The Pavilion-Style Hospital of the American Civil War and Florence Nightingale
William T. Campbell, Ed.D, RN
Originally published in 2018 in the Surgeon’s Call, Volume 23, No.1
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The American Civil War created a huge demand for hospitals that neither the North nor the South could meet early in the War. There were early examples of temporary hospitals near a battlefield using the available space where and when needed. These temporary hospitals would always be needed to meet the sudden demands of the battles and the post-battle influx of wounded, and were pressed into service for a few weeks. Well-known examples include the Pry House/Barn/Mill of Antietam, the post-battle hospital of Smoketown at Antietam, the Lutheran Seminary of Gettysburg, and the post-battle Camp Letterman Hospital outside Gettysburg. Following the early response of these hospitals a more general, longer term hospital distant to the battlefield was a necessity. Space for the wounded or ill, in the form of an existing building, was often seized when necessary. The Rotunda of the US Capitol, an empty tobacco warehouse in Lynchburg or Richmond, the 3rd floor of the newly constructed US Patent Office, or Alexandria’s Mansion House Hotel are examples. These were more permanent structures but were not intended for hospital use. They were still temporary, but now measured in months or even years, instead of days or weeks. They were convenient and inexpensive, but not efficient or effective, and often had poor patient outcomes. Patients died due to incorrect building choices, poor designs, and lack of planning. Everyone was aware of what had happened to the British Army in the Crimean War during the previous decade because of a similar situation. The North and the South did not wish to have a parallel outcome and repeat history.
The demand for military hospitals was great. Early in the war contagious diseases claimed thousands of victims. As the war progressed the number of wounded increased and necessitated continuous expansion. These hospitals needed to be of an effective and efficient design. An important goal was better patient outcomes so that the wounded would survive and return to active duty. It was desirable that the structures be of a permanent construction, not tents. They wanted them to be located in urban areas where resources such as man-power, material supplies, plentiful drinking water, and transportation were readily available. If several could be located in a major city such as Richmond, Lynchburg, Washington City, or Philadelphia, their combined resources would greatly increase efficiency. Most important, the buildings must be of an ideal design for a hospital and approved as such before the construction began.
Searching for the ideal design was not a new concept and pre-dates the Civil War. Jefferson Davis, as US Secretary of War, had sent Major Delafield, Major Mordecai, and Capt McClellan to the Crimea as observers, including hospital inspections, in 1855-56. Now with a more pressing need the US Sanitary Commission was on the hunt. They formed a commission to review possible plans, make recommendations, and to offer an approved design for that ideal hospital plan. The USSC asked “that General Hospitals should be erected, whenever needed, upon plans recognized as best by universal European experience” (Stille, 1866, p. 123). William Hammond was looking even before he became US Surgeon General. He was making recommendations to improve ventilation before taking office and once officially in office it became one of his pet projects. Samuel Preston Moore, CS Surgeon General, was also searching and would create the first example of a general hospital using this new design at Chimborazo (Green, 2004).
But first, let’s go back one decade to a previous major war where someone else was searching for that ideal design. Her name was Florence Nightingale. During the 1850s she researched existing hospitals looking for the best hospital design, the best patient care practices, and the best patient outcomes. She started this search due to the dismal hospital mortality during the Crimean War. Early in the war that mortality reached 60%. She inspected existing hospitals, reviewed plans of existing and soon-to-be-built hospitals, interviewed physicians and staff, reviewed the patient data, and applied statistics to the collected data. She conducted a detailed investigation into hospitals in the Crimean War arena—also England, Ireland, Germany, France, Belgium, Italy, and Egypt–both military and civilian. If she could not personally travel there she communicated with the officials on site. Her use of statistics would earn her the top award in statistics in England. By 1858/59 her research would result in her naming the Four Best Hospitals: King’s College (civilian) and Netley with 1000 beds (military) in England, and Lariboisiere (civilian) and Vincennes (military), both with 600 beds, in Paris (Nightingale, 1859a). Her research was ongoing and she would later revise that distinction in 1863 to include Herbert Hospital, of Woolrich, England, while still under construction, and state “…will be the best in all of Europe” (Nightingale, 1863).
