* 1 Hospital Construction and Management. 1/ / Z z HOSPITAL Construction and Management BY BIRMINGHAM LIBRARY FREDERIC J. MOUAT, M.D., F.R.C.S. Local Government Inspector, Deputy Inspector-General of Military Hospitals, Bengal (Retired) Formerly Professor of Medicine and Clinical Medicine, Bengal, and First Physician to the Medical College Hospital of Calcutta, Member of several Learned Societies, &c. &c. &c. AND H. SAXON SNELL Fellow of the Royal Institute of British Architects, Member of Council and Fellow of the Sanitary Institute of Great Britain ; Architect to the Guardians of the Poor of the Parish of St. Marylebone, of the St. George’s, the Holborn, and the St. Olave's Unions, and of other Metropolitan and Suburban Parishes ; and Author of " Charitable and Parochial Establishments " LONDON J. & A. CHURCHILL & CO., n NEW BURLINGTON STREET 1883 London Printed by F. Chifferiel & Co., 31 to 37 Cursitor Street and 38 Chancery Lane Preface. T HERE is no systematic work in the English language on the arrangement, management, and construction of hospitals, in their hygienic, administrative, and structural relations. The present is, we believe, the first attempt in any language to treat the whole question in a strictly logical manner, by considering primarily the principles necessary to be observed to fit them to fulfil their purpose ; and then by applying those principles to practice, so far as they are accepted by the leading authorities on the subject. All hospitals are intended for the relief of suffering, the cure of disease, and the repair of injuries — their raison d'etre is, consequently, based on medical and hygienic grounds, which need medical knowledge and experience for their right understanding. Hence, this portion of the work has been undertaken by a member of the medical profession, who has for many years, in his official and private capacity, devoted special attention to the question in each and all of its aspects. For the architectural portion the responsibility rests with a member of that profession, who has had considerable personal experience in hospital construction and arrangements ; who has made himself practically acquainted with the best recent types of hospitals in Europe; and who has thereby been enabled to form independent opinions as to what to do, and what to avoid, in the practical working of this great question. The issues in the two sections of the work differ essentially in character. In the medical relations of the matter, some of the principles involved must be more or less speculative in character, inasmuch as the problems of life and death, health and disease, the loss of the one and the recovery of the other, are still, and must probably for ever remain, beyond the iv Preface. reach of rigorous solution by any means of investigation or instruments of research in our possession. Not so mechanical and physical agencies, most of the relations of which can be determined with some approach to mathematical accuracy. Hence, of necessity, greater precision in the practical application of the principles, than in the determination of the principles themselves, to be observed in hospital construction and arrangement. Not the less important, nevertheless, is it to indicate those principles so far as they are at present ascertained and accepted, and to subordinate the structural arrangements to their right interpretation. The history of the efforts made in Paris for a century past, since the right path was indicated by Tenon in 1788, to reform the Maternities of that centre of civilisation, is an instructive example of the criminal folly of disregarding the counsels of those alone capable of guiding and directing public opinion in such matters, and of the lamentable as well as needless sacrifice of human life which has been, and still continues in some institutions to be, the result. We believe that this attempt to submit the whole question in a strictly logical form to the consideration of the professions most imme- diately concerned, and to the public, which has so deep and abiding an interest in all that relates to the sick and suffering, is a step in the right direction. We are not without hope that, however imperfect it may be in design and execution, it will prove useful to the numerous authorities engaged in the administration and direction of the public and private charities of the country, amongst which none demand or receive more earnest and devoted attention than those to which this work direCtly relates. It was originally intended to make the work a complete representation of the hospital systems of the civilized world, with typical and illustrative examples of the best-known and most recent models in existence of such institutions. It has been found, however, that to collect the materials for this purpose would necessitate very considerable delay — a postponement of publication so considerable, in fact, as to be altogether inadvisable. We have, therefore, determined to publish at once so much of the materials as we have been able to digest regarding the principles to be Preface. v observed in the management and construction of such institutions, with descriptions and illustrations of the most advanced types to be found in Europe generally. As respedts the United States of America, we are promised plans of the Johns Hopkins’ Hospital, of Baltimore, fast approaching completion, and shall content ourselves with this example of the most advanced views of our Transatlantic brethren, inasmuch as the general description of the hospitals of America will, we understand, be undertaken by the most competent of all authorities on the subject, Dr. J. S. Billings, the learned and accomplished author of the Baltimore plans. F. J. Mouat, Athenaum Club. H. Saxon Snell, 22 Southampton Buildings, London. CONTENTS. Sections I and III. By F. I. MOUAT, M.D. I. — The Principles of Hospital Construction and Management in Relation to the Successful Treatment of Disease. Illustrated by several Woodcuts. III. — The Organization of Medical Relief in the Metropolis, shewing its Present Distribution. Illustrated by a Map. Section II. By H. SAXON SNELL, F.E.I.B.A. Typical Examples of the General Hospitals of various Countries. Illustrated BY UPWARDS OF FlFTY LITHOGRAPHIC PLATES AND NUMEROUS WOODCUTS. . I TABLE OF CONTENTS. Section I. Preface ... General Introduction to Sections I and III. ... i. The Control and Management of Hospitals ... General Management Special or Executive Control Nursing ... Hospital Records ... ii. The Principles of the Construction and Arrangements of Hospitals (a.) Site and Surroundings ... (b.) Ventilation and Warming ... ... ... . . (c.) Water Supply and Drainage ( d .) Distribution and Dimensions of Buildings and Wards (/.) Furniture and Fittings of Hospitals Types of the most Recent Forms of Hospital Construction and Arrangement The General Hospital of Friedrichshain in Berlin . Menilmontant Hospital of St. Eloi at Montpellier ... The Western Infirmary, Glasgow The New York Hospital The Civil Hospital of Antwerp The Civil Hospital of Mons Classification of Hospitals Clinical Hospitals ... General Hospitals... Lying-in Hospitals Fever and Small-pox Hospitals Special Hospitals ... Cottage Hospitals ... Convalescent Hospitals Section II. Introduction to Section II. Herbert Military Hospital. Woolwich, England Principal Sick Wards Blackburn and East Lancashire Infirmary, England Principal Sick Wards Leeds General Infirmary, England Principal Sick Wards St. Thomas's Hospital, London ... Principal Sick Wards PACE ... iii to v ... i to 7 7 9 ... ii ... 12 15 18 ... 22 24 31 32 37 38 40 43 45 49 51 55 57 59 ... 60 ... 62 65 70 75 ... 76 77 i to ii 3 7 11 13 16 18 22 29 X Table of Contents Royal Infirmary, Edinburgh, Scotland ... Principal Sick Wards Glasgow Western Infirmary, Scotland ... Principal Sick Wards Norfolk and Norwich Hospital, Norwich, England Principal Sick Wards St. Marylebone Infirmary, Notting Hill, London Principal Sick Wards Extracts from Official Documents as to the Construction of Workhous St. George’s Union Infirmary, Fulham Road, London Pavilions Generally Administrative Offices Principal Sick Wards Hull General Infirmary, Yorkshire, England ... Principal Sick Wards Mons Civil Hospital, Belgium ... Antwerp Civil Hospital, Belgium Principal Sick Wards Heidelberg University Hospital, Germany Surgical One-storied Pavilions Medical One-storied Pavilions Medical Four-storied Pavilions Surgical Four-storied Pavilions Berlin Civil Hospital ... Surgical Pavilions Medical Pavilions... Infectious Wards ... Berlin Military Hospital, Templehof, Germany Principal Sick Wards Isolation Sick Wards Konigsberg Military Hospital, Germany Dusseldorf Military Hospital, Germany Ehrenbreitstein Military Hospital Germany ... Custrin Military Hospital, Germany Dresden Public Hospital, Germany The Mutterhaus ... The Pavilions Strasburg University Hospital, Germany Wards of Central Block Pavilion Wings The Moabite Barrack Hospital, Berlin, Germany Principal Sick Wards Halle University Hospital, Germany ... Medical One-storied Pavilions Surgical One-storied Pavilions Isolation Pavilion... Lariboisiere Hospital, Paris, France Principal Sick Wards Puerperal Fever Wards Hotel Dieu, Paris, France Principal Sick Wards Infirmaries PAGE 33 37 42 46 49 55 58 61 68 220 221 222 223 256 2C0 77 79 84 88 94 98 98 99 100 104 in 112 115 120 124 125 126 127 128 129 130 132 137 138 139 205 207 210 215 217 218 141 144 149 151 165 Table of Contents. xi Tenon Hospital, Menilmontant, Paris, France ... Principal Sick Wards The Maternity St. Denis Hospital, France Principal Sick Wards Bichat Hospital, Paris, France... Principal Sick Wards ... ... __ ... Bourges Military Hospital, France Principal Sick Wards Saint Eloi Hospital, Montpellier, France Principal Sick Wards Utrecht Hospital, Holland Amersfoort Military Hospital, Holland Summer Sick Pavilions Winter Sick Pavilions Hospital of St. Andrew the Apostle, Genoa, Italy Principal Sick Wards Riga Town Hospital, Russia List of Riga Hospitals Principal Sick Wards Nativity Hospital, St. Petersburg, Russia Principal Sick Wards Johns Hopkins Hospital, Baltimore, United States ... ... .%. Principal Sick Wards M. Tenon’s Proposed Hospital ... Takhtsingji Hospital, Bhavnagar, India Principal Sick Wards Burdon Sanderson's Proposed Hospital Ward ... Summaries ... ... ... ... ... ... ... ... ... 278, 279 and Section III. Organization of Medical Relief in the Metropolis Finance of Hospitals Out-Patient System The Mortality of London Hospitals... London Hospitals... Suggestions Hospital London ... Index to Map Map General Index ... PAC.E 168 171 173 175 178 l8l 183 186 l8cj 191 193 I98 200 201 204 228 233 236 237 238 24I 242 244 250 264 271 272 274 280 3 22 24 28 3i 37 39 42 45 49 I L L US TRATIO N S. Section I. PACE Berlin Civil (Friedrichshain) Hospital — P lan ... ... 42 Tenon (Menilmontant) Hospital — P lan 44 St. Eloi Hospital — V iew 46 New York Hospital — V iew ... 52 Section II. Herbert Military Hospital — V iew 3 ., ,, ,, Plans and Section 4 Blackburn and East Lancashire Infirmary — V iew 11 ,, ,, .. Plans... 12 and 14 Leeds General Infirmary — E levations ... 16 ,, „ ,, Plans and Section 18 St. Thomas's Hospital — V iew and Plan ... 22 ,, „ Plans and Section ... ... 26 Edinburgh Royal Infirmary — V iew... .... 33 „ „ Plans and Sections 34 Glasgow Western Infirmary — V iew 42 ,, ,, Plans and Section ... 44 Norfolk and Norwich Hospital— V iew 49 ,, ,, ,, Plans and Section... 54 St. Marylebone Infirmary — V iew ... ... 58 ,, ,, ,, Plans and Section 60 ,, „ ,, Thermhydric Stoves ... 62, 64, 65 St. George’s Union Infirmary — P lans, Elevation, and Section ... 220 ,, ,, ,, Construction of w.c.'s 225 and 226 Hull General Infirmary — P lans and Elevation ... 256 ,, „ ,, Plans and Details ... 260 Johns Hopkins' Hospital — P lans and Sections 244 Dr. Burdon Sanderson's Proposed Annular Hospital Ward— Plan and Section 274 Heidelberg University Hospital — V iew 88 ,, ,, ,, Plans and Section 92 ,, ,, ,, Plans cf Pavilions 98 and 99 Berlin Civil (Friedrichshain) Hospital — V iew ... ... 100 „ ,, ,, ,, Plans and Sections ... ... 102 ,, ,, ,, Plan of Isolation Pavilion ... 113 Berlin Military Hospital — E levation, Sections, and Plans ... ... ... 115 ,, ,, ,, Plan of Proposed Staircase ... 123 „ ,, ,, Details of Ice House ... 128 Custrin Military Hospital — B lock Plan ... ... 128 Eiirenbreitstein Military Hospital — B lock Plan ... 128 Dusseldorf Military Hospital — B lock Plan ... 128 XIV Illustrations Konigsberg Military Hospital — Block Plan ... • ... Dresden Public Hospital — Block Plan of Additions ... ,, ,, ,, Mutterhaus, Basement and Ground Plans. ,, „ „ Basement and Ground Plans of Pavilions. „ „ „ Elevation and Section of Pavilions Strasburg University Hospital — Plans and Sections Moabite Hospital, Berlin — Plans, Elevations and Section Halle University Hospital — Bird’s Eye View and Block Plan ,, ,, Plans and Sections of Pavilions, &c. Mons Civil Hospital — View and Plan Antwerp Civil Hospital — Elevations ,, ,, ,, Plans and Section Lariboisiere Hospital — Elevation and Sections ,, ,, Plan and Section of Pavilion „ ,, Plan and Section, Puerperal Fever Wards Hotel Dieu — V iew „ ,, Plans and Section Tenon Hospital (Menilmontant) — Bird's Eye View... „ „ ,, Plans and Section ,, ,, ,, Plan and Section of Maternity St. Denis Hospital— Plans and Sections Bichat Hospital— Plans, Elevations, and Sections Bourges Military Hospital— Plans, Elevations and Section ... St. Eloi Hospital — Plans, Elevations and Section M. Tenon’s Proposed Hospital — Plan Utrecht Hospital — Plan and Elevation Amersfoort Military Hospital — Front Elevation ,, ,, „ Plans and Sections... St. Andrew the Apostle, Hospital of, Genoa — View „ ,, ,, ,, ,, Plans and Section . Riga Town Hospital — Plans, Elevation and Sections ... Nativity Hospital, St. Petersburg — Elevation, Plan and Section Takhtsingji Hospital — View ,, ,, Plans Map of Hospital London PAOE 128 130 131 134 133 and 135 i37 205 210 216 77 79 82 141 144 148 151 162 168 170 148 i75 181 186 191 264 198 200 202 228 233 239 241 271 272 45 Hospital Construction and Management. GENERAL INTRODUCTION. S INCE the institutions devoted to the relief of the suffering from disease and accidents have ceased to possess an ecclesiastical character, and become what they now are, and long have been, part and parcel of the general praiflice of charity and benevolence in their purest forms, Hospitals, with special reference to the successful treatment of those admitted within their walls, have scarcely kept pace in their con- struction and management, with the advance of civilisation in other branches of social economy. The present system of treatment of disease in public institutions in this country has not yet been two centuries in existence, as the following table, taken from Dr. Steele’s Essay on the Mortality in Hospitals,* shows, viz. : — Hospitals/ Date of Foundation. Hospitals. Date of Foundation. Hospitals. Date of Foundation. London : — Westminster Guy's St. George's London Middlesex Special Hospitals. British Lying-in City of London Lying-in Queen Charlotte’s ) Lying-in } Small-Pox Lock (Female) „ (Male) Provincial : — York Salisbury Cambridge I 7 I 9 i 7 2 3 1733 1740 1745 1749 1750 1752 1746 1745 1747 1710 1716 1719 Bristol Edinburgh Windsor Aberdeen Northampton Exeter Manchester Chester Newcastle Glasgow Norwich Stafford Worcester Leeds Oxford Leicester Dumfries Hereford Birmingham Montrose 1735 1736 1736 1739 1743 1745 1753 1755 1757 1794 1771 1769 1745 1767 1770 1771 1775 1776 1778 1780 Nottingham Canterbury Dundee Stafford Irish : — Jervis Street Steevens' Meners' The Meath House of Industry Special, in Dublin. The Rotunda The Lock The Westmoreland ( Lock j Cork Limerick Belfast 1782 1793 1795 1795 1726 1733 1734 1756 1774 1745 1754 1755 1720-22 1759 1797 St. Bartholomew's and St. Thomas’s Hospitals, originally ecclesiastical establish- ments, were instituted several centuries earlier, and were secularised, the former in * Statistical Journal, vol. xl., p. 181. B 2 General Introduction. 1547, the latter in 1538. Kurt Sprengel, in his learned work on the History of Medicine, has stated that the supervision of hospitals was taken out of the hands of the Church, in consequence of the “insatiable avidity” and crying frauds of the ecclesiastics, which at length provoked the decision of the Council of Vienna, in the 14th century, ‘that those institutions should thereafter be only administered by laymen, in order that the sick might be better treated.’* The Church appears, thereupon, to have made a final effort to retain a part of its authority in the matter, by in- ducing the Pope to order that in Italy, at least, no physician should attend' the same case twice, without calling in a priest to watch over the safety of the soul of the sick person. The early history of hospitals on the Continent of Europe, previous to the 1 8th century, and so long as they were direcftly associated with, or governed by, ecclesiastical authorities, was of the same character universally — the interests of the sick being sacrificed to those of the persons immediately connected with their direction and management. Indeed, they were rather houses of entertainment, than hospitals according to the present understanding of the term. The Hotel Dieu in Paris, first appeared in history early in the 9th century, under the name of the Hospital of St. Christopher. In the nth and 12th centuries, the Crusaders imported from the Levant, Leprosy and St. Anthony’s Fire (Erj'sipelas), to arrest the rapid and fatal spread of which special institutions were created, said to have amounted to more than 19,000 in number in Christendom. In France alone there were 2,000, in the reign of Louis VII. The creation of the religious Hospital Orders gave a new character to the institutions established by them — partly for the care and entertainment of pilgrims and travellers, and in part for the treatment of the sick and infirm. But one or two of these now survive in name, their exact nature and purpose having long since disappeared. The greater number of the hospitals created from the 12th to the 16th centuries were in reality religious institutions for particular classes and brotherhoods, in which the treat- ment of disease played a very secondary and unimportant part, during the whole of the Middle Ages. To the Arabs belongs the credit of having, as early as the 8th and 9th centuries, established hospitals in the modern sense of the word — the greatest and best of which was at Cordova, in Spain ; at once a renowned school of practical medicine, and a splendid asylum for treatment of the sick and afflitfted from the disorders and pestilences, prevalent in that age of dirt and disease. As hospitals became rich from the bounty of sovereigns and individuals, their abuses multiplied. “ Funds designed for charitable purposes were diverted from their destination by the cupidity of priests and monks. The hospital houses were con- verted into benefices in the hands of the ecclesiastics charged with their direction. The misconduct of the male and female ecclesiastics, their quarrels and their dissensions, often invoked the intervention of the higher authorities,”! until at length * Kurt Sprengel, op. cit. voi. ii.. p. 428. t Art. : Hopital — Grand Dictionnaire Universel du XIX me Siecle. Par M. P. Larousse. General Introduction. 3 such public feeling as existed in those times, was outraged by these scandals, and the hospitals were permanently made over to laymen to manage. In the ultimate change amongst ourselves, the progress of the Reformation had much to say; and the new departure, which began in England in the 18th century, spread rapidly to the rest of Europe. That the hospitals built in the 18th century should not present the conditions now deemed essential in such places, is scarcely to be wondered at. Regarding them, Mr. Lawson Tait, of Birmingham, has said that — “ I* cannot be surprising if we look at the houses in which our forefathers lived in the 16th and 17th centuries, that their children in the 18th should be ignorant of all true principles of hospital construction or management; or that they should be impressed with any other idea than that which, in Miss Nightingale's words, tended to make it ‘sufficient for all purposes of curing and healing, that the sick man and the doctor should merely be brought together, in any locality, or under any conditions whatever.’ “ Cut, it is surprising to find that, nearly a hundred years after Howard’s vivid descriptions of hospital mis-construdtion and mis-management, and many years after the burning words of Florence Nightingale, in a great hospital of six hundred beds, we have been able to diminish the mortality only one per cent, from what it was in Howard’s time. (Guy’s Hospital rate of mortality from 1780-90. 102 per cent.; 1850-60, 91 per cent.) If we go further back still to the first few years of the existence of Guy’s Hospital, we find the mortality 13-8 per cent. If we also bear in mind that then there were many zymotic diseases now unknown, all of which were then treated in the hospital, and almost only there, and that even of those which still remain to us, cases are admitted to the hospital only by accident, and in a proportion which is infinitesimal (about 38 per cent.), the conclusion is inevitable, that hospital hygiene thas not advanced as it might and ought to have done." The present conditions of life in all civilised communities, impose a strain upon mind and body by day and by night, which is extremely difficult to bear, without serious risk of premature decay and death. The ever-increasing dangers to life and limb from the continuous and progressive multiplication of mechanical contrivances to supplement and supplant manual labour, and to annihilate time and space, have imported into surgery fresh forms of accidents and injuries, and new pathological states resulting therefrom, which tax the highest resources of the science and art of the Surgeon, to contend with and counteract. The gravitation of rural populations to urban centres, the result of new conditions of society, has caused the aggregation of human beings upon areas insufficient to main- tain them in health and strength, without the aid of complex artificial contrivances. These conditions, with the insanitary surroundings inseparable from them, especially among the poor and improvident, coupled with the vices which are largely the outcome of undue pressure of population upon space and the means of subsistence, have become important factors in changing the form and character of many diseases, more especially those of the inflammatory and zymotic classes. This state again demands the employment of the most advanced means which scientific progress has placed at the command of the Physician, to deal with successfully. All the above conditions, with a multitude of collateral circumstances intimately con- nected with them, invest hospitals with even greater interest and importance now, than they have ever previously possessed. Not only are they “Nature’s schools where pupils B 2 4 General Introduction. are taught her ways in diseases and casualties, and the effefts of the application of the means of relief,” but they are emphatically the only places in which all the phases and varieties of sickness, whether of new or of old types, can he studied in a strictly scientific manner. The administration of the atftive principles of curative substances when sepa- rated from the inert or injurious matters with which they are combined in their natural state ; the proper employment of anaesthetic and antiseptic agents ; the skilled use of all new physical and mechanical contrivances for the detection, treatment, and removal of disease and its consequences, in circumstances where alone they can be subjected to the strictest observation and control ; and, above all, the pursuit of pathological inquiry in the manner absolutely necessary for the advancement of science, are among the most important uses of hospitals. It is, I think, much to be regretted that no provision was made by the organisers of the late International Medical Congress, held in London in the year 1881, for the consideration and discussion of the all-important subjedl of the Construction and Man- agement of Hospitals. It was the largest gathering of professional experts, from all parts of the world, ever brought together; and although its scientific results were in no degree commensurate with its social success, there were few questions submitted to it of greater present and future importance than that referred to above, or on which an authoritative expression of the opinions of the whole civilised world, would have carried greater weight. The adoption alone, could it have been secured, of a uniform general system of record of sickness and mortality in the hospitals of all countries, would have impressed a more imperishable stamp of usefulness on the work of the Congress than even the invaluable teachings of Pasteur and Lister, for they were as well and widely known before as after the meeting of Congress, to which they contributed nothing new. Great doubts, apparently on good grounds, exist among ourselves as to the advantages and disadvantages of large hospitals as compared with small; as to the real causes of the persistent unhealthiness of many of those institutions, both new and old, whether dependent on strucftural or other conditions; and as to the best means of securing all the conditions necessary to minimise the risk to life of those who seek admission, or are taken to them. There is by no means universal consensus on this and many similar questions conneifted with hospitals. It would, therefore, have been invaluable to obtain upon them the views of the eminent practical workers in kindred institu- tions of every part of the world, after personal examination of all that we had to show them. The primary function of hospitals is the successful treatment of diseases and accidents, in the strictest relation to the interests and advantages of the sick and stricken individually. To this all other relations, scientific and administrative, must be absolutely subordinated, in spite of the wide-spread popular belief to the contrary, particularly as respedls Clinical Hospitals, or Hospitals forming part of Medical Schools. What, then, are the cardinal conditions to be observed in the constriuftion, manage- ment, and distribution of hospitals, to fit them for their special purposes in all the General Introduction. 5 important relations in which they stand to the public, and to the profession most imme- diately concerned in their efficiency ? It was truly said by one of our most eminent surgeons, Sir William Blizard, nearly a century since, that — “The value of medical science in every walk of life, independently of its application in preventing and curing disease, should be seriously considered. All men are indebted to the discoverers and cultivators of natural truths for some share of their useful knowledge, and of the felicity they enjoy. Many, therefore, are the objects, interesting to society, that present themselves in contemplating the professional concerns of a hospital ; and, as in commercial and other affairs of life, they will be best understood by men who have most devoted their time and attention to the subjedl. Everything liberal may be expedled where charity is the governing principle of action, and where the good done bears proportion to the degree of knowledge exercised. Purity of motive, sincerity of attention in the surgeons, will not then be doubted. It may not, however, be improper to observe that their credit and interest are involved in all the proceedings of a hospital ; for its prosperity is their elevation, its depression their loss and regret." To consider, then, this important question correcftly, it seems to me to be desirable to group hospitals roughly into certain classes, and then to discuss, in as much detail as may be necessary to their right understanding, the general attributes which are common to all, and those which are more or less restricted to the special purposes of each group, the successful treatment of disease being the cardinal condition, or raison d'etre, of every such institution. The simplest arrangement of all hospitals actually in existence, is the following : — 1. Clinical Hospitals, or Hospitals attached to, or forming part of Medical Schools. 2. General Hospitals, or those in which all classes of cases, medical and surgical, are treated, with or without detached wards for infectious diseases and parturition. In this group, I think, should be placed the great separate Workhouse Infirmaries, for reasons which will be mentioned when they come under review. 3. Special Hospitals, such as Fever and Small pox Hospitals, Lying-in Hospitals, Opthalmic, Skin, Orthopaedic, and other institutions devoted to specific pur- poses, usually indicated by their names. 4. Cottage Hospitals. 5. Convalescent Hospitals, the “ missing link between the hospital and the home. Each of the above groups, again, needs to be considered with reference both to institutions now in existence, and to the hospitals of the future, brom them I exclude dispensaries, free or provident, and all institutions which have no beds for taking in patients. These with the out-patient departments of all hospitals, which might, I think, with advantage in most cases be separated from them, are most important complements of our hospital system, and, with the home treatment of such cases as are adapted for it, render it complete in organisation. But the latter scarcely fall within the scope or purpose of this work. The first step in the whole inquiry is to determine, as far as possible, what constitutes 6 General Introduction. a healthy hospital, for this is universal in its application. In one of his classical reports, Mr. Simon has defined a healthy hospital to be — “A hospital which docs not by any fault of its own aggravate ever so little the recovery of persons who are properly its inmates, and this, the only right sense of the absolute word, governs the words comparative applications; so that when we compare them together with regard to their ■ healthiness,' and call one of them the ' unhealthier ' hospital, our meaning is that in this hospital, by means o^ some faults of its own, disease cannot be treated as successfully as in the other hospital ; and the fault of its own, through which an ' unhealthy 1 hospital fails to attain the best results for its medical and surgical treatment, is of two kinds— either it is an inherent fault, as of site and constru<5tion ; or else it is a fault of keeping, as dirtiness, or overcrowding, or negled of ventilation.” * Various attempts have been made to solve the question of the healthiness of hospitals as compared with each other, by contrasting the results, chiefly of surgical praiftice, by an appeal to statistics. This doubtless is the true means of forming a correct judgment on all such questions as can be solved by the application of the numerical method. When figures are really exponents of faeffs, and are collected with mathematical accuracy, they “ formulate the past, render the present fruitful, and prepare the future.” But the terms of all comparisons, to be exact, must be identical, as dissimilar things cannot be compared in the stricfl sense of the word. Vital phenomena are so complex in their nature, whether in health or disease, and arc influenced by so many collateral conditions, all of which require to be stated with minute care and accuracy, that the basis of a correcT statistical comparison of the results of the practice of different hospitals, does not at present exist. Nowhere are the records of hospitals so kept as to afford more than a rough approxima- tion to the truth, which has no pretension to scientific accuracy. In each and all of them some important faeftors are omitted, and in none that I am acquainted with are any statistics of therapeutics, or particular plans of treatment, properly kept. That these latter exert an important influence in determining the results of medical and surgical treatment in hospitals, independent of all internal faults of their own, who can doubt who has watched and noted the changes in doctrine and practice of the present century, from the heroic blood-letting and nimia cum inedici of its early part, to the medicine expec- tante, homoeopathy, hydropathy, and the important antiseptic surgery of our own times ? It is sufficient for my purpose to state that, although we have no sound comparative data to guide us to a stricftly logical conclusion, we have an abundance of testimony from figures which are of considerable value in themselves, in relation to many medical and surgical questions of great importance. Taken by themselves, they show that when varying proportions of mortality occur from the same classes of surgical procedure in similar cases, in the same or different localities, or where the death-rates from fever inflammation, the process of parturition, and other general causes, range to an extent indicative of greatly increased risks to life in some circumstances, as contrasted with others, they point to the existence of something wrong. This somethin g wrong demands the strictest investigation, which is the real position in which the question now is. What, then, are the different factors which require to be taken into account in estimating Sixth Report of the Medical Officer of the Privy Council, 1864, pp. 39. 40. Control and Management of Hospitals. 7 the general conditions of healthiness, in the sense used by Mr. Simon, or the reverse, of every hospital intended for the reception of the sick or disabled ? As usual in all human affairs, the agencies to be considered are moral and material. The former refer to those employed in the control, direction, and management of hospitals, the latter relate to structural and other conditions which we know, or believe, to contribute to placing such institutions in the best possible state to fulfil their special purposes. It is manifest, and to this general rule hospitals form no exception, that the best and most perfeift instruments may fail in careless or incom- petent hands, whilst good work may be done with imperfect instruments by the more skilled and careful. The question of the government and staff of hospitals is thus scarcely second in importance to the principles which should be observed in their construction and arrange- ments, in relation to the successful treatment of disease. For convenience of treatment, I shall consider the whole subject under the following heads : — I. The Control and Management of Hospitals. II. The Principles of the Construction and Arrangements of Hospitals, with brief general descriptions of some typical examples of recent Hospitals. III. The Consideration of the several Groups of Hospitals. The organisation of medical relief in the Metropolis is a matter of so much im- portance, in connection with the hospital question, as to demand discussion in a work specially devoted to that objeCt ; but' as it does not deal with principles intended for guidance in. the future, and, although of national interest, cannot be applied to circumstances for which no parallel exists elsewhere, I have placed it in an Appendix. I.— THE CONTROL AND MANAGEMENT OF HOSPITALS. ✓ In the Introduction to his “ Etude sur les Hopitaux,” one of the most eminent and successful Directors of the Assistance Publique, in Paris, M. Husson, wrote that questions of salubrity and hygiene, when they treat upon the regimen of hospitals, and the welfare of the sick poor, move and excite public feeling and opinion more than any other domestic discussions. “Science rightly attributes to them,” said he, "a decisive influence on the results of treatment; the administration, on the other hand, bears them constantly in mind, and attaches so much importance to the application of the principles flowing from them, that it does not reduce them to practice without appealing to the lights and experience of the medical staff of hospitals.” “ This exchange of ideas and views, always so useful, between the administration which watches over the national interests of the sick, and the practitioner who affords them his assiduous care, is one of the oldest and most precious traditions of the hospital administration of Paris." And yet this ‘ precious ’ remnant of antiquity has resulted in securing for the capital of France, one of the most costly and least healthy of all recent monumental hospitals, and, in its authoritative interference with the ‘ lights and experience of the medical 8 Control and Management of Hospitals. staff,' extinguishing those lights and disregarding that experience at its own will — for, in truth, in practice it scarcely affects to regard them — through the medium of lay directors, it constitutes as mischievous and inefficient a system of the internal govern- ment of hospitals, as it was possible to devise. M. Tenon, the earliest and best of the scientific reformers of hospitals, said, nearly a century since, that “ the merit of a hospital does not consist exclusively in its construction and, he added, that a false estimate would be formed of such institutions if from the buildings, the furniture, and fittings, the sick and the attendants were dis- associated, and if the rules and regulations which animated and directed their work, were not taken into account. In truth, by no means the least important faCtor in the successful working of hos- pitals, is their right government. The concerns of all such institutions are many and various. For their proper regulation, the fittest agency for each part of the appointed work, should be selected or elected. The general government (including the financial control), the special regulation, and the professional agency (superior and subordinate), are all necessary for their effective management. In the general government, the public, as distinguished from the purely professional interests, should be chiefly regarded. In the immediate management, the professional element should not only be predomi- nant, but absolute; for professional training alone can fit a man thoroughly to understand the multitude of matters of detail which require to be dealt with, with economy, despatch, and efficiency. In most foreign countries the central and superior control, as well as the imme- diate management, is in the hands of a governmental administrative agency. In Paris, this is represented by the Director of the Assistance Publique, under the super- vision of a council, presided over by the Prefect of the Seine, and consisting of members of the municipal council, medical members, mayors, and other notabilities. The director is believed to be praiflically an independent officer, in all executive measures. He has under his orders a staff, comprising a general secretary and several bureaux, each with its superintendent in charge, as may be found detailed in the French National Almanac. The lay director of the hospital is a member of his staff. A study of the laws of most European countries regulating the control and manage- ment of institutions devoted to the care of the sick, and to the relief of destitution, with which they are usually associated, has satisfied me that they will not fit easily into our system of self-government and absence of dire(ft State interference ; and that, beyond some useful general principles, there is little in them that will bear direct transplantation. That our manner of dealing with them, although right in principle, is susceptible of considerable improvement in practice, I hope to be able to show when treating of the organisation of medical relief in this great Metropolis, which is a kingdom in itself. The chief and most important change required, I hold to be the entire separation of sickness from mere destitution, the former being merged in the general hospital system of the Control and Management of Hospitals. 9 country, as an integral and inseparable part of the great question of public health ; all other matters connected with destitution continuing as at present, under the Poor-law Authorities. The hospitals themselves, I consider, ought to have just so much of State control as to secure their proper direction, with the remedy of such defects as may be shown to exist. I know of no good reason why the different hospitals of London, and other great cities, should exhibit such different risks to life in similar circumstances, diseases, and accidents, as they do now, and have done for long past ; and why a proper uniform system of hospital record, in all departments of their administration, should not be as compulsory as customs, trade, and other economic returns, in matters of far less general and scientific interest. If the State interferes, as it does rightly, to protect all classes who are unable to protect themselves from injury and misgovernment, surely the sick and those who are afflicted by causes over which they themselves can exercise no control, demand the same consideration for the body, as they now receive for the mind and its disorders. It involves but the extension of a principle which is firmly established in our legislation, and it can easily be so regulated as in no way to interfere injuriously with the self-government which is still more deeply impressed on our national character, and guides us so surely and successfully in most matters of social and domestic economy. In the lives of the poor, and of all engaged in manual labour, sickness plays a much more important part than it does with any other class of society. The munificent public and private charities of this country are amply adequate to deal with all legitimate demands upon them, without inflicting additional burdens upon the purses, or taxes upon the time and attention of the wealthy and benevolent, if they were only better organised, and somewhat more judicious care were bestowed upon their distribution. General Management. The general supervision of the concerns of all hospitals should be in the hands of a mixed committee, or body of governors, sufficient in number to be sub-divided into sections of convenient size, to control the financial arrangements, additions to, or altera- tions of buildings, and similar matters. For small institutions small committees would be sufficient. Should the present precarious existence and unsatisfactory state of many hospitals depending entirely on voluntary charity — which live from hand to mouth, constantly exceed their incomes, draw upon their capital, if they possess any, press the benevolent with perpetual piteous appeals for aid, and are compelled to keep beds unoccupied from want of funds to fill them — lead to a change in the general administration of medical relief, by incorporating them in the Poor-law system of the country in such manner as to separate sickness from the relief of destitution from whatever causes, and rob it of the stigma now attached to pauperism ; a change in the management of all State-supported, or State-aided hospitals, would become absolutely necessary by the introduction of an official element in their direction. 10 Control and Management of Hospitals Should it not be deemed expedient, however, to introduce an official element into this body, there is fortunately, in such a community as ours, no lack of persons of cultivation and leisure, strongly imbued with philanthropic sentiments, ready and willing to under- take such duties. This general committee, by whatever name it is called, should be purely adminis- trative, and have no executive funtftions. On it should be men possessed of an adequate knowledge of finance, of structural arrangements, and of such economic principles as are required in the general control and direction of an establishment, of which the special function is to do the largest amount of good to the sick and suffering without prodigality or parsimony, and without fear or favour. There are many circumstances connected with this general management of hospitals, in which the aid and advice of educated women would be valuable, both in council and in action. The laundry, the cooking department, the domestic arrangements of the nurses and female servants, as well as the women’s and children’s wards, would all benefit by such supervision. Hence, a certain proportion of all general committees should consist of ladies. On the committee should also be the consulting physicians and surgeons of the hospital itself, and possibly other distinguished members of the profession, unconnected with the hospital, to act as a special medical committee; to see that, in the application of the means of relief, the institution is kept well abreast of the progress of the art and science of Medicine and Surgery, and to assist their lay brethren to deal with abuses where they are found to exist, in which technical and special knowledge are needed, to suggest the best means for their remedy or removal. At present, the indisposition to associate members of the Medical Profession in such bodies, is as incomprehensible as it is prejudicial. Had they, for example, formed an integral portion of the governing bodies of some celebrated institutions which have recently appeared in an unenviable light, and shewn how thoroughly unsound their system of management is, the scandals which have shocked public feeling, would never have been allowed to occur. In such a body, the public and the profession would alike have confidence. The former would have the assurance that their money was well spent, that the hospital was humanely conducted, and that the poor and afflifted obtained all the advantages in- tended for them. The latter would be assured that the personal benefit of each patient was carefully considered, and that while none were made the subject of questionable experiments, the interests of the progress of Science were not negleded in introducing new and improved means for the cure, and, above all, for the prevention, of disease — the latter being of national importance. Such an organisation would not interfere injuriously, if at all, with vested interests or founders’ wishes, so long as these latter were in harmony with the constantly progres- sive changes in society, and the new conditions arising out of such changes. The above is no hypothetical or speculative scheme, for, with some modifications of detail, it may be seen in active operation in some of the well-condu(fted hospitals of the United States at the present moment, and in the great hospitals of Edinburgh and Glasgow. Control and Management of Hospitals ii All persons engaged in inquiries into our hospital system know how difficult it is to obtain reliable information, and how little the public or the profession know of the exaeft state of most of our sick asylums. This does not usually arise from any desire for concealment, but because each is more or less a law unto itself, and there is a want of uniformity in the system of records, which are seldom kept in such manner as to be of any real scientific or administrative value, so far as the published statements of most hospitals indicate. Special or Executive Control. The immediate government of a hospital should be intrusted to a resident Medical Superintendent. It is so generally in the United States of America, in some of the greatest hospitals on the continent of Europe, in the most important hospitals of Scot- land, and in the large and well-managed separate Poor-law Infirmaries of this Metropolis. To the medical superintendent, all persons within the walls of the institution, should be stridtly and direiftly subordinate. There should be no concurrent, separate, or conflicting authority. He should not be charged with the treatment of the sick, and should neither possess nor exercise any power of interfering with the physicians or surgeons in their treat- ment of cases of disease, accident, or injury. The direction of all other internal concerns should be exclusively in his hands — such as the maintenance of order and discipline, the regulation of supplies of all kinds, the custody of all appliances and instruments, and the initiation of all such structural and other changes, as may, from time to time, be found necessary. In matters of finance and supply he should act under the orders of the special sub-committees of finance and buildings, appointed from the general governing body. He should regulate the admission and discharge of patients, and the keeping of the records of the hospital, with the aid of such subordinate staff as is always required in great institutions. The out-patient department should also be under his control. The appointment, removal, and distribution of all nurses, servants, and subordinates generally should likewise be vested in him, subject to the immediate control of a house-committee. He and all the sub-committees should submit an account of their proceedings monthly, or as much or less oftener as might be deemed necessary, to the general committee at its appointed meetings, with whom should rest the final sanction and approval of all matters connected with the institution. The general committee should have a paid secretary to arrange and keep its records, and be the official medium of communication between that body and the officers of the hospital. If there be any class or kind of public institution which more than any other demands the possession of special and technical knowledge, and more direct unity of authority in its immediate management, I hold it to be a hospital. A medical superintendent, from his professional training, is alone competent to gauge at once with promptitude and decision all the requirements of such an institution ; and, as he must always be appealed to in the last resort, common-sense and the proper conduct of business of all kinds in every other walk in life, indicate that he should possess the power, in the first instance, of dealing with every such matter as pertains to the economical and efficient control of a place devoted to the healing of the sick. Fettered as he would be by his responsibility 12 Control and Management of Hospitals. I to special committees and the general committee, there would be no fear of his abusing such authority, for a sure and swift remedy could be found for such abuse. But, as a matter of fatft, it is not abused in those institutions in which it is in use, as I have had abundant opportunities of seeing. However, even our existing system, mediaeval and out of harmony as it is with the age in which we live, is better than that of the director of a French hospital, acting solely under the orders of a central official authority, which is, as stated before, about the most inefficient and mischievous form of government that I have ever seen in action. Reform in the direction above indicated will not, I know, meet with ready acceptance from many benevolent and philanthropic persons whose views are entitled to respecftful consideration. We are, as a people, slow to mend our ways, and have a not unnatural dread of changes, which are usually regarded as, more or less, leaps in the dark. Yet this is in no way a speculative change, for it has long been in practical operation in other places, and is so in one important class of public hospitals among ourselves. Let those who have any misgivings on the subjeift visit and examine the institutions referred to for themselves, and see in their economy, efficiency, and the absence of all friction in their working, undeniable proof of the soundness of a system, which has passed from the region of discussion to that of accepted fact. The axiom that unity of executive control means efficiency of management, applies quite as much to public as to private business. Hospitals, I contend, form no exception to this, and the more general rule that those are best qualified to conduct a business successfully, who are best acquainted with its requirements. Nursing. The most important of all the subordinate agency required in hospitals is undoubtedly that of nursing, of which, indeed, it would be difficult to over-estimate the value in its proper place, and in due restriction to its special purpose. For the moral and domestic direction of the nurses, and for the thousand daily needs essential for their comfort and happiness, together with many collateral duties which a male superintendent cannot properly discharge, a Matron is required — not as an indepen- dent and co-ordinate authority, but as an integral part of the machinery of management, kept in harmony by the single direct ruling authority. That skilled and trained labour is infinitely more efficient and trustworthy than unskilled and untrained labour, is undeniable. But, to elevate nursing into a special profession, and to arm it with independent authority in the management of disease or accident, I hold to be a mischievous mistake, alike in public institutions as in private life. It is, and must always be from its very nature, a subsidiary function, but not the less valuable or important on that account. To elevate the minor to the position of the major is as illogical in theory, as it is unsound in practice. Neither the education nor the training of the most accomplished nurses can fit them for independent charges, nor are they intended to do so. The elementary and, of neces- sity, superficial acquaintance with so much of anatomy, physiology, chemistry, pharmacy, and physics, as are now imparted to them, are important auxiliaries in their practical Control and Management of Hospitals. 13 training, but cannot go further in rendering them in any way independent of the physician or surgeon, under whom they are rafting. To charge the head of the nursing staff with the maintenance of discipline, and to render her independent of the resident medical superintendent in such matters, is certain to cause friiftion, and to lead to disorder and disorganisation. The experiment was sub- jected to full and fair trial in the Episcopal Hospital of Philadelphia, a few years since, and ended in disastrous failure, as might have been foreseen. This erroneous procedure is also responsible for most of the scandals which have recently come to light, in con- nection with hospital management. Nurses stand in the same relation to the surgeons and physicians of a hospital that non-commissioned and warrant officers do to the officers of the army and navy, and that skilled artisans in a factory or workshop do to the foremen and scientific directors of the works. To arm them with independence in any form is as impolitic in the one, as it would be destructive in the other. I cannot, again, concur in any scheme of connecting the duty of nursing with any form of religious, or quasi-religious, organisation ; for hospitals are open to all classes, sects, and creeds, and should be absolutely free from even the suspicion of any sectarian bias or proselytising tendency. I have myself witnessed the great distress caused to conscientious sick persons by the reading of prayers, of the terms of which many of them disapproved ; and I was more than once compelled to put a stop to it in my wards, in which intelligent men from all parts of the world were assembled, and amongst whom were representatives of nearly every known sedtion of Christians. Far be it from me to underrate the possession on the part of a nurse of the deepest religious feeling; for there can be no better guarantee of her tender consideration for the sick, and of her conscientious fulfilment of her proper duties, which are entirely secular and professional, and should remain so. Nearly fort}' years ago I myself applied to the Roman Catholic Archbishop of Calcutta, to grant me the services of some of his religious ladies to organise and introduce into the female wards of the Medical College Hospital, then under my executive charge as secretary and resident medical officer, an improved and skilled system of nursing, at that time quite unknown in British India. He complied, and for some four or five years these exemplary and truly Christian women condudted the duties of nursing in the most perfedt manner, under my constant personal supervison, and that of my late colleague, the then Professor of Midwifery. The successor of the Arch- bishop above referred to, much to my regret, and with many apologies on his part for taking a step in opposition to the action of his predecessor, withdrew the ladies in question. His plea was that the earnest devotion of the nuns to purely secular work, interfered with the strict performance of their religious duties. From first to last they never stepped beyond the exadt line of their hospital work, so far as the sick were concerned, or assumed fundtions or powers inconsistent with their relations to the professor or myself. The harmony of action and efficiency of nursing were unbroken; and we parted with mutual regret and regard. I assume, then, to speak with authority on a question which has recently greatly exercised the public mind. 14 Control and Management of Hospitals. I do not enter into the question of the right method of training nurses, because it would need an undue amount of space, and is not necessary to my contention. More- over, it has been treated exhaustively by one who can never be mentioned without an expression of the respect and admiration due to exceptional knowledge of the subjeeft, to rare ability in its consideration, and to a life-long devotion to a work which will for all time be associated with her name. The only parts of Miss Nightingale’s scheme of which I disapprove, are some of the provisions touching the relation of hospital manage- ment to efficient nursing. The nursing department of St. Thomas’s Hospital, with the exception above noted, the excellent arrangements of the great infirmaries in Scotland, and the special provision for the same end made at the John Hopkins Hospital at Baltimore, with many others which might be mentioned, are all typical and efficient modes of dealing with the question of training, in the only manner that appears to me to be thorough and free from objection. In most of them the religious difficulty is very properly avoided, and the divided responsibility is non-existent. The proportion of nurses to sick, and the establishment required for day and night work, must vary so greatly with the nature of the cases and the character of the hospital, as to render it difficult to adopt any fixed rule or standard on the subject. The following remarks of Professor De Chaumont on the whole question, represent the most recent professional view of — " Nursing .- — The arrangements for nursing the sick have greatly improved in recent times, although controversy still goes on as to the best means of carrying it out. In arranging for the nursing in a hospital, both efficiency and economy have to be considered. Miss Nightingale recommends large wards of thirty-two beds each, as at the Herbert Hospital, on the ground that the head nurse is sufficient for such a number by day, and one by night. In the Edinburgh New Infirmary the wards are not so large, the medical being arranged for twenty-one and the surgical for fourteen patients. Circumstances must to a large extent determine the arrangement ; but it seems desirable, on the whole, that the work of a nurse should be confined to a single ward at a time, if possible. The duties of nurses ought also to be confined to attendance on the sick, and no menial work, such as scrubbing floors, and the like, should be demanded of them ; a proper staff of servants ought to be employed for such purposes. It is also desirable that a separate pavilion for lodging the nurses should be set apart, and that fair and reasonable time for rest and recreation should be allowed. Some discussion has taken place as to the advisability of placing the nursing of a hospital in the hands of a sisterhood or separate corporation. It will, however, be admitted that the best plan is for the nursing staff of each hospital to be special and under one head in the establishment itself, even although it may be connected with some main institution outside. The nursing must, of course, be carried on in accordance with the dire&ions and treatment of the physicians and surgeons.” * The slight condemnation, more implied than expressed in the above remarks, as to giving a quasi-religious character to hospital nursing, does not indicate the real danger of our hospital system drifting back to the condition so strongly reprobated in the 18th century. Regarding a much later period, when the supreme ecclesiastical control had long ceased, M. Husson says — "The almost unlimited authority accorded to different religious congregations in divers hospitals, if we put faith in La Rochefoucauld Liancourt, who cannot be suspe&ed of exaggeration in such a matter, had engendered numerous abuses.” * Art. : " Hospitals,” Encyclopadia Britannica, Ninth Edition, vol. xii., p. 305. Control and Management of Hospitals. *5 In his seventh report, speaking of the Hotel Dieu, he says — “The religious hospital attendants have the direftion of all the wards, and of nearly all departments of the interior ; they control the treatment of the sick, the administration of remedies, and the distribution of food. All the servants of the house are subordinate to them ; they are absolute mistresses of the disci- pline of the wards, under the diredion. nevertheless, of the Bureau of Administration, and of the conduit of the medical staff. They are, no doubt, to be admired for their zeal, their piety, and their assiduous care of the sick ; but whatever may be the merit of this eulogy, we cannot help qualifying it by some less favourable remarks after certain recent authenticated fads .... We cannot help believing that it is chiefly to the despotism exercised by these religious attendants in the Hotel Dieu, and their resistance to all authority, that the perpetuation of certain abuses must be attributed, as well as very great inconveniences, of which we do not hesitate to denounce the deplorable results." And further on — “ The poor are equally discontented with the services of the sisters and of the servants, accusing the former of hardness and despotism ; the latter, of negled and ill-will.” * The nursing arrangements of the Western Infirmary, Glasgow, are models for imitation elsewhere, and are free, as are those of all Scottish hospitals, from the errors and pretensions of the otherwise excellent system adopted in England. The mode of appointment of the medical officers of all civil hospitals in the kingdom is probably not free from objection ; but so long as it brings the best men to the front, and secures to the sick the ability and care necessary for their restoration to health, there is no pressing reason for suggesting a change. To men possessed of the requisite know- ledge and skill, hospital offices are sure passports to public favour and to professional reputation. This will, however, do little for those who lack the higher qualities which go to the formation of a perfect surgeon and physician, such as are to be found in all our great institutions. Hospital Records. The only other matter necessary to notice in this place, is that of the proper keeping of hospital records, an all-important branch of the management of such establishments. From the absence of uniformity of system, from the indisposition of many hospital authorities to afford any information as to their affairs, from the untrustworthiness of most of what is made known, and from the omission in some, even of the best-kept returns, of important fatftors, there is scarcely a fact connected with the treatment of diseases, accidents, or injuries in these institutions, which can be determined with any- thing approaching to scientific accuracy. Mr. Lawson Tait, in his Essay on Hospital Mortality, has stated, on the authority of others, that a loss of life as great, although not as striking, as that which excited public indignation in connection with the Scutari Hospital + during the Crimean War, is * Husson, Etude stir les Hopitaux, p. 174. Rapport fait au nom du Comite de Mendicite, des Visites faites dans les Hopitaux de Paris, par M. le Due de La Rochefoucauld Liancourt, p. 3. t A parade has constantly been made of the mortality of the army in the Crimea, and we are left to draw the inference that it was, in a great degree, due to the shortcomings of the medical department of the army at that time. Nothing can be more untrue. It was caused entirely by military mal-administration, and by the medical branch of the service having no effective control over its own affairs. i6 Control and Management of Hospitals. constantly going on in our civil hospitals, and that it may be checked by exacftly the same means which in 1855-56 brought down the disease and death rate of our Crimean Army from 40, to less than 3 per cent. “That there is some truth in this,” he goes on to say, “ no one who has had much hospital work can doubt for a moment, though to what extent it is true must, I fear, long remain a mystery, and that chiefly for the reason that it is almost impossible to obtain data which are not open to objedions more or less for- cible. How carelessly kept are the records of most of our medical charities, none know save those who have had to examine them. The managing authorities are usually content with publishing a report which con- tains a balance sheet and a bare statement of a number of patients which have been treated during the year, often without mentioning so important a feature as the number of deaths which have taken place. And this is by no means confined to small hospitals, for some of the largest and most important hospitals in the country, publish reports which are absolutely worthless as sources of information. In one point they all join. There is a uniform tone of congratulation on the success of the hospital, and an increase in the num- ber of patients is hailed with rejoicing ; whilst the committees always regret when the ‘ usefulness of the hospital has been somewhat diminished during the past year.' Surely this is done in thoughtlessness. They must be oblivious of the fad that anyone accepting gratuitous assistance is being pauperised, and that our indis- criminate system of medical relief has much to answer for in the improvidence of our labouring population. “ Be that, however, as it may,” Mr. Tait adds, “ one thing, I think, will be admitted on all hands. If any body of men take upon themselves not only to administer public charity, but to look after the lives and health of our poorer neighbours, they are bound to give an account, not only of their expenditure but of their results. There are few hospitals which do this completely and well ; but amongst those which do, I think it desirable to mention especially, as worthy of mention, the reports of Charing Cross Hospital, of the infirmaries of Glasgow, Paisley, and Greenock, and the Hospital for Sick Children at Birmingham.” For the financial and business concerns of hospitals nothing more is required than the ordinary forms of balance sheets, so constructed as to show to what exact head each portion of income and expenditure should be assigned. The disease register, without being overladen with redundant or unnecessary details, should contain all needful particulars as to age, sex, domicile, occupation, disease (whether primary or secondary), length of time under treatment, hereditary tendencies, and, as respects surgical cases, the careful separation of traumatic from other classes of surgical affections, with special reference to those requiring operative proceedings. Pathological and therapeutical statistics should also be included in hospital returns, probably in separate tables. The whole of the particulars above mentioned should be carefully tabulated, and analysed in the briefest possible form, but on a uniform system. In 1877, in recording the proceedings of the Public Health Section of the ninth International Statistical Congress, I stated that, among the questions which press most urgently for solution, is that of a proper system of hospital record to determine a number of questions which demand the scientific application of numbers for their solution. The statistics heretofore collected are constructed on far too narrow a basis to afford more than a very rough, and, in most instances, inaccurate idea of the risks to life from treatment in particular public institutions. Except with respect to amputations, fevers, parturition, and such diseases as are treated in special institutions, the published returns furnish no information whatever of a multitude of facts of vital importance in relation to disease generally, which are scarcely of less interest and value than a more accurate and exhaustive acquaintance with epidemic visitations. And even as respects those diseases which have been the subject of special investigation, the records are not so specific as they ought to be. Control and Management of Hospitals. France is no better off than we are, in this respeCt. M. Husson, in his great work on hospitals, recorded the following remarks, which are as true now as when they were written twenty years ago. He says — “After an attentive study of all the material ameliorations which the Administration has introduced into the service of these hospitals, it remains to examine the results attained by so many efforts, and so much solicitude for the care of the sick. “ Figures, rigorously exad, can alone enlighten us upon this point ; but it is, unfortunately, only too certain that beyond the tables of mortality published annually, and which present, in an abstract form, the relation of the number of admissions to that of deaths, the hospitals of Paris have never possessed the essential and indispensable elements of a rational and conclusive system of statistics. “ It is true that since 1857 the Administration has gathered together from each hospital, an account of their great surgical operations and their results. But this is only a special side of the question, and, with regard to it, we shall see how defective their statements, the objedt of a special examination of a particular subject, really are. “ It should be, then, with the greatest reserve that the tables published by the Administration since 1804 must be studied, to ascertain the death-rate in the hospitals, and the average duration of treatment. “These documents can be studied with profit only on the understanding that they contain general fadts and summaries, from which the light of circumstantial detail is absent."* I have dwelt long, and placed great stress upon this matter, partly because it is one of the gravest and most injurious defecfts of our present hospital system, and, in part, because no perfectly satisfactory means of correcting other cardinal defects can be devised, unless their exact causes are accurately ascertained. There is, probably, no branch of human knowledge, to which the application of the numerical method is better fitted, and from which it is calculated to yield a greater harvest of valuable truth, than to the logical interpretation of the facts of medical science. Nowhere can these facts be more perfectly collected and scrutinized, than in the practice of our hospital wards. There is, at the same time, none other in which it is more necessary to guard against the fallacies incidental to, and, in some degree, inseparable from, this method of inquiry ; in which more rigorous exactness is necessary in the collection of the facts themselves; and in which greater caution is required to avoid hasty or dogmatic deductions from mere numerical results. It cannot be denied that the facts of medical science are so complex in their nature so liable to be influenced by an infinite number of collateral and minor considerations, which can only be properly studied in public institutions under a continuity of control and observation impracticable in any other circumstances, as to render the application of numbers to their solution much more difficult, than to the interpretation of purely physical phenomena in any other branch of scientific inquiry. All attempts, therefore, to compare large hospitals with small, to show the superiority of one form of construction over another, based on their mortality results, as at present ascertained, or on the average length of time cases were under treatment, are so deficient in scientific accuracy as to become mere guesses at the truth ; and they must rely upon other data for their solution, still more fallacious than the partial and imperfeiff figures to which we now nave access. * Etude sur les Hopitaux. Husson: Paris, 1862, pp. 24, 7-8. C i8 Principles of the Construction and Arrangements of Hospitals. Since the late Sir James Simpson and Professor Erichsen wrote upon the subjeft of hospitalism, a large amount of information has been collected which requires to be care- fully digested ; and if, with even such imperfedt data as now exist, it can be shown that inexpensive huts and tents afford the best chance of restoration to health, and diminished risk to life to those struck down by accident or disease, and that costly palaces in the shape of monumental hospitals, not inaptly termed “ Versailles of Misery,” are liable to become abodes of pestilence, however well administered, some fixed rules for the guidance of the future will doubtless be adopted, to turn to the best possible account the experience of the past. In dealing with health — which when once lost is so difficult to find again, and with life, the needless sacrifice of which can never be repaired — by statistical evidence alone, gathered in the hospitals themselves on a stridfly scientific basis, can this consummation, devoutly to be desired, be attained ; and by it alone will it be possible, in the words of Professor Radicke, of Bonn, “ to stem the stream of baseless, and, to a great extent, erroneous dodfrines by which medical science threatens to be overwhelmed.” II.— THE PRINCIPLES OF THE CONSTRUCTION AND ARRANGEMENTS OF HOSPITALS. For more than a century past the subject of the construction of hospitals has attracted attention, and been discussed and re-discussed by a multitude of able men ; sometimes with scientific precision uninfluenced by personal feeling ; often with anger and acrimony, for few social questions have at times more strongly moved public feeling ; and, not unseldom, with the profoundest sentiments of sympathy with the sick and suffering, and the most earnest desire to place them in the position best calculated to afford them the fairest chances of life, and restoration to health. The labours of John Howard in this field are well-known ; and various other persons, particularly on the Continent of Europe, devoted attention to the matter long anterior to his time, as, for example, in a proposal to establish a convalescent hospital in connection with the Hotel Dieu in the middle of the 17th century, which, however, was never carried out ; in the plan of a radiating hospital devised by Desgadets, the architect of Louis XIV., whose work is contained in a folio manuscript, deposited in the National Library of Paris ; and, subsequently, in the various plans devised and discussed in relation to the rebuilding of the oldest Hotel Dieu, after the destructive fire of 1772. In January,- 1773, the administrators of the Hotel Dieu strongly advised its removal to the Plain of Grenelle, for the following reasons: — “ The public press has long demanded it ; the restricted area of ground occupied by it ; the corruption of the air and water ; the injury which this house causes by its infection to everything surrounding it ; the danger of fire, and a thousand other disadvantages seem to have united all suffrages on this point, if we except certain personal interests, which should always be set aside in such institutions.” And it was added, that it would free the Seine from the filth with which the Hotel Dieu pollutes it ; it would procure pure air, vast courts, and gardens necessary for convalescents. Principles of the Construction and Arrangements of Hospitals. 19 The first serious attempt to treat the subject with scientific accuracy was that of MM. Tenon and Bailly, when considering the grave defects of the old Hotel Dieu, and the best means of remedying them. The classical work of the former laid the foundations of the system now being adopted, and is the most valuable contribution ever offered on the question. It is somewhat singular, that after the lapse of nearly a century, the question of the entire removal of the same Hotel Dieu should again have given rise to prolonged discussions in the Academy of Medicine and the Surgical Society of Paris, and of the official commission appointed to consider and carry it into effect. It is still more singular that, in spite of all this, the new Hotel Dieu is still in Paris itself, and the experience of a century has been disregarded in its location, so persistent is error and so difficult to dislodge. The conclusions arrived at by the Societe de Chirurgie have since guided the action of the most advanced reformers in this direction, as I shall endeavour to show further on. They preceded those issued officially in 1864. The Crimean War, the contest between Prussia and Austria after the Schleswig- Holstein conflict, the great war of secession in the United States, and the Franco- German war, again strongly directed the attention of the public and of the profession to the best means of dealing with accidents, injuries, and disease in large bodies of men suddenly collected in overwhelming numbers, so as to avoid the fearful destruction of human life, inseparable from the old methods of managing such matters. The successful application of the arts of peace to the operations of war, was shown in the adoption of the principles so long since advocated by Tenon. The removal of St. Thomas’s Hospital, the building of the Herbert and Nctley Hospitals, the reconstruction of the Edinburgh and the building of the Western Glasgow Infirmaries, and the building of several new hospitals in different parts of England, the best of which are indisputably some of the great Poor Law Infirmaries, attest the practical interest in the subject taken by ourselves. The detailed report of Messrs. Bristowe and Holmes, with the remarks of the distinguished medical officer of the Privy Council, published as a Parliamentary paper, with the writings of Miss Nightingale and Captain Douglas Galton, are still authorities of value on this important and vexed question. More recently the hospital question has been taken up in Germany, and treated with the scientific accuracy and thoroughness characteristic of the German nation. To attempt to take note of the ground covered by the various contentions in this century of conflict of opinion, would be as unprofitable as it is impracticable, in a reasonable compass. It is, however, unnecessary. It will be sufficient for my purpose to state the conclusions arrived at, after prolonged discussion in Paris in 1864, inasmuch as they have in the main been observed in the latest hospitals built on the continent of Europe, and in some of those recently constructed elsewhere ; the chief exceptions being the costly failures of the new Hotel Dieu and St. Thomas’s Hospital, the former from a deliberate and intentional disregard of the true principles which have taken so long to establish, the latter from a singular, and not very intelligible misapplication of those principles. It is difficult to understand how those responsible for this latter structure could have considered its division into huge blocks, six stories in height from the basement, C 2 20 Principles of the Construction and Arrangements of Hospitals. connedted by continuous closed corridors, with many of its internal arrangements equally defective, to be a corredt representation of the pavilion principle, as understood and described by those who have so long advocated it. That it is, in its infancy, more unhealthy than many of the older hospitals is the truest test of the grave error which has been committed. With us the deathblow to the aggregate or palatial plan was given by the late Sir James Simpson and Mr. Erichsen ; for although the accuracy of the basis of the arguments of the former has been disputed, and the views of both have not obtained the same acceptance with us that they have done in other countries, their practical adoption in the most recent hospitals of Germany, France, and the United States, affords the best possible proof of their accuracy. It was well said by Leon Lefort, one of the most competent authorities on the subjedt, that it is sometimes supposed that the question of hospital construction is an easy one, that architectural considerations should predominate, that hospitals should serve for the orna- mentation of towns, that they are as easily planned as streets, and that the science of health or hygiene has little to do with them. He disputes the correctness of this view, inasmuch as the best authorities on health and disease have shown that it demands the application of the most profound knowledge of medicine in all its branches, for its correCt understanding. The celebrated Philibert Delorme, the protege of Catherine de Medicis, and first architect of the Tuileries, now about to rise from its ruins, in his “ Traite Complete d’ArchiteCture,” published three centuries ago, foreshadowed the true principles involved in the construction of hospitals. “It would be better,’’ he wrote, “for the architect to fail in ornamentation, such as columns and facettes, which all study most, than in those rules of nature which tend to the convenience, use, and profit of the inhabitants, and not the decoration, beauty, and enriching of buildings, which are only for the contentment of the eye, and bring no advantage to the life and health of man.” I pass over other authorities, some of considerable eminence, to come to one who will, 1 believe, exercise a more permanent influence on the whole question of collective dwellings than most of his predecessors or contemporaries. I refer to Monsieur C. Toilet, a French civil engineer and architect. In 1876, M. Toilet presented to the Academy of Sciences in Paris, a memoir concerning the principles which should regulate the construction of collective buildings for both men and animals. In it, he states, that he was thus inspired by views formulated for then a century by the most competent hygienists, views which have remained sterile by the united influence of routine and vanity, and by the irrational opinion that the potential voice was that of the constructor in a question of health, touching which the only profession competent to deal thoroughly with it, was scarcely considered, and when consulted, disregarded. M. Toilet has applied his system successfully to barracks, schools, and hospitals. I hat system, which bears his name, is one of single-storied pavilions, raised on plinths and built in separate blocks on a peculiar form of construction — that of the spiral or pointed arch — which, in my opinion, unites in the greatest degree the best sanitary conditions with moderate cost, and the greatest permanent retention of healthy attributes. I shall refer more at length to them when I come to the general description of the St. Principles of the Construction and Arrangements of Hospitals. 21 Eloi Hospital at Montpelier, and other institutions of a like character, constructed, or in progress, by him. In the chain of hospitals now arising on the ramparts around Paris, in which old abandoned barracks have been utilized as administrative buildings, and wards on the Toilet system are constructed to contain the sick, will be found the means of best providing for the sick poor in their own localities, and of removing some of the old hospitals which are beyond the reach of remedy of the original evils of their construction. One of these Toilet institutions, the Hopital Bichat, is completed and in use. I shall not attempt to discuss the difficult and still undetermined problems conneifted with the causes of the vitiation of the air of a hospital, together with the conditions under which septicaemia and blood-poisoning occur in wounds, and in some constitu- tional diseases. The existence of such influences cannot be denied. Whether they be due to putrefactive fermentation, to the development of germs and living organisms, or to any more subtle and less easily detected general morbific agency, is comparatively of little importance in the determination of the question under consideration. The end to be sought is the best means of depriving these agencies of their power of mischief; and this is now admitted to be by placing all institutions in which many persons are congregated under the same roof, whether in health or in disease, in the best possible state to secure the utmost attainable purity of all the essentials of health and life, such as air, soil, water, and the agencies which affect an individual, or may from him extend to other persons, and ultimately infect whole communities. Hence I shall reproduce, in exteiiso, the conclusions arrived at in Paris, for reasons already stated ; and after considering the leading features connected with hospital construction, briefly refer to such of the most recent as appear to be best fitted to fulfil their purposes. The conclusions of the Surgical Society of Paris, after ten prolonged sittings, were as follows : — " i. A hospital should be placed in an open space, upon a dry soil, with an inclined surface. This space should be large. A superficial area of fifty square metres (about sixty square yards) for each sick person is the minimum space that should be allowed, and this should be increased as much as possible and should be augmented progressively with the increase of the number of sick. " 2. The air of a hospital will be pure in proportion to its distance from thickly populated places. In the centre of cities, hospitals for urgent cases alone, which are necessarily restridted in numbers, and for clinical purposes, should be retained. This measure of health will be at the same time one of economy, as it will allow large towns like Paris, to instal their hospitals on large areas at less cost. “ 3. Good hygienic conditions are easy to obtain in hospitals of from 200 to 250 sick. These conditions are impossible to obtain in large towns, if double the amount of these figures is exceeded. Within these limits of numbers, the expense for all purposes, is not in excess of that of hospitals containing larger numbers. “ 4. The constituents of the atmosphere intermingle chiefly in a horizontal direction ; hence the necessity of combating, by increased space, the effedts of contact, and of the proximity which constitutes crowding and the influence of which is communicated from patient to patient, ward to ward, and from one building to another. " 5. To strive successfully against contagious influences not only needs an increase of the cubic space allowed to each sick person, but in addition, and above all, demands an increase of superficial area, which is at present insufficient in all our civil hospitals. For similar reasons the multiplication of stories is contra-indicated, as each of them generates a more or less vitiated atmosphere. From a rigorous hygienic stand-point, the superposition of stories should be limited to two. " 6. It is illusory to believe that a large cubical capacity in wards can replace an absence of external space and aeration, or to suppose that an abundant artificial ventilation can supply the place of either of those conditions. Nothing can compensate for the insufficiency or absence of natural aeration. 