations some buildings were rented.
Supplies and replacements of personnel were received through the port of Puerto Plata, which was connected with the headquarters at Santiago by a narrow gauge railroad forty-four miles in length. This railroad extended twenty-two miles east of Santiago to the town of Moca, from whence a railroad of wider gauge connected with La Vega and the eastern seaport of Sanchez on Samana Bay, and by a branch line with the interior town of San Francisco de Macoris.
Santiago was connected with the western seaport of Monte Cristi by a wagon road seventy-two miles in length, and by an excellent macadam road with Moca, thirteen miles, and La Vega, twenty-six miles.
Having all of these facts in view, it was decided to erect a field hospital at the headquarters at Santiago, with .small sick bays at the outposts of Monte Cristi, Puerto Plata, Maca, La Vega, San Francisco de Macoris, and Sanchez. These small sick bays were designed to care for the men at the outposts who might be temporarily sick or disabled, and, as the means of communication by railroad or motor ambulance over the wagon roads would serve the purpose efficiently, it was planned to transport all of the sick and wounded who might require lengthy treatment to the main field hospital at Santiago, from whence those who might require treatment that could not be given efficiently at the field hospital could be easily evacuated by rail to Puerto Plata and thence by the monthly transport to Hampton Roads.
In the fall of 1919 requests had been made for the shipment of certain small portable buildings which had been manufactured for use as temporary naval field hospitals in France and Belgium and which were understood to be in storage in the United States. Requisitions were also made upon the Bureau of .Medicine and Surgery for the medical and surgical equipment for an efficient field hospital designed to care for the sick and wounded of a force of 1,500 men.
These requests received favorable action at the Headquarters of the Marine Corps and the offices of the Navy Department having cognizance and in February, 1919, the medical and surgical equipment had been delivered at Santiago and six portable buildings had also been received. This number of buildings was just half enough to carry out the plan, but the additional buildings required were constructed of native lumber of poor quality, but the best that could be obtained locally. The cost of this lumber was much higher than the cost of good lumber in the United States and it would have been more economical, first cost alone considered, to have waited for shipments of lumber from the United States. But the rented buildings had to be vacated by the end of the fiscal year, June 30, 1920, and in order to have the new buildings ready in time it was decided to use the native lumber, the ultimate saving in rentals more than balancing the extra cost of the lumber.
A site was selected on a ridge on the outskirts of Santiago, having good drainage possibilities and admirably adapted for the purpose on account of this fact and the facts that it was far enough removed from the noises of the city and overlooked the valley of the Yaqui River down which prevailing breezes tended. This site was cleared and leveled and all surrounding streams and low places drained to reduce the mosquitoes. On the site there was an old field mess hall, the frame of which was adapted for use as a foundation for the building to house the mess hall; and kitchen and afford a small room for use as recreation room for convalescent patients and the medical corpsmen attached to the hospital.
The plan of the hospital as finally completed shows the general design of the institution. In use it has been found that it fulfills the requirements of such a field hospital for a tropical country, and that with the addition of a heating plant such a plan would fulfill the requirements for even a cold climate. The width of the portable buildings, twenty feet, has been found sufficient to accommodate comfortably two rows of beds for patients in the wards, but in future buildings designed for this purpose it would be more economical in manufacture and erection to make the buildings forty-eight feet long, the ones furnished for this hospital being but thirty-two feet long.
The work of grading and placing the foundations was done by prison labor under the supervision of marine officers and noncommissioned officers; while the carpenter and plumbing work was done by enlisted men of the Marine Corps, assisted by prisoners under vocational training.
All of the buildings were placed upon foundations of concrete piers as experience had demonstrated that in the tropical climate wooden foundation posts soon rotted out and had to be replaced in a short time at considerable trouble and expense.
Some of the men who worked upon the building acquired thereby sufficient knowledge of tradesmen's craft to enable them to engage in such pursuits to their own advantage after they were later discharged from the service the same thing applied to the prisoners employed on the building and it was noticeable that the prisoners were anxious to be trained in such work so that they might command higher wages after their release. These facts are mentioned here to show that the benefits derived from the erection of the hospital were not confined to the patients who received treatment therein.
The Santiago field hospital consists of eight separate buildings arranged on the pavilion system, side by side, and connected by galleries running along the front and rear of the line of buildings. These galleries form a porching six feet wide with a roof over all which gives access to all of the buildings of the hospital and along which sick or wounded men can be moved from one room to another by means of the wheeled chairs and carts which are provided for this purpose.