Nightingale’s research not only centered on the best hospital design, but also highlighted the optimal environment for nursing and healthcare to achieve the best patient outcomes within that design. Her research identified ventilation, light, and warmth as important in hospital design and nursing care. Hygiene, diet, cleanliness, and observation were also identified as important factors in patient care (Nightingale, 1859b). Design plays a lesser but still important role in these later factors. Her research led to her recommended design for the ideal hospital – the pavilion design. Note that her role in hospital design was a recommendation based on detailed research and at no time did she invent this design, and this author is certainly not implying that claim. However, her work in patient care was new and ground breaking. Her work was probably the earliest example of evidence-based practice. She may have revised the hospital design plans to highlight the positives, but most importantly she disseminated them.
A very important part of this pavilion design was ventilation. This is the factor that was missing in most of the permanent existing structures that were seized for hospital use in the Crimea in the 1850s and in the Americas in 1861. The reader should visualize the physical structure of a hotel and its many small rooms and partitions to understand the lack of effective ventilation. The pavilion design, according to Florence Nightingale in her 3rd edition of Notes on Hospitals (1863) included: 20-32 patients as the ideal census per pavilion, with a 80-128 ft length pending census, a 30 ft maximum width, a 16 ft minimum floor to ceiling dimension, 8 ft by 12 ft of space for each bed, and 1500 cubic ft minimum of space per patient. There should be two beds per window, with windows of double glass, able to open, 4 ft 8 in wide, positioned 1-2 ft above the floor and extending to 0-1 ft from the ceiling, and located in opposing pairs. There should be two open fireplaces for heat and also for ventilation. Beds should be positioned in no more than two rows, 12 ft between rows, 3 ft minimum between beds, and the beds should be iron bed frames with hair mattresses. The pavilions should be oriented for windows to face East & West for direct sunlight. The Head Nurse’s dayroom/office should have an observation window into the patient area. The building should be constructed to have a clean area at one end and a dirty area at the other end. The clean end would contain the entrance(s), nurse’s dayroom, scullery, storeroom, linen closet, coat closet, private watercloset, and staircase, if any. The dirty end would include the patients’ watercloset, lavatories, sinks, and a separate ante-room located prior to the former spaces. The walls would be nonporous Parian cement or tile; the floors of oak or pine flooring, sealed, or of tile. The minimal furniture should be of oak construction. The pavilion could be of two stories maximum, although one was preferred, and if it was two stories the staircase must be open and sunny. The many pavilions should have connecting corridors or covered walkways. The sewer must never run under the building and always away from the building and would never be positioned at the entrance end of the building. The grounds plan, in addition to the North-South orientation for light and the covered walkways, would include an arrangement of side-by-side units with the unit-to-unit spacing being double the height of the pavilion. Administrative buildings, any support buildings, kitchens, laundry, and the dining hall would all be separate buildings.
The dissemination of the pavilion-style design, the hospital plan, and the nursing or patient care interventions was written. Nightingale was a writer, not a speaker. She spoke through her written words in the form of thousands of letters and her 200 books. Her writing was from her tiny apartment and often from her bed where she was confined due to her chronic illness of brucellosis that she contracted in the Crimea. Notes on Hospitals (1858) was the research and the hospital design part of her huge project. It included the best hospital design and presented it as efficient, effective, with the best outcomes, using ventilation, light, warmth, and space. Notes on Nursing (1859) was the presentation or application of the best healthcare or nursing care. It included ventilation, light, hygiene, hand washing, diet, and observation. The two books together represented one huge research project and application to practice of that research. What was detailed on these pages would later become the framework for the first school of nursing in England at St Thomas Hospital, and for the first three nursing schools in the US in 1873. But, this author believes the information was used long before 1873. To understand the possible connections one must view the timeline of events relative to 1861.
