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The management of the congress was under the nominal control of the ministro de la gobernacion (interior), and all the social functions and excursions were managed by government officials. As this was the week in which the President of the United States had delivered his message to Congress, and that body was on the eve of passing resolutions which meant war, it can be readily seen that the Spanish Government officials had but little time to enter into the spirit of the literary and social proceedings of the congress of hygiene. The whole atmosphere was that of restraint. It was the sole topic of conversation, and the newspapers were filled with the most inflammatory articles, and the dead walls on the streets placarded with appeals to Spanish patriotism and pride and caricatures of the “Yankee pig.” The secretary of the congress, Senor Dr. D. Amalio Gimeno, had been engaged in a political campaign as candidate for senator of the Cortes from the province of Valencia, and it is not difficult to see how he was unable successfully to carry the innumerable details of the congress and at the same time give consideration to the greater political matter which was then agitating the Spanish Government. During it all, however, there was a courageous attempt to ignore the unpleasantness of the situation, and most of the social functions were carried out with an attention to the entertainment of the guests which could but excite the admiration of those who knew the difficulties under which the officials labored. Many of the excursions were postponed from day to day and at last fell through, owing to the “political situation,” which was the accepted explanation of all deficiencies. The social functions consisted of a bull fight on Easter Sunday, a reception by the Queen Regent at the Palacio Real, a performance at the Royal Opera House, another at the Opera House Alphonso XIII, a reception by the civil governor of Madrid at the Ayuntamiento, closing with a bull fight at the Plaza del Toros on the 17th (Sunday). In addition to these there were advertised excursions to Toledo, the Escorial, and Grenada, but, owing to the difficulty of obtaining information and the frequent postponements, but few attended. The American legation was so much occupied with the existing political situation, living from day to day at the official residence in “marching order,” that it could not give any time or attention to social courtesies to the official representatives of our Government, and under the circumstances none were expected. For the same reason the wearing of uniforms was omitted by the delegates from the United States. Erom the above statements it will be seen that in consequence of the unfortunate time in which the congress was held the fulfillment of my detail was accomplished under unpleasant circumstances. Sessions of the congress were held in the Palacio de la Biblioteca y Museos Nacionales, a fine building on the Paseo de Recoletos. It is devoted to the exhibition of literary and art collections, but owing to its internal arrangements was quite unsuited to the purposes of a large assembly which intended to devote its time to scientific discussions. Rooms assigned to different sections opened into each other, and were necessarily passageways to other rooms, so that there was the continual noise from morning till night of delegates passing to and from sections, making careful attention to the proceedings almost impossible. The ground floor was used for the display of machinery, paraphermalia, and articles employed in the conservation of the public health. A large part of the display came from the Spanish peninsula, and consisted for the most part of articles intended for military and naval use, water filters, models of municipal sewerage systems, and hospital construction. It was a creditable exhibit. France was represented by surgical appliances, disinfecting stoves, instruments of precision; Germany by chemical products, disinfectants, and disinfecting apparatus, and England by prepared foods and lavatory and sanitary appliances.

The congress was divided into thirteen working sections, and it was the opinion of those who had attended previous meetings that the acknowledged mistakes of administration at Berlin and Budapest were repeated by this dissipation of the working strength of the members by an excess of specialization. The bacteriological section attracted the greatest interest and attendance. Dr. Behring read a paper on - Tuberculosis antitoxin;" Dr. Janowsky, of Warsaw, on a “Uniform standard for therapeutic serums," and Dr. Durham on the “ Micrococcus of Malta fever." This section passed a resolve in favor of an international bacteriological commission, which was adopted by the general congress. The section of preventive medicine discussed vaccination and revaccination and serum therapy of cowpox. The section on demography considered the subject of climatology of tuberculosis, the sanitation of cemeteries, and child labor. The section on school hygiene held animated discussions, amusing to one accustomed to the phlegmatic debates of the Anglo-Saxon, relative to education of children. The ardor of the Latin temperament in manner and expression upon abstruse subjects was extravagantly expended upon a proposition of an official of the public instruction board of Spain that children should not have books for study, but be didactically instructed until 10 or 12 years of age.

The closing session was held in the great hall of the Central University, and consisted of the adoption, without discussion, and probably without much understanding upon the part of the delegates, of the resolutions prepared by the several sections. Out of a large attendance of many hundred but a few could hear the announcements, and but a few voted upon the propositions. Complimentary speeches followed from the representatives of the various nations, and adjournment was taken, to meet in Paris, France, for the next congress in 1900.

As the Congress of the United States had practically agreed to the passage of the resolutions granting the President power to intervene on Monday, the 18th, and having no further business to detain me, I left that day, and our minister was given his passports on the 20th.

I proceeded to Paris and remained three days in the fulfillment of your order respecting the inspection of hospitals, equipment of same, and the municipal ambulance system, and thence to London, Leeds, and Liverpool on the same duty, and sailed for New York on the 4th of May.



WASHINGTON, D. C., September 10, 1898. SIR: In accordance with instructions contained in your letter of March 16, 1898, directing me to visit, “ while in Europe, such civil and military hospitals as may conveniently be seen, for the purpose of inspecting hospital equipments and modern improvements in ward furniture and the ambulances in use," I have the honor to submit, as therein directed, a written report of my investigations for the information of your office.

The duty involved in the above-named order was contemplated in connection with my detail as delegate to represent this Service at the Ninth International Congress of Hygiene and Demography, held at Madrid, Spain, April 10-17, 1898, and the opportunity afforded during my travel to and from Madrid was made available as far as possible in fulfillment of the plan. I did not alter the usual route of travel for the purpose of extending my journey in this respect, but confined myself to the large cities of Madrid, Paris, Southampton, London, Leeds, and Liverpool, with the exception of the towns of Greenwich and Chatham, England. I visited these two last-named points because at them are located the famous seamen's hospital (lately known as the “ Dreadnought)" and the branch

of it in the latter-named place. I was especially gratified at this opportunity to study and examine these hospitals, their equipments, and the ambulance systems of those parts of Europe, as it was in direct line with my official duties at the Bureau for the past three years as acting medical purveyor in attending to the supply of our own hospitals with similar equipments. In the beginning I might say that I was disappointed, generally speaking, with the comparison of the hospitals of those places and the modern establishments in our American cities and our own hospitals. With some exceptions, which I shall refer to at length, I did not see any institution which equaled the modern municipal hospitals of our large cities, and, indeed, of many of our small cities as well— either in construction, equipment, or ambulance system. I certainly saw none that surpassed them, one only excepted, and my final impression of the entire examination was one of gratification at our national progress in these matters. Judged from the standpoint of aseptic environment, ward equipments, furniture, trained nurses, and ambulance systems, the general run of hospitals that I saw have much to learn from the new world. I shall, therefore, not specifically mention the hospitals which I regarded as of a standard inferior to our own, viewing them from the modern attributes of cleanliness and aseptic equipment, because many of them are, as is well known, old structures, built before the days of antisepsis, and from their internal arrangements not specially fitted for such transformation as our own ideas of construction require, except at great expense and radical rearrangement. In Paris this is particularly true of such hospitals as La Pitié, St. Louis, Necker, Charité, and even the celebrated Hotel Dieu, which in its rebuilt form is about a quarter of a century old. These remarks apply, of course, to the buildings proper, and not to their management. England.—I visited hospitals in Southampton, London, Leeds, Liverpool, Greenwich, and Chatham—fourteen in number. Many of them are extensive institutions, with considerable pretensions to architectural design, but the consumption of soft coal destroys all exterior beauty in the large cities of England. Most of these hospitals are familiar to medical men, and their construction and plans are well known. I found them as a rule indifferently equipped with modern iron and glass ward furniture and surgical operating furniture, now seen in all our own hospitals; or if some was to be found it was only a partial equipment. In one case I saw a modern iron and glass operating table alone; all the rest of the room was fitted with the old-style articles. The floor and walls were unregenerated. This table was shown to me with evident satisfaction. The Royal Infirmary, Liverpool, answered more nearly to our ideas of a model than any English institution I visited. With the splendid basis of stone, brick, iron, and tile, it lends itself easily to the requirements of a modern hospital in its rooms, wards, lavatories, etc., and the management liberally met the conditions imposed by the canons of asepsis. It is one of the most, if not the most, elaborate and elegant institution of its kind in England. In conversation with a dealer in aseptic operating-room furniture in London, I was told that there was very little demand for it in England, and one superintendent of a hospital characterized the use of iron and glass surgical equipment as “fuss and feathers.” Of ambulances and ambulance systems I saw none worthy of the name, or anything that could compare with our municipal and Government systems. As a matter of fact, the hospital authorities took the ground that it is a municipal duty to bring the sick to the hospitals, and not, as one superintendent expressed it to me, the business of the hospital “to be running like mad through the streets, clanging a gong as if going to a fire, and advertising your institution with a flaming sign on the side of the wagon.” The injured, picked up in the streets, are carried to hospitals in any sort of a public conveyance, of which there are innumer

able quantities in all large towns, or, perhaps, in the curious two-wheeled handcarts with a canvas bonnet top, used by the police to transport inebriated persons from the street to the police station. Those with whom I talked on the subject maintained that no harm results from the slight delays which might be due to an absence of ambulances at each hospital, but they contend that by the use of such conveyances as are at hand the victims of accidents or disease on the streets reach the hospital more quickly by that method. It was further stated that the constabulary are instructed in “first aid to the injured," and that all the hospitals were so fully occupied that they did not need to drum up trade."

As above stated, I made a special visit to the seamen's hospital at Greenwich and its branch at Chatham. This hospital in a sense represents a character of work similar to our own marine hospitals, although it is not a government institution. In the last century a hospital for the care of sick and disabled seamen was erected at Greenwich, in accordance with a provision of an act of Parliament, the history and character of which I shall make the subject of a special article in connection with the centennial of the establishment of this Service, and I shall now only refer to it incidentally in connection with my visit. Its successor still exists in Greenwich. The seamen's hospital known as the “Dreadnought" has no connection with the older institution, though it is situated contiguous to it. The seamen's hospital is maintained as a private institution, dependent on public charity, for the benefit of seamen, sick or disabled, both foreign and domestic. No charge is made for such patients, and from the character of the commerce that comes up the Thames it will readily be seen that the nationalities represented by the patients are many and picturesque. I saw sick seamen from all the continents representing the different races of men. This hospital maintains a branch lower down the river near the Chatham dockyards. These institutions are old-style buildings, and, beyond their interest in connection with the work carried on in them similar to our own, merit no special remark.

France.-I visited seven hospitals in Paris-Hôtel Dieu, La Pitié, La Charité, St. Louis, Lariboisière, Necker, and Boucicaut. The general character of the Paris hospitals is a part of every medical man's education, and it will not be necessary to undertake a description of them except in the case of the magnificent Boucicaut Hospital, lately completed. La Pitié I found in a state of reconstruction. The other hospitals are old, and present no features of equipment worthy of adoption. At the Hotel Dieu a partial surgical outfit of iron and glass furniture was observed, but no attempt to improve its environment.

The Boucicaut is the latest addition to Paris hospitals, and is the gift of the late widow of the proprietor of the celebrated Bon Marché, in memory of her husband and his business enterprise. It is on the south side of the Seine, occupying nearly a square, and constructed on the pavilion plan, with a large central court containing a chapel and statue of Madame Boucicaut and ornamental garden. All the most modern ideas of hospital construction are here engrafted into the ensemble, and after one has walked through the great establishment with its mosaic floors, tiled walls, and seen its elaborate preparations for rendering the structure and its contents aseptic, the acme of design and fulfillment seems to have been reached; and yet it can not be said to compass more than the standards observed in the latest additions to our New York city hospitals, and it only demands unusual notice because it is up to our own best level, and so much superior to anything else in Paris. The equipment was in keeping with the building-every attention being paid to the cleaning of the floors and walls. I noticed the use of hospital suits and a minimum of paraphernalia in the wards. It is a general hospital for both sexes.

There is an approach to an ambulance system in Paris, and I saw one of the vehicles used as such, but it is an institutional system-only transporting patients

from one hospital to another for special forms of continued treatment. The wagon was an unwieldy closed van, weighing 14 tons, resembling the “Black Maria” in appearance, although it was rubber-tired and had some modern conveniences inside. It is the duty of the police to send persons suffering from accidents or disease, found in the streets, to the hospital in any convenient public vehicle which may be first at hand. The wagon referred to is never used for that purpose. I was informed that the authorities are experimenting with an aluminum ambulance, to secure lightness. Spain.—As I was considerably occupied during my stay in Madrid in attendance on the sessions of the congress, and owing to the difficulty of getting accurate information as to the visits to various institutions planned by the committee of arrangements, I was obliged to make such inspections as I could alone. The principal and largest hospital in Madrid is the new military hospital at Carabanchel. It is on the site of a medical university established by Philip V, which was partially built and left in ruins. In 1873 the sanitary military corps pressed their demand for a new military hospital for the garrison of Madrid and the soldiers of the Spanish army in general. The site is a commanding one on the slope of the hill of Almadovar in the municipality of Carabanchel. The extent of the grounds is 84,123 square meters, which does not include some adjacent lands not yet acquired, and which will be devoted to buildings constructed for epidemic diseases. This new military hospital is a magnificent set of buildings, constructed upon the most liberal plan, based upon the most advanced ideas of construction and equipment. It consists of twenty-four buildings or isolated pavilions, four of which are intended for the treatment of internal diseases, two for surgical operations, three for infectious diseases, and the remainder for the medical service proper and quarters for the officials, officers and subalterns, patients and employees. Included in this last class is a building known as the bath house, which is something more than its name implies, for besides the necessary places for the application of hydrotherapy in its various forms, it has apartments for aerotherapy and electrotherapy, with all the modern appurtenances for carrying out same. It also contains a swimming pool for the use and exercise of officers and soldiers. The hospital is practically independent in respect to heating and lighting, having its own plant for each, besides ice-manufacturing plants. To such an extent has the separation of the various classes of buildings been carried to prevent possible contamination, Imight mention that the necropsy building has a separate ice plant of its own. The system of ventilation which will be finally adopted is that of the Belgian engineer, M. M. Putzey, with some modifications devised by the Spanish engineers. A provisional system of ventilation, the Bayle system, with air pumps, is now in use. The buildings are to be heated by a system of indirect radiation. The buildings are constructed of iron and stone and glass, and would seem to be incapable of harboring infection for any length of time, if properly administered. The entire hospital is not yet completed, but even in its present state it is a remarkable and altogether creditable institution. It was a wonder to me how provision was made for financing this expensive military hospital during a time when the Spanish nation was engaged in prosecuting two wars and, according to common report, with her fiscal arrangements very unsatisfactory. I also visited the institute of Sr. Ch. Rubio, an institution for the treatment of childrens' diseases, built at his own private expense within the last few years. This also answers every requirement of modern hospital construction and equipment. As far as I could learn there was no ambulance system, as such, at the hospitals at Madrid, excepting such as was attached to the military hospital as a part of the army system.


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