The first building is eighty-two feet long and eighteen feet wide and contains the recreation room, mess hall, pantry, kitchen and store room for commissary and general stores. The recreation room is eighteen feet square, and the mess hall eighteen feet wide and thirty feet long; the pantry six feet by eighteen feet; the kitchen is an L-shaped room with three hundred and eighty square feet of floor space, and the storeroom is eighteen by ten feet in size.
The next six buildings are each twenty feet wide and thirtytwo feet long. The first one has two offices in front, each ten by twelve feet floor space, the dispensary in rear with a floor space eight by twelve feet, and the remainder of the building is occupied by the medical storeroom which has a floor space of three hundred square feet and shelving especially designed to hold the medical stores of the regiment.
The second building contains the laboratory, with a floor space sixteen by twenty feet, in the rear and two offices in front, each sixteen by ten feet in plan; one of these offices being the office of the medical officer-of-the-day and the examining room and the other being the workroom of the dental surgeon. The laboratory is fully equipped for research with a special view to disease prevalent in the tropics.
The third building of the row contains the operating rooms and accessories, the main operating room extending across the rear of the building with floor space twelve by twenty feet. In the front of the building is a dressing room eight by twelve feet, and a special treatment room eight feet square. A six-foot hallway runs from the dressing room a distance of twelve feet back to the operating room and on either side of this hallway there is a room eight by nine feet, one room being occupied by the sterilizers and the other being for use as an anesthetizing chamber. There are ample quarters in the dressing room, special treatment rooms, sterilizing room and anesthetizing room, where the surgical dressings and stores are kept.
The next three buildings en suite along the galleries are wards one two and three, each having a floor space of twenty by thirtytwo feet, comfortably containing ten beds with bedside lockers and serving tables.
The last building in the row is the officer's ward which is thirtytwo by twenty-two feet in plan, and contains four rooms with ten by twelve feet of floor space, arranged on either side of a central hallway seven feet and a half wide, at the end of which is a bathroom with floor seven and a half feet square. Each room has two windows with glazed sashes opening on side hinges. Each room has a large closet for the occupant's clothing and effects and there are two large closets opening into the hallway in which are stored the bedding and linen for the officers' rooms.
In the rear of the center of the suite of buildings there is a building twelve by twenty-eight feet which contains the lavatory, closets and shower baths for the patients in the hospital.
For use of patient having contagious diseases there are three hospital tents with permanent wooden floors pitched on line in rear of the hospital.
In rear of the mess hall and galley there are six wall tents with permanent wooden floors and side frames for use as quarters of the hospital corpsmen attached to the field hospital.
The equipment and furnishing of the new hospital are in thorough keeping with the fine buildings. The three men's wards are furnished with white enameled beds, bedside lockers, serving tables and chairs and each ward has a white enameled table with linen cover presented by the Fourth Regiment Society, an organization composed of the wives and sisters of officers of the regiment and engaged in welfare work for the enlisted personnel of the regiment. On this table there is a neat pincushion and flower basket which is kept filled with flowers by the ladies of the society, and the books and magazines for the patients are also kept on the table. In each ward there is a white iron and glass medicine case.
The officers' ward is very completely furnished, each one of the four rooms having a white enameled bed, bureau, side chair and a large morris chair, and a table with a handsome drop light. All of the fine linen sheets and pillow cases, bureau and table covers, and the woolen blankets for this ward have been presented through the efforts of the Fourth Regiment Society. The Bureau of Medicine and Surgery has supplied a fine set of china and silver for the use of the officers sick in the hospital. In the hallway of the officers' ward there is a writing table with a complete writing set presented by the Fourth Regiment Society.
The laboratory and operating rooms are completely fitted out with every modern necessity and convenience, all provided especially for the new hospital by the Bureau of Medicine and Surgery, and the same bureau has furnished desks, office chairs and filing cabinets for the offices of the regimental surgeon, the medical officer-of-the-day and the pharmacist.
The office of the dental surgeon is completely fitted up with every necessity and convenience for the highest class of modern dentistry.
The dispensary is fitted with handsome marked shelf bottles for the medicine in daily use and the medical storeroom adjoining it is fully stocked with all of the medical supplies that may be required in this hospital and also in the sick bays at the outposts in the northern district.
A modern plumbing system has been installed with running water all over the institution and a large septic tank to receive all the drainage. The lavatory is in a separate building in rear of the main building and connected with the rear gallery. It is fitted with porcelain hand basins and toilets and excellent shower baths.
The kitchen has every convenience, a large ice box, sinks with running water and sanitary drains, wheeled serving tables and a large storeroom for commissary supplies. Between the kitchen and mess hall is a pantry for storing the china, glassware and tableware; in the mess hall there are four tables with chairs to seat forty persons, corpsmen and patients.
The recreation room has a fine new pool table, large morris chairs, tables for magazines and papers and cases for books.
The buildings are lighted throughout by electric lights and current for these lights is supplied by the Santiago Light and Power Company with a Delco plant for emergency use.
Water is supplied from the Santiago city reservoir but a large iron tank has been erected for an emergency supply in case the reservoir should run dry as sometimes happens.
The hospital corpsmen are quartered in wall tents pitched in a line east of the hospital recreation room and mess hall.
An excellent macadam road has been built from the head of 27 de Febrero Street up past the supply company camp to the field hospital and along the front of the hospital. There is also a wide concrete sidewalk along the entire front of the hospital buildings and this walk is separated from the front gallery of the hospital buildings by a five-foot garden space in which a large number of ferns and plants are planted.
The location of the hospital is admirable for the purpose, the institution being built upon a ridge running north and south which gives excellent drainage in every direction away from the buildings. There are no city streets or houses near the hospital, so that the noise of traffic and city life will not interfere with the rest of the sick. The view from the galleries over the city of Santiago and up and down the valley of the Yaqui River is a fine one and the prevailing easterly breeze coming down the valley has a full sweep through all of the buildings.
No trouble or expense has been spared in designing, building and fitting up the hospital and the result is an ideal institution for the care of the sick officers and men of the northern district, where they may have every care and attention that medical, skill has devised and every comfort that can be thought of by those having the welfare of the fourth regiment at heart.
Electric current for the lighting of the hospital was originally supplied by the power company which furnished current for lighting the city of Santiago, but the financial difficulties of this company have resulted in shut-downs for long periods, and a large Delco lighting plant was installed to furnish light for the hospital and nearby buildings and camp of the quartermaster department.
As the local power company also furnished power for pumping water for the city system, there was no water in the city reservoir when the power plant was shut down. In order that the hospital might always have a sufficient water supply, its water system was connected with an emergency system installed by the force of occupation to pump water from the Yaqui River into the cisterns and reservoirs of the garrison.
The small sick bays erected at the outlying stations were small buildings containing an office for the surgeon, a small operating room, a dispensary, and a room large enough to hold six beds for sick under limited treatment.
The whole system answered the requirements of a regiment distributed to the principal towns of the northern portion of Santo Domingo, in that it provided immediate hospital facilities at each of the outlying stations, with excellent hospital and surgical facilities at the central field hospital for any treatment of a protracted nature.
Following out the policy of centralization of the forces of occupation in a few of the principal cities of the Dominican Republic, in preparation for the establishment of complete control of the affairs of the country by its own officials and the ultimate withdrawal of the American forces, most of the outlying stations above mentioned have been discontinued, the fourth regiment of Marines being mostly concentrated in Santiago. Under these conditions the small sick bays at the outlying stations are no longer needed, but the field hospital at Santiago is ample to care for the normal sick of the regiment concentrated at Santiago.
This account of the system planned to meet the local conditions in Northern Santo Domingo for a Marine Corps force of occupation is published with the idea that it may be of assistance to the officers who may be confronted with like conditions in other countries where we may be called upon to operate. The buildings were erected by adapting the means at hand to the necessities as they appeared at the time, and it is thought that the best results practicable were obtained with the means at hand. However, if the whole subject should receive investigation and study, having in view the experiences of the past and the possible requirements of the future, much time and expense might be saved in future operations. Everything that can be done in the way of practical planning for the future in the provision of excellent hospital facilities for Naval landing forces will result in the reduction of the number of total sick days, thus giving more men for active duties and reducing the overhead expense in caring for sick men, who are, unfortunately, only a burden to any operating military force.
Putting aside the cold-blooded, practical questions of military efficiency produced by reducing the total number of sick days in any military force, humanitarian considerations should dictate a policy which would give the quickest and most efficient relief to sick and wounded men, and this can best be accomplished by providing the best possible and practicable facilities for hospitalization and evacuation of sick and wounded officers and men.
It is suggested that the subject be given careful consideration by both line and medical officers, in order that provision may be made beforehand to meet the requirements likely to arise. In this as in all other questions of preparedness, "an ounce of prevention is worth a pound of cure."