The Crimean War occurred 1853-56. Notes on Hospitals was published 1858/59 with a much more detailed 3rd edition in 1863. Notes on Nursing was published in London in 1859/60 with a New York version and a Boston version both printed later in 1860. All three versions were written for the lay public. In London, 15,000 copies were sold before the American versions were even printed. The New York and Boston versions were also best sellers and most young ladies were familiar with Nightingale’s interventions and resultant outcomes. The American Civil War began in 1861. Lincoln calls for 75,000 troops and thousands of new recruits immediately became ill with contagious diseases. In July 1861 the first major battle occurred with thousands of wounded soldiers needing medical care. Both the sick and the wounded required thousands of nonexistent beds in general hospitals. The demand for an ideal hospital design was now a reality and the plans already existed in print. The US began a major hospital building campaign in 1862/63 in the North and the South began even earlier in the fall of 1861. This hospital construction would follow the same pavilion design that Nightingale had recommended, but if they were following her exact design from her book is lost to history. The timing was correct. Letters have been found from Civil War era nurses to families back home thanking them for sending “the book” and repeatedly mentioning Nightingale’s name and her patient care interventions, which were not routine or even widely accepted at that time. Did the US Sanitary Commission and the Surgeons General find her book? It is difficult to believe they could have missed it.
Only slight variations or adaptations were made to the pavilion design as championed by Nightingale. The US used stoves for heat instead of open fireplaces. This was much more efficient for heating, but less so for ventilation. Nightingale actually addressed heat from secondary sources (heated metal) in her book as being unsatisfactory. The Northern adaptation also included ridges at the peak of the building’s roof with windows and flues for additional ventilation (Adams, 1952). These ridges had been suggested earlier by Hammond. The Southern adaptation which may have been Stout’s version included vents/shutters below and above the head of each bed for a very efficient vertical ventilation or air flow design. This design would have led to fewer cases of patient-to-patient acquired infections. While Nightingale championed ventilation in her pavilion design, she did not address patient-to-patient contamination and infections as a result of air currents acting as vectors. Stout’s adaptation also included a narrower pavilion design of 22-24 ft instead of 30 ft for a better cross ventilation or horizontal air flow (Schroeder-Lein, 1994).
At the beginning of the Civil War there were no military hospitals in the Eastern US. The demand for these was quickly realized and the seizure of buildings began, but they were insufficient for the needs or the demands. Thus the hospital building campaign began. The South responded first with the construction of Chimborazo in Richmond VA. Built in October of 1861, it was the largest in the CS with over 4000 beds. It contained 150 pavilions (Green, 2004). West Philadelphia US General Hospital or Satterlee was Hammond’s pet project. It opened in June of 1862, with 3519 beds arranged in 36 pavilions and 150 additional overflow tents. It was one of the largest in the North. The pavilions were arranged in parallel rows and it was later discovered that the pavilions were too close together. Mower Hospital was also built in Philadelphia, making Philadelphia a major Union hospital center, and opened in January of 1863, with 3100 beds. It had 50 pavilions arranged in a full circle. McClellan Hospital opened in February 1863, with 1080 beds arranged in the 18 pavilions (Taylor, 1913). The other Union hospital center was Washington City. Lincoln Hospital opened in December of 1862, with 2575 beds. The 20 parallel pavilions were arranged in an arrow shape. Armory Square was built a short distance from the Capitol in 1862. It had 11 pavilions with about 1000 beds. Nurse Amanda Sterns (1909) stated in her diary, “…at President Lincoln’s suggestion and with his practical assistance, flower beds were arranged between each of the long barracks (pavilions)…” Nurse Catherine Lawrence (1893), who is recognized as the first Nurse Anesthetist, wrote in her diary, “The rooms were nicely furnished, with hot and cold water and gas lights. It was indeed a fine hospital.” Not all pavilion hospitals were built from the ground up as new construction. Military instillations already contained a building in design that was very similar to the pavilion hospital – the barracks. At Campbell Hospital, also in Washington City, the original cavalry barracks were converted into pavilions. The 11 pavilions contained 900 beds. The hospital had some design problems probably due to remodeling. Even with the documented flaws it would see years of service first as Campbell Hospital, then as the Freedman’s Hospital post-war, and then as Howard University Hospital. Nurse Annie Wittenmeyer (1895) stated in her diary, “The sick and wounded were quartered in great wooden barracks 80 ft long. There were rows of cots on either side of the room.” Some other hospitals had pavilions that were 160-170 ft long. Harewood Hospital opened in September 1862, with 15 pavilions containing 2080 beds. It was one of the model hospitals opened by the US Sanitary Commission. Hicks was the finest of all the Union pavilion hospitals and opened in June of 1865. It was too late for the war, but the extra time had allowed for all the problems to be resolved and it was said to be the best. It was located in Baltimore and had 18 pavilions with 1080 beds. The pavilions were arranged in a semi- or half- circle. The plans called for a full circle like Mower in Philadelphia, but construction stopped with the end of the conflict (Medical and Surgical History of the War, 1870-85).