22 Principles of the Construction and Arrangements of Hospitals. •• 7. Buildings completely isolated, and all having the same asped, freely exposed to light, and to the action of wind and rain, should be placed in a single or in parallel lines, at intervals of from 80 to 100 metres (rather more than from 101 to 119 yards), so as to secure effedtive separation and external aeration. " 8. Small wards of from fifteen to twenty beds are easy to superintend with care. In them the mutual discomfort of patients, and the chances of direct contagion, are diminished, and the rapid removal of all impurities is increased. They are preferable for the ordinary care of the sick, and do not affedt prejudicially the special arrangements required for certain classes of disease, which need more space and the isolation of separate rooms. " 9. The furniture of wards should interpose no obstacle to the free circulation of air. Bed curtains should be suppressed whenever it is considered necessary. “ 10. Wards should be separated by partitions, or rooms devoted to common service. One of them should be used as a day and dining-room for the benefit of all patients able to get up, and thus cause a daily incomplete emptying of the sick room. “ix. The periodical and regular evacuation of all sick wards, and their complete rest for months at a time, have produced such good effects in the military hospitals of France, and in the hospitals of other countries, as to be deserving of general adoption, which is a pressing necessity in times of epidemics. “ 12. Arrangements should be made to secure that all odorous and infectious matters, deje&ions, dressings, water used in cleansing, &c., should be rapidly destroyed or removed, and never be allowed to remain within or near the rooms occupied by the sick, or be permitted to cause any perceptible smell. “ 13. The central administration of the hospitals should be supplemented and assisted by a permanent consulting (advising) committee of health, holding periodical meetings. This committee should consist of physicians, surgeons, administrators, architects, and engineers, with power to call into council all the heads of hospitals who are not members of the commission. “ The periodical meetings of the physicians, surgeons, and administrators of each hospital could furnish valuable advice to the central administration, to enable it to deal efficiently with all measures of progress.” Bearing these conclusions in mind, and knowing that, although susceptible of modifi- cation in some circumstances, they were based on a careful examination of the hospital systems of all countries at that time, and of our own in particular, I shall now proceed to consider the chief points which require examination, in any proposal for the building of the hospitals of the future. These are (a) site and surroundings, ( b ) ventilation and warming, (e) water supply, (a) the dimensions and distribution of buildings and wards, ( e ) size of hospitals, together with (/) furnishing and fitting. (a) Site and Surroundings. An ideal site for a hospital would be where the conditions of soil, -subsoil, drainage, water-supply, and all surroundings were most free from local causes of impurity, and where there were fewest buildings and habitations to exclude or intercept air and light, or to be themselves active agents in the creation of causes of unhealthiness, such as factories, workshops, &c. Sufficient practical experience and knowledge of the subject have been acquired to show that gravel and sand are more likely to be healthy than clay or any impermeable medium, which needs costly artificial contrivances to get rid of surface moisture and soluble impurities ; that a hillside would in most, but not in all, circumstances be prefer- able to the base of a hill; that an elevated plateau or plain would, in temperate climates, be more advantageous than a bottom or valley, and so on. But the necessities of the times in which we live, particularly in great cities and centres of industry, compel us to select, not that which is best in itself, but what is procurable at least cost, and in most accessible proximity to those who need it. Principles of the Construction and Arrangements of Hospitals. 23 In London, for example, most of the older hospitals, which are now in densely crowded, or in unhealthy localities, were, when they were originally built, either in open fields,' or so far removed from buildings of all kinds as to be free from most of the reproaches which now attach to them. Each recurring census return in Europe and in the United States shows with what startling rapidity manufacturing and other industrial towns and cities are expanding, and how quickly the centres of population in them are shifting. A glance at the map, which will be found in the Appendix, will bring out in startling relief this fact as respects London. The census of 1871 gave it a population of 3,254,260 inhabitants, occupying an area of 125 square miles, in which the density of the population of the whole area was 40 persons to an acre, and in its most crowded and least healthy localities range from 205 per acre in Whitechapel, to 325 per acre in St. Anne’s, Soho. The census of 1881 changed these figures considerably, as shown in the Appendix. Now, Switzerland, with a population of 3,000,000, is spread over 15,980 square miles; Sweden, with a little more than four and a half millions, occupies 171,000 square miles; Holland, with about four millions, 12,730 square miles; and Denmark with scarcely half the population of London, 14,760 square miles. In addition to this extreme pressure of population upon space and the means of sub- sistence, the map indicates the present provision of all kinds in the metropolis for sickness in all its forms, and how very unequally it is now distributed, as I shall endeavour to explain when treating of the organisation of its medical relief. The same fact is witnessed, although in a diminished degree, in the sixteen towns of the United Kingdom which have a population of more than 100,000, and in the half dozen others which have probably by this time reached that number. This condition must be carefully borne in mind in all discussions on the relative merits of town and country sites, as proper places for hospitals for the use of town populations. Wherever practicable, general hospitals should undoubtedly be placed in the outskirts of towns, as near as possible to the bulk of the population who require to resort to them ; and all convalescent hospitals, imbecile asylums, hospitals for incurables, and similar institutions, should invariably be placed well clear of the town. But hospitals attached to schools of medicine, and those which are intended for accidents, injuries, and acute cases which will not bear distant carriage, must still be in towns ; hence their construction and arrangements should be so managed as to minimise the evils inseparable from their position. Dispensaries, and all institutions for out-patients, or those who are not sufficiently ill to be confined to bed, should be placed in the midst of the populations needing them, for obvious reasons. Every hospital, wherever placed, should be surrounded by a zone of aeration, unencumbered with buildings or any other cause of obstruction of light and air, to a distance of at least double the height of the buildings. The interspaces, which should be found in all hospitals in town or country, should not be paved or concreted yards shut in by buildings, but open cultivated gardens, accessible to the convalescent, with shelter from the weather, so as to enable them to be as much in the open air as possible, whenever it is prudent or proper for them to be out of doors. 24 Principles of the Construction and Arrangements of Hospitals. The aspect of a site, which will determine that of the buildings, should, wherever there is a choice in the matter, be such as to command the greatest amount of sunlight at all seasons. The duration, force, and other conditions of the prevailing winds should also be closely studied, as they now are in France and Germany, and the greatest care should be taken not to place hospitals where those winds blow over parts of country unhealthy, from whatever cause, natural or artificial. The natural drainage and watershed of the locality should also be noted, together with its geological formation, where there is any choice of position. ( b ) Ventilation and Warming. Some authorities seem to think that the healthiness, or otherwise, of hospitals is more a question of ventilation than of any other condition— that, so long as you give to each occupant of a sick bed an adequate amount of space, cubical and superficial, and renew the atmosphere in which he lives and breathes, to such extent as to remove with sufficient frequency, all obvious and perceptible causes of impurity, without making this admission of itself a source of danger or annoyance — it matters little how many you place in each ward, to what extent you pile story upon story, or whether your hospital be placed in town or country. Some, again, appear to be satisfied that artificial systems of ventilation are of little or no use, and that what is termed natural ventilation is the only sound and efficient means of procuring a sufficient current of pure air, to counteract the unavoidably unwholesome influences of a sick ward. Others believe that dilution of the septic poison is sufficient to rob it of its power of mischief, provided it be carried to a sufficient extent. I take leave to differ somewhat from all these views. Although not susceptible of strict mathematical proof from any statistical data at our command, there is an abundance of evidence on record of an adequately exact nature, as regards prisons, barracks, factories, schools, and other institutions in which large numbers of human beings are congregated under one roof, to prove that their healthiness, or the reverse, bears a direct and definite ratio to the numbers aggregated upon a given surface, each having a sufficiency of air for healthy respiration in ordinary circumstances. So true is this, that in many examples known to me personally, in India and elsewhere, a hygeiometric scale of their salubrity might almost have been constructed, based upon the increase or decrease of the number of persons contained in them, all other conditions remaining unchanged. If two or three persons, sick or well, are placed in the space which only one can occupy with safety, not only is a state of atmosphere conducive to disease created, but disease itself is the result. A very striking example of this is mentioned in Tardieu's “ Diction- naire d'Hygicnc Publique.” From 1843 to 1847, whenever King Louis Phillippe went to St. Cloud, the number of soldiers who were attacked by and died of virulent typhus fever, was very considerable. A disastrous epidemic broke out on every occasion eight days after the arrival of the King, but as soon as His Majesty left St. Cloud and returned to Paris, the fever disappeared and the troops were healthy. The condition of the soldier was the same ; his food was the same ; his clothing the same ; his duty the same, except that there might have been more pomp and parade when the King was present than when he was absent ; but, beyond that, he was not exposed to any of the vicissitudes of war which Principles of the Construction and Arrangements of Hospitals. 25 could account for this unusual sickness and mortality. The cause of it was simply overcrowding. The usual garrison contained 400 or 500 men, for whom there was ordinarily ample space in the barracks, but when the King was present 1,200 men were packed into the same quarters; hence sickness and death, as always happens in such circumstances. It is tolerably certain, again, that any one person can bear his own exhalations with comparative impunity, but, that he is liable to be poisoned by those of his neighbours, in an increasing ratio proportionate to their number. To such an extent is this correct, that if it were possible to place every sick or wounded person in a separate cell, and isolate him strictly from all others, the extension of all infectious diseases dependent upon a specific contagium, and all the ordinary forms of septicaemia, might be checked, and possibly extinguished. The beneficial influence of such separation was remarkably illustrated by an in- voluntary experiment performed in one of the prisons under my supervision in Bengal. Towards the end of the Orissa famine, a large number of half-starved, sickly men were sent to a district jail, on account of certain grain robberies of which they were convicted. When that prison became dangerously overcrowded they were transferred to another prison in a different district, which had spare room. The majority of these prisoners were placed in fairly ventilated wards, with ample room for each, according to the standard measurement allowed. About 120, however, for whom there was no spare room elsewhere, were put in as many separate cells, having 480 cubic feet of space each, and practically without ventilation ; for, although they had open grated iron doors, they were situated in long corridors at right angles to the prevailing winds. A considerable number of the former died from different diseases, but chiefly from diarrhoea ; while there was not a single casualty among the latter, who were said to have been the sickliest of the lot on admission, and who were on this account placed in the cells, which had long been known as the healthiest part of the prison in question. A remarkable paper has recently been published in the Annates d' Hygiene et de Medecine Legale , 0 by Dr. Layet, Professor in the Faculty of Medicine at Bordeaux, on what he terms “ The Co-efficients of Aeration, or the Renewal of Air necessary to Prevent the Effects of Overcrowding in Inhabited Spaces.” The professor contends that the quantity of air to be renewed for a person breathing in a space of 20 cubic metres, differs from that required for the same person breathing in a space of 100 cubic metres. In the same manner if three, four, five, or six persons breathe in the same space, the figure of ventilation would not be the same, as if each of them breathed in the whole extent of this space. There is, therefore, no uniform unvarying figure of ventilation, without reference to the size of the room, and the number of persons breathing in it. He has accordingly prepared a table of the co-efficients of aeration, to show at once the amount of air required to be renewed, in the different conditions of space and number, and, in addition to habitation, the deterioration caused by the ordinary processes of lighting, which rob air most of its oxygen, and return to it most carbonic acid gas. This is of * No. 25, 4me Serie, Jan. 1881. 26 Principles of the Construction and Arrangements of Hospitals. importance where large numbers of people are assembled in a given space, and shows the considerable amount of air needed for renewal in such circumstances — a fact in harmony with the necessity at all times to counteract the ill effects of overcrowding, and other causes of devitalisation. The table, which appears to me to be one of con- siderable interest, is contained in the note subjoined,* and the question has been discussed ♦Table of Co-efficients of Aeration. Space in Cubic Metres. f Co-efficicnt of Aeration or quantity of air necessary per man and per hour. Co-efficient of Aeration per candle producing 15*45 litres of Carbonic Acid per hour. Co-efficicnt of Aeration for a lamp burning 43 litres of oil per hour, and producing 55.65 litres of carbonic Actd per hour. Co-efficicnt for jet of gas, giving a light equal to that of preceding light, and producing 88 litres of Carbonic Acid per hour. 4 Mctr. Cub. 151*000 ... Mctr. Cub. Mctr. Cub. Metr. Cub. 5 121*000 ... 6 101*000 ... 7 86600 ... 8 76000 ... 9 67600 ... ... IO 61 000 ... ... 31900 ... ... 110*300 ... ... 177*000 15 4IOOO ... ... 21 600 ... ... 75*200 ... ... 118300 20 31 000 ... ... 16450 ... ... 56000 ... ... 89000 25 25OOO ... ... 13480 ... ... 45520 ... ... 71-400 30 21*000 ... ... 11-300 ... ... 38000 ... ... 59666 35 18 200 ... ... 9828 ... ... 32-800 ... . — 51285 40 16000 ... ... 8722 ... ... 28824 ... ..._ 45000 45 14520 ... ... 7-866 ... ••• 25733 ... ... 40*111 50 13000 ... ... 7180 ... ... 23-250 ... ... 36-200 55 11*900 ... ... 6618 ... ... 21236 ... ... 33000 60 11*000 ... ... 6150 ... ... 19-550 ... — 30333 os 10*230 ... . ... 5754 ... ... 18123 ... ... 28-160 70 9600 ... ... 5410 ... ... 16900 ... ... 26-142 75 9000 ... ... 5*120 ... ... 15840 ... ... 24-570 80 ... 8500 ... ... 4862 ... ... 14912 ... ... 23*000 _ 85 8-294 ... ... 4635 ••• ... 14-139 ... 21770 90 7650 ... ... 4525 ••• ... 13-366 ... - 20555 95 7540 ... ... 4253 ... 12748 ... ... 19570 IOO 7*000 ... ... 4090 ... ... I2*I30 ... ... 18600 105 6512 ... ... 3-945 ... ... 11-623 ••• ... 17-800 no 6454 ... ... 3-800 ... ... 11116 ... ... 17*000 115 6216 ... ... 3686 ... ... 10-692 ... ... 16200 120 6000 ... ... 3 572 ... 10275 ••• ... 15666 125 ... 5800 ... ... 3 474 ... ... 9-904 ... ... 15 IOO 130 5616 ... ... 3376 — ... 9-571 ... ... 14-538 135 5444 ... ... 3291 ... ... 9-255 ... ... 14055 I40 5284 ... 3206 ... ... 8950 ... — 13-571 145 5136 ... ... 3131 ••• ... 8682 ... ... 13150 150 5000 ... ... 3060 ... ... 8420 ... ••• 12733 155 4870 ... ... 2*992 ... ... 8188 ... ... 12370 160 4750 ... ... 2931 ... ... 7-956 ... ... 12*000 165 4636 ... ... 2874 - ... 7752 .. ... 11676 I70 4 530 ... ... 2818 ... ... 7-547 ... ... 11352 175 4430 — ... 2762 ... ... 7-365 ... ... II 120 180 4332 ... ... 2716 ... ... 7183 ... ... 10889 t A Cubic Metre is 35*316581 Cubic Feet English. 27 S Principles of the Construction and Arrangements of Hospitals. at a meeting of the Society of Public and Professional Hygiene in Paris, where it was objected that the method was defective in taking note only of the amount of carbonic acid and aqueous vapour present in an atmosphere breathed by many persons, whereas it is the presence of organic matters that is really most injurious in such circumstances. True as this may be to a certain extent, the impurity caused by carbonic acid is a factor Table of Co-efficients of Aeration — (continued.) Space in Cubic Metres. 185 ... 190 ... 195 ... 200 ... 205 ... 210 ... 215 ... 220 ... 230 ... 240 ... 250 ... 260 ... 270 ... 280 ... 290 ... 300 ... 320 ... 340 — 350 .. 360 ... 380 ... 400 ... 420 ... 440 ... 450 ... 480 ... 500 ... 520 ... 540 ... 550 ... 580 ... 600 ... 650 ... 700 ... 750 ... 800 ... 850 ... 900 ... 950 ... 1,000 ... 1,500 ... Co-efficient of Aeration or quantity of air necessary per man and per hour. Metr. Cub. 4242 ... 4157 ••• 4076 ... 4000 ... 3922 ... 3852 ... 3800 ... 3726 ... 3608 ... 3'500 ... 3400 ... 3306 ... 3222 ... 3142 — 3068 ... 3000 ... 2874 ... 2764 ... 2715 ... 2666 ... 2 579 - 2500 ... 2428 ... 2362 ... 2304 ... 2254 ••• 2 200 ... 2154 ... 2TII ... 2071 ... 2 034 ... 2 000 ... I -922 ... 1857 ••• I’800 ... 1-750 ... I727 ... 1-666 ... 1632 ... 1 600 ... 1400 ... Co-efficient of Aeration per candle producing 15-45 litres of Carbonic Acid per hour. Metr. Cub. 2666 2 626 2585 2545 2' 508 2482 2458 2 445 2 344 2285 2236 2188 2143 2103 2066 2030 1 '955 1915 1872 1-840 1810 1772 1726 I '7 I 3 1700 1-659 1618 1596 1-575 1-562 1538 1515 1-475 1440 1421 1388 1365 1-343 1326 1309 1 206 Co-efficient of Aeration for a lamp burning 42 litres of oil per hour, and producing 55-65 litres of Carbonic Acid per hour. Metr. Cub. 7020 ... ... 6-857 ••• ... 6711 ... ... 6565 ... ... 6432 ... ... 6300 ... ... 6179 ... ... 6 059 ... ... 5865 ... ... 5663 ... ... 5'452 ... ... 5291 ... ... 5130 ... ... 4983 ... ... 4837 .» 4710 ... ... 4490 ... ... 4272 ... ... 4180 ... ... 4133 ... ... 4086 ... ... 3782 ... ... 3670 ... ... 3550 ... ••• 3 473 ••• ... 3350 ... ... 3226 ... ... 3 io 5 — 3080 ... ... 3025 ... ... 2940 ... ... 2855 - ... 2712 ... ... 2590 ... ... 2482 ... ... 2391 ... ... 2325 ... ... 2256 ... ... 2185 ... 2113 ... ... 1742 ... Co-efficient for jet of gas giving a light equal to that of preceding light, and producing 88 litres of Carbonic Acid per hour. Metr. Cub. ... 10-576 ... 10263 ... 10030 ... 9800 ... 9-590 ... 9381 ... 9200 ... 9000 8652 ... 8346 ... 8040 ... 7810 ... 7580 — 7 325 ... 7070 ... 6-866 ... 6512 6158 ... 6028 ... 5830 ... 5-634 ... 5400 ... 5200 ... 5000 ... 4-911 ... 4715 ... 4520 ... 4 390 ... 4258 ... 4 200 ... 4026 ... 3853 ... 3708 ... 3'5 l6 ... 3 346 3200 ... 3080 ... 2955 2830 ... 2-760 ... 2173 28 Principles of the Construction and Arrangements of Hospitals. of sufficient importance to be able to determine in all circumstances, for it is chiefly upon this, that most of the practical rules adopted in ventilation are based, and upon it is founded the doctrine of the amount of cubic feet of air necessary for healthy respiration Table of Co-efficients of Aeration — ( continued .) Space in Cubic Metres. Co-efficient of Aeration or quantity of air necessary per man and per hour. Co-efficient of Aeration per candle producing 15-45 litres of Carbonic Acid per hour. Co-efficient of Aeration for a lamp burning 42 litres of oil per hour, and producing 55-65 litres of Carbonic Acid per hour. Co-efficient for jet of gas, giving a light equal to that of preceding light, and producing 88 litres of Carbonic Acid per hour. Metr. Cub. Metr. Cub. Metr. Cub. Metr. Cub. 2,000 ... ... 1300 ... ... 1154 ••• ... 1.556 ... ... x*88o 2,300 ... ... I24O ... ... 1138 ... ... 1*445 — ... 1704 3,000 ... ... I 200 ... 1 103 .. ... 1*371 ... ... 1587 3.500 ... .. II72 ... ... 1088 ... ... 1*325 ... ... 1*518 4,000 ... ... 1*150 ... ... 1062 ... ... 1*278 ... ... 1*440 5,000 ... ... I 120 ... ... 1060 ... ... 1222 ... — 1352 6,000 ... ... MOO ... ... 1051 ... 1185 ... ... 1*293 7,000 ... ... ro8o ... 1044 ... ... 1158 ... ... 1251 8,000 ... ... 1074 ... ... 1038 ... ... 1139 ... ... 1220 10,000 ... ... 1060 ... ... 1031 ... ... IIII ... ... 1176 20,000 ... ... 1030 ... ... I.OI5 ... ... 1055 ... ... 1088 40,000 ... ... IOI4 ... ... 60,000 ... ... I OOI ..* ... Now, as to the manner of working this Table: Suppose one person to breathe in a space of io metres, we see at once in consulting the second column that the quantity of fresh air to be introduced is 61 metres per hour. In another space of ioo cubic metres, for instance, a school-room, if there be but one scholar in it, 7 cubic metres an hour of pure air will be sufficient to introduce. If there is one pupil and a lighted lamp, there will be required 7 cubic metres + 12 cubic metres, or 130 litres, which corresponds in the fourth column to the space of 100 cubic metres. If instead of one pupil there should be 10, each of these ten would have 10 cubic metres, and for each of them the corresponding co-efficients at 10 metres each would be 61 ; the total amount of fresh air per hour would be equal to ten times these 61 metres, or 610 cubic metres. If, with the above, there were two lamps, each vitiating 50 cubic metres, twice the co-efhcient of 50 cubic metres should be added, that is to say, twice 23 cubic metres, 250 = 48 cubic metres, 500 : from which it follows that ten pupils breathing in a room of 100 cubic metres, lighted by two Carcel lamps, the co-efficient of total aeration would be 656 cubic metres, to give 500 per hour. The following prefatory remarks in Dr. Layet’s paper, explain the grounds on which the above calculations are based : — “ Ii is generally admitted by physiologists, that an adult man takes into his lungs (inspires) 10 cubic metres of air (353*17 cubic feet), which gives 7 litres (each litre being one part, three quarters and r-iooth) a minute, or 420 litres an hour. Consequent on the change which it undergoes in the lungs during respiration, this adult takes in these 420 litres, 22 litres, 320 of oxygen, and throws out in the expired air it) litres. Two hundred of carbonic acid is, in round numbers, 20 litres 4 20 gr. 4oof watery vapour. “ Suppose, then, a space of 10 cubic metres, in which a single person breathes, these 10 metres have the normal vitiation, tr., C O 2 - 0*0005, At the end of an hour his breathing will have thrown out 20 litres of carbonic acid, which arc TtTOoo of to cubic metres. These 10 metres then present at the end of an hour a figuie of vitiation equal to 0 o or 25 ten thousands ; at the end of 10 hours, the figure of vitiation w ill be represented by the 5 ten thousands of normal vitiation already existing, plus ten times 20 litres, or toHoo* What then must be the amount of air which must be introduced and breathed during these ten hours, so that the amount of vitiation caused by carbonic acid gas must stand at the normal rate 0 0005 I “ Let x be the quantity of air necessary, 205 must be to a* as 5 is to 10,000, and a rule of three calculation gives for x the figure of 410 cubic metres, lint as x is the quantity which has been breathed in 10 hours, it has only to be divided by 10, to give the co-efficicnt of aeration per hour and per person for a space of 10 cubic metres, which is 41 cubic metres. In this calculation no account Is taken of the organic matters held in suspension in thesurTOunding aquaeous vapour. In representing by to litres the mean of the watery vapour which remains in suspension in the air watery vapour which is fed by our perspiration and by respiration it is in this quantity of water that the organic products exhaled arc contained ; so that it is an hourly mean of 30 litres of gas and noxious vapours in our normal state, and not the causes of vitiation only derived from ourselves, that we have to compensate by a renewal of air. The calculation is the same, but it acts upon 30 instead of 20 litres.”* • Layet .* Revue d* Hygiene et dc Police Sanitair, vol. ii., pp. 1091-1099. 2 9 Principles of the Construction and Arrangements of Hospitals. in all circumstances. Professor Tyndall’s lecture on Dust, and the labours of Pasteur and others on the nature of Organic Impurities, are gradually throwing a flood of light upon the whole question, and prove that the fewer the number of sick persons collected in a given space, however perfect the ventilation and other physical conditions, the better, and the more likely they are to escape the consequences of the particular vitiation of the atmosphere which causes blood-poisoning in most of its forms. The problem, then, to be solved in all questions of ventilation is somewhat complex ; hence the difficulty of dealing with it in such manner as to establish a general law applicable to all places and circumstances, as well as to all seasons and climates. From this cause, doubtless, arise the very different plans recommended by the highest authorities, engineering and medical. The conditions to be secured are the utmost purity of air obtainable ; that it shall never fall below the normal standard of the external air, or contain more than 000-5 of CO 2 Gas; as uniform a temperature as is found to be consistent with the main- tenance of health at different seasons, and as rapid a renewal conformable to the above conditions, as will secure that as little vitiated air as possible shall enter the lungs in each act of respiration. Physiology and chemistry have scarcely dealt decisively with the first two factors, for persons in health, since Arago considered 10 cubic metres an hour to be necessary; General Morin from 20 to 25 for an adult; M. Hudelo 30; and M. Wazon 40 cubic metres for a full grown person, so that in any case the introduction of fresh and the removal of effete air, must be tolerably rapid and complete in all circumstances. Pathology is still engaged in determining what amount and kind of organic impurities are prejudicial to persons in health and injurious in disease, not only in relation to the individual, but to his becoming in turn a focus of infection to others ; for it is in this manner that zymotic diseases arise and extend. The sick, moreover, require a larger amount and more rapid renewal of fresh air than those in health. The advocates for the antiseptic system of surgery again claim that it has removed some of the important objections to the old plans of hospital construction and aeration, in a manner and to an extent which I consider to be extremely doubtful, but with this I shall deal anon. The measure of the purity of the atmosphere surrounding a building of any kind, will be that of the air finding its way into it, and its temperature will stand in very much the same relation. Hence the necessity of artificial contrivances to regulate it, in the extremes of heat and cold. But, in so mild and equable a climate as ours, expensive and complex contrivances for artificial ventilation do not appear to me to be needed so much as they are in the hospitals of the northern parts of the United States, and in Central and Northern Europe. All mechanical arrangements for ventilation should include warming, as a measure of economy as well as of comfort. Not only does the air of a sick ward need to be pure and of uniform temperature, but the floors ought equally to be warmed, as they were in old Roman buildings, and are in China. There are many and ingenious and efficient contrivances for effecting this. 30 Principles of the Construction and Arrangements of Hospitals. The union, then, of natural and artificial ventilation, the former by means of sash windows, Tobin’s tubes, and a multiplicity of simple means of admitting and removing air, the latter by open fires, acting as ventilating shafts, supplemented by the moderate and judicious use of warm water coils, will usually accomplish all that is desired. To attempt to enumerate the infinite mechanical devices by which all this can be accomplished, is impossible. They may safely be left to the architect and the engineer, for whose guidance there is an abundant literature on the subject, both as to the end to be attained, and the means of securing it. They will be dealt with authoritatively in the second part of this work. A point generally disregarded in all discussions on the subject of ventilation, is the purification of the air itself in sick rooms, which constantly contain the elements of their own corruption. These septic agencies may be diluted, and, to a certain extent, removed, by constant and rapid renewal of the hospital atmosphere ; but they have a tendency to attach themselves to walls, bedding, See., and their entire removal is a matter of much importance — so subtle is their action, so difficult their detection, and so imperfect our knowledge of the exact mode of their operation. The Hindus of every part of part of India with which I am acquainted, have, from time immemorial, possessed a means of purifying the atmosphere of their rooms and huts, by spreading a light coating of a mixture of earth containing organic matters, on their walls and floors, which enables them to dispense, to a considerable degree, with ordinary ventilation. The process is called “ leoping,” and is usually performed by the women of the household. With a view to submit this proceeding to a practical test, I had four cells in the Presidency Jail of Calcutta, each containing 480 cubic feet of air and practically unventilated, carefully prepared. Two of them were limewashed throughout, and the two others “ leoped.” I had four healthy prisoners locked up in them at night, one in each cell. On opening the cells next morning, the two which were limewashed were stuffy and offensive, redolent of the peculiar animal odour exhaled by native prisoners in such circumstances. The two others were as fresh and as pure as if no one had slept in them. This led me, as head of the prison department, to direct the application of the principle generally in all the jails under my administrative control, so far as it was sus- ceptible of direct application to walls, floors, and earthen beds. I also employed charcoal extensively for the same purpose — the purification of the air of prison wards from animal exhalations — and, I had reason to believe, with success. This seems to me to be deserving of careful trial in Europe. In crowded cities, and in all positions in which the external air is likely to be contaminated by organic matters and malarious emanations, in winter especially, it might be subjected to a certain appreciable amount of purification by being passed through cotton-wool or charcoal, particularly in winter, when all openings for the direct admission of the cold external air are compulsorily closed. Some writers have recommended that the walls of all masonry hospitals should be porous, to admit of the penetration of air at all times. This would, however, be attended with the grave disadvantage of their intercepting and retaining septic poisons. Masonry walls should therefore, I am of opinion, not only be absolutely impenetrable, but be coated Principles of the Construction and Arrangements of Hospitals. 3i with some hardened substance capable of being thoroughly cleansed without injury, whenever such a proceeding is desirable or necessary. In some great hospitals, in addition to the effete air of the buildings generally, that of all waterclosets, sinks, and lire-places, and all other sources of noxious exhalations, are passed through a great central ventilating shaft, represented by a tall, towering chimney. This does not appear to me to be in all situations a safe proceeding, and it may possibly explain the cause of the origin of the sickness, which is said to find its way into houses situated in the immediate vicinity of some of the great hospitals in Paris. I have dwelt thus at length upon the subject of ventilation because, as I have already mentioned, some eminent authorities regard the whole matter of the unhealthiness or otherwise of hospitals to be mainly a question of this character. Hence also the coining of the barbarous term “ hospitalism,” which has led to much of the “ logomachy ” and differences of opinion which have arisen on the hospital question. The French term “ malaria nosocomiale" is both more correct and expressive, and if it could be condensed into a single word, such as “ nosocom-aer,” would be preferable to Sir James Simpson’s invention, which is liable to considerable misapprehension, and includes other conditions which have no real connexion with the atmosphere of hospitals. I assume that the best adjunct of all schemes of ventilation — scrupulous cleanliness — is observed, as it undeniably is in every well-regulated hospital in this country, par- ticularly since the introduction of a higher class of nurses, for it is upon their intelligent and incessant care and attention, that the absence of all noxious agencies from impurities of any kind, of person, place, or appliances, is dependent. Associated with the purity of person and place is that of the disinfection and cleansing of all clothing and bedding, and the immediate destruction of all dressings, &c., for which, as a rule, due and proper provision is or requires to be made. ( c ) Water Supply and Drainage. The question of water-supply is one of the greatest importance in relation to the healthiness of hospitals, for if soluble impurities be dangerous to persons in health, their ingestion into the systems of the sick is still more injurious, from their diminished power of resisting disease. The great attention now paid to the subject, and the improved supply and distribution in all our larger towns, secure an abundant, and it rests with the hospital authorities to make it a wholesome, allowance. When hard it should be rendered soft by the Porter-Clark process, and the supply should be constant and practically unlimited, for at least double the quantity needed for the healthy, is required for the sick. Connected with water-supply is that of baths, and in this respect the French and German hospitals are, as a rule, much better furnished than our own. Every large hospital should have a complete system of baths for cleansing and therapeutic use, such as are now found in the University College Hospital of London; and all smaller institutions throughout the country should be supplied with both fixed and movable baths. 32 Principles of the Construction and Arrangements of Hospitals. Should the water-supply in country places be obtained from wells, or from storing of rain water, the greatest attention to its purity should be paid. The drainage in towns must of necessity be connected with the general drainage of the locality, and exceptional care be taken for the disconnection of the drains and pipes of all kinds with the wards, by means which are now well known to all architects and engineers. To cause the ventilation of closets, sinks, and lavatories to be connected with great chimneys in crowded localities I hold to be erroneous, and likely to be injurious, as they are now believed to be. To allow them to ventilate directly or indirectly into the sick wards, or into any part of the building, is a fatal and michievous error, for there are no more efficient agents of evil in disseminating foul air throughout a many-storied structure, than staircases and corridors, which act as ventilating shafts, and rapidly render the atmosphere of such places impure in composition, by the operation of the general law of the diffusion of gases. The measure of the worst will, in a few hours, become that of the best, and the upper floors consequently be less pure and wholesome than those lower down, in many-storied buildings. When hospitals of any kind or class are isolated, and unconnected with any general system of drainage, all excretory matters should be strictly dealt with on one of the dry systems in use, and on no account should connection with cesspools or tanks, or any scheme of sewage utilisation with water be allowed, unless all such matters are previously disinfected. The more carefully they are deodorised, and, if necessary, as in typhoid dejections, disinfected, the less liable they will be to prove injurious before they are returned to the great natural purifier — the earth — aided by rapid vegetation. In the construction of all hospitals proper provision for the above purposes should never be neglected, or sacrificed to any false economy, as too often obtains at present. ( d ) Distribution and Dimensions of Buildings and Wards. In all the most recent hospitals of Germany, France, Belgium, the United States, and Scotland, and in several of our great Poor-law infirmaries, the pavilion plan has been adopted for the sick wards, and all accessory and administrative buildings are more or less completely separated from them. In some the blocks of all kinds are absolutely detached, without connecting corridors of any kind (Friedrickshain in Berlin, the John Hopkins Hospital at Baltimore, the Fever and Small-pox Hospitals at Glasgow). In others the separation is nearly as complete, having external open covered passages for intercommuni- cation (the Heidelberg Hospital, the St. Eloi Hospital at Montpellier, and other similar buildings on the Toilet system in France). In a third arrangement the intercommunication is by means of closed corridors and staircases run up to the first floor, thus leaving the sick wards as respects their aeration and lighting partially detached (the Menilmontant Hospital in Paris, the Royal Infirmary in Edinburgh, the Western Infirmary in Glasgow, and several Poor-law infirmaries). I omit all reference to such institutions as the new Hotel Dieu in Paris and St. Thomas’s Hospital in London, as their cost alone prohibits their being accepted as examples for imitation, even if they were not, as I believe them to be, defective in other Principles of the Construction and Arrangements of Hospitals. 33 respects. Some recent Poor-law institutions, well constructed and otherwise not badly arranged, are made to contain from one to two thousand inmates — an aggregation of sick, in mind and body, universally condemned by the medical authorities of all countries, and therefore not to be quoted for instruction or guidance; for in them, the cardinal principles which should regulate all such matters, are sacrificed to administrative convenience and economic reasons. As a rule, in all the above forms of arrangement the administrative buildings are centrally.situated ; and the out-patient departments, pharmacies, laundries, kitchens, nurses’ and servants’ quarters, &c., are grouped in the manner most convenient for the general administration of the whole institution. They will of necessity vary very considerably, according to the uses and size of the hospital, and its connection or other- wise with a medical school. It is obvious that if kitchens, laundries, and store rooms have any tendency, as some of them must have, to create an atmosphere likely to be prejudicial to the sick, their complete separation is the only perfect plan of dealing with them. The exact arrange- ments will be mentioned in connexion with the special institutions described in Part II., as illustrating the most recent forms of hospital construction which have found acceptance — such as the Menilmontant Hospital in Paris ; the St. Eloi Hospital, about to be erected at Montpellier, in France; the Friedrickshain Hospital at Berlin; the Western Infirmary at Glasgow; the St. Marylebone Infirmary just completed; and an example of a town hospital in New York on the many-storied plan, which is a remarkable and successful attempt to adapt old principles of construction to modern sanitary requirements in a restricted locality. The number of beds a hospital should contain must depend so much on its nature and position, coupled with the needs of the population in whose midst it is placed, that no fixed rule can be adopted, such as the Chirurgical Society of Paris hinted at, in its third conclusion. Sanitary conditions, subordinated in a limited degree to administrative and economical convenience, are alone entitled to consideration in the determination of the question. If economy of administration alone were consulted, or in combination with a decrease in the cost of the ground on which a hospital is placed, the number of beds might prac- tically be unlimited, as it was in that pest-house, the old Hotel Dieu ; and as it is in a lesser degree, in some of the older general, and more recent poor-law hospitals. The number of stories on the same base and covered by the same roof might in such cir- cumstances be as many as could be occupied with safety, by means of lifts and similar contrivances. But, supposing these conditions to be correct, which they assuredly are not, the limit of the sick who may safely be congregated on a given area is soon reached, and would long since have been determined with absolute accuracy, had proper hospital records been kept. The problem to be solved has been well put by M. Irelat. He said — “ It is now an undisputed fact that great collections of men and animals generate a condition of health, which is injurious to all exposed to it. Whether these aggregations are temporary or permanent, accidental or periodic, much or little crowded, in a close or an open space, consisting of healthy or sick, the result is always of the same character. The effects of aggregation soon make themselves felt, varying only in their intensity and gravity according to their internal conditions.” D 34 Principles of the Construction and Arrangements of Hospitals. Dr. Farr, in the Twenty*fourth Annual Report of the Registrar-General (p. 230), constructed a table to show the relative mortality of hospitals, based upon the number of their inmates. Principal General Hospitals in England and Wales, 1861. (Special Hospitals excluded from this Table.) Number of Hospitals. Inmates. Average number of Inmates in each Hospital. Deaths. Mortality per cent. Hospitals containing 300 inmates and upwards 5 2,090 418 2,101 10053 200 and under 300 4 913 239 838 9178 100 and under 200 22 2,898 132 2,041 7043 Under 100 49 2,634 54 1,240 4708 Total 80 8.535 IO7 6,220 7288 It is obvious that there are so many sources of fallacy underlying such a statement, so many conditions necessary to be understood are not mentioned, so much difference in the classes of sick admitted to such institutions, and the period over which the inquiry extends is itself so extremely limited, that the table is of no further scientific value than as embodying a rough approximation to what may prove to be a truth, on a more extended and strictly scientific examination. Mr. Lawson Tait has constructed tables on a wider and more reliable basis for determining the same question, with a nearer approach to accuracy, as the following statement shows : — Summary of those Hospitals (179) from which Complete Information was Obtained. (Arranged in Groups, according to the number of Beds in average occupation.) No. Period of Observation— 1861-70. Average Bet Is Average number of Mean Residence Mortality per cent, of District Mortality REMARKS. Occupied. eat h Bed. in Days. Beds. Patients. per 1,000. 1. 54 Hospitals under 5 beds 2 82 1 2 ' 34 5 6292 5 03 20 14 11. 12 Hospitals from 5 to 9 beds 682 11*14 32 03 59'97 5*02 2125 In this III. Group there are 6 hospitals, with an average mortality of 1 1 ’57 hi. 26 ,, ioto 19 ,, 1344 n '3 3223 7977 7 00 21 * ‘ and if these were elimi- nated the average mor- IV. 8 1 • „ 20 to 29 „ 25- 9'4 3965 46' 1 6 563 21 * talitv of the 20 others would be 5 636, and the V. 6 It .. 30 to 39 „ 3396 988 3512 5809 594 22-3 bed rate 61 ‘26. VI. 8 1 • ,, 40 to 49 ,, 43 77 96 4017 5706 597 223 VII. II „ 50 to 74 ,, 6188 1035 3633 6169 577 21-8 VIII. 15 1 1 „ 75 to 99 „ 84-05 11 08 3426 7754 6 66 2413 IX. IO ft ,, 100 to 124 ,, 113 35 11-85 3248 79- 1 8 67 24- X 17 1 • ,. 125 to 199 ,, 143 74 1 1'95 3146 9334 792 24-92 XI 5 11 ,, 200 to 299 ,, 211*91 12 39 30 18 11885 9 15 306 I f the mortality were the XII. 7 over 300 beds 4173 1074 3338 10153 9-6 25- same in XII. as it is in XI. (that is ’433 less), 140 lives a year would be ^ saved. Regarding this table, Mr. Tait remarks, as all statists hold it to be, “that if the employment of large masses of figures enables us to get rid of minor errors, I think I Principles of the Construction and Arrangements of Hospitals. 35 may fairly say that the returns now before us afford as reasonable a basis for estimating what really is the mortality of our general hospitals, as can be obtained and he adds, “ that if all hospitals would keep their records correctly, and publish all necessary details, their relative and absolute utility could be rightly estimated." * The same accurate authority shows that mere size has not a constant influence in raising the death-rate of a hospital, and that by mismanagement and other causes, a small may be made as unhealthy as a large hospital. Again, although I at one time accepted and acted upon the doctrine of averages as the surest basis for determining mortality rates in public institutions, I am now disposed to think that a more correct comparative estimate of the healthiness or unhealthiness of hospitals would be obtained, by calculating the number of deaths on the actual number treated, and by determining the actual risk to life of a day’s residence in each institution. From a statement of this kind recently published by Monsieur Loua in the Journal de la Societe de Statistique of Paris, it appears that in the hospitals of the whole of France the mortality rate from 1871-6 oscillated between 8-5 and 10-5 per cent, of the actual number treated, and the risk to life of a day’s residence in hospital from 0-00237 to 0-00327. In 1876 it was 0-00268, while the daily risk to life of each individual of the entire population was 0-000063, from which it follows that the chances of death in a hospital were forty-two times greater, than in the ordinary conditions of life. The sick, however, are only subject to this increased risk during their actual stay in hospital. All such modes of calculation must, however, of necessity be incomplete and fallacious, and no plan will afford even an approximation to scientific accuracy until the whole of the factors involved — age, sex, hereditary tendencies, actual disease, accident or injury, occupation or position in life, &c., &c. — are carefully collected and collated. All this has not yet been done, even in relation to amputations and obstetrics. A curious experience of the superior value of the pavilion to the block system of hospital construction, was acquired during the occupation of Paris by the allied armies in 1814. The sick and wounded soldiers, French and foreign, were treated in the hospitals until no more room could be found for them, when they were placed in the slaughter-houses, vacated for the purpose. In the great hospitals, the Hotel Dieu, Pitie, and St. Louis, the mortality of wounded French soldiers ranged from 1 in 5, to 1 in 8. In the abattoirs (slaughter-houses) of the Roule, Montmartre, and Menilmontant, the number of deaths among the French varied from 1 in 7, to 1 in 13. Of the foreign soldiers wounded, the deaths in the hospitals were from 1 in 7, to 1 in 13; and in the slaughter-houses, 1 in 10, 1 in 11, and 1 in 19. So struck was the Conseil-General des Hopitaux by these results, that they reported, “ That the use made of the buildings (abattoirs) for the treatment of the sick had made it manifest that their distribution was better fitted for their new use, than any of the existing hospitals. That experience had thus proved the correctness of the views of Tenon and Bailly in their reports on the [old] Hotel Dieu, and the utility of the division of hospitals into separate pavilions — an idea which should be followed in the construction of all hospitals, in which should be united conditions of health and * An Essay on Hospital Mortality, by Lawson Tait, F.R.C.S. ; London, 1877 ; pp. 42 and 43. D 2 36 Principles of the Construction and Arrangements of Hospitals. convenience.” Still earlier in the field was our own countryman, Dr. Brocklesby, art army physician, who published in 1764 a nearly forgotten work, under the title of “ (Economical and Medical Observations, from 1758-1763,” tending to the improvement of military hospitals, and the cure of camp diseases incident to soldiers, &c. This work has been rescued from oblivion by one of the most learned and philosophical writers of our time, Dr. Guy, in his Lectures on Public Health, and will be referred to again when I speak of hut hospitals and tents, and their proper place in the treatment of disease in civil life. It is now beginning to be ascertained that the accumulation of large numbers of sick in hospitals, in addition to being detrimental to themselves, is a source of danger to those dwelling in their immediate vicinity; and that this is especially true of fever and of all other hospitals in great cities or densely-peopled localities. Nearly a century since, Sir William Blizard wrote — " Hospitals are too much crowded with patients. Parade of numbers blinds the judgment, and diverts attention from simple principles and clearly deduced rules of conduct. The system of hospitals in respect of numbers, is founded on a glaring error. By curing, relieving, and dismissing in a shorter time, the sum of patients admitted in a given period, may be even greater from a less, than from a larger number of inhabitants. However airy, then, the situation of a hospital, of whatever amplitude and number its wards, still its happy effects will be governed by the proportion of sick persons within its walls. It may be admitted, upon the whole, that the limitation of number in hospitals should be far below what it generally stands.” . . The late Dr. Rumsey, in one of his excellent papers on “ Some of the Fallacies of the Statistics of Health and Disease,” sums up the general results of the discussion on hospital mortality in the following words: — , " (1) That the disease in hospitals and other large institutions, especially the mortality following operations (and universally that after childbirth), are greatly increased by the mere aggregation of patients and, catcris paribus, in proportion to the density of that aggregation, apart from all other circumstances which might affect success or endanger life; (2) that the death-rate calculated, as it should be, on the number of patients, and not on the number of beds, increases with the size of the establishment and the number of its inmates ; and (3) that wherever this assemblage of the sick and hurt occurs in the centre of a crowded population, the rate of mortality attains its maximum.” In strict relation to its uses, the number in a hospital may range from the few beds in a cottage hospital, through every stage of increase, to the large hospitals required for town populations, which, in turn, will each fulfil its functions by restriction of its beds to a maximum of 200 or 300 ; whilst in the vicinity of great cities, where ample ground is procurable at reasonable cost, and the pressure on space is minimised by subdivision, there may be 600 beds, which number should never, in my opinion, be exceeded on any pretext whatever. As to the number of beds in a ward, however ample and complete the ventilation and healthy the surroundings, they ought never to exceed thirty-two, with annexes containing one, two, or three beds for the separation of cases which need them. Indeed, it would be better if the numbers were still more limited, were it not for the difficulty and cost of nursing the sick scattered through a large number of very small wards. Each pavilion in which they are placed should be self-contained, with provision for nurses, baths, water- closets, lavatories, small kitchen, and all other accessories. The minimum of cubic space Principles of the Construction and A rrangcmcnts of Hospitals 37 allowed should be 1,200 feet, and of floor space ninety-six square feet for ordinary cases of sickness, these quantities being increased for surgical cases, and for all diseases causing exceptional deterioration of the air of a ward. But one bed should, if possible, be placed in the interspaces or piers of windows, and two rows of beds should never be exceeded in a ward, of which the width should vary from twenty-four to thirty feet — the latter in clinical wards only — and all beds should, if possible, be nine feet apart, as wisely obtains in the new Royal Infirmary at Edinburgh. As to the number of stories of which the portions of hospital buildings devoted to the sick should consist, I entirely agree with the views of the Chirurgical Society of Paris, and in the manner in which they are now being carried out in Germany, Belgium, in the United States generally, and by M. Toilet, in France. Professor Lister is reported to have said to a distinguished surgeon of New York, in reply to a question as to how far the construction of a hospital would be likely to influence the results of antiseptic surgery — a question suggested by the four stories of superposed wards at Blackwell Island, which he was then visiting — “ It is immaterial how many stories of wards there may be in a hospital, provided that the details of the antiseptic method are accurately carried out in them all. If these details are faithfully observed, hospitalism can be prevented.” This is a much too restricted use of the term “ hospitalism,” as generally understood. That antiseptic surgery has done much to counteract the evil effects of septic poisons in some classes of surgical cases is undoubted ; but, all other conditions being unchanged, I do not understand how it can exert the smallest influence in preventing the evil effects of an atmosphere laden with the exhalations of a large number of sick in other wards, placed in several stories under the same roof. The cases to which the antiseptic method is strictly applicable are a minority of those admitted to most general hospitals, even in surgical wards, and the majority, particularly of fevers, lung diseases, &c., demand a purity of atmosphere on their own account, which is difficult, if not impossible, to obtain in a multiplication of stories. In the United States, in Germany, and in M. Toilet’s plans in France, single stories are preferred for surgical and fever wards on good and sufficient grounds, a,nd two stories are not exceeded for medical cases. (/) Furniture and Fittings of Hospitals. This is a matter of much importance as respects all cases, medical and surgical. It was first seriously considered in Tenon’s “ Memoir on the Hospitals of Paris,” and has been dwelt upon at a considerable length by M. Husson, in his “ Etude sur les Hopitaux,” published eighty years afterwards. The mechanical contrivances of the last century were so rude and rough, and so little attention has been paid to personal comfort, that many of the defects noted by Tenon no longer exist. They have not, however, altogether disappeared, for four rows of beds are still found in some of our hospitals ; not a few workhouse infirmaries have still two in a bed; and, in the cases of young children, I have seen as many as four sick in the same bed. In some of them, again, the beds are placed lengthways along the 38 Principles of the Construction and Arrangements of Hospitals. walls, and so close together, that it is difficult to get between them, and in a few instances they are still encumbered with the curtains which have nearly everywhere become things of the past. The remarks of Tenon, on the terrible state of the old Hotel Dieu, in relation to this matter, may still be studied with much advantage. The furniture and fittings should be of the plainest and most simple description, consistent with their fitness for their special uses, and should interfere as little as possible with the free circulation and purity of the air in the wards. Hence all curtains, shelves, cupboards to contain medicines or dressings, and everything not absolutely necessary for the comfort of the sick, should be prohibited. Foreign observers have remarked upon the cheerless and comfortless look of our hospital wards, but have admitted, after careful examination, that combined with their scrupulous cleanliness, they were, after all, best adapted to secure the successful treatment of disease. The introduction of flowers, pictures, and other amenities to a moderate extent is not only permissible, but beneficial, yet, even in this matter care requires to be taken, that they do not diminish the purity of the air in the wards. To attempt to enumerate the numberless articles of furniture for the sick room now existing, would be a hopeless task. It is sufficient to state generally that all contrivances calculated to secure the most scrupulous purity and cleanliness of place and person, to give ease and comfort to the sick, to arm the surgeon with the intruments best fitted for his work, and to provide the physician with the agencies he needs, should be found in all well-regulated hospitals. Those who desire further information on the subject should consult M. Husson’s great work, notwithstanding its being now nearly out of date, and should visit the Parkes Museum, in which it is hoped will ultimately be found all the most recent contributions of art and science, to this important department of hospital arrangements. Types op the Most Recent Forms of Hospital Construction and Arrangements. The great work of M. Husson, the reports of Messrs. Bristowe and Holmes, the treatise of Dr. Oppert, the excellent monograph of Capt. Douglas Galton on the Herbert Hospital, together with many others scattered through our medical and architectural publications, particularly in the Builder , under the able direction of Mr. George Godwin, contain detailed and valuable information on the subject of hospital construction and arrangements, brought up to a late period. In Germany, in Italy, and in the United States of America, there is also a wealth of information for those who seek for further instruction. I must, therefore, content myself with a very few typical examples, bringing the question up to date, to show how far the principles now accepted are being carried into effect. Some authorities who have written wisely and well, after long practical acquaintance with hospitals, have doubted whether they were blessings or the reverse to the sick poor, from the heavy, and in some cases lamentable, risks to life incurred by those resorting to Principles of the Construction and Arrangements of Hospitals. 39 them. One of them, apparently despairing of their ever being so constructed and managed as to diminish those risks adequately, has even recommended their entire abolition. More than one other, of the greatest eminence amongst authorities, is of opinion that the hospitals of the future should be constructed of temporary materials, so as to be destroyed and renewed every ten years without undue cost, and that no more money should be squandered in building palaces which rapidly become abodes of disease and death. Upon this subject, M. Ch. Sarazin, one of the best and most reliable of recent authorities, has said — “To these generally admitted ideas [detached pavilion hospitals, not exceeding two stories, and constructed of permanent materials], is opposed the radical view. No more permanent hospitals; they must be replaced by hut hospitals [wooden huts]. The permanent hospital is the hospital sepulchre, which nothing can keep wholesome, and which entails fabulous expenditure. The hut hospital, renewed in nearly all its parts every ten or fifteen years, alone presents the hygienic conditions necessary for hospitals, and admits of the realization of appreciable economies." Mr. Lawson Tait, in remarking upon the gangreous action in wounds taken on in the Scutari Hospital, from disgraceful insanitary conditions, states that — “This gangrene used to be common in our civil hospitals, and is too frequent even now. It may affect wounds of the most trifling nature. No reasonable person now doubts that it was and is due to bad sanitary arrangements That is, it is certain that a badly constructed or badly managed hospital will give bad results, even when it is not sufficiently unhealthy to be constantly exciting ‘ hospital gangrene ’ and 1 hospital fever,’ and from the facts of ovariotomy it is equally certain, that the nearer a hospital approaches the conditions of an isolated private dwelling in its construction, and in the relations of its inhabitants, the better will its results be. “ In conclusion, I can only reiterate the opinions of Miss Florence Nightingale and Mr. Cadge, that it would be infinitely better to leave the sick and hurt in their own homes, than to place them in buildings where they are exposed to the risks apparent in the returns of certain hospitals." * The celebrated Paul Dubois, in 1855, declared before the Academy of Medicine in Paris, that a woman would incur less danger to life in being confined unaided in the streets, than in being delivered in the Maternity or the Clinique. The perverse and persistent disregard of the true principles involved, which have been pointed out for more than a century, justified this gloomy view, particularly in Paris, where some of the practices pursued until lately, would be a reproach to the heads of the profession in that city, were they really responsible for them. The recent changes made in some of our metropolitan hospitals, in the vain attempt to bring them up to a higher standard than their original defects will admit of, show that those principles are far from being accepted among ourselves; while the enormous cost, and other objections to the new Hotel Dieu and St. Thomas’s Hospital, make it impossible to refer to them otherwise than as examples to avoid. The most notable examples of erroneous views of re-constru G k 0 \) \> k Section ou Lme -AB CqIccI om a n f^oacf ~ ■ Plan - of' Site * a Oic^ OJaroLo B do C do H. do d do D *3mo// fibred E do F Central JfaJl K Oldiro and. Operating e tba/r& L Office d tdjroroco or/mc.n / an; a// context ned tn tu louio-r floor ol OcaU o. oj c . — The water-closets, baths, and other sanitary appliances are situated at the extreme corners of each pavilion ward, and the passage-ways leading to them are entered from the canted ends. These passages are ventilated by windows at either end of them. No provision is made for heating the sanitary offices, and, consequently, the air from them tends to be drawn towards and into the warmer atmosphere of the adjoining sick ward. . The compartment on the right hand side of each ward contains a bath room, 7 feet 6 inches by 5 feet, fitted with a fixed porcelain bath, and in another compartment there are three “Jennings’ tip-up” lavatory basins, and a lead sink, 3 feet by 2 feet. The bath and sink are supplied with hot and cold water, but the lavatory basins with cold water only. At one end of the lobby of communication there is fixed a large lead- lined basin or sink, fitted with hot and cold water taps, and chiefly used for the washing and emptying of bed-pans and other slops ; this is an undesirable arrangement. The compartment on the left hand side of the ward contains three water-closets, 2 feet 8 inches by 4 feet 9 inches, separated from each other by slate divisions, and fitted with “Jennings’ patent valve closet apparatus;” there is also a recess corresponding in size to one of the water-closets, in which is placed a “Jennings’ lipped urinal.” These urinals are, however, never used. The soil and waste pipes are carried down in a recess formed on the inside of one of the outer walls of each compartment, and are cased over. It is stated that those from the slop sinks are four inches Leeds General Infirmary. diameter, and are ventilated at top with a pipe two inches diameter carried above the levels of the eaves of roofs, but that all others are unventilated. Day Rooms . — No day room accommodation is provided for the use of the patients. Duty Rooms. — The duty rooms have each an average area of 118 feet, and they are provided with an ordinary open fire-grate, having a trivet for holding a kettle or saucepan. There is also a stone sink, with hot and cold water taps, for washing up crockery. Nurses' Rooms . — The nurses’ rooms and staircases are situated at the entrance ends of the wards. Each has an area of 165 feet, and they were originally fitted up as combined sitting and sleeping rooms, but; now that the new building for the accommodation of nurses is in use, these rooms are unappropriated, and it is contemplated to use them as additional separation wards. Attendants' Sleeping Rooms . — The height of the nurses’ rooms and duty rooms last described is only about half that of the adjoining wards, and the space over them forms two rooms for the accommodation of the ward attendants and other officers of the establishment. Lifts. — Leading off the corridors, next each duty room, there is a lift, 7 feet 6 inches long and 4 feet wide, worked by hydraulic power, with a ram 6 inches diameter descending into a well a depth equal to the height travelled by the lift. Staircases . — The pavilion staircases occupy an area of 608 feet, and are constructed with stone steps carried upon cast iron girders. Each step is 6 feet long, with a tread 11 inches wide, and a rise of 6 inches. Basements . — The basements of the front pavilions are variously occupied for adminis- trative purposes, but there are no basements to the rear pavilions. Area of Pavilion . — The area covered by each floor of the larger pavilions, including the walls surrounding them, is 5,636 feet, or 176 feet per bed, and the corresponding area of each floor of the three smaller pavilions is 5,169 feet, or 185 feet per bed, so that the average area of all is 180 feet per bed. My best thanks are due to the General Manager, Mr. Thomas Blair, for much valuable information, and for the facilities afforded myself and assistant in taking detailed particulars of the structure. Mr. Thomas Ilewson, the Borough Surveyor, also very kindly assisted my enquiry. ( 22 ) ST. THOMAS’S HOSPITAL, LONDON— ENGL A ND. The old St. Thomas’s Hospital, situated at the southern end of London Bridge, adjoining the South Eastern Railway terminus, was removed for the purposes of the Charing Cross Railway, now running through the site of the building. Pending the erection of a new structure, the patients were transferred to the Surrey Gardens, 45 where buildings were prepared for their temporary occupation. It was then necessary to obtain an Act of Parliament, enabling the Governors to purchase land for the site of a new Hospital. This having been done, advertisements for offers of sites were inserted in the public papers, and out of seventy-seven, the following six were selected for special consideration : — 1. That occupied by Bethlehem Hospital. 2. A plot of land in Walworth Road. 3. The Surrey Gardens (with additional land if desired). 4. A plot of land near Newington Church. 5. Myatt’s Garden Ground, Camberwell. 6. Southern Thames Embankment. The site of Bethlehem Hospital was thought to be the most suitable, and an offer was made to the Governors of that establishment for procuring them another site and erecting a new Lunatic Hospital, at a cost (including the site) not exceeding £150,000. These terms the Governors of Bethlehem Hospital did not, however, feel themselves at liberty, in the interests of that Charity, to accept, and the negociation consequently came to an end. It is to be regretted that the amount of the offer was not increased, for the cost of the present site, including its expensive foundations, approached £160,000, and its area is nearly three acres in extent less than that of the Bethlehem Hospital ground. Then, again, the latter site was capable of almost indefinite extension, whereas the building as now placed is hemmed in on all sides by roads, and enlargement is out of the question. Last, and certainly not least, the building would have been free from the deleterious effects of the fogs and damp which prevail on all parts of the river’s bank. Negociations were, however, next entered into for the acquisition of the present site upon the Albert Embankment, adjoining the southern side of Westminster Bridge, and ultimately, the land was agreed to be purchased, subject to the approval of the Court of Chancery; this application was opposed by the Corporation of the City of London, but in February 1864, the contract was approved, and afterwards, upon appeal, confirmed. Then, after various additional negociations with the Archbishop of Canterbury and other adjoining proprietors, resulting in the acquisition of additional ground and an alteration of the boundaries, the agreements for the purchase of the site as it at present exists, were adopted by the General Court and approved by the Vice-Chancellor. * These gardens are now removed, and the site devoted to building purposes. U Hospital Construction and Management. St. Thomas's Hospital. 23 During the time these negociations were going on, steps were taken for obtaining information which might be useful in determining the design and plans of the proposed new buildings. A deputation, consisting of the Treasurer, Dr. Leeson, two of the Governors, and the Architect (Mr. Currey), visited the principal hospitals of Paris, Brussels, and Rotterdam, and their observations and suggestions were afterwards embodied in a report, and communicated to the Grand Committee of Governors. Then the Medical and Surgical Staff of the hospital were requested to furnish their suggestions for the internal arrangements of the new hospital. Ultimately, they were invited to depute three members of their body to advise on the arrangements relating generally to their department, and Dr. Peacock, Dr. Bristowe, and Mr. Simon conse- quently assisted the committee in the consideration of the plans. In July 1865 the plans w T ere laid before the General Court, and on the 18th of that month it was resolved unanimously that they should be carried out under the direction of the Architect and a Sub-Committee of the Governors.* The foundations, owing to the peculiarities of the site, were of a very extensive, and consequently expensive character, and these were first executed under a contract entered into with Mr. Webster, who was also the contractor for the adjoining new Embankment. Then the plans of the new building having been approved by the Vice-Chancellor, specifications and forms of tender for its eretftion were prepared, and twenty leading building firms invited to send in tenders on the 15th July 1867. That of Mr. Perry (being the lowest) was accepted, and the contract sanctioned by the Vice-Chancellor on the 27th of the same month. Building operations were commenced in the latter part of 1867, and the first stone of the new hospital was, on the 13th May 1868, laid by Her Majesty Queen Victoria, in the presence of their Royal Highnesses the Prince and Princess of Wales, the Prince Leopold, the Princess Louise, the Prince and Princess Christian, the Duke of Cambridge, Her Majesty’s Ministers, a large number of Peers and Members of Parliament, repre- sentatives of the medical profession, and of various learned and scientific societies, the Governors, the Architect, the Medical Staff, &c., &c. On the 21st June 1871 Her Majesty again visited the site for the purpose of opening the new building, and she was accompanied, as on the former occasion, by other members of the Royal Family, and attended by the Governors and the principal officers of the establishment. The propriety of erecting palatial strudtures for charitable purposes has recently been seriously questioned by some of the most eminent authorities on the subject of hospital construction, and this building, which has been designed upon a grander scale than, perhaps, any other hospital in the world, has frequently been pointed to as an * The Sub-Committee consisted of the Treasurer (Mr. Bagallay), Sir William Tite, Mr. Du Buisson, Mr Edgington, Mr. Vaughan, Alderman Sir Sills Gibbons, Mr. Alderman Stone, and Mr. JohnE. Johnson ; and they were advised as to the internal arrangements by Dr. Peacock, Dr. Bristow, and Mr. Simon. Sub- sequently, when the erection of the building was decided upon, there were added to this Committee, Mr. Alderman Finnis, Mr. Robert Pott, and Mr. Ware ; and, as vacancies occurred during the progress of the works, Mr John Bagallay, Mr. C. L. Francis, Mr. Laurence, Mr Silver, and Mr Tomkins became members. 24 St. Thomas's Hospital. exemplification of this error. It ought not, however, to be forgotten that a very large proportion of its total cost was due to the treacherous nature of the ground upon which it stands, rendering unusually expensive foundations necessary, and that this was probably a contingency impossible to have been foreseen at the time the erection of the building was determined upon. Perhaps, too, its apparent grandeur is due more to the effective grouping of its various parts, and to the architect’s skilful treatment of the external details, than to an undue employment of costly material. Its comparative proportions and cost, in relation to other similar establishments, will be shown in a later part of this work. Shortly before my last visit to the building, it had been determined, as want of funds had necessitated the closing of many of the wards, to try the experiment of fitting some of them up for the admission of persons of the upper and middle classes able and willing to pay for the benefits of medical attendance and nursing therein. In order to carry this into effect, the Governors have appropriated two wards situated in the block marked B on the general plan, and these are approached by a separate gate and entrance. The following is the description given by the hospital authorities of the accommodation provided, and the regulations under which the patients are admitted and treated : — " The two wards have been fitted up and furnished expressly for the purpose of accommodating patients of the classes above mentioned. Each patient has a separate sleeping compartment, curtained off with thick impervious linen curtains from the others, and each compartment is lighted by a large window and is appro- priately and comfortably furnished. The ward on the ground floor, which has sixteen of these compartments besides two small rooms, is for females. The ward on the first floor, which has twenty-four of these com- partments besides a small ward or room, is for males. Both wards have a large day or sitting room distinct from the wards, and which are well and comfortably furnished and thoroughly warmed and ventilated. There are warm and cold baths, and every requisite of the best description. “ As the hospital is situate in a large garden facing the River Thames and the Albert Embankment, and is also in close contiguity to Lambeth Palace, the occupants of the Home have the advantage of these open spaces and good air. “ The patients in the Home will be under the professional charge of a resident officer of superior medical and surgical qualifications, and of him exclusively, for their ordinary treatment ; but every patient will have the option of employing at his or her expense any legally qualified medical practitioner in consultation with such resident medical officer. “The minimum charge for each patient will be 85. a day, but the Governors reserve to themselves the right to take into consideration the state, position in life, and circumstances of each patient, and the nature of the case, and to require a higher daily charge when necessary. Patients having the use of one of the separate small rooms will be charged according to the circumstances. Such payments will entitle the patients to their board, medical and surgical attendance, medicine, and appliances, and also to be nursed and attended by trained and experienced nurses selected from the nursing staff of the hospital, and who will be under the immediate supervision and control of the matron. " It is not intended to admit as patients any persons suffering under any incurable or infectious diseases. “ Regulations for Patients therein. “ 1. — In all cases where possible applicants for admission should apply personally to the resident medical officer at the Home at 12 o’clock on any day except Sunday. “ 2. — When personal application is not possible, the application must be accompanied by a certificate from the patient’s medical attendant, stating fully the nature and facts of the case. “ 3, — Patients may employ at their own expense, in consultation with the resident medical officer, under the ordinary usage of consulting practice, any qualified medical or surgical practitioner, whether attached to St. Thomas's Hospital or not. ■ • 4 . Patients are held responsible for the orderly and proper behaviour of all persons (whether medical practitioners or friends) who visit them, and the House Committee reserve authority to themselves and to St. Thomas's Hospital. 25 the Treasurer to exclude or remove any such person who does not conform to the Rules of the Home and to the directions of its authorized officers. •' 5. — Patients may be visited by their friends any day, including Sunday, between the hours of 3 and 5 p.m. *'6. — In the event of any case of an infeftious nature arising, the Resident Medical Officer shall transfer the patient to the part of the hospital set apart for the treatment of such cases. “7 — No article of food or drink shall be brought into the Home without the express permission of the Resident Medical Officer. “ 8 — The hours for the daily meals shall be fixed and determined by the Resident Medical Officer, and all other domestic matters shall be arranged and carried out under the dirc&ion and authority of the Steward and Matron of St. Thomas’s Hospital." Site. — The buildings are situated southwards of and adjacent to the western end of Westminster Bridge, and they therefore stand in the parish of Lambeth, in the county of Surrey. The site is entirely enclosed by roads, the Embankment of the River Thames running on the western, and Westminster Bridge Road on the northern side, whilst Palace Road forms the southern and eastern boundaries. The extent of the site is about 378,507 superficial feet, being 8 acres, 2 roods, 30 perches, or nearly 660 superficial feet per bed. Subsoil. — The following is a description given by the Architect of the subsoil and the construction of the foundations of the buildings : * “The building stands partly on land reclaimed from the river and partly on the shore. Foundations on the river portion are carried down to the London clay. Those on the shore stand on a sound bed of gravel, which overlays the London clay, the difference in level being obtained by wide steppings, as shown on the sedtions. The ends of the blocks next the river have a solid foundation of about 22 feet deep over the entire surface, and the same depth 22 feet up to the old river wall. The concrete is then stepped up, and a platform of concrete, about five feet deep, is laid over the whole surface of the remaining portion of the building. The land or spring water stands at a level of about four feet above the clay. A drain was laid along the whole length of the hospital at the back of the river wall to a sump, and the excavations were all pumped dry before the concrete was put in. The whole of the concrete is composed of blue lias lime and clean Thames ballast up to a little above the land water line in the proportion of six to one ; all above that in the proportion of eight to one. The strata on the shore consisted of made ground, then gravel varying in compactness, resting on the London clay, which rises gradually up from the river. The strata on the river portion consisted of loose and sandy gravel down to the clay.’’ General Arrangement. — The accompanying plate illustrates the ground plan of these buildings, together with the details of the larger of the sick wards. The principal entrance to the building is on the ground floor of the main central block at the point marked G on plan. The whole of the ground floor of the main central building is occupied by the out-patients’ department, waiting rooms, coroner’s inquest room, dispensary, steward’s and matron’s offices, kitchen, stores, and other administrative offices. In the Block marked B, there are on this floor two wards, for the accommodation respectively of one and of twenty ophthalmic patients ; in each of the Blocks D and K there are two similar wards for ordinary cases, and there is also a ward in Block M for eight “ special cases.” The basement beneath the floor last described contains store rooms, furnace rooms, dining rooms for nurses and other like offices, and there is a corridor running Transactions of the Royal Institute of British Architects; London, 23rd January 1S71 26 St. Thomas's Hospital the whole length of the building, with a subway continued to Block N for the conveyance of dead bodies to the mortuary. Block C has three stories above the ground floor, and contains accommodation for the matron and also apartments for the “ Nightingale” nurses. The ground floor of Block E contains the applicants’ waiting rooms and other offices, and on the first floor an operating theatre. The ground floor of Block G contains the entrance hall and the steward’s and other offices, and on the first floor a chapel and medical officers’ rooms. The ground floor of Block J contains the out-patients’ department and consulting rooms, and on the first floor another operating room. Block L has three stories above the ground floor, and contains the steward’s and other residential offices. The parts marked RRR are not carried up beyond the ground storey. Blocks B, D, F, H, and K each contain on the first, second, and third floors, the principal sick wards hereafter described. Each floor has one large ward for the accommodation of twenty-eight patients, and one smaller for two patients. Block M contains on the ground floor a ward for eight beds only, on each of the first, second and third floors ; there are also two wards each for the accommodation of eight patients, and, in addition, two smaller wards each for two special cases. All the wards in this block are devoted to the reception and treatment of special or infectious diseases. The whole of the top or fifth floors of the Blocks B, D, F, hi, K, and M are devoted to the accommodation of the ordinary nurses and servants of the establishment. There is a closed corridor marked xxxx on plan, running the whole length of the building, and forming on the first floor a means of communication between the several blocks, and on the second floor an open air ambulatory. Block A contains board room, committee room, clerks’ and other administrative offices, and the treasurer’s residence. Block N contains the school department, with its anatomical, medical and chemical theatres, laboratories, materia medica museum, library, dissecting room, mortuary and post-mortem room. Block P contains workshops and gardener’s residence. 1 am informed that a very complete separate bathing department, with a well- appointed I urkish bath, was originally provided for the use of the patients, but it has latterly been converted to other purposes. There is no laundry. total Accommodation . — Accommodation is provided for 573 inmates, viz. : — 15 wards for 28 beds each, 3 for 20 each, 7 for 8 each, 17 for 2 each, and 3 for 1 each. Owing to want ol funds, tlie building has not been fully occupied ; during the years 1880-81, for example, the average daily number of patients was but 362. Connecting Corridors . — 1 he main corridor connecting together the various blocks of buildings contained between the six pavilions is 13 feet 9 inches wide on the ground floor, and on the first floor 9 feet wide, dhe roof of the upper corridor is so constructed Hospital Construction and Management. » G. franco Dial!. ty//rcce> . Chanel RDEHK.M. \ E. Quailing S^oom-s, (Spera/rng- Q/neairc J. t)a! ftahcnlsi, (Operating 5 j \om\ ^ L .(Micert mportment*. " 05 A . fyoarcl ( /?oom , Ojjiceo ^ //treasurers prudence ^ N V/[orluary czJahora/orrcs, (School tbeparlment. ^ P. Tdorhohcpte, Qorc/mcrls- k. 9^eoic/cnee . S 1 ‘ ThoindsVHosr nM / a c , ^T -. 1® 1 HP 1 1 E 1 1 r | G | | H 1 MT> < 1 1 l 1 1 «i " 1 I r amici- H io::::: :::::cL a::::ci - d :::: c - t t ft. tL ZJ- a rnc o Plcirr-of -Site - 'S/tdrooo ' | j" \ liar,/ 1 * \ COarJ ^ Hare/ .1 ^ Hare/ u | ’^/^aocrTUrnt b First Floor Plan of one PaVtlton _C £ d!_ SeciioVovlirre ’AB* dco/c 3 K/ k o N. ‘ s. k k 0 0 • Defc^iCof ‘FixF Oft 1 ices r f° r V_5 c a / c a / ccr F Photo Lithographed & TVmtedhy James Akrrmai»,6 Queen Squarc.W f H Saxon Snell . del 2 7 St. Thomas's Hospital. as to afford a means of external communication between the several pavilions at the second floor level, and it may also be used by the patients as an ambulatory. Water Supply . — The whole of the water used in the establishment is supplied by the Lambeth Water Company, and delivered into cisterns distributed over various parts of the building. Drainage.— The drainage of the building is effected by earthenware pipes, discharging into the main sewer. Area Covered . — The area covered by buildings is about 153,366 feet, being nearly two- fifths of the site, and 267 superficial feet per bed. Cost . — According to a report of the Building and Sub-Committee, dated July 2nd 1873, the sum paid for the land and the cost of erecting the building was as follows: — Land - £ s. d. Sum originally paid for land 95.000 o o Subsequent exchange of land to improve boundary, and the acquisition of 1,660 yards additional ground 13,000 o o For new wall to Lambeth Palace Gardens, consequent upon the above alteration of boundary 1.995 o o £r o 9.995 o o So the total cost of the site was at the rate of about £"192 per bed. Buildings. A contract was entered into with Mr. Webster for the execution of the necessary concrete and brick foundations (including the area retaining walls), at a schedule of prices, and resulted in an expenditure on these works of £48,545. Tenders for the erection of the buildings were invited from eighteen leading building firms, and the following table shows the amount of the estimates for four alternative modes of construction : — Name of Buildf.r.* Stocks and Red Bricks with Stone Dressings. Gault and Red Bricks with Stone Dressings. Stock Bricks and Stone Facings. Gault Bricks and Stone Facings. Ashby and Horner £ 382,100 £ 384,960 £ 400,400 £ 402,450 Hill and Keddell 381,050 383.950 400,300 402,150 Piper and Wheeler 377,060 379.784 395.106 397.637 Brass 367,021 381,617 383,826 397.334 Lee 364,000 371,000 390,000 392,700 Gammon 362,664 366,755 395.566 398,276 Thorne 353.745 353.745 362,645 362,645 Webster 353.654 353.654 375.306 375.306 Higgs 349,260 352,909 367,276 370.653 Mansfield 347,168 350.132 364.173 366,918 Holland and Hannen *... 344.252 348.995 364,488 368,878 Myers 340.946 344,996 362,540 366,370 Lucas 339 . *60 342.443 357.455 360,494 Perry 332,748 334.596 356,780 358,409 •Messrs. Baker, Messrs. W. Cubitt & Co., Mr. Downs, and Messrs. Trollope, were also invited to submit tenders, but did not do so. 28 St. Thomas's Hospital. Mr. Perry’s tender was accepted for the eredfion of the building with stocks, red brick facings, and Portland stone dressings, for the sum of £'332,748. The following account, however, shews what was the ultimate total expenditure : — £ d . £ S. Mr. Webster's account for the foun- Brought forward 434.794 II dations 48,545 0 O For cooking apparatus in the prin- Mr. Perry's general building ac- cipal and other kitchens 875 9 count, architect's and surveyor's Lavatory and bath fittings 1,667 9 fees, and clerk of works’ salary ... 359,409 18 3 Stoves and chimney pieces 1,721 15 Mr. Perry’s additional account for Electric communication and bells 946 9 sundry wood fittings 6,500 0 O Engineers' works in the dispensary For warming, ventilating, and and other laboratories and fit- hot - water services and ward tings in the chemical laboratory 1,788 8 stoves 11.345 0 O Fire appliances 313 O For hydraulic lifts 5,229 12 9 Laying-out grounds and planting 2,820 14 For gas mains, pipes and fittings ... 3.765 0 O Sundries 597 5 Carried forward £434.794 11 O Total £445.525 3 d . o 6 o 9 o 3 io o IO 2 The total cost of the buildings, exclusive of the site, was therefore at the rate of about £777 per bed. But it should be borne in mind, that of this sum nearly £85 per bed was expended upon the foundations, which, owing to the peculiarities of the site, were unusually costly. The total cost, including the land, was £969 per bed. It may be also interesting to note here the cost of the furniture which is given in the report referred to, as follows : — For bedsteads supplied to wards, sisters’ rooms, nurses’ dormitories, proba- tioners’, nurses' home, and College house 838 For bedding for ditto, ditto, ditto 1,119 For blankets, counterpanes, sheeting, linen, &c., for ditto 1.397 For locker seats for wards, £550, included in Mr. Perry’s account For tables for wards and ward kitchens ... 215 For chairs and seats for wards, out- patients' rooms, dormitories, gardens, &c 405 For furniture in rooms for residential medical staff 236 For ditto for sisters’ rooms, nurses’ dor- mitories, and probationer nurses’ home 1.059 For ditto in out-patients’ and dispensary departments 301 For ditto in medical school 172 Carried forward £5.742 £ Brought forward 5.742 For furniture for court, committee, trea- surer’s and almoners' rooms, count- ing-house, steward's office, &c 406 For carpets and druggets for sisters' rooms, committee and court rooms, &c 496 For kamptulicon in out-patients' depart- ment, counting-house, steward’s office, probationers' home, library, &c 593 For blinds in wards, out-patients' depart- ment, and officers' residences 807 For screens for wards 128 For turnery, cutlery, earthenware, and kitchen requisites 643 For dispensary, glass and earthenware, scales, weights, &c 195 For fenders and ironmongery throughout buildings 462 For chapel furniture 42 For sundries, including adapting and reno- vating furniture for hospital generally ... 570 Total £10,084 I he cost of the furniture here enumerated, was therefore at the rate of £17 12s. per patient. 29 St. Thomas's Hospital. Principal Sick Wards. The main sick wards are contained on the first, second and third floors of Blocks B, D, F, H, K, and they are connected together by staircases, and also on the ground and first floor by corridors running the whole length of the main building. Aspect . — The axes of the sick_ pavilions all run east and west, so that the windows on either side of the wards face north or south, whilst the balconies overlooking the river face the west. Relative Position of Pavilions. — The height of the pavilions as measured from the lower floor of the sick wards to the junction of the upright lines of the outer front walls with the sloping lines of the Mansard roof is about 78 feet, and the least distance between each pavilion is 125 feet or about ifths of the above height. Size of Wards . — Each main sick ward is of parallelogram shape, contains twenty-eight beds and is 120 feet long, 29 feet 4 inches average width, and 15 feet high. The total superficial space is therefore 3,520 feet, or about 126 feet per bed, and the cubic contents 52,800 feet, or about 1,886 feet per bed. Bed Space . — The average lineal wall space per bed is eight feet. This does not include the spaces at ends containing the doors leading to w.c.’s, bath, &c. Windows . — There are thirteen windows in each side wall, and the total area of their effective glazed surface is 808 feet, or about 29 feet per bed. If, however, the windows and the glazed door opening at the end of the ward overlooking the balcony be taken into consideration, the effective glazed area per bed is 32 feet 6 inches. All the sashes are glazed with plate glass. The side windows are each in two divisions the lower portion being ordinary double-hung sashes, and the upper portion having a sash constructed to drop only a few inches. The two end windows are ordinary double hung sashes, with circular heads. The door opening from the ward to the balcony is glazed, and has a large fanlight over it. When all the windows are opened to their fullest ext'ent, the total area through which air can be admitted by them into the wards is 418 feet, or nearly 15 feet per bed. Warming . — Each ward is warmed by three open fire-places, standing centrally between the beds, and these are supplemented in very cold weather by two coils of heated hot-water pipes, placed on a line with the stoves. The stoves are formed with an air chamber at the back of them, having a large heating surface of metal standing in a pan of water somewhat similar to the Gurney stove. Vertical smoke flues of wrought iron, fifteen inches in diameter, are carried from the basement to some feet above the roof, and pass behind and are connected to the stoves on each floor, so that each of these flues forms a general smoke shaft for each tier of stoves. Each stove is provided with a valve to close its connexion with the flue when not in use. These smoke shafts are surrounded by casings of cast iron, to prevent the atmosphere of the wards coming in direCt contact with the heated metal, and they are put up in pieces and bolted together, so as at any time to be easily removed when necessary for repairs. In the upper storey a casing of brickwork, built on the concrete floor is substituted for that of iron, as being in that position more suitable for conducting the smoke tube through the roof into the outer air. The spaces between the smoke flues and 30 St. Thomas's Hospital the casings are used as foul air extraction shafts as described below under the head of ventilation. Ventilation . — The ventilation of the wards is effected in summer time mainly by the windows, but each pavilion has an extraction shaft running from the basement through the well hole into the outer air above the roof of the staircase. The tendency of foul air to rise up this shaft is promoted by a cast-iron flue pipe from the basement furnaces being carried through the centre of it, and in the upper part there is placed a hot water circulating cistern, which also tends to assist the upward draught. When this shaft reaches the underside of the roof, it is met by a trunk running towards it horizontally along the line of the pavilion, and this trunk gathers together all the ventilating flues that rise from the wards below it. These ventilating flues from the wards consist of the large casings previously described as surrounding the smoke flues from the fire- places, and also of four flues running up the side walls and having openings into the wards at both ceiling and floor levels. It would appear that the ventilating openings in the wards pass diretftly into these upright shafts, and that no precautions have been deemed necessary to provide against the possibility of foul air from the lower wards being drawn on occasions into the upper ones. Lighting . — The lighting of the wards is effected at night by means of four gas brackets fixed round each of the the three ventilating shafts last described, at a height of 6 feet 6 inches above the floor. Floors . — The flooring of the wards is constructed on the fire-proof principle known as “ Dennett’s,” the ceilings being formed with a flat surface and plastered. The finished surface of the floors is of wainscott ploughed and tongued with hoop iron, the nail holes stopped with coloured putty, and the whole waxed and polished. Walls . — The walls are built of stock bricks faced with red Fareham bricks and Portland stone dressings, and the thickness of the main ward walls varies from 3 feet on the lower to 2 feet 3 inches on the upper floors. The walls of the wards, w.c.’s, bath rooms, sculleries, sisters’ rooms, small wards, staircases, &c., were originally finished with polished parian cement, but most of them are now painted in oil colours. Baths , W.C.’s, &-c . — The water-closets, baths, and other sanitary appliances are situated at the extreme corners of each pavilion ward in compartments projected from the main building, and connected thereto by lobbies opening directly into the wards. Cross-ventilation is obtained to these lobbies by means of windows in either side wall. There are also windows on all four sides of the projected rooms containing the water- closets, &c. In addition to the ventilation afforded by the windows, each compartment has small outlet shafts next the ceiling for the escape of foul air, and fresh air is admitted from the outside and passed over coils of hot water pipes. The projected compartment on the left side of each ward is divided into two by a framed partition, the upper portion of which is glazed. In that division which is entered directly from the lobby, there is placed the slop sink, about 4 feet 6 inches by 1 foot 6 inches, and the foul linen and dust shoots. 1 he other division entered from the last contains on the men’s side an urinal and also two water-closets, one being about 3 feet 10 inches by 7 feet 9 St. Thomas's Hospital. 3i inches and the other somewhat less. The water-closet apparatus is of the kind known as “ Jennings’ patent valve closet,” the seats are of deal. The urinal is also “ Jennings’ patent,” and has a treadle at the floor level which admits the water to flush the pan only while the person is using it. The slop sink is all of slate, with a drainer at one end; both cold and hot water is laid on to it ; the taps being placed at such a height from the bottom of sink as to admit of a pail being placed underneath. The projected compartments to the right of each ward contain the bath and the lavatory basins. A dwarf-framed partition divides the bath cubical from the lavatory, but in some cases this partition has been removed to provide sufficient space for the performance of small surgical operations. The lavatory is furnished with “Jennings’ patent tip-up ” basins, of white earthenware sunk in slate shelves, and both hot and cold water are laid on to them. The bath cubical is about 15 feet 9 inches long by 7 feet 10 inches wide, and is fitted with a “ Finch’s ” porcelain bath and hot and cold water supply. The soil and waste pipes run down recesses in the inner parts of the walls, and these recesses are cased with deal framing, so as to be easily accessible. The pipes are all trapped at the bottom before entering the drain, and the soil pipes are carried up to the roof and capped at the top, but have perforations around the sides. Day Rooms . — No day-room accommodation is provided for the use of the patients. Verandah . — From the extreme end of each of the larger sick wards, glazed casement doors lead on to a verandah about six feet wide and forty-five feet in length, where the patients might with advantage, if the water-closets did not adjoin it, enjoy the fresh external air and the cheering and enlivening view of the River Thames which runs beneath. Separation Wards . — On the left of the entrance to each of the pavilion wards on the upper floors there is a small ward, for the accommodation of two patients, containing 240 superficial and 3,600 cubic feet. Duty Rooms . — The duty rooms have each an area of about 360 feet, and they are provided with an ordinary cooking range and a glazed earthenware sink for washing crockery, fixed in one of the window recesses, the other window recesses are fitted with low cupboards, and there is a large- cupboard by the side of the food lift continued up to the ceiling. Nurses' Rooms. — Nurses’ rooms and staircases are situated between the wards and the corridor connecting the several pavilions. Each nurse’s room has an area of 248 feet, and is fitted up as a sleeping apartment, and being contiguous to the ward, it has an inspection window for overlooking the patients. Lifts . — There is one passenger lift for patients, 7 feet by 6 feet 6 inches to each pavilion, partly occupying the centre of the staircase. It is constructed upon the hydraulic ram principle, and is worked by the fall of water from a tank fixed in the roof at a height of 104 feet above the level of the basement floor. This tank contains 2,500 gallons, and the water in it exerts a pressure upon the lift ram of 45 lbs. on the square inch. The ram is nine inches diameter working in a cylinder eleven inches diameter, the stroke is sixty- three feet, and the lift is calculated to raise six persons at one time. The overhead gear is placed at the sides in a chamber especially provided for it, so that in the event of any fraCture no damage would arise to the cage. 32 St. Thomas's Hospital. There is also an hydraulic food lift to each pavilion, constructed upon the rack and piston principle, the machinery for this being placed in the basement. The weight intended to be raised is one hundredweight ; the height is 63 feet ; and it is worked from the same tanks as the passenger lifts. Staircases. — The pavilion staircases each occupy an area of 625 feet, the treads are 6 feet in length, 12 J inches wide, and the risers 5! inches. The well holes which are included in this area are occupied by the passenger lift and the ventilating extraction shafts previously alluded to. There are coils of hot water heating pipes on each landing. Basement. — The basement floors of the pavilions are generally about 10 feet 6 inches high, and they contain diningrooms and such like offices for the nurses, also furnace and store rooms, and general domestic offices, and all parts are connected together by a corridor running beneath the one above. Of course, this arrangement, and the position of the kitchen offices, would be quite subversive of all the rules of good hospital planning, if the limited area of the site had not rendered any other scheme an impossibility. Area of Pavilions. — The total area occupied by each pavilion floor, including its surrounding walls, is 7,292 feet, or 243 feet per bed. The foregoing account of this magnificent building does not agree in many important particulars with others previously published, and it may be well, therefore, to say that all the statements here given are the result of my own personal investigation. 1 he detailed plans have been made from careful measurements of the building itself, but the illustration at page 22 is copied from an engraving in “ Transactions of the Royal Institute of British Architects ” for the year 1871. New Royal Infirmary -Edinburgh ( 33 ) ROYAL INFIRMARY, EDINBURGH— SCOTLAND. This building has been erected by public subscription for the medical and surgical treatment of the sick poor of the city of Edinburgh, and it contains one of the largest medical schools of Great Britain, a school which is said to date from the appointment of Alexander Monro primus to the Chair of Anatomy in 1720. The foundation stone of the building was laid by His Royal Highness the Prince of Wales, in October 1870, and the building was opened on the 29th October 1879 by the Lord Provost, assisted by the Magistrates and Council of Edinburgh, together with other corporate bodies of the city and neighbourhood. Representatives from the University and Extra-mural Schools also attended. It is certainly one of the most important buildings of its kind, and great credit is due to the architect, the late Mr. Daniel Bryce, for the able manner in which he grappled with the constructive difficulties of the site, and so designed his building as to produce, without the sacrifice of skilful arrangement, a really handsome structure, well illustrative of the Baronial style of Scottish architecture. It must not, however, be supposed that this building is in all respects a model for the future designing of hospital buildings, for already a very large amount is being expended in the reconstruction of some details that have been found by experience to require alteration. The existence of some objectionable features in the general planning of the building is to a great extent due to the fact that the architect had to utilise an old structure standing centrally upon the site, and now appropriated as the administrative department of the establishment. A very exhaustive and ably-written description of this building was published in the Lancet about a twelvemonth after it had been opened, and the editor concludes his criticism in the following words, which equally apply to my own observations upon the various details of the buildings : — “ Many of the points to which we have taken exception are not peculiar to the Edinburgh Royal Infirmary, but are common to most pavilion hospitals which exist at present. The Edinburgh Royal Infirmary is certainly one of the finest and best hospitals in this country; but it would be a mistake to regard it as perfe&ion, and for future hospital builders to be content with merely imitating it.”* Site . — The buildings stand upon a plot of ground bounded on the south by the public park known as “ The Meadows on the north by the grounds of George Heriot’s Hospital ; on the east by Meadow Walk ; and on the west by Lauriston Place. It is situated upon a hill, having a rise from the southern to the northern boundary of 40 feet. It is not far from the centre of the city, and the proximity of the buildings to those of the University is advantageous to the students by reason of the facilities it at all times affords for transit from their academical to their clinical studies. Greater part of the The Lancet, September 4th and 18th 1880. 34 Edinburgh Royal Infirmary. central building is old, and was originally occupied by “ George Watson’s Hospital.” It has, however, been adapted to the purposes of this institution, though at great expense, and, probably, with no advantage beyond the creation of a pleasing economical delusion in the minds of the subscribers to the institution. It is, perhaps, now unnecessary ^o speculate as to whether the general arrangement of the buildings might not have been improved had this building been removed. The extent of the site is about 520,740 superficial feet, or 1 1 acres 3 roods 32 poles, being about 888 feet per bed. Subsoil . — The buildings on one side stand upon the upper stratum of old red sand- stone, and on the other upon the solid rock. General Arrangement— The accompanying plates shew, by a block plan, the general arrangement of the buildings upon the site, plans of one of the medical and one of the surgical wards, and a detail of the ward offices. A perspective view of the exterior is also illustrated. The establishment is divided into the medical, the surgical, and the pathological departments, the administrative offices, the laundry, engineering department, &c. Owing to the very great fall of the ground (forty feet) from Lauriston Place to Meadow Walk, it will be somewhat difficult to clearly understand the arrangement of the various buildings in their relation one to another, without first referring to the small section on the accompanying plate. It will there be seen that the ground floor of the buildings next Lauriston Place is placed below the level of the entrance roadway, and that the principal entrance to the building is upon the first floor; then, that the ground floor level of these front blocks becomes the first floor level of the central block ; and, lastly, it will be seen that the ground floors of the rear buildings are, again, at a considerable lower level than those of the central block. The pavilion wards contained in the buildings, shewn upon the block plan as facing Lauriston Place, are devoted to the surgical, and those in the rear facing Meadow Walk to the medical treatment of patients. The buildings lying midway between these two departments are principally of an administrative character. The establishment is entered by the gates adjoining the porters’ lodges, A and R on the plan of site. The entrance A is for the use of visitors, and R for patients. A flight of steps leads to the entrance hall at 13 , and a porter’s room and the treasurer’s and other offices adjoin this entrance hall. Blocks C C are pavilions containing on their ground, first and second floors respectively a large ward for the treatment of fourteen surgical cases, and a smaller or separation ward for two patients. Enlarged plans of these pavilions are shewn upon the accom- panying plate. Block D has similar accommodation on the two upper floors, but the ground floor of this pavilion is devoted to the treatment of twelve patients suffering from delirium tremens, and for whose accommodation one ward is provided for eight, and two others for two beds each, with padded room, nurse’s room, and other attached offices. 1 he upper floors of block E are also similar to those of blocks C C ; but the ground storey is used as an accident ward for six patients, and there is another smaller or separation ward for the accommodation of two patients. The remaining ground floor space of this block consists of a patients’ entrance and waiting room, doeftors’ and Hospital Construction and Management. i* ROYAL INFIRMARY ''M. 6 perch no, theatres. T. Mmmtkahvc- V. 9alholo. > *hc 30 erf/ cr of C 7^cr c / Fcoio i ithdgraphed i IVmtedby Janies Akerirjm. S Oucen Square ,W C J H Saxon Snell del Edinburgh Royal Infirmary 35 nurses’ rooms, and a convalescent day room. Basement store rooms are contained under part only of these four pavilions nearest to the connoting corridor, but not under the space occupied by the large wards. The wider parts of each pavilion next the main corridor are carried up to form a third storey, and planned to contain the ward assistants’ and the night nurses’ sitting and .bedrooms. Another accident ward for six beds is placed in block F, which is one storey only in height. Block J is an entrance hall and hat and cloak room for the use of students. The pavilions K and L have on each of their two upper storeys two wards for the accommodation respectively of fourteen and two patients, and there is in each of these buildings, on the lowest floor, a ward for ten patients, besides in K one, and in L two separation wards. Each floor has a day room, duty room and attached offices, as described for the other pavilions. In pavilion K this ground floor contains, besides the wards just mentioned, the waiting and examination rooms for ophthalmic patients. There are basements under these two pavilions devoted to the uses of the chief porter, the engineer and the laundry women ; there is also a ward in block L containing accom- modation for six “ doubtful cases.” Blocks M M are two small operating theatres, one storey only in height above the ground floor level. The basements are used for storeage purposes. The upper floors of the principal entrance, block B, contain one ward for six patients, and two wards each for eight syphilitic or “ lock ” patients, all having appropriate offices attached ; there are also in this block rooms for the use of students. It will be remembered that owing to the rapid fall of the site the first floor of block F corresponds to the ground floor of the front building last described. This block F contains, then, on the ground floor, the general kitchen offices, the stores, steward’s quarters, dispenser’s apartments, laboratory and drug room, the housekeeper's rooms, nurses’ kitchen and dining room, the general medical waiting room, and general male, female, private, and students’ examination rooms. On the first floor accommodation is provided for the lady superintendent and the resident physician and surgeon, a chapel for the general use of the patients and officers, and registrar’s and clerks’ offices. There are also on this floor cubicles for nurses and domestics. On the upper or second floor there is a large operating theatre and additional cubicles for nurses, as also the treasurer’s clerk’s, and superintendent’s offices, and the board room. The pavilions H H H H are devoted to the treatment of medical diseases, and are each three storeys in height above the basements. On each of the upper floors there is a ward for twenty-one beds, and a separation ward for two beds, and at either end of these buildings there are the usual ward offices. The wider portion of these pavilions next the connecting corridor are carried up an additional storey for the accommodation of ward assistants, night nurses, &c. ; but the basements of these portions are at present unappropriated. The basements of the narrower portions beneath the large wards are available for use as day rooms by the convalescent patients, and they are entered from the outside. Blocks O O are two lecture theatres, each one storey only in height above the basement. D 36 Edinburgh Royal Infirmary. Block N contains two porters’ rooms on either side of the corridor connecting the medical department with the central administrative offices. The building marked S is the superintendent’s residence, three storeys in height. The laundry and washhouse is situated in block R, the engine and boiler room being placed beneath the adjoining yard. Block T is the mortuary. Block V contains the pathological theatre, with its adjoining preparation and demon- stration rooms, and a surgeon’s private room. There is a subway communication between this department and the medical and surgical pavilions. Blocks P P contain a coffin store and the carpenter’s, upholsterer’s and joiner's shops ; also stores with joiner’s residence over. According to the original plan for this building published in the Builder, it appears to have been intended to ereCt on the block indicated by dotted lines and marked W an isolated building specially adapted for the reception of patients suffering from infectious and contagious complaints ; but at the time of my last visit, in the latter part of the year 1882, this portion of the hospital had not been ereCted. The original plan referred to would also seem to have contemplated the ereCtion of an out-patients’ department and dispensary ; also receiving rooms. Total Accommodation . — The total number of patients provided for is therefore 586, viz., twelve wards for twenty-one patients each, fourteen for fourteen each, two for ten each, three for eight each, five for six each, and thirty-two for two each; but some of the private rooms are occasionally occupied by more patients than was originally intended. The average number of beds occupied daily during the year 1880-81 was 495. The greatest number at any one period was 576, and the low'est 453. Connecting Corridors . — The surgical pavilions fronting Lauriston Place are connected together on the ground and first floors by closed corridors, xx on plan, n feet 6 inches wide, 14 feet high ; the roofs also form a means of open-air communication between the various blocks, and ambulatories for the use of the patients on the top floor. In the basement beneath these corridors there is a subway level with the ground floor of the central block. The medical pavilions in the rear are connected together on the ground floor by a closed corridor, y y on plan, 12 feet wide, 13 feet 3 inches high, the roof of which forms an open-air communication and an ambulatory for the patients upon the first floor. This corridor communicates with the central block by another enclosed and inclined corridor, z z on plan, 11 feet wide, and an average height of 12 feet 3 inches. The roof forms an open-air communication between the first floors of the medical pavilions and the central administrative blocks. The whole of the corridors in the building are heated by coils of hot-water pipes placed at regular distances apart. Water Supply . — 1 he water used in the institution is supplied gratuitously from the Corporation works, and is distributed throughout the building in cisterns situated principally in the various turrets at the angles of the pavilions. Drainage. 1 he drainage of the establishment is effeefted by means of glazed earthen- ware tubes, which converge on the outside of the building, and enter a conduit running Edinburgh Royal Infirmary. 37 through the adjoining “ meadows,” and ultimately joining the town sewer in its progress towards the outfall. Ana, Covered .— The area covered by buildings is 137,905 superficial feet, or about one-fourth of the site, and 235 feet per bed. Cost. The cost of the land, including Parliamentary expenses, was £"64,453 I 5 5, o3^9> but that property was subsequently exchanged at cost price with the Corporation of Glasgow for a portion of the lands at Donaldshill. This ground, of which about nine acres were available for hospital purposes, was considered to possess the advantage of moderate elevation, proximity to the open grounds of the University and Western Park, and good accesses from the surrounding districts. In addition to the above-mentioned ground, the committee subsequently purchased about three and a-half acres of land lying to the north and west, at a price of £8,990, for the purpose of improving the site, and with the view of more fully securing open space, and of controlling the nature of the buildings in the neighbourhood of the hospital. I he price, therefore, of the whole ground acquired amounted to £26,379. Part of Hospital Construction and Management. Glasgow Western Infirmary . 43 this sum, however, has been recovered by the sale, for building purposes, under proper restrictions, of a portion of the outlying lands. Having regard to the future wants of the district, and to the inexpediency of too great an enlargement of single hospital buildings, it was determined to plan a hospital fitted to accommodate from 300 to 400 beds, but, as it appeared that funds might not be immediately forthcoming to provide for the erection of the whole building as designed, the architect was directed to prepare modified working plans of a part of the hospital, which, though containing fewer beds, might serve in the meantime the purposes originally intended, and admit of the completion of the whole buildings at a later period. It will be seen, then, that these and the new University buildings were erected adjoining one another, at about the same period, with a view to affording the students better facilities than usually attain for the joint prosecution of their academical and clinical studies. The same object appears to have been aimed at in the erecftion of the new Royal Infirmary at Edinburgh, and these two great capitals of medicine have cause for congratulation for the far-seeing policy that guided the Managers in this and other important details of their arduous and philanthropic undertaking. The buildings first erected were for the accommodation of about 220 patients only, the blocks E and G on the accompanying plan of the site being deferred until a future period. The blocks of buildings first erected were commenced on 17th March 1871, and the foundation stone was laid on 10th August in the same year, with Masonic honours, by Walter Montgomerie Neilson, Esq., of Queenshill, Grand Master Mason for Lanarkshire, in the presence of a large and distinguished assembly. The central portion and the left hand wing of the building was completed in the year 1874, and was formally opened by a Conversazione, at which the Lord Provost, Dr. Cameron, Sheriff Dickson, Dr. Fergus, and Mr. James A. Campbell explained to the assembled company the objects of the Institution and the steps which had so far been taken to accomplish its erection. The completion of the main structure did not take place until 1st June 1881, on which date the blocks E and G, having then been erected, were formally opened by the Lord Provost, and at the ceremony, which was conducted in the clinical theatre, it was made known that this addition to the building was due to the munificence of the late Mr. John Freeland, who left by his will the sum of £40,000 to be devoted to this purpose. The wash-house, lodge, and erysipelas wards have since been erected; the latter were not quite completed at the time of my visit, but the total cost, as stated hereafter, includes the estimated value of these additions. The plan of the building, taken as a whole, is quite opposed to the principles laid down by all modern authorities upon hospital construction, for, instead of the wards being detached as far as possible from one another and from the administrative depart- ment, they are connected not only vertically but horizontally, and no precaution whatever is taken to prevent the air from any one ward being carried into that of another. The kitchens and scullery are also objectionably situated in the basement, adjoining corridors which communicate, by means of lift-holes and well staircases, with the sick wards 44 Glasgow Western Infirmary. above. It cannot, however, be doubted that this system of planning a hospital is less expensive in construction than that by which the buildings are detached, and the management must be more economical, by reason of the greater facilities afforded for communication between the various departments. The wards themselves are well designed, lighted, ventilated, and heated, and the details of the arrangements of the building are generally excellent, and reflect great credit upon the architect, Mr. John Burnet. Nevertheless, it is quite evident that, if the present views entertained by all enquirers into the subject of hospital construction be maintained, this must not be regarded as a model for the design of other hospitals. The departments devoted to clinical purposes are especially worthy of study. My thanks are due to the Superintendent of the institution, Dr. John Alexander, for his great courtesy in affording me facilities for obtaining the following details of construction, and for providing me with particulars as to various other matters of interest. I am also especially indebted to the Architect, who kindly gave me much valuable information, and specially prepared for my use a photograph and a carefully measured block plan of the site and buildings. Site . — The buildings are situated at Donaldshill, an outskirt of the city of Glasgow, and the site is bounded on one side by the Dumbarton Road and on the other by the open grounds of the University and the Western Park. The ground has a considerable inclination from east to west, and also from north to south. The extent of the site is about 537,850 superficial feet, or 12 acres ij roods nearly, being about 1,386 superficial feet per bed. Subsoil . — The western end of the building is said to occupy the site of an old stone quarry, and, having been filled up with loose earth, this portion had to be built on piles; the remainder stands upon a bed of hard blue clay. General Arrangement . — The general arrangement of the buildings, together with plans and details of the principal sick w r ards, are shewn upon the accompanying plates. The establishment is entered by the porter’s lodge, marked N on the block plan of the site, and this lodge also affords access to the adjoining University buildings. There is an additional entrance at the rear, adjoining the lodge at M. The principal entrance to the main buiiding is the central block A, upon the basement floor of which are the stores, larders, kitchen, and scullery. On the ground floor there is the entrance hall, a board room, superintendent’s office, staircase to upper floors, housemaids’ pantries, doctors’ dining room, housemaids’ rooms, and the upper part of kitchen. The mezzanine floor contains housemaids’ bed and sitting rooms. On the first floor there are six doctors’ rooms, with an adjoining bath room, head nurses’ bed and sitting rooms, a sick ward for 16 beds, with attached offices, and a separation ward for two beds. On the second floor there is a ward for 16 beds, with attached offices, a separation ward for two beds, and a theatre for surgical operations and lectures, with dressing rooms attached. Block B contains on the basement a dispensary, porters’ rooms, and a drug store, and on the ground floor nurses’ parlours, and rooms for the use of the superintendent. The whole of the first floor of this block is occupied as a ward for 16 patients, with attached Hospital Construction and Management. Photo -Lithographed l Hinted by James Akerman, 6. Queen Square ,WC H Saxon Snail .del . ■ Glasgow Western Infirmary. 45 offices, but the second floor is divided into smaller rooms, intended to be used as private wards for six patients ; they do not, however, appear to be so occupied at present, private patients generally being placed in the separation rooms adjoining the larger wards. Block C has store rooms on the basement, and on the ground floor a napery and the matron or lady superintendent’s living rooms and office. The first and second floors of this block are planned in every respect similar to those of block B, last described. Block D contains on the basement, store rooms and an out-patients’ department, consisting of waiting rooms, physicians’ and dodlors’ rooms, bath room, w.c., &c. On each of the ground, first and second floors of this block, there are two wards for 18 beds each, and two separation wards, each for the accommodation of two patients. There are also in this block doctors’ and nurses' sitting and bed rooms, and the usual ward offices. Block E contains on the basement a nurses’ dining room and a meter room, the centre portion only being carried down. The ground, first and second floors contain wards and offices somewhat similarly planned to those last described for block D, and containing the same accommodation for patients. Block F contains on the basement floor the janitor’s house, a waiting room for out- patients, and a doctors’ consulting room. On the ground floor there is a ward, with the usual attached offices, for the accommodation of eight patients suffering from skin diseases, and also seven bath rooms, fitted with ordinary and spray or needle baths and other appliances. The first floor contains a ward and attached offices for 12 patients also suffering from skin diseases, and there is a circular staircase for access from this floor to the bath rooms on the ground floor last described. The second floor of this block contains attic rooms, but they are only used to store lumber. Block G contains on the ground, first and second floors respectively a ward for the accommodation of 12 patients, with the usual attached offices. There is no basement here. Block H is the medical, clinical, and pathological department, and contains a theatre, lecture room, museum, professors’ room, mortuary, workshop, and other usual offices. Block J is the laundry, and in the basement there is a dust house, engineer’s shop, and furnace room. Block K is devoted to the accommodation of those nurses who are being trained in the institution, and is approached from the main building by a covered corridor. Block L is now in course of construction, and when completed will provide accom- modation for 12 patients suffering from erysipelas. Total Accommodation . — Accommodation is provided for 388 sick, viz.: twelve wards for 18 beds each, four for 16 each, four for 12 each, one for eight, and fourteen for two each. In addition, there are private wards for the accommodation of 12 patients, and erysipelas wards also for 12 patients. Water Supply . — The water is supplied by the Town Corporation Waterworks Com- pany, without charge. In the portion of the building first erected there is a slate cistern over each of the blocks of w.c.’s and bath rooms adjoining the main sick wards, and also a cistern for supplying hot water to the heating pipes ; but in the wings lately ereifted the supply is directly from the mains, and there are only a few small intermediary cisterns, or water waste preventers, to the w.c.’s, &c. 46 Glasgow Western Infirmary. Drainage . — All the drainage is effected by glazed earthenware pipes, carried directly into the town sewers, without disinfection. Area Covered . — The area covered by buildings is 56,242 feet, being rather more than one-tenth of the site, and 145 superficial feet per bed. Cost . — The cost of the land was £23,136, or about £60 per bed. The buildings erected to this date, including fittings, laying out the grounds, architect’s commission, clerk of works, &c., have cost £97,051, and the erysipelas wards and medical officers’ residence are estimated to cost £3,186, so that, when complete, the whole of the buildings will have cost £100,237, or about £258 per bed. The total cost, including the land, will, therefore, be at the rate of about £318 per bed. Principal Sick Wards. The two main blocks of sick wards of this building are each planned so as to form the four arms of a cross, the centre or connecting portion of which contains the staircases, nurses’ rooms, &c. The end of one arm of each of these blocks connects itself with the central or administrative department, and thus all parts of the main building are, unlike an ordinary pavilion hospital, connected together on every floor. An additional block of sick wards also juts out from the rear of the central building. But for the fact of these sick wards being thus connected together, they are generally planned as ordinary pavilions. The following details refer more particularly to the wards on the first floor of Block E ; the other blocks are necessarily in some respecffs different, but not so in any essential particulars. A sped . — The form of the building being that of a double cross, the axes of the wards run in different directions — viz., from north to south and from east to west. Size of Wards . — Each ward of the double pavilion contains 18 beds, and is 70 feet 6 inches long, 26 feet wide, and 15 feet high. There is a canted recess at one end, eight feet deep. The total superficial floor space is 1,944 feet, or J °8 feet per bed, and the cubic contents 29,160 feet, or 1,620 feet per bed. Bed Space . — The average lineal wall space per bed is 7 feet 10 inches. Windows . — There are eight windows in each side wall, and the total area of their effeiffive glazed surface is 379 feet, or 21 feet per bed. If, however, the windows situated in the end recesses be taken into consideration, the effective glazed area is 472 feet, or 26 feet per bed. When all the windows are open to their fullest extent, the total area through which air can be admitted by them into the wards is 96 feet, or 5^ feet per bed. The sashes are generally double glazed, with two thicknesses of 16 oz. or 21 oz. sheet glass. They are generally double hung sash windows, with small casements at the top hung on their lower rails and opening inwards. The lower ordinary sashes are prevented by a catch from opening to a greater extent than six inches, excepting for the purposes of cleaning, when a special key is used. It is stated, as a reason for this very objectionable method of stopping the main source of ventilating these wards, that a delirious inmate once opened one of the windows and jumped out. Thereupon the objectionable catches were ordered, but it appears to have been overlooked that the windows at the ends of the wards are without these special Glasgow Western Infirmary. 47 fastenings, and the balconies on to which they lead still invite the attention of those having suicidal tendencies. Warming . — Each ward is warmed with one double open fire-stove, standing centrally between the feet of the beds, and having upright flues running through the ward ; they are supplied with fresh air through channels running under the floors, from openings outside the walls. Besides these stoves, there is on the ground floor a hot water circulating heating pipe, running down each side of the ward, and branching off from this pipe, at each of the four end windows, there is a coil of pipes enclosed in a casing, and having a flue for conveying the air heated in this casing to the floor above. On the upper floor the four corresponding windows of each large ward have coils of hot water pipes enclosed in grated boxings beneath them. Ventilation . — The ventilation of the wards is effected in summer mainly by the windows, which, as before stated, can be opened to the extent of about 5! superficial feet per bed, and in winter by the introduction of fresh air through the central stoves. For outlets there are four openings in each ward, 18 inches square, situated in the upper parts of the walls, and in each corner of the ward. These openings, which are controlled by flaps, are made to communicate, by means of flues, with two large shafts situated in the roof over each block of wards, and these shafts have in each of them a hot water cistern, to assist the extraction of the foul air from the wards. Lighting . — Each ward is lighted with two gas pendants, having four arms with one burner each. No means are provided for carrying off the products of combustion. Floors . — The flooring of all the wards is of pitch pine boards, four inches wide, grooved and tongued, and polished with bees’-wax, turpentine, and resin, and these boards are carried upon ordinary wood joists and wrought iron girders. Walls . — The outside walls are of stone, 2 feet 4 inches thick, the interior faces being battened, lathed, plastered, and finished with ordinary papering, and sized and var- nished. The walls of the w.c.’s and bathrooms are tiled with white tiles, 6 inches square. W.C.’s, Baths, &c . — The water-closets, baths, and other sanitary appliances are situated at the extreme corners of each pavilion, and they are entered by lobbies from the recess at the end of each ward. No provision is made for heating these offices, and the lobbies are not cross ventilated, but this is an omission only too common in many otherwise well-designed hospital buildings in this, and especially in foreign countries. One of the compartments is divided into a room about 7 feet 6 inches long and 6 feet wide, containing a slop sink and urinal, and adjoining there are two water-closets, each 4 feet long and 3 feet wide. The water-closet apparatus are of the kind known as Bramah’s valve closet, and the seats and risers are made of teak. There are three foul air outlets, 10 inches square, in the ceiling, one being directly over each w.c., and one in the centre of the compartment containing the sink and urinal. The slop sink is of glazed stoneware, 1 foot 6 inches diameter, and about 1 foot deep, and the shelf in which it is fixed is covered with copper. The urinal is of earthenware, and fitted with an ordinary water tap. The other compartment is 12 feet long and 6 feet wide, and is fitted up as a bath room and lavatory. The baths are of glazed earthenware or porcelain, manufactured by Messrs. Rufford and Co., of Stourbridge. The lavatories have two white earthenware 4 8 Glasgow Western Infirmary. basins, sunk in slate slabs, and have hot and cold water laid on to them. The soil pipes, which are enclosed by wooden casings, run down recesses inside the building, and there is a space of about 4 feet 6 inches deep between the floor and ceiling of the bath rooms and w.c.’s, for access to the various pipes. Separation Wards. — These wards were apparently originally intended as day rooms for the convalescents, but they are now used as separation wards, and some of them are occupied by private patients. They vary somewhat in size, but the average area of each is about 282 feet, or 141 feet per patient, and their average cubic capacity is 4,230 feet, or 2,115 feet per patient. Day Rooms. — No day rooms are provided, but there is a large open space at the junction of the passages leading to the wards, and this is available as a lounging place for the patients ; it does not, however, appear to be made use of for this or indeed any other purpose, probably because, being lighted only by one comparatively small window, it is by no means so cheerful as the ward itself. This space in the opposite wing is partitioned off to form an additional separation ward. Duty Rooms . — Each large ward has a duty room adjacent to it, of varying size, but the average area of each is 104 feet ; they are fitted with ranges, earthenware sinks, and dressers. Nurses' Rooms . — Adjoining the large wards there are three rooms, having an average area of 100 feet each, and one with an area of 165 feet. These rooms are used indis- criminately as nurses’ bed rooms and sitting rooms, and in some cases as a doctors’ instrument room or a bath room. There is also on each floor a room that is in some cases used as a lumber or store room, and in others as a bath room. The appropriation of these small rooms varies very much. There are no inspection windows for overlooking the wards. Lifts. — Adjoining one of the nurses’ rooms, and entered from the corridor, there is a room which gives access to the lifts. There appears to be no other special use for this room, but it is made use of as a depository for all kinds of ward utensils. The lifts are each 4 feet 6 inches w r ide and 7 feet 6 inches long, and rise from the basement floor ; they are worked by hydraulic power directly from the water company’s mains. Staircases.-— The staircases of each set of four pavilions occupy an area of 481 feet, and are constructed with stone spandril and moulded steps, tailed into the walls, and carried on cast iron moulded girders. The landings and all the corridors are of oak, polished with bees-wax, turpentine, and resin. The steps are six feet long, with a tread of twelve inches and a rise of six inches. Basement. — There is no basement to the pavilions last erected, and more particularly referred to in the foregoing description, but in the opposite wing the lower floor, owing to the fall of the site, is to a great extent level with the ground, and is occupied by the out-patients’ department, dispensary, janitor’s house, stores, and other offices; it is ten feet in height. Total Area of Pavilions. — The total area covered by the principal floor of the four sick wards just described is (including the surrounding walls) 14,169 feet, or about 208 feet per bed. Hospital Construction and Management. ( 49 ) NORFOLK AND NORWICH HOSPITAL, NORWICH— ENGLAND. This institution is said to have been founded in the year 1771, and the old buildings, greater part of which are now removed, were eredted about the same period. In comparison with other hospitals erected prior to 1880, it was a remarkably well-planned structure ; but the wants of an increasing population had outrun the capacity of the building, and overcrowding ultimately reached to such an extent that “ during the ten years, 1865 - 74, there had been an increasing tendency to fatal pyaemia among the surgical cases, and during the year 1874 a tendency to fatal erysipelas in the same class had been added, a condition of things that would, if persistent, almost of necessity give rise sooner or later to an unmanageable intensity of traumatic atmosphere.” 0 Under these circumstances, it is not to be wondered at that a determination was come to by the Governors to make an alteration at any cost. As a first step, the advice of Captain Douglas Galton, Architect of the Herbert Hospital (then the best one existent), was asked as to the plan to be adopted for altering and enlarging or rebuilding the structure. Captain Galton made a very careful examination of the premises, and sent in an elaborate Report, containing suggestions few of which have been acted upon. Mr. Edw. Boardman, F.R.I.B.A., was then requested to prepare plans for adding to and adapting the old hospital ; these, after great scrutiny by the medical men and other authorities, were approved by the Governors, and on the 20th November 1876 a meeting was held at St. Andrew’s Hall, presided over by the Earl of Leicester, and attended by the Prince and Princess of Wales, and most of the nobility and gentry of the county and city, for the purpose of raising funds for carrying it out. At this meeting the Earl of Leicester announced his intention of giving £ 1 1,000 (since augmented by his lordship to £15,000) as a sustentation fund, conditionally upon the public building an entirely new hospital, instead of altering the old one. No decided step seems, however, to have been taken until the following year, when the late Mr. T. H. Wyatt, Past President of the Royal Institute of British Architects, and Architect to Middlesex Hospital, was requested to associate himself with Mr. Boardman in preparing designs for the new buildings. These gentlemen suggested two different schemes, which were submitted to Dr. F. de Chaumont, Professor of Military Hygiene at the Army Medical Schools, Netley, for his opinion as to the merits of each. Ultimately, in June 1878.it was decided to carry out the work in the manner shown upon the accompanying plans, and on July 17th 1879 the foundation stone was laid by His Royal Highness the Prince of Wales, in the presence of many of the nobility; the Earl of Leicester, K.G., President of the hospital ; the Lord Bishop, Vice-President ; the Mayor of the city, Mr. H. Bullard; * " Report on the Sanitary Condition of Norfolk and Norwich Hospital.'' Mr. Netten Radcliffe. 1875. 50 Norfolk and Norwich Hospital, the Sheriff, Mr. D. Steward ; the Chairman and Vice-Chairman of the Board of Management, Mr. H. W. Edwards and the Rev. Canon Heaviside; the Chairman of the Building Committee, the Rev. Canon Copeman ; the Architects, the Medical Staff, and other local celebrities. Mr. Wyatt, who had then been for some time in very bad health, did not live to see the completion of the ' enterprise, and at his death, in August 1880, the work was and is still being carried out by Mr. Boardman, to whom, and also to Mr. Matthew Wyatt, I am much indebted for the facilities afforded me in gathering together the following details of the structure. The central administration block and the south-west pavilion having been completed, these portions of the building were formally opened by the Mayor of Norwich, Mr. S. Grimmer, on the 30th June 1881. The key, together with a Report of the work so far as completed, was handed over by the Chairman of the Building Committee to the Chairman of the Board of Management, Mr. Humfrey Mason, and the ceremony was attended by the Sheriff, Dr. Eade ; the Dean of Norwich ; the Rev. Canon Copeman, Chairman of the Building Committee ; the Architect, Mr. Boardman, and other distinguished citizens. Since then the further execution of the design has been continued, and it is hoped that it will be entirely completed and occupied in the early part of 1883. The following “ Remarks and Suggestions,” extracted from Dr. F. de Chaumont’s Report, previously referred to, contain much interesting and useful advice as to the leading principles to be observed in the construction of hospitals : — " I venture to append a few remarks and suggestions for the consideration of the Committee, believing it to be their desire that I should do so. " I propose to touch upon the following points: — “ I. The construction, ventilating, and warming of the general wards. “ II. Ditto, of the operating block, and of the smaller wards round the theatre. " III. Ditto, of the isolation wards. “ IV. The ventilation of the out-patient department. “ V. Ditto, of the chapel. “ VI. Ditto, of the nurses’ apartments. “ VII. On the laundry and disinfection arrangements. "VIII. The drainage. " IX. The periodical evacuation of the wards. " X. Sanitary supervision. “ 1. Construction, ventilating, and warming of the general wards. The wards are to be for 24 beds, each patient to have about 108 square feet of floor-space. This is a fair amount, but not excessive when surgical and medical cases have to be placed together. It would be desirable to leave a vacant bed in the neighbourhood of any serious surgical case, where circumstances admit, in order to increase the floor-space. “ The breadth of the ward ought certainly not to exceed 26 feet, as the difficulties of ventilation, especially perflation, are thereby increased. " The height of the wards is an important question. It is proposed to make it 14 feet, which, with 108 feet of floor-space, would give 1,512 feet of cubic space. In my opinion, nothing is gained by making the height greater than 12 feet, indeed, in some directions it is a distinct disadvantage, as it increases the difficulties in the way of ventilation and warming. A notion prevails that lofty rooms are advantageous, and they are so under certain limitations. Thus, in tropical climates, or in extremely hot weather in this country, they give a larger mass of air, and so favour coolness; also in large buildings, such as churches, meeting halls, &c., which are to be occupied for only a short time (a couple of hours, say), height is advantageous, as it supplies a store of fresh air where proper ventilation is difficult of accomplishment. But if a space is to be occupied continuously, like a ward of an hospital, that is, if it is to be in occupation beyond a couple of hours, the size of the space becomes a matter of indifference, so far as any value is to Norfolk and Norwich Hospital. be got out of it for ventilation purposes. The following Table illustrates this. The results are compared as calculated in spaces of 1,200 and 1,400 cubic feet, each having one inmate, and an hourly supply of 4,000 cubic feet of fresh air. A similar calculation is added for a cubic space of 10,000 (ten thousand) cubic feet, occupied by one inmate, and with the same supply of air per hour, namely, 4,000. The impurity is stated in terms of carbonic acid (CO2) per 1,000 volumes over and above what the incoming fresh air normally contains* Hours the Air-space has been occupied. Size of Air-space = 1.200 cubic feet. Size of Air-space = 1,400 cubic feet. Size of Air-space = 10,000 cubic feet. 1 hour O' 144650 0141580 0-04948 2 hours 0*149810 0*149500 008260 3 .. o* 149990 0-149970 0-10480 4 .. 01 49999 0- 149998 OTI97O 5 .. — — 0*12970 6 ,, — — 0-13640 IO ,, — — 0-14725 15 .. — — 0-14963 20 ,, — — 0-14995 24 „ - 014999 ‘ 1 Remark.— T he limit to which all are approaching is 0.150 : the differences in the smaller spaces become rapidly inappreciable, so that the numbers have been omitted after the fourth hour. “ This is on the supposition that diffusion of the vitiated air is uniform ; if it be not uniform the case is rendered, if possible, worse, for it then argues a stagnation of air and a continually increasing impurity in some part of it; that part is usually the upper part in a lofty room, and this will always be the case unless there be ventilating openings at the top, either in the ceiling or at the top of the walls. Such a space of stagnant air is favourable for the retention of organic particles, which may at any time be sent into the breathing space of the room, to the danger of the occupants. Therefore, although with care it is possible to keep a lofty ward in good condition, it becomes much more difficult, and the difficulty is not counter- balanced by any material advantages. From the foregoing table it may be seen that there is practically no difference in favour of 1,400 over 1,200 cubic feet, for, if we stop, as is usually done, at the third decimal place, the conditions are identical at the end of the second hour. Even in the exaggerated case of 10,000 cubic feet of space per patient, the conditions are practically the same after 10 hours, that is, one night’s occupation, and absolutely the same after 15 hours. “ When, therefore, we take into account the increased difficulty of warming, and the greater cost of construction, there seems little or no advantage to be gained by passing a certain limit in height. We must, however, look at the limit from another point of view, namely, the practicability of ventilation. We can hardly hope to change the air much oftener than three times in the hour, and as 4,000 cubic feet is the minimum that ought to be given hourly in hospitals, the third of this, or 1,333 cubic feet, ought to be provided as air-space per head. Now, if the floor-space be 108 square feet, this would argue a height of 12.35 f eet . or 12^ feet would give 1,350 cubic feet, which multiplied by 3 would yield 4,050 cubic feet; this slight margin would allow for the space occupied by the furniture and the inmates themselves. I do not, therefore, see any necessity for raising the wards beyond this height, certainly not beyond 13 feet. On this question I may point out that Captain Galton in his Report (page 7, line 31), has also put 13 feet as a limit which need not be passed. I hope I have shown reason for not going beyond this, because the acceptance of this principle will prove, I believe, more convenient in practice, and will save some considerable outlay in the original construction. " As regards vieans of ventilation, it ought to be remembered that in cold weather in this country, warming part of the air is necessary, if a sufficient supply is to be brought in for sanitary requirements. For this purpose, air brought in directly from without over coils of hot-water pipes is the best for a large ward. Heated air brought through basement stories is always unsatisfactory, and seldom pure. As regards outlet, if a number of Sheringham valves be provided close to the ceiling, these will act very well; or they may be supplemented by extraction shafts at the corners, as suggested in Captain Gabon's Report. But in * The formula from which this table is calculated is (1 — e ~ 4 °^° h ) , where e is 2.718, h = the hours of occupation, and c = the size of the air-space, E 52 Norfolk and Norwich Hospital. the upper-storey wards the opportunity may be taken to have central extraction through the ridge of the roof, by three or four openings in the ceiling, communicating with shafts surmounted by extraction cowls. The lighting of the wards by gas may also be adapted, by means of sunlights, to aiding the outgoing current. One thing to be remembered is that the upper storey must have more proportional ventilation opening than the lower — in the ratio of about 5 to 4 — so that, if a total of 72 square inches per head be allowed on the ground floor, 90 ought to be allowed on the upper floor. These numbers include outlet and inlet area. “The advantages of impermeable floors, walls, and ceilings so as to obviate the necessity of constant scrubbing, and to admit of immediate drying when scrubbing is resorted to, are sufficiently obvious. "II. The operating block ought to be connected by means of a short corridor, at right angles to the main corridor, as shown in the amended plan of B. “ The theatre ought to be ventilated by means of ceiling outlets, with fresh air brought in below, warmed in winter. Perhaps the best plan would be to provide perpendicular tubes (such as those known as Tobin's), which would supply air continuously, whilst the place could be warmed with hot water when required. “ The small wards ought to be arranged so as to admit of a constant supply of not less than 5,000 cubic feet of air per head per hour. A floor-space of 140 square feet, and a height of 12 feet, would give a cubic space of 1,680, and this changed three times in the hour would supply 5,040 cubic feet of fresh air. In surgical cases it is not unfrequently desirable to have even more than this, and this can be accomplished if the air be warmed. These wards, not admitting of cross windows, ought to have perpendicular tubes brought to the inside walls, so as to ensure a supply of air on all sides. Two tubes, each 25 square inches in sectional area, ought to be supplied for each inmate. Besides the chimney, an outlet shaft might be carried up through the roof. “ III. The isolation wards would be treated on similar principles, but a floor-space of not less than 150 square feet should be given, and 120 square inches of outlet and inlet opening. “ In every case it ought to be laid down as a principle that fresh air is not to be sacrificed to considerations of temperature, except of course in very extreme and exceptional conditions. Most cases do well at comparatively low temperatures; and extra covering, if general means of warming should fail, is much more advisable than the closing up of ventilators. “ For the smaller wards the use of a “ Calorigen ” would probably be convenient for combining warmth and ventilation. “ IV. The ventilation of the out-patient rooms is of great importance. I have tested the air in such places during the time of occupation and found the amount of impurity to be excessive, producing a condition of matters offensive and injurious to both doctor and patient. The proposed out-patient room may be ventilated by providing outlets through the roof, and inlets in the form of perpendicular tubes. Of these I should propose about 20, each about 7 inches square, or 8 inches in diameter if circular ; the room of course to be warmed sufficiently, either by fires or by hot-water pipes. “ V. It is of importance to secure the warming and ventilation of the chapel. This may be done by roof outlets, with fresh air brought in over hot-water pipes, or with perpendicular tubes delivering cold air into the warmed building. “ VI. For the comfort and health of the resident medical officers, pupils, nurses, &c., I would recommend the plan of Tobin for ventilating the sleeping rooms, viz., cutting a hole between the two sashes of the windows, so as to allow a current of air to come in vertically while the window is shut. This plan is well adapted to ordinary rooms. " VII. I would call attention to the necessity for very great care with regard to the laundry and disinfection chamber. The most complete separation between the foul and clean linen ought to be secured. It seemed to me that this was not satisfactorily accomplished as regards the disinfe&ion chamber when I visited it, and I called the attention of the members of the Committee present to the fact. "VIII. I presume care will be taken to secure a perfect system of drainage, including thorough ventilation of soil-pipes, the emptying of sink-pipes, bath-water pipes and rain-water pipes freely in the open air over gratings, and as complete disconnection as possible between the house and the drains. "IX. It is most desirable that every ward in the hospital should be periodically evacuated and left empty for some time, at least a month in the year. During that time cleaning could be carried on, as well as the freest perflation of air. As I believe it is contemplated not to fill all the wards at once, this plan may be easily carried out. " X. Lastly, I beg to call attention to the necessity of responsible sanitary supervision. This is cogently urged by Mr. Netten Radcliffe in his Report, and I am glad to add my testimony in support of its necessity." Norfolk and Norwich Hospital. 53 It will be noted as singular in the following detailed description of the building that the points most urged upon the Board of Management by both Captain Galton and Dr. F. De Chaumont have been ignored in the acftual construction of the building. Site . — The buildings stand upon nearly the highest ground surrounding the city of Norwich. The main front faces the Newmarket Road, but all other sides are at present bounded by open gardens, excepting on the north side, where there are a number of small cottages. The extent of the site is about 233,194 superficial feet, or 5 acres 1* roods, being about 1,070 superficial feet per bed. Subsoil . — The subsoil is principally a loamy gravel, intermixed with occasional veins or patches of clay. General Arrangement . — The accompanying plates show, by a block plan, the general arrangement of the buildings upon the site, also a plan of the principal floor of one pavilion, and detailed plans and sections of the ward offices ; a perspective view of the exterior of the building is also illustrated. The principal entrance to the establishment is from the Newmarket Road ; there is no porter’s lodge. The building is entered through Block A, and this portion of the building contains upon the ground floor a secretary’s office, porter’s office, visitors’ waiting room, board room, library and surgery, and, adjoining the main connecting corridor, a dispensary and matron’s store rooms. A large and well-lighted hall is placed in the centre of this block, and is available as a general waiting room for patients and others. On the basement floor, immediately beneath the large waiting hall, there is a kitchen, and surrounding it -the scullery, stores, servants’ hall, and other usual domestic offices. This kitchen is both lighted and ventilated by a large shaft, about nine feet square, carried upwards from the centre of the ceiling through the large waiting hall above, and terminated with a glazed lantern light. There are two windows, opening on to small areas, at one end of the kitchen, but the principal light and ventilation is obtained through the shaft here described. Leading right and left from this kitchen there are two corridors, communicating with the pavilions on either side, chiefly for the purpose of conveying food to the lifts. This is an objectionable feature in the plan of the building. Leading off these corridors, and on either side of the kitchen, there are two chambers containing apparatus for heating water for the baths, lavatories, &c., and also for warming the wards and other offices. The front portion of this Block A is carried up to form first and second stories, the rooms of which are devoted to the use of the house surgeon, matron, and other officials and pupils. Block B is one storey only in height, and contains the operating theatre, with three adjoining wards for two patients each and three for one each, also a duty room, nurses’ room, bath room, and other usual offices. Block C is a double pavilion, two stories in height, and contains, on the ground and first floors respectively, two large wards for the accommodation of 24 patients each, and two separation wards for two each. The central portion of this building is carried up to form a third storey, containing two separation wards for two and one for three patients each. Block D is also a double pavilion, two stories in height, containing two large wards for 24 patients each, two for 17 each, and four separation wards for two each. The E 2 54 Norfolk and Norwich Hospital. central portion of this building is carried up to form a third storey, similar to that of Block C, but the rooms are used as dormitories for the domestic servants. Block E contains on the ground floor a nurses’ dining hall and a chaplain’s room, and on the basement a patients’ bath room. Block F is a chapel. ' Blocks H, I, K and M comprise the only remaining portions of the old hospital. Block H has been adapted on the ground floor to the purposes of an out-patients’ department, with surgeons’ and physicians’ rooms, a dispensary, and a museum. The first floor is divided into nurses’ dormitories, with a day room, kitchen, and other offices. Block I contains on the ground and first floors four isolation wards, with nurses’ dormitory, duty room, and other attached offices. Block K is the mortuary and post-mortem room, L is a carriage shed, and M out- houses, N is the laundry, and O a disinfecting closet. Total Accommodation . — The total number of patients provided for is, therefore, 218 — viz., six wards for 24 patients each, two for 17 each, one for 3, 17 for 2 each, and three for 1 each. Connecting Corridors . — The central administrative block and the two main pavilions are connected together by corridors x x on plan, 10 feet wide and 10 feet 6 inches high ; the roofs form a means of open air communication between the pavilions, and ambu- latories for the use of the patients. The corridors throughout the buildings are heated by coils of hot water pipes. The floors of the ground storey are paved with blocks of pitch pine, 3 inches square and 18 inches long, laid in diagonal patterns upon concrete, and bedded in hot tar ; a bordering next the walls is formed with Staffordshire coloured tiling. Water Supply . — The water used in this establishment is supplied by a water company; all the outside pipes are of iron, but inside they are of Id&d. Drainage . — The drainage of the various buildings is effected by means of three 12-inch earthenware main drains, connected with the city sewers, but intercepted near the boundary o£the building by traps having open man-holes for access and ventilation; two of these main drains are connected to the furnace chimney shaft, with a view to the extraction of any foul air. There is in each pavilion a flushing cistern, capable of holding 200 gallons, connected to each end of the main drains, so as to thoroughly scour them out when desirable. Lamp and inspection holes are provided at all suitable parts, and the architects believe that every precaution has been taken to make the system perfedt. Area Covered . — The area covered by buildings is 51,640 feet, or nearly a quarter of the site, and about 237 feet per bed. Cost . — The value of the land is estimated at £10,000, or about £46 per bed. The buildings are not yet completed, and the cost of them cannot, therefore, be stated exactly, but the architect estimates that it will not exceed (including the laundry, which was eredted some years since) £54,000, or about £248 per bed. It should, however, be borne in mind that part of the administrative and the out-patients’ department consists of old buildings. The land and buildings together will therefore cost, according to the architedVs estimate, £294 per head. Hospital Construction and Management. Norfolk • and • Norwich Hospital o. {fentJatin O hajt c 0 L, GJarcL ■ M ♦ II- 1 Gdfa. rai 1 F\ Udmuu.it ratiuz Offlctz B. Operating ^ l/icalrc <&■ GJardo CD *J*c^ GJardo E. J/urots ©t riinaf Jja.ll F. Chape . / J. tio/dtion. GJardo W.Out-patLento JYurjC3& L.M. OWj Y^.Jjortuarj N . Jaundry O. ljninjecfina Clood I / x x. Cdnnecfiny^ L Co rrcdoro Secti ion * on * Line RB • dddd. 0 y James Akermaa,6 Queen Square W C H Saxon Snell del 55 Norfolk and Norwich Hospital. Principal Sick Wards. The following description refers more particularly to the wards on the upper floor of Block C : — Aspect. — All the pavilions run from north-west to south-east, so that the windows of the wards face north-east and south-west. Size of Wards. — The large wards are of parallelogram shape ; they each contain 24 beds; ‘their extreme length is 100 feet, their width 26 feet, and their height 14 feet. The superficial floor space of each, after allowing for the canted ends, is 2,591 feet, or about 108 feet per bed, and the cubic contents 36,274 feet, or 1,511 feet per bed. Bed Space. — The average lineal wall space per bed is 7 feet 10 inches, the entrances to the towers at the ends being deduced. Windows. — There are nine windows in each side wall, and their total effective glazed surface is 305 superficial feet, or i2f feet per bed. If, however, the end window be taken into account, the effective glazed surface is 367 superficial feet, or 15J feet per bed. When the windows next the beds are opened to their fullest extent, the total area through which air can be admitted by them into the wards is 147 superficial feet, or 6J feet per bed ; but if the end windows be added, this area is increased to 204 feet, or feet per bed. The windows next the beds are each divided into two heights by a wooden transom. The upper part consists of a sash hung upon its lower rail, and opening inwards to the extent of about five inches at the top ; the lower part is an ordinary deal-cased sash and frame. The two side windows in the end wall of the ward are similarly constructed, but the lower part of the central window is a folding casement opening on to a verandah. All sashes are glazed with 21 -ounce sheet glass. Warming. — Dr. F. De Cliaumont advised in his Report that air should be brought into the wards “ directly from without, over coils of hot water pipes,” and Captain Douglas Galton recommended the use of open “ ventilating fire-places.” In this case it was deemed advisable to follow the advice of these gentlemen, and, in consequence, it was determined by the authorities to warm the principal wards by means of two double “ Thermhydric Hot-water Grates,” inasmuch as these apparatus combine in their con- struction the above desiderata. See page 62.* Ventilation. — The ventilation of the wards is in principle similar to that of St. Thomas’s Hospital, previously described. The water-closets and bath rooms in the angle towers are separately ventilated, by means of coils of hot water pipes placed in chambers beneath the louvred turrets which crown each roof, and an upward current is thus induced through the flues which rise into these chambers from the floors below. The outer air is admitted through gratings, first into casings formed between the brickwork and the panelled window backs, and then into the rooms through “hit or miss” gratings fixed in the wooden capping over these casings. Lighting. — Each of the wards is lighted at night by two sunlights, having ventilating tubes, which rise upwards through the ceiling, and then travel horizontally to flues in the side walls ; they no doubt act, when lighted, as powerful additions to the other contrivances provided for the removal of foul air from the wards. * Also, Charitable and Parochial Establishments. London, 18S1. 56 Norfolk and Norwich Hospital. Floors . — The flooring of the upper wards is constructed with wrought-iron joists and concrete, but that on the ground floor consists of timber joisting laid on two sleeper walls, which run longitudinally down the centre, and so form a passage-way, four feet wide, for the conveyance of the hot and cold water pipes running to the offices in the angle towers at the ends of the buildings. The finished surfaces of the floors are formed of pitch pine tongued and grooved battens, inches thick and 5 inches wide, stained, beeswaxed, and oil polished ; the ceilings are plastered. Walls . — The outer walls of the wards are built throughout with brickwork 18 inches thick, finished on the outside with red bricks and Bath stone dressings. The interior faces, to a height of 4 feet 6 inches above the floors, are rendered with parian cement, and the remainder with ordinary plastering, prepared for painting. W.C.'s, Baths, &c . — The water-closets, baths, and other sanitary appliances are situated in towers which jut out from the angles of the extreme ends of each pavilion ; these towers are separated from the wards by cross-ventilated lobbies, about four feet square. The arrangement of these offices shows a marked improvement upon that of many other hospitals illustrated in this work, and is well worthy of study. They are warmed with coils of hot water pipes, and the temperature can always be kept higher than that of the adjoining wards ; consequently, the tendency is rather that air shall be drawn from the ward than that it should flow in an opposite direction ; then the arrangement for drawing off any vitiated air, as previously described under the head of “ ventilation,” is very satisfactory. The tower on the left hand side of each ward forms on each floor a bath room, and is fitted with a “ Rufford’s” porcelain bath and two enamelled iron lavatory basins fixed in slate shelves ; the area of this room is about 84 superficial feet. The tower on the right hand side contains on each flcor two somewhat irregularly shaped water-closets, 3 feet 4 inches wide, and an average length of 4 feet, fitted with “ Dodd’s” patent white earthenware pans and traps and plain deal seats; there is also a compartment in the centre, fitted with “Beard and Dent’s” enamelled iron slop sink, 14 inches square, with shelves on each side for the bed-pans. The partitions dividing the various compartments are about seven feet high, and it is worth noting that the lower parts of these stand four inches above the floor, so that the air will more readily circulate around them. All the soil pipes are of lead, and are carried down the inside of the walls of the buildings, and they are open at the top, above the level of the eaves, for the purpose of ventilating them. Verandah . — The casement windows at the ends of the wards open on to verandahs, 5 feet wide and about 25 feet long, intended for use as lounging places for the patients when the weather is suitable, but, as I have pointed out in another instance, they are in too close proximity to the water-closets to be commended. Separation Wards . — There are two separation wards on each floor, situated in the centres of the double pavilions. Each one is intended for the accommodation of two patients, and has an area of 243 square feet, and are 14 feet high, so that the occupants of them would each have about 122 superficial and 1,702 cubic feet of air-space. Duty Rooms . — The nurses’ duty rooms have each an average area of 107 feet, and they are fitted with gas cooking ranges and hot closets. 57 Norfolk and Norwich Hospital. Nurses' Rooms . — In addition to the duty rooms, and adjoining each large ward, there is a nurse’s room, having an average area of 107 feet. Lifts . — Each double pavilion is provided with a food lift, 4 feet long and 2 feet 9 inches wide, which descends to the subway situated in the basement ; there is no bed lift for the use of the patients. At the side of each of the food lifts there is a cupboard for the temporary deposit of dust, &c. Staircases . — The pavilion staircase, in the wing first built, occupies an area of 332 feet, and is constructed of teak, on ordinary timber carriages. The treads are 4 feet 6 inches long and 12 inches wide; the rise is 6 inches. The staircase of the pavilion now being erecfted to the right of the main entrance descends to the basement, but that to the left, first built, does not do so. Total Area of Pavilions . — The total area covered by each floor of the double pavilion just described, including the surrounding walls, is 8,924 feet, or about 172 feet per bed. I ST. MARYLEBONE INFIRMARY, NOTTING HILL, LONDON. This Infirmary was erefted for the accommodation of the sick poor of the Parish of St. Marylebone. The foundation stone was laid July 7th 1879, by Mr. Edmund Boulnois, M.A., Chairman of the Board of Guardians, and on June 29th 1881, rather less than two years afterwards, it was formally opened by their Royal Highnesses the Prince and Princess of Wales, in the presence of a large and distinguished assembly. Being the architect of the building, I cannot well say much as to its merits or demerits, beyond stating that the details of it embody to a great extent, and so far as the limited means at my disposal would permit, the result of previous experience in the design and erecftion of five other large Metropolitan Infirmaries, and that the inducement to give it a place amongst these memoirs arises from the high commendations passed upon it by some of the most eminent authorities upon the subject of hospital con- struction. It must not, however, be supposed that I consider it to represent the model of a perfect hospital building: the limited extent of the site would alone render this impos- sible ; nevertheless, it is allowed to be “the most perfect building of its kind yet erected.” Workhouse Hospitals contain a large proportion of patients suffering from maladies of a non-acute character, though surgical cases and all classes of diseases (other than those of an infectious character) are admitted ; the proportion of these is, however, so small as compared with those in ordinary hospitals, that the average area and cubic space per patient is made much less. It would not, however, appear that this reduction in the size of the wards makes a proportionately large difference in the first cost, for the extent of the ward offices, and of the administrative departments of the building generally, are necessarily the same in both. The actual cost of erecting this building, for example, was at the rate of £ 161 per bed ; but had the wards contained 1,200 instead of 936 cubic feet per bed, the total cost of the whole would not have been increased by more than ^10,000 ; that is to say, it would have been £175 instead of £161 per bed. Site. I his building is situated in one of the western suburban districts of London, near the Ladbroke Grove Road, Notting Hill, in the parish of Kensington. At the present time it is surrounded by open fields, excepting on the east side, where it is separated by a road from the end houses in Rackham and Treverton Streets. According to the original plan of laying out the adjoining ground, public roads were to have run down either side of the northern and southern boundary, but since the occupation of the building the road and a piece of land on the southern side have been purchased and added to the site, and it is possible that a similar improvement may be made upon the northern side. It is much to be regretted that this additional ground was not acquired in the first instance, as the planning of the building could have been much improved and especially so by placing the pavilions at a greater distance apart than they are at present. Hospital Construction and Management. St. Marylebone Infirmary. 59 The fall of the ground from the south-east to the north-west corners of the site is nearly 15 feet, and, inconsequence, the ground floors of the western pavilions are at a lower level than those on the eastern side. The original extent of the site was 140,225 superficial feet, or 3J acres nearly, being about 188 feet per bed ; but now that more ground has been purchased, the area per bed is about 264 feet. Subsoil . — The subsoil is of brick earth, overlying the London Blue Clay, but every part of the site has been well drained. General Arrangement . — The general disposition of the buildings upon the site, and detailed plans of the principal sick wards, are shewn upon the accompanying plate, page 60, and a perspective view of the exterior is also illustrated at page 58. The principal entrance to the main building is through the centre of the block marked A on the plan of site. This building contains on the left of the central roadway the medical officers’ residence, and on the right the residences of the matron and the assistant medical officer. Immediately over this central gateway and entrance there is a chapel for the use of the officers and convalescent patients. Block B contains on the basement floor the helpers’ and men-servants' dining rooms, coal and beer cellars, and on the west side, which is level with the garden, the nurses’ dining and recreation rooms and library, and a servants’ hall ; on the ground floor an en- trance and waiting hall, male and female reception wards and bath rooms, dispensary and drug store, committee room, matron’s office and stores, steward's office and stores, kitchen, scullery, bakehouse and larders; the first floor is entirely occupied by the nurses’ bed-rooms. Block C contains on the basement a furnace, engine and well room ; the engineer’s residence is situated at the west end of this block ; on the ground floor there is a large store for patients’ own clothing, a disinfecting closet, and a store for clean linen when brought from the laundry above. At the east-end of this block there is a mortuary and post-mortem room, entered from the outside, and separated from the main building by an open court ; on the first floor there is a laundry with drying horses ; on the second floor an open drying ground surrounded by arched openings, and the third and top floor a wash-house and laundry. Blocks D D D D each contain on their ground, first, and second floors, six sick wards, each for 28 beds, -with attached offices, as described in detail hereafter, and nine separa- tion wards for the accommodation of two patients each. Block E is a porter’s lodge, which has been ereifted since the purchase of the additional ground. The porter’s lodge originally formed part of the entrance, block A. The ereeftion of a nurses’ home is contemplated, and it is proposed that it shall be placed upon this additional ground, at the point indicated on the block plan by dotted lines, and marked F. Total Accommodation . — Provision is thus made for 744 inmates — viz., 36 wards for two beds each, and 24 wards for 28 beds each. The following detailed account of the space allotted to each of the various offices of this institution may possibly be useful to the designers of workhouse hospitals to be erected in the future : — 6o St. Marylcbone Infirmary. Pavilions Generally. Area in feet. 24 wards, each for 28 beds, and each ... 