What was the influence of Nightingale? The Medical and Surgical History of the War of the Rebellion (1870) made no mention of Nightingale, however others are not as silent. Adams said, “…The Army’s pavilion hospitals seem to have been suggested by British experiences in the Crimean” (1952, p. 150-51). Schroeder-Lein stated that “…pavilion wards, based on a concept that was not new during the Civil War…Florence Nightingale had only recently strongly advocated these structures…” (1994, p. 101). Green discussed, “the pavilion plan received little widespread attention until the 1850’s, when Florence Nightingale returned from her experiences in the Crimean War and began her crusade to change many features of hospitals. Her opinions, printed in Notes on Hospitals …supported the idea of hospitals [of the pavilion design]” (2004, p. 11). In Dock & Steward (1931), “Miss Nightingale was closely associated with the United States Sanitary Commission …In correspondence she gave them continuous advice” (1928, p. 128). McDonald in her 16 volumes on Nightingale stated “It is not clear how much Florence Nightingale’s advice was used by either the Northern or Southern armies, although there is some evidence to indicate that both did” (2011, p. 593). She also said “Florence Nightingale was the ‘single greatest influence’ on hospital architecture for a century” (McDonald, 2012, p. 6). While much of the evidence is circumstantial, related to timing and the availability of her publications, some is much more direct. Evidence exists that she advised post-war on 49 hospital designs in the UK, US, Canada, and Germany. One of her most noteworthy direct written consultations was for the design of Johns Hopkins Hospital in Baltimore in 1876 (McDonald, 2012).
How much influence Florence Nightingale had on the Civil War hospitals’ designs is inconclusive. Her research and her recommended design was available to the military planners at the time when needed. The adaptation of the pavilion design for general hospitals improved the outcomes for the ill and wounded soldiers and its use proved that the design was effective and efficient. Many later hospitals were constructed based on that design and its proven Civil War application.
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About the Author
As a youth Dr. William Campbell learned to respect the Civil War and to honor his ancestors’ history in the War. Later as a RN he put the interests of his youth and his profession together in the study of medicine and nursing during the War. He holds a Doctor of Education from the University of Delaware, a Master of Science in Family Nursing from Salisbury University, and undergraduate degrees in Nursing, Psychology, and Biology from the University of Delaware. An Associate Professor in the Nursing Department at Salisbury University in Salisbury Maryland he teaches in the pediatrics, pharmacology, and nursing history courses. A board member of the National Museum of Civil War Medicine, he has served as a volunteer docent at the Pry House Field Hospital Museum on the grounds of Antietam Battlefield National Park and as a frequent speaker for the Museum’s conferences and workshops. He is also a member of the American Association for the History of Nursing, American Nurses Association, Delaware Nurses Association, and Sigma Theta Tau International Honor Society of Nursing.
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