2,016 36 separation wards, each for 2 beds, and each average i 200 6 day-rooms 5 20 4 day-rooms 4 24 nurses' duty-rooms, each ... 24 bath rooms Administrative Offices. Area in feet. ... 514 ... 202 203 ... 58 Vestibule Area in feet. ... 250 Entrance hall and waiting-room 1,080 Porters’ office ... 270 Two receiving wards for males and females, each 347 One bath-room and w.c. to each, and each... 165 Chapel (over entrance gateway) to about 230 seat 1,800 Vestry (with w.c., lavatory, &c.) 240 Committee room 775 ,, ,, w.c., lavatory, &c. Dispensary ... 617 Matron's office ... i95 Steward’s office ... 178 Medical officers’ consulting room 195 ,, ,, drawing-room . ... 395 ,, „ dining-room 348 ,, ,, breakfast-room 348 ,, „ study ... 207 ,, ,, kitchen 270 ,, „ scullery 113 ,, ,, larder, coal and wine cellars 161 ,, ,, bed-room . ... 282 11 i» II •••••• •• 230 11 11 It ••• ••• •• 196 11 11 II ••• ••• •• . ... 143 II il 11 ••• ••• •• . ... 109 „ ,, bath-room • 9i ,, ,, w.c.'s and china closet, &c. Assistant medical officers’ sitting-room 250 i, 1, ,, bed-room .. • 213 1, ,, „ kitchen • ... 95 ,, ,, „ bath-room, and sink.. W.C. 90 Matron’s sitting-room 270 „ bed-room . 218 ,, ,, • 99 ,, kitchen . 123 ,, bath-room, w.c. and sink • ... 90 ,, larder, coal store, cupboard, Dispenser’s sitting-room &c. 152 Additional officers’ sitting-room ... . . ... 246 1, „ bed-room ... . . ... 246 Engineers' living-room 235 ,, kitchen 170 ,, scullery 55 ,, pantry, coals, w.c., &c. Engineers’ bed-room 29 Nurses' rooms, each (average) 4 .. .. 10 ,, ,, 2 ,, ,, 2 bath-rooms, w.c.'s, and sinks, each General kitchen Scullery Bakery Servants' hall Officers' recreation room „ mess ,, ,, reading ,, ,, cloak room, lavatory, w.c.'s ,, scullery Female helpers' dining-room ,, sitting-room Male officers' dining-room Store-rooms, larders, &c Inmates’ clothing store General coal-cellar, with two lifts for raising coals to ground floor Laundry, &c. Receiving room Wash-house Officers' wash-house Drying-room, with horses Covered drying ground Ironing and folding room Clean linen store and delivery room 2 Lifts and shoots for raising and lowering clothes Laundresses’ living-room ,, bed-room Workshop Engineers’ shop and boiler-room Engine-room Artesian well and pump-room Furnace coal-cellar Disinfecting closet and ante-room to ditto, w.c., dust-hole, &c., &c. Dead-house Post-mortem room Gardeners’ tool shed Area in feet. 232 ... 152 ... 80 54 ... 100 ... 120 — 133 ... 150 77 1,840 330 240 425 621 613 425 137 105 500 300 300 3,663 544 3,840 492 1,625 492 475 2.055 1,580 432 180 no 426 1.570 287 286 470 426 291 217 35 Hospital Construction and Management. Photo -Lithographed it TVmted by James Akrrmaa,6 Queer. Square ,W C H Saxon Snell . del St. Marylebone Infirmary. 61 Connecting Corridors . — The main corridor connecting together the various blocks of buildings is io feet wide; it runs through the centre of each double pavilion, and has passages six feet wide leading off from it to the various wards. It is enclosed with ordinary double hung sashes, and it is so roofed as to form an ambulatory for the use of convalescent patients. Water Supply . — The building is supplied by water from an artesian well, having iron cylinders 6 feet diameter sunk firmly into the upper stratum of London Clay, so as to stop out all surface water, and continued downwards with a brick shaft 5 feet diameter, to a depth of 235 feet below the surface, from thence cast-iron pipes 12 inches diameter are carried down to the level of the chalk, found at a depth of 289 feet below the surface and then a bore hole is sunk to a further depth of 213 feet ; the total depth of this well is, therefore, 502 feet. Provision is made that in case of failure from repairs being required to the pumps or other causes, the supply can be supplemented from the mains of the Grand Junction Water Works Company, and these mains are continued to all the principal buildings, and to other parts of the buildings where it has been thought best to place hydrants for the protection of the building in case of fire. Drainage . — The drainage of the establishment is effected by means of glazed earthen- ware pipes, 6 and 9 inches diameter, leading respectively from the various soil and rain water pipes to four main drains 9 inches diameter, running midway between the five principal blocks of buildings into a brick culvert situated beneath the road on the southern side of the site, and thence into the parish sewers. The main drain from the laundry to the brick culvert is about 12 inches diameter. Area Covered . — The area covered by buildings is 60,658 superficial feet, or nearly half of the original site, and 8i£ superficial feet per bed. Cost. — The total cost of land now acquired has been £1 1,500, or about £15 95. 0 d. per bed. The buildings and their appurtenances, including engineering works and fixtures of every description, also professional fees and clerk of works’ salary, cost £120,037, or about £161 per bed, so that the total cost of both land and buildings was at the rate of £176 9 s. o d. per bed. Principal Sick Wards. The main sick wards of this building are, like those of the Herbert Hospital, planned as pavilions, in pairs, connected together, in each case, by a staircase, duty and day rooms, and other offices. Each double pavilion contains three floors of wards. A detailed plan of one floor is shewn upon the accompanying plate, at page 60. In accordance with the rules laid down by the Local Government Board for the planning of this class of building, the superficial and cubical contents of the principal sick wards are, as has already been stated, somewhat less than obtain in ordinary hospital buildings ; but little difference was shown to result in the total first cost of the two kinds of structures, inasmuch as the attached offices and the administrative departments generally cannot be correspondingly reduced in size, and the latter generally form the larger portion of a hospital building. Aspect . — The axes of the pavilions run nearly direiftly north and south, so that the windows of the wards face east and west. 62 St. Marylebone Infirmary. Relative Position of Pavilions . — The height of the pavilions, as measured from the lower floors of the sick wards to the junctions of the upright lines of the outer front walls with the sloping lines of the roofs, is 39 feet 6 inches, and the least distance between any two pavilions is 75 feet, or about 1-9 times the height. Size of Wards. — Each ward is of parallelogram shape, contains 28 beds, and is 84 feet long, 24 feet wide, and 13 feet high. The total superficial floor space is, therefore, 2,016 feet, or 72 feet per bed, and the cubic contents 26,208 feet, or 936 feet per bed. Bed Space . — The average lineal wall space is 6 feet per bed. Windows . — I much regret to have found it impossible to induce my clients to admit the introduction into this building of the casement windows, usually adopted by me for pavilion wards, and described in another part of this work : 0 as it is, the windows, of which there are seven in each side wall, are ordinary double-hung sashes, glazed with 2 1 -ounce sheet glass, and the total area of their effective glazed surface is 406 feet, or 14^ feet per bed. When all the windows are opened to their fullest extent, the total area through which air could be admitted by them into the wards would be 225 feet, or about 8 feet per bed. Now, had the windows been of the combined casement form I so strongly recommend, the air area would have been at the rate of about i2§ feet per bed; moreover, in the latter case the head of the patient being protected from draught, the casements could be fully opened at all times and independently of the quarter from which the wind was blowing, whereas the present windows can only be opened when the wind is in a favorable direction ; otherwise the patients, as they lay in bed, would suffer from the effects of draughts. Warming . — The system adopted for warming these wards is that of open fireplaces, combined with hot water heating pipes, on a principle invented by myself. This apparatus is known as the “ Thermhydric Grate,” and its construction, as shewn upon the accompanying plate, f is such that the sides, back, and top of the fire are surrounded by a wrought-iron case containing water, and communicating by means of short tubes with upright coils of pipes so placed on either side that the water when heated by the fire circulates through them. Thus the whole of the products of combustion are utilized for heating purposes, and it will be seen that as the water cannot attain a temperature higher than 212 0 Fahrenheit, the iron over which the air passes cannot, as is the case with the ordinary air body stoves, be so heated as to burn the air impinging against its surface. As the water in the apparatus becomes warmed it expands and rises into the vase placed upon the top of the apparatus, and the slight vapour that is consequently emitted from this vase serves to moisten the air of the rooms in which the apparatus is placed. It will be seen that when, as shewn by the accompanying plate, the apparatus is placed in the centre of an apartment, the smoke has to descend and run in horizontal pipes beneath the floor before entering the brick upright flues. The channel containing these horizontal flues is also made to serve the purposes of a duct for fresh air to pass from the outside round the stove and through the heated coils of pipes into the room. Stoves, * See also, Cliariluble ami Parochial Establishments, page 19. f Ibid, page 2i, for drawings to a larger scale. Hospital Conspii yQ stall hr Centra! dhermhudric Ctouee n THE THERMHYDRIC VENTILATING HOT WATER OPEN FIRE GRATE H. SAXON SNELLS, PATENT. l^otted lines dt&C4\ Ji Qtr inftfj I f THIS INVENTION CONSIST S Of AN OPEN FIRE GRATE SURROUNDED ON THREE SIDES AND ON TOP BY A WROUGHT IRON CMAN8ER CONTAINING WATER WHICH WHEN WARNED BY THE FIRE CIRCULATES THROUGH UP RIGHT COILS Of PIPE6 PLACED OH EITHER SIDE THE HEARTH IS MAOE OT IRON AND THE WHOLE SPACE BELOW THE GRATE AND PIPES IS TORNED INTO A CMANBER FOR THE AOMlSSION ANO COLLECTION OF AIR FROH THE OUT SIOE THE OUTER FRESH AIR THUS AONITTED PASSES UPWAROS ANO IMPINGING AGAINST THE SIDES OF THE HOT WATER CHAMBER AMO PIPES BECOMES THOROUGHLY HEATED WITHOUT BEING BURNT BEFORE ENTERING THE ROOM THE OBVIOUS ADVANTAGE POSSESSED BY THIS GRATE IS THAT UNLIKE ALL OTHER 9UCM INVENTIONS THE AIR CANNOT BE BURNT OR HEATED ABOVE THE TEMPERATURE OF BOILING WATER ANO THE WATER CONTAINED IN THE VASE BEING SLIGHTLY WARMED it EVAPORATES ANO THUS KEEPS The AIR OF THE ROOM MOIST MANUFACTURED BY Messrs POTTER (3- SONS 298 Oxforo Street. W the height of the Chi Tfincu Shaft above the floor tine should be at least 26 feet and u/here possible U is better to arrange that all the upright flues may be swept from the ground or basement .6 -Jt.J vJcchon thro 1 1 mmm a mm i mmm mmm. v we* ' mmm mmm mmm. mmm. wwi mmm mmm mmm m. ci*/ Jaot Phoio Lithographed Iffrinted hj James Alcermao 6. Queen Square ,W C UBIHB M ana gem exit S" jii/cQi'ftce // \farc/e. 13,73 thro v3tocjc c h O/o nt Urfi JL cU/a. \Jcchon thro fresh air Q^n/cf St. Marylebone Infirmary. with descending flues, are generally found to smoke when the flue gets cold, through the fires being neglected or from their being let out during the night, but this difficulty is surmounted by encasing the horizontal iron flue pipes (as shewn) in sand, where they pass through the floor. The sand retains the heat of the flue for many hours ; and it is only once, therefore, if at all, and then at the beginning of the winter, that the flue will require “ piloting.” These Thermhydric Fire-places have been patented, and they are manufactured by Messrs. Potter & Sons, of 44 South Moulton Street, London, W., from whom all in- formation respecting them can be obtained. They may also be seen there in operation, as well as at St. George’s, St. Olave’s, St. Marylebone, and Holborn Infirmaries ; also at the Norfolk and Norwich Hospital, and at many other important public buildings. Those at St. Olave’s Union Infirmary, in Lower Deptford Road, Rotherhithe, maybe compared with other central stoves of an ordinary description working in the same building, and the following letter received from Dr. Shepherd, the Medical Superintendent of that establishment, describes the result of his observations on their action : — “ St. Olave's Union Infirmary, “Deptford Lower Road. “ Dear Sir, “ March 19th 1880. " It has occurred to me that you may be pleased to hear a good report of the Patent Thermhydric Warming Apparatus which have been in use in three of the large wards here during the past winter. I must confess that I was inclined to think, from the size of the fireplaces, that the old plan would give better results as far as warmth was concerned, even if at the expense of more fuel, but experience has proved to me that I was thoroughly mistaken. You will remember that of the six male wards, all built in a precisely similar manner, three are provided with simple open fire-places, and three are furnished with 'Thermhydric' apparatus, the fireplaces being in a precisely similar situation in all six of the wards ; this permits of an exact comparison being made, and, as a matter of fact, I have found the wards heated by the 'Thermhydric' apparatus to be from 3°F. or 4 0 F. to 5°F. warmer than those heated on the old plan, notwithstanding the fact, a most important one I think, that the ' Thermhydric ’ grates consumed about a third less fuel. " There are other and by no means unimportant advantages belonging to the ‘Thermhydric’ grates, but the above facts were, during the severe winter we are just emerging from, most striking and appreciable, and most incontestably in their favour. “ The impression left upon my own unbiassed judgment by the facts I have given is so favourable that I have felt bound in common justice to bring you acquainted with them. “ I remain, Dear Sir, " Yours faithfully, “R. SHEPHERD, "To H. Saxon Snell, Esq.’’ “ Medical Superintendent. As a further testimony to the value of these apparatus for the heating of hospital wards, it will be well to state the results of the tests to which one of them was submitted, in competition with other “air heating” stoves, at the Smoke Abatement Exhibition, held November 1881, at South Kensington, and the opinion formed of the apparatus by the Jurors. At page 88 of the Report * they say : — “Class 1. Air Heating and Ventilation: Wallsend Coals. — T. Potter & Sons' Thermhydric Grate stands at the head of the list for efficiency in virtue of the great expansion of radiating and air-warming surface developed in the hot-water tubes to the right and left of the fireplace, whilst excessive temperature of heated air is avoided." Official Report of the Smoke Abatement Committee. London, 1882. 6 4 St. Marylebone Infirmary. Then, on page 83, there is given the following results of the tests : — "Class r. — O pen Grates having ordinary Bottom Grids and Upward Draught. No. of Test. EXHIBITOR AND GRATE. Average rise of temperature per lb. of coal per hour. Average radiation per lb. of coal per hour. Air Heating — Wallsend Coal. Deg. F. Deg. F. 10 T. Potter & Sons, Thermhydric grate 5 16 535 19 A. B. Verrier, Comet grate 469 200 20 Do. do. 3 04 156 21 Rosser & Russell, Firebrick lining, fluted 385 5 7 1 23 G. Holler & Co., Kohlhofer's hot air stove 373 241 3 The British Sanitary Company, Enclosed grate 3 14 1 64 II Perceval & Westmacott, Parlour stove 2 98 298 26 E. H. Shorland (G. L. Shorland’s Patent), Man- chester grate, firebrick lining 216 1 77 6 ]. Wright & Co., Hygienic ventilating stove ... i ’55 146 Averages 337 288 9 Anthracite. J. Wright & Co., Hygienic ventilating stove ... 324 i ' 59 When not standing in the centre of a room, but next the wall, they are constructed in the manner shewn in the accompanying Figs. 4 and 5. HALF LONGITUDINAL HALF SECTION XX ELEVATION OOOO jc OOOO OOOO OOOO OOOO ’ x' OOOO OOOO oooor 1 il "x X PLAN Z Z Fig- 4. St. Marylebone Infirmary. 65 They are often enclosed in ornamental cases, one of which is shewn in the accom panying Fig. 5. . Fig- 5 - It will be seen by the next paragraph that an unusually large amount of ventilating area is provided for in these wards by inlet and outlet flues, which are kept constantly open during all seasons of the year; and as I was somewhat doubtful whether the Thermhydric stoves would, under the circumstances, be found always sufficient for supplying the requisite amount of heat, provision has been made for the addition of circulating hot water pipes down each side of the rooms. The experience of two winters, however, shows that the stoves are so far all-sufficient for maintaining the wards at a suitable temperature, and it has not, therefore, been found necessary to provide the additional source of heat referred to. A similar result has been experienced in the case of those fixed at the Norfolk and Norwich and other hospitals. In these two buildings two stoves were fixed in each ward, but in the other hospitals above referred to there is only one; consequently hot water pipes round the walls were, in these cases, provided in addition. Ventilation . — The ventilation of the wards is effected by purely natural means, and is dependent therefore upon the very simple and well-known fact that heated air will always rise to a point higher than that of the colder air surrounding it, and that in its passage it will carry away with it noxious gases, and other deleterious matters which would otherwise, by reason of their greater density, remain stationary or descend to the floor level. Behind the head of each bed, and next the floor and wall, there is a large hollow skirting box, the front of which is formed of perforated zinc ; this box is made so as to be easily lifted out of position for the purposes of cleaning, but when in its place it covers an aperture in the floor, from which a ventilating inlet pipe descends in a slanting direction to the outside wall, and through this pipe the external fresh air is admitted, first into the skirting box, and then out of it through the perforated zinc panels (situated under the heads of the beds) into the room. It was intended that hot water pipes 66 St. Marylebone Infirmary. should also pass through these boxes. In the ceiling immediately over, and between each pair of beds there are perforated panels running the whole width of the ward ; these panels cover large channels, the full depth (12 inches) of the floor, and these channels communicate at each end, with flues 14 inches by 9 inches, which run upwards in the thickness of the wall like ordinary chimney flues. Now, returning to the skirting box, it will be obvious that a greater part of the air passing into the room through the perforated front immediately under the head of the bed would be drawn upwards, and, passing through the perforated ceiling channel, be conveyed through the uprigfit flue and find an exit at its termination ; and it will be observed that the air in thus passing upwards from the skirting box to the ceiling must encircle, as it were, the space surrounding the head of the sick patient, and carry away with it his or her foul emanations. Thus, therefore, each pair of beds is provided with its own separate system of ventilation, whilst the general ventilation of the wards is supplemented by the central stoves previously described, and also by upcast shafts in the side walls. The total area of outlet and inlet flues in each of these wards is 15 feet, and no means are provided by which they can be closed, excepting in the case of four of the outlet shafts in the end walls which have doors that may be opened and shut as occasion may require. Lighting . — The lighting of the wards is effected at night by three gas pendants. The burners are placed under inverted wrought-iron japanned basins, with white fire-proof enamelled inside faces; and from the upper part of these basins galvanised iron pipes, three inches diameter, are carried along the ceiling ventilating channels, and thence into the upright flues described in the last paragraph ; thus, it is hoped, a greater part, if not the whole, of the produces of combustion is carried into the outer air. Floors . — The flooring is formed of ordinary timber joists covered with ij-inch tongued boards in half deal widths; the ceilings are plastered. Ventilation channels, as before described, communicating with upright flues in the outer walls, are formed in the ceiling over each pair of beds by the omission of the plastered ceiling between two joists, and inserting instead panels of perforated zinc, made easily removable for the purpose of cleaning. Walls . — The two outside walls are of brick, two feet in thickness and they are all much perforated with ventilating flues. The facings are of ordinary London stock bricks, and stone only is used for the cills of windows and other parts likely to be affected by the weather. All other walls are of similar construction ; those at the ends of the wards are 18 inches thick, but are perforated with ventilation flues. W.C.'s, Baths , &c . — The main ward water-closets, baths, and other sanitary appliances are situated at the extreme ends of each pavilion, and are cut off from the wards by cross ventilated lobbies, 6 feet wide. The buildings containing them are carried up above the ordinary level of the adjoining pavilions, and form towers, the upper parts of which contain hot and cold water cisterns for the supply of the various baths, w.c.’s, &c., beneath them. A fully detailed drawing of the general arrangements of this department of the building, to which considerable attention was given, has been published else- where,* and it will be sufficient, therefore, to state that there are on each floor two * Charitable and Parochial Establishments, page 17. London, 1881. St. Marylebone Infirmary. 6 7 water-closets, each 2 feet 8 inches wide, and 6 feet 3 inches long, fitted with ordinary blue earthenware hopper pans and traps, and with Underhay’s regulating water valves. The slop sink, which is placed in a recess next the water-closets, is formed of lead, 1 foot 10 inches long, 1 foot 7 inches wide, and 10J inches deep. The bath room is 9 feet 3 inches long, 6 feet 3 inches wide, and Contains a glazed fire-clay bath, manufactured by Mr. Finch, of Stourbridge, who also supplied the necessary brass fittings. The lavatory consists of one blue earthenware basin, sunk in a slate shelf. There are no urinals. The soil and waste pipes are well formed of cast-iron hot water socketed tubes, caulked with gaskin and red lead ; they are carried down on the outside walls, and are so arranged as to render it almost an impossibility that any foul air contained in them can enter the building. Leading off the staircase landings of each pavilion floor, and separated from them by cross-ventilated lobbies, there are water-closets for the private use of the nurses, and compartments containing slop-sinks for the purposes of the separation wards. Day Rooms . — Situated on each floor, and midway between the two large sick wards, there is a day-room, 39 feet 6 inches long, 12 feet 6 inches wide, with two bay windows, the total area being 540 feet, or about gf feet per patient, occupying the adjoining large wards. They are heated by open fire places, standing centrally between the bay windows. Separation Wards . — There are on each floor three separation wards, each for the accommodation of two patients ; they vary slightly in size, but their average area is 200 feet and their cubic contents 2,600 feet. Each patient has, therefore, 100 superficial and 1,300 cubic feet of air space. Duty Rooms . — Attached to and overlooking each large ward there is a nurses’ duty- room, having an average area of 203 feet. They are fitted with ranges, sinks, and racks and shelves for ward crockery, &c. The nurses’ sleeping and recreation rooms are, as previously described, situated in another part of the establishment. Lifts . — Adjoining the main corridor, and forming a centre round which each pavilion staircase winds, there is a lift, 8 feet 3 inches long and 5 feet wide, for conveying coals, food and patients from the lower to the upper stories. These lifts are each worked by an hydraulic ram, which descends into a brick well a depth corresponding to the extreme height through which the cage has to be lifted. Staircases . — The pavilion staircases, including the lifts, each occupy an area of 390 feet, and they and the corridors adjoining them are all fire-proof, being formed of Yorkshire stone, resting upon brickwork vaulting or iron joists and concrete. The steps are each' 4 feet 3 inches long, with a tread of 1 1 inches and a rise of 6J inches. Basement . — The whole of the ground beneath the various buildings is covered with a layer of cement concrete six inches thick. In each pavilion the only part carried down to lorm a basement is that immediately below the ground floor duty-room adjoining the staircase, and likewise the tower-building containing the nurses’ water-closets ; this basement is utilised as a coal store and also as a furnace-room, in which are placed boilers for heating the sanitary offices at the ends of each pavilion and providing hot water for the supply of the various baths, lavatories, sinks, &c. F 68 St. Marylebone Infirmary. Total Area of Pavilions. — The total area covered by each floor of these double pavilions, including the surrounding walls, is 8,336 feet, or about 149 feet per bed. A complete set of the plans and sections of this institution will be found in a work entitled Charitable and Parochial Establishments , published by Batsford, London, 1881, and before referred to. The erection of workhouse infirmaries is subjeeft to the control of the Local Govern- ment Board, and it will doubtless be both interesting and useful to learn the principles which guide this body, in their approval or rejection of any designs submitted to them. These principles are those laid down in the Report of a Government Committee, of which the following is a copy * : — " The Committee appointed by the Right Honourable the President of the Poor Law Board to advise upon the amount of space to be required in metropolitan workhouse infirmaries, and upon other allied matters, have had under their most careful consideration the questions proposed to them, and upon these questions, taken in their order, the Committee beg leave to offer the following observations and replies: "Question 1. ‘What amount of floor and cubical space should be allotted to the bed of each sick inmate in wards occupied both by day and night ; it being understood that fever and small-pox patients, idiots, and epileptics are for the future to be provided for in separate and distinct buildings ? ’ “ The essential condition of the needful cubic space is the maintenance, in the air which fills that space, of such degrees of purity and temperature as shall keep it free from danger to the health of those who habitually breathe it ; and this condition evidently involves the difficult problem of ventilation. The purity of the air within an inhabited space enclosed on all sides is necessarily vitiated by the emanations proceed- ing from the bodies of those who inhabit it, and especially by the effects upon it of their respiration. What is the precise limit between safety and danger from vitiation of that kind, science has as yet been unable to determine. Experience, and impressions made upon the senses, are herein more trustworthy guides than authority, which on this question has been strangely at variance with itself. “ It is stated in a Return laid before the Committee from the medical officers of 42 metropolitan and suburban workhouses, that in nine instances only of the 42 could any fads be alleged by them showing that patients in sick wards had suffered at all from overcrowding. In two of these nine instances the spread oj fevers was the evil specified; in one case, inconvenience; in another, retardation of cures and deterioration of health; and in the remaining five, slowness of convalescence; — were ascribed to that cause. "In another Return of 40 answers to the question, ‘Is the recovery from illness retarded by the existing accommodation and arrangements generally, or in any particular wards? ' 10 are in the affirma- tive, 21 in the negative, and nine are either vague, inconsistent, or not to the point. “ One very remarkable fact disclosed by these returns is the infrequency of childbed fever, and the small ratio of mortality produced by it in those houses ; where within the last five years nearly 12,000 poor women have been delivered. " The wards of nearly all the metropolitan workhouses and infirmaries have been visited, some of them more than once, by more or fewer of the members of the Committee, both by day and in the night, without previous notice ; and although the visitors found some of those wards free from close or offensive odours, yet most of the wards were not exempt from the peculiar odour which results from overcrowding; the sense of smell being a very delicate test of that sort of impurity. Under a better system of ventilation, stridly enforced, it may reasonably be concluded that a more favourable condition of the air would have been noticeable. “The result of the information thus colleded, of the personal knowledge and experience of the several members of the Committee, of other diligent inquiries, and of careful and repeated consideration of the whole subject!, is that, in the opinion of the Committee, there should be allotted to each sick inmate in metropolitan workhouses an air space of not less than 850 cubic feet on an average, and that in those cases where the height of the ward is more than 12 feet, such additional height should not be taken into account in calculating the cubic space of 850 feet ; that there should be allowed a clear space of 6 feet across each bed, and that no bed should be placed on the middle of the floor. Report oj the Committee appointed to consider the Cubic Space op Metropolitan Workhouses. London, 1867. St. Marylebone Infirmary 69 “ In thus fixing the space which they consider requisite for the comfort and proper administration of the sick in workhouses, the Committee have not overlooked the fact that it may be impossible (on account of the construction of the present buildings) to give immediately, in every case, the space recommended, and they feel that a certain amount of discretion must be left with the administrative, in carrying into effect the recommendations of the Committee. But it is their strong opinion that, even under existing circumstances, there should in no case be allowed a less space than three feet between the beds, and that no bed should, under any circumstances, contain more than one person. “The amount of floor and cubical space recommended by the Committee is less than that which has been assigned, by men whose opinions command resped, as the requisite amount for hospitals generally. "The discrepancy is more apparent than real. The difference arises from a difference in the objeds contemplated. Hitherto contagious fevers have been rarely admitted, and never long retained, in work- house infirmaries, and henceforth they are to be entirely excluded. Persons suffering disorders of that kind are to be sent to hospitals appropriated to such cases ; or, should that not be practicable, are to be placed in separate wards, provided and arranged beforehand for the purpose. “ Now, between wards in which infedious fevers and other contaminating disorders are admitted, and wards from which they are excluded, the difference is immense; and it is a difference which concerns the welfare and safety, not so much of the sick who are so afflicted, as of the other inmates of the ward. "Wherever these infedious disorders are present, ample space and a very free circulation and change of the air, are imperatively required for diluting and dissipating, and so rendering innocuous the contagious produds and emanations which they engender ; and for thus obviating a danger far greater and graver than that belonging to an atmosphere made impure by mere overcrowding — the danger, namely, lest the air should become and remain so charged with the poison of the specific disease, as to excite the same perilous disease in other occupants of the ward. " The Committee further recommend that cases which give rise to offensive smells should be placed in wards completely separated from the wards occupied by ordinary cases, and called ' Separation Wards ; ’ and that an air-space of not less than 1,200 cubic feet on the average should be allowed for each of such offensive cases; the seledion of these cases being left to the discretion of the medical officer of the workhouse. "To question 2, which is — ‘ What amount for each bed in those wards which are partially occupied by day and by night by the “ chronic ” and infirm, many of whom are usually able to leave these wards during a portion of the day for change of air in any adjoining yard or day-room ? ’ the Committee answer — "That each of such wards should have the use of a day-room. This bbing provided, an average of 500 cubic feet for each bed will suffice. "As bearing upon this question, the Committee would call attention to the fact that while the bulk of the patients admitted into General Hospitals are of adult and middle life, a very large proportion of the habitual inhabitants of these wards are simply men and women whom age has rendered mentally and bodily infirm ; and it is well ascertained that far less air is respired in a given time, and far less vitiation is there- fore occasioned, by old persons than by persons in the vigour of life. "To question 3, which runs thus : ‘ What space should be allotted to each bed in those wards which are termed " surgical ” ?' the Committee reply — “The same as has been recommended in the answer to question No. 1, it being understood that in workhouse infirmaries surgical cases of a serious charader are of rare occurrence. "To questions 4 and 5, namely — ' What space should be assigned to each patient in venereal or lock wards ? ' and ' What for inmates having itch, and other cases of cutaneous disease ? ’ the Committee reply — " The same as to the other sick. " Question 6 is — 1 What for lying-in wards ? ' " The general exemption of these wards in the workhouse infirmaries from serious disease, and especially from puerperal fever, and the very small amount of mortality which they present, have already been noticed. It appears, indeed, from a minute analysis of the returns laid before the Committee on this subject, that, in point of fact, a very large air-space, much exceeding 850 cubic feet, has been enjoyed, on an average, by each of the parturient women in almost all the workhouses. The comparative freedom of the lying-in wards from disaster may probably have been owing in part to the ampler air-space thus adually shared among the women, though the Committee are conscious that much of the immunity was attributable to other causes. F 2 7 ° St. Marylebom Infirmary. They recommend, therefore, that a rule should be laid down limiting the air-space to be allowed in each ward, for the future, as a minimum for these cases, to 1,200 cubic feet on the average. “ Question 7. 1 Do the Committee consider it essential for health that any addition should be made to the minimum space of 300 cubic feet which is now required for each bed in wards occupied by night only by healthy adults or children ? ’ “ The Committee have had before them no evidence to show that the minimum space now required is too little; they recommend, however, that whenever there is sufficient width in these wards to admit of more than one row of beds along their centre, the ward shall always be divided longitudinally by what is called a spinal partition. They also recommend that in future the dormitories be so constructed as to contain two rows only of beds. “ Question 8. ' What course would the Committee recommend for adoption in the event of its being temporarily necessary under present pressure to retain cases of fever or small-pox in a workhouse until admission can be obtained at one of the hospitals specially provided for such cases ?' “ The Committee recommend that, under the circumstances specified, such cases should be removed at once into a separate ward ; or, if that should not be practicable, that a bed should be taken away on each side of every fever or small-pox patient lying in the ordinary wards. “ Question 9. ' What space would they recommend for each patient in special hospitals for fever and small-pox ? ’ “The same space as is allotted in the existing fever and small-pox hospitals; or, 2,000 cubic feet. “Question 10. 1 Can they offer any and what general recommendations on the subjed of ventilation of existing sick wards; or, as to the best proportions for, arrangements, and ventilation of new wards in any workhouse hospitals hereafter to be built ? ' “ The question of cubic space is subordinate to the more important question of ventilation ; by which the Committee mean the continuous renewal of the air within a given confined and inhabited space, of what- ever shape, size, or surroundings, so that it shall be kept pure or nearly pure, and shall vary within a few degrees only of moderate temperature. “ It is plain that the complete and scientific solution of the problem of ventilation, thus understood, would govern and include the scientific answer to the questions of space proposed by the Poor Law Board for consideration by the Committee. “The requisite space, when settled once for all, will need no further pains; deviations from the pre- scribed amount can scarcely escape notice. It is not so with ventilation; yet if this be negleded, all regulation of cubic space becomes an idle care. The Committee, therefore, would suggest watchful and constant attention to this subject of ventilation ; to its easiest, cheapest, and most effectual methods, and to the means of adapting them to the various forms and dimensions of existing rooms. Whatever methods are adopted should be rigidly enforced by some resident official or frequent inspector ; they should be made secure against the intermeddling of the pauper inmates and servants of the house ; and they should avoid the ingress of strong currents of cold air, or at least the incidence of such currents upon the bodies of the inmates : for to aged persons there is much more, both of peril and of discomfort, from exposure to a low temperature, and especially to cold draughts, than from the closeness which may be consequent upon over- crowding. In the sick wards, and in the rooms of the aged and infirm, the temperature during the night ought not to be allowed to fall much below the day average ; and this arrangement should be under the control of the medical officer. “ In respect of both present and future infirmaries, the Committee are desirous of directing the attention of the Poor Law Board to a plan described* by one of the Members of the Committee, as having been devised, and found practically successful in solution of the analogous problem — the ventilation of barracks and military hospitals. “In relation to the general subject submitted to their consideration, the Committee hold it to be most desirable that adequate day-rooms well ventilated and lighted, and proper exercising grounds, should be provided for the paupers who are not confined to their beds. " Question 11. ■ Can the Committee advise the Board as to the best means of securing and keeping up an efficient supply of trained nurses, and as to the proportion of nurses to patients which it is desirable to maintain in workhouse infirmaries?' “ The Committee, not having gone into the subject themselves, refrain from expressing any opinion of their own respecting it. They append, however, a paper relative to this question, which Miss Nightingale See Extract from Captain Gabon's Paper following. St. Marylebone Infirmary. 7 1 has been kind enough to send, in answer to a request from the Committee, conveyed to her through their Chairman.* “ Throughout their deliberations and enquiries the Committee have regarded the questions submitted to them as being, not merely speculative, but, on the contrary, eminently practical questions, involving vast and wide principles, moral and economical. They conceive that the balance needs to be held as evenly as may be possible between the well-being of the ‘inmates of the workhouses, and the interests of the ratepayers, by whom those places of refuge are supported. The problem to be solved really is, What is the amount of floor and cubical space which shall not be too little on the one hand, nor more than enough on the other — not too little for the health and due comfort of the pauper inmates, sick or well, not pressing too much upon the means of the poorest ratepayer ? This practical aspect of the question the Committee have deemed it their duty to keep steadily in view ; always with an inclination, if the balance cannot be strictly adjusted, towards the side of the sick and poor. It is fit that these houses be made safe, decent, and commodious ; it is neither necessary nor expedient that they be made inviting. " In cpnclusion, the Committee desire to say that while the space which they have recommended is in excess of the minimum space hitherto allowed, the increase has been suggested, both because the latter space is not, in their judgment, compatible with the rapid restoration of the sick to health, and because they think it insufficient for the purposes of ventilation, decency, and administration — matters of importance to all inhabitants of a workhouse, whether to those who are actually ill, or to those who may be regarded as inhabitants for life." The following is the extract from Captain Douglas Galton’s Report on Ventilation above referred to : — “ The problem for ventilating workhouses is much the same as that laid down for barracks, which was stated by the Barrack and Hospital Improvement Commission Report of 1861, p. 71, as follows : — “ ' In a building consisting of a number of rooms generally entered from common passages or staircases, sometimes diredly from the outer air, and each having an open fire-place, which it is essential in every instance to retain, how to supply, at all seasons and temperatures, and by day and night, each rcom by itself and independent of every other room, with a sufficiency of air to keep the room healthy, and at the same lime to prevent the temperature from falling below what is required for the comfort of the men. To do this with the least possible interference with the structure of the rooms, on a plan not easily deranged, and at a minimum of cost ? ' ‘‘The principles laid down by that Commission appear to be those best calculated for workhouses, viz.: — • “ I. To keep each room independent of every other room in resped of ventilation. “ II. To depend for the ventilation upon the fire-places and upon the difference of temperature between the external air and the air within the rooms. " These principles can be carried into effect as follows : — “ 1. Outlets for heated and impure air should be provided by means of shafts carried up from the ceiling to above the roof, affording a sedional area of 1 inch to every 50 cubic feet of space in the room for the upper floors; of 1 inch to every 55 cubic feet in rooms on the floors next below, and of 1 inch to every 60 feet for rooms on lower floors. “ These shafts should be placed if possible on the same side as the fire-places, but in the corners of the room furthest removed from the grates. “ Each gas jet burning in the bed rooms at night should be covered with a bottomless lantern, connected by a tube with the foul air extradion shaft, thus carrying off the produds of combustion and also tending to put the air in motion upwards in the shaft. “ 2. Inlets for fresh air. Means for the admission of air of the ordinary temperature should be pro- vided dired from the outer air, independent of the windows and doors; for this purpose, Sherringham’s ventilators should be placed between the windows near the ceiling, which should afford a combined area of at least 1 square inch for every 100 cubic feet of space in the room, and openings of equal size should be placed close to the floor under the beds, but these latter should be capable of being easily and securely closed. * This Paper is not published here, as it relates rather to the management than the structural details of a hospital. 7 2 St. Marylebone Infirmary. " For the admission of fresh warmed air, the ventilating grate which has been adopted in barracks should be used.* " It is essential that the ventilating apparatus should be periodically thoroughly cleaned, and that some person in the workhouse should be charged with the superintendence of the arrangements, and be respon- sible that they are maintained in an efficient condition. " In all newly construfted infirmaries the wards should be on the pavilion principle, with windows on opposite sides, the beds being arranged along the walls between the windows. The pavilions should not have more than two floors of wards, i.e., the ground floor and the first floor, and the adjacent pavilions should be placed laterally apart, at a distance equal to at least twice the height from the level of the floor in the wards on the ground floor of the building to the eaves of the roof. " The width of the wards should not be less than 24 feet. The other dimensions would follow’ from the cubic space laid down in the recommendations of the Committee. “ The number of windows should be at least equal to half the number of beds, and they should extend from 2 feet 6 inches or 3 feet from the floor to within one foot of the ceiling. As light is second only to air in importance in sick wards, the proportion of window space to cubic contents should be as nearly possible 1 square foot to 50 cubic feet, which is the proportion adopted in hospitals of the best construction. 11 It would economise space to place the fire-places in the middle of the wards, with a chimney carried in a trough under the floor to a flue in the wall, and arranged to warm the fresh air which is admitted from the external air by means of the trough on the plan adopted in the wards of the Herbert Hospital, and explained in detail in a report presented to Parliament in the session of 1865.! “ Every ward should have attached to it or should have easy access to — “1. A nurse's room. " 2. A ward scullery, with a grate and oven, racks for crockery, a sink for washing up, and table. " 3 - Water-closets and a sink for emptying bed pans, placed in a chamber cut off from the ward by a lobby. These chambers and lobbies should have separate through ventilation by means of windows, and an independent supply of fresh warmed air in winter, so as to prevent the smell from the water-closets and sinks from being drawn into the wards in cold weather ; they should be closed by means of swing doors. Urinals should be placed in these chambers for the use of those patients who can leave their beds. " 4. Bath and ablution rooms, with hot and cold water laid on, should be attached to each ward, but cut off from the ward, in the same manner as the water-closets, by a ventilated lobby, and separately warmed and ventilated.'' The Local Government Board act generally upon the recommendations contained in the above report, but they have issued “ regulations ” for the construction of country infirmaries (from which the following is an extract) that allow a much smaller cubic space in the sick wards. Excepting, however, in respect of this question of space, these regulations are equally applicable to metropolitan as to provincial infirmaries. “ Sick Wards. "1. The sick wards should, as far as practicable, permit of the sub-division of the patients of each sex into the following classes : — C Ordinary sick : 1. Medical. 2. Surgical. (a.) (*■) (O (<*•) (*■) (/) (g) Dirty and offensive cases. Itch cases. Venereal cases. Children. Infectious fevers ( vide Isolation Wards). Lying-in women, with separate labour room adjoining the lying-in ward when necessary. “ 2 - 1 he infirmary should also contain suitable apartments for the nurses, and such kitchen offices as the size of the building and its position relatively to the general kitchen may render necessary. * These grates were invented by Captain Galton, and they may be seen in use in many barracks and large public buildings. The 1 hermhydric Ventilating Grates, recommended by the author, and illustrated at page 62, had not been introduced at the time Captain Galton wrote this Memorandum, f A similar arrangement is shewn at page 62, St. Marylebone Infirmary 73 “ 3. In any case where the number of sick is sufficient to justify a special establishment, it is desirable to arrange the infirmary so as to be under separate management from that of the workhouse wherever it is deemed necessary or advisable. " 4. No single infirmary should, as a rule, be arranged for more than from 500 to 600 patients ; any such separate infirmary should possess suitable apartments for a resident medical officer, also offices, surgery, and the rooms for the other necessary resident officers, such as matrons, nurses, &c., Ac., in such proportions as may from time to time be determined. “ 5. The itch and venereal wards should be so arranged that the patients occupying them may not come in contact with the other patients. These wards, moreover, should be respectively provided with distinct water-closet and lavatory accommodation. “ 6. The following minimum amount of space per bed is necessary in sleeping wards: — Wall Space, irrespective of that occupied by doors and fire-places. Floor Space. Cubic Space. Feet. Feet. Feet. Wards for ordinary sick 6 60 600 Itch and venereal cases 6 60 600 Wards for lying-in, &c 8 80 960 Offensive cases - 8 80 960 ( S if the wards are 20 feet in width Children 5 6 18 •• " 7. Sick wards to hold one row of beds only should not be constructed, but in the case of already existing rooms when appropriated to the sick they should have a width of at least 12 feet, the gangway and fire-place being, if possible, on the side opposite the beds. “ 8. Day wards for the sick should afford accommodation at the rate of 20 feet superficial of floor space per patient for not less than one half of those who occupy the day and night wards. “ 9. Day wards should ordinarily be upon the ground floor, and should have ready communication with the airing yards, but in large infirmaries some day room accommodation should also be provided on the upper floors for those who are unable to get up and down stairs. “ 10. Sick wards should be 20 feet in width if the fire-places are at the side or in the end walls ; and 24 feet in width if they are in the centre. They should be from 10 to 12 feet in height. “ 11. In the case of small infirmaries a room or suite of rooms may be connected with a similar suite in the same line by the central part of the building in which would be placed the apartments of the nurses and other officers. “ 12. The walls of all sick wards should be plastered internally with some hard and non-absorbent plaster, or should be painted to a height of 6 feet with some material which can be thoroughly washed and purified without vacating the ward. " 13. Yards for the sick should be enclosed with dwarf walls and palisades where consistent with due classification. They should be furnished with seats and covered places of refuge in wet weather. “ 14. In the cases in which hot water is not laid on or very near to sick wards the grates should be provided with self-feeding boilers of adequate size. “ Isolation Wards. " 15. The isolation wards for fever, small-pox, or other infectious cases, if at the workhouse, may some- times be constructed of a temporary character. They should be so placed as, with ordinary precautions, to preclude the possibility of the spread of infection from them to the other parts of the establishment. It is further desirable that where practicable the building should contain distinct accommodation for the safe treatment of at least two different kinds of infection. “ Note . — In regard to the provision for isolating cases of infectious disease at workhouses, it should be considered whether arrangements can be made for the reception of paupers suffering from any such disease into some local public hospital for the purpose, or into the hospital provided by the Sanitary Authority under the provision of the 131st section of the Public Health Act 1875, the provision at the workhouse being in that case limited to such accommodation as may be necessary to the treatment of any cases that may arise there or may be accidentally brought there. 74 St. Marylebone Infirmary. " 16. The space per bed in wards for infectious cases should be at least as great as that required for offensive cases, and the ventilation as complete in summer and winter as can be possibly attained. “ 17. Adequate means of disinfecting linen, clothes, bedding, &c., should be provided at a convenient distance from the isolation wards, and a detached wash-house for washing infected linen, &c., should also be provided. " General. '■ 18. Suitable store rooms for linen and clothing of the several classes of inmates and for dry and other goods should be provided in convenient situations. These should be properly lighted and ventilated. “ 19. A suitable dead-house should be provided. It should be a detached one-storey building with ample ventilation at the roof as well as at the sides. “ 20. Special means of ventilation, apart from the usual means of doors, windows, and fire-places, should be provided, and so arranged that each ward may be brought into constant communication with the outer air. No plan is recommended for universal adoption. One of the simplest methods is the use of air bricks 9 x 3 or 9 x 6 inches covered on the inside with finely perforated metal in moveable frames (the perfora- tions being about -jL of an inch in diameter) inserted about 8 feet or 10 feet apart in the upper and lower parts of the external walls (that is, at the floor level and immediately under the wall plate), by which means only a small body of air would be admitted in one place, and it would be so diffused as to prevent strong draughts. No permanent means of closing the upper set of ventilators should be provided, but the lower set may be fitted with hit-and-miss gratings made to lock so that they may be regulated by the proper authorities. The outer opening should be placed a little above or below or to one side of the inner one, the two being connected by a flue or shaft. Ventilating fire-places, providing when in use a constant supply of warmed fresh air, are found to be very useful. It is very desirable that where hot-water pipes are used they should run round the wards, and be so arranged that a portion of the fresh air admitted into the room may pass over them and so be warmed. “21. Arrangements should be made for the distribution of hot and cold w'ater where necessary in the quantities needed for all purposes. Care should be taken to place the cisterns so as to be easy of access for inspection and periodical cleansing ; and the pipes where the water in them will not be likely to be affected by frost. " 22. Where no other system of warming is adopted, fire-places should be provided in all inhabited rooms. As a general rule wards 30 feet or less in length require one fire, 30 to 60 feet in length two fires, and so on : the fire-places in the dormitories being arranged so as to interfere as little as possible with the bed space, and those in the day rooms being placed so that the inmates may sit round them without being exposed to draughts from the doors. “ 23. External windows should be filled in with double hung wooden sashes, and should extend to within 1 foot of the ceiling, and to 3 feet or 3 feet 6 inches from the floor of the ward. They should ordinarily be placed about 8 feet or 10 feet apart from centre to centre. Windows are not to be glazed with ground or opaque glass except for special reasons to be approved by the Local Government Board. " 24. Water-closets, earth-closets, and slop sink closets in connection with buildings should be placed in projections from the building with an intervening lobby between them and the adjoining rooms/ External windows arranged so as to ensure thorough cross-ventilation should be provided in this intervening lobby as well as in the closets themselves. “ 25. Drains from buildings should be constructed of glazed stoneware pipes not less than 4 inches in diameter laid in direct lines, and with uniform gradients between the points where they change direction, with water-tight joints, and man-holes or lamp-holes for inspection at the points of junction or change of direction. The soil pipes of water-closets and slop sinks should be of lead, and not less than 4 inches in diameter, and should be fixed outside the building and carried up without diminution of diameter in such a manner as to allow a safe outlet for drain air. 26. No drains should pass under any building, but all drains should terminate outside the buildings, and the waste pipes from sinks, lavatories, and baths, the overflow pipes from cisterns and tanks, &c., should be taken through the external wall into the open air and discharged visibly on to a surface channel leading to a trapped gully grating at least 18 inches distant. Special care must be taken to ensure the proper ventilation of the drains, and also to preclude the entry thereto of sewer air. For this purpose a suitable trap must be provided in the drains as near to their outfall or junction with the public sewer as possible, and a suitable and sufficient opening for ventilation should be provided in the drains immediately above this trap, a second opening being also provided at the highest point in the drains. Other intermediate openings St. Marylebone Infirmary 75 for ventilation may also be provided, but if suitable inspection holes are formed, as suggested in par. 25, they may ordinarily be made to answer the purpose. Means of flushing the drains by the discharge of a body of water at the head of the drains should also be provided. “ 27. Glazed stoneware or enamelled iron stop and waste water shoots should be provided in suitable positions on the bedroom floor of all large workhouse buildings. " 28. The sewage of the workhouse premises, whether or not it contain matters from water-closets, should be conveyed whenever possible into the public sewer. If this cannot be done it should be carried into impervious tanks placed at such a distance from inhabited buildings as to preclude any nuisance. The tanks must be properly ventilated, and have arrangements for the delivery of their contents at frequent regular periods to properly prepared ground. So far as water-closets are not in use, the excremental matters may be disposed of on the dry earth system, or, in case of closets outside buildings, may be received into a pail under the closet seat, and be afterwards applied to properly situated land. " Note. — It must be understood that the application of sewage, to land and the collection and disposal of excremental matters on the dry earth system require that certain appliances for them should he provided and maintained, and that certain service requisite for keeping them free from nuisance shall be regularly supplied ; and no plan for thus dealing with sewage or excrement is admissible except on condition that the necessary appliances and service must be provided. The earth used must be garden mould, containing organic matter, and be properly dried and sifted. All excre- mentary matters applied to the land must be so disposed of before putrefaction has commenced. “ 29. In addition to the ordinary means of water supply to the workhouse, the rain water from the buildings should be collected in covered tanks conveniently placed for the purposes of the wash-houses. It may be desirable to provide means of filtering the rain water. " 30. The airing yards for all the classes of inmates should have the best practicable aspect. If the yards are partially or wholly paved with stone or brick, or asphalted or gas tarred, it will frequently be found preferable to a covering of gravel. All yards should be formed so that the water may readily pass off into the drains. Airing yards should be drained to channels and gratings at the sides, so as to leave the centre space free for use. “ 31. The external walls of all buildings of two or more storeys in height, and of one-storey sick wards and school rooms, should, if of brickwork, be not less than 14 inches thick, and if of stone, not less than 18 inches thick. “ 32. A proper damp course should be provided in the walls of all new buildings, slightly above the level of the ground adjoining the walls, and below the floor-timbers. In some cases it may be desirable to construct the external walls hollow. “ 33. The staircases should be constructed as ' return staircases ’ 7 feet in width, and have stone stairs 3i feet wide. The stairs should be supported on iron strings, or be properly tailed into the walls, and the landings supported on iron girders. All the steps should be ' flyers,' none exceeding 7 inches rise, and those to the wards of sick and children not exceeding 6£ inches rise. Steps of the former rise should have 10 inches tread, and of the latter rise 11 inches tread. “ 34. The floors of inhabited rooms should be boarded, and the boards tongued and grooved ; the floors of w-ater-closets, bath-rooms, and lavatories may be similarly floored, or may be paved with tiles or some other form of washable and impervious floor, in which case wooden gratings to stand upon are indispensable. “ 35. All sleeping rooms should be ceiled at the level of the wall plate. “ 36. The timber used in the construction of workhouse buildings should be Baltic fir and English oak, properly seasoned. *• 37. Means of escape in case of fire should be most carefully considered." A document, of which the following is an extract, has recently been issued by the Local Government Board. It enumerates the points to be attended to as regards fittings and medical appliances in workhouses. “ The fittings should be such as are usually provided in the Wards of General Hospitals, and amongst them • the following : — “ 28, The bedsteads should be of iron, of modern make, and kept in good order. The length should be 6 feet 2 inches, and the width 2 feet 9 inches, except for the bedridden, the lying-in cases, and women with children, for whom the width should be 3 to 4 feet. 76 St. Marylebone Infirmary. " 29. A palliasse of straw or other material, or a layer of cocoa fibre matting, to be placed beneath the bed. " 30. The beds, whether of feathers, carded flock, wool, cut straw or chaff, to be properly made, kept in good order, and sufficiently full. Sometimes, hair beds are found to be better, especially when placed on suitable mattresses. " N.B. — The beds for all wet and dirty cases should be in three equal divisions, so that when fouled or otherwise rendering a change necessary, the centre one may be removed and another put in its place without difficulty. “31. Two sheets, two or three blankets, and a white counterpane or cheerful-looking rug. " 32. One half the number of bedsteads to have a raising rack. “33. Separate bed rests; also ropes with wooden handles suspended from the ceiling or otherwise arranged over some of the beds, to assist bedridden cases. " 34. Spittoons. "35. A stoneware urinal to each bed and special strong glass urinary bottles for the use of bedridden men. Glass is preferable to stoneware as it permits the contents to be always visible. " 36. Medicine glasses and feeding bottles. •' 37. Stoneware or metallic feet and chest warmers. “ 38. Air or water beds. “ 39. Mackintosh sheeting to be used to all lying-in beds. “ 40. The same with funnels for dirty cases. " 41. Square and round mackintosh cushions with depression in the centre to prevent bed sores " 42. Mackintosh urinals to be worn by men who pass their urine involuntarily. “ 43. A locker with open shelves for the use of two inmates. '* 44. A suitable place, with lock and key, for the safe keeping of medicines. “ 45. Arm and other chairs for two-thirds of the number of sick ; also one or two arm chairs on noise- less wheels, and a few special chairs for epileptic cases. " 46. Short benches with backs and (for special cases) cushions. “ 47. Rocking chairs for the lying-in wards “ 48. Little arm-chairs and rocking chairs for children’s sick wards. "49. Tables. " 50. Moveable bed-tables for use by patients in bed. “ 51. Moveable bath on noiseless wheels, with suitable means of charging it with hot and cold water and of emptying it. “ 52. Stoneware wash-hand basins for those who are washed in bed. " 53. Fixed stoneware lavatory basins for others, or washstands with fittings. " 54. A sufficient number of round towels on rollers, and one small towel to each person who is usually washed in bed. " 55- A proper supply both of combs and hair-brushes, to be kept clean and in good order, in each ward. “ 56. Sealed night-stools. “ 57. Two or three screens (on wheels) large enough to completely surround a bed when a patient is being bathed in the ward, or is very ill or dying. " 58. Gas, where practicable, to remain alight during the night. ■' 59. Bells to the nurses’ room. "Co. Jackets with long sleeves, for lunatics. " 61 11 may be desirable that an inventory of the furniture, fittings and medical appliances supplied, should be fixed in some conspicuous place in each ward.” 0 Hospital Construction and Management. Tons: Civil: Hospital: •Belgium- • Bird 3 -Eye View . m bcr C CO C> PhotoLtfeogMft.: i by Jatats Akrra«&.6 l^uten Squarr W C H Saxon Snell del ( 77 ) CIVIL HOSPITAL, MONS, ► BELGIUM. There are very few hospitals at present erecfted in Belgium the plans of which can be considered to represent the more advanced views of hospital construction ; yet there can be no question on reading through the Reports of the Conseil Superieur d’ Hygiene Publique at Brussels, to whose approval all plans are submitted, that its members are quite at one with all other nations in advocating the principles now almost universally laid down for the construction of hospital wards. The Hospital of St. Jean, at Brussels, accommodates 550 beds, and is on the pavilion principle ; but these pavilions are much too close together, and in other important respects the architect has quite ignored the conditions necessary to be observed in the design of a good hospital building. The hospital at Mons is one of the best types of construction at present existing in Belgium. The designs for this building, prepared by the architect Mons. Hubert, gave rise to considerable controversy, in consequence of the opposition raised by Mons. Defontaine, Surgeon of Hospitals, who strongly condemned the scheme and proposed a counter project. A plan of one of the pavilions, as proposed by Mons. Defontaine, is shewn at Fig. 6, and is taken from the printed reports. U is a bath-room, V a lavatory, T a lift, and S S the water-closets ; the other details are, however, not clear. If this plan be compared with that of Mons. Hubert, it cannot but excite surprise that a proposal for carrying it out should have been so seriously entertained as it appears to have been. The ultimate overthrow of the scheme was, however, finally due to the decision of the Council of Hygiene, to whom the question was referred. I do not propose to give any very detailed description of this building, as I have been unable to obtain access to reliable documents relating to it; and I was net at all satisfied that the information given to me on the occasion of my visit, as to matters of detail, was quite accurate. Mons. Hubert, the architect, who, unfortunately, was unable to accom- pany me over the building, has, however, sent me much interesting printed matter, detailing the progress of his controversy with Mons. Defontaine, before referred to. 78 Civil Hospital , Mons The building is situated on the outskirts of the town of Mons, the country around being very open, and the adjoining land occupied as market gardens. The extent of the site is stated to be 2 \ acres. The general disposition of the buildings upon the site will be seen by the accompanying block-plan and bird’s-eye view. The general adminis- trative offices, with the operating and consulting rooms, form a front fa$ade to the structure, the central feature being the roof of the chapel, which is situated on the upper floor. Branching off from either end of this building are the corridors, which give access to six pavilions that jut out at right angles from each of them; the front pavilion to the right of the accompanying view is occupied by a religious sisterhood, the members of which act as nurses to the sick ; the corresponding wing on the left is devoted principally to the accommodation of private paying patients ; the rear blocks are the sick wards proper, for males and females respectively ; the lower floors being devoted to the surgical and the upper floors to medical cases. The distant central building is intended to be crecfted for the reception of patients suffering from infectious diseases ; the distant building on the left is the wash-house, laundry, and disinfection house. The total accommodation at present provided in the building is stated to be 146, viz., eight wards for 16 beds each, and 18 for one each. The average number of patients in actual occupation is from 80 to 90. The cost was originally estimated to be ,£4,520, or £153 per bed ; but although the building is still in a very unfinished condition, this outlay has already been very considerably exceeded. The only peculiarity observable in the structure of the main sick wards is their entire isolation from the connecting corridors, the w.c.’s, nurses’ rooms, and other usual offices, by means of low covered bridges, having large glazed doors at either end of them ; these doors, excepting in very cold weather, are kept open, and the cross ventilation thus set up effectually prevents the communication of the ward atmosphere to other parts of the building. The position of the w.c.’s and other sanitary offices, is, as is usual in Continental hospitals, unfortunately chosen. The ventilation of the wards is effected principally by the windows, but there is, in addition, between each pair of beds, and at the level of the floor, a large opening about 14 inches square, closed by double doors, which can be opened for the admission of fresh air from the outside. The arrangement for warming is, however, found to be a failure, and will be altered. It consists simply of a closed circular pedestal central stove, and the flue pipe from it is carried along the entire half-length of the ward in a slanting direction, and from 8 to 10 feet above the floor, into a flue situated in the end wall. A further account of this building is given by Dr. Mouat, in the first seftion of this Work. Hospital Construction and Management. ( 79 ) ANTWERP CIVIL HOSPITAL, > BELGIUM. Considerable interest attaches to this building, in consequence of its being the first hospital erecfted having circular sick wards. A proposal to eredt hospital buildings of this form was first made in England, by Professor John Marshall, F.R.S., of the University College and Hospital, London, in a paper read by him at a meeting of the Social Science Congress, in the year 1878, and shortly afterwards this paper was published as a pamphlet, together with some interesting and valuable criticisms by Mr. P. Gordon Smith, F.R.I.B.A., Architect to the Local Government Board. In the year 1881, I published a work,* containing a design prepared by me for the eredtion of a Workhouse Infirmary for 700 inmates with circular wards, on Professor Marshall's system, but up to this time it does not appear to have been generally known that the foundation stone of the hospital at Antwerp, about to be described, had actually been laid in the same year that Professor Marshall, in total ignorance of this fact, had first propounded his scheme to an English audience. I am indebted to Dr. E. Janssens, one of the members of the Counseil Superieur d’ Hygiene Publique, at Brussels, and to Mons. Baeckelmans, the designer of the building, for their courtesy in affording me the opportunity of perusing reports of the proceedings of the authorities charged with the eredtion of this building. I am also particularly indebted for much valuable information to Mr. A. J. Bacon (of the well-known engineer- ing firm, Bacon and Co., Antwerp), and also to the very intelligent clerk of works, both of whom accompanied Dr. Mouat and myself over the building on the occasion of our visit. From the documents referred to, I gather that, on the 19th May 1873, a meeting of delegates was convened for the purpose of considering the appointment of an architect for the construction of the new building ; there were present — “ Mons. Oudart, Inspector of the ‘ Establissement de Bienfaisance et d’Alienes,' delegated by the Government; Dr. Haylen, Member of the Permanent Deputation of the ' Conseil Provincial,’ delegated by the Province : Mons. Lefeber, Sheriff and ' Bex Conseiller Communal ' at Antwerp, delegated by the City of Antwerp; Mons. Bayaert, architect, and Mons. Athanase de Meester, delegated by the Hospitals Com- mission ; the latter gentleman was subsequently elected secretary to the jury ; Mons. Eugene Meens, Vice President of the Hospitals Commission, by whom he was delegated ; Mons. Olivier Van Stratum, President of the Hospitals Commission, accompanied by Messrs. Wontners and Grossens." At their next meeting, on the following 26th of May, it was unanimously decided to recommend to the approval of the Communal Administration of Antwerp the design with circular wards, prepared by Mons. Baeckelmans; and, in submitting this design, together with two others having wards of a parallelogram shape, a strong hope was expressed that the former would be allowed to be executed, as “ it more surely satisfied than any others, the conditions of aeration and facility of service so long looked for in hospitals, * Charitable and Parochial Establishments . London, 1881. 8o Antwerp Civil Hospital. and, moreover, the design, inspired by a new idea, seemed to realise a notable progress on all that had been produced to that day.” The administration, before coming to a conclusion upon the question submitted to it, forwarded the designs to the managers, and medical officers of the hospital of St. Elizabeth, for their consideration. The reports of these bodies contained suggestions for improving the arrangements of some of the minor offices, but otherwise they were in perfect accord with the decision of the Committee as to the form the plan should take. Great diversity of opinion appears, however, to have been expressed by the various authorities consulted as to whether the plan of circular wards was or was not more expensive than that of parallelogram form, and as to whether in carrying out the works the system of contracting for the whole in one sum was more to be preferred than that by divided contracts and schedules of prices. Ultimately, however, the plans were agreed to unanimously by the Administration, and forwarded for approval to the “ Ministre de l’lnterieur ” at Brussels, together with an exhaustive report upon the whole matter. The Minister of the Interior refered this report, together with the plans, to the “ Conseil Superieur d’Hygeine Publique,” and this body instituted a Commission, con- sisting of Mons. J. F. Vleminckx, Dr. E. Janssens, and Dr. Victor Vleminckx, to consider and report upon the matter. The following extracts from the report of this Commission deal principally with the question of the advantages to be derived from the ereCtion of circular wards; and, as will be seen, the opinion arrived at was directly opposed to that unanimously entertained by the authorities at Antwerp : — “ The circular form to which great advantages are attributed, appears to have for its origin the counsel given to you at divers times to 1 round the angles of the wards. - The author of the designs under discus- sion said to himself: 1 Since no angles are desired, let us make a circle, and we shall completely satisfy the hygienists.' No doubt, it is very important to prevent the stagnation of organic dust in the angles of the wards, but the complete circle which is proposed has also its inconveniences. “ In the first place, it is evident that in a round room the beds next the walls are a less distance apart than they would be in a redangular ward having the same superficies, and that the beds at the feet being very close together, the nurses and doctors will be inconvenienced. Then again, although it has by some been thought otherwise, we have no doubt that this radiating position will be found distressing to the sick, since any patient can the more easily see a larger number of his companions in misfortune. “ Now comes the question, Would superintendence be more easy ? We do not think so. “ The nurses placed in the centre of the circle in a sort of cabin would certainly not be able to so easily keep their eyes upon the patients confided to their care as if they were at the extremity of an oblong ward. And when so placed in the middle of the emanations of the sick patients, will they not be under much more unfavourable conditions, especially during an epidemic, than if they were out of the ward and in a separate room overlooking it and provided with special ventilation ? “ Finally, with resped to the principal argument advanced in favour of the circular system of wards, that a maximum capacity with a minimum surface is to be obtained, thus securing the acquisition without extra cost of an enormous cube of air, one of the most sure guarantees for salubrity. “ We at once admit that the volume of air will indeed be considerable, for, according to the calculations of the author of the plan, each sick person would have 2,120 cubic feet. But, is this great cube of air the best solution of the problem of ventilation ? “ With good ventilation much less would suffice, and is it not rational to admit that a smaller quantity of air would be more easily renewed in a given time. In the matter of ventilation, the important fad must not be forgotten that it is not only necessary to supply pure air incessantly, but we must arrange for the evacuation in the smallest possible time of all the vitiated or altered air, and this without causing trouble- some draughts. The present methods of ventilation have not yet arrived at such a degree of perfedion as Antwerp Civil Hospital. 81 to give us full and entire confidence in them, and our mistrust would, therefore, warn us not to run the risk of constructing wards of too large a size, and so exposing ourselves to one or the other of the incon- vcnijnces referred to. "In our opinion, then, gentlemen, there is nothing which authorises an a priori declaration that circular wards, as proposed by the designer, are better than oblong pavilions with rounded corners. ■ “ We now come to that part of the projeft which has given us cause for serious criticism. It concerns the general arrangement of the plan.” It is here necessary to remark, that by the plan first prepared and now under discus- sion, the connedting corridors were to be continued up to the first floor, and were intended to be closed in by low buildings on the sides next the interior courts, and in such wise that these courts would be entirely shut in. The report goes on to say : — “ The central blocks of buildings, grouped in the form of a parallelogram, are destined for the general administrative offices of the hospital, and contain four closed courts. " It is almost unnecessary to remind you, gentlemen, that you have at all times shown yourselves decided adversaries to the construction of interior courts (batiment concentre) ; during the whole of the 27 years that the council has had existence, it has made ceaseless efforts to oppose the construction of every kind of interior court. Now, in the Antwerp project, the four courts of the central building would be closed in on four sides by buildings carried up to the first storey. These courts, surrounded as they are by pavilions for the sick, would necessarily become receptacles for miasmas, and the entire building would form by its mass an obstacle to the free circulation of air round the pavilions. “ We are quite aware that it will be objected that the pavilions alone are destined for the occupation of the sick, and that the central building is simply to be devoted to administrative purposes ; but surely we must protect the healthy as well as the sick. And we must not forget after what we have just said, that those in health occupying the closed centre of this vast edifice, would not be placed under proper conditions of salubrity. In addition, we may observe that in and around the buildings referred to, it is proposed to place isolation wards and the ambulatories for the convalescent patients. ‘‘ No closed courts, neither for the healthy nor the sick, are principles upon which your Commission are unanimous, and cannot admit discussion.” The report deals with a large number of questions of much interest ; and amongst other things, it makes objetftion to the proposed position of the mortuary, which is \ considered to be too close to the entrance ; and it suggests that the number of beds in each circular ward, if eredted, should be reduced from 24 to 20, also that the extent of the site should be increased, in order that the various blocks of buildings might be distributed at a greater distance apart from each other. Adting upon this report, the Ministre de l’lnterieur sent back the plans to the Communal authorities of Antwerp, with a request that the recommendations in it should be adted upon. After much angry discussion, it was agreed to carry out all the suggestions with the exception of the proposed alteration of the form of the wards and the removal of the site of the mortuary, but Mons. Baeckelmans positively declined under the circumstances to act as architedt of the building, and so it was ultimately arranged that two of his pupils, Messieurs Belmeyer and Van Kiel, should be deputed to make the necessary alterations in the design, and superintend the carrying out of the work. The revised plans ultimately received the sandtion of the “Ministre de l'lnterieur not, however, without a grumble from the Commission before referred to, which would have had substituted parallelogram for circular-shaped wards. The foundation stone of the building was laid December 1878, and at the time of my visit in May 1882 the carcasing and plastering of the walls was all completed, but the 82 Antwerp Civil Hospital. authorities informed me that another three years would certainly elapse before the building would be ready for occupation. Great commendation is due to the acting architects, Messieurs Belmeyer and Van Kiel, for tire loyal manner in which they have preserved, as far as it has been possible to do so, the main features of the original design of their master, Mons. Baeckelmans ; to a superficial observer no alteration whatever is apparent. Site . — The site upon which the buildings stand has the shape of an irregular pentagon, and it is bounded on all sides by open roads, the northern, or main entrance, front faces the Rue des Images, and the eastern front faces the Rue de Lazaret, but all the other roads were new and unnamed at the time of my visit. The extent of the site is about 427,833 superficial feet, or 9 acres 3^ roods, being about 1,126 superficial feet per bed. General Arrangements .— The general arrangement of the buildings, together with plans and details of the principal sick wards, is shewn upon the accompanying plates. The principal entrance to the establishment is through the centre of the front block A. The basement of this building is used only as cellarage, whilst the ground and first floors contain the director's residence and offices, reception rooms for the sick, and apart- ments for the resident surgeons and the porter. Block B is a building one storey only in height above the basement or cellar floor, and it contains on the ground storey an operation room with two adjoining wards, each for the accommodation of one patient. Block C is the mortuary and post-mortem house. The six blocks marked D contain the principal sick wards, and their offices dd are connected with them by low enclosed passage ways or bridges. All these blocks are two storeys in height above their basements, and on each of the floors there is a large ward for the accommodation of 20 beds, and three isolation wards for one bed each ; but, on the ground floors, where each of the blocks O adjoin, there are only two of these smaller wards. These pavilions will be more particularly described hereafter. The blocks marked F f are similar to those last described, but the parts ff nearest to the main corridor are larger than the corresponding blocks dd, and instead of ordinary separation wards, they contain, on each floor, rooms for the reception of six private patients. Block J is a building one storey only in height, and will be fitted up as a bathing establishment, not only for the use of the inmates, but for the outside public. Block K is the laundry and wash-house. The linen from all the other hospitals under the charge of the Communal authorities of the town will be washed here. Block L is two storeys in height above the basement, and contains apartments and a dining room for the nurses, and on the first floor linen stores. Block M is generally one storey only in height above the basement floor, but the centre portion is carried up another storey. On the ground floor there is a dispensary and drug stores, and also the kitchen, scullery, stores, and other offices ; apartments are provided lor the use of various officers of the establishment on the upper floor. Block N is a chapel. Hospital Construction and Management. Photolithography &FVint»d by James Ahermao.6,Qu<*en Square. W C Antwerp Civil Hospital. 83 Blocks marked O are one storey only in height, and are intended to be used as dining rooms for convalescent patients. Total Accommodation. — Accommodation is thus provided for 380 sick inmates, viz.: 34 separation wards, and two wards next the operation room, with one bed in each; 24 wards each for one paying or private patient; and 16 wards each having accommodation for 20 ordinary patients. Connecting Corridors. — Covered arcades, marked x on block plan, about 10 feet wide inside, encircle the whole of the buildings and connect them together upon the ground floor, excepting only the laundry (block K), which stands entirely detached. The two lengths of arcade connecting the front administrative building with the pavilions in the rear are covered with ordinary span roofs, but all the rest have flat roofs and so form, on the first floor, galleries of communication between the several departments, and also ambulatories for the use of the patients in suitable -weather. All these corridors are carried down to the basement level and form subways for conveying away the dust and dirty linen to their respective destinations. The lifts also descend to this basement for the purpose of removing the dead bodies to the mortuary, with which it communicates. Water Supply . — The water to be used in this hospital will be supplied by the town authorities, and the service will be constant. Iron piping is employed throughout. Drainage . — Two separate systems of drainage are provided for. The whole of the foecal matter from the various water-closets is conveyed into two large brick cess-pits, each 285 feet long and 13 feet wide, built underground, and respectively placed parallel with and near to the eastern and western boundaries of the ground. Access to them is obtained from the adjoining roads, so as to facilitate the removal of the contents by carts. All surface and ordinary dirty water is conveyed away into the town drains by a distinct system of pipes. \ Area Covered . — The area covered by buildings is 114,611 feet, being rather more than Aths of the site, and 302 superficial feet per bed. Cost. — The building is not yet completed, and as the w r orks are not being carried out under one contract, it is impossible to say what will be the ultimate cost. Mons. Baeckelman’s original estimate was £"101,432, but up to the time of my visit in 1882 this sum had already been exceeded, as will be seen from the following statement given me of the contracts then entered into, viz. : — Foundations... The carcasing Joinery Stone pavings and steps Plasterer Carried forward £ 7.200 60.000 1 0,800 3.160 2,400 £83,560 Brought forward £83,560 Ironwork 920 Heating and ventilation, including all trades 15,680 Boundary walls 4,800 Total ... £104,960 So that the above works, without extras, will have cost £"104,960, or about £"276 per bed, and this is exclusive of any drainage, water supply, lifts and other engineering works, fixtures, laying out grounds, architect’s fees, or clerk of works. From what I could gather at the time of my visit as to the nature of the proposed works, it did not appear G 8 4 Antwerp Civil Hospital. to me possible that the building could be completed for a less sum than £140,000, or about £368 per bed. Principal Sick Wards. The main sick wards are circular on plan, and stand detached from the other parts of the building, excepting that cross-ventilated lobbies afford a means of communication wifh the w.c.’s, bath-rooms, and the other usually attached offices; but it is important to notice that these lobbies, like those at Mons Civil Hospital last described, are not nearly so high as the adjoining wards, and that the upper forms a bridge over the lower one with the result that currents of air can pass between the two ; this is a great improvement upon the ordinary mode of constructing lobbies of communication, and should be adopted in all new hospital buildings. Relative Position of Pavilions . — The height of the pavilions, as measured from the lower floor of the sick wards to the outer edge of the iron roof gutter, is 40 feet, and the least d stance between any pavilion is 74 feet, or about i-*.ths of the height. Size of Wards . — The dimensions of the wards are not materially altered from what was shown to be intended by Mons. Baeckelman’s original drawings, but the number of beds have been reduced from 24 to 20, as it was thought by the governing authorities that they would otherwise be too close together. As now planned, the diameter of each ward is 61 feet 6 inches, and the average height 17 feet. The total superficial floor space will therefore be 2,970 feet, or about 149 feet per bed, and the cubic contents 50,490 feet, or about 2,525 feet per bed. It will, however, be observed that this includes a space in the centre which is divided off by a low partition only for use as a nurse’s room, “ cabinet de la soeur,” but although a bed is indicated on the original plans I could not ascertain whether this is really intended to be used as a sleeping apartment for the nurse; no doubt, however, this point will have reconsideration. Bed Space . — The average lineal wall space per bed (deducting the width of the entrance lobbies) will be 9 feet, but as the beds will necessarily converge towards the centre of the ward, the distance between the feet of them will be reduced to about 7 feet. Windows . — Eighteen windows are ranged round the outer walls, and it is intended that one bed should be placed between each of them. These windows are designed somewhat similarly to those of the three infirmaries erected by me some years since for the St. George s, the Holborn, and the St. Olave’s Unions, and they more nearly approach than any I nave seen elsewhere the form that I have in another part of this work recommended for general adoption in hospital wards. .They each consist, for three-fourths of their height, of a pair of folding casement sashes ; but the upper part, which is separated from the lower by a transom, is a sash hung on centres. It will thus be seen that the whole of the window is capable of being opened to its fullest extent. The objection generally urged against casement windows similar to those used in this hospital is the difficulty of keeping them wind and weather tight, but I find no such difficulty arise where the meeting rails are made to shut against a central mullion, and when proper grooved and tongued joints arc formed at all junctions of the sash with the frame ; a proper weather bar on the sill and lower rail is also essential, and for this I have always found Archibald Smith’s patent contrivance to answer well, The total area of effective glazed surface in the 18 windows 85 Antwerp Civil Hospital. now being described is 567 feet, or 28J feet per bed, and when all the windows are opened to their fullest extent the total area through which air can be admitted into the room is 812 feet, or about 41 feet per bed. Warming . — At the time of my visit to this building, a contract had just been entered into for the execution of the ventilating* and warming appliances for the sum of £11,680, and it had been determined that the method of heating the wards should be by means of air passed over coils of hot -water pipes contained in a chamber situated in the basement under the central portion of each tier of wards, and that the air so heated should be propelled into the wards at the upper parts of the central columns by means of the machinery situated in the laundry building. Ventilation . — The ventilation of the wards is intended to be effected mainly by the windows during weather which will permit of their being opened, but, during night and in the winter time, fresh air will be propelled into the wards by means of fans and other machinery situated in the laundry building, and this air will, when required, be warmed in the manner described in the last paragraph. For the removal of foul air from the wards, there is provided at the lower part of' the outer wall, between each window and beneath the heads of each pair of beds, an outlet from which a flue 10 inches long and 8 inches wide descends to the level of the basement, and then, travelling horizontally, it enters a central chamber that is heated by coils of hot-water pipes ; from the upper part of this chamber there is carried a large iron shaft which passes vertically through the centre of each ward and finds an outlet at the apex of the conical roof of the building. It will thus be seen that the current of air in this upright shaft is intended to carry with it the foul air drawn into the chamber through the flues, radiating from it to the openings in the wall beneath the heads of the beds in the manner described. All the ward offices and the separation wards are ventilated by distinct flues formed in the brickwork by cutting off the angles of the various rooms, and these flues are connected by horizontal ducts with the central ventilating shafts. Floors . — The flooring of the wards is to be formed of deal boarding five inches wide, tongued with iron, and to provide for shrinkage it is not to be permanently fixed for the first 12 months. It will be laid on timber joists resting on the brick vaulting of the ground floor and on the iron joists and concrete of the first floor. The ceilings are to be plastered. Walls . — The outside walls of the wards are built of brickwork two feet in thickness. The outer surfaces of the walls generally are finished with red brick and stone dressing, and_the interior faces with a plastering formed of two parts of lime and one of plaster of Paris. W.C.'s , Baths, &*c . — The water-closets, baths, and other like offices are situated in buildings connected with the main wards by enclosing cross-ventilated corridors about 12 feet in length and 4 feet 3 inches wide ; they are onty 8 feet 6 inches in height inside, and the upper one in consequence forms a bridge over the lower one, thereby allowing currents of air to pass freely between the two. These connecting corridors are continued on into the centre of the detached building, and then passages branch right and left from them and give access to the various compartments now to be described. 0 2 86 Antwerp Civil Hospital. To the left of the entrance corridor there is a bath-room, 8 feet 3 inches long 6 feet 6 inches wide, and opposite to this there is a duty-room, or “ tisanerie,” described hereafter. Leading off the cross passage and opposite to the entrance corridor there is a lavatory 7 feet 6 inches long and 6 feet 6 inches wide, intended to be fitted with three basins and with a slop sink. Two urinals will be placed in a compartment 6 feet long and 4 feet 3 inches wide leading off one end of the cross passage, whilst at the other end there are two water- closets, each 4 feet 3 inches long and 3 feet wide. Arrangements appear to be made for warming the bath-room and “ tisanerie,” but not the other offices in this detached building ; special ventilating flues leading into up-cast shafts are provided for all the compartments. The description of w.c. apparatus, baths, and other fittings had not been decided upon at the time of my visit, but if these are perfect the whole arrangement of these departments of the building will be worth the study of future hospital designers. Separation Wards. — The “ chambres d’isolement ” are situated in the detached buildings which give access from the connecting corridors to the large circular wards. These two buildings are separated by other low enclosed corridors 6 feet 6 inches wide and 15 feet in length, but otherwise similar to those described as connecting the wards with the sanitary offices on the opposite side. There are three separation wards on each floor, each for the accommodation of one patient. Their dimensions vary, but their average superficial contents and cubic capacity are respectively 133 and 2,050 feet. Duty Room . — The “ tisanerie,” situated opposite to the bath room, corresponds to what, in England, we term a duty room. It is like the bath room on the opposite side of the passage, 8 feet 3 inches long and 6 feet 6 inches wide. Lifts . — Adjoining the staircases and main corridors of each pavilion there is a lift space 10 feet long and 8 feet wide, but I was unable to ascertain upon what principle it was proposed that the apparatus should be worked. Staircases . — The principal staircase of each pavilion occupies an area of about 485 feet, it is constructed of stone, and the treads are 6 feet long 12 inches wide and 6 inches high. On the first floor, adjoining the lift space, there is a smaller staircase leading to an attic storey, the use of which is not defined. Adjoining the principal staircase there is a room having three divisions opening out of it into shafts descending to the basement level ; one of these shafts is used for conveying away dirty linen, another for dirty rags, disused poultices, &c., and the third is a conduit for pipes. Basement . — The basements of the pavilions are about eight feet in height, and the central portions beneath the circular wards contain the arrangements for ventilation and heating previously referred to. All other parts are unappropriated, and I could not ascertain whether it was intended to enclose any portion of them by windows. Total Area of Pavilions . — The total area covered by each floor of the pavilions, including the covered ways connecting its three divisions and the walls surrounding them, is 5,810 feet, or 290 feet per bed. Antwerp Civil Hospital. 8 7 A proposal has lately been made by Dr. J. Burdon Sanderson for the erection of annular sick wards for the reception of small-pox patients. These wards would have a central chamber 20 feet diameter, inside which an aspirator would be placed for the pur- pose of removing the foul air from the adjoining ward. It is proposed that this air should be made to pass through a furnace, or otherwise be subjected to a sufficiently high temperature to ensure the destruction of all organic matter contained in it. The beds would be placed with their heads against the inner chamber and would be divided from each other by partitions ; thus the patients would face the windows in the outside walls, placed at a distance of 18 feet from them. No step has, however, been taken at present to test the efficiency of this system, though it would seem to be an excellent plan for preventing the spread of contagion in the district surrounding a small-pox hospital ; but more of this hereafter. ( 88 ) HEIDELBERG UNIVERSITY HOSPITAL, GERMANY. No country in the world has, up to the present time, made such progress towards a practical elucidation of the recognised principles of hospital construction as Germany. There, the development of the system of erecting sick wards as single-storied isolated pavilions, has for some years been fully carried out, ancLnumerous examples of this mode of building are now, therefore, to be found in all parts of that country. France is slowly following the good example thus set to it in the hospitals erecfting on Mons. Toilet’s system referred to hereafter. England has not to the present time awakened to the obvious desirability of altering the present method of constructing its hospitals three, four, and five storeys in height, and although the fact has long been generally recognised that the various blocks of sick wards should be kept well apart from one another, yet (excepting in one or two isolated instances) this separation is rendered incomplete through the intercommunication of the blocks by means of enclosed corridors. Complete separation has, however, been carried out in some of the hospitals for contagious diseases crecfted in different parts of England, and it is to be hoped that the system may shortly become more general. It remains to be seen, however, whether the pavilion system of construction is suited to very cold climates, such, for example, as exists in the northern parts of Germany and Russia ; and although I am disposed to think that the corridor system may ultimately be found more suitable in such situations as these, there can be no question as to which is best in our climate. Great difficulty is experienced in keeping the one-storied wards of the Berlin hospitals properly warmed, and, in those lately ereefted, special means have been taken for construcfting the roofs to prevent the passage of heat through them ; this is more particularly referred to in the description given of the Tempelhof Military Hospital. The erection of the Heidelberg University Hospital is due to the persistent efforts of Professor Otto Weber, who, so early as 1865, repeatedly “ and in very emphatic language,” drew public attention to the wretched condition of the old structure. He did not, how- ever, live to see his idea for a new building realised ; but, subsequently to his death, a design was prepared, and the carrying out of it entrusted to a Commission of eminent scientists. 0 The final designs for the eredlion of the buildings were completed in the month of September 1868 ; exactly twelve months afterwards the first sod was turned, and in October 1876 every part was pronounced to be ready for occupation. The Friedrichshain * 1 he Commission consisted of Professor Dr. Knauff, Herr Geh Rath Bluntschli, Herr Geh Rath lriedreich, Hofrath Simon, Bauinspector Waag, and Oberingenieur Esser. Before the works were com- pleted Hofrath Simon died, and Bauinspector Herr Waag having retired, their places were supplied by Professor Lossen and Bauinspector Schaffer. The interior and general arrangements of the Ophthalmic Department and the Pathological Institute were entrusted to the care of Herr Hofrath Becker and Professor J. Arnold. Hospital Construction and Management. Heidelberg University Hospital. 89 Hospital at Berlin was commenced at the latter end of the year 1868, and was completed in October 1874. Practically, therefore, the conception and carrying out of the two buildings may be said to have occurred during the same period, and the reader will con- sequently find it interesting to note the results arrived at by two different corporate bodies of the same nationality, each afting under the guidance of some of the most eminent medical and other scientific savants of the day. In both cases it seems to have been determined upon as undeniably requisite that the hut, or one-storied pavilion, system, should be adopted for some at least of the buildings ; but there was. an evident and somewhat natural hesitation as to the adoption of this principle throughout, seeing that such an innovation had not before been attempted in a permanently ereCted hospital. In the result, therefore, we see in both the Berlin and the Heidelberg buildings a combination of the three systems, viz., the corridor, the one-storied, and the two or more storied pavilions. At Berlin the whole of the surgical cases are provided for in one- storied pavilions, the general medical cases in pavilions two storeys in height, whilst the contagious cases are located in a building three storeys in height, planned partly on the pavilion and partly on the corridor principle. At Heidelberg eighty of the surgical and twenty-eight of the medical cases are treated in one-storied buildings, and the remaining patients of these classes, including those suffering from contagious diseases, occupy pavilions three and four storeys in height ; whilst patients suffering from eye diseases are provided for in a separate building planned on the corridor principle. As a question of economical management, and indeed of first cost, it is undoubtedly a defeeft in the arrangement of the wards of the Heidelberg Hospital that so small a number of inmates are placed under the control of each nurse. The best authorities state that a head nurse can, with proper assistance, efficiently supervise from 28 to 32 patients, and these numbers have been taken as the unit for the construction of, the Friedrichshain and many other modern hospital wards ; whereas here we find that half, and in some cases less than half, this number of patients are given to the care of one head nurse, and it cannot but result either that the expenses of management are thereby increased inordinately, or that patients must suffer from inefficient nursing. In this and in many other matters of detail, there is a marked absence of that careful deliberation and forethought which characterised the proceedings of the Friedrichshain Commission ; but, as a whole, the ereeftion of the building is a long step in advance of others. It will be observed that provision is made for the reception of a large number of private paying patients (nearly 15 per cent, of the total number of patients), and it will be interesting to compare the following translation* of the printed regulations for admission, with similar rules in force at St. Thomas’s Hospital, given at page 24 : — “Rules for Admission into the Heidelberg Academical Hospital. "I. " Patients of three classes are received ; — " (1) Private room with one bed. “ (2) Room with two beds for two patients. “ (3) General ward. * Eleventh Annual Report oj the Local Government Board . London, 1SS2, go Heidelberg University Hospital. “ii. “The payments for maintenance according to the dietary table or the physician’s order, for lodging, with service, fire and lights, bed and table linen, and the occasional use of the ordinary douche and sitz baths, are as follow : — “ ist class. — In winter (16 October — 15 April) 8 marks a day. “In summer 7 „ „ “ 2nd class. — In winter 5^ „ ,, “ In summer 5 ,, ,, “ Additional charges are made for — special nursing (2 marks for day and night, and 1 mark for night) ; medicated and steam baths (2 marks) ; the use of drugs, bandages and instruments ; specially desired foods and beverages (wine, beer, &c.) ; finally, medical treatment, the fee for which is regulated by the chief diredtor of the hospital. “ In the third class, the charge for entire maintenance is two marks a day, but an addition to this fee may be demanded according to the circumstances of the patient. “III. “ For patients under two years of age the fees for maintenance are one-half the above in all three classes if admitted with a person in charge, if not so accompanied they pay the full amount. “IV. “ Persons in charge pay the full fees of the class in which they are received. “ Patients of the ist class may be accompanied by a person in the 2nd or 3rd class. “ Such persons must, in that case, share the rooms of the patients, except those in the 3rd class on attendance on patients in the ist class. These are quartered in the general wards. "V. “ Before admission, or immediately thereafter, an undertaking for the future discharge of the demands of the establishment and of the physician's fee to be given to the governing body of the hospital.’’ The description of this building, written by Dr. F. Knauff, 0 has afiorded me much valuable information as to many of the details of its constnnftion, and my especial thanks are due to the following gentlemen, who, upon the occasion of our visit, personally con- dutfted Dr. F. J. Mouat, Mr. Pcrcival Gordon Smith, and myself, through the wards, and explained the details of the arrangements of their various departments, viz., Dr. von den Steinen in charge of the medical division, Dr. Arthur Thost in charge of the surgical division, and Dr. Julio R. da Gama Pinto in charge of the ophthalmic division. Mr. Gordon Smith’s observations upon the details of this building have been recorded in a valuable and interesting report made by him to the Local Government Board. t After giving a general description of the building, he sums up as follows: — “ There are many other points of the greatest interest and well deserving of attention by anyone con- cerned in the erection of a new general hospital and medical school. Thus, the special arrangements in the eye wards for darkening the wards without affeding their ventilation, and for facilitating the treatment of the various diseases of the eye are most complete ; the various departments for galvanic and electric treatment, for the use of the laryngoscope and other modern appliances and instruments, the arrangement in connedion with the hospital as a school of medicine and surgery, the pathological and disseding departments, microscopic department, museum, experimental physiological department, &c., appear to be equally complete. The furniture also is, in many respeds, deserving of attention. The ward beds are of iron, with wire spring mattresses, upon which are laid canvas mattresses, filled with horse-hair, and made in three parts, so that the middle portion, which is most frequently soiled, may easily be removed and replaced, without serious inconvenience to the patient ; and each bed has at its head an upright post, on which is placed a black- board with the patient's name, disease and treatment, written in white chalk, in such a way that it can be easily read by anyone. A narrow shelf is also provided below the blackboard, and likewise a simple * Das Neut! Academische Kraukenhaus in Heidelberg. Miinchen, 1879. t Eleventh Annual Report of the Local Government Board. London, 1882. Heidelberg University Hospital. 9i arrangement for suspending an ice-bag for cooling the patient’s head. The bedside table is entirely open, so that everything can be seen, and the chamber utensil to each bed is a clear glass vessel, the contents of which are kept in their entirety until they have been seen by the medical officer in charge.” The following notes, by Dr. Mouat, attached to Mr. Gordon Smith’s report above referred to, will also be read with interest : — " In what I regard as clinical hospitals or institutions devoted to the teaching of medicine, as well as scientific research, based on the treatment of the sick, the Heidelberg Hospital is in advance of any of the endowed or other hospitals attached to medical schools in the United Kingdom. ■' It not only contains an exceptionally perfed ophthalmic clinic, but in its mechanical and other contrivances for treating diseases of the nervous system, air passages, skin and organs within the reach of such remedial means, it is in advance of any hospital I have yet seen in any country. " The use of baths as therapeutical as well as cleansing agencies is carried to a much greater extent on the Continent than among us; and the dired removal of impure air from diseased lungs, and its replace- ment by condensed, or rarefied, air, as may be required, is, so far as I am aware, altogether unknown as a pradical application in Great Britain, where lung disease is so prevalent and fatal. “ Of the superiority of the method of heating and ventilation by the machinery described by Mr. Smith I am not so convinced, except as respeds the condition of the climate of Heidelberg. I do not consider it necessary, however, to resort to such costly contrivances in our milder, damper, and more equable climate, in which the uniform temperature required can, I think, be secured by simpler means. “ In their dealing with latrines and lavatories, and their disposal of excretory matters, the arrange- ments at Heidelberg contain nothing that can be usefully adopted by us, and much to avoid.” Site. — The buildings are situated on the outskirts of the town of Heidelberg, close to the southern bank of the Neckar, and about 400 feet distant in a westerly direction from the new bridge crossing this river. The height of the ground above “medium” high water mark is said to be about 27 feet. The extent of the site is 409,032 superficial feet, being about 9 acres x rood and 22 perches, or 1,070 feet per bed. Subsoil. — The upper surface of the ground is stated to consist of a clayey and strong vegetable soil, the next stratum is that upon which the foundations of the buildings are placed, and is a firm clay several feet in depth ; below this, gravel is found ; and the level of the underground water occurs about 52 feet below the surface. This level is in no way affedted by the water of the river, which is shut off by the intervening impenetrable stratum of clay. General Arrangement. — The accompanying plans, page 92, indicate the general arrange- ment of the various blocks of buildings, and also the details of the principal medical and surgical wards. The establishment is entered through the central block A, situated at the junction of Voss Strasse and Hospital Strasse. This entrance building contains on the ground floor the manager’s offices, the medical and the surgical officers’ consulting rooms, and the apothecaries’ apartments; also the patients’ and visitors’ waiting rooms, the laboratories and surgery, and three rooms for the condudt of therapeutic, laryngoscopic,and microscopic investigations. On the first floor there are apartments for the assistant medical and surgical officers, and for the manager and steward ; also the waiting, consulting, and other rooms of the “Poliklinik” department. The second floor is divided into 14 rooms, each of which is devoted to the use of one first-class private patient only ; and there are also on this floor two nurses’ rooms, two bath rooms, w.c.’s, &c. 92 Heidelberg University Hospital. Block B contains the culinary department of the establishment, including store rooms, the engine house and boiler room, and apartments for the engineer and porters. It also contains a vapour bath room with shampooing bench, an ante-room with spray and shower baths, and in addition bath rooms for the use of the officers of the establishment. A water tower with chimney shaft rises from the centre of the building. Block C is a building three storeys in height, containing the wash-house and laundry, with linen stores, work room, apartments for the matron and housekeeper, and sleeping rooms for various officers of the establishment. It can hardly be considered a desirable arrangement to place the living rooms of the officers in a building principally devoted to the washing of linen more or less infecfted. Block D is a building containing apparatus for the disinfeiflion and disposal of sewage. Block E is an ice house. Block F a coal store. Blocks N N are medical pavilions four storeys in height above the basement floor, and each one contains on the ground floor bedrooms and dining rooms for the nurses of the medical division, and on the lirst and second floors four sick wards, each for eleven beds, with attached offices, four separation wards for one bed each, and three rooms each for two private second-class patients ; there is also on each floor a nurse’s bed room and a duty room. The third or garret floor is available for officers’ apartments, and as “ private second-class wards for lightly-affected patients.” Block I is a third medical pavilion for the exclusive treatment of patients suffering from syphilis, itch, and other skin diseases. On the ground floor there are four wards with accommodation for four beds each, and a separation ward to contain one bed only. There are three bath rooms on this floor. On the first and second floors there are four wards for eight beds each, as also three private or separation wards (these are, when required, used also for prisoners) each for one bed only, and bath rooms. Blocks J J are medical pavilions one storey only (exclusive of basement) in height. The basement of each contains heating chambers, and coal and patients’ clothes stores. On the ground floor there is a ward for fourteen beds. The bath room, water-closets, and duty room are situated on either side of the entrance. At the opposite end of the ward there is an enclosed verandah or glazed room. These buildings will be more particularly described hereafter. Block K is a surgical pavilion four storeys in height above the basement storey, con- taining bed rooms for the nurses of the surgical division and other offices, a library for the use of patients, and a “ consulting room for the Hospital Committee.” On the first and second storeys there are two wards containing each nine beds, two separation wards for one bed each, and four wards each for two private patients of the second-class, or for those who may have undergone severe operations. The operation theatre is placed upon the first floor, and over it, on the second floor, there are apartments for the use of the head nurse. The attics forming the third storey of this building are available for officers’ apartments, and as separation and children’s wards. Blocks L L L L are surgical pavilions one storey only in height (exclusive of base- ment). The basement of each contains heating chambers, and coal and patients’ clothes Hospital Construction and Management. Heidelbero • Jniversitv • Hospital • A f\ Odmmutratnfc & 'folifyfrwfy T)cpartrncnf B. Cultnara TDcpartmcnt C. foundry D. t>6a>ayf %)/j in j^cf/on E. oJa rJfcc/JC F . Coal *3 tort,. J N. Sfcd/cal TbtJi/iony / . <5 fan 'fonoascii. K.L. Ciuryicat Fbotitons. M. Gye TJ/o&asod P. 'fiblhofogical 'l&zpartmcnf H. ofortoa T Section * on ‘Line - AB air Gx.tr action jnafts .v v S R T. Otoac E. f)ta c r o to Qa/tc of J^antcrn Plan • of • Surgical * 1 civilian • L vD Plan • of • Medical Pavilion *J v Jcalc of iQf>£njar \ - D. ){ltcfrer>,^fau nd/^-j, (onQ/nf/to . (Pavilionf) P. P. CJaclalion Cjaraa . x x oc Corrtc/ora a x — ' c r Platvof'Sde ' jf GJ ca le. of al/) & Tdrcaaing " om nol aflacncd /o M<£ O • Section- t hro W ai d • Grou nd-Plan- of -Blocks -L-M-NO _3 3 (1 ft 3 3L_ Q) c ale of c. — The w.c.’s, baths and other sanitary appliances are here found, almost for the first time, to be entirely detached from the wards, a step in the right direction, but they should also be detached from the building itself, for the foul air from them can now find its way into the corridors and staircases. The apparatus are generally similar to those described for blocks L, M, N, O. The bath rooms are 18 feet long and 9 feet wide. Day Rooms . — At the extreme end of the large ward, to the right of the entrance, there is a day room, entered from the ward by two glazed doors on either side of the open fireplace. It is 28 feet 6 inches long, 16 feet wide, and 13 feet 9 inches high. The area is, therefore, 456 feet, and this gives 28^ superficial and about 392 cubic feet to each patient occupying the adjoining ward ; but, inasmuch as this day room is also used by those in the opposite ward, these figures should, perhaps, be taken only as 14J feet and 196 feet respectively. Separation Wards . — At the extreme end of each of the wings, to the left of the entrance, and corresponding with the day room last described, there are two separation wards leading direCtly out of the large ward. One, for the accommodation of two beds, is 16 feet long, 1 1 feet wide, and 13 feet 9 inches high, and, therefore, contains 88 superficial and 1,210 cubic feet per patient ; the other, for the accommodation of three beds, is 17 feet long, 16 feet wide, and 13 feet 9 inches high, thus giving in this case about 91 feet superficial and 1,246 cubic feet of space to each patient. Berlin Military Hospital. 123 Duty Rooms . — Immediately adjoining the large ward to the right of the entrance hall, and entered from the cross corridor, there is a room 18 feet long 9 feet wide, or 162 superficial feet, that is used for the purposes of a duty room (“ Theekiiche”). It is fitted with a gas cooking stove and warming oven, and with a sink having both hot and cold water supply, and other usual domestic appliances. Nurses' Rooms . — The nurses’ duties in military hospitals are performed generally by men, though the director informed me that four sisters were attached to this establish- ment. There is, to the right of the entrance, a room for the use of a male nurse (“ Warter”), and, in the corresponding space on the left, a hospital assistant’s room (“ Lazarethgehilfe ”). Each of these rooms has an inspetftion window for overlooking the adjoining large ward ; they are 17 feet 3 inches long, 10 feet 3 inches wide, and each contain, therefore, about 177 superficial feet. The room on the first floor, directly over the vestibule, is also available as an additional attendant’s room, or, in case of need, as a separation ward. Staircases . — The staircases are situated in the centres, and immediately opposite to the main entrances to the buildings, and each occupies an area of 334 feet. The steps are generally of rough stone, faced with oak well steeped in linseed oil. The balusters are of iron with handrails of polished oak. The staircases leading to the upper floors or garrets are of pine. The architects of the building are desirous that it should be known that the disposition of the main central staircases as executed was discordant to their wishes ; they were desirous, as far as possible, to cut ofT the communication of foul air from the lower to the upper wards, and to obtain direeft light to the staircase, and, with this view, they designed the staircase as shewn upon the accompanying Fig. 10. Fig. 10. a, Bath and Lavatory; b, Duty Room ("Theekiiche”) ; c, w.c.’s and Urinals; d, Nurses’ Room ; e, Staircases; s s, Sick Wards. If this arrangement had been carried out, the first floor could have been reached from the outside without first passing through the lower corridor of communication. So far as regards the staircases this plan would, undoubtedly, have accomplished the desired object satisfactorily, but the planning of the duty rooms (“ Theekiichen”), and the other adjoining offices, is by no means so good as that carried out. Basement . — The central portion only of the building is carried down to form a base- ment, and this is used as cellarage. 124 Berlin Military Hospital. Area of Pavilions . — The superficial area occupied by each pavilion floor, including its surrounding walls, is 6,738 feet, or 182 feet per bed. Isolation Sick Wards. — Blocks R R R. The arrangements of these buildings are generally precisely the same as those of blocks P P last described ; but they are one storey only in height, and the consequent absence of staircases necessitated an alteration in the disposition of the rooms placed in the rear of the central portions of the buildings. The only other noticeable deviation is the addition of verandahs, each 22 feet 3 inches long and 10 feet 10 inches wide, placed outside, and entered through the large central windows of the day rooms. Area of Pavilions . — The superficial area occupied by each pavilion, including its surrounding walls, is 6,329 feet, or 171 feet per bed. This building was visited in company with one of the architects, Herr Schmieden, in November 1882, and to him I have to express my thanks for the facilities afforded me for obtaining many of the foregoing details of the principal sick wards. Those who desire a fuller account of the details of the administrative buildings may consult a work entitled “Das Zweite Garnison-Lazareth fur Berlin bei Tempelhof.”* * Ernst and Korn. Berlin, 1879. ( 125 ) KONIGSBERG MILITARY HOSPITAL. Germany. The erection of the Tempelhof Military Hospital last described was found to be so great a success in all its details that the military authorities subsequently commissioned the architects of that building, Messrs. Gropius and Schmieden, to prepare designs for four other garrison hospitals, the block plans of three of which, Konigsberg, Diisseldorf, and Ehrenbreitstein, are illustrated at page 128. These being smaller establishments than the Tempelhof Hospital, and the details of the various structures nearly all of them similar to that building, it will only be necessary to give a short description of the main features of them. The Konigsberg Hospital ( see plan of site at page 128) is designed for the accommo- dation of 374 patients, 300 of whom are located in three blocks of buildings, each three storeys in height, containing 100 beds, and marked “4 ” on plan of site, and 74 in two isolation pavilions, marked “ 5 ” on plan. These buildings generally correspond in their plan and details with blocks L, M, N, O, and R R of the Tempelhof Hospital, illustrated at page 116, excepting that the wards for the ordinary sick are three storeys in height. The administrative building immediately faces the entrance to the establishment from the Alte Reiferbahn, and contains offices and residences for the head surgeon and the chief and subordinate inspector, also the married officers, the dispenser, and general hospital assistants. At the rear of this building is a garden for the use of these head officers, and between it and the domestic offices there are three low buildings, used as a furnace-room, w.c.’s, dust-bin, &c. Then comes the domestic offices, marked “3” on plan, which combine in one building the kitchen, scullery, stores, wash-house, and apart- ments for some of the subordinate officials. The mortuary, “7” on plan, is situated at the extreme south-west corner of the ground, and an ice-house, “8” on plan, occupies the opposite corner. The axes of the principal sick wards are almost due east and west, so that the ward windows face the south. The axes of the isolation pavilions are in an exactly opposite direction, and the windows of the wards in this case, therefore, face nearly east and west. Water is supplied to the establishment by the municipal authorities, and cisterns are provided for the storage of about 15,000 gallons, or about 40 gallons per inmate. The drainage of both rain water and sewage matter is discharged into a conduit leading into the river Pregel, but it is filtered and disinfected before being carried away from the building. The extent of the site is stated to be 550,040 superficial feet, or 12 acres 2 roods 20 perches, being about 1,470 feet per bed. The total surface covered by buildings is 52,313 feet, or 140 feet per bed. The building was eredted under the superintendence of the military authorities, and cost £81,000 (1,620,000 marks), or £216 ns. 6d. per bed. DUSSELDORF MILITARY HOSPITAL. The plan of site of the Military Hospital of Diisseldorf is illustrated at page 128. The building, as designed by the architects, Messrs. Gropius and Schmieden, is for the accom- modation of 150 patients, 65 of whom are located in a two-storied building, marked “ 4” on plan, and the details of which are similar to blocks P P of the Tempelhof Hospital, illustrated at page 116; 74 patients are provided for in two one-storied pavilions, marked “3” on plan, similar in detail to blocks R R of the Tempelhof Hospital, also illustrated at page 1 16, and twelve are located in an isolated building placed in the southern corner of the ground and marked “ 5 ” on plan of site. The administrative building, immediately facing the entrances from the I'aber Strasse, contains the residences of the officers, and the kitchen, scullery, and all other domestic offices. The wash-house and laundry, to which is attached a mortuary, are situated at the eastern corner of the ground, and in the rear of these buildings there is an ice-house. The water supply and drainage is provided for by the adjoining mains and sewers belonging to the town authorities. The extent of the site is stated to be 191,728 superficial feet, or 4 acres 1 rood and 2.} perches, being about 1,278 feet per bed. The total surface covered by buildings is 27,706 feet, or nearly 185 feet per bed. The axis of the central pavilion, which is planned on the corridor system, runs from W.S.W. to E.N.E., and the windows of the wards face S.S.E. The axes of the side pavilions run in an opposite direction, so that the windows of them face W.S.W. and E.N.E. The building was eretfted under the superintendence of the military authorities, and cost ,£29,880 (597,600 marks), or £199 4 s - P er bed. ( 127 ) EHRENBREITSTEIN MILITARY HOSPITAL. At page 128 there will be found a block plan of this establishment, together with a section shewing how the peculiar position of the buildings upon the steep sloping sides of the site necessitated the construction oT terraces. The restricted area of the site is much deplored by the architects, Messrs. Gropius and Schmieden, but it appears to have been unavoidable. The building is designed for the accommodation of 124 patients, 96 of whom arc located in the central block, marked “ 2 ” on the plan, and the remaining 28 in an isolation block, marked “ 3.” The main building is similar in plan to that of blocks M and O of the Tempelhof Hospital illustrated at page 116, but the plan of one floor of the isolation wards is shewn at page 128. The axis of the main sick wards runs N.N.E. and S.S.W., and the windows of the wards, which are planned on the corridor system, face E.S.E. The question of aspect had to be made subservient to that of site, for if the windows of the wards had been placed W.N.W. they would have been hidden from the sun by the steep sides of the adjoining hill. The administrative building is situated on the left of the entrance from Tcichert-Weg. This is an old building refitted to accommodate all the residential and domestic offices and the general stores of the establishment. The wash-house and laundry, together with the mortuary, is placed in a building situated to the right of the entrance gates. The water is supplied by a well, from which it is raised by a steam pump into a reservoir containing nearly 5,000 gallons, or about 40 gallons per patient. Both the rain water and sewage is carried away from the establishment into the Rhine, but it is first filtered and disinfected ; the solid residue is carted away. The extent of the site is 45,209 superficial feet, or 1 acre and 6 perches, being about 364 feet per patient. The total surface covered by buildings is 16,327 feet, or 131 feet per patient. In the reports as to these buildings, the military authorities pointedly remark that so small a site was chosen only after much deliberation, and as an exceptional matter. The building was erected under the superintendence of the military authorities, and cost £ 28,200 (564,000 marks), or £227 8s. 4d. per bed. ( 128 ) CUSTRIN MILITARY HOSPITAL. A block plan of this establishment is shewn below, Fig. n. It was designed by the architects, Messrs. Gropius and Schmieden, for the accommodation of 170 patients, but provision is made for increasing this number to 232 by the addition of another block of sick wards in the position indicated by dotted lines upon the plan. E, Washhouse, Laundry, and Mortuary ; F, Ice-house ; X X, Connecting Corridors. The sick wards marked B B, two storeys in height, are planned upon the corridor principle, and can each contain 62 patients ; they are similar in their details to those of blocks L, M, N, O of the Tempelhof Hospital, illustrated at page 116. The block of wards, marked “C” on the plan, contains isolation or contagious wards, one storey only in height, and it is planned similarly to those of blocks R R R, likewise illustrated at page 1 1 6. The laundry, wash-house, and mortuary, are placed under one roof, and occupy the extreme eastern corner of the ground. The administrative building imme- diately faces the entrance from “ Landstrasse nach Warnick,” and it contains all the residential and domestic offices, and the general stores of the establishment. The water supply is obtained by a well, from which it is pumped up by an engine into tanks constructed to contain 6,600 gallons, or about 39 gallons per patient. The drainage system is connected with the main sewer, which flows into the Warthe, but before leaving the establishment it is filtered and disinfected. The extent of the site is 278,949 superficial feet, or 6 acres 1 rood 24 perches, being about 1,641 feet per patient. The total surface covered by buildings, including the block D not yet erected, will be 39,887 superficial feet, or 172 feet per patient. Hospital Construction and Management. PlanofSite' Sect ion - * PI an oflsolatio n 'Yv£i ret A\ i I i la i v • Hospital 1’ hren b rei istei n ■f ( an. o/J bail Jin g ) 2 JjCfarJa 3 < ?%>o/ahon UdarJ* 4 JPl or fu a rtj dx&Taoh h outc 'A\ilitaryHosp[tfll'Di)ssel(Jorf‘ AXiliWyl lospibilKonibsherO ' i lf\dminisfraht$e.J(itclicn «5 - ' j olafion &ardf / t/jjmmijro/uf e ^ 'Jic 6L onncofi rtp. C orrtaor^. Domco/zc 0 icy [Card* ch LfiarJ* . An 5 J solution CSarcts / i n lo/rof/Jc UlTicc* 0 onnccH df. JE)omw//c OH’cc-3 6 (Zaohhousc PL rluary 3 jfifchcn df %)omccfic Offices 7 J^ortuarcj g !)ce.-ti ouoc. 3 * 5 tc 4 [Card 4 7 ,n g (®) roanj 4 H)tcU a arjj icfa LSarJs ^ Jcc hou*c 3 $oolaficnfx)orJit 9 furnace - ho 10&-C* // ^ c to/. •EleVatlon- Plan* • I c e • H o u s e • D en j I i 1 1 • A\ i I i K\ r v ' H n s n i l a I ~ r 4 , r r r .d-XJ 1 — 1 3ca/< of S'cct to (j/cva/ionlcSAc/icn JcJLJ. 7- ^ Jc ale offfe.f fo 9la Pboto lithographed Jt Printed by Ja*n*s Akerman.6 .Queen Square W C ( 129 ) DRESDEN PUBLIC HOSPITAL. GERMANY. Since my journeys to Germany for the purpose of inspecting its hospitals were under- taken, my attention has been called to the building now about to be described, by reading an account of its construction in a work entitled “ Die Bauten Technischen und Industriellen Anlogen von Dresden,” and it appeared to me to contain so much that was interesting that I applied to the publishers, C. C. Meinholm and Son, of Dresden, for their permission to have electrotypes taken of the illustrations, and they courteously acceded to my request. As I could not, without unduly delaying the publication of this work, visit the building in question, I am unable to give the details of it so satisfactorily as I could desire. All that can be learned, however, from the publication referred to, is, I believe, contained in the following account. The origin of this hospital dates back to the sixteenth century, when a plague broke out with such gteat virulence that a temporary building was erected for the reception of the sick on the Viehweide, and this building was afterwards converted into a permanent hospital. After various enlargements it was, in the middle of the nineteenth century, abandoned, and another building erected upon the present site. It appears that in the year 1821 a large amount of money was devised to this hospital, and the inheritance so acquired had, by the year 1849, accumulated to the sum of 776,175 marks (£"38,809). In the year 1845 the Town Council resolved to purchase, by means of this legacy, and at a cost of 204,000 marks (£"10,200), the site of the “ Marcolini’schen Palais,” situated in the Fricdrichstrasse, and to add to and rearrange this building for the purposes of an infirmary. The site contains 857,277 square feet, being 19 acres 2 roods and 28 perches, or nearly 3,297 superficial feet per bed. Thanks (says the description of this building) to its situation in the town, to its grounds planted for the most part with noble and umbrageous trees and partly laid out in pleasure gardens; thanks, also, to its spacious buildings and extensive area, leaving room for still further extensions, this site presented advantages for the construction of a hospital such as no other in Dresden could offer. First of all, the palace was rearranged and partially rebuilt, and by this means, and at an expense of 210,000 marks (£"10,500), accommodation was provided for 260 patients* in 53 sick wards, including two separation rooms for distinguished patients (“distin- guirte”). In this building there are ten attendants’ rooms, a dispensary, the kitchen and its offices, the wash-house and laundry, baths, furnace and boiler rooms, and numerous •The records of the numbers of patients throughout the description, from which this account is quoted, give, first, the nominal, or proper numbers, and then the numbers that could be squeezed in, in case of epidemics or other like contingencies. I have neglected the latter figures. 130 Dresden Public Hospital. apartments for the officials. In the year 1857 there was added an isolated building for the reception of infectious diseases, in 1859 an addition was made to the east wing, in 1861 tire mortuary and dissecting room were built, and in 1866 further buildings were added. Fig . 12. The accommodation then provided sufficed for many years, but, eventually, the numbers of patients had so much increased as to necessitate further extensions, and then, between the years 1870-76, the additions shewn upon the accompanying block-plan, Fig. 12, were commenced from the designs of the Town Architect, Herr Friedrich, and carried out under his superintendence. The Mutterhaus. Of these buildings the Mutterhaus was the first ere&ed. This structure is three storeys in height above the basement, and covers an area of 15,295 feet. It is intended for the reception of patients of both sexes, and two staircases were therefore necessary. Accommodation is provided here for 124 patients, there being twelve wards for 7 patients each, and one for 2 beds; three rooms for convalescents, with 4 beds each; ten rooms, each for one private patient ; and sixteen single-bedded rooms for lunatics ; besides day rooms. Then there are, in addition to the usual ward offices, six bath-rooms, two of which contain vapour baths, an operation and instrument room, attendants’ rooms, and a residence for the assistant-surgeon. The plan of the principal floor is shewn at Fig. 13 ; the sick wards for the most part face the south and east, but the principal corridors face the north. The heating of the principal wards is effected by hot water circulating through pipes from four boilers situated in the basement. The staircases and corridors can also Dresden Public Hospital, be kept heated to 12° Reaumer (59° Falir.). The single rooms, which are only occa- sionally in use, are heated separately by stoves. Basement Plan of Mutterhaus. Fig. 13. a, Living Rooms of Engineer, Stokers, &c. ; b, Cellars and Stores ; c, Engine Room and Ventilating Fans ; d, Furnace Room ; e, w.c. s ; f, Wash-house ; h, Hot-air Furnaces for Stairs and Corridors; i, Steam Heating Apparatus ; k, Occasional Kitchen ; 1, Lift. Ventilation is effected by means of fans worked by a steam-engine of 3-horse power situated in the basement, whereby warmed air is propelled through flues into the various rooms of the establishment. The removal of foul air is effected by means of flues running from all the rooms downwards to the basement, where they enter extraction shafts, which, during the winter, are kept heated by the hot-water apparatus, and in summer by special furnaces. It is stated that the quantity of fresh air calculated to be introduced b)t these means into the wards per head per hour is 100 cubic metres Ground Plan of Mutterhaus. Fig. 14. Sick Wards; b, Reading and Day Room ; c, Imbecile Sick Wards ; d, Private Patients ; e. Nurses ; f, Vestibules : g, Clothes Store ; h, w.c.'s ; i, Bath Rooms ; k, Assistant Physician ; m, Duty Rooms (Theckiichen) ; s, Hot and Cold Water 1 ups. / K i3 2 Dresden Public Hospital. (3,532 feet), and that experiments shew this standard not only to have been maintained, but surpassed. It is also stated that when the outer temperature stands at 6° Reaumer (45 0 Fahr.) the rooms are sufficiently heated by the warmed air forced in by the venti- lating apparatus. Warm and cold water is supplied in all the corridors, and (with the exception of the cells for the lunatics) in all the wards, and to the baths, closets, lavatories, and day rooms. The cost of the warming apparatus is said to have been 39,500 marks (£1,975). The plan of the basement containing this apparatus is shewn on the previous page, Fig. 13. Cost. — The cost of this building (inclusive of machinery) was 543,548 marks (£27,177), or about £219 per bed. The Pavilions. In the year 1871 two of the pavilions, “b” upon the block plan, Fig. 12, shewn in detail at Figs. 15 to 19, were eretfled, then in 1873 two more, and it is understood that the erection of the four others will follow eventually. These buildings are each one storey only in height above the basement, or rather above the ground storey, for the floors of the wards are raised nearly nine feet above the level of the ground outside. They are connected together, and to the Mutterhaus, by covered corridors. Aspect. — The axes of these pavilions run north and south, so that the windows of the wards face east and west. Relative Position of Pavilions. — The height of the pavilions, as measured from the floor of the sick wards to the junctions of the sloping roofs with the upright lines of the outside walls, is 14 feet 9 inches, and the distance between each pavilion is 56 feet, or about four times the height. Size of Wards. — Each main sick ward is of parallelogram shape and can properly accommodate 24 beds only.* The total superficial floor space is stated to be 2,864 feet, or about 1 19 feet per bed, and the cubic contents 48,929 feet, or 2,038 feet per bed. The opposite ends of each ward are divided off by low partitions, the one end to form two separation wards, and the other to form a duty room, w.c.’s and bath room, &c. Bed Space. — The average lineal wall space per bed appears to be about 7 feet i£ inches. This includes the spaces partitioned off to form separation wards. Warming. — The rooms are heated by two calorifers placed in the basement beneath the main sick wards of each pavilion, and the outer fresh air as it is warmed is carried upwards through flues, the upper parts of which form stoves, with glazed earthenware sides, standing centrally in the room and upon the floor immediately above the furnaces. The temperature and the admission of fresh air are regulated by suitable apparatus, and * The plan of one of these pavilions, Fig. 16, appears to indicate that four beds would be placed down the centre of the large ward, and in the description of the building it is stated that these wards accommodate 30 beds each. It cannot, however, be intended that such an arrangement should exist, excepting incases of emergency, and, in the above calculations, it has been assumed therefore that the ward is intended for the accommodation of 24 beds only. The beds shewn upon the verandah would be wheeled out of the wards only when the weather would permit, and are, of course, not taken into account in a consideration of the number of patients. Dresden Public Hospital. 133 evaporaters (“wasserverdampfers”) are placed in the interior of the stoves to secure the proper admixture of moisture with the incoming air. Ventilation . — In winter time fresh air is introduced into the wards in the manner described in the last paragraph ; in summer time the fresh air, as it passes through the flues into the wards, is made to flow past running water and sometimes ice, and by this Basement Plan of Pavilions. Fig . 15. 10 5 O IO 20 30 40 SO 60 70 80 OO 1 1 1 1 j 1 ! | i_ 1 1 1 Scale of Feet. means it is said that the temperature in the wards, even on the hottest days, does not exceed 18° R. (72-5 Fall.). The withdrawal of air from the wards is provided for by four aspiration shafts in the end walls, as shewn upon the elevations and sections. Besides these artificial means of ventilation there are the windows in the side walls and the ten additional windows contained in the roof lantern, all of which are capable of being Ground Plan of Pavilions. Fig . 16. 1 0 ^ o 10 20 jO jjO 60 70 Scale of Feet. opened simultaneously. These lantern lights are left open all night during the summer time. Experiment, it is said, has proved that the air in the pavilions, amounting to 1 .5 15 cubic metres (53,505 feet), can easily, and without draught, be renewed more than 134 Dresden Public Hospital. 6 7 times in 24 hours, thus giving, when the building is occupied by 30 patients, 132 cubic metres (4,662 feet) per head per hour. Lighting .— The whole of the buildings are lighted by gas, but no special provision is made for the removal of the products of combustion. Floors . — The floors generally are formed of deal boarding, nailed to timber joisting, which rests upon the brickwork vaulting of the lower storey. Elevation of Pavilions. Fig . 17. r ? ? v r r v r 7 .° ? . r SCALE OF FEET. Walls . — The lower or basement storey is built of sandstone, but the upper or ward floor walls arc of brickwork. W.C.'s, Baths, <&>c . — It is singular that the Germans, and most other Continental nations, appear until very lately to have entertained a profound indifference to the necessity for keeping the foul air of their latrines, w.c.’s, and urinals, from entering the sick wards adjoining them ; and there are but few — if any — instances in Germany where Tran verse Section through Pavilions. Fig . 18. 10 S O 10 20 30 40 SO 60 70 1 1 L 1 « j J ! I 1 SCALE OF FEET. the compartments containing these apparatus are properly separated from the main building; but in the building now under discussion, the w.c.’s are not only not separated from the sick wards, but they actually stand inside of them, and are separated from the view of the patients only by a low partition ! They receive both light and air Dresden Public Hospital. 135 from the wards only, for they are placed in the centre of them, and away from the external walls. Comment upon such an extraordinary arrangement having been allowed is quite unnecessary, yet one cannot but express surprise that it should be permitted still to exist in these days of improved sanitary knowledge. The bath room is placed in a cubicle to the left of these sanitary offices. Verandahs . — At both ends of the pavilions there are verandahs, upon which beds may be wheeled, with or without the patients in them, whenever the weather will permit. A similar arrangement exists at the Berlin Civil Hospital, and at others illustrated in this work. The verandah nearest to the entrance is divided into two by the flight of steps which ascends from the covered way connecting the various pavilions together. Duty Room. — There is to the right of the passage-way leading from the end of the ward to the verandah a room which appears to be provided for the ordinary uses of a duty room (a “Warmkuche”), and it is fitted with a warming apparatus and other usual appurtenances. \ {Separation Wards . — On either side of the passage-way forming the entrance to the wards there are two cubicles, formed by low partitions, each of which is intended for the separate occupation of two patients ; but they really form part of the large ward, and have been treated as such in the foregoing description of the interior planning of the building. Longitudinal Section of Pavilions. Fig . 19. jo § o 10 20 30 40 50 60 70 80 90 1 T 1 1 j 1 L 1 ! ! ! ! SCALE OF FEET. Basement. — The floors of the basements of these buildings are an average height of 7 feet 3 inches from floor to ceiling, and are little below the level of the outside ground ; thus currents of air can continually play round all parts of the building. The outer base- ment walls are constructed with open piers and arches, but the openings so formed can, when desired, be closed by sliding shutters. In order to prevent the rising of damp and the penetration of cold air into the ward, the ceiling of this basement is constructed with brick arched vaulting ; the portion under the verandahs is used as cellarage and store rooms. Area of Pavilions. — The total area occupied by each pavilion, exclusive of the verandahs, is said to be 3,320 feet, or 138 feet per patient (24 in each); but, if the verandahs be included, the area is 4,150 feet, or 173 per patient. 136 Dresden Public Hospital. There are many points about the design of these pavilions that appear to make them superior to many other like buildings lately eredted in Germany ; the elevation of the sick ward floor so far above the level of the ground and of the roof of the covered connecting corridors, and the entire freedom in the basements for currents of air to play beneath the floors of the wards make them in these respedts approach, more nearly than others, the ideal representation of model pavilion sick wards. Certain of the interior arrangements previously referred to are, however, bad almost beyond precedent. Hospital Construction and Management. Strasbui •< > • University • Hospital • \ irsi Floor- of - Cenli al-Block- Secfi on Photo Lithographed & IVifited by James Akeim&fl . 6. Queen Square .W C H Saxon Snell del ( 137 ) STRASBURG UNIVERSITY HOSPITAL, GERMANY. This hospital was visited by me in company with Dr. F. J. Mouat and Mr. Percival Gordon Smith in the latter part of the year 1882. I was not very favourably impressed with the structure generally, and did not consequently take so many notes of its details as in the case of other hospitals visited during the same journey and described in this work. Dr. Mouat, however, while admitting that the building is not as a whole satis- factory, considers it to be “ superior in its arrangements to most of those of the surgical wards now to be seen in any of our great towns.” Mr. Gordon Smith also considered it to be of sufficient importance to merit detailed description in the very valuable Report piade by him to the Local Government Board on the subject of “ Certain Hospitals in Germany and France,”* and it is to this report, and to the aid afforded by Mr. Smith's private notes, that I am principally indebted for my ability to give so full an account of the building. The accompanying detailed plans of the structure did not, however, form part of the report, and they have not to my knowledge been previously published in England or elsewhere. This, the Clinical Surgery Hospital of the “ Kaiser Wilhelm’s Universitat, Strasburg,” is a newly-erected building in connection with the old City Hospital (Burger Spital) and Medical School, which stand on the southern side of the city, just within the fortifications. It has been built as portion of a larger scheme for the reconstruction of the whole hospital from the designs of Herr H. Eggert, of Berlin, under advice from Dr. Liicke, and was opened about the beginning of the year 1881. Site . — The site immediately belonging to the surgical hospital itself contains probably about i£ acres of land, or 535 superficial feet per bed ; but as it is for the present administered from the old hospital adjoining, where all the food is cooked, the general stores kept, and so forth, the limited extent of the site cannot be considered so serious as it otherwise would be. General Arrangements . — The accompanying plans indicate the general arrangement of the buildings, which, it will be seen, comprise a central block three storeys in height above the basement floor, and, separated from it by short corridors, two pavilions, which jut out at either end of and at right angles to this central building. In the latter buildings the portions occupied by the main sick wards and day rooms are two storeys only in height. The centre block contains, on the ground floor, a small out-patients’ department, rooms for the medical officers, and a large room for instruments. There is a handsome central hall and staircase leading to the two upper floors, on each of which are wards for the accommodation of patients, with the usual attached offices. These larger wards will be described in more detail further on. * Eleventh Annual Report of the Local Government Board, 1S82. London. 138 Strasburg University Hospital. The pavilions forming the two wings of the building contain sick wards on the ground and first floors. The third storeys of these buildings are carried over the staircase ends only, and contain accommodation for officers of the establishment. The basements immediately below the ground floor of the buildings are about 9 feet in height, and are occupied as store and furnace rooms, but there is, beneath this, another, or sub-basement, about six feet high, the construction of which was probably necessitated by the nature of the ground. Total Accommodation. — It will thus be seen that the accommodation provided for patients is as follows : — Patients on first floor of central building, in two wards with 1 bed in each 2 Do. do. do. two do. 12 beds in each ... ... 24 Do. second floor do. two do. 12 do. ... 24 Do. ground floor of pavilions, two do. 2 do. ... 4 Do. do. do. two do. l 6 do. ' ... 32 Do. first floor do. two do. 2 do. ... 4 Do. do. do. two do. l 6 do. ... 32 Total ... 122 Drainage. — The sewage is said to be conveyed by drains to a cesspool, from which it is periodically removed by a steam pump. Connecting Corridors. — The wings of the building are connected with the central block by short enclosed corridors, 8 feet wide and about 10 feet high. Area Covered. — The area covered by buildings is 17,649 feet, or about 3roths of the site, and nearly 145 feet per bed. Cost. — The cost of the building is said to have been 600,000 marks (^o.ooo), or about ^246 per head, but it is not stated if this includes professional fees and superin- tendence, boundary walls, and other contingent matters. Wards of Central Block. These wards are situated on the first and second floors, and are direCtly over the directors’ and porters’ rooms and other offices situated upon the ground floor. Aspect. — The axis of this building runs from W. by N. to E. by S., so that the windows of the wards face N. by E. and S. by W. Size of Wards. — Each of the two principal wards is of parallelogram shape, and is designed to accommodate twelve patients. The length is 41 feet 4 inches, the width 28 feet 10 inches, and the average height 13 feet 10 inches. The total superficial floor space is therefore 1,192 feet, or about 99 feet per bed, and the cubic contents 16,489 feet, or 1,374 f eet P er bed. Bed Space. — The average lineal wall space per bed is about 6 feet 10 inches. Warming and Ventilation. — The building generally is warmed by means of calorifers placed in the basement, and the heated air rises into the wards through flues situated at the heads of the beds. Adjoining these flues, but at a higher level, there are other flues running upwards for the extraction of foul air. There are also in the end walls five air-extraCtion flues, heated by the iron furnace smoke pipes, which are made to pass through them. Strasburg University Hospital. 139 Floors. — The whole of the floors are carried on brick vaulting, so that, in this respcdt, the building is fireproof. W.C.’s and Baths . — The arrangement of the offices containing these apparatus is, as usual, unsatisfactory, but, inasmuch as they do not lead immediately out of the wards, they are somewhat less open to objection than those of other German hospitals. The w.c. and slop sink compartments on each floor are contained in a room which leads by a short lobby out of the central corridor connecting the two main wards. The w.c.’s are each 4 feet long and 3 feet wide. A bath and lavatory room leads out of the central day room, and is 12 feet long and 7 feet wide. It is fitted with a metal bath and two lavatory basins. Day Room. — The day room is situated centrally between the sick wards, and is 16 feet long, 12 feet wide, and 15 feet 4 inches high. The total area of the room is 192 feet, or 8 feet per patient occupying the adjacent wards. This room, unlike the others, is warmed by means of a stove. Terrace . — The windows on the south side of these wards are casements, and open on to terraces, each 15 feet wide, running along the full length of the wards. Separation Wards. — On the first floor, and leading out of the day room, there are two separation wards, each 11 feet 6 inches long, 9 feet wide, and 15 feet 3 inches high, and intended for the accommodation of one patient, each of whom would thus be provided with 103! feet superficial and 1,578 cubic feet of space. Duty Room . — Leading off the central corridor there is a duty room (“ Theekuche”) having an area of 102 feet. It is fitted with the usual apparatus for warming food, and other domestic appliances. This room is badly placed, as its only light is borrowed from the adjoining separation ward and corridor. It is artificially ventilated by inlet and outlet flues. Nurses’ Room. — The nurses’ room adjoins the day room, and is entered from the central corridor. It is 16 feet long and 12 feet wide, and so has an area of 192 feet. A window in the side wall overlooks the adjoining large sick ward. There is, in addition, a smaller room for a “ ward attendant,” leading out of one of the large w’ards. It has an area of 79 feet. Both apartments are fitted as bed chambers. Staircase . — The staircase is situated centrally between the two large sick wards and occupies an area of 306 feet. The steps are each 5 feet long, nj inches wide, and 7 inches high. Lifts. — Leading off the central corridor, and to the right and left of the staircase, there are two lifts ; one, 6 feet 10 inches long and 3 feet 3 inches wide, for patients ; and the other, 3 feet 3 inches long and 2 feet 9 inches wide, for food, coals, &c. Area of Building . — The total area covered by the first floor of this central building, including the outer walls, is 5,381 feet, or 207 feet per bed. The corresponding area of the top floor is 4,957 feet, or 206 feet per bed. Pavilion Wings. Aspect . — The axes of these pavilions run from N. by E. to S. by \\ ., so that the windows of the wards face W. by N. and E. by S., or diametrically opposite to that of the central building last described. L 140 Strasburg University Hospital. Size of Wards. — Each large ward is of parallelogram shape, and is designed to accom- modate 16 patients. The length is 55 feet, the width 28 feet 10 inches, and the average height 13 feet 9 inches. The total superficial floor space is therefore 1,586 feet, or about 99 feet per bed, and the cubic contents 21,808 feet, or about 1,363 feet per bed. Bed Space. — The average lineal wall space per bed is 6 feet 10J inches. Floors . — The floors are carried on brick vaulting, for the support of which columns are ranged down the centre of the ground floor wards. Warming and Ventilation .■ — The mode of warming these wing buildings is similar to that described for the central block. W.C.’s, Baths, &c. — The water-closets are situated in a compartment entered from the adjoining corridor, and are each 4 feet 6 inches long and 3 feet wide. The bath room and lavatory is 16 feet 6 inches long, 10 feet wide, and is fitted with a metal bath and two lavatory basins. Day Room. — At the extreme end, and leading out of each large sick ward, there is a day room, 28 feet 10 inches long, 14 feet wide, and 14 feet 3 inches high ; the total area is 404 feet, or about 254 feet per patient occupying the adjoining large ward. Separation Ward . — The separation ward on each floor is designed for the accom- modation of two patients; it is 16 feet 6 inches long, 11 feet 3 inches wide, and an average height of 13 feet 9 inches. It contains, therefore, 186 superficial feet, or 93 feet per patient, and 2,558 cubic feet, or 1,279 feet P er patient. Duty Room. — This room (the “ Theekiiche ”) has an area of 67 feet, and like those of the central block is objectionably situated in the centre of the building, and without means of light excepting that to be obtained through a window looking into the adjoining ward attendant's room ; it is fitted with an apparatus for warming food, and other usual appliances. Nurses' Room . — The nurses’ room has an area of 157 feet, and is entered from the corridor; it adjoins the larger ward, and has an inspection window overlooking it. There is also a smaller room, having an area of hi feet, for the use of a ward attendant. Both of these apartments are fitted as bed chambers. Staircase . — The staircase occupies an area of 181 feet. The steps are each 4 feet 7 inches long, n4 inches wide, and 7 inches high. There are no lifts in these wing buildings. Area of Pavilion . — The total area covered bj’ each floor of these wards with their offices, including the walls surrounding them, is 4,533 feet, or nearly 252 feet per bed. Hospital Construction and Management. Akermes 6 Queer. Square W C ( I 4 I ) LARIBOISIERE HOSPITAL, PARIS?, FRANCE. Before commencing a description of the buildings selected as types of French Hospital Construction, I cannot refrain from expressing gratitude for the valuable aid afforded me in the course of my investigations by the Director of the “ Administration Generale de l'Assistance Publique at Paris. Not only were instructions issued to the architects and the chief controlling authorities of the various institutions visited, that every facility should be afforded me for taking the most detailed particulars, but, since my return, all written enquiries (and they have been numerous) that I have made to the Administration, as to matters of cost and other like details, have been answered with great promptness and in the fullest manner. Those only who have had occasion to be dependent upon the courtesy of individuals or public bodies for gathering together particulars, such as are required for a work of this kind, can appreciate the valuable assistance that has been thus afforded me. To France is due the credit of having been one of the first to put in practice the principle of constructing hospital sick wards as detached pavilions, for no important building of the kind had been erected before the Lariboisiere Hospital now about to be described. Plans for the erection of this building were prepared by M. Gautbier, a member of the Institute, and it is stated that the instructions given to him were that the design should be made conformable with “the suggestions issued in 1788 by the Commissioners of the Academy of Sciences and the recommendations of v M. Tenon in his work on the construction of hospitals.” 0 It is admitted that this building carried out in every respect the views of the most experienced authorities of that time upon the subject of hospital construction. There does not appear to be any reliable record of the date upon which the foundation stone of the building was laid, but it is stated that the first wing was formally opened by the Emperor Napoleon III. in the year 1853. The whole of the building was not, however, occupied until March of the following year. The project for erecting the building was originated in the year 1839, and it was then decided to build it, under the name of the “ Hopital du Nord ” ; afterwards in the year 1841 it was changed to “ Hopital Louis Philippe,” then in 1848 to “ Hopital de la Republique,” and in 1852 the original name was reverted to ; lastly, when the building was nearly completed, the name of “ Hopital Lariboisiere ” was given to it, in com- memoration of the pious liberality of the Countess of Lariboisiere, who about that time had given her entire fortune to the Administration of the “Assistance Publique.' This legacy, when realized, amounted to the sum of 2,600,000 francs, or ^104,000. *For M. Tenon's recommendations, sec Appendix. .V 142 Lariboisiere Hospital. The great interest attaching to this building naturally arises from the fact of its being the first large hospital erecded upon the pavilion principle. It has formed a model for the design of numerous other hospital buildings, but, unfortunately, the many faults which exist, and which naturally might be expected to exist in so early an attempt, have been too faithfully copied in many like structures since ereifted. Site . — The establishment is situated in the northern quarter of the city, within the ramparts, and close to the “ Gare du Nord.” The site is bounded- towards the front by Rue Ambroise Pare, in the rear by Boulevard de la Chapelle, and on the sides by Rue Guy Paten and Rue dc Maubeuge. The enclosed area is about 590,651* superficial feet, being 13 acres 2 roods 10 perches, or about 963 feet per bed. Subsoil . — The building stands upon the site of an old stone quarry, and the foundations rest upon the solid rock. General Arrangement . — The principal entrance to the building is through the centre of the block marked A on the general plan. This block is one storey only in height above the basement floor, and contains the direiftor’s, steward’s, clerks’ and porters’ offices. Block B is three storeys in height, and contains on the ground floor the out-patients’ department, on the first floor thesteward’s residence, and on the second floor officers’ rooms. Block C is three storeys in height, and contains doctor’s rooms on the ground floor, the director's residence on the first floor, and officers’ rooms on the second floor. Block D contains on the ground floor a general kitchen, with scullery, larders, and other offices, and also a drug room for the officers. The first and second floors are devoted to the use of officers. Block E contains on the ground floor a dispensary and drug stores, on the first floor the priest’s and the chief dispenser’s residences, and on the second floor medical students’ apartments. Blocks F F F F F F each contain on the ground, first, and second floors the principal sick wards hereafter described. Each floor has one large ward for the accommodation of 32 patients, and one small ward for two patients. The blocks situated on the eastern side are occupied by men, and those on the western side by women. The first floor of one of the women’s blocks is devoted tc-^ying-in cases, and here the number of beds in the large ward is reduced to twenty-eight. The adjoining small ward is used as a lavatory and labor room. Blocks G G were designed as libraries, but are now used as consultation rooms. Blocks 1 IHHHHH, one storey only in height, are intended for cif^jMrooms for the convalescents, but on both occasions when I visited the establishment it was so over- crowded that it had bec'ome necessary for four of these blocks to be used as additional sick wards, another as a creche, and a sixth one as a bed store. Block J is three storeys in height, and is entirely devoted to the use of the nurses. Block K is also three storeys in height, and contains, on the ground and first floors, the wash-house, boiler room, and linen stdres, and on the second floor servants’ dormi- tories. The laundry is contained in the adjacent block S. * This is much in excess of the amount stated by Husson and other writers, but agrees with the official measurements. Lariboisicre Hospital. 143 The blocks connected to and in the rear of the main building are all one storey in height, and they consist of L, the chapel; N N, lecture rooms ; O O, coach-house and stabling ; P, stores and stoker’s apartments ; Q, mortuary and dissecting room. Blocks M M contain a very completely arranged set of baths for the general use of the patients ; those on the left of the entrance are for females, and those on the right for males ; each side consists of a room containing ten ordinary hot-water baths, divided from each other by curtains only, and another similar room for ten sulphur baths ; there are also two large rooms fitted in the ordinary manner for vapour and douche baths, also a room containing baths for the officials of the establishment. Block R is a lying-in ward for seven women, but is more especially devoted to puerperal fever cases, and will be described in detail further on. The following outbuildings are one storey in height, and consist of — T, dust sheds ; U, wood store; V, cart shed; W, yardman’s residence; X, foul linen store and fire- engine shed ; Y, covered shed with laundryman’s sleeping room attached ; Z, summer houses, conservatories, and covered sheds. Total Accommodation. — The building was erefted for the accommodation of 606 patients, but the lying-in ward, since added, raises the total number (exclusive of infants’ cots) to 613 beds, as follows : — Male patients in blocks F F F in nine wards with 32 beds in each Do. do. do. 2 do. Female patients do. eight do. 32 do. Do. do. one do. 28 do. Do. do. eight do. 2 do. Puerperal fever block R in seven wards with 1 bed in each ... Total 288 18 256 28 16 7 613 This number, however, is generally much exceeded ; the day rooms are more often than not made use of as sick wards, and almost as a rule additional beds are placed down the centre of the large wards. 0 Connecting Corridors . — The main corridors, marked x on site plan, connects together the various blocks of the main building; they are all one storey in height, 12 feet 7 inches wide, and 18 feet from floor to ceiling. They are closed in on both sides, and have windows and glazed doors opening on to the inner courtyard. The roofs are so construtfled as to afford a means of external communication between the several pavilions at the first floor level and they are used as ambulatories by the patients. Water Suptyj . — Greater part of the water used in this establishment is supplied by the city authorities, but some of it is pumped up from the Canal d'Ouercq. Iron storage cisterns are situated in various parts of the buildings, but their capacity is said to be very inadequate to the requirements of the institution. Drainage . — The drainage of the building is effected generally by earthenware pipes, but that from the water-closets and other offices at the extreme ends of the large sick wards is carried into two masonry culverts, 3 feet 6 inches wide and 5 feet high, which run at right angles to the axes of the pavilions, and discharge into the city’ - sewers. 1 he ♦This overcrowding has reached su^h a chronic state that the daily average number of patients during the years 1880-81 was 737, or 124 more than the building was designed to accommodate. M 2 144 Lariboisicre Hospital. pipes conveying the soil from the water-closets pass into iron vessels situated in the basement beneath, and these vessels are so constructed as to retain the solid matter and allow the liquid portion only to run away into the adjoining sewer. They are removed and replaced by others when full. No means are provided for disinfecting the sewage. Area Covered . — The total area covered by buildings is 129,503 feet, or nearly one-fifth of the site, and 21 1 feet per bed. Cost . — The cost of the land is stated to have been £127,597, or about £9,410 per acre, and £208 per bed. The cost of the buildings and their appurtenances amounted to £267,491, or about £436 per bed, so that the total outlay upon land and buildings was about £644 per bed. The following is a detail of the items of cost of the buildings forwarded to me by the Administration of the “ Assistance Publique”: — Excavator, bricklayer, and mason £1 55, 134 16 O Brought forward £211,953 17 8 Ironwork 22,640 12 9 Heating and ventilation ... 16,403 17 2 Carpentry 3,824 17 8 Asphalte 741 16 0 Roofing 9.047 12 O Gas lighting 325 0 O Joinery 10,596 5 8 Wash-house — 2,359 17 8 Painting 2.037 7 2 Hydraulic pump 360 0 0 Glazing 5 22 14 5 Water supply and service 2,706 4 0 Chapel glazing 408 4 10 Various fittings — 4.653 1 II Furnaces and chimneys ... 658 O IO Sundry expenses 287 18 5 Pavings 1.239 15 2 Alteration of boundary walls, con- Plastering 2,885 18 5 sequent upon increase of site ... 3.311 13 8 Carving... 820 7 2 Extra works ... 12,424 9 10 Footways I.IOI 2 5 The puerperal fever wards 1,282 0 0 Gardens and planting " 1,036 3 2 Professional fees ... 10,680 15 8 Carried forward ... £211,953 17 8 Total £267,490 12 0 The original cost of the furniture was, for the main building, £24,000; and for the puerperal ward, £205 ; or, together, about £39 10s. per bed. Principal Sick Wards. The main sick wards of the building are contained on the first, second and third floors of blocks marked F, and they are connected together by staircases, and also on the ground floor by enclosed corridors. Aspect . — The axes of the pavilions all run W.N.W. and E.S.E., so that the windows nearly face N. and S. Relative Position of Pavilions — The height of the pavilions, as measured from the lower floor of the sick wards to the junctions of the upright lines of the outer front walls with the sloping lines of the roofs, is about 59 feet, and the least distance between each pavilion is 68 feet, or about ij of the above height. Size of Wards . — Each of the large sick wards is of parallelogram shape, contains 32 beds, and is 125 feet 9 inches long and 29 feet 5 inches wide ; the ground floor wards arc 17 feet high, and those on the first and second floors an average height of 16 feet. The total superficial floor space is 3,695 feet, or 115 feet per bed, and the cubical contents on the ground and the first and second floors respectively 62,815 and 59,030 feet, or 1,963 and 1,845 feet P er bed respectively. Hospital Construction and Management. Lariboisicre Hospital. *45 Bed Space. — The average lineal wall space per bed is eight feet. Windows. — There are eight windows in each side wall, and the total area of their effective glazed surface is, on the lower, intermediate, and upper floors, 545, 516, and 477 feet, or 17, 16, and 15 feet per bed respe3 T ur&co^ftjcd room u _J 1 [ ll: G) or cl k 0 * fidard • 1 U -c j 1 o J -Puerperal -Fever • q | * 'Weirds • aw ° ♦ Laribotsiere -Hospital • I n nl Je=m -Purisj cJco/c df Plan" Pboto LthooraphM lcfVint>> Separation Ward . — The corridor, which gives access to the w.c.’s, also leads to the separation ward. It is intended for the accommodation of two patients, and has an area of 212 feet, and an average height of 16 feet 4 inches, so that the occupants would each have 106 superficial and an average of 1,731 cubic feet of space. The position of these w’ards is bad, not only on account of their close proximity to the w.c.’s, but that they are so far removed from the nurses’ rooms situated at the other end of the large ward. Duty Room. — The nurses’ duty room (“ tisanerie ”) has an area of 115 feet, and is fitted with a stone sink supplied with hot and cold w r ater, and an iron hot plate with ovens. A bath for the use of the patients is fixed in a recess 5 feet 4 inches long and 5 feet wide, which juts out from one side of this room. The bath is of metal, without casing, and is supplied with hot and cold water ; it is 4 feet 6 inches long only inside and 2 feet wide. Nurses’ Rooms. — In addition to the duty room last described, there is a nurses’ room of irregular shape, but having an area of 92 feet. It is not used as a sleeping apartment. The duty and nurses’ rooms are not carried up to the height of the adjoining wards, but a mezzanine is formed over them, and used as a store for patients’ clothing, and as a students’ cloak room. Staircases. — The pavilion staircases generally occupy an area of 578 feet, and they are constructed of oak with steps 7 feet in length, and with treads n4 inches wide, and risers 5 inches high ; the balusters are of iron, with a wooden handrail. Basements . — The basements are generally about 10 feet 6 inches high, and are variously occupied by furnace rooms, and lumber and coal stores. Total Area of Pavilions . — The total area covered by each pavilion, including its surrounding walls, is 6,493 feet. or about 191 feet per bed. Puerperal Fever Wards. The mortality in the lying-in wards of this hospital had been so great for many years that it was at last determined to erect a separate building for the treatment of cases of puerperal fever. M. Toilet was consulted, and, after much careful consideration, his design, illustrated upon the accompanying plate, was adopted. The building occupies the south-west corner of the site ; it is in all parts one storey only in height, and consists of 7 wards, each 13 feet long and 1 1 feet 6 inches wide ; each ward has an open fireplace, and is furnished with a bed for one woman, and adjoining it a child’s cot, an iron chair, footstool and table (similar to those seen outside cafes), and a “ table de nuit.” The flooring is of cement, and without covering of any kind, excepting a small india-rubber mat 3 feet 4 inches by 2 feet. Against one of the walls there is fixed a sort of drinking-fountain, with cold water tap and waste pipe. Each ward is furnished with an electric bell. There are no windows to three of the wards, excepting the fanlights over the two entrance doors leading from the adjoining verandah ; the upper panels of all doors are Lariboisierc Hospital. 150 glazed with ordinary glass ; the openings leading into the wards have all double doors, with double fanlights over them. The windows of the other four wards are formed as double casements, opening inwards, and with fanlights over them, also hung as casements. For the ventilation of each ward there is a hole about six inches in diameter in the centre of the ceiling, with a tube carried through the ridge, and terminating with a terra-cotta ornamental chimney. M. Toilet, who was so kind as to accompany me over the building, said that 80 cubic metres (2,825 feet) of air pass through this ventilator per hour. The construction of the wards is, in section, that of a pointed arch, “a forme ogivale,” so that the four side walls rise perpendicularly to a height of eight feet, and then, as they continue upwards, are made to converge towards the centres of the room at a considerable height (15 feet 9 inches) above the floor; it is at this central point that the ventilator described in the last paragraph is fixed. M. Toilet asserts that this formation of the sides of the room induces steady and constant ventilation in the simplest and most perfetfl: manner, and he also points out that there are no surfaces for the lodgment of dust and organic matter. It will be seen by the plan that each ward is entered from the outside, under the cover of a verandah, six feet wide, and therefore complete isolation is effected. The administrative portion of this building comprises an entrance hall, 13 feet by 15 feet 6 inches, and, to the left of this hall, there is a room, 9 feet 6 inches by 10 feet 6 inches, originally intended for a doctor’s room, but apparently now used as a sitting room for the nurse; adjoining this room there are two water-closets. To the right of the entrance hall there is a kitchen, 10 feet 6 inches by 9 feet 6 inches, furnished with a very complete cooking apparatus (“fourneau de cuisine”), having two ovens and a hot plate, besides a hot closet for linen and a cistern for heating the bath water ; then there is in this room a stove, sink and dresser, and other like fittings. The bath room, 7 feet by 6 feet adjoins the kitchen and is fitted with a metal uncased fixed bath. The nurses’ dormitory is situated in the rear of the building and centrally between the various wards, three of which it overlooks ; it is 14 feet long and 13 feet wide. The construction generally is similar to that of the Hospital of St. Denis, described in another part of this work. The total area covered, including the verandahs, is 2,770 feet, or 396 feet per patient. The cost of the building was £1,282, or about /183 per bed ; the furniture cost /’204, or about ^29 per bed. It was completed and opened on 1st July 1871, and it is stated that no deaths had, after twelve months’ use, occurred in it. . I To M. Grandjacquet, the present acting architect, and to M. Toilet, I am much indebted for the facilities kindly afforded me for obtaining much of the information contained in the foregoing account, Hospital Construction and Management. Pbolo Lithograph*! MVintwl by James Akrrx&a&.6 ,'^uefo Square W C ( i5i ) HOTEL DIEU, PARIS, FRANCE. Plans for the erection of this establishment were prepared by the architect, M. Diet, in the year 1864, and, having received the sanction of the late Emperor Napoleon III., the foundation stone was laid without ceremony in January 1866. It was not, however, until ten years after, July 1876, that it was opened by Marshal MacMahon, the then President of the new Republic, in the presence of the Diredleur dc l'Assistance Publique and his staff, the Municipal Council, and other distinguished visitors. Even then it was only partially completed, and to this date it is unfinished. The painful necessity for the ereiftion of this building, which took the place of the old Hotel Dieu, is pointed out by Dr. De Chaumont, who says — “ It can be shewn that outbreaks of disease arc co-incident with individual overcrowding, whether the hospital be large or small. Thus the terrible mortality of the Hotel Dieu, of I’aris, in the last century was due as much t utorhshop w tl Rtai/es and Coach house F sorters Office. Qhspenscrs 9\joom (fflu dents Atom CtneJ dispensers Qpar!‘ Operating Rheotrcs. (Reparation fiords H General dialling G?oom Rtudents fame Jrirory directors (ffart- Opraling/heahe Jtcfure Room Reparation fiords I Rich fiards x Corridors : Hotel*. D ieu: Huai *7Tajao/< ic< :Pa ris: *T Jjnen (jtore Oisters Chapct Ttooi hates dormitory, Ghr/yJjricn store K (Reparation fiards 6 Gbou /rooms L < Reparation fiords. c 2)ay npoms and Hate General Roths M (Reparation fiords. *2)00 Rooms and Reparation fiords, day Rooms & Genera! ffitchen . 0 Chapct 1 ’ Pathological depod, Ifortuary & H Officials depad, Rif tents C/oHnng store S Gnhy mto Curt yard, fiC* T Garden fyusejor Officials * SOtS HfirtH — \ Rarcrrs ddolre (Z/ome. Plan :<>f Site- : 1 Mcimof :Cetltr<\l:PaV(l { ^Tj\ f\j| B \5 lode nlj 7 !&r a rj «* C ' C 6 ///P rg ( Acms ops. dire (Sng»- '< ‘Tfaitse, < Voiles u< . M d\smje(/ing Closet. N i fechous fiord's. O JS> rJ o fiords ■ Tenon •• Hospital : • Me n t I won tan 1 • — Pa rt s • yjfmq rn ^y/or/uaro. Wok slant $>sl mortem fflom. '•ole slant 0 doman Co! ho he Chapels. Con id o 5 ^t/cr d c Ice C '/hi •Plan .• of • f>de- Section: A.B: Oco/e ^c. f o ni □□ un Do fiord J or 29 fytds Corridor [a jc a ^ m ^ 4 ^.p : Plan: of: ore : Pa Vt lion ; tiarol dnook B. Jresh air Jvkl (pdestak :De^il:of:one:of:Eml:B)oel?B: :De Wl:of -.Central sBlocfe: Vj calc ■ *C?c c / Photolithography:! & Printed by James Akermeu. 6. Queen Square W C H Saxon Snell del Tenon Hospital. 171 Area Covered . — The area covered by the building is 136,041 feet, or about one-fifth of the site, and about 187 feet per bed. Cost . — The cost of the land is stated to have been £63,120 (1,578,000 francs), which is at the rate of about £4,841 per acre, or. £87 per bed. The cost of the buildings and their appurtenances amounted to £304,284 (7,607,099 francs), or about £419 per bed, so that the total outlay upon land and buildings was about £506 per bed. The cost of the furniture was £24,640 (615,985 francs), or about £34 per bed.* Principal Sick Wards. The following description refers more particularly to the medical pavilions, but the others are almost precisely similar. Aspect . — The axes of all the principal pavilions run N.E. and S.W., so that the windows face N.W. and S.E. Relative Positions of Pavilions . — The height of the pavilions, as measured from the lower floors of the sick wards to the junctions of the upright lines of the outer front walls with the sloping lines drawn from the angles of the mansard roofs, is about 70 feet, and the least distance between each pavilion is 157 feet, or about 2J times the above height. Size of Wards . — Each main sick ward is of parallelogram shape, contains 22 beds, and is 84 feet 8 inches long, 27 feet 9 inches wide, and 19 feet high on the ground and 17 feet high on the first and second floors. The total superficial space is therefore 2,350 feet, or about 107 feet per bed, and the cubic contents 44,650 feet on the ground and 39,950 feet on the first and second floors, or 2,030 feet and 1,816 feet per bed respectively. Bed Space . — The average lineal wall space per bed is 7 feet. Windows . — There are six windows in each side wall, and their total effective glazed surface is on the ground floor 419 and on the first and secopd floors 388 superficial feet, or 19 and 17! feet per bed respectively. When all the windows arc opened to their fullest extent the total area through which air can be admitted by them into the wards is 624 superficial feet on the ground floor, and 586 superficial feet on the first and second floors, or 28| and 26^ feet per bed respectively. The lower portion of each window consists of a folding casement opening inwards, but the upper portion is formed with two tiers of casement sashes, also opening inwards, and fixed between transoms and mullions. They are all glazed with ordinary sheet glass. Warming . — The warming of the wards is effected by means of fans placed in a base- ment beneath the engine-house, and these draw the outer fresh air through a large inlet opening situated in the rear of block J, and then force it along subways which run beneath the various corridors of the buildings to the basements of the pavilions, in each of which there are placed six coils of steam pipes, enclosed in casings through which the air passes, and becoming heated by impingement against the steam pipes, is carried vertically through flues in the walls, and ultimately discharges itself into the wards through ornamented pedestals which are placed on either side of the entrance doors. The above figures are furnished me by the Dire&or of the “ Assistance Publique. " 172 Tenon Hospital. There are also additional inlets formed by the projecting jambs of the fireplaces. These are ordinary fireplaces, and have large open grates, but are seldom, if ever, used. Ventilation. — The outer fresh air being forced into the wards in the manner described in the last paragraph, the removal of the foul air from the rooms is a comparatively simple matter. There are outlet openings at both the level of the ceilings and the floors which communicate with vertical shafts that ascend in the outer walls into two channels which run longitudinally along the centre of the roof, and these channels, when they reach the centre of the building, enter a chamber that is heated by hot air, for the purpose of further inducing an upward current, and assisting the eventual discharge of the foul air through the sides of the fleche which surmounts the roof of the building. Lighting. — The lighting of the large wards is effected at night by gas in a manner precisely similar to that described at page 148, as in use in the upper wards of the Lariboisiere Hospital, excepting that the ventilating pipes are carried horizontally in the thickness of the floor, and then upwards in the outer walls into the foul air channels passing along the roof, and described in the last paragraph. Floors. — The flooring of the wards is constructed with wrought-iron girders and joists, filled in between with hollow brickwork and concrete, on which is laid timber joisting. The surface of the floors is finished with oak boarding four inches wide, beeswaxed and polished ; the ceilings are plastered, and finished similarly to the walls. Walls. — The outer walls are built of masonry, and are generally 2 feet 3 inches thick ; the inside faces are finished with a plastering “ stuc ” composed of lime and powdered marble, and the finished surface appears to have been treated by a process somewhat similar to that adopted in this country for the production of “ scagliola.” All the angles formed by the junction of the walls one with another, and with the plastered ceilings, are rounded to a radius of about six inches ; at the level of the floor there is a wooden skirting about nine inches high. IT.C.'s, Baths, &*c. — The water-closets, baths, and other sanitary appliances are situated midway between the two large wards, and are entered from a passage-way connetfting the two. The w.c.’s are 2 feet 9 inches wide and 3 feet 6 inches long, and are fitted with an apparatus somewhat similar in construction to Jennings’ patent valve closet. The enclosures to these closets are formed of deal framing 7 feet high, having dwarf doors in front 4 feet high and 12 inches above the floor ; the slop sink is of glazed earthenware, 2 feet 8 inches long and 1 foot 6 inches wide, enclosed by an iron casing ; it is supplied with cold water only ; above this sink there is an iron rack for holding bed- pans. There are two urinals of white earthenware, with ordinary slate divisions and backs, and they are provided with a treadle flushing apparatus similar to those introduced into this country by Mr. Jennings. On the female side the slop sink takes the place of the urinals, and a bidet is fixed in this compartment. The planning of these offices is open to all the objections made on page 148 to those at the Lariboisiere Hospital, and cannot, therefore, be too strongly condemned. The bath and lavatory room lias an area of 109 feet, and is fitted with a metal bath and three “ tip-up ” white earthenware basins sunk in a white marble shelf. The bath and basins are all supplied with hot and cold water. Tenon Hospital. 173 The soil and waste pipes are of iron 9 inches diameter, with short curved branches from the various apparatus, each 44 inches diameter. They are carried down the inside of the wards without enclosure of any kind, and it is stated that they are not ventilated at the top ; they descend into a room in -the basement, and discharge themselves into iron receptacles, which retain the solid and fcecal matter and pass away the liquid portion by an overflow pipe into the drains {see Drainage). In the passage-way leading to the bath room there are foul linen shoots descending from the various floors to the basement. Day Rooms. — Situated centrally between the two large wards, and entered from the passage which connects them, there is a day room for the use of convalescent patients. It has an area of 431 feet, which is at the rate of about 9I feet for the patients occupying the adjoining large wards. Separation Wards. — At either end of each block, and leading off the two principal staircases, there are two separation wards (four in all) ; two of them are for the accommo- dation of 3 patients each, and afford a space of 108 superficial and about 1,842 cubic feet per bed ; and the other two are for the accommodation of 1 patient each, with about 120 superficial and 2,040 cubic feet per bed. Duty Rooms. — The nurses’ duty room (the “tisanerie”) is situated in the central block between the two large wards. It has an area of 149 feet, and is fitted with a stone sink, supplied with cold water only, as also an iron hot-plate, with ovens and hot-water boilers. Nurses’ Rooms. — In addition to the duty room last described, there is a nurses’ room adjoining the day room, and having an area of 178 feet. It is not used as a sleeping apartment. Staircases. — The pavilion staircases generally occupy an area of 900 feet, and there are two of them to each double block, one at either end, of the building. They are constructed of oak treads and iron risers, 6 feet 6 inches in length, 13^ inches wide, and 6 inches high. There is also in the central block a small winding staircase having an area of about 50 feet, for the exclusive use of the officials. Lifts. — At the side of the passage-way in the central block there is a lift opening 7 feet 9 inches long and 6 feet wide ; the cage, which ascends from the basement to the various floors, is constructed of iron, and is worked by hydraulic power. Basement. — The basements generally are about 9 feet 2 inches high, and arc variously occupied as lumber and store rooms ; but running under the main ground floor corridors there is another corridor 10 feet wide, having a tramway communication with the kitchen and other domestic offices. Total Area of Pavilions. — The total area covered by each double pavilion, including its surrounding walls, is 11,048 feet, or about 212J feet per bed. The Maternity. The erection of isolated blocks of buildings for the reception of lying-in patients is a thing almost unknown in England, for here the mortality amongst this class of patients is not so great as it is in the ordinary hospitals of France. In the case of the Lariboisiere Hospital, wards have lately been built specially for cases of puerperal fever {see page 148), 174 Tenon Hospital, but in this, the Tenon Hospital, an isolated building is ereefted for the accommodation of the lying-in patients generally. A plan and section of this building is also shewn at page 148. It contains on the ground floor eight rooms, each for the reception of one parturient woman and her child, and there is a similar arrangement upon the first floor. Each of these rooms is 12 feet 9 inches long, n feet 9 inches wide, and 9 feet 10 inches average height ; so that the superficial floor space is 149 feet 9 inches, and the cubical capacity about 1,472 feet. The windows are ordinary casements, opening inwards ; the superficial extent of their glazed surface is 14 feet, and when these windows and the doors are opened to their fullest extent the area through which air can be admitted into the room by them is 42 feet. There are no other special means of ventilation, excepting that each room has an open fireplace, and that there is an opening in one corner through which air warmed in the basement can be brought in. The floors of the ground storey wards are of cement, but those on the first floor are of marble mosaic. The walls are of stone, and 19 inches thick ; they are plastered and painted on the inside ; the plastered ceilings are also painted, and the angles formed by the junctions of the walls and ceilings are curved to a radius of about 6 inches. Each ward is furnished with a bedstead for one woman, and adjoining it a child's cot, an arm-chair, an ordinary chair, a footstool, a round table, and a charnbn de unit, all of iron ; there is in one of the corners of each room a fixed lavatory basin, supplied with hot and cold water; at the head of each bed there is an electric bell button, communicating with the nurses’ duty room. Each ward is entered through a lobby from an open corridor 8 feet wide that runs along the whole length of the building forming a covered verandah, so that the rooms are isolated from one another. To the right or left of each entrance lobby there is a small closet, the use of which is not apparent, and, indeed, does not seem to be under- stood by the officials. The administrative offices are situated in the centre of the building, and they consist of, on the ground floor, a doctors’ room to the right of the entrance-passage, 16 feet 6 inches long and 1 1 feet 6 inches wide, and on the left a nurses’ duty room (a “ tisanerie”) of the same size. In the rear there is the staircase, and to the left of it an attendants’ room, and to the right a w.c. and slop sink. On the first floor there is another duty room, and a matron’s room, as also a w.c. and slop sink. The central portion of the building is carried up one floor higher than the side wings, and the additional storey so formed is occupied as a creche or nursery for infants whose mothers have died or are unable to suckle them ; there is also on this floor accommodation for the night nurses of the establishment. The total area covered by this building is 4,440 feet, or 555 feet per bed. My especial thanks are due to M. Vibert, the architeift at present in charge of the building ; this gentleman afforded me every facility for making a detailed examination of the structure. I am also indebted to M. Pety, now an architect, but who at the time of the erection of the building acted as clerk of works. Hospital Construction and Management. ( i?5 ) ST. DENIS HOSPITAL. FRANCE. The St. Denis, Bichat, Bourges and Montpellier Hospitals, now about to be described, are designed upon the principle introduced by M. Toilet, an engineer of great eminence, and who has devoted a considerable amount of time to the consideration of all questions concerning hospital construction. A large number of buildings, especially military barracks, schools and other like public institutions, have been, and are being, ereCted in France upon this principle by a company designated as the “ Societe Nouvelle de Constructions Systeme Toilet.” It appeared to me desirable, therefore, to investigate with more than ordinary care how far the results, as they affeCted hospital construction, had realized the anticipations of the inventor. My enquiry has been materially assisted by the courtesy of M. Toilet, who personally conducted me through some of the buildings here described, and, inasmuch as I have been compelled to take exception to some of the details of his work, it was but right that I should submit the proof sheets to him for correction ; this task he likewise most kindly undertook. The St. Denis Hospital is remarkable as being one of the best of the executed types of M. Toilet’s system of constructing sick wards. The principle consists of forming both the sides and the roofs of the wards with curved wrought-iron I-shaped ribs, placed about five feet from centre to centre, and filling in between, at the lower part, with brickwork, and the upper, or roof-portion, with tiling and brickwork, or concrete. In the buildings erected by M. Toilet, the outer surfaces of the roof are finished with a coating of cement or tiles, and the inner surfaces with plaster, upon which is laid three coats of oil paint. M. Toilet’s claim for originality re'Sts not only upon the novelty of this mode of construction but upon the formation of the finished interior faces of the walls and roofs in the shape of a pointed arch, “de forme ogivale," and it is claimed that buildings constructed in the manner described are not only incombustible, but that the absorption of disease germs, and other organic matter, is prevented ; also that the free passage of air is not checked by sharp angles ; and, lastly, it is pointed out that it is at all times possible, should it be requisite after an epidemic, to flush the whole of these inside surfaces either with flames of gas or streams of water. Judging by the executed examples of this system of construction, it would seem that of necessity the sick wards must be of unusual height and of large cubic capacity. In F ranee it is not unusual to see ordinary sick wards 18 to 20 feet in height, and containing from 2,000 to 2,500 cubic feet of space per bed, but in England the highest authorities on hospital construction would limit the height to 13 feet, and the cubic content to 1,200, or, at the most, 1,500 feet ; and carefully conducted experiments have certainly appeared to shew that the above limits should not, upon hygeinic grounds, be exceeded. M. lollet’s principle could not, therefore, be introduced where these opinions prevail, but in France it is otherwise. M. Laynaud, the architect of this building, has loyally carried out all the principles advocated by M. Toilet, and, in conjunction with him, has introduced many features that 0 2 176 St. Denis Hospital. arc obviously improvements upon all other buildings of the kind hitherto ereifted. One important oversight in M. Toilet’s ordinary mode of construction is that the end walls are upright, and that the angles formed by the intersections of the vault with the end walls are, if at all, very slightly rounded ; but if the arched system is really to effect the object proposed it is clear that the end of the rooms should be curved similarly to the sides, and the angles forming the junctions of the two vaults should also be curved. M. Laynaud accordingly constructed his wards after this manner.* One of the great objections urged against M. Toilet’s system of construction is that the thin crust of these vaults is insuffi- cient to keep out the cold, but this is a fault for which a remedy should easily be found. t M. Toilet has at all times strongly advocated our English plan of separating the w.c.’s from the wards by cross-ventilated lobbies, and it was really quite refreshing after visiting other French and German Hospitals to find in the building now being described that this principle is carried out in its entirety. In Germany and some other countries, the system of ereCting one-storied pavilions is being much brought into use, and it has been by every one strongly advocated that all such buildings should be raised from the ground by open basements ; but, almost invariably, these basements (see “Heidelberg” and “ Friedrichshain” Hospitals) are wholly, or almost wholly, enclosed. Here, however, the principle is- fully carried out, and the wards are entirely raised above ground, and stand upon a series of brick piers without enclosures of any kind. The foundation-stone of the building was laid by the Mayor and Town Council of St. Denis, June 1880; and the building was opened without ceremony on the nth of October 1881. Site. — The buildings stand upon a plot of ground of irregular pentagonal shape ; they face the “Rue du Fort de l'Est,” and are situated between the slope of the fort itself and the “ Parc de la Legion d’Honneur.” The extent of the site is 279,864 superficial feet, or 6 acres 1 rood and 7 perches, being 1,686 feet per bed. Subsoil. — The buildings stand upon a subsoil of chalk, but the surface of the ground itself is of very irregular thickness. General Arrangement. — The plate at page 175 shews by a block plan the general arrangement of the buildings upon the site, and a detailed plan and setflion of one of the surgical pavilions. The buildings are divided into the medical, surgical, aged, chronic and infirm patients’ departments, and these include special wards for lying-in women and children. Infectious diseases are provided for in separate blocks. The establishment is entered by the central gates situated between the administrative blocks A and C on the plan of site. Block A is three storeys in height above the basement, and contains, on the ground floor, the porter’s office, and a sitting and dining room for the use of the officials of the * One of the designs published by M. Toilet indicates this mode of construfting the ends of the wards, but he does not appear to advocate it, because, says he, “ in this instance, for example, although more elegant in appearance it reducesthe cubic capacity of the whole ward by 1,040 cubic metres, or 65 metres (213 feet) per bed.” f M. Toilet considers that this remedyPias been found by enlarging the space that intervenes between the outside of the vault and the inside of the roof covering. St. Denis Hospital. 1 77 e ablishment ; on the first floor, the official apartments ; and on the second floor, linen stores. Block B is one storey in height above the basement, and contains the kitchen and its offices. The basements of both blocks A and B are used as coal stores and other minor offices. Block C, like blocks A and B, is used for administrative purposes ; it is three storeys in height, and contains, on the ground floor, the steward’s offices; and on the first and second floors, his residence. Block D, one storey in height above the base- ment, is the dispensary. The basement of blocks C and D is used for storage purposes. Blocks E and F are pavilions, one storey only in height, for the accommodation of aged, chronic and infirm men and women respectively ; each block contains two wards for 8 beds each, and two smaller rooms each for the reception of two incurable cases ; these latter wards are used in block A for two lying-in women ; there is a day room in the centre of each building, and the usual attached offices. Blocks H H are pavilions, one storey only in height, for the accommodation respectively of male and female patients, each block contains two wards for 16 beds each, and two smaller wards each for the accommodation of two children ; there is a day room in the centre of each pavilion with the usual attached offices. Blocks III are pavilions one storey in height for the accommodation of surgical patients. The eastern block is occupied by women, and the central and western blocks by men. Each block contains a ward for 16 beds, with attached offices, and are more particularly described hereafter. Blocks J J are pavilions one storey in height for the accommodation of male and female patients suffering from infectious diseases, and each consists of four wards containing one patient each with detached water-closets, kitchen, and a ward attendant’s room. Blocks K K are one storey in height, and each contains two ordinary baths, and one medicated bath, a vapour and douche bath, and two small dressing rooms. Blocks L, M and N are all one storey in height above the ground level. L is a wash-house and engine house. M contains three chapels for Protestants, Roman Catholics and Jews respectively ; the basement of the building is used as a laundry. N is a mortuary, post-mortem room, doctor’s room, and coffin store. Total Accommodation. — The total number of patients provided for is therefore 166, viz. : — Aged, chronic, and infirm men in block E, in two wards of 8 beds each 16 Ditto in two wards of 2 beds each ... 4 Aged, chronic, and infirm women in block F, in two wards of 8 beds each iG Ditto in two wards with one parturient woman in each 2 Medical male and female patients in blocks H H, two wards in each block with 16 beds in each 64 Also in block F two wards in each block with two children in each ... ... ... ... 8 Surgical male and female patients in blocks III, one ward in each block with 16 beds in each 48 Male and female infectious cases in blocks J J, four wards in each block with 1 bed in each 8 Total 166 The blocks generally are connected together by a tramway for the conveyance of food, medicine, &c., to the various wards, and there is a complete system of electric bell communication throughout the establishment. 178 St. Denis Hospital. Connecting Corridor. — The blocks D B are connected together by an open covered way 9 feet wide in the clear, but all the other blocks are entirely detached. Water Supply. — The water used in this institution is pumped up from an artesian well, sunk below the engine-house floor in block L, and it is raised into two large iron tanks, situated above the roof of this building, and from thence is distributed throughout the establishment. Drainage. — The drainage from the various blocks of buildings is effetfted by means of Doulton’s glazed earthenware pipes ; all foecal matter being caught in iron tanks and removed periodically in a manner similar to that described as being in use at the Lariboisiere and other Parisian hospitals ; no means of disinfection are employed, and the outlet from the drains is into the public sewers. Area Covered. — The area covered by the building is 49,147 feet, or about one-sixth of the site, and 296 feet per bed. Cost. — The architect informs me that the cost of the land was £%,ooo, being about ^1,271 per acre, or ^48 3s. lod. per bed ; and, according to the same authority, the cost of the building was ^"40,000, or ^241 per bed nearly, so that the total cost of the land and buildings was about ^289 per bed. Principal Sick Wards. The following description refers more particularly to the surgical wards, illustrated at. page 175, each of which is self-contained in pavilions one storey only in height above the basement : — Aspect. — The axes of all the pavilions run almost due E. and W., so that the windows of the wards face N. and S. Size of Wards. — Each pavilion contains one large ward 65 feet 3 inches long by 27 feet 7 inches wide, and the total height to the apex of the pointed roof is 26 feet 4 inches, the average height throughout is, however, only 22 feet. The superficial floor space, after allowing for the rounded angles at the junctions of the side with the end walls, is 1 ,787 feet, or about 112 feet per bed, and the cubic contents are 39,314 feet, or 2,457 feet per bed. Bed Space. — The average lineal wall space per bed is 8 feet 1 inch. Windows . — In the south wall there are seven glazed doors which give access to the external balcony, and above these doors there are fanlights having glazed iron frames hung on the lower rails to open inwards. In the north wall are folding casement windows, with fanlights over, similar to those last described ; as also at each of the four curved angles of the room smaller casement windows and fanlights to cor- respond. All the doors and sashes arc glazed with ordinary sheet glass and the total effective glazed surface is 406 feet, or 25J feet per bed. When all the windows and balcony doors are opened to their fullest extent the total area through which air can be admitted by them into the ward is 617 feet, or 38^ feet per bed. Wanning. — The warming of the wards is effected principally by two calorifers which stand in the open covered space beneath them, and hot air is taken from these calorifers along channels which run down either side wall at the level of the basement ceiling. These channels open at intervals into boxes (having perforated zinc sides) placed behind the heads of the beds at the level of the ward floor. In addition to this mode of heating St. Denis Hospital. 17 9 there is, in the centre of each ward, a stove having two open fireplaces. The day rooms are warmed with ordinary stoves. Ventilation . — The ventilation of the wards is effected mainly by the windows and doors, but also to a large extent by a 'system of inlet and outlet apertures. Under each of the windows in the nortli side wall there is a large louvred opening closed by doors, through which air may be allowed to enter the wards ; fresh warmed air is also, during winter, brought into the wards by the calorifers. There are three outlet openings ; two of them situated at the junctions of the roof hips are formed with circular tubes 12 inches diameter, covered at the bottom next the ceiling with perforated zinc, and having their upper ends next the outer air finished as ornamental perforated finials. These outlets have valves for opening and closing when required by means of lines and pulleys. The other outlet opening is in the centre of the ceiling, and there is also a tube about 2 feet 3 inches diameter which surrounds the stove pipe, 9 inches diameter passing through it ; this combined chimney and ventilator has its termination in a kind of zinc roof rider, and forms a conspicuous ornamental feature to each block of building. No means are provided for closing this outlet. Lighting . — The ward is lighted at night by means of gas jets enclosed in glass globes placed over the entrance doorways at either end of the room. No special means are provided for carrying away the produfts of combustion. Flooring . — The flooring is constructed with brick arches, springing from the lower flanges of w r rought iron joists, and covered with concrete, on which is laid timber joisting ; the finished surface is of diagonal-shaped oak frequently beeswaxed and polished. Walls . — The outer walls are 15 inches thick, and are finished on the outside with red facings, without dressings of any kind. The inside faces are finished to a height of 5 feet 7 inches, with a plastering “stuc” composed of lime and powdered marble, and finished with a floated surface. The vaulted surface above 'this is finished with ordinary plastering and painted. There is a wood skirting 9 inches high at the level of the floor. W.C.’s, Baths, &c . — The ward offices and the day-room are situated at either end of the large w T ard, and are separated from it by cross-ventilated corridors about 5 feet wide. At the end of one of these corridors there are three marbled earthenware “ tip-up” lavatory basins, sunk in white marble slabs and supplied with cold water only ; at the other end there is a winding staircase descending to the basement level. There is an entrance-hall at each end of the building, and a passage-way leads of] from one of them. This passage is continued by a covered bridge 8 feet in length with glazed sides, giving access to the water-closets. There are two water-closets each 3 feet 1 inch wide by 4 feet 6 inches extreme length, with white earthenware valve closets and oak seats. There is an arrangement by which a moveable funnel-shaped metal pan can be placed into the hole of the closet seat when emptying slops. In the lobby outside the water-closets there is a linen shoot. The soil pipes are formed b}^ short lead branches about 4 inches diameter connected to longer branches of red unglazed earthenware 6 inches diameter, and these pass into a pipe of similar material 9 inches diameter which descends into a room in the basement and discharges itself into an iron receptacle that retains the solid and fcecal matter, and allows the liquid portion i8o St. Denis Hospital. to pass away through an overflow pipe into the drain, much in the same manner as that described for the Tenon Hospital, at page 173 ; it is, however, to be observed that in this instance the main soil pipe is carried up to above the level of the ridge of the roof, and so keeps the iron receptacle tolerably well ventilated ; no such precaution is, I am informed, taken at Menilmontant. Adjoining one of the entrance halls there is a bath- room about 53 feet in area, fitted with a metal bath and supplied with hot and cold water. There is also a stove which, in addition to warming the room, heats the hot water and towels. Day Room . — Adjacent to one of the entrance-halls, and entered from it, there is a day room for the use of convalescent patients, the area of which is 218 feet, or about 13^ superficial feet per patient occupying each pavilion. Verandah. — The doors in the external southern wall of the ward give access to a balcony 9 feet in width and about 65 feet in length, and in suitable weather the patients in their beds may be wheeled out on to the balcony, and can be protected from the sun, when requisite, by a lean-to awning fixed against the outer wall in a manner similar to an ordinary shop blind. Duty Room . — Adjoining one of the entrance-halls there is a duty-room having an area of about 57 feet ; it is fitted with a sink and a gas warming apparatus, and there is also a lift worked by a rope for bringing up the food from the level of the tramway in the basement. Nurses' Room . — At either end of the building there is a nurses’ and a ward attendants’ room having areas of 72 feet and 53 feet respectively, the ward attendants’ (“ infirmiers ”) room is fitted as a sleeping apartment, the nurses’ as a sitting room. Doctors' Room . — Leading off one of the entrance-halls there is a room used by the doctors for surgical operations ; it is 266 feet in area. Basements. — With the exception of a small chamber beneath the water-closets containing the iron receptacle for soil, the whole of the basements of these pavilions are entirely open at the side, the superstructure being supported on stone piers. The height from the ground to the underside of the ward floor is 8 feet 9 inches. Total Area of Pavilion. — The total area covered by this pavilion, including its sur rounding walls, is 3,572 feet, or about 223 feet per bed. Hospital Construction and Management. Photo htho$rapb*cl & footed by Janes Akerman. 6. Queen Squ»r«.W C n oaxon Dneli aei Bichat 1 -Hospital -Paris- boulevard i *7 A -Jorfcro JoJqc O' Entrance H | _ €* C7 * 1 B C?i/ fla./dy-eenUmj for»,n,M, e ‘ I IftH ‘ Ol ‘ O t TO* bjKtt c. — The water-closets, baths, and other sanitary appliances are placed in a wing corresponding to those of the separation wards, and they are separated from the main wards by a passage-way about 5 feet wide. There are two water-closets to each ward fitted with ordinary pan apparatus. The bath-room is fitted with a metal bath, and is 6 feet 6 inches long, and 5 feet 3 inches wide. Day Rooms. — No day rooms are provided on the sick ward floors, but the floor beneath one of the separation wards is fitted up’as a dining room for the use of the patients. This room cannot, however, be reached by the patients without passing outside the building. Verandahs . — Like all M. Toilet’s buildings, there runs longitudinally down the outside of the wards a verandah. In this case there are two, one on either side, 8 feet wide, and both can be entered from the ward by casement windows, reaching to the floor line, and in such manner that the beds may, either with or without the patients in them, be wheeled on to these verandahs in fine weather. There is likewise an arrangement by which awnings can be drawn over the verandahs for protection from the direeft rays of the sum. This is an important feature well worthy of notification. Duty Rooms » — The duty room (the “tisanerie”) is 7 feet 4 inches long, and 6 feet 6 inches wide ; it is situated between the w.c. compartments and the bath-room. Nurses’ Room . — The attendants’ or nurses’ (“ surveillants ”) room is situated to the right of the passage-way leading into the large ward, and it has an inspection window Bichat Hospital. 185 overlooking the ward. The corresponding room to the left of the passage is designed for use as a clothes room (“ vestiare ”). Staircases . — At the ends of the covered ways marked x on the plan, and adjoining the pavilions nearest to the central buildings, there are staircases which give access to the first floors forming the corridors connecting each pair of pavilions. There is also an outside staircase to each pavilion, which leads from one of the verandahs down to the yards below. Basements . — The central portion of the ground floor or basement of each pavilion (that portion of the length contained between the projecting separation wards), is intended for use as a covered recreation ground. The corresponding space between these wings is planned as clothes, bedding, or ordinary store rooms. The spaces under the two end separation wards are intended to be used as dining rooms for the patients and officers, and under the separation ward next the connecting corridor there is a room for the heating apparatus. The spaces between each pair of pavilions marked S on plan, are intended to be used as linen stores. The only objection that can be urged against this practice of stilting sick wards above the ground is the inducement offered for afterwards converting the lower space into sick wards, whenever the increase of population demands the erection of an additional hospital. There is a temptation, also, to utilise these open spaces as store and lumber rooms, or additional administration offices. I know of only one instance where this has not been done, and I have visited a large number of buildings in foreign countries where the plan of open basements has been adopted. When Dr. Mouat visited the building now under consideration in the early part of the year 1883 — that is to say, within twelvemonths after it had been opened — these covered recreation grounds had already been partially closed in to form additional offices. Area of Pavilions . — The total area occupied by the sick ward floor of each pavilion, including the surrounding wails, but exclusive of the verandahs, is 4,972 superficial feet, or 1651 feet per bed. If the verandah is included the space per bed is 270.1 feet. BO URGES MILITARY HOSPITAL. FRANCE. This was the first hospital erected on what is known as the “ Systeme Toilet.” The arrangement of the various buildings, especially the planning of the sick wards, is generally in accordance with the rules laid down by all the most eminent authorities upon hospital constriuftion. The claim of M. Toilet to originality, it will be remembered, consists in his system of constructing the inside faces of the walls and roofs in the form of a pointed arch, and in the manner detailed more particularly in the description of the Civil Hospital of St. Denis. M. le Dr. Ch. Sarazin, in an interesting account of the design and construction of this building, says — " A laborious childbirth was that of the Military Hospital of Bourges. Its history would be an interesting and curious one to relate, for it is that of the struggle which new ideas always have to maintain in order to cut their way, even when they are founded on experience, on the scientific and positive side of health, and on common sense. One has seen repeated at Bourges that which has been gone through for the last thirty years whenever the question has arisen of building hospitals : the physicians recommending the improvement and application of modern hospital hygiene, the administrators and architects wishing to raise monuments. At Bourges, for the first time, it is the hygienic notion which has prevailed. " On my arrival at Bourges the Commander-General of the Eighth Army Corps did me the honour to request that I would suggest a scheme for organising the hospital service. I was anxious that the system of small separate pavilions should prevail, the block-system of which the English and Americans have shown us such excellent models. The type recommended by M. Toilet for the barracks that had just been constru&ed at Bourges appeared to me to fulfil all the desirable conditions, and with the enlightened co-operation of the head engineer, Commander Gripois, we succeeded, after many struggles and vicissitudes, in getting a plan accepted which, with some slight modifications, has become that of the present hospital. Thanks to the firmness of the General, M. Ducrot, Bourges now possesses the first specimen in France of a hospital with independent pavilions without superimposed storeys, and having each a single large ward ; a hospital as nearly as possible what both hygeists and physicians for a long time since, and with much unanimity, have called for.” It will be seen that M. Sarazin, as is not unusual with some few members of his profession, takes credit for all that is hygienically good in the design of this building, and would have it understood that the sole aim of architedts is the production of structures magnificent in appearance but in total disregard of all the laws of health. Yet it is singular that, almost in the same breath, he has to acknowledge that when requested to formulate a scheme for the hospital administration of this army corps he found a system already prepared for him by the architect, M. Toilet, and that he had the good sense to adopt it. These oft-recurring attempts to engender a feeling of rivalry between the two professions is much to be regretted, for it is quite apparent to those who have any knowledge of the design of hospital buildings that while it is always desirable that the joint experience of the medical man and architect should be brought to bear upon the consideration of all parts of hospital construction, yet the questions to be decided by each are of essentially different natures. Hospital Construction and Management. • Rotir6cs: h YUU‘( • AA t^ortirj $cJae & ’Jua.rol Jicu'Se R Gallic, tyiopenaarc/ C t ^arrt/ion.6 temporarily in uoc ac @ermiteria), Chapel, Qjlorti, (S^rcerl eCuar/en & other J^jrmmtfra/we fyhcee Cj Jrlaoilono containing {Jich tutardc, D orluary E C 'coach Jiouac F oS/icdo ^ ^ H &afar C?an^ • one -Pavilion : Side • Elevation » of ■ Pavilion : /• j* eJeo/c cf 9fct Purfr : Elevation : of : Co r r idor •• Section-throu gh- Pavi 1 1 on : Photo Lthographad Sc Printed by James Akerman.6 Queen Square. W C H Saxon Snell del Bourges Military Hospital. 187 I have before had occasion to remark that, although M. Toilet’s expressed principles of hospital construction are all that could be wished for, no building hitherto ereCted by him properly represents the rules which he advocates, and that this is so probably arises from the occurrence of circumstances over -which he has no control. The building about to be described was in its conception, no doubt, one of the best of hospitals, but the alterations made by the military authorities, ostensibly for purposes of economy, have had for their result the production of a building the tout ensemble of which is anything but satisfactory. That this has been so no one deplores more than M. Sazarin, the officer deputed in the first instance to organise the hospital service of this district. It was originally intended that the whole of the twelve pavilions should be devoted to the use of the sick patients, and that the officers’, nurses’ and hospital attendants’ quarters should be located in the central court, the chapel being at the extremity of it. Now, however, five of the pavilions are utilised for these purposes, and the accommo- dation for the sick is correspondingly reduced. But this is not the only instance of false economy. The heating appliances are singularly insufficient, and generally the building in its details is not well finished. Site. — The building is situated on a very elevated spot, and in the environs of Bourges. It is reached by the two roads, Dun-le-Roi and the new Boulevard of Serancourt. The site forms an irregularly-shaped square, and is bounded on three sides by new roads, and on the back, or rear side, by the road leading from Bourges to Gionne. The extent of the site is 59,800 feet, being about 12 acres 1 rood 17 perches, or 277 feet per bed. Subsoil. — The buildings stand upon a substratum of limestone, full of fissures, and, consequently, “ so absolutely permeable to water that the natural drainage is perfect.” A very thin crust of vegetable mould overlies the chalk. General Arrangement . — The general arrangement of the buildings upon the site is shewn upon the plate at page 186, as also a detailed plan, seCiion, and elevation of one of the principal pavilions. The porter’s lodge and the guard-house are situated on either side of the entrance gates, at the points marked A A upon the block-plan. The central block, B, contains, on the basement floor, stores, larders, &c., and, on the ground floor, the dispensary, surgery, library, operation ward, with doctors’ and dispsensers’ rooms, the kitchen, with its offices, a furnace and boiler room, Turkish and other ordinary bath rooms. The upper floor of the central portion is occupied as living rooms by some of the officials, and as store rooms. The twelve blocks marked C C 2 on plan are all ere(fted as if for sick wards, and eventually, when the administrative offices are completed, they will be used as such, but at present only seven of them, C2, are so occupied; the remaining five are used as dormitories and dining rooms for the hospital attendants, chapel, with chaplain’s room and vestry, store rooms and other like administrative offices. One of these pavilions contains thirteen rooms for officers, with the usual offices attached. The seven pavilions, C 2, each contain a large ward for the reception of 28 patients, and an isolation ward for 1 patient. These pavilions will be more particularly described hereafter. Dr. Sazarin, Bourges Military Hospital. 1 88 and others who take an interest in this building, have much deplored the false economy that induced the military authorities to postpone the completion of the building, seeing that in its present state it is quite inadequate to meet emergencies. Block D is a mortuary ; E, a coach house ; F F, store and lumber sheds ; H, the tank and riding house. Total Accommodation . — The building, it will be seen, as at present arranged, can accommodate 216 patients in seven wards for 28 patients each, seven for 1 each, besides thirteen rooms for officers with 1 bed in each. When, however, the proper administrative blocks are ereifted the building will accommodate 332 patients. Connecting Corridors . — The twelve pavilions and the central administrative block, B, are connected together by closed corridors, about 13 feet wide, having “ogival” shaped walls and ceilings; the extreme height is about 13 feet, and, being on a level with the floors of the sick wards, they are raised high up above the ground, consequently flights of steps are provided at intervals that the patients may reach the airing courts situated between the pavilions. These corridors are also available for the use of the patients in rainy weather, though, in consequence of the low height of the windows, they do not make very cheerful ambulatories. The flooring is of cement, and the walls are plastered. They are not, at present, heated, but arrangements have, it is understood, been made for doing so when “ funds will permit.” Water Supply . — The height of the buildings above the town is so great that difficulty might have been experienced in obtaining a proper supply of water for the buildings, but this evil has been averted by the provision of a large storage tank. Area Covered . — The area at present covered is about 83,173 superficial feet, or 385 feet per bed, but as the buildings are incomplete this estimate will hereafter have to be modified. Cost . — Information as to the price paid for the land does not appear to be obtainable, and as respeefts the building it is difficult to arrive at what has been the exadt cost. The information on this point given by M. Sazarin, so far as it can be understood, would, however, seem to shew that in its present unfinished state it has cost £"31,920 (798,000 francs), as follows : — The kitchen Dispensary Baths Furnaces, &c Pavilions and all other buildings £808 0 0 168 0 0 464 0 0 280 0 0 30,200 0 0 Total £31,920 o o This does not, however, give any clue to what the cost of the building will be when it is completed. So far, it would appear to have cost, exclusive of the price of the land, about £”148 per bed.° * M. Toilet informs me that since this account was written a large two-storied building has been eredted for the distindt accommodation of the hospital staff, thus setting free the whole of the pavilions for the purposes of sick wards and reducing the cost per bed of the building. Bourges Military Hospital. 189 Principal Sick Wards. The principal sick wards, like all those of M. Toilet’s buildings, are one storey only in height above the basements, and the walls and ceilings of the interiors are shaped in the form of a gothic arch (“a forme ogivalc”). A detailed plan, sciftion, and elevation, of them are shewn at page 186. Aspect . — The axes of the pavilions run from N.W. to S.E., so that the windows of the wards face N.E. and S.W. M. Sazarin says that “ the pavilions being placed in a northerly and southerly direction, their long fronts are exposed to the east and west, and so receive the rays of the sun at its rising and setting, that is to say, at the times when it is nearest to the horizon and when, therefore, its rays can best penetrate into the wards of the pavilions. This is the orientation which best suits mild climates, and simple window blinds are always, under these conditions, a sufficient provision against the access of solar heat during the hottest days of the year. In warm countries, on the contrary, the east and west axis should be preferred, one of the fronts thereby being exposed to the north, and, in consequence, always cool, the other exposed to the south, but protected by a covered gallery-balcony, or verandah. These latter appendages do not appear necessary in our climate, and can be discarded in hospital plans as constituting a luxurious expenditure.” Relative Position of Pavilions. — The height of the buildings, as measured from the floors of the wards to the junctions of the upright lines of the outer front walls with the sloping lines of the roofs, is 16 feet 6 inches, and the distance between the buildings is 49 feet, or about three times the height. Size of Wards. — Each ward is of parallelogram shape, contains 28 beds, and is 96 feet 5 inches long, 24 feet 7 inches wide, and 20 feet average height (the extreme height is about 25 feet). The total superficial floor space is therefore 2,370 feet, or about 89 feet per bed, and the cubic contents 47,678 feet, or 1,703 feet per bed. Bed Space. — The average lineal wall space is 6 feet 11 inches per bed. Windows. — The windows are placed between each pair of beds, and consist of double casements, with transom lights over. These windows are very low, and would be oppressive in appearance, but that they are supplemented by other dormer windows, about 24 inches square, situated about half-way up the roof. Warming. — Each ward is heated by two cast-iron stoves, enclosed by casings, through the perforated sides of which fresh air escapes into the ward after it has been brought in through flues passing beneath the floors and heated by contact with the sides of the stoves. Arrangements are made by which the heated air may be moistened by passing over water. The flues from these stoves are so encased as to form extraction shafts for drawing away the vitiated air from the wards. In addition to these stoves there is in the centre of each of the wards a double grate with open fires. I he apparatus is undoubtedly deficient in heating power during very cold weather, yet M. Sazarin tells us that the cost of it per pavilion reached the large sum of ^240 (6,000 francs), or £ 8 (200 francs) per bed. Ventilation. — Besides the ventilation afforded by the heating apparatus as last described, there are the upper and lower windows, and, in addition, sixteen ventilators on Bourses Military Hospital. 190 whenever the weather will permit. Lighting . — The wards are lighted by large glass lanterns fixed against the side w r alls and closed tightly by glazed doors. Curved pipes are carried from the upper parts of them into flues in the walls, which rise upwards to the level of the roof and so assist the ventilation of the wards. Floors . — The flooring is carried on arches, and the finished surface is of oak, which is stated to be laid in a bed of bitumen so as to ensure complete security from the rising of damp from the soil below. Walls . — The basement walls are of stone, and so also are those of the ground floor to the height from which the arched vaulting commences. This vaulting, which continues to the ridge, is formed by T-shaped iron ribs bound together horizontally by iron cross ties and filled in between with hollow specially-made bricks ; over this there is a space, and then iron battens are laid longitudinally for the support of the tiles which form the outer covering of the roof. W.C.’s . — Almost for the first time in this history of modern hospital constnnftion I am enabled to chronicle the faift of an existing Continental building having the w.c.’s entirely detached from the wards by means of cross-ventilated lobbies. Indeed, in these wards the connecting lobby is entirely open at the sides and should, perhaps, more properly be designated as a “covered way.” This is somewhat to be regretted, for it is clearly impossible for delicate patients to make use of these conveniences excepting during the mildest weather. But for this objection, it might be hoped that the principle once introduced would rapidly extend to other like institutions hereafter to be erected in France. The bath and lavatories are situated to the right of the passage-way leading from the end of the ward, and they are placed in a room 9 feet 6 inches long and 9 feet wide. Day Room . — To the left of the passage-way last described there is a day room, 14 feet 9 inches long and 9 feet 6 inches wide, and having, therefore, an area of about 140 feet, or 5 superficial feet for each patient in the large ward adjoining it. Separation Ward . — This ward is situated to the left of the entrance passage-way, and is for the accommodation of one patient only. It is of the same size as the day room last described, and its cubic capacity is about 2,000 feet. Nurses’ Room . — A ward attendants’ room is situated on the opposite side of the entrance passage, and is of the same size as the separation ward last described ; it is fitted as a sleeping apartment. Duty Room . — The duty room, or “ tisanerie,” is situated adjoining the bath room at the end of the large ward. It has a superficial content of about 50 feet, and is fitted with the usual warming apparatus and other domestic appliances. Basement . — The whole of the structure is raised upon low vaulted basements, varying from 4 to 5 feet in height and cross ventilated by openings in the opposite walls. Total Area of Pavilions . — The total area covered by each pavilion, exclusive of the connecting corridor, is 4,305 feet, or about 148 feet per bed, Hospital Construction and Management. • S* Elm ~ Hospital 'Montpellier • A Admin csira ture. Offices B "f(ifchen enters anddccfuu ^oom £ %afhs D. ChajSt! £ dturses Jfomc F Wic^ Wards H Iso la Icon Wards I J Wards Jor fyytng blunts K.L ^rouahohar y Wards y\^atrxg-Ln Ward W ruerjtero/ jfcuer fipsrds 0 Xaundry + Washhouse P J&undry Detects dormi- tory Tidt/orfuary S W is injection dfouse T d> tab Una. +Coach hou*t Plan - of • Si te jh Sect ion ‘on - Line - oJcalt of • A.B • Plan of Ci t on nd - Floor ~ L± 1 t 2 £ r ¥ «i* /f v v r ■■« r* ■» « o)ca/e oj IFcert Photo LUm$taf>h»V. C H Saxon Snell del Utrecht Hospital. 199 an orchard and other premises. The extent of the site is about 35,080 superficial feet, or 7 acres, 3 roods, 13 perches, being nearly 133 superficial feet per bed. Subsoil . — The foundations of the buildings in many parts of Holland are difficult of construction owing to the loose sandy' nature of the ground upon which they stand and the close proximity of water to the surface. This building was no exception to the general rule. General Arrangement . — The accompanying plate shews the general disposition of the buildings upon the site, and a plan of the principal or first floor ; also an elevation of the entrance front. The ground floor of the front block contains the administrative offices and residences, the laboratory, dispensary, instrument, lecture, waiting, and receiving rooms ; also the out-patients’ department and two sick wards, each accommodating 12 patients. The first floor contains six wards, each for the accommodation of 12 patients, together with the usual attached offices. There is also a small operation room on this floor. The floor above contains four wards, each for the accommodation of 12 patients, with the usual attached offices, besides store rooms and servants’ dormitories. The ground floor of the central block contains the kitchen, scullery, dining room, larder and store room. The first floor provides accommodation ior the director and doctor, besides two wards, each for the accommodation of 8 patients, and four separation wards, each for 1 paying patient. The two wings running right and left from the rear portion of the central block contain, on the ground floor, four wards, each for the accommodation of 12 patients, with the usual attached offices, a large recreation or day room, and two rooms, each for 2 lying-in women, besides bath rooms and other offices. On the first floor of these wings are four wards, each for the accommodation of 12 patients, with attached offices, two recreation or day rooms, and bath rooms as on the floor below. The block of building at the rear is one storey only in height. It is connected with the main structure by an open covered way, and contains the engine house, furnace room, mortuary, &c., and in the rear, the pathological institute, with lecture room, laboratory, &c. Total Accommodation . — It will be seen that provision is thus made for the reception of 264 inmates — viz., four wards for 1 bed each, two for 2 each, two for 8 each, and twenty for 12 each. The planning and construction of the principal wards is undeserving of special notice. ( 200 ) AMERSFOORT MILITARY HOSPITAL. HOLLAND. Of all the buildings of Holland, erected for the occupation of the sick and wounded, this is the only one planned upon the general principles now universally recognized by the best authorities as those which should at all times govern the designs of hospital buildings. The structure is not, in every detail, perfect, but there are many points about it well worthy of notice, and especially so the combined heating and ventilating arrangements of the wards. To Professor Van Overbeek de Meijer, of Utrecht University, all praise is due for having, by his advice, led the way to this great advance in the hospital construction of Ins country, and to him, and also to Dr. Wilson, chief military surgeon at Amersfoort, I have to offer my especial thanks for the facilities afforded me for obtaining the following information as to the details of the structure. The plans and working drawings of the various buddings were prepared and their erection superintended by Captain G. J. de Jongh. The ereCtion of the buildings was commenced in the year 1875 and completed by 1877. Site . — The buildings are situated in one of the outlying districts of the town of Amersfoort. The principal front faces the high road leading from Amersfoort to Hoevelaken, and the other three sides of the building are surrounded by open fields and gardens. The extent of the site is 230,349 superficial feet, being about 5 acres, 1 rood and 6 perches, or nearly 2,953 feet P er bed, but the surrounding land being for some distance uncovered by buildings, the site may, from an hygienic point of view, be considered almost unlimited. Subsoil . — The subsoil is a light sandy loam of great depth, and much difficulty was experienced in securing proper foundations ; the normal level of the land water being, as is mostly the case in Holland, within a few feet of the surface. General Arrangement . — The general arrangement of the buildings upon the site is shewn upon the plate at page 200, also there are detailed plans and sections of one of the principal sick wards, and of the contagious or isolation wards. The grounds are entered by a gate indicated at H on the plan of site, and the main entrance-hall of the building is in the centre of the administrative block A. The basement of this block, which is brick vaulted throughout, is devoted principally to storage purposes, one room, however, originally intended for, but never used as, a disinfecting chamber, is shortly to be converted into a ward for insane patients, or prisoners, as may be required. The ground floor of this block contains an entrance-hall, with three rooms on the left of it for the occupation of the porter, and two on the right that are made use of as offices. In the rear, and immediately opposite to the entrance-hall, is the main staircase, on the right of which is the kitchen and scullery, and on the left the dispensary Hospital Construction and Management. Photo Lthographwl &JVioi»d hy James Altemon.6 Queen Square. W C ■ . Amersfoort Military Hospital, 201 and a “ tisanerie.” The first floor contains the apartments of the “ Administrateur.” There are likewise on this floor two rooms for the use of sick officers, and a bath room. The office “ bureau ” and a store room are also placed on this floor. The third floor is entirely contained in the roof, and is used as a linen and clothes store. The water cisterns, for the general supply of the establishment, are also placed on this attic floor. Blocks B B are pavilions, one storey only in height, for the reception of patients. Each block has a large ward containing 12 beds, and two smaller wards with 2 beds each. They are seldom in use during any but the summer months, the ventilating arrangements being such that it is found extremely difficult to keep them properly warmed during the winter. These and the other pavilions will be more particularly described hereafter. Blocks C C are similar to blocks B B, but the roofs are differently constructed and in such wise that the buildings may be used during the winter months. They are, when it is possible, closed during the summer time. Block D is a pavilion, one storey in height, used for the reception of patients suffering from diseases of a contagious or infectious character. There is one room for 8, one for 4, and two for 1 patient each. Block E is a mortuary. Block F is a pump house, and at the side of it a well for the supply of water to the establishment. No laundry is provided as all the clothes are washed in the town of Amersfoort. Total Accommodation. — Accommodation is thus provided for 78 beds, viz. : — Patients in blocks B B, in two wards with 12 beds in each, and four wards with 2 in each 32 Ditto in blocks C C, ditto ditto 32 Ditto in block D, with one ward for 8 beds, one ward for 4 beds, and two for 1 bed each 14 Total 78 Connecting Corridors. — The four ordinary sick pavilions are each connected at one end to the central administrative building by circular enclosed corridors, 8 feet 3 inches wide and 11 feet high. These corridors are used by the patients in the daytime as ambulatories. Water Supply. — All the water used in the establishment is raised by a hand pump to two large tanks situated in the highest portion of the central administrative offices, from whence it descends to the various sinks, baths, &c. Drainage. — The rain and the bath and sink water are carried away from the building in earthenware pipes. No drainage is provided from the water-closets, the contents of which are carried away daily in iron tanks. Area Covered . — The area covered by buildings is about 18,881 superficial feet, or nearly one-twelfth of the whole site, and 242 superficial feet per bed. Cost . — The cost of this building is stated to have been about ^"15,000, or ^192 6s. 3d. per bed. No particulars are obtainable as to the value of the land. Summer Sick Pavilions. The pavilions marked B B on the block plan of the site (see page 200) are, like all the Others, one storey only in height, and, as before explained, they are not inhabited during 202 Amcrsfoort Military Hospital. the winter months unless, it is absolutely necessary, it being found that the loss of heat through the open roofs and lanterns is too great for it to be possible to keep the apartments properly warmed without an unusually large expenditure of fuel. The actual number of sick at any one time in this establishment is, however, seldom during peace greater than one half the total accommodation provided. Aspect. — The axes of the buildings throughout run from W. by S. to E. by N., so that the windows of the wards face N. by W. and S. by E. Relative Positions of Pavilions. — The height of the buildings, as measured from the floors of the wards to junctions of the upright lines of the outer front walls with the sloping lines of the roofs, is 17 feet 6 inches, and the distance between the pavilions running parallel to one another is 77 feet 6 inches, or nearly four and a half times the height. Size of Wards. — The large ward of each pavilion is of parallelogram shape, and contains 12 beds. It is 38 feet long, 26 feet 3 inches wide, and 18 feet 6 inches average height, exclusive of the ventilating roof lantern, 5 feet wide and 3 feet high, which runs the whole length of the ward. The total superficial space, therefore, in each large ward is 997 feet 6 inches, or about 83 feet per bed, and the cubic contents 19,024 feet, or about 1,585 feet per bed. Bed Space. — The average lineal wall space per bed is 6 feet 4 inches. Windows. — There are three windows in each side wall, and the effective glazed surface in each ward is 183 feet, or 15 feet 3 inches per bed. The. glazed sides of the lantern light are not taken into consideration as they are obscured when the louvred ventilators, as they mostly are, are opened. The sashes are constructed somewhat peculiarly ; the top portion of each one for about one-third of the total height of the window opening is hung by pivots on its bottom rail, and can be made to fall forward into the ward by means of lines and pulleys ; the lower two-thirds of the height is in one piece and hung as an ordinary sliding sash with lines and weights, and it will be seen that as this lower portion is opened it more or less prevents air entering through the upper part. 1 he windows are not, as they should have been, placed mid-way between each two pair of beds. Warming. — The warming of the large wards is effected by two stoves, standing centrally between the feet of the beds; and these stoves are so constructed that air brought from the outside and beneath them passes rotind the heated iron surfaces next the fire and flue pipes and escapes into the room through the upper part of the casings which surround the whole apparatus. Iron-moulded rims, forming cornices round these casings, are so constructed as to contain water, which, as it evaporates, moistens the air of the ward. Ventilation. — The ventilation of these summer wards is effected mainly by the windows and lanterns. The latter run down the centre of the roof and the full length of the wards ; each side is divided into seven panels, or divisions, and these divisions are alternatively formed as glazed, sashed and louvred openings. The sashes cannot be opened, but panelled sliding shutters cover the louvres, and are so contrived that they can be drawn horizontally away and across the sashes when the weather will so permit, Hospital Construction and Management. Amersloorl' • A\i I i Un Hospi l~al 7 t n a. lO T 2 3 L on 2 , Qctmiriisfraftt/c. fe)ui tit B.J nmm&r ra ltl / i C BTcntcr tyaui/i D Jso/q fcon &Tarcl& E. a >ict i ia/r mm wmmmm rt*h air eha> 5 G CD 0 wmmmm w, mm, • Transverse Section W' oJca/s of / • I ■‘lan • of* S i to t°- . . . y. . . ? t ! iinf a — * in m N a ' Lon <^i hitUnal • Section • throw ol i • Summer • Wards • IttfllQ 00 □□ I n J oil c ft ■ ... L , a^“‘ h u i ward , raooD □□ DiaKi T Ma ii of- Wards ' R &C Plan of - Isolation 'Wards V V ¥ >r *r XW Photo Ltkographwi Jt Printed by James Akerman,6.Queen Square. V/ C- H Saxon Snell del Amersfoort Military Hospital 203 Air is also admitted into the ward by means of a brick channel, about 3 feet 4 inches wide and 1 foot 8 inches high, which runs beneath the floor from the outside wall to the centre of the room, from whence it branches right and left, and passing through channels, 1 foot 8 inches wide, opens into the room beneath the stoves in the manner described in the last paragraph. Provision is also made in each ward for the exit of foul air by two brick shafts, 1 foot 4 inches square inside, which run from the level of the floor to the ridge of the lantern, where they are capped by ornamental iron wind guards. The iron flues from the adjoining stoves pass into these brick shafts at the level of 14 feet 3 inches above the floor line, and, rising upwards, they find their exit above the top of the wind guard, and thus add warmth to, and induce an upward current in, the ventilating shafts. The foul air passes out of the ward into these flues through doors placed next the floor and on the sides opposite to that on which the stoves are placed. Floors . — The floors of the wards are formed of deal boarding, about 6 inches wide and 3 feet 6 inches long, laid diagonally on timber joisting. The surface appears to have been stained, beeswaxed, and polished. Walls . — The walls are all constructed hollow and in two thicknesses of brickwork. The external finishings are of cement, with the exception of the sills, copings, and other weatherings ; these are of stone. The inside faces are plastered, and so are those of the roof. W.C.’s, Baths, &>c . — The w.c.’s and urinals are contained in a room, n feet 6 inches long, and 10 feet 2 inches wide, adjoining the entrance corridort. The w.c. compartments are 5 feet long, and 3 feet wide. The apparatus is a simple eartherware pan dipping into an iron syphon trap, and this discharges itself directly into an iron tank, situated in the basement, beneath each w.c. compartment. Three years ago, however, a sewer was constructed, discharging itself into the watercourse close to the hospital. These tanks are removed daily, and emptied on land far away from the hospital ; but, under such an arrangement, it is obviously necessary to curtail the use of the water, for, otherwise, the iron receptacles would too soon become overcharged, and, therefore, the pipe convej'ing water to the pan is furnished with a cock that can only be turned by a key that is kept by a non-commissioned officer in charge ; the consequence is, as might be expected, that the apparatus does not always get properly cleaned, and, seeing that the rooms in which they are placed are not separated from the building by cross-ventilated lobbies, the result cannot but be harmful to the patients. It is stated that the water-level being so close to the surface of the site, it is found impossible to convey this sewage away from the building in the ordinary way through pipes; but, if this is so, it might have been better to employ the dry earth system than to continue the present unsatisfactory arrangement. The rain and other clear water discharges itself by means of drains into the watercourses running near to the hospital grounds. The baths are of plain metal, and unenclosed. They are supplied with hot water from small portable coppers, which, with their furnaces, stand in the corners of the rooms, and at the feet of the baths. These coppers are very compact in form, and are said to act effectively. They are manufactured by Corneau Freres, of Charleville, in France, 204 Amersfoort Military Hospital, Adjoining, and entered from each of the large wards, there is a lavatory room, n feet 5 inches long, and 4 feet 7 inches wide, furnished with three tiny white earthenware basins, and supplied with cold water only. Separation Wards . — At the further end of each ward, and entered off either side of the corridor leading to the recreation grounds, there are two separation wards, each of which is intended for the occupation of two patients; they are 15 feet 5 inches long, 11 feet 5 inches wide, and 16 feet high, and so the floor space allowed to each patient is, consequently, 88 superficial feet, and the corresponding cubical contents, 1,408 feet. It is seldom, however, that more than one patient is placed in these rooms. Duty Rooms . — Duty rooms are not attached to each block of wards, but in the central administrative block there is a “ tisanerie," and this partially answers the purpose of a duty room for all four blocks. Nurses' Room .— The nurses are, as is usual in military hospitals, all men, and their rooms adjoin and can be entered from the large wards. They are each 1 1 feet 5 inches long and 7 feet 10 inches wide. Area of Pavilions . — The total area, including the outer walls, covered by each pavilion is 2,241 feet, or 140 feet per bed. Winter Sick Wards. These buildings are in every respect similar to those of the summer wards, excepting that there are no roof lanterns, and the ceilings, therefore, instead of following the sloping lines of the rafters are made flat and on a level with the tie beams, and consequently the cubic space per bed is only 1,330 feet instead of 1,585 feet as in the summer pavilions. Hospital Construction and Management. • 1 be • A\oabite • Hospital • Berlin • dctcLn L 1 Ground ~I Mai rot • Kitv I vMi -BinMim i ■ ; * '^T %y r j tjnC» i< « jrS «(]» X a L ji. Jg ii ; li Ji Aka/e. a/ *r Subsoil . — The ground upon which the buildings stand is of a very dry, sandy nature, and is well drained. General Arrangement . — The general disposition of the buildings upon the site, and detailed plans, elevations, and sections of one of the wards and of the kitchen building, is shewn upon the accompanying plate, page 205. The principal entrance is by a gateway adjoining the porter’s lodge, marked A on the block-plan of the site. The building to the right of the entrance (marked B) contains the administrative offices and residences. Block C is an exceedingly well arranged kitchen building, having, on the basement, cellarage for keeping milk, butter, and other perishable stores, and, on the ground floor, a scullery, larder, ice cellar and stores, and the kitchen, fitted up with a well appointed cooking apparatus; the walls of this building have from time to time been very tastefully decorated in colors by the inmates. Block D is an engine-house, and contains the furnaces and the boilers, from which steam pipes are conveyed round the whole of the buildings for the purposes of heating and for the supply of hot water to the baths and sinks, situated in various parts of the Moabite Barrack Hospital. 207 establishment. At the rear the block E contains a very excellently-contrived disinfecting chamber and accessories. Block F is the wash-house and laundry, a two-storied building, having drying rooms and apartments for the attendants upon the upper floors. Blocks H H are cart and other sheds; I is a fire-engine station; and J is an additional ice cellar. The twenty-four blocks marked K are pavilions, each containing one large ward capable of accommodating 29 patients ; but in some of the wards a part is partitioned off to form a day room, thus reducing the number of beds to 28. These pavilion blocks arc more particularly described hereafter. Block L is a building that was in course of eretftion at the time of my visit, and consists of three rooms each for the accommodation of three patients suffering from acute contagious diseases. The five blocks marked M are temporary pavilions, roughly put together, and originally eretfted to meet the exigencies of an outbreak of cholera, but they are now dilapidated and used only as storehouses and coal sheds. The northernmost of these blocks has lately been burned down, and will probably not be rebuilt at present. Blocks N, O, and P are respectively a mortuary, a waiting-hall, and a shed for burning clothing and other infected matter. Total Accommodation . — It may thus be estimated that provision is made for 700 inmates, in twenty-four pavilion wards with from 28 to 29 beds in each, and three wards with 3 beds in each. Water Supply . — The water is supplied partly by the town authorities and partly by an artesian well situated near the engine-house. Area Covered . — The area covered by buildings is 116,456 superficial feet, or about one-seventh of the site, and 166 feet per bed. . \ Cost . — The entire cost of buildings to the present time is stated to have been £57,805 (1,156,114 marks), or about £83 per bed. Principal Sick Wards. Each of the main sick pavilions are of similar design, and consist of one large ward, with attached offices, as shewn in detail upon the plate at page 205. Relative Position of Pavilions. — The height of the pavilions, as measured from the floors of the wards to the junctions of the upright lines of the outer front walls with the sloping lines of the roofs, is 11 feet, and the least distance between any two pavilions is 56 feet, or five times the height. Size of Wards . — The sick wards are of parallelogram shape, and each generally contain 28 beds. They are 86 feet long, 22 feet 6 inches wide, and 12 feet 6 inches average height. The total superficial floor space being, therefore, 1,935 f eet i or about 69 feet per bed, and the cubic contents 24,187 feet, or 864 feet per bed. In some of the pavilions the day room is omitted, and, in these cases, the space being thrown into the ward, another bed is obtained. Bed Space . — The average lineal wall space per bed is 6 feet 2 inches. Q 2 208 Moabite Barrack Hospital . Windows. — There are fourteen windows in each side wall, but they are not of the same size in all the pavilions ; the effective glazed surface of those in the ward measured was 313 feet, or about 11 feet per bed ; when these windows are opened to their fullest extent the total area through which air can be admitted by them into the wards is 427 feet, or 15^ feet per bed. The external doorway at the end of the ward, when open, affords additional ventilation to the extent of about 2 feet per bed. The windows generally are divided into two heights by a wooden transom. The upper part consists of a sash hung upon its lower rail and opening inwards to its full extent ; the lower part is an ordinary folding casement sash. Warming. — The arrangements for heating the various buildings were entirely remodelled in the year 1879, under the direction of the engineer, Herr Voight. All the pavilions are heated from the central steam apparatus, situated in block D, from whence steam pipes are carried in brick channels round the grounds, and branches extend to the various pavilions and pass round the walls of the wards and offices. It is stated that no difficulty is experienced in maintaining a temperature of 68° in the wards in the depth of winter and when the ventilation is perfect. Ventilation. — The ventilation of each ward is effected principally by the external door and the windows, but there are, in addition, in each side wall, next the floor, seven inlet ventilators, having an area of about 60 inches each, and covered with perforated zinc ; also, in the ridge of the roof, nine outlet ventilators, each 2 feet 9 inches long and 1 foot 9 inches wide, fitted with wooden flaps for closing when necessary. Floors. — The flooring is formed by dry brick rubbish, about 18 inches thick, laid upon the natural surface of the ground, which is of a very dry and sandy nature. The upper part is floated with cement and is about 18 inches above the ground level outside. Walls and Roof. — The main body of the walling is constructed similarly to English brick nogging, the joints being pointed on the outside, but the inside is covered with narrow deal boarding jointed with moulded fillets, and forming a wall in all about inches in thickness. The roof, which is of very simple construction, is covered with tarred and sanded felt, laid on deal boarding ; no gutters are provided, but the eaves overhang the outer side walls by rather more than 3 feet and the end walls by 5 feet. W.C.'s, Baths, &c. — The w.c.’s, baths, and other sanitary appliances are situated at the end of the ward adjoining the entrance corridor ; they are not separated by ventilated lobbies, but lead direcftly out of the ward. The two w.c.’s, which are placed in one room, without a division between them, are fitted with ordinary pan-closet apparatus, the end nearest the ward is partitioned off and fitted with a small cast-iron sink and a tap for drawing water. The adjoining bath room, 10 feet long and 6 feet wide, is fitted with an uncased metal bath and supplied with hot and cold water. Duty Room. — A duty room, 12 feet long and 10 feet wide, is situated to the right of the entrance corridor and adjoining the large ward, which it overlooks ; it is not, as is usual, fitted with cooking or warming apparatus. Nurses’ Room . — The room adjoining is of the same size as that last described, and is fitted as a sleeping room for nurses. Moabite Barrack Hospital. 209 Lumber Room . — On the opposite side of the passage a room of similar dimensions as the last is used as a lumber or store room, a not unusual addendum to the offices of foreign hospital sick wards. It is termed an “ abstellraum,” or “ putting-away room,” and is supposed to be useful as a store room for surplus ward furniture and appliances, but in nearly all cases it will be found that these rooms are receptacles for hospital rubbish of all kinds, and consequently they would be better done without. Total Area of Pavilions . — The total area covered by each pavilion, including the walls surrounding it, is 2,868 feet, or about 103 feet per bed. ( 210 ) HALLE UNIVERSITY HOSPITAL. GERMANY. On again visiting Germany, after the publication of the first part of this work, I was made aware that the building about to be described was nearly completed, and partially occupied. Little, however, appeared to be known as to it, and I was therefore quite unprepared, when the visit was determined upon, to find the building to be undoubtedly the finest establishment of its kind in the country. The following description is taken from the original working drawings and from personal inspection of the buildings, but considerable difficulty and expense has been incurred in obtaining this information in consequence of the architect not feeling himself justified in assisting my inquiry, inasmuch as he had promised similar information to the publishers, Messrs. Ernst and Korn, of Berlin, who, nevertheless, I have much pleasure in stating, are engaged in the preparation of an elaborate work descriptive of the building, and containing large detailed engravings of the various blocks. The architect, Von Tiedemann, commenced the preparation of the plans May 1874. The ereCtion of the building began June 187b, and, although the greater part was completed and in occupation, some of the blocks were, at the time of my visit (June 1883), )'et in course of construction. Site .- — The buildings are situated in a very elevated position, near to the eastern borders of the town, and upon the “ Marienbreite,” Magdeberger Strasse bounding it on the west, Schlemmel Strasse on the east, and Stein Strasse on the north-east. Subsoil . — The upper scil is stated to be of a loamy nature, but, at no great depth, a hard sandstone rock is met with, the material of which has been used in the construction of the basement walls. General Arrangement . — The general disposition of the buildings upon the site is shewn upon the accompanying plate ; and at page 216 will be found detailed plans and sections of the principal pavilions. There are several entrance gates, by which access can be obtained to the various departments, but the main entrance to the establishment is by the gate opposite to the blocks marked A. These blocks, A, constitute the surgical department of the establishment, and consist of a central building, two storeys in height above the basement floor, and four one-storied pavilions, to be more particularly described hereafter, jutting out in the rear, and connected together by means of spacious corridors. The basement of the central block, about half of which is sunk below the level of the ground, contains the porters’ and male attendants’ rooms, and there is cellarage beneath the operation theatre. On the ground floor there is a well arranged and lighted operation theatre and various dormitories for the occupation of patients immediately after or prior to operations. Here also is the out-patients’ department, the instrument and bandage Hospital Construction and Management. •v 5 ■ ' Halle University Hospital. rooms, bath rooms, and the director's and assistant doctor’s rooms. The first floor also contains doctor s rooms, one large ward, 89 feet 2 inches long and 26 feet 8 inches wide, and several other smaller wards, each for one or more patients. The accommodation provided in this surgical department is as follows, viz. Two pavilion wards, containing 20 beds each 1 wo do. do. 24 do. One ward in central building, containing 24 beds One do. do. do. 4 do. One do. do. do. 3 do. Two do. do do. 2 do. 40 48 24 4 3 4 Total ... 123 Blocks marked B indicate the principal medical department, and consist of a central building, with two wings, all two storeys in height above the basement, and two detached pavilions, each one storey only in height. The general plan of this central portion is not unlike the Strasburg University Hospital, illustrated at page 137 of this section. The basement floor is sunk about half its height below the general ground level, and contains rooms for the use of the porter and other male attendants. In the two wings there are, on this floor, four rooms, two on either side, and each for the accommodation of 6 syphilitic patients, with the usual attached offices ; likewise, on each side, a room for the reception of 3 lunatic patients, with a padded room attached. The ground floor contains the out-patients’ department, with leCture hall, rooms for the conduct of thera- peutic, elecftric, laryngoscopic, and microscopic investigations ; also the director’s, assistant doctor’s, and porters’ rooms. In each of the two wings on this floor there is a ward, with the usual attached offices, for the accommodation of 12 patients, and also three smaller rooms, one being for the accommodation of 3 ordinary patients, and two for 1 private patient each. On the first floor there is another leCture hall, a library, the matron’s apartments, and additional assistant doctor's rooms ; likewise, in each wing, a ward for the accommodation of 12 patients, with the usual attached offices, another for 3 ordinary patients, and- two for 1 private patient each. In the central portion there is a ward for the accommodation of 6 children, with an isolation ward for 2. The outer pavilions will be more particularly described hereafter ; they each contain accommodation for 16 patients in one large ward, and a separation ward for 1 patient. The accommo- dation provided in this department is as follows : — Two wards for 16 patients each ... ... 32 Four do. 12 do. ... 48 Five do. 6 do. ... 30 Six do. 3 do. ... ... 18 One do. 2 do. ... 2 Twelve do. 1 do. ... 12 Total ... 142 Block C is a building for the isolation of patients suffering from diseases of an infectious or contagious nature, and will be more particularly described hereafter. It contains two wards, each for the accommodation of 12 patients, and two for 1 patient each, or a total of 26 beds, 212 Halle University Hospital. Block D is gynaecological department, and, as the name implies, is devoted to the treatment of the diseases of women. It is a building two storeys in height above the basement floor, and contains, on the basement, cellarage, storage, and attendants’ rooms ; also dining and reading rooms for the general use of the students of all departments. The ground floor contains the entrance-hall, the direiftor's and assistant doiftpr’s rooms, and various small wards for the patients ; also a lecture room. The first floor provides accommodation in small wards for patients of various classes, with lying-in and delivery rooms, waiting room for students, examination, leifture and operation rooms, and apart- ments for the midwife. The accommodation provided in this department consists of One ward for 6 patients each Seventeen wards for 4 patients each Two do. 2 do. Two do. 1 do. 6 68 4 2 Total 80 Block E is the residence of the director of the establishment. Block F is a building, two storeys in height above the basement, for the treatment of patients suffering from diseases of the eye and ear. The departments are nearly separated from each other, being united only by the leifture hall and operation theatre, which are placed on each floor of the centre of the building. The basement, half of which is sunk below the general ground level, contains various rooms for the use of the officers ; also stores and cellarage. The ground floor of the building is entered through two large vestibules by doorways situated on either side of the apsidal-shaped staircase that projects from the front wall of the central portion of the building. The door on the right gives access to the ear, and that on the left to the eye department. The direiftor's office, the assistant doiftor’s apartments, and a room for anatomical collections are placed on the right hand side of the central building, and the adjoining wing contains three wards, with the usual attached nurses’ rooms and offices. Each ward is planned for the accommodation of 6 patients suffering from aural complaints. A waiting and three examination rooms (one darkened) are situated on the left hand side of the building, and the adjoining projeifting wing contains two wards, with the usual attached nurses’ rooms and other offices ; each ward is planned for the accommodation of 6 patients suffering from eye diseases, and also a separation ward for 1 patient. A leifture room and stair- case occupies the centre of the building on this floor. The first floor has an operation theatre and staircase in the centre, and, on the right hand side of them, the apartments of the assistant doiftor and a separation ward for 1 patient. The adjoining wing contains, on this floor, three wards, each for the accommodation of 6 patients suffering from aural complaints, and the usual attached nurses’ rooms and offices. The accommodation on this floor, to the left of the centre, consists of a room for the use of the direiftor and apartments for an assistant doiftor ; also a separation ward for 1 patient, and three wards, each for 6 patients suffering from diseases of the eye, together with the usual attached nurses’ rooms and offices. Indoor accommodation is thus provided in this department for 69 patients, in eleven rooms containing 6 beds in each, and three with 1 bed each, Halle University Hospital, 213 Block H is a building four storeys in height above the basement floor, and contains the kitchen, with its larders, store rooms, and other usual offices, the wash-house and laundry, with a summer drying room (occupying the whole of the upper, or attic, floor of the building), the servants’, hospital attendants’, and officers’ day and bed rooms, and, generally, the whole of the principal administrative offices of the building. The kitchen department is situated to the right, and the laundry wash-house, from which it is separated by a division wall, on the left. Block J is the boiler and engine house. Blocks K and L are additional isolation wards for the use respectively of the medical and surgical departments. They appear to be erected for the reception of a lower class of persons than those forming the general body of the hospital inmates. The director’s report describes them as “ vagabonds, beggars, persons suffering from venereal diseases, and others totally without means of support.” The buildings, which are two storeys in height, each have, on each floor, a large ward for the accommodation of 12 patients, and one separation ward for 2 patients, and, in addition to the ordinary ward offices, there are apartments for the assistant doctors delegated to the charge of these departments. The total number of patients accommodated in the two pavilions is 56 ; viz., four wards for 12 patients each, and four for 2 each. Block M is the pathological institute. The basement storey, owing to a fall of the ground, can be entered from one side on the level, and in it are placed the rooms for the dead, the chapel, the mourners’ and visitors’ room, and apartments fitted with kennels, hutches, stalls, and tanks for the preservation of animals, reptiles, &c. ; also, on this floor, are apartments for the department attendant. On the ground floor, to the right of the centre, are placed the director’s and students’ rooms, and various apartments devoted to the purposes of chemical, microscopic, and other special investigations. The post-mortem room occupies the rear portion of the right hand wing. The rooms on this floor, to the left of the centre, consist of a porter’s offifce, preparation, vivisection, and class rooms, also a lecture hall. The rooms on the first floor, to the right of the centre, are principally devoted to the study of microscopy, and the central and left-hand rooms are fitted as laboratories and for the exhibition of pathological collections. Block N, the physiological institute, like the department last described, is fitted with various apartments for the study of microscopy, chemistry, optics, vivisection, &c. ; also a library and museum. On the basement floor accommodation is provided for animals, reptiles, and other objects of study; also mechanical workshops, fitted with an “Otto” gas engine, rotary fans, dynamo-electric, and other machinery. Apartments are provided here for the use of the director of the department. Block O is the anatomical institute ; the left wing contains the professor's and students’ rooms, but the right hand side is principally occupied as a museum. In the rear of the centre is a large lecture hall. The basement contains kennels, hutches, tanks, and such like accommodation for objects of anatomical investigation. Apartments are also provided for the custodian and for other officers employed in this department. Block P is a chapel ; block R an ice cellar ; and block S a building for intercepting and disinfecting the whole of the sewage of the establishment. 214 Halle University Hospital. Total Accommodation . — According to the foregoing description of the various depart- ments it will be found that accommodation is provided for 494 inmates, viz. : — The Surgical department (block A) ,, Medical do. (block B) ,, Isolation wards (block C) ‘ „ Gynaecological department (block D) „ Eye and ear department (block F) Supplementary isolation wards (blocks K and L) 123 142 26 80 69 56 Total 496 Water Supply . — The establishment is supplied from the town mains, and, as there is a constant service, it has been deemed unnecessary to provide cisterns in the various buildings. Drainage . — All the sewage of the establishment is conveyed by pipes to a building, marked S on the block-plan of the site. After undergoing the process of disinfection the solid matter is deposited in tanks and carted away at intervals, whereas the liquid portion is conveyed by pipes into the town sewers. At the time of my visit carts were being filled with this disinfected matter, and no objectionable effluvia was perceptible. Area Covered . — The area covered by building is 162,227 superficial feet, or nearly one-fifth of the site, and 327 feet per bed. Cost . — The buildings were not at the time of my visit completed, and, although a greater part of them were occupied, the accounts had not been finally adjusted, nor have they been to this date ; therefore, the following estimate of the cost, given b) r the architect, Herr von Tiedemann, can only be considered as partially approximate. Medical department (block A) Surgical do (block B) Isolation pavilion (block C) Gynaecological department and the director's residence (blocks D and E) Eye and ear department (block F) Administrative building and boiler and engine house (blocks H and J) Chapel (block P) Anatomical institute (block O) Physiological do. (block N) Pathological do. (block M) Additional isolation wards (blocks K and L) ... Sewage disinfection building (block S) Total ... ... £26,075 24 . 37 ” 2,710 22,750 13.550 10,100 875 19,000 9,000 9,000 6,300 850 £144.580 The above sum does not include professional charges, and salary of clerk of works, laying out roads, boundary walls and fences, and pumps and boilers in engine-house. If. therefore, we add for these items as follows : — Boundary walls, laying out grounds, &c. ... ... ... ... ... 4,000 Boilers and pumps ... ... 1,000 Five per cent, for superintendence .. ... ... ... ... ... 7.479 h ive per cent, on all the preceding items for extra and contingent work not included in the architect’s original estimate 7.853 » ■ a • Total ... £20,332 Halle University Hospital. 215 It may, therefore, be taken that the cost of the building and fittings will probably amount to about £165,000, or £334 per bed. The land cost £20,250, or about £44 per bed, so that the total outlay will have been at the rate of £378 per bed. Medical One-Stosied Pavilions. These buildings consist of a pair of detached pavilions belonging to the medical department, but they are isolated from the main, or central, building, as shewn upon the block-plan of the site. A plan of the principal floor and a secftion are shewn upon the plate at page 216. Aspect. The axes of these and all other pavilions (excepting the isolation wards) run nearly directly east and west (E. by N. and W. by S.), so that the windows of the wards face nearly north and south (N. by W. and S. by E.). Relative Position of Pavilions. — The height of the pavilions, as measured from the ward floors to the junctions of the upright lines of the outer front walls with the sloping lines of the roof, is 15 feet, and their distance from the adjacent main building is 90 feet 3 inches, or about six times the height. Size of Wards. The principal ward of each pavilion is of parallelogram shape, contains 16 beds, and is 73 feet 6 inches long, 29 feet 6 inches wide, and 15 feet average height. The total superficial floor space is, therefore, 2,168 feet, or 135 feet 6 inches per bed, and the cubic contents 32,524 feet, or 2,033 feet P er bed. Bed Space. — The average lineal wall space per bed is 9 feet 2 inches. Windows. — The sashes in the lower portion of the windows of the side walls are hung as folding casements, and the sashes of the upper portion are made to open by lines and pulleys ; they are all glazed with sheet glass. When all the windows are opened to their fullest extent the total area through which air can be admitted by them into the wards would be 304 feet, or about 19 feet per bed ; the total area of their effective glazed surface is 264 feet, or i6i feet per bed. Warming. — The system adopted for warming the buildings generally is that by which steam is conveyed in pipes underground to the various blocks from the engine-house, marked J on the block-plan. In the ward now being described these steam pipes are connected with coils placed next the walls, as shewn upon the plans. The condensed water from these coils is taken by a separate pipe back to the large tank situated in the furnace-house, and is then again pumped up into the boilers. Ventilation. — The ventilation of the wards is effecfted during the summer time by purely natural means, that is to say, by the opening of the windows and roof ventilators. When, however, the coldness of the weather necessitates the closing or partial closing of these openings the foul air is drawn off from the ward by means of an underground flue, which communicates with the furnace-shaft of the boiler-house at the point marked J on plan. This furnace-shaft, which is circular on plan, has a clear diameter of 16 feet 4 inches, and is 131 feet high. The two vertical smoke flues, each 4 feet 11 inches diameter, are made of cast-iron, and pass up the centre of the brick shaft, thus heating the space surrounding it, causing a strong upward current, and drawing, with great force, the foul air through the underground flues that converge towards it from the medical, surgical, and gynaecological departments. It is stated that when three boilers only are 2l6 Halle University Hospital . in use the heat of the iron casing rises to from 356° to 456° Fah., and that it is found to be capable of drawing air through a pipe 12 inches diameter at the rate of 22,600 to 32,500 cubic feet per hour. The se< 5 tional area of the underground ventilating flues, as they enter the chimney, are 6 feet 6 inches square, but they reduce in size towards the ends to about 20 inches wide and 4 feet high, and so can be crawled through for the purpose of cleaning. The admission of fresh air into the wards is likewise provided for by means 01 openings in the side walls, next to and below the hot water coils. Lighting . — The buildings generally are lighted by gas. No special provision is made in the wards for conveying away the produces of combustion. Flooring . — The floors are laid with deal boarding, secured to the timber joists resting upon the vaulting beneath. These boards, in many of the wards, are painted a brown color, and varnished. Walls . — The outer walls are of brick, about 14 inches thick, faced on the outside with banded courses of various colors. They are plastered on the inside, and, where they have been completed, are painted very tastefully. W.C.’s, Baths, &c . — The water-closets are, as is usual in Germany, planned without any attempt to cut them off from the main building. They are situated in compartments leading from the corridor joining the large ward to the verandah, and each division is about 5 feet 6 inches long and 3 feet 3 inches wide. The apparatus employed in many of the buildings is a kind of cast-iron latrine, and, therefore, is kept constantly full of water ; when the contents is emptied a contrivance exists by which the incoming water is mixed with disinfectants: disinfectants being, apparently, in this, as in all other cases, the panacea for all continental unsanitary arrangements. The urinals are the ordinary white glazed earthenware apparatus. The adjoining bath room is 6 feet 6 inches wide and 10 feet 9 inches average length, and is fitted with a moveable metal bath. The pipes supplying hot and cold water to these baths are joined together, and have one outlet, so that the turning of the stop-cocks attached to each pipe enables the assistant to exactly regulate the requisite temperature of the outcoming water. Duty Room .— The principal entrance to each block is through a large ante room, 20 feet long and 14 feet wide, and in it there is placed a warming apparatus, a sink, shelving, and the usual fittings of a duty room. To enter through what is really the scullery of the building appears, at first sight, wrong, but the duty rooms of sick wards are too often kept very uncleanly, and are made receptacles for much dirt, whereas when, as in this instance, they are made entrance-halls, it is argued that the greatest attention must necessarily be paid to keeping them scrupulously neat and clean — an advantage certainly not to be lost sight of in considering the question of the planning of hospital wards and their offices. Separation Ward . — Entered from the corridor which leads from the rear end of the large ward to the verandah, and opposite to the bath room and w.c.’s, a separation ward is provided for the accommodation of one patient. It is 13 feet 11 inches long and 12 feet 7 inches wide, and contains, therefore, 175 superficial and 2,626 cubic feet. Verandah . — No day room is provided, but at the extreme rear end of each pavilion an open verandah, 33 feet long and 9 feet 10 inches wide, is provided (similar to that at the Hospital Construction and Management. Photo Lithographed It Printed by James Akerman.6 Queen Square .W C H. Saxon Sncii aol Halle University Hospital. 217 Friedrichshain Hospital in Berlin), and on to this the beds, either with or without the patients in them, can be wheeled when the weather permits. Nurses' Room. — The nurses’ room leads out of the entrance vestibule, and it also has a door communicating with the large ward. It is 13 feet 11 inches long and 12 feet 7 inches wide; the area of it is, therefore, 175 feet. Basement. — The ground floors of these pavilions are raised about 3 feet 3 inches above the surface of the outside ground upon low open arches, and there is, therefore, a free space for the passage of air beneath. The whole of the site is covered with brick vaulting. Although the practice is now very common on the Continent of raising pavilion wards high above the ground upon open arches, yet I have had before to remark that in nearly all cases it will be found that these arched basements become filled up and are used as store rooms, or for other hospital purposes. In the building now being described the height of the crown of the vaulting above the ground line is only 2 feet 4 inches, and there is no inducement, therefore, to convert them from the purpose for which they were intended. Shall we find, however, in years to come that these supposed fresh air spaces are receptacles for dust and dirt that would otherwise have been removed from the building? Total Area of Pavilions. — The total area covered by each pavilion, including its offices, but exclusive of the verandah, is 3,544 feet, or about 208 feet per bed. If the verandah be added the area is 3,939 feet, or about 232 feet per bed. Surgical One-Storied Pavilions. These buildings consist of two pairs of pavilions connected by corridors to the main entrance block, or surgical department, as shewn upon the block-plan of the site. A plan of the principal floor and a section through one of the buildings are shewn upon the accompanying plate. Aspect. — The axes of these buildings run nearly direiftly east and west (E. by N. and W. by S.), so that the windows of the wards face east and west (N. by W. and S. by E.) Relative Position of Pavilions. — The height of the buildings, as measured from the ward floors to the juniflions of the upright lines of the outer front watts with the sloping lines of the roofs, is 24 feet 3 inches, and the least distance between any two of the blocks is 55 feet, or about times the height. Size of Wards. — The large wards are of parallelogram shape, and those furthest from the main block each contain 24 beds. They are each 114 feet long, 29 feet 6 inches wide, and an average height of 15 feet 9 inches. The total superficial floor space is, therefore, 3,368 feet, or 142 feet per bed, and the cubic contents 53,046 feet, or 2,210 feet per bed. The wards of the pavilions nearest to the main block are somewhat shorter than the above, and contain 20 beds only, but otherwise they are similarly planned. Bed Space. — The average lineal wall space per bed is 9 feet 6 inches. Windows. — The sashes in the lower portions of the windows of the side walls are hung as folding casements, and the sashes of the upper portion are made to open by lines and pulleys ; they are all glazed with sheet glass, and the total area of their effective glazed surface is 624 feet, or 26 feet per bed. When all the windows are opened to their fullest extent the total area through which air can be admitted by them into the wards would be 768 feet, or 32 feet per bed. 2l8 Halle University Hospital. Warming and Ventilation . — The arrangements for the warming and ventilation of these pavilions are generally similar to those of the medical department, described at page 215, but instead of the steam passing through coils it is carried round the walls next the floors and at the backs of the beds by means of cast-iron pipes, every alternate length of which has a series of gills-for the purpose of more quickly radiating heat. Flooring. — The floors of the large wards are formed by brick vaultings covered with concrete, the surface being finished with “ terrazzo,” a material formed of marble clippings bedded in concrete, then ground to an even surface, and, when dried, polished. Walls. — The finished thickness of the walls of these buildings is about 10 inches, and they are formed of timber framing, 5 inches in thickness, wrought and stopt chamfered on the outside, and filled in with brickwork, finished internally with wall boarding, and tastefully decorated by painting. W.C.’s, Bath, &c. — The water-closets are each 3 feet 9 inches long and 3 feet 4 inches wide, and are contained in a compartment leading out of the ante room at the end of the ward. The apparatus is similar to those described at page 216 for the medical pavilions. The bath room averages 9 feet 9 inches long, 6 feet 4 inches wide, and is fitted with a moveable metal bath. The lavatory is a room n feet 5 inches long, 6 feet 4 inches wide, and is fitted with five wash basins ranged down one side. Duty Room . — This room, like those of the medical pavilions, forms the entrance-hall of the building. It is 33 feet 6 inches long and 13 feet wide, and is fitted with warming apparatus, sink, shelving, and other usual appurtenances. Verandah . — On the southern side of each pavilion there runs the full length of the ward an outside covered verandah, and from it at either end are flights of steps leading to the airing yards below. These verandahs are about 10 feet wide, and can be entered from the wards by means of two folding casement doors. Nurses' Room.— At the further end of each large ward is a nurses’ room, 1 1 feet 5 inches long and 6 feet 4 inches wide, and it has an area, therefore, of 72 feet 4 inches. Ante Room. — This room, which is 13 feet long and 9 feet 9 inches wide, forms the means of communication between the ward and the bath, lavatories, and w.c.’s ; it also contains a small staircase, which gives access to store rooms situated in the basement. Basement . — The floors of the wards are raised about 8 feet high above the outside ground on an open vaulted basement ; the ends are covered in and made use of as store rooms ; the central portion is left open. Total Area of Pavilions . — The total area covered by each of the pavilions furthest from the main block, including its offices, but exclusive of the verandah, is 4,571 feet, or 190 feet per bed. If the verandah be added the area is 5,800 feet, or about 242 feet per bed, whilst for the pavilions nearest to the main block, the area covered, exclusive of verandah, is 3,960 feet, or 198 per bed, or, with the verandah, 4,994 feet, or 249 feet per bed. Isolation Pavilion. This building consists of a double pavilion, one half of which is devoted to the use of male and the other half to female patients. A plan of the principal floor and a section through the central portion is shewn upon the plate at page 216. The construction and Halle University Hospital. 219 details of the building generally are similar to those of the medical pavilions, and it will, therefore, only be necessary to describe the points of difference in the planning. Aspect. — The axes of the pavilions exceptionally run nearly direcflly north and south (N. by W. and S. by E.), so that the windows of the wards face the east and west nearly (E. by N. and W. by S.) / Size of Wards. — The principal sick wards are of parallelogram shape, and each contains 12 beds; they are 57 feet long, 27 feet wide, and an average height of 15 feet. The total superficial space, therefore, is 1,540 feet, or 128 feet per bed, and the cubic contents 23,100 feet, or 1,925 feet per bed. Bed Space. — The average lineal wall space per bed is 8 feet 2 inches. Windows. — The total area of the effective glazed surface is about 292 superficial feet, or 24J- feet per bed, and when all the windows are opened to their fullest extent the area through which air can be admitted by them into the wards is 326 feet, or 27^ feet per bed. W.C.'s, Baths, &c.— The compartments containing the w.c. apparatus lead direCtly out of the large wards, and are 6 feet long and 4 feet 10 inches wide. The bath rooms are 11 feet 10 inches long and 6 feet wide, and are fitted with metal moveable baths. Duty Room. — The duty room consists of a large kitchen, 17 feet 2 inches long and 14 feet 4 inches wide, situated in the centre of the building and opposite to the main entrance. All the cooking for the inmates is done here in order to avoid the communi- cation, which otherwise would be unavoidable, with other parts of the establishment. The two rooms placed on either side of the kitchen are each 14 feet 4 inches long and 6 feet 6 inches wide ; they are used as a larder and store room for kitchen purposes. Separation Wards. — At the rear of each of the large wards, and leading off the corridors that give access to the verandahs, are separation wards, each of which is intended for the accommodation of one patient; they are each 13 feet long and 11 feet 10 inches wide, and contain, therefore, 154 superficial feet. Verandahs. — No day rooms are provided, but there are'at the ends of the buildings open covered verandahs, similar to those described for the medical wards at page 218. Nurses' Rooms. — The nurses’ rooms are situated on either side of tire entrance vestibule and have direct communication with the large wards. They are each 14 feet 4 inches long and 11 feet 10 inches wide, but contain an area, owing to projections into the rooms, of only 152 feet. Basement. — Those portions of the basement situated immediately under the large sick wards are raised about 3 feet above the surface of the outside ground open arches and vaulting, and there is, therefore, a free space for the passage of air beneath. The portions beneath the central and end offices are, however, sunk lower, and are utilised generally as store rooms, and also for the purposes of washing and disinfecting the linen used in this part of the establishment. Total Area of Pavilions.— The total area covered b} r this double pavilion, including the ward offices, but exclusive of the verandah, is 5,970 feet, or about 230 feet per bed. If the verandah be added the area covered is at the rate of 258 feet per bed. ( 220 ) ST. GEORGE’S UNION INFIRMARY. FULHAM ROAD, LONDON. It was not intended these types should illustrate more than one example of a workhouse hospital, hut since the publication of the first part of the work I have been requested to give an account of the above building, erecfted from my designs some few years since for the Guardians of the Poor of the Parish of St. George’s, Hanover Square, inasmuch as it contains a larger number of inmates than any other hospital in the Metropolis, and is by many considered to be equally as good a building as the one erected for the St. Marylebone Guardians, and illustrated at pages 58 and 60. So far as concerns the wards and offices I believe this is so, but experience has shewn that one or two details, pointed out further on, are capable of improvement. On the other hand, there are details, such as the construction of the ward windows, more particularly referred to at pages 62 and 223, that are far better than those at St. Marylebone, and will be found well worthy the attention of those interested in the constructive details of hospital design. The great defccft of the building is the smallness of the site, resulting in the too close proximity of the various blocks of buildings to one another, but this is a fault common to nearly all metropolitan buildings, where, as in this case, the cost of ground is unusually high. The foundation stone was laid July 26th 1876 by Hugh Horatio Seymour, Esq., J.P., Chairman of the Board of Guardians of St. George’s Union, and, on February 20th 1878, it was formally opened by the Right Honorable G. Sclater Booth, M.P., then President of the Local Government Board. Site . — The building is situated at the western end of the Fulham Road, in the parish of Chelsea. The entrance and main front face the road, but the other sides are bounded by the open gardens of small semi-detached villas and the grounds of the adjoining workhouse. The extent of the site is about 123,192 superficial feet, or 2 acres 3 roods 12 poles, being nearly 153 feet per bed. Subsoil . — The ground immediately below the surface soil consists of loamy sand and gravel overlying the London blue clay. General Arrangement . — The accompanying plate shews the ground floor plan of the establishment and a detailed plan and section of one of the principal pavilion blocks. 0 It will be seen that the building is entered from the Fulham Road by a porch, which forms part of the ground floor storey of the first of the seven pavilions throughout which the patients are distributed. The remaining portion of the ground floor of this pavilion is occupied by the porter’s lodge, steward's office, medical superintendent’s consulting room, and the assistant medical officer’s living rooms. On each of the three * Enlarged detailed drawings of this building, and also those of St. Marylebone Infirmary, are published in Charitable and rarockial Establishments. Batsford, London. 1881. S* Geo roc's men Fill haul Drauum roun . Cx^ard J>on Csroonc/ xc rcaf /on roun i \ccrcohon Cni ranee orrii JX>rfe.rj O 0 IC.C. (jjmmi/fcc Room \OUAC' t-i,j i e £ i r *r iVo/s O "t _5 £_ PI cv n o f ( r PhotoLUvocraphwifcIWeiby Janes Ajr*rm*n.6 Qut*n Squara.WC Management. "Firgl Floor Plc\n of RvVi lions* Ci )arU CCiard i\tcYeofion (Ground (§rvunc. ' Corn c/or (da/ More 'P/** jfror/t *p/»etrsjt \fce//// 2 t H. Saxon Snell del ■ • St. George's Union Infirmary. 221 upper floors there are two wards, one for 28 patients and one for 4 patients, with the usual attached offices, and thus accommodation is provided in this pavilion for 96 patients. The remaining six pavilions are each three storeys in height above the ground floor, and, on each floor, similar accommodation is provided to that described for the upper floors of the first pavilion, excepting that the smaller wards are omitted on the ground floors, and that the top floors of one of the pavilions are divided by partitions into small rooms for the use of nurses. Of these six blocks, therefore, five contain accommodation for 124 and one for 92 inmates. The medical officer’s residence is situated between the chapel and the end of the first pavilion, and it faces the Fulham Road. The chapel,- shewn upon the plan, does not really form part of the infirmary buildings, although it is available for the use of the patients. This building belongs to the adjoining workhouse establishment. On the right of the principal entrance there is a mortuary and post-mortem room. On the opposite side of the corridor, adjoining the second pavilion, is the inmates’ own clothing store. Then, opposite to, and between the ends of, and adjoining the third, fourth, and fifth pavilions, a building, one storey in height, provides kitchen and stores accommodation. The guardians’ committee room and the dispensary are also located in this block. The basement is used as cellarage. The low building adjoining the end of the sixth pavilion was constructed for use as an officers’ wash-house, but under the present management it is made use of as a carpenter’s shop. The steward’s and matron’s apartments, the principal nurses’, and the domestics’ dormitories, also the engineer’s house, are placed against the boundary wall and opposite to the kitchens and stores buildings, from which they are separated by a road, 20 feet wide. The laundry, wash-house, and coal stores form a continuation of the last-mentioned block of buildings, and are as far removed from the occupied portions as the small extent and peculiar form of the ground would permit. Total Accommodation . — Provision is thus made for the reception of 808 patients, in twenty-six wards of 28 beds each and twenty wards of 4 beds each. The following is a detailed account of the space allotted to each of the various offices of this institution : — Pavilions Generally. Area in feet. Twenty-six wards, each for 28 beds, and each 2,01 G Each pavilion has, on the ground floor, a w.c. for the use of the officers. Each pavilion is provided with a dired-ading hydraulic lift; and, in the basements, there are furnace rooms containing boilers for heating purposes. Twenty day rooms, to be used, when re- quired, as separation wards, for 4 beds each, and each ... 306 Area in feet. Twenty-three nurses duty rooms, each ... 144 Three do. do. do. ... 289 Each sick ward floor has 3 w.c.'s, 1 sink, 2 linen closets, 2 lavatories, and a move- able bath. The staircases surrounding the lifts, as also the corridors, are all of York stone, supported upon brick vaulting, so that these portions of the buildings are fire- proof. 222 St. George's Union Infirmary Administrative Offices. Area in feet. Area iu feet. Entrance-hall 1 66 Engineer's living room 144 General waiting room 298 Do. kitchen 176 Porter's office 180 Do. scullery 49 Committee room 517 Do. bed room 144 Do. lavatory and w.c., &c. 49 Do. do. 176 Dispensary 226 Do. larder, coal cellar, dust, w.c.'s, &c. Chaplain's room ... 104 Eleven nurses' rooms, average each 93 Matron's office 133 Six do. do. 200 Steward's office 104 Two do. do. 210 Medical officers’ consulting room 104 Fourteen do. (on top floor of one Do. drawing room 298 pavilion) average each 120 Do. dining room ... ... 283 One do. do. 306 Do. study 92 Three do. bath rooms, average each ... 90 Do. kitchen 172 Nurses’ w.c.'s, lavatories, linen room, &c. Do. scullery 7 i General kitchen 1,422 Do. coal cellar, larder, beer Do. scullery 182 cellar, &c. Officers' mess room 575 Do. bed room ... 201 Buttery, larders, and kitchen stores 893 Do. do. • •• 112 General store 1,422 Do. two bed rooms, each 139 General coal store, w.c.'s, dustholes, &c., &c. 1,060 Do. bath room 56 Two store rooms in upper part of tower, Do. w.c., china closet, &c. each 131 Two assistant medical officers’sitting rooms, each 136 Laundry, &c. Two do. do. bed rooms, each 136 Receiving room ... 506 One do. do. bath room ... 104 W ash-house ... ... 1,182 One do. do. kitchen ... ... 133 Drying room, with horses 538 Assistant medical officers' w.c., &c. Ironing and folding room 1,182 Matron's sitting room 256 Clean linen store and delivery room 497 Do. bed room 336 Wash-house for officers' clothing... 145 Do. do 195 Ironing room 275 Do. kitchen 126 Laundress' room 128 Do. w.c., larder, linen closet, &c. Disinfecting chamber 77 Steward's sitting room 208 Engineers' shop and furnace room 519 Do. bed room 284 Boiler and engine room 3*5 Do. do 190 Coal cellar for furnace coals 120 Do. kitchen ll 7 Inmates' own clothing store 455 Do. w.c., larder, linen closet, &c. Dead house 261 Porter's bed room 146 Post-mortem room 220 Connecting Corridors . — The main corridor connecting together the various blocks of buildings is 1 1 feet wide ; it runs through the ends of the pavilions and occupies the space used as day rooms or separation wards on the upper floors. Water Supply . — The water used in the establishment is supplied by the Chelsea \\ aterworks Company, and is delivered into a large cistern in the large tower, from whence it is distributed to cisterns situated in various parts of the building. 1 here is also a large brick tank under portion of the main corridor for the collection of rain water from the various roofs, and this water is pumped up into a tank situated over the laundry, for the use of which it is principally required. Drainage . — The drainage is effected by means of glazed earthenware pipes, varying from 6 to 9 inches diameter, leading respectively from the various soil pipes, baths, St. George's Union Infirmary 223 lavatories and sinks to a main drain, 12 inches diameter, running down the centre of the road into the parish sewer. The rain water is conveyed to the storage tanks before referred to in similar pipes, 6 inches in diameter, but it first passes through settling and filtering chambers. Area Covered. — The area covered by buildings is 51,902 feet, being about three- sevenths of the site, and 64 superficial feet per bed. Cost. — The cost of the land was ^20,467, or about £25 6s. 7 d. per bed, and ^7,244 19s. id. per acre. The buildings and their appurtenances, including engineering works and fixtures of every description, also professional fees and clerk of works’ salary, cost ^78,177, or about ^96 15s. per bed, so that the total cost of both land and buildings was at the rate of ^"122 is. yd. per bed. It should be borne in mind that this building being erected under the rules of the Local Government Board the cubic contents per patient is 936 feet only, instead of 1,200 feet as prescribed for general hospitals; but it has already been pointed out, at page 58, that this reduction in the size of the wards does not make a corresponding difference in the price per bed, because the extent of the ward offices and of the administration departments of the building generally remain the same in both cases. The cost, for example, of erecting this building, with ward accommodation at the rate of 1,200 cubic feet per patient, would have been increased by only ^14 14s. per bed — that is to say, it would have cost about £m instead of ^"96 15s. per bed. Principal Sick Wards. The sick wards throughout this building are all of one size and are similarly arranged, so that, with the exception of one or two slight modifications previously pointed out, the following account may be considered as descriptive of them all. Aspect. — The axes of the pavilions run nearly directly N.E. and S.W., so that the windows of the wards may be said to face N.W. and S.E. Relative Position of Pavilions. — The height of the paviliqns, as measured from the lower floors of the sick wards to the junctions of the upright lines of the outer front walls with the sloping lines of the roofs, is 56 feet, and the least distance between any two pavilions is 60 feet, or I rV times the height. Size of Wards. — Each ward is of parallelogram shape, contains 28 beds, and is 84 feet long, 24 feet wide, and 13 feet high. The total superficial floor space is, therefore, 2,016 feet, or 72 feet per bed, and the cubic contents 26,208 feet, or 936 feet per bed. Bed Space. — The average lineal wall space is 6 feet per bed. Windows. — There are seven windows in each side wall, and the total area of their effective glazed surface is 437J feet, or 15I feet per bed. When all the windows are opened to their fullest extent the total area through which air could be admitted by them into the wards is 177 feet, or about i2f feet per bed. All the windows are glazed with 21 oz. sheet glass. In nearly all modern hospitals for the acute sick the beds are ranged down the outer walls, and between them are the windows. The object of this arrangement is obviously to insure a free draught of air passing between the beds and through the wards from one window to another, whenever they are opened. It is, however, found practically impossible, in consequence of down draughts, to at all times have the windows (if of R 2 224 St. George's Union Infirmary. ordinary construction) so opened whilst the patients are lying in bed, excepting only when there is little wind or the external and internal temperatures are about equal. This evil has been successfully combatted in this and other hospitals for which I have acted as architect by the introduction of a combined casement and lifting sash, so designed that the lower sashes, when opened, form a protection to the heads of the patients from any draught that may be passing through the windows while they are lying in bed, and, therefore, cross ventilation is possible at all times, without annoyance or danger to the patients. The construction of these casements is such as to render them more nearly air-tight than ordinary lifting sashes, and they are in other respects free from many of the objections appertaining to casements of ordinary construction. In order, however, to meet the prejudice of those who have been accustomed to, and still believe in, the ordinary lifting sash, it is contrived that the upper parts of the window shall open in this fashion, and be used, therefore, for additional venti- lation whenever the weather will so permit. The outer part forms a balcony, upon which the patients may stand in the summer weather. A very cheap and effective iron espagniolette bolt fastening, suitable for these casements, may be purchased at a cost of about 6s. each.* Warming . — Each ward is provided with one patent double open fire hot-water apparatus (a “ Thermhydric grate ”), illustrated and described at page 62 of this section. Had there been two of these apparatus, it would have been unnecessary to supplement this means of warmth by hot-water pipes round the walls. The success of the invention had not, however, been proved at the time of erecting this building, and it was, therefore, thought desirable to provide against failure. Ventilation and Lighting . — The system of ventilation and lighting is similar to that at St. Marylebone Infirmary, described at pages 65 and 66, with the exception that the inlets for fresh air are formed by parged flues in the outer brick walls, instead of by iron piping. Floors and Walls . — The construiftion of the floors and walls is similar to that at St. Marylebone Infirmary, described at page 66. W.C.'s, Baths, &>c . — The main ward water-closets, baths and other sanitary appliances are situated at the extreme end of each pavilion. The buildings containing them are carried up above the ordinary level of the adjoining pavilion, and form towers, the upper parts of which contain hot and cold water cisterns for the supply of the various baths, water-closets, &c., beneath them. There are on each floor two water-closets, generally 2 feet 7 inches wide and 6 feet long, each fitted with ordinary blue earthenware hopper pans and traps, and with Underhay’s regulating water valves. As it is always desirable that water-closets, baths, and lavatories should be placed in contiguity to all w r ards occupied by the acute sick, too much care cannot be bestowed upon the endeavour so to construct these offices that the chance of any foul air entering from them into the wards shall be reduced to a minimum ; and to this end it has in all modern buildings been deemed advisable to separate the two by a lobby, having opposite * I'or detailed drawings of these windows, see Charitable anti Parochial Establishments. Batsford, London. 1881. St. George's Union Infirmary. 225 windows for cross ventilation. If these windows properly perform the functions allotted to them, it is clearly desirable that they should be as far distant as possible from any of the ward windows, otherwise the fouled air would, when the wind sets in certain directions, be blown into the wards through these adjoining windows, when open ; and, to avoid this, it is, therefore, always better to place these offices directly at the ends of the wards, as has been done in this and the St. Marylebone Infirmary, rather than, as is usual, at the sides. Arrangements are seldom made for the warming of these lobbies and water-closets, and, in consequence, air is drawn through them into the wards, whereas, when they are heated to a higher temperature than the wards, the passage of the air is, as it should be, in an opposite direction. Moreover, it is clearly often prejudicial to the recovery of the patients that they should periodically be compelled to remain, in a more or less nude state, in an atmosphere often very many degrees colder than that of the adjoining wards. The lobbies, water-closets and bath rooms of this building are all heated by hot-water pipes passing round the walls. The construction of the lid coverings of the water-closets and sinks of this building is shewn upon the accompanying wood -cuts, Figs. 20 and 21, from which it will be seen that when the lids are closed the apparatus stands practically in the outer air, and any offensive gases rising through the soil and waste pipes would not, therefore, be so likely to find their way into the building as with the ordinary mode of construction. When the lids are raised, the outer air is, of course, shut off. Theoretically, this invention is all that could be desired for solving the problem of how to prevent sewage gas entering a dwelling, but practically it is found to fail because the patients cannot be induced in all cases to close the lids, and I have not, therefore, excepting in this instance, adopted the invention in hospital wards. Previously, however, to abandoning the idea, I made a contrivance by which the shutting down of the lids caused the water-closet basins to be flushed and emptied similarly to the action resulting from pulling up the handle in the ordinary manner ; but the patients still neglected to shut down the lids, and so the evil was only intensified. The contrivance would, however, be found useful in hospitals erected for a better class of patients, and many such have been put up by the maker. 226 St. George's Union Infirmary. Experience has, however, shewn that the position of the gratings immediately at the backs of the water-closet apparatus or sinks is objectionable, because when the wind sets directly towards the building the air is forced inwards rather than outwards. It was also found that in very cold weather the water pipes were liable to get frozen, and they are now so constructed that when the lids are closed the apparatus are opened to flues built in the adjoining walls, and running upwards like ordinary chimney flues, as shewn at Figs. 22 and 23. It is better that a gas burner should be inserted into and that an extraction cowl should be placed upon the tops of these flues. The invention was patented by myself, but I have no pecuniary interest in it. The maker, Mr. Edward Howard, of 34 Upper Gloucester Place, London, W., has, I believe, eretffed a large number, and will, no doubt, be only too glad to afford any information as to them. The slop sink, which is placed in a recess next the water-closets, is formed of lead, 1 foot 10 inches long, 1 foot 6 inches wide, and 10 inches deep. The lobby separating the ward from the w.c. compartments is 9 feet long and 6 feet wide, and it contains a metal moveable bath, which, when required, can be wheeled to the bedside of a patient. Lid Closed. Fig . 22. Lid Opened. Fig . 23. It would have been a great improvement if these offices had been planned in a similar manner to those of St. Marylebone Infirmary, see page 60,* but a prejudice existed in the minds of some competent authorities against the provision of bath rooms, they deeming it desirable that the bath, when required to be used, should, in all cases, be wheeled to the bedside of the patient. The soil and waste pipes are formed of cast-iron hot-water socketted tubes, caulked with gaskin and read lead. They are carried down on the outside walls, and are so arranged as to render it almost an impossibility that any foul air contained in them could enter the building. Separation Wards . — On each of the upper floors there is a small -ward for the accommodation of 4 patients, containing 306 superficial and 3,978 cubic feet; therefore, * Fully detailed plans of these offices are published at page 17 of Charitable and Parochial Establishments. Latsford, London. 1881. St. George's Union Infirmary. 22 7 each patient is here provided with 76 superficial and 994 cubic feet of air space. A cross ventilated lobby, leading to a w.c., is attached to each of these small wards. Day Rooms . — The separation wards last described, when not otherwise urgently required, are made use of as day rooms ; indeed, it is seldom that they are used in this building for the purpose they were originally designed for. Duty Rooms . — Attached to and overlooking the large and small wards there is a nurses’ duty room, having an area of 144 feet. It is fitted with a range and sink, and racks and shelves for ward crockery, &c. The nurses’ dormitories are situated, as previously described, in other parts of the establishment. Lifts . — Adjoining the main corridor, and forming a centre, round which each pavilion staircase winds, there is a lift, 8 feet long and 4 feet 3 inches wide, for conveying paiients, coals, and food from the lower to the upper storeys. These lifts are each worked by an hydraulic ram, which descends into a brick well a depth corresponding to the extreme height, through which the cage has to be lifted. Staircases . — The pavilion staircases, including the lifts, occupy an area of 323 feet, and they and the corridors adjoining them are all fireproof, being formed of Yorkshire stone resting upon brickw'ork vaulting. The steps are each 4 feet 3 inches long, with a tread of n inches and a rise of 6J inches. Total Area of Pavilions . — The total area covered by each floor of the pavilions, including the surrounding walls, is 3,665 feet, or about 1 1 4 feet per bed. ( 228 ) HOSPITAL OF ST. ANDREW THE APOSTLE. GENOA, ITALY. A calculation was made in 1875 that there were about 800 hospitals in the Kingdom of Italy, and, although in the southern provinces extensive distri&s are entirely unprovided with them, hospitals are to be found in almost all the chief towns of provinces and districts, and also in many places of minor importance. The following account of hospitals in Rome is extracted from an able and interesting report upon the relief of the poor of that country, drawn up, in the year 1875, by Mr. Herries, then H.M. Secretary of Legation at Rome. " 1. The oldest and most extensive of the Roman hospitals is that of S. Spinto in Sassia. founded at the beginning of the thirteenth century by Innocent III. It was first called S. Maria in Sassia, or Saxia, from the name of an ancient church built, together with a house, for the resort of Anglo-Saxon pilgrims by Ina. King of the West Saxons, who, about the year 728, after his retirement to Rome, established the Schola Saxonum in a part of the Borgo, which thence obtained the popular appellation of Sassia. The place having become deserted was chosen by Pope Innocent for the great charitable institution soon afterwards called S. Spirito, from the religious Order of that designation, to which he entrusted its management. “ It was originally intended not only for the cure of the sick and the relief of the poor in various ways, but also for the reception and education of foundlings. In 1608, Paul V. incorporated with it a bank of deposit for the profit of the institution ; and, in 1726, Benedid XIII. transferred to S. Spirito the lunatic asylum existing elsewhere in Rome. “ The hospital, properly so called, which, like the other branches of the institution, is devoted to the assistance of poor persons, without distindion of class or nationality, is principally for the medical treat- ment of acute cases of disease. It has room for 730 beds. “ Its medico-surgical staff consists of 10 chief physicians and 4 chief surgeons, 10 assistants, 4 substitutes, 10 sub-assistants, 8 under-substitutes, 1 chief and 1 under apothecary, with 13 assistants. There are, besides, 39 sisters of charity, and 126 other hospital attendants, porters, &c., &c. “ The daily average number of persons treated from 1855 to 1870 was the following : — 1855 ••• 573 1859 ... 434 1863 ... 399 | 1867 ... 376 1856 ... 646 i860 ... 510 1864 ... 385 1868 ... 390 1857 — 732 1861 ... 494 1865 ... 352 | 1869 ... 344 1858 ... 617 1862 ... 443 1 1866 ... 345 1 1870 ... 380 " The total number of persons admitted during the ten months ended October 31, 1870, and during the corresponding period of 1871, was respedively 8,204 and 10,799. The increase in the latter period was, therefore, 2,595. " A military hospital, where soldiers of the garrison are treated by contrad with the government, is annexed to the general civil hospital, and placed under the same diredion. “ The second branch of the institution of S. Spirito is that which is devoted to the care of foundlings. A portion of the hospital building, specially construded for that purpose in the pontificate of Sixtus IV., and restored a few years ago, is large enough to contain about 100 infants and from — to 50 nurses, with all requirements. The total number of foundlings received during the twenty years ended December 31, 1870 was 23,191, of whom 11.437 are males, and 11,754 females. For the ten years 1860-69, the annual average was 1,141 infants admitted, of whom 382 were ascertained to be of illegitimate birth, 300 of legitimate birth, 459 being of uncertain origin. The average annual number of foundlings supported by the establishment was 3,268, and that of the deaths among those of all ages 981. By far the greater number of the infants received are given out to nurse in the country. According to calculations made for a period of twenty- seven years, from 1844 to 1870, the average rate of mortality among foundlings in their first year was 8-i 78 per cent for those in the hospital (annual average, 651), and 12 80 per cent, for those in the country (annual average, 2,285), the general average for the whole being 29 64 per cent. Hospital Construction and Management. iph»d It IVinted Ky James Akerman. 6, Queen Square ,W C . Hospital of St. Andrew the Apostle 229 “ In connexion with the foundling establishment there is what is called a conservatory open, where those girls who are not disposed of in marriage, or otherwise, are maintained at the expense of the institution of S. Spirito. To those who marry portions are given at the rate of about 530 francs. Boys, when not adopted, as is frequently the case, by the persons who undertake their care until the age of ten years, are brought up or apprenticed in one way or another, remaining, however, eventually at the charge of the hospital until the age of twenty-one. " The average annual expenditure incurred on account of foundlings is 305,603 francs. “ The lunatic asylum of S. Spirito contains 669 patients, under the care of a directing physician, a vice- direCtor, 3 medical assistants, and 68 keepers, nurses, &c. “ As already observed, there is a bank annexed to the institution. It was formerly, but has now ceased to be, a source of considerable profit * “ 2. The hospital of the “ SS. Mo Salvatore ad Sancta Sanctorium," founded by Cardinal John Colonna, in the year 1216, is now reserved for women only. Patients are admitted without distinction of age, condition, nationality, or religion. Their average number is little more than 250, though the hospital would be capable of containing 561 beds. The gross income of the institution amounts to 252,000 francs, and, after deduction of the charges on the property and cost of administration, there remains a net income of 165.000 francs. The daily cost of each patient in 1870 was calculated at 180 francs, and that of every attendant at 2 60 francs. “ 3. The hospital of St. James in Augusta, founded in 1339, in pursuance of the testamentary dispositions of Cardinals James and Peter Colonna. It is principally for ulcers, tumors, and similar affections. Incurable cases are also admitted. It could give accommodation to about 450 patients, but the ordinary number of those treated is about 250. No conditions of nationality, religion, or class are required for admission. The income of the hospital amounts to 228,437 francs. “ 4. The united hospitals of S. Maria in Portico , founded by Pope Celestin III., towards the end of the twelfth century ; 5 . Maria delle G ramie, established by Gregory VI., in 1045 ; and . 5 . Maria della Consolazione, for wounds and other injuries requiring immediate surgical treatment. There is room for 180 beds. The total income is 97,000 francs. “5. The hospital of S. Maria and S. Gallicano, for cutaneous diseases, established by Benedict XIII., in 1726, contains 238 beds. It has a yearly income of 13,975 francs, besides 53,750 francs received from the State (this was under the Pontifical government) as compensation for property confiscated. The cost of every patient is about 2 04 francs a day. The average number of patients is nearly 100. “ 6. The convalescent hospital of the Holy Trinity. The average number of persons in it is reckoned at about 95; the maximum being, for men, 120; for women, 60; and the minimum for both men and women, 10. \ " The primary object of this foundation, which dates from 1550, was the reception of pilgrims to Rome in years of jubilee under the care of the arch-confraternity of the Holy Trinity. The house destined for that purpose has dormitories capable of accommodating about 500 persons, and refectories where nearly 1.000 can be fed at once. " Pilgrims seeking the hospitality of the institution were required to prove that they had come from a distance exceeding 60 miles, and for the purpose of visiting the holy places. “The following statistics of the numbers received in the years'of jubilee, from 1575 to 1825, are given by Cardinal Morichini. Years of Number of Pilgrims Years of Number of Pilgrims Jubilee. who received Hospitality. Jubilee. who received Hospitality 1575 . ... 116,848 I7OO ... 300,000 1600 . ... 324,600 1725 ... 382,140 1625 852,760 1750 136.513 1650 308,533 1775 ... 99,667 1675 311,777 1825 263,592 The arch-confraternity of the Holy Trinity. when first approved by Pope Pius IV., had 15 ducats a year of its own, and made up what was wanted by collecting alms. It now has an income of 174,976 francs, and the annual expenditure of the whole institution is reckoned at 172,300 francs. * " The above account of S. Spirito is principally taken from an interesting report on the management of the institution, by its director. Dr. Pantaleoni. The statements which follow, concerning other hospitals and charitable institutions generally at Rome, are extracted from Cardinal Morichini’s work, already noticed 230 Hospital of St. Andrew the Apostle. “ 7. The lying-in hospital of S. Rocco has an income of 23,377 francs. The principle of the institution is the observance of absolute secrecy. Any pregnant women are admitted without inquiring as to name or condition. Those who are not considered as poor pay a small sum monthly, when, as is frequently the case, they come into the hospital for the purpose of concealment a long time before delivery. " 8. The hospital of St. John Calibita, commonly called “ dei Benfratelli," for acute cases of disease, was founded in 1581 by the monks of the Order of S. Giovanni di Dio, popularly designated as the “ Fate bene fraUlli.” This Order has the entire management of the hospital, and, with the exception of the principal physician and surgeon, all the persons employed are members of it. As a rule, patients are admitted only on the recommendation of a benefadtor of the institution. The average number under treatment is about 40. " In 1867 the receipts, a considerable proportion of which was derived from the sale of medicines prepared in the pharmacy of the establishment, amounted to 75,000 francs, and the expenditure for the hospital, and the maintenance of the brethren attached to it, amounted to 53,750 francs, the remainder being applied to repairs, charges of administration, &c. At the beginning of that year there were 50 patients in hospital ; 919 were admitted in the course of the year, 59 died, and 865 went out. The daily cost of every patient was 1-50 francs. “ 9. A special hospital for poor priests, founded in the seventeenth century by a certain Giovanni Antonio Vestri. " 10. The hospital of 5 . Francesca Romana, for chronic affedions, founded by the will of the late Cavaliere Carlo Doria Pamphily, was opened in i860. To be qualified for admission patients must be Romans domiciled in the city, who are incapacitated for work by chronic maladies, and who cannot be received into other hospitals. Persons suffering from cutaneous diseases are excluded. " 11. A room for the treatment of eye diseases, established by Prince Torlonia. " 12. Of the great number of special hospitals for particular guilds and nations, or provinces, which formerly existed in Rome there remain only two of the former category — a hospital for apothecaries or druggists, and a hospital for bakers; and one of the second category — the Spanish hospital, founded in 1350 by two ladies of Barcelona, and the endowment of which was augmented by Charles V." Little addition has been made to the number of hospitals in Rome since the above account was written, but it may be expecfled that before long a building will be ereefted outvying anything of the kind yet attempted in Italy. Plans are now being considered for the erection of an establishment to contain from 450 to 500 patients, at a cost of ^’320,000 (eight million lire), or from ^640 to £711 per bed. The site chosen lies between \ ia le Manzoni and Porta Maggiore, and will extend from Via le Principessa Margherita on the north-east to Via Conte Verde on the south-west. A large project is likewise on foot for the erection of a combined workhouse and hospital, “ Ospiziodi Carita,” at Turin, which, if carried out, will contain accommodation for 1,600 inmates, with hospital accommodation for 400. Designs for this establishment have been prepared by the architect, Signor P. Carrera. The hospital wards appear by the plans to be disposed in six 1 -shaped blocks, each two storeys in height, the wards being placed in the extremities of each oi the three arms, and the offices at the junctions of them. The arrangement is very compact, and, although by no means perfect, might, with slight modifications, be made to conform with modern principles. A full description of the details of the proposed building, together with plans, are contained in a memoir presented by Signors L. Pagliani and P. Carrera to the Royal Italian Society of Hygiene, and published in its journal. 0 The only hospital in Italy known to have been planned in accordance with modern piinciples is the one now to be described. The architect, Signor Cesare Parodi, before • Giornale della, ReaU Socieia Italiana D'Jgicne. Milan. 1883. Hospital of St. Andrew the Apostle 231 r preparing his design, tells us that he made an especial study of the plans of the following hospitals : Lariboisiere, Hotel Dieu, St. Louis and Bourges in France ; The Woolwich Military, Royal Free, King’s College, Blackburn and Netley Hospitals in England ; Boston Hospital in America; and the Grand Hospital of Milan. 0 Signor Parodi has been so good as to give me much valuable information as to the general characteristics of this building and also a block-plan of it, but, as he declined on any consideration whatever to let me have a detailed plan and section of one of the pavilions, it has been necessary for me to send over and have the accompanying sketch of the principal front taken upon the spot, and the detailed plan and section at page 233 measured. The building has been erected by the order and at the expense of the Duchessa de Galliera, and it was intended to have been completed by the year 1884, but the Duchessa’s agent is said to have robbed her of a very large sum of money, and the progress of the building was, therefore, delayed. The carcase and much of the internal finishing were complete at the time it was visited. Signor Parodi is, so far, much contented with the result of his labours, and he assures me that the building even now attracts a continuous stream of visitors, students of hygiene, architects, engineers, and artists, to say nothing of tourists, who are drawn from all quarters by eulogistic descriptions in the guide books. f Architectural and artistic effect appears to have been studied in the design of all paits of the building. The entrance hall, Signor Parodi tells me, is to be embellished “ with frescoes from the skilful hand of Giuseppi Isola,” and the frescoes on the inside of the arched ceiling of the chapel are being “ executed by another highly distinguished artist, the Chevalier Niccolo Barabino, a name famous for the magnificent works of art executed by him in that pure and classical style which calls to mind the days of Raphael,” whilst “ the architectural decoration, designed in the classic style, breathes the spirit of Galeazzo Alessi, the architect of the Basilica of Carignano and so many other of the ancient palaces that enrich Genoa.” Site . — The ground upon which the buildings stand was presented by the city authorities. It is in the district of Carignano, the highest part of the town, and just within the south-east angle of the city walls. The extent of the site is about 538,750 superficial feet, being 12 acres 1 rood 18 perches, or nearly 1,259 superficial feet per bed. Subsoil . — The foundations of the building are carried down to a bed of solid rock. * Politecnico. Giorn. dell' Ing. Arch. Civ. ed Industr. Anno, 28. t "Oramai quest' opera attira a se continuamente innumerevoli visitatori, studenti, sanitarii, architetti, ingegneri, artisti. Achne la schiera dei turristi vi accorre perche trovasi gia consegnata nelle guide. Sotto il punto di vista artistico il Courier de l' Art che si stampa a Parigi, nel suo numero del 4 Ottobre 1883. si esprimeva in questi termini. 1 Les travaux exterieurs de 1 immense hopital monumental dont ’inepuisable charite de Mme. la Duchessa de Galliera a dote la ville de Genes sont entierement termines. Cette enorme construction, elevee dans la situation la plus salubre sur les hauteurs de Carignano qui dominent presque toute la ville, fait le plus grand honneur a l'architede, M. Parodi, qui n'a pas moins intelligemment combine les dispositions interieures auxquelles on travaille sans relache ; aussi compte-t-on que l'inauguration pourra avoir lieu au commencement de l'annee 1885.' " — Extract from letter of Signor Cesare Parodi. 232 Hospital of St. Andrew the Apostle. General Arrangement. — The pavilions containing the principal sick wards are seven in number, and on plan they radiate from a front connecting corridor, which, on plan, forms the segment of a circle. The principal entrance to the establishment is placed in the centre of block A on the plan of site. This building is four storeys in height, and contains the principal administrative offices, including a large and handsome hall and staircase, a council chamber, and apartments for the use of the manager, sub-manager, house-surgeon, and others of the principal officers. In the rear there is an annexe, two storeys in height, for use as receiving wards, with three rooms on each floor for 6 patients each, and examination and bath rooms and other offices adjoining. The central pavilion, block B, contains, on the basement floor, the kitchen and general dining hall, also the boiler and engine room, and machinery for ventilating and heating. The ground floor contains sick wards for 24 patients, but these are only to be used on emergencies and when the ordinary wards are full. On the first floor is a chapel, with a library and residence for the chaplain, also apartments for the sisterhood in the rear, fftr whose use a gallery is provided at the back of the altar, and screened from it by iron grills. The principal sick wards arc situated in the six pavilions, C, D, E, F, H, J, to tlu: right and left of the central building last described. They are each two storeys in height above the basement and contain, on each floor, a large ward for 20 patients and four separate wards for 1 patient each. The attics of these buildings will be available as apartments for the domestics and other officers of the establishment not provided for elsewhere. The basements, which are partially above the ground level, are variously occupied — that of block C is devoted to the out-patients’ depart- ment ; block D contains the dispensary, laboratory and drug stores ; block E is fitted up as a general store room ; block F is a linen and clothing store room ; block H is the general bathing department of the establishment, for use by both sexes, but approached by separate corridors and entrances; block J is similarly arranged, but with all the usual appliances for the hydropathic treatment of patients. Block K forms a corresponding wing to the entrance ; block A contains operation rooms and a lecture theatre, also apartments for students and other usual arrangements for academical purposes. Block L, one storey in height, is the mortuary, post-mortem room, and anatomical museum. Block M is the wash-house and laundry, which it is intended shall be fitted with washing and wringing machinery worked by steam, and with the latest improve- ments. Block N is the mattress department ; block O is the gardener’s residence ; block P a fuel store ; and block R a convalescent home, five storeys in height, for the accommodation of 80 paying patients. The space marked S is intended for the erection of tents for the occupation of patients during warm weather. ] i ontfitiidinal • Section A B Hospital Construction and Management. Hos pital • of • St Andrew • the • Apostle •Genoa* A JJdministrahue Offices cutting Wards K Students 6 lecture 7%tafre II j(itchtn. Engine Jjcvsc Chattel S Jfurses Li SJ ortuortj C Sick Wards 6- Outpatients department M Wash-house r ll Sick. Wards £ %itp>inssru E Sick Wards, f Gfeniral Store. F Sick Wards 6 Clothing Store . H Sick Wards i fyalfts «T Sick Wards & Jj tjdroJSalhic department N deddtng Store O ( lardcnerj Residence P 7t,J Store. R Convalescent Jpome S 'Tents . Phoio Lnbc$r«ph«l h PnotfJ by jWt Aktrtnaii. 6 Qumo Siju«r«. W C H Saxon Snell del Hospital of St. Andrew the Apostle. 233 Total Accommodation. — Provision is thus shewn to have been made for the accommodation of 428 patients, viz. : — Twelve wards, in blocks C, D, E, F, H, J, for 20 patients each Forty-eight do. do. do. Six do. A, for 6 patients each... ... Reserve do. B Convalescents do. R ... ... Total ... 2 o 48 3 24 80 428 Connecting Corridors. — The main corridors, connecting together the seven pavilion blocks, are two storeys in height, and they each, are 16 feet wide and 25 feet high. They are lighted on either side by French casement windows, and are intended to be used as ambulatories by the patients. Water Supply. — The generous founder of this establishment, the Duchessa de Galleria, has likewise with equal liberality had a water conduit constructed at her expense for the benefit of the town, and this will also supply the hospital building. A well has likewise been sunk, the water from which will be used for certain purposes. Drainage. — It is stated that the drains are formed of stone cemented upon the inside, and that they are carried away from the building on the western side and into the sea. Area Covered. — The area covered by buildings is about 112,553 feet, being rather more than one-fifth of the site, or 263 superficial feet per bed. Cost. — It is estimated that the value of the land is £ 6 o,oco (i£ million lire), or ^*140 per bed, and ^4,853 75. 9 d. per acre. The cost of the buildings, Signor Cesare Parodi informs me, will not exceed ^"280,000 (7 million lire), or ^654 per bed ; so that the total cost of both land and building will be ^"794 per bed. Principal Sick Wards. The principal sick wards of this building are shewn in detail on the accompanying plate. Aspect. — The axis of the central pavilion runs W. by N. to E. by S., so that the windows of the wards face S. by W. and N. by E. ; the axes of the other pavilions change until at the two extreme ends they run respectively from W. by S. to E. by N. and N.W. to S.E. Relative Position of Pavilions. — The height of the pavilions, as measured from the lower floors of the sick wards to the juntftions of the upright lines of the outer front walls with the sloping lines of the roofs, is about 61 feet, and the average distance between each pavilion is 76 feet or about 1} times the height. Size of Wards. — Each of the large sick wards is of parallelogram shape, will accommodate 20 beds, and is 79 feet long and 28 feet wide. The total superficial floor space is, therefore, 2,212 feet, or no feet per bed, and the cubical contents 50,876 feet, or 2,544 feet per bed. The window recesses are, however, unusually deep, and if this were taken into account the contents as above stated would be somewhat increased. Bed Space. — The average lineal wall space per bed is 7 T n jj feet per bed. Windows. — Each side wall has five large folding casements and above each one is another smaller window hung on centres ; the total area of their effective glazed surface 234 Hospital of St. Andrew the Apostle. is 435 feet, or about 22 feet per bed, and when all are opened to' their fullest extent the area through which air can be admitted by them into the wards is 573 feet, or 28f feet per bed. All windows are fitted with outside jalousie blinds. Warming and Ventilation. — The system of heating is said to be that by which air is forced into the various wards through flues radiating from a sub-basement in the central pavilion, and there the air is passed over pipes heated by the circulation of hot water ; the flues as they reach the pavilions are carried upwards in the side walls and find an outlet under the heads of the beds and at the floor level ; the openings, which are 9 inches square, are fitted with dampers to control the admission of heated air. In warm weather fresh air is also brought into the wards in a similar manner ; but it was not apparent whether the same flues answered this purpose. The extraction of fresh air is said to be provided for by a fan fixed in the roof over each pavilion and communicating with the wards by means of openings, 6 inches square, over each bed, and flues running up the side walls and horizontally through the roof. The arrangements for lighting were not completed when the building was visited. Floors. — Iron joists and concrete are used in the construction of the flooring, and the surface is finished with polished marble slabs ; the ceiling over each pair of beds is vault- shaped, and is supported entirely independently of the floor, in order, it is said, that if the physicians should be at any time of opinion that disease germs have permeated the plaster, these ceilings could readily be removed and danger averted. Walls.— The walls are constructed of brickwork, and finished on the outside with cement ; they are about 4 feet 6 inches thick, and consist of an outer wall, 3 feet 3 inches thick, then a space of 10 inches, and lastly, a half-brick casing, which, like the ceiling, is made capable of removal whenever thought necessary. The inner faces of the walls are plastered. Baths, W.C.’s, S*c. — The water-closets and other like sanitary offices are placed in towers, at a distance of 10 feet from the end of each pavilion, to which they are connected on each floor by means of glazed covered bridges, similarly to those of the Antwerp Hospital, described at page 85. Each turret has two water-closets, 3 feet 9 inches long and 3 feet 3 inches wide, fitted with white earthenware pans and wainscoat seats ; and there is besides an urinal fitted with a treadle for flushing, a stoneware slop-sink, 18 inches long and 12 inches wide, with marble slab, 4 feet long and 2 feet 6 inches wide, and, over the same, a dust and a linen shoot. The bath rooms are entered from the corridors running from the ends of the large wards to the tower bridges ; they are 1 1 feet long and 8 feet wide, and are fitted with marble baths. The lavatories are of the same size as the bath rooms, and are placed on the opposite side of the corridor. They are each fitted with two “ tip-up ” earthenware basins, and in one corner of the room there is a small spiral staircase, descending to the basement, for the use of the attendants. Day Rooms. — The day room adjoins the conneifting corridor, and forms an entrance hall to each pavilion ward. It has an area of 938 feet, or about 46 superficial feet per patient occupying the large ward. Hospital of St. Andrew the Apostle. 235 Separation Ward. — Entered from the end of the large ward is a corridor leading to the end tower, and on either side of this corridor there are two rooms (four in all) each of which is devoted to the use of one patient. Each room has an area of 161 superficial and 2,898 cubic feet. Duty Room. — The nurses’ duty room is entered from the day room. It has an area of 310 feet and is fitted with a marble sink and gas cooking range. Nurses' Room . — Adjoining and overlooking the large ward is a nurses’ or sisters’ room, having an area of 160 feet. Death Chamber . — On the opposite side of the passageway giving access to the ward, and of similar size to the nurses’ room, there is a room called “ the death chamber ” ; it would appear to be provided for the separation of the recently dead or dying from the patients occupying the adjoining ward. Staircase . — Leading out of the day room, and adjoining the connecting corridor, there is a staircase covering an area of 175 feet. The steps are of marble, 13 inches wide, 61 inches high, and 4 feet in length. Lift. — There is to be but one lift, and this will be placed in the central pavilion B adjoining the connecting corridor. It will be 7 feet long and 6 feet 6 inches wide, but had not been erc(fted when the building was visited. Basements. — The basement floors are 13 feet high, and are occupied for the various purposes enumerated at page 232. Area of Pavilions. — The total area occupied by each pavilion floor, including the outer walls, is 8,419 feet, or nearly 351 superficial feet per bed. ( 236 ) RIGA TOWN HOSPITAL. RUSSIA. There does not appear to be any general law for the government of the poor of Russia, nor for the regulation of its hospitals. The inhabitants of each town of the Baltic provinces frame rules for their own guidance, and the ordinances under which the rural parishes of this part of the Empire are, in this respeft, governed is related by the following extracts from a report made to our Government by Mr. J. Grigurn, H.M.’s Consul at Riga : — .. j t j s the duty of every parish to support its orphans, foundlings, and children of tender age and unfit for employment, as well as all parishioners who are unable to support themselves on account of old age or sickness, as also those who have no relations of any kind, or who, if they exist, are not in a condition to render assistance. Such persons must, however, be natives of the parish or have resided in it for a period of 15 years. The parish is likewise responsible that medical attendance is given to poor sick members. Finally, the parish is bound to support all insane persons belonging to it out of its own funds, and to afford them all necessary protection. Should, however, a greater number of insane persons be thrown upon the parish than it is in its power to support, it has a right to apply, through the parish court, for an order from the governor of the province that they shall be received into an institution for the assistance of the poor, with or without payment, as the case may be. To the poor wives of recruits and their minor children the parish is bound to allow, in addition to free lodging and fuel, at least 20 quarts of rye or oatmeal monthly for the wife and half that amount for each child. The parish police is also bound to take care that the children of recruits receive free lessons in the parish school, and that the persons charged to look after the interests of the mother shall be proper persons. '■ A nominal list is to be made out by the parish police each year of all poor and sick persons requiring aid, fixing, according to circumstances, the amount of allowance for each person in need. This statement is to be laid before the parish committee for preliminary inspection and approval. Should any change be made in the amount of assistance proposed, such change must receive the especial approval of the committee. •• All members of the parish able to work who have repeatedly come on the parish for support, as well as those who have not fulfilled their parish duties during two years, are placed under the special surveillance of the district police. It is the duty of that police to bring these persons before the parish court, which will sentence them to work out their debt by a period of service on public works, either in or out of the parish. “ To cover the charges to which a parish is liable it can have recourse— To the poor funds of the parish, where such funds exist ; to the income arising from the produce of land rented or bought by the parish for the use of the poor ; to voluntary gifts ; to the interest paid on advances made out of the stock magazines. All persons receiving loans from the magazines of grain which exist in each parish pay interest, never more than six per cent., on the value of such loans ; to general collections, to be made in each parish every year on the Sunday before Michaelmas Day by persons specially authorised for that purpose by the parish committee ; to monies allowed for that purpose out of the general parish funds. "Should these funds not suffice, the parish court may lay on an extraordinary tax, distributed among farmers according to their rent, and farm servants according to their wages. The sum to be levied must, howefver, be fixed by the parish at a parish meeting, and must be approved of by the district police. The parish committee controls all parish capital, and other parish property. This committee fixes the amount of the contributions to cover the parish expenditure, and decides the manner in which the necessary sum shall be raised. "A manager of the poor, called a 'parish warden,’ is chosen annually by the parish, subjedl to the approval of the district police, who, in conjunction with the parish court, have under their care the distribution of ail money. The managers of the poor or the parish court must account quarterly to the Hospital Construction and Management own I\.C/(JrninLsfrariut Cuildi ru} B. ‘fyui/iona dito ofortes htyji C do One jtory ht.^h D Venereal diseases Hospital Hi 6 a ■ /<0 F. Q>rna// ( /&jc Gards Gards WJ^itchin t^tces Gash house. Qnd (intend house L furnace, sliajt AY dee houses N Coal houses 0 . d^orlua ref q)/q6/c arid Coach house. kdlf transverse 4 ion4ttuJ«riahints ^Dtpor/me nt * 1j Ctfioj ZUash-houst and a%Hot Ztsatcr fprfdi next 'Walls Prospect Street Prosy, • Plan ’of* Site 'a frpre sent • Plairof-Site’a s'altered • Stab sf&ssf .00 to o '«• '*• H.Daxon .Snell del * Elevation * Phot o Lithographed icfrinted by James Akerman. 6 Queen Square .W C Hull General Infirmary 261 well to pay a visit to the new lying-in wards of St. George’s Union Workhouse in the Fulham Road, or the sick wards of the adjoining Infirmary, and they will there see that it is quite possible to construct casements free from the above objections. 0 Warming. — Each ward will be warmed by patent double open-fire hot-water apparatus (Thermhydric grates), illustrated and described at page 62 of this section, and hot-water pipes next the outer walls. Improvements have, however, been made in the manufacture, by which the operation of sweeping the flues is made much more simple than heretofore. Ventilation and Lighting. — The ventilation of the wards will be effected by purely natural means, the windows being chiefly depended upon for the supply of fresh air ; in addition, however, inlets for the admission of fresh air are contained in the walls between each pair of windows, and generally consist of two flues, 9 inches wide by 4^ inches deep, running vertically up each pier, and opening outwards through gratings fixed upon the face of the wall at about the level of the floor line, and inwards to the wards at the level of the floor, and also through hoppers fixed about 30 inches below the ceiling line, and having the fronts so inclined as to defied the incoming air upwards and towards the ceiling. These flues will be provided with flaps, the opening and closing of which by the nurses will regulate the quantity of air to be admitted at times when the wind may be blowing too strongly towards the inlet gratings. Removal of the fouled air of the ward will also be provided for by means of shafts, 12 inches square, constructed in the ceilings between the joists, and continued upwards through flues in the side walls. These flues will terminate in grated openings fixed on the outer faces of the walls. The lighting of the wards at night will be effected by means of gas burners placed under inverted wrought-iron japanned basins ; ventilating pipes will run from the upper parts of these basins through the ceiling ventilating channels into the shafts last described, and thus not only will the products of combustion be carried away from the wards, but the extraction of foul air from them will be assisted. Floors. — The flooring will be formed of ordinary timber joists, covered with oak- flooring boards, wax polished ; the ceilings will be plastered. It is seldom that floors above 20 feet bearing are constructed with single joisting ; but joists 12 inches deep, 3 inches thick, and 11 inches apart are all-sufficient for hospital wards 24 feet in width, and many advantages arise where this method of construction can be adopted.! The wards of this building being 26 feet wide, it would, perhaps, have been found more economical to construct the floors on the double framed principle, but then the depth would have been nearly double that of a single joisted floor, and the height from floor to floor being restricted by the levels of the old building, this loss of space could not be afforded ; it has, therefore, been determined to use single joists, 12 inches by 3 inches, and to reduce the bearing to 24 feet by the introduction of stone templates and brick corbelling. * For detailed drawings of the construction of these Infirmary casements, see Charitable and Parochial Establishments. Batsford, London, 1881. t Tredgold and other authorities recommend joists of this size, 12 inches apart, for floors not exceeding 20 feet bearing. 262 Hull General Infirmary. Walls . — The outside walls are of brick, the exterior faces being covered with Portland cement, with cornices and other architectural features to correspond with the classical character of the adjoining building. The inside faces will be covered with Keene’s cement and painted. W.C.'s, Lavatories, &c . — The plan and position of these offices were determined by the architectural character of the present building, necessitating the construction of towers or such like features at the junctions of the new buildings with the old, in order to break the otherwise apparent incongruity of the windows and strings being at a different level. These features then being formed by projecting forward the duty rooms, it was desirable that similar projections should, for the sake of uniformity, be constructed at the other ends of the wings, and here, therefore, it was determined to place the water-closets and lavatories. Each water-closet will be 5 feet long and 2 feet 9 inches wide, and there will also be a compartment, 5 feet 6 inches long and 3 feet wide, containing a slop sink. These offices are in both cases cut off from the wards, first by lobbies and then by wide cross ventilated and well lighted passage ways, and they will be warmed by means of gas stoves placed in the angles, and having flues running up the walls for the purpose of carrying off the produces of combustion. Wash-hand basins supplied with hot and cold water for the use of the patients w r ill be placed in these passages. The bath rooms are situated in the extreme ends of the present buildings as re-modelled ; they are each 1 1 feet 3 inches long and 7 feet 6 inches wide, and will be fitted with a fixed earthenware bath. A bath, moveable on wheels, will also be placed at the bottom of each staircase, and will be available for the use of patients on the upper floors by means of the lifts, which rise from the level of the entrance- hall. The soil and waste pipes will be formed of cast-iron hot-water sockettcd tubes caulked with gaskin and red lead, and carried down the outside walls. They will generally be constructed and ventilated in a manner similar to those at St. Marylcbone Infirmary, described at page 66. Day Rooms . — It is to be regretted that the available space does not admit the provision of separate day room accommodation for the patients, when the building contains its full number of inmates ; when, however, the numbers will permit it, the wards shewn on the upper floors to contain six patients each will be available as separate recreation or day rooms for the patients generally. Separation Wards . — A separation ward for two patients is planned on each floor adjoining the large wards, and they will be 16 feet long, 14 feet 6 inches wide, and 14 feet high; each patient occupying them will, therefore, be provided with 116 superficial and 1,624 cubic feet of air space. Duty Rooms . — Attached to and overlooking each of the large wards will be a nurses’ duty room, having an average area of 210 feet, and being fitted with a range, sink, and racks and shelves for ward crockery, &c. The nurses’ sleeping apartments will be, as previously pointed out, situated in the old central building, and in other parts of the establishment. Hull General Infirmary. 263 Lifts . — Leading out of the entrance-hall on the ground floor, there is a lift, 7 feet 6 inches long and 6 feet wide, for conveying patients, coals, and food to and from the various wards. Staircases . — The principal staircases of each pavilion will occupy an area of 405 feet, the hard Yorkshire stone steps being 5 feet long, with a tread of 12 inches and a rise of 6 inches. Total Area of Pavilions. — The area covered by each floor of this new wing, including the staircase, bath room, duty room, separation ward, and all surrounding walls will be 4,619 feet or about 165 feet per bed; but if the old building, so far as it is adapted to the use of the sick patients, be added, the corresponding area will be 7,428 feet, or 169 feet per bed. As space will allow, it may be well to say that since the above account has been written the one hundred and first annual meeting of the Governors of the Institution has been held, under the presidency of the Mayor, Dr. Rollit. Mr. Henry Simpson, Chairman of the Board of Management, explained in great detail the considerations which led to the adoption of the present plan for altering and enlarging the building and rejecting the proposal for ereCting a new one. He also paid a well-merited compliment to the professional skill of the local architects, and explained the reasons which guided the Committee in their determination to employ, in this instance, the services of one who had made the construction of hospitals an especial study. The adtion of the Board of Management was unanimously approved by the Meeting, and a cordial vote of thanks passed for its unremitting labors in the matter. ( 264 ) M. TENON’S PROPOSED HOSPITAL. Ff.w works liave been written upon t lie subject of hospital construction without reference being made to the rules laid down by M. Tenon in his great work, entitled “ Memoirs sur les Hopitaux de Paris,”* and as this has been many years out of print, and is scarce, it will not be inappropriate to make my readers acquainted with the general principles laid down by him for the construction of hospitals ; especially so that these principles gave rise to the system, now so generally adopted, of erecting hospitals on the pavilion system. The scope of this work will not, however, permit so lengthy a notice of M. Tenon's views as their interest would otherwise demand ; it must therefore suffice that I give, in addition to illustrating his proposed plan for a model hospital, the substance of his general opinions, as set forth by a Committee of the Royal Academy of Sciences, of Paris, appointed in the year 1787, to examine and report upon the memoirs above referred to. "Extract from the Registers of the Royal Academy of Sciences, September 1787. " The Academy having directed the Hospital Committee to examine the Memoirs on Hospitals, collated and presented to the Academy by M. Tenon, we proceed to give an account of them. “ This interesting work is composed of four memoirs, and we will give to the Academy an idea of each of them successively. “ The first is a table of the hospitals of Paris, shewing their particular purposes, and the total amount of help they give to the poor of the capital. " We there see that Paris has 48 hospitals for the poor, 22 being for sick, 6 for sick and healthy, 20 for the healthy only. •' In these hospitals, the number of sick aided may be put at 6,236, and of healthy and infirm about 14,105 ; then, if we add the 15,000 foundlings who are brought up, it will be seen that the City of Paris administers help to 35,341 poor. This number is large relatively to the population of Paris, supposing this to be, as M. Tenon puts it, 660,000; it results that one individual in every 18J requires charity of this kind. Leaving out the foundlings, the poor of Paris are to its population as 1 to 33, and the poor sick as 1 to about 106. M. Tenon, in finishing this memoir, observes that two additional hospitals are still required in Paris, one for the treatment and cure of the blind, another for the inoculation of the people's children. “ After this general table, based on the results and the calculations of the first memoir, the second enters into detail as to the different hospitals ; their form is described and their purposes shewn. M. Tenon also remarks on their conveniences or inconveniences. The object of M. Tenon's enquiry into the con- dition of the hospitals of the capital has been to ascertain what should be avoided and what initiatedjn the establishment of any new hospitals ; also to colled together information as to all that is good in those which have been built up to the present time, and so give a quantity of information as to this important object that will not only serve as a guide to the building projects of the present time, but in all those which may be contemplated in the future. “ In one of these hospitals, M. Tenon learns that wards for putrid fever must not be placed near the wards of the wounded. The fad was disclosed to him that the wounded whose beds were near the doors of communication of these wards did not get cured at all, or were cured with greater difficulty. In a second hospital, he remarks that the linen and clothing were separated according to the locality of the different diseases, so that the linen, even when clean, is prevented from being taken from one kind of sick person to another. In a third, he discovers that furious maniacs have rooms where they are shut up and are not mixed with the more quiet inmates. In others, he observes that the beds or the window frames are of * Paris, 1788. Hospital Construction and Management. M. Tenon's Proposed Hospital. 265 iron, the kitchen utensils of vvrought-iron, that linen may be washed out by payment, and that the supply of food may be contracted for. " His observation of the hospitals of Paris collectively lead him to a recognition of the fad that the convalescents are in proportion to the total number of sick as 1 to 3, and the wounded as 1 to 5 ; and also that of all these the women are to the men as 1 to 3. These important elements will be useful when considering questions as to the distribution and attribution of beds to the different diseases in hospitals, that it may in future be proposed to ered. lie observes that, generally, the hospitals of Paris are not sufficiently provided with water, whereas it is necessary that they should have an abundance, since it is upon this abundance that the cleanliness and, consequently, the salubrity of the place, and the cure of the sick depends. We think it useful also to mention here a hope of M. Tenon, that the reservoir commenced in the neighbourhood of the hospital of the Valpetriere, having become useless for its purpose, should be immediately filled up; the water stagnates in dry weather, and the exhalations cannot, therefore, but be fatal to the sick of this hospital, besides possibly being noxious to the inhabitants of the capital, when the exhalations are blown about by the winds. “ M. Tenon, having thus first instructed himself by detailed investigations of all the hospitals of Paris, passes to a consideration of the Hotel Dieu, which appears to be the principal object of his work, forming as it does the subject of the third and fourth memoirs, which are much more extended than either of the others. M. Tenon considers separately the buildings of the Hotel Dieu and its dependencies, its furniture, its sick, and its attendants. All these matters contribute their part to the well-being and comfort of the sick, and they form separate articles, each of which being treated with sufficient detail, it is possible to acquire a considerable knowledge as to building and appurtenances of the Hotel Dieu. “ In this examination, M. Tenon finds more to avoid than to imitate ; there is useless multiplication of administrative offices, complication of administration, confusion of the departments, and an improper accumulation of sick in a space too small for the 3,400 patients which the Hotel Dieu accommodates, calculating only four sick per bed,* there are 2,600 in the single building of the Rue de la Bucherie, and on an area of 970 '‘toises" ; the disposition of the staircases is bad, they are without air, and are infeded ; the rise of the steps, although sufficient for healthy people, is not correct for convalescents ; there are double wards where the air is renewed with difficulty ; large quantities of combustible materials are placed under the wards. No ambulatories are provided for the convalescents, at least, there is but one for men, and this for all maladies. Women are unprovided with this important assistance towards the cure of their complaints. We will not enter into the details of the article which treats of the furniture, and we will only repeat a curious and interesting extrad as to the inconvenience of placing three, four, and six patients in the same bed ; the physical causes, from which the danger and sickness of the patient result, are developed thereby, and this result which has been inferred from an extract in the first report of the committee is known to the Academy. We hasten to pass to the article which deals with the sick. M. Tenon remarks, first of all, in comparing the Hotel Dieu with various other hospitals, that it is the only one where the number of the wards is so small in comparison with the number of the sick ; the result being that each ward contains too many patients, and M. Tenon protests with reason against this abuse; he comes to the conclusion that it is absolutely necessary to so multiply the number of the wards, that each should contain a moderate number only of sick. M. Tenon devotes himself next to the dimensions of the wards, and shews that their length is regulated by the number of the beds, and their width by the eighth of a man, from which it results that for two rows of beds, the width of the wards must be 25 " pieds " ; lastly, that their height is regulated by the class of patient. Inflammatory diseases require high rooms ; old or debilitated people who require warmth must have rooms less lofty. M. Tenon has devised a means of comparison in this resped of wards one with the other ; it is to consider the quantity of air each patient has to respire, and its circulation and renewal. The Hotel Dieu in confounding all the departments, and bringing together all classes of diseases, develops the cause of a frightful mortality, and has shewn M. Tenon the * It will be observed that at page 1 51 reference is made to M. Husson's work. '• litudes sur les Hopitaux," where doubt is thrown upon the assertion that four, six, and more patients laid in this hospital in the same bed, because “ nothing in the archives justifies such an assertion," and that the •• Memoire of the Physicians of the Hotel Dieu, presented in 1756, makes no allusion to the circumstance, although a description of the form of the beds occupies a large share of the report," but here we have the testimony of M. Tenon, confirmed by his colleagues in the year 1787, that the average minimum number of patients to each bed was four. 266 M. Tenon's Proposed Hospital. necessity for the classification of these diseases, and for their separation as much as possible. There are above all, in the Hotel Dieu, six classes which should be separated in a well-ordered hospital ; those who are attacked with contagious diseases, lunatics, ordinary sick, wounded, pregnant or lying-in women, and the convalescent. It would be desirable to determine from a large number of sick, such as that of the Hotel Dieu, the relation of the number affefted by these different maladies to the sum total of the inmates; but the registers of the Hotel Dieu were unattainable by M. Tenon, as they were by the Commission of the Academy. M. Tenon, nevertheless, considers he may believe that there are 130 small-pox cases at times of overcrowding in the Hotel Dieu ; and it is useful to know that he desires the small-pox cases to be for ever separated from the other sick, and that he considers those attacked by measles should also be separated. Itch is again an important malady at the Hotel Dieu ; the Hotel Dieu gives it and does not cure it, since it refuses those who have it without another accompanying malady. M. Tenon believes that as many as 1,200 is the number of those, both sick and attendants, who are thus attacked ; he thinks also that scorbutic, scrofulous and cancerous patients should be separated from the other sick ; they are, in fact, at the Hotel Dieu, for they are all such patients as are sent to Saint Louis. M. Tenon proposes also to separate malignant fever and dysentery cases. ‘‘The lunatics are an important department at the Hotel Dieu, for it is the only place in Paris where they are treated. This establishment is necessary, not only for the poor, but for those who, without being absolutely poor, are not in good enough circumstances to undergo an expensive treatment. M. Tenon takes notice of the necessity for a separate room for violent patients, in order that cases of hydrophobia may not be confounded with madness, as is the case at the Hotel Dieu ; but the two most important articles are those on the wounded and lying-in women ; these two departments are numerous. The State has the greatest interest in caring for individuals in good health but wounded by accident, and mothers in the flower of their age, both of which renew the population. These two subjedts have been treated by M. Tenon with a care proportionate to their importance. He remarks and proves that every thiing which is essential to the wounded — pure air, cleanliness, and quiet— are wanting at the Hotel Dieu. He asks that the wards for the wounded shall be well ventilated, kept clean, separated from any bad odours, and preserved from the noise of the house and the street traffic. He asks for wards for inmates in preparation for operation, wards to carry out the operation, and wards to achieve the cure. By these means more wounded may be cured in a hospital, and the State thus preserve a large number. As for the lying-in cases, we will not repeat here the table which the notes and observations of M. Tenon (of which this memoir is the result) have enabled' us to trace in this report to the Academy ; we have shewn to us the confusion of all the parts of this department — the want of air, damp, and all other causes of danger which threaten the lying-in cases. There are some curious fads concerning the number of Caesarian operations and laborious accouchments ; but these have already been given in the report. We could not then say any- thing on the mortality which is the result of the bad arrangement of the Hotel Dieu ; we did not have the abstradl of the registers. M. Tenon has procured it, and it goes over a period of eleven years. The result is to shew that whilst the mortality of the British hospital is 1 in 51 that of the Hotel Dieu is 1 in 15® ; a frightful mortality, and which alone would necessitate the reform of the Hotel Dieu ; for it is as well to observe that it is not a question either of a period of epidemic, or where puerperal fever makes ravages. The mortality in these cases has often been half, and sometimes 19 out of 20. M. Tenon, to remedy this mortality, proposes to entirely separate lying-in cases from the other sick— above all from the wounded ; to put a smaller number in the same wards ; to ventilate these wards ; to shelter them from damp and noise ; to separate healthy pregnant women from unhealthy; and, for the sake of morality, prostitutes from poor and honest women. " M. Tenon again asks that there should be a room or the patients to work in whilst waiting delivery, and a private promenade where those who desire it may retire and not be seen. M. Tenon then passes on to the convalescent, who require great care in a hospital, as much from their number (about one-third of the sick) as from the necessity of completing their cure, and also to avoid anything which may cause a relapse, or otherwise retard their complete cure. M. Tenon asks for them open promenades, with covered ones in bad weather ; he desires to see them lodged on the ground floor and that they should descend to their walks by gentle slopes, to save the stepping up and down of those with weak legs. He desires them to be well clothed, as at the Charite, and he proposes that they should have gentle exercise to hasten the return of their strength. Above all he recommends that the different species of convalescents should be separated — small pox, itch, and all those recovering from contagious diseases. They should have their own separate promenades, and even their own wards, M . Tenon's Proposed Hospital . 267 " We had already announced this work in the report which we have made on the aAual state of the Hotel Dieu. We then said that we would not enter into an infinity of the details which the salubrity and the cleanliness of the hospital and the care of the sick might demand, because these details were included in the work which one of us, M. Tenon, had communicated to us, and which he had the immediate intention to publish. It is the fruit of a twenty years’ study of hospitals that the committee had charged M. Tenon to publish. We then announced that this work would be useful both to the architect charged with the construAion of a hospital and to the administrator who would govern it. What we said on a first examination we repeat to-day after a deeper one. The memoirs and the observations which M. Tenon has communicated to us have supplied the information we required concerning the Hotel Dieu. The Academy, in the account we have just rendered, may recognise several of the elements of our report. This knowledge, which has been useful to the Academy in forming a judgment on the projeA for new hospitals, will be equally useful to those who propose to construA them. We look upon this work as the most profound and the most complete of its kind, and we believe it deserves the approbation of the Academy and to be printed under its privilege. V At the Louvre, September 5, 1787, Lassone, Tillet, Laplace, Daubentar, Darcet, Coulomb, Lavoisier, Bailly. “ I certify the present extraA to be conformable with the original and the judgment of the Academy at Paris, September 7, 1787. “The Marquis de Cardorcet.’’ As a further exemplification of the views laid down in the memoirs referred to, M. Tenon gives a plan shewing how he would arrange a hospital for 100 inmates. This plan is illustrated at page 264, and the following is his explanation of its principal features : — Entrance. — The entrance in the centre of the front block is the only one to the establishment ; this is insisted on by M. Tenon as a proper arrangement for all hospitals, in order that there may be one porter responsible for every person or thing entering or leaving the establishment. The vestibule, as will be seen, is very large. Offices of the Governing Body. — Above this entrance are the offices of the governing body of the hospital, consisting of two ante-chambers, clerks’ office, board room, private room, room for the archives, and a treasury. These are approached at either end by the two staircases shewn on plan, and are on the first floor above the entrance and between the two staircases. Officers' Apartments. — On the second floor, above these offices, are the steward’s rooms and the apartments of the various officers and attendants, whose duties would be in this front building. Porter's Rooms. — On the right hand side of the vestibule is the porter’s office and night room. Waiting Room. — On the left hand side is the waiting room for the sick and their friends, with benches around, and warmed by a stove, which also supplies warmth to the doctors’ consulting room. Doctors' Room. — Adjoining this waiting room is a doctors’ room, where all the patients are seen on their entry, and where persons found either drunk or insensible in the night would be brought to be seen by a dotftor, who should always be in attendance. Receiving Room.- — This room, which adjoins the doctors’ room, would have two counters, one for registering the name and other particulars of the patient admitted, and the other for registering their portable property, which would be deposited in a strong room under the staircase. 268 M. Tenon's Proposed Hospital. Dressing Room. — This room, leading out of the last, is for the purpose of clothing the admitted patients, and preparing them for admission to their allotted ward. Bath Room. — Adjoining is a hath room, with two baths and linen closets for bathing the patients. Hot water would be supplied by a stove placed in the undressing room. It should be observed that there are wide doors exactly opposite one another in all these reception rooms, in order that a patient on a litter may be carried through without much disturbance. Disinfection Chambers. — The disinfection chamber is furnished in one part with a stove for burning sulphur, and a vaulted room adjoins it with racks for placing clothes containing vermin, or contagious miasmas, and exposing them to the vapour of the sulphur. Inmates' Clothing Store. — All the clothing of the patients during their sojourn in the hospital would be taken from them, cleaned, and disinfeefted, and placed in this room, which is entered from the left hand corridor. It should be provided with numbered lockers, each about 2 feet wide, 2 feet deep, and 20 inches high ; they should be quite open on racks, and not above arm’s reach. The windows should be glazed, the sashes and skylights being closed in warm and opened in cold weather. M. Tenon gives his reasons for this, as follows : — " These precautions are necessary to guard against moths and dormestidue, voracious insects which swarm in a temperature of 5 degrees of heat, and certain species of which devour animal substances, particularly w-oollen stuffs ; the least clean woollen stuffs, stuffs v'hich are least woven, those of a velvety nature, those but slightly dyed, are in general more exposed to the voracity of these insedts. " The laying time of moths is, in our (the French) climate, during April, May, June and July, and during these seasons most care should be taken of the clothes of the poor, inasmuch as these give out bad odours. The clothing store is one of the unclean departments of a hospital, and this is why I have put it at a distance from the sick wards ; and for convenience of service it is placed in the neighbourhood of the undressing room and the disinfection room Nothing better is known, in the second hand clothing shops of Paris, where quantities of old clothes are stored, than the practice of opening each packet once every fortnight during summer, brushing gently and then refolding them." Attendants' Dining Hall. — On the right hand side of the entrance is the dining hall for the attendants. Officers Dining Hall. — Adjoining the above is the dining hall for the medical students and upper officers generally. Room for Drunkards. — Beyond the right hand staircase there is a room for keeping drunken and other non-sick patients found during the night, until they are restored to their families. Dead House. — Adjoining the above are two dead-houses. Officers' W.C.'s . — At the ends of the corridors of this first block are w.c.’s, &c., for the use of the attendants and officers. Steam and Fire Pump Shed. — Leading out of the right hand corridor is a shed for containing a covered bier and a pump and buckets for extinguishing fire. Workshop. — At the extreme left end of the first block is a workshop. Laundry. — At the extreme right end is a laundry, for use in winter. Wood and Coal Store. — In the large courtyard on the left, and on the top left hand corner, is a large wood and coal store. M. Tenon's Proposed Hospital. 269 Bed Clothes Shed. — In the large courtyard on the right and in the top right hand corner are sheds for beating and airing the bed clothes, &c. M. Tenon says that those simply charged with dust should be beaten every fortnight in the yard and exposed to the air, and that those charged with vermin or contagious miasmas should be first washed in potash and water, say about 1 lb. to a mattress. Sick Ward Block. — M. Tenon considers it indispensable in cold and damp countries that this block should be raised three or four feet out of the ground and built on vaults. Kitchen. — The kitchen, as shewn on the ground plan, is in the left hand wing, and in the basement would be the scullery and the stores. Dispensary. — On the ground floor of the right hand wing, and in a similar position to that of the kitchen, is the dispensary and laboratory. At the entrance is a place for the distribution of medicines, surrounded with tables to contain the numbered baskets from the sick wards. At the back is a proper laboratory for preparing medicines, washing bottles, &c., and stores would be provided in the basement. The tisane is here prepared in an apparatus consisting of two tanks of lead, with a pipe leading into the corridors and furnished with taps for drawing off at will. Principal Sick Wards. — One of the two wards on the ground floor is for men and the other for women. Each is of parallelogram shape, contains 24 beds, and, as shewn by the drawings, is 98 feet long and 28 feet wide. The total superficial floor space is, therefore, 2,744 feet, or IJ 4 feet per bed; the cubic contents cannot be stated, as no section is shewn. The average lineal wall space is 8 feet 2 inches per bed. The ward is warmed by a stove placed in the centre against the front wall, and at the back there is a horse for wanning the linen of the patients. The small cabinet shewn in the centre of the ward is for a night nurse, and on either side are tables with cupboards under. Oratory. — Between these two ground floor wards is an oratory for the use of the sick. Other Sick Wards. — On the first floor these wards are split up into five, three being for women, and two for men ; the first women’s ward is for fever cases, the second for wounded, and the third for operation cases ; the first men’s ward is for wounded, and the second for operation cases. Operation Room. — In the centre, over the oratory, is the operating room. Sisters' Room. — The second floor is divided into various wards for the use of the sisters. Staircases. — These, as designed by M. Tenon, are in three flights, with two landings provided with seats, both sides are hand-railed; the steps are 10 feet long, 14 inches wide and 4 inches high. Water Supply. — Above the staircases are two large reservoirs to hold water. W.C.'s, &>c. — These are approached by a lobby with double doors : there are two water-closet seats, with a leaden trough underneath and a water tap and waste leading into the lead down pipe from the upper w.c.’s. The slop sink is formed of a slab of hollowed stone covered with lead, with water tap and waste to the leaden down pipe ; it is covered with a wood seat, and used for emptying chambers, &c. The urinal is a long trough of hollowed stone covered with lead, and laid to slope to the down pipe ; it is provided with a water tap, and the wall at the back is dressed 4 feet high with lead. There is also a U 2JO M. Tenon's Proposed Hospital. sink to take the drainage of the floor, which is covered with “ Canigou,” and laid to fall towards this sink. Stores . — At the ends of the wards there are closets for fuel, bed linen, and general ward stores. Lavatory . — This room, called by M. Tenon, “ Recuroir,” is approached from a lobby, and contains several sinks for washing purposes, constructed of stone lined with lead. It also has a grating for drying the utensils over a fire after washing. Ward Laundry . — Adjoining the “ Recuroir” last described, is a room which M. Tenon would devote to the washing of the ward linen immediately after its removal from the patient, it being considered desirable that the linen from one class of patients should not be intermixed with that of another, as is the case when a general laundry is provided for the purposes of the whole establishment. A lift is shewn in one corner of this room for raising the articles when washed to the attic floor, where means would be provided for Day Rooms . — Above the kitchen and dispensary are the day rooms, which, together with the very large vestibules and lobbies, give ample space for convalescent patients. drying, &c. Hospital Construction and Management ( 27T ) TAKHTSINGJI HOSPITAL. BHAVNAGAR, INDIA. The more modern hospitals of India have generally been erecfted from designs prepared by the military authorities or by Government engineers. In some few instances, however, architects in England have been commissioned to prepare the designs, but the erection of the buildings has nearly always been entrusted to local authorities. Such was the case with the Takhtsingji Hospital, illustrated upon the accompanying plates. This building was designed by Mr. W. Emerson, to whom I am indebted for the following brief particulars. Its erection was superintended by Mr. R. Proctor-Sims, Executive Engineer of the Bhavnagar State. The foundation stone was laid January 1879, by His Highness the Thakore Sahib, on the day of his coming of age. This prince is one of the most popular, as well as advanced, of the native Indian rulers. An account of the building, written by the architect during its erection, states that “ It was desired that the design should depart from the Mahometan type of Indian architecture, which has been adopted in so many of the modern Indian buildings, and a more Hindoo feeling introduced — a somewhat difficult thing to accomplish, as the Mahometan pointed arch lends itself so naturally to the verandah requirements. For this reason the lower tier of openings has square columns and corbelling. In the upper tier, instead of horseshoe arches, an arcade of a sort of cusped arch is introduced, mainly because it was desired that the building should be elaborate in carved work, and the spandrils of the arches seemed the most suited for enrichment, following many good examples of the transition period. The balusters, some 800 in number, will be sent from England, cast in Portland cement concrete, colored to match the stone of which the hospital is being built. These are being made by Mr. W. H. Lascelles ; and also the dome, which is of peculiar construcftion, with ribs, forming a sort of fixed centreing, on which the roofing slabs will be laid — the ribs and lower rings of the slabs being of concrete as heavy as Portland stone, the upper rings and lantern with lions of similar material but as light as pumice stone. The whole building, except the roof timbers, will be fireproof.” Site . — The building stands upon one of the most elevated parts of Bhavnagar, overlooking the town on the north and north-east of the site. A number of small hills, rising about 80 or 90 feet above the plain, are ranged at a distance of about a quarter of a mile. The site had no defined boundary at the time these particulars were taken, so that the area cannot be stated. General Arrangement . — The building consists of two blocks, connected together by a long corridor ; the front block being devoted to the patients, and that in the rear to the administrative department. The patients’ block consists of a double pavilion, having, Takhtsingji Hospital. 272 on the ground floor, a large central entrance-hall and staircase, store rooms, dispensary and waiting room ; also one sick ward for 14 ordinary patients, and another for 6 patients suffering from contagious diseases. The bath rooms, lavatories, and water-closets are placed in towers at the four angles of the building ; they are completely isolated from the wards, and are reached by passing along the open verandahs surrounding the building on each floor. The upper storey contains one ward for 18 beds and five separation wards for 1 patient each, and, although the building is intended principally for the accommodation of male patients, there is an additional ward on this floor for the reception of 10 female patients. An operation room is placed over the entrance-porch. The rear block of buildings contain the officers’ quarters, with separate kitchens for Hindoos and Mahometans, a wash-house, and laundry. The mortuary is placed near to one of the gates giving access to the ground. Total Accommodation . — The total number of patients provided for is 53, in four wards, containing respectively 18, 14, 10, and 6 beds each, and five wards with 1 bed in each. Connecting Corridor. — The corridor connecting the front pavilion with the administrative buildings in the rear is 6 feet 6 inches wide and 10 feet high ; it is 3 feet 9 inches below the level of the principal or ground floor. Principal Sick Ward. The following description of the largest ward will sufficiently explain the general arrangement for the accommodation of the patients. Aspect . — The axis of the front pavilion building runs from N.E. to S.W., so that the windows of the wards face N.W. and S.E. Size of Ward . — The wards generally are of parallelogram shape, and the one under description contains 18 beds. Its extreme length is 77 feet, its width 25 feet, and its height 15 feet 6 inches, so that the superficial floor space is 1,925 feet, or about 107 feet per bed, and the cubic contents 29,838 feet, or 1,658 feet per bed. Bed Space . — The average lineal wall space per bed is 8 feet 6 inches. Windows . — All the windows open on to the verandah, and are double folding casements or doors, 14 feet high. The outer casements open towards the verandah, and their panels are filled in with deal louvres, the opening or closing of which can be regulated at pleasure. The inner casements open inwards, and are glazed in the ordinary manner. The total effective glazed surface of those next the beds is 264 superficial feet, or about 14! feet per bed, but, if the end window be added, the glazed surface per bed is 15^ feet. When all the windows next the beds are opened to their fullest extent the total area through which air can be admitted by them into the room is 860 feet, or 47I feet per bed, but, if the end window be added, this area is increased to 5of feet per bed. Warming and Ventilation. — No means of warming are requisite, and the ventilation is effected solely by the opening and closing of the windows. Walls and Floors. — The walls are generally 2 feet in thickness, the external faces being of red sandstone. The floors are constructed with rolled iron joists and concrete, and the surfaces finished with tiles. W.C.'s, Baths, &>c. — The water-closets are each 6 feet 3 inches long and 3 feet 9 inches wide. No drainage from them is provided, moveable pans being employed, and Hospital Construction and Management. •Tcrtehtsino ji : Hospital • Bhau nttoar • • Ind i S.E. ,, Antwerp 30 7 6 IOC 1.346 1763 19*70 21*10 2153 20 9 0 149 2.525 2835 40*60 Heidelberg (Surgical), one-storied ... 16 6 5 94 1.638 1250 16*75 15-00 2093 ,, (Medical), ,, 14 6 7 97 1,689 14*28 19*14 1714 2393 ,, fSurgical), four-storied ... ,, (Medical), ,, 9 11 8 7 2 2 137 129 2,050 1,909 Berlin Civil (Surgical and Medical), upper floor ... 28 6 II 108 2,076 23 35 24*36 Berlin Civil (Medical lower floor) ... 28 6 II 108 1,722 Berlin Military, blocks P P ... 16 6 c 93 1.273 2250 2344 Dresden 24 7 I 1 19 2,038 Strasburg (pavilions) 16 6 IO 99 1.363 Moabite 28 6 2 69 864 ii‘i8 1525 17*32 Halle (Medical) 16 9 2 135 2.033 1650 IQOO ,, (Surgical) 24 9 6 I4O 2,207 2600 32*00 Lariboisiere, 2nd floor 32 7 IO 115 1,850 1491 20*66 ,, ist floor 32 7 IO 115 1,850 1613 22*66 ,, ground floor Hotel Dieu, 2nd floor 32 7 IO 115 1.965 1703 23*69 24 8 4 125 2,222 1592 1808 21*92 24 33 ,, ist floor ... 24 8 4 125 2,254 1842 20*67 24 79 27*29 „ ground floor Tenon (Menilmontant), ist and 2nd 24 8 4 125 2,411 1963 21*92 25*79 28*33 floor 22 7 0 I0 7 1,816 1764 26*64 Tenon (Menilmontant), ground floor 22 7 0 107 2,030 1905 28*37 St. Denis 16 8 2 1 12 2,457 25 37 ... 3856 Bichat 24 7 3 107 2,205 1575 20*50 Bourges (Military) 28 6 II 85 ! 1.693 St. Eloi 28 7 2 108 2,328 i 6'57 2075 Amersfoort (Military) 12 6 4 83 1.538 15-25 28*65 Genoa 20 7 II no 2.544 21-75 ! Riga 28 5 9 86 1,522 St. Petersburg IO 7 6 99 1,902 28*00 14*63 Johns Hopkins, U.S.A. 24 7 7 105 1,675 2142 II 17 28o Summaries Table No. 3. Shewing the average area and cubical contents per bed of the separation wards and the Name of Building. Separation Wards. Day Rooms. Name of Building. Separation Wards. Day Rooms. Average Area per Bed. Average Cubic Contents per Bed. Average Area per Patient. Average Area per Bed. Average Cubic Contents per Bed. Average Area per Patient. feet. feet. feet. feet. feet. feet. Blackburn 152 2.432 Strasburg (pavilions) ... 93 1,272 25-25 St. Thomas' 120 1,800 ,, (central block) 103 1.578 12 OO Edinburgh 162 2,268 17*00 Halle (Medical) ... >75 2.159 Glasgow 141 2,115 Lariboisiere 106 1. 731 9-48 Norfolk and Norwich ... 122 1,701 Hotel Dieu 1 1 2 2.159 21 08 St. Marylebone IOO 1,300 964 Tenon (Menilmontant) ... III 1,892 9- 80 St. George’s Union 76 994 IO92 St. Denis 1363 Hull General Infirmary Il6 1,624 Bichat ... ”4 1,368 Antwerp 133 2,050 Bourges (Military) 140 2,000 5 00 Heidelberg (Surgical) ... 81 1,288 2166 St. Eloi ... 129 1,680 ,, (Medical) ... 2475 Amersfoort (Military) ... 88 1,408 1 Berlin Civil (Surgical) ... 154 1.783 2064 Genoa l 6 l 2,898 4690 ,, (Medical) ... 122 1,508 24*00 Riga J 54 1,845 1275 BerlinMilitary (blocks PP) 90 1.232 1425 Johns Hopkins, U.S.A. ... 135 1,890 13 75 Section III. Organization of Medical Relief in the Metropolis. BY FREDERIC J. MOUAT, M.D., F.R.C.S. Organization of Medical Relief in the Metropolis. There are few problems connected with the unprecedented growth and government of London as a whole, that are more complex in character, more encumbered by conditions of life of which little that is certain is known, and, in consequence, more difficult of solution, than that of the relief of the sick poor of an aggregation of human beings on a restricted area, such as the world has never before seen. Within a limit of 125 square miles, with a pressure of population of 30,718 to each square mile, or 50-8 to an acre, is contained the people of a kingdom. They comprise every caste, class, and almost race and condition of life, from unbounded wealth and luxury, down to some of the most squalid objects of misery, destitution, and suffering to be found on the face of the globe. To consider the question in all its branches, it is necessary to disintegrate this mass of humanity into its constituent parts, to ascertain for which portions public relief in sickness is really required. According to the last Census Report, as to Nationality there were, in whole numbers, 50.000 Scotch, 80,000 Irish, and 60,000 European foreigners, with some 4,000 or 5,000 from America, Asia, and Africa, dwelling in London, the remainder of the inhabitants, constituting the bulk of the population, being English. With respect to occupation, the numbers of the domestic, commercial, and industrial classes are overwhelming. In the minor professional class were 1,147 males, and 177 females; in domestic services there were 60,850 males and 320,838 females ; engaged in commerce were 264,957 males and 4,935 females; in employments connected with agriculture, 21,920 males and 910 females; and in the great industrial class were 677,682 males and 224,867 females, making a grand total of 1,026,560 males and 551,727 females. Of the first and three last-named classes a considerable proportion are representatives of capital and employers of labour, of whom the exacft details are not given in the Census return. They probably represent at least 10 per cent, of the whole, and these are all in circumstances beyond the need of gratuitous hospital aid in sickness. The vast majority are wage-earners, more liable than those better off to disease, accidents, and injuries from their surroundings and occupations, and their more or less precarious means of subsistence. In addition to the above — exclusive of the great professional class, numbering about 128.000 men and 41,000 women — of persons of no specified occupations, and returned as J3 B 2 4 Organization of Medical Relief in the Metropolis. of properly and rank, there were 431,193 males and 1,117,346 females, a disproportion well deserving of careful inquiry. They do not fall within the scope of my contention. And last of all were 248,619 hoys and 248,425 girls — in all close upon half a million — under five years of age, or nearly an eighth of the whole population. Of these children 148 per 1,000 die under one year of age, and the greater part of this loss of life is among the children of the poor and wage-earning classes, to whom again the larger portion of the half-million of children belong. For the care of the sick and injured of all the above classes, and of the remainder or the professional and all other classes, there were 3,705 male and 10 female medical practitioners; 1,122 dentists, all men ; 2,391 male medical students and assistants and 40 females of the same class, with 307 midwives; and, in subordinate medical work, including nursing, 421 males and 10,176 females. This is irrespective of the number of quacks of all complexions who prey upon the wealthier members of the community, but who may be disregarded in the present argument. Among the causes influencing the health of this extraordinary and heterogenous community, there is perhaps no more potent faeftor than the manner in which verj r large numbers of the poor are housed ; and yet, even regarding this state, which is comparatively so easy to ascertain with some approach to mathematical accuracy, we are absolutely without trustworthy information. Lord Salisbury, in his recent endeavour to solve the question, remarks that the State, having samftioned improvements which cause congestion, is bound to relieve this bj' intervening directly in its removal. He adds, “ The difficulty is greatly aggravated by the entire absence of accurate information on the subjeift. Statistics on this point are absolutely silent. That London is overcrowded we know, and that the ill effetffs of overcrowding on health and character are very terrible. But we do not know even approximately the number of the sufferers, where they live, or what they earn. How are we to judge of the measures required to remove this evil if we have no notion of its extent or how far it is the offspring of mere poverty ;” and he concludes that “ it ought to be within the means of our central or local authorities to throw light upon the circumstances and conditions of the hardships to which a vast number of the inhabitants of London are probably exposed — hardship which is known to be acute and is believed to be growing.” * If this be so, and it is in truth beyond the reach of doubt or denial with respect to the mere physical facts, which an efficient government of London could readily ascertain, inasmuch as it presents no scientific difficulty and deals with no recondite conditions, how immeasurably is the difficulty increased in relation to the causation and incidence of sickness. Herein enter a multitude of conditions which are only imperfe— 2 I 0 .2 O' 00 l O' b M IO I in O' d M Lx m b> b m t-x. O' O' m b m c X DO m b *-4 O O' i.L z.L DO 6 m tx O' HI M m O' Ratio per ccnl deaths to Hospital popula 00 IX. CO m M m O' •n c X c b m O' m O' b rx b m O' x in b HI X X tx d M in O' fx N CO m b w d n* ON C> O »n Ci 0 Cl X b Lx O' O' b m b O' b M in m tx in d M tx 00 O' b HI tx O' m 0 O' m vO vO Lx M m m O' O lO m m M m Lx M O' m m in O d O' CO* ►H in in 1-1 •-« P, M m X Lx 0 0 Lx M X O 0 m X m X X O' m x Lx m G\ in O' O 1 ' Lx X m m O' 5 5 r HH in *h in N NT m *-< m ►1 H g 5. 0 m vO rx X O in N vO 0 rx in O M X 2 rx m Tf- VO lO Q t-x -f 'T X O' i-i O O tx HI in O cs m »-• m *"* m — m 10 Lx lO Lx M vO m O' X m d d 0 X O X i/i m *~i 0 M M m n s C4 m m d m ►H T L 0 lO L. O' d O' tx in d tx d M ■0 oo‘ O O Lx Lx m c bx m O' T *H d HI m cs 10 «/•; m d m H . Q 0 O m i-i m X 0 m m X vO X m 1 rx Ci Lx ft Lx iO N Lx d Lx NT l-l m C<) d -=r O' M m *0 0 5’ ’ O O n m n O in (s in *t- m O ^ l o ^f MO lO W d_ NfO N rr Tt* m in C'T >n m o O X m o in d m m tx tx .. m tx d lOdtxdlXMdvOdmd m O' fo n minx H rj- L O L CO 00 in L lO 00 m rf- m in H Tf f'l H 3 m X in G O' 0 d O' 0 -l d c 0 d x _L 00 m mm-i--. O O' O O O d m co in in vO *-*_ •-T t h vo in m O' *-• cc l«» in in n ► in O' ci o_ cc ►h ^ m *- Oi (MO 00 mm o O hi O O' d O X d tx vO m Received during the year. O' X 00 00 tx O' m O' - tx O Ovo ^ Lx md^- m O' rj- 00 x d hi 'H m d c vo hi »-i 1^ x c ^ ox Hixxxxvox txHi mtxd txLxd i _7 in hi in d’ in m d m hi hi d m m <5 m . CO X 00 xo tx x h 00 mo m d vo Lx 0 x x vo tx m vo txm^rm-r'rmmxo x 0 d vo x m O' x tj- 0 q w l q p} 0 d ^ Lx d m ++ in m vo d in m d m m d vO HI O' m X X 00 0 mu-iN t »i n h 0 2 -2''2. I £ a ,0 ft. ro ov d d d Cii-ivO i“i ^Ld C 1 tx 1/ 1 8 )^ OO S to O N H ^ {) 't 00 IN ® f' H m M ' 10 m to’ ti t »i N m M . tx d d_ tx m Remaining in Hospital on xst January. O' X 00 r\ rr> i^O O i-i N t M » O H 3 m hi in hi m d^mr-irnM hi X X. m CO X CO OD -J-rONtO N 00 O O N !S S S' JJSS 10 ® S 0 '" 2 2 d d vO m X X 00 2 a 2"£,c§ J? « § 3. S' & 2 +- X O' in m cu £ o l-l fa > > 6 m ° <3 ^ H G 0 ) r. O ^ n •? H P rt .ti >> o o- o rt O H w d g .tj ° S5oc 5 o 5 )c 75 ^S^c 3 ^ d Ut Sn .•G G a. c >> 3 T. x d © « * v £ •5 c z rt •a 8 £ 2 rt h d G 4>* e *9 a fa £ o £ T3 v V & W x: -c 3 T; o *> S qj *■* u —• cu d CO •-? a) O. 10 G O x; T 3 r • > ■ i 1 Hilt ..WEST HAM H 6 x : PLAISTOW BETH NAS iiWehouse Siam VnOTTINC HILl ACTON VAI SHEPHERDS?/ 8 USh" 0 '| VICTOnIB OOC* sir fix ton \ 2 + S0U ^ H 0,S0 /r!m^ >K CREEfC hsi.i: riotf'Z ▼ iERMONDSfcj R OTHER H \Tp5r* * n Jl ABBEYWOC JRHHAM GREEN CHISWICK CASTELHAU iRLTON KENN1 Nct^N* ?tC KHAMK£jv r I NORTH BRLXli \RSpNS CR. f EAST WICKHAM r BARNES BI/AC K H I J TRAH()Ull.>M iMORTLAKE STOCKV.ELL- »ULHAM HUNHEAt WELLINC SELL CROVE v+ xxm EAST SKEEN BJi I X T O N, PUTNEY ait crest' I ^uw lev/v$hI\m WANDSWORT^- WESTMIU SOUTH END 10TTINCHAM 'CApRATT tALEWAY STREET; jtnev vale. /UPPH^YDEWIAM tsrttio* SIDCUJP ( ^OWER TOOTING LOWER $Y ★ xxxvm rows CRAY UPPER NORWOOD , NEW WI#LEOOir MERTON PENCE y HEW SWfflii BROMLEY ^TBECKLNHAI iRE^IfflRATlON DISTRICT BROMLEY new maiden WIOMORE ( 47 ) C ONCLUSION. W E now present our work to the benevolent public, and to the professions most intimately associated with the relief of sickness and injuries in hospitals. We believe it to represent fairly the present state of the question in its medical and architectural aspects, without pretending to be exhaustive in either. 1 he progress of science is so rapid, the mechanical and other means of dealing with its discoveries are so numerous, and the views of the exponents of the one, and the active agents of the other are so constantly changing and advancing, as to render it well nigh impossible at any given time, to represent the actual state of either the science or the art of hospital construction and arrangements. Among the criticisms of the first part of our work to which we have given attention, a request has been preferred, that we should formulate our own views and opinions on each of the questions treated, and draw up rules for the guidance of the authorities engaged in providing new, or re-modelling old institutions for the successful treatment of the sick and afflicted. This would demand a more profound study of the whole question than the time at our disposal, at present, admits of. But, should the demand for the work in its complete form induce us to believe that an addition of this nature would increase its usefulness and value, we shall be happy to comply with the request in a supplement, reviewing the subjeCt carefully in the sense desired. In the meantime we trust that the index and illustrations will enable all inquirers easily to find the information they desire, on each of the details of hospital construction and management, which they are in search of. The only classes of hospitals of which illustrations have not been given, are fever and convalescent hospitals. These are in a transition state, and the views regarding them are still to a great extent matters of speculation and discussion. We have, in consequence, had so much difficulty in fixing upon types that fulfil all the conditions required, as to induce us to leave them in abeyance for the present. Should, however, another edition of the work be called for, we shall endeavour to supply the want as far as pra&icable. ■ ' ( 49 ) GENERAL INDEX. The Roman figures i, ii, iii, refer to the various Sections into which the Booh is divided. ABBATOIRS used as Hs., i, 35. Accident Hs. in London, Number of beds in, iii, 12. Accommodation in various Hs., ii, 5, 13, 18, 26, 36, 45. 54. 59. 78, 83, 93, 103, 1 17, 125, 126, 127, 128, 130, 132, 138, 143, 164, 170, 177, 183, 188, 193, 199, 201, 207, 214, 221, 233, 237, 242, 250, 259, 272. ,, in Hs. in England and Wales, iii, 5, 6. ,, Insufficiency of, in London Hs., iii, 14. ,, required in London Hs., iii, 15. ,, Dr. Buckle on, iii, 15. ,, Dr. Oppert on, iii, 15. Accounts and Finance, iii, 22. Administrative Departments, i, 41, 48, 54, 56, 57 ; ii, 4, 12, 17, 25, 34, 44, 53, 59, 60, 82, 91. 101, 1 16, 125, 126, 127, 128, 137, 142, 162, 168, 174, 177, 182, 187, 191, 199, 200, 206, 213, 222, 232, 238, 248, 258. 267, 271. Admission, French rules for, iii, 39. Aeration, Dr. Layet on Co-efficients of, i, 25, 78. ,, Table of Co-efficients of, i, 26, 78. ,, Zone of, i, 21, 23. ■Aggregation of Patients, Danger of to Neighbourhood, i. 36. M ,, Sir Wm. Blizard and Dr. Rumsey on, i, 36. ,, I, limit of, i, 33, 36. „ 1, Trelat on, i, 33. Air, Contamination of, by one person, i, 25, 28. ,, horizontal currents of, i, 21. ,, purification of, by earth containing organic matter, i, 30. ,, ratio of contamination of to number of people, i, 25, 28. Air space required for each patient, i, 36 ; ii, 175. Airing Yards, ii, 75. Alteration of Old Hs. ( see Old Hs.). American Hs. (see Johns Hopkins H . and New York H.). Amersfoort H., Holland, general description, ii, 200. n „ the sick wards and their offices, ii, 201, 202, 204. M ,, ,, Summary of, ii, 278, 279, 280. ,, „ elevation (plate), ii, 200. M „ ., plans and sections (plate), ii, 202. Anatomical Institute, ii, 213. Anatomical Museum, ii, 213, 232. Annular Wards, ii, 87, 275. proposed by Burdon Sanderson, ii, 87. 274- Ante Room, ii, 218. Antwerp Civil H., general description, i, 55; ii 79. ,, ,, the sick wards and their offices, ii, 84. ,, ,, Commission and Report on, i, 57 ; ii, 80. ,, ,, Professor Marshall on, i, 56. ,, ,, Summary of, ii, 278, 279, 280. ,, ,, elevations (plate), ii, 79. ,, „ plans and sedtions (plate), ii, 82. Apothecaries H., Rome, ii, 230. Area covered by H. buildings, ii, 6, 13, 18, 27, 37, 46, 54, 61, 83, 94, 104, 1 19, 125, 126, 127, 128, 138, 139, 140, 144, 150, 164, 171, 174, 178, 183, 188, 193, 201, 207, 214, 223, 233, 238, 250, 260. ,, of Pavilions, ii, 10, 15, 21, 32, 41, 48, 57, 68, 86, 98, iii, 112, 114, 121, 124, 135, 140, 144, 149, 167, 173, 180, 185, 190, 195, 204, 209, 217, 218, 219, 227, 235, 240, 243, 255, 263, 273. ,, of London Registration Districts, Tableof, iii, 11. ,, of London Parishes, Table, iii, 9. „ of Site, i, 41, 55, 78; ii, 3, 12, 16, 25, 33, 44, 53, 58, 78, 82, 91, 101, 115, 125, 126, 127, 128, 129, 137, 142, 162, 168, 176, 182, 187, 191, 198, 200, 206, 210, 220, 231, 238, 241, 248, 258, 271. „ of Site, Summary of, ii, 278. Arrangement of Buildings (see General Arrangement). Artificial ventilation, i, 29, 41 ; ii, 85, 95, 107, 112, 131, 133, 138, 145, 172, 189, 202, 215, 218, 234, 239, 253. Aspect of Principal Wards (see Wards, aspect of). Asylurrts, Poor Law in London, Number of beds in, iii, 14. Attendants’ Dining hall, ii, 268. ,, Rooms, ii, 21, 112, 212. Aural Wards, ii, 212. BAKER'S H., Rome, ii, 230. Baltimore, U.S. (see Johns Hopkins Hospital). Basement Arrangements, i, 51, 57; ii, 200, 210. Basements under sick wards, ii, 10, 13, 15, 21, 32, 41, 48, 67, 86,97, 111.112, 114, 121,123,135, 149, 167, 173, 180, 185, 190, 195,217, 218, 219, 235, 240, 255, 273. „ ,, Precautions as to, ii, 185. Bathing Departments, i, 45 ; ii, 26, 78, 102, 143, 169, 177. 192. Baths, Necessity of, i, 31. „ and w.c.’s, i, 50; ii, 5, 9, 15. 20, 30, 40, 45, 47, 56, 66, 74, 75, 78, 85, 96, 120, 122, 130, 134, 139, 143, 148, 166, 172, 179, 184, 190, 194, 203, 208, 216, 218, 219, 224, 234, 239, 243, 255, 262, 268, 269, 272. General Index. 50 Beaujon H., Paris, Number of beds in the, iii, 5. Bed Clothes Beating Shed, ii, 269. Bed or Wall Space ( see Wards, size of). ,, Cubic contents per ( see Wards, size of). ,, Floor space per ( see Wards, size of). „ Pavilions, area of per (see “ area covered ”). „ Cost of buildings per ( see “ cost ''). ,, Sites covered per ( see “ area covered ”). ,, Window glass per (see windows). ,, Window ventilation per (see windows). Beds at various Hs, Summary of No. of, ii, 278, 279. „ in Hs. in Lcndon parishes, Table of, iii, 9. „ Number of, in London Hs., Summary of, iii, 14. „ Ratio of, in Hs. to the population, Table of, iii, 9. ,, Ratio of, to population in London, iii, 9, 10, 11. ,, Total of in Hs., &c., in London, iii, 9, 14. ,, Total number of, in Hs. in England and Wales outside the Metropolis, iii, 14. Belgian Hs. (see Antwerp Civil H. and Mons Civil H.) Bellevue H., N.Y., Sturges Pavilion of the, i, 55. Berlin Civil H., general description, i, 40, 63 ; ii. 100. „ ,, the sick wards and their offices, i, 41; ii, 104, iii, 112. ,, ,, Summary of, ii, 278, 279, 280. ,, ,, View (plate), ii, 100. ,, ,, isolation pavilion, plan (plate ) ii, 113. ,, ,, plan and sections (plate), i, 42; ii, 102. Berlin Military H., general description, ii, 115. ,, ,, the sick wards and their offices, ii, 120, 121, 124. Summary of, ii, 278, 279, 280. ,, ,, elevations and plans (plate), ii, 115. ,, ,, staircase (plate), ii, 123. ,, ,, Ice House, elevation and plan (plate), ii, 128. Berlin Moabite Barrack H. (see Moabite H.) Bhavnagar H. (see Takhtsingji H.) Bicetre Asylum for Lunatics, Paris, Number of beds in, iii, 5. Bichat H., Paris, general description, ii, 181. ,, ,, the sick wards and their offices, ii, 183. .. 1. Summary of, ii, 278, 279. t. ,, plan and elevations (plate) ii, 181. Billings, Dr. John, on Dr. Sanderson's scheme, ii, 277. n n on Warming and Ventilation, ii, 250, 252. Blackburn Infirmary, general description, ii, 11. 11 .1 the sick wards and their offices, ii, 13- • 1 ii Summary of, ii, 278, 279, 280. 1. ii front view (plate), ii, 11. 11 n plan (plate), ii, 12, 14. Blizard, Sir Wm., and Dr. Rumsey on Aggregation of Patients, i, 36. Board of Management for Hs., iii, 39. Boston City H., Pavilions at, i, 55. Bourges Military H., France, general description, ii, 186. ,, ,, ,, the sick wards and their offices, ii, 189. ,, ,, ,, Summary of, ii, 278, 279, 280. ,, ,, ,, Dr. Ch. Sarazin, on, ii, 186, 189. ,, ,, ,, plan and elevation (plate), ii, 186. Bridges (see connecting bridges). Bristow and Holmes on H. statistics, iii, 28. Brocklesby, Dr., on Military Hs., i, 36. Brussels International Congress on Lying-in Hs., i, 66. Buckle, Dr., on H. accommodation, iii, 15. Buildings, cost of, per bed (see cost). Burdon Sanderson on Annular Wards, ii, 87, 275. ,, ,, ,, plan section, ii, 274. ,, ,, Evidence of, before Commission on Fever Hs., ii, 274. Buxton, Sir T. Fowell, on H. management, iii, 21. CALCUTTA H., nursing in, i, 13. Cancer Hs. in London, Number of beds in, iii, 12. Cardorcet, Marquis de, on M. Tenon’s proposed H., ii, 264. Ceilings (see Floors, &c.). Chadwick, Edwin, on cost of sickness in Manchester, iii, 27. Chapels, i, 45, 48, 57 ; ii, 5, 12, 18, 26, 35, 54, 59, 82, 93, 102, 103, 116, 121, 143, 163, 169, 170, 177, 187, 192, 213, 221, 232, 249, 259. Charite H., Paris, Number of beds in. iii, 5. ,, ,, Patients in, ii, 102. Chaumont, F. de (see de Chaumont). Cheadle Convalescent Home, i, 77. Chest Affections, Hs. in London for, Number of beds in, iii, 12. Children's Diseases, Hs. for, in London, Number of beds in, iii, 13. ,, The Sick, H., Paris, Number of beds in, iii. 5; Children’s Ward, i, 52 ; ii, 21 1, 259. Circular H., Antwerp (see Antwerp Civil H.). Clark's, Dr., system for softening water, i, 31 ; ii, 6. Classes and Schools in H., i, 60. Classification of Hs., i, 59. Classified List of London Hs., iii, 12. Clinical Hs., Requirements and arrangements of, i, 60. Clinique d’Accouchements H., i, 69. Clothing Stores, i, 45, 4S, 53 ; ii, 92, in, 163, 169, 177, 185, 201, 221, 232, 255, 268. ,, ,, Requirements of, ii, 268. Co-efficients of Aeration, Table of, i, 26, 78. Commission on Small Pox and Fever Hs., Evidence of Dr. J. Burdon Sanderson before, ii, 274. Committee of Management, Constitution of, i, 10, 22. General Index. 51 Committee of Management, Executive, i, n. 11 ,, for Districts, iii, 39. ■ • ,, Ladies on, i, 10. i. ,, Medical Men on, i, 10. Connecting Bridges, i, 54; ii, 78, 84, 257, 259. Conseil Superieur d’Hygiene Publique, Brussels, report on circular wards, &c., ii, 80. Construction and Arrangements, General, i, 18. Construction, Early works on, i, 18, 19. n Leon Lefort on, i, 20. .. Philibert, De Lorme, on, i, 20. 1. Sarazin, Dr., on, i, 72. i> Surgical Society of Paris on, i, 21. i. Toilet, C., on, i, 20; ii, 196. Consumption, Hs. for, in London, Number of beds in, iii, 12. Contagious Matter, Destruction of, ii, 274. Contaminated Air, Purification of, by Fire, ii, 274. Contamination of Air by one person, i, 25, 28. .. ,, Ratio of, to number of people, i, 25, 28. Continental Hs., proportion of to population, iii, 5 Control of Hs. by State, i, 9; iii, 20, 36. „ Executive, i, 11. ,, of Nurses, i, 13. Convalescent Home, Cheadle, i, 77. ,, Hs., i, 77. Convalescent, Hs. for, in London, Number of beds in, iii, 12. „ Home for paying Patients, ii, 232. .1 Rooms, i, 54; ii, 35, 142, 192, 195. Cool Air, Effect on the Lungs, ii, 251. Corridors, i, 64 ; ii, 5, 13, 18, 26, 36, 54, 61, 78, 83, 93, 103, 117, 121, 138, 143, 164, 170, 178, 183, 188, 201, 222, 233, 238, 250, 272, Summary of, 278. Corridor and Pavilion system combined, Hs. built on, Rudolf-Stiftung, i, 40; Glasgow Western Infirmary, i, 49 ; ii, 42. Corridor System, suitability for cold climates, ii, 88. Cost of various Hs., i, 40, 42, 54; ii. 6. 13, 18, 28, 37, 46, 54, 61, 78, 83, 94, 104, 125, 126, 127, 132, 138, 144, 150, 164, 171, 178, 183, 188, 193, 201, 207, 214, 223, 233, 238, 241, 250, 260. ,, ,, Summary of, ii, 278. ,, ,, Altering and Improving less than new building ( see Old Hs.) Cottage Hs., i, 76. „ in England, Accommodation in, Table, iii, 6. ,, in England and Wales, Total number of beds in, iii, 5, G, 14. Creches, ii, 142, 174. Crimean War, Mortality in, i, 15. Cubic contents per bed ( see Wards, size of). Ciistrin Military H., general description, ii, 128. „ ,, the sick wards and their offices, ii, 128. Ciistrin Military H., Summary of, ii, 278. ,, ,, plan (plate) ii, 128. DAY ROOMS, ii, 10, 15, 21, 31, 35, 40, 48, 67, 97, no, 112, 114, 122, 139, 140, 149, 167, 173, 180, 184, 190, 194, 199, 227, 234, 239, 255, 262, 270. ,, ,, Summary of, area per bed, ii, 280. Dead House ( see Mortuary). ,, ,, Ventilation of, ii, 74. Death Chamber, ii, 235. Death Rate, Modes of calculating, i, 35. ,, ,, Dr. Farr on, i, 34. ,, ,, from Puerperal Fever, i, 67. „ ,, in Lying-in Hs., i, 66, 69, 70. ,, ,, in Paris Hs., i, 35, 66, 69, 70. ,, ,, in various Hs., i, 50. ,, ,, in Workhouse, Lying-in Wards, i, 67. ,, ,, in Vesinet H., i, 77. ,, ,, in London Hs., iii, 28, 31. ,, ,, and Disease, Statistics of, in Prussian Hs., iii, 32. ,, ,, in London Hs., Reduction of, iii, 33. „ ,, Manchester, iii, 27. Deaths from Pyaemia in London Hs., Table of, iii, 34. De Chaumont on Heights of Wards, ii, 195. ,, on nursing, i, 14, ,, on overcrowding, ii, 151. ,, on ventilation, ii, 51. ,, on warming, ii, 55, Decline of H. funds, iii, 18. Deformities of the Limbs, Hs. for, in London, number of beds in, iii, 12. De Lorme Philibert on construction, i, 20. Desgadets’ Radiating H., i, 18. Destitution and Sickness, Separation of, i, 8 ; iii, 16, 26, 38.' Dimension and distribution of buildings, i, 22, 32. Disinfecting Chambers, ii, 52, 169, 182, 192, 207, 222, 249, 268, 276. Dispensary, i, 23 ; ii, 248, 269; iii, 7. Dispensaries, Poor Law, iii, 25. „ Table of, in England and Wales, iii, 6. Drainage, i, 22, 31, 32 ; ii, 6, 13, 18, 27, 36, 46, 52, 54, 61, 74, 83,94, 104, 117, 118, 125, 128, 138. 143, 164, 170, 178, 201, 214, 222, 233, 243, 262. ,, Calculations for, ii, 1 18. ,, on Dry System, i, 32. ,, Precautions as to, i, 32. „ and removal of waste matters, i, 22. Drains, Ventilation of, i, 32. Dresden Public H., general description, ii, 129. ,, ,, The Mutterhaus, ii, 130. ,, The sick wards and their offices, ii, 132. ,, ,, Pay wards, ii, 130. ,, ,, Summary of, ii, 278, 279. ,, Planof Mutterhaus (('late), ii, 131. EE 52 General Index. Dresden Public H., plan of pavilions (plate), ii., 133. ,, ,, „ elevations and sections \t>lates), ii, 134, 135. ,, „ plan of additions (plate), ii, 130. Druggists’ H., Rome, ii, 230. Drunkard's Room, ii, 268. Dry system of Drainage, i, 32. Diisseldorf Military H., general description, ii, 126. ,, ,, Summary of, ii, 278. ,, ,, Plan (plate), ii, 128. Dust shoots, ii, 112. Dutch Hs. (see Amersfoort M. H., and Utrecht H.) Duty Rooms, ii, 10, 15, 21, 31, 35, 41, 48, 56, 67, 86, 97, no, 120, 123, 135, 139, 140, 149, 167, 173, 180, 184, 190, 194, 204, 208, 216, 218, 219, 227, 235, 240, 243, 255, 262. Du voir- Leblanc system of heating and ventilation, ii. 145- EAR and Throat Hs. in London, Number of beds in, iii, 13- Economy in the Treatment of Disease, iii, 22. Edinburgh, Royal Infirmary ( see Royal Infirmary, Edinburgh). Education and Examination of Students, i, 61. Ehrenbreitstein Military H., general description, ii, 127. ,, ,, Summary of, ii, 278. ,, ,, plan (plate), ii, 128. Elevators, Steam, i, 52. England and Wales, H. accommodation in, iii, 5, 6. ,, ,, Table of Hs. in, iii, 6. ,, ,, Total number of beds in Hs. in, outside the Metropolis, iii, 5, 6, 14. English Hs. (see Blackburn Infirmary, Herbert Military H., Hull General Infirmary, Leeds General Infirmary, Norfolk and Norwich H., St. George’s Union Infirmary, St. Marylebone Infirmary, St. Thomas’ H.) Enlargement of Old Hs. (see Old Hs.) Epilepsy, Hs. for in London, Number of beds in, iii, 12. Erection of various Hs., Dates of, Summary of, ii, 278. Erysipelas Wards, ii, 43, 45. Esse, Dr. C. H., on pavilion principle, i, 40. Executive control, i, 11. Extension of Existing Buildings ( see Old Hs.) Eye ( see Ophthalmic). FAN for ventilation, ii, 131, 275. Farr, Dr., Table of death-rate, i, 34. Fawcett on Poor Law Relief, iii, 26. Fever Patients, space required, ii, 70. Fever and Small-pox Hs., Requirements and general arrangements for, i, 70 ; ii, 70. bever Hs. in England and Wales, Accommodation in, Table iii, 6. Fever Hs. in England and Wales, Total number of beds in, iii, 5, 6, 14. ,, in London, Number of beds in, iii, 12. Finance and Accounts, iii, 22. Fires ( see Warming, also Thermhydric Grates). Fistula, Hs. for, in London, Number of beds in, iii, 12. Floor space per bed (see Wards, Size of). Fittings for Workhouse Hs., ii, 75. Floors, Fireproof, ii, 8, 30, 10S, 112, 139, 166, 172, 179, 234, 255. Floors, Walls, and Ceilings, Construction of, i, 43 ; ii, 8, 14, 20, 30, 39, 47, 52, 56, 66, 75, 85, 96, 108, 112, 114, 120, 122, 134, 139, 148, 166, 172, 179, 190, 203, 208, 216, 218, 224, 234, 239, 243, 255, 261, 262, 272. Floors, Warming of, i, 29 ; ii, 109. Foundation, Table of date of, of Hs., i, 1. Foundling H., Paris, Number of beds in the, iii, 5. French Ms. (see Bourges Military H., and St. Eloi H., Montpellier), see also Paris Hs. ,, ,, Regulations for, i, 63 ,, Lying-in Hs., Death-rate in, i, 66, 69, 70. ,, rules for admission, iii, 39. Funds, Decline of H., iii, 18. ,, Mode of raising, iii, 23. Furniture and Fittings of wards, i, 22, 37. ,, for Workhouse Hs., ii, 75. GALTON, Captain Douglas, on ventilation, ii, 71. ,, ,, on warming, ii, 55. ,, ,, on Norfolk and Norwich H., ii, 49. General Arrangement of Buildings, i, 18, 63 ; ii, 4, 12, 17, 25, 44, 53, 59, 74, 82, 91, 101 , 115, 137, 142, 162, 168, 176, 182, 187, 191, 199, 200, 206, 210, 220, 232, 238, 248, 258, 271. General Hs., Requirements and arrangements of, i, 62. ,, „ Table of, in England and Wales, i, 34 ; iii, 6. ,, ,, in England and Wales, Total number of beds in, iii, 5, 6, 14. ,, ,, in London, Number of beds in, iii, 12. Genoa ( see St. Andrew the Apostle H.) German Hs. (see Berlin Civil H., Berlin Military H., Custrin Military IT., Dresden Public H., Dussel- dorf Military H., Ehrenbreitstein Military H., Halle University H., Heidelberg University H., Konigsberg Military H., The Moabite Barrack H., Strasburg University H. Glasgow Western Infirmary, general description, ii. 42. ,, , ,, the sick wards and their offices, ii, 46. ,, ,, ,, average number of patients and time of residence, i, 50. ,, ,, ,, nursing arrangements, i, 15- ,, ,, ,, Summary of, ii, 278, 279, 280. . ,, >, view (plate), ii, 42. ,, ,, ,, plan (plate), ii, 44. General Index 53 Gordon Smith on Heidelberg H., ii, 91. Government Inspection of Hs., iii, 20. Governmental Management, i. 8, 9. Grassi, M., on ventilation, ii, 147. Grigurn, Report of J., on Russian Hs., ii, 236. Grouvelle's, M., system of heating and ventilation, ii, 145. Guy, Ur., on H. mortality, iii, 30. HALLE University H., Germany, general descrip- tion, ii, 210. ,, the sick wards and their offices, ii, 215. ,, Summary of, ii, 278, 279, 280. ,, ,, view and plan [plate), ii, 210. ,, ,, plans and sections of wards [plate), ii, 216. Hard Water, Modes of softening, i, 31 ; ii, 6. Healthiness, Ratio of, to space, i, 24. Heart Diseases, Hs. for, in London, Number of beds in, iii, 12. Heating [see Warming). Herries’, Mr., account of Hs. in Rome, ii, 228. Heidelberg University H., general description, ii, 88. ,, ,, the sick wards and their offices, ii, 94. ,, „ ,, Summary of, ii, 278, 279, 280. ,, ,, Gordon Smith on, ii, 91. ,, ,, general view [plate), ii, 88. ,, ,, plan [plate), ii, 92. ,, ,, plan of pavilions [plate), ii, 98, 99. Herbert II., Woolwich, general description, ii, 3. ,, ,, the sick wards and their offices, ii, 7. ,, ,, Summary of, ii, 278, 279. ,, ,. general view [plate), ii, 3. ,, ,, plan and section [plate), ii, 4. Holland, Hs. in [see Amersfoort Military H. and Utrecht H.). Holmes and Bristow on H. statistics, iii, 28. Holy Trinity, Convalescent H. of, Rome, ii, 229. Hope Infirmary, Manchester, i, 63. Hot air, and Hot water, Warming by [see Warming). ,, „ advantages of, ii, 105. Hotel Dieu, Paris, general description, i, 18; ii, 151. ,, ,, the sick wards and their offices, ii, 165. ,, ,, Mortality at, ii, 266. ,, „ Number of beds in, iii, 5. „ ,, Patients in one bed, ii, 151, 2C5. ,, ,, Objections to, i, 18, 32, 39. „ ,, Overcrowding at, ii, 151, 265. „ „ Report of Commission on plans and mode of construction, ii, 152. M ,, Report of Special Commission of the "Lancet" on the building, ii, 161. I( „ Summary of, ii, 278, 279, 280. Hotel Dieu, view (plate), ii, 151. ,, plan (plate), ii, 162. Hull General Infirmary, general description, ii. 256. ,, ,, the sick wards and their offices, ii, 260. ,, plans for enlargements, ii, 257. ,, „ Sanitary arrangements at, 257- ,, ,, Summary of, ii, 278, 279,280. ,, „ plans and elevation (plate), ii, 256. ,, ,, plans and details (plate), ii, 260. Husson on management, i, 7. „ on overcrowding, ii, 151. ,, on records, i, 17, „ on religious control in Hs., i, 14. ,, on ventilation, ii, 147. Hut Hs., ii, 94, 241 (see also Tent Hs.). ,, Advantage of, i, 18, 74. „ for military use, i, 73. Hydropathic Department, ii, 192. ICE HOUSE, i. 41, 42 ; ii, 92, 102, 11G, 125, 126, 128, 206, 207, 213, 238. ,, Elevation and plan (plate), ii, 128. Improvement of old Hs. (see Old Hs.). Income of London Hs., iii, 15. „ Sources of, iii, 18. Incurables, H. for, in London, Number of beds in, iii, 12. Indian Hs. ( see Takhtsingji H.) Infectious Wards, ii, 70, 103, 112, 117, 170, 201 ; iii, 15. Infirmaries, Poor Law, iii, 25, 26. „ (see Workhouse Infirmaries). Inspection of Hs. by Government, iii, 20. Interior Courts, Objections to, ii, 81. Invalids, Hs. for, in London, Number of beds in, iii, 13- Isolation and Itch Wards, i, 41, 43, 52, 53, 56; ii, 5, 56, 73, 92, 124, 213, 218, 249. Italian Hs. (see St. Andrew the Apostle H. ; see also Rome, Hs. at). Italy, Number of Hs. in, ii, 228. Itch Wards (see Isolation Wards). JOHNS HOPKINS H., Baltimore, U.S., general description, i, 55 ; ii, 244. the sick wards and their offices, ii, 250. f> „ Summary of, ii, 278, 279, 280. plans and sections (plate), ii, 244. KITCHENS, i, 45. 5L 53. 54. 5^, 57 i 4. 17. 25. 32. 35. 44. 53. 54, 59' 82 ' 9 2 ’ 102 ’ II6, I42 ’ l63 ' l69 ' 177, 182, 187, 192, 199, 200, 206. 213, 219, 221, 232, 238, 249, 259, 269, 272. Kitchen and Laundry, Separation of (see Laundry). 54 General Index. Konigsberg Military H., general description, ii, 125. ,, ,, the sick wards and their offices, ii, 125. ,, ,, Summary of, ii, 278. ,, ,, plan of site [plate ), ii, 128. LABORATORY, ii, 26, 35, 91, 116, 169, 182, 192, 199, 213, 232, 249, 269. Ladies on General Committee, i, ro. Land and Buildings, cost of, per bed ( see Cost). Lariboisiere H. , Paris, general description, i, 69 ; ii, 141. ' ,, ,, the sick wards and their offices, ii, 144. ,, „ Number of beds in, iii, 5. „ ,, Summary of, ii, 278, 279, 280. j ,, ,, Overcrowding at, ii, 143. „ ,, elevations and sections plan (plate), ii, 141. ,, ,, plan of pavilion (plate), ii, 144. ,, ,, puerperal fever wards, plan and sections (plate) ii, 148. Larnure H., Paris, number of beds in the, iii, 5. Laundry and Kitchen, Separation of, i, 33, 54 ; ii, 17, 43, 52, 102, 221. ,, and Wash-house, i, 48, 50, 51, 53, 54, 56, 58 ; ii, 5, 17, 34.36. 43.45.54.59.78, 82,92,101, 102, 116, 123, 126, 127, 128, 129, 142, 177, 192, 207, 213, 221, 232, 238, 249, 259, 268, 270, 272. Lavatories, ii. 9, 15, 20, 31, 40, 47, 56,67, 86, 96, 109, 120, 122, I39, I4O, 166, I94, 204 , 234, 255, 262, 27O, 273 - Lawson Tait on H. Gangrene, i, 39. ,, on H. mortality, i, 15, 34 ; iii, 33. „ on H. records, i, 16. Layet, Dr., on the Co-efficients of Aeration, i, 25, 78. Lecture Rooms, i, 50; ii, 35, 45, 93, 103, 143, 199, 211, 212, 232, 249. Leeds General Infirmary, general description, ii, 16. ,, ,, the sick wards and their offices, ii, 18. 1, n Summary of, ii, 278, 279. ■ ■ 1. elevation (plate), ii, 16. ,1 1, plans and sections (plate) ii, 18. Leforte Leon on construction, i, 20. Leoping, i, 30. Library, ii, 4, 5, 53, 59, 92, 162, :68, 187, 191, 192,211, 232, 248, 249. Lifts, i, 52 ; ii, 10, 21, 31, 41, 48, 57, 67, 86, 139, 167, 173, 227, 235, 255, 263, 273. Lighting, warming, and ventilation ( see Warming). L : nen Shoots, ii, 86, 112 Linen Stores (see Clothing Stores). Lister, Prof., on superposed wards, i, 36. Local Government Board Arrangements as to Work- house Infirmaries, ii, 68. Lock Hs, in London, Number of beds in, iii, 13. London Hs. (see St. George's Union Infirmary, St. Marylebone Infirmary, St. Thomas's H.) ,, Classified list of, iii, 12. ,, Deaths from Pyaemia in, Table of, iii, 34- ,, Death rate, Reduction of, iii, 33. ,, Income of, iii, 15. ,, Insufficiency of accommodation in, iii, i 4 - ,, Mortality of, iii, 28. ,, Patients in, discharged, cured, died, &c., Table, iii, 31. ,, Total number of beds in, iii, 14. London Districts, Table of H. Accommodation in, iii, 10. London Parishes, Areas of, Table, iii, 9. ,, „ Number of Hs. and beds in, Table of, iii, 9. ,, „ Number of persons per acre, Tabl of, iii, 9. ,, ,, Ratio of beds in Hs. to the popu- lation, Table of, iii, 9. ,, ,, Table of area, population and Hs. in, iii, 9. ,, ,, Table of population of, in 1881, iii, 9. London, Population of, iii, 3. ,, Rateable value of, iii, 19, 38. ,, Registration Districts (see Registration ,, Districts in London). London, Poor Law Asylum, Number ofbeds in, iii, 19. ,, Small-pox Hs. in, i, 71 ; iii, 13, 15. Lumber Room, ii, 193, 209. Lunatic Asylums in London, Number of beds in, iii, 13. Lying-in Hs., i, 65, 69 ; ii, 230 ( see also Maternities). ,, Brussels, Congress on, i, 66. ,, Death-rate in, i, 66, 69, 70. ,, in London, Number of beds in, iii, 12. ,, Requirements and arrangements of, i, 65. Lying-in Wards, i, 43, 56, 69 ; ii, 73, 142, 148, 173, 176, 192, 199, 212, 238. ,, Advantages of space in, ii, 69. ., first opened in England, i, 65. „ Precautions to be observed, i, 68. ,, Surgical Society of Paris on, i, 68. ,, Cubic space in, i, 67. MAINTENANCE, Ratio of cost, iii, 21. Maison Dubois H., The, Paris, Number of beds in, iii, 5- Management, Constitution of Committee of, for Hs., i, 10, 11, 22 ; iii, 39. Management of Hs., i, 7, 50. ,, ,, by Government, i, 8, 9 ; iii, 20. ,, ,, Husson on, i, 7. ,, ,, in Paris, i, 8. „ ,, objections to French system, i, 21, General Index. 55 Management of Hs., Ratio of cost, iii, 21. ,, „ Suggestions by Dr. Mouat for, i>i. 39 - ,, ,, Sir T. Fowell Buxton on, iii, 21. „ „ Tenon on, i, 8. Manchester, Cost of sickness in, iii, 27. ,, Death rate, iii, 27. ,, Hope Infirmary, i, 63. Marshall, Prof. John, on circular wards, i, 56. Marylebone Infirmary (see St. Marylebone). Massachusetts General H., Pavilions at, i, 55. Maternities, i, 48, 69. „ at Paris, i, 69, iii, 5. ,, Number of beds in, iii, 5. ,, at Antwerp, i, 56. Maternity, Tenon H., i, 43 ; ii, 173. „ ,, plan and section (plate), ii, 148. „ (see also Lying-in H.'s and Wards). Matron, Authority of, i, 12. ,, Necessity for. i, 12. Medical Appliances for Workhouse Hs., ii, 76. ,, Men on General Committee, i, 10. ,, Schools in connection with Hs., iii, 34, 37. Medical Superintendent, i, 11. Menilmontant H. (see Tenon H.) Metropolitan Separate Workhouse Infirmaries, Number of beds in, iii, 14. Military Hs., (see Amersfoort, Berlin, Bourges, Ciistrin, Diisscldorf, Ehrenbreitstein, Konigsberg and Woolwich). Military Hs., Dr. Brocklesby on, i, 36. Moabite Barrack H., Berlin, general description, ii, 205. ,, ,, „ the sick wards and their offices, ii, 207. ,, ,, I. Summary of, ii, 278, 279. ,, ,, tabulated statement of classes of diseases treated, ii, 205. ,, ,, plan (plate), ii, 205. Mons Civil H., general description, i, 57 ; ii, 77. „ the sick wards and their offices, i, 58 ; ii, 78. ,, Summary of, ii, 278. ,, view and plan (plate), ii, 77. Montpellier (s« St. Eloi H.) Morin, General, on Hs., i, 63. „ ,, on ventilation, ii, 254. Mortality in Crimean War, i, 16. ,, Dr. Guy on H., iii, 30. „ at Hotel Dieu, ii, 266. „ in relation to number of inmates, table of, i, 34 - ,, Lawson Tait on, i, 15, 33 ; iii, 33 - Dr. Steele on, iii, 33. ,, of London Hs., iii, 28. „ Statistics as to, in London Hs., iii, 29. Mortuary, i, 42, 45, 51, 56, 58; ii, 5, 17, 26, 36, 45. 54, 59, 68, 74, 82, 93, 102, 1 16, 125, 126, 127, 128, 130, 143, 163, 170, 177, 182, 188, 192, 199, 201, 207, 221, 232, 238, 249, 259, 268, 272. NATIVITY H., St. Petersburg, general description, ii, 241. ,, ,, the sick wards and their offices, ii, 242. ,, Summary,of, ii, 278, 279. ,, ,, plan, elevation and sec- tion (plate), ii, 241. Necker H., The, Paris, Number of beds in, iii, 5. Nervous Disorders, Hs. for, in London, Number of beds in, iii, 12. New York H., general description, i, 51. ,, ,, the sick wards and their offices, i, 53. ,, ,, view (plate) i, 52. Norfolk and Norwich H., general description, ii, 49. ,, ,, ,, the sick wards and their offices, ii, 55. „ ,, ,, Summary of, ii, .278, 279, 280. ,, „ ,, Capt. Douglas Galton on, ii. 49 - ,. .. ,, plan (plate), ii, 54. ., ,, ,, view (plate) , ii, 49. Number of Hs. in England and Wales, iii, 7. Number of Patients in one H., i, 21, 33, 36; ii, 265; iii. 33 - Nurses' Apartments, Necessity for separating from Sick Wards, ii, 257. ,, Control of, i, 13. „ Home, ii, 59, 249, 259. ,, Rooms, i, 18, 43, 50, 53, 56; ii, 10, 12, 21, 31, 41, 45, 48, 57, .59, 82, 92, 103, no, 121, 123, 139, 140, 149, 162, 163, 167, 173, 180, 184, 190, 194, 204, 208, 217, 218, 219, 235, 240, ' 243, 249. „ Training of, i, 14. Nursing, i, 12, 15, 50. ,, Arrangements at Glasgow Western In- firmary, i, 15. „ De Chaumont on, i, 14. OBSTETRIC Wards, &c. (see Maternity also Lying-in). Officers' Quarters, necessity for separating from sick wards, ii, 257. ,, Mode of appointment of, iii, 35. Old Hs. badly planned, capable of improvement, ii, 256. ,, injudicious alterations, example of, ii, 256. „ description of alterations to Hull General Infirmary, ii, 257. ,, modernized at less than half the cost of new buildings, Example of, ii, 260. One-storied Pavilions, Advantages of and objections to, ii, 94. Open Fires ( see Warming also Thermhydric Grates). Open Stoves (see Warming also Thermhydric Grates) General Index. 56 Operating Rooms, i, 57; ii, 26, 78, 82, 103, no, 116, 130, 192, 194, 199, 232, 243, 249, 269, 272. Wards, ii, 5, 187. „ Theatres, i, 50, 53, 56 ; ii, 5, 17, 26, 35, 53, 92, 99, 162, 169, 210, 212, 259. Oppert, Dr., on Special Hs. , i, 75 ,, on H. accommodation, iii, 15. Ophthalmic Hs. in London, Number of beds in, iii, 12. ,, Wards, i, 4 ; ii, 17, 25, 93, 96, 164, 212, 230. Oratory, ii, 269. Outdoor Medical Relief in London, iii, 8. Out-patients Departments, i, 51 ; ii, 12, 17, 25, 48, 54, 162, 168, 191, 199, 211, 232, 249, 258 ; iii, 25. ,, Home treatment of, iii, 37. ,, Rooms, Ventilation of, ii, 52. ,, system, Evils of, iii, 24. ,, suggested improvements, iii, 25. Overcrowding, i, 21, 33. jG ; ii, 143. 17°- 26 5 iii. 4. 33' „ de Chaumont on, ii, 151. ,, at Hotel Dieu, ii, 151, 265. ,, Sir Wm. Blizard and Dr. Rumsey on, i, 36. ,, Husson on, ii, 151. ,, at Lariboisiere H., ii, 143. ,, in London, Lord Salisbury on, iii, 4. „ Result of, i, 24. PARIS Hs. (see Hotel Dieu, Lariboisiere H., Tenon H., Bichat H., St. Anne H., St. Louis Bicetre Asylum for Lunatics, Pitie, Foundling, Larnure, St. Antoine, Children's Sick II., Charite, Beaujon, Necker, Maison Dubois, St. Eloi H., St. Denis H., M. Tenon’s proposed H.) ,, Death rate in, i, 35, 66, 69, 70. ,, Maternities at, i, 69 ; iii, 5. Paris Surgical Society on construction and Position, i, 21. Parishes (see Londo parishes). Parkes Museum, i, 38. Pasteur, Professor, on organic impurities, i, 29. Pathological Department, i, 50, 53 ; ii, 34, 36, 45, 163, 249. ,, Institute, ii, 93, 199, 213. ,, Society's report on Pyaemia, iii, 34. Patients in London Hs. discharged, cured, died, &c. table, iii, 31. ,, limit of number in one H., i, 21, 33,36; iii, 33. ,, number in each ward, i, 22, 40, 64. ,, payments by, iii, 26, 27. Pavilions, Area of ( see Area of Pavilions). ,, One storied, advantages of and objections to, ii, 94. ,, Relative positions of, ii, 7, 18, 29, 37, 62, 84, 104, iii, 113, 124, 132, 144, 165, 171, | 184, 189, 193, 202, 207, 215, 217, 223, 233, 238, 250. Pavilion System, Advantages of, i, 35 ; ii, 94. „ ,, Dr, C. H. Esse on, i, 40. Pavilion System, first established in France, ii, 141. Pavilion and Corridor System (see Corridor System). Pay wards, ii, 24, 89, 130, 192, 199. ,, Regulations for, ii, 24, 90. Periodical evacuation of wards, i, 22 ; ii, 52. Philadelphia Presbyterian H. collecting committee, iii, 23. ,, ,, One -storied pavilion at, i, 55. Physiological Institute, ii, 213. Pitie H., Paris, Number of beds in, iii, 5. Poor Law Asylums in London, Number of beds in, iii., 13. ,, Board Committee Report, ii, 68. ,, Infirmaries and Dispensaries, iii, 25, 26. ,, Relief, Fawcett on, iii, 26. Poor Priests, H. for, at Rome, ii, 230. Population of London, Classification of, iii, 3. ,, ,, parishes in 1881, Table of, iii, 9. ,, ,, Districts, iii, 10. ,, ,, Registration District in 1881, Table of, iii, 11. ,, Proportion of Hs. to, on the Continent, iii, 5- Porous Walls, Disadvantages of, i, 30. Porter-Clark's process for softening water, i, 31 ; ii, 6. Post Mortem Rooms, i, 51 ; ii, 5, 17, 26, 54, 59, 82, , 116, 163, 170, 177, 182, 192, 213, 221, 232, 249, 259. Power, Dr., on Small-pox Hs., i, 71. Presbyterian IL, Philadelphia (see Philadelphia). Prince Torlonia's Room for Eye Diseases, Rome, ii, 230. Private Charity in London, iii, 16. Prussian Hs., Statistics of disease and death in, iii, 32 (see also German Hs.) Puerperal Fever, Death rate from, i, 67. ,, ,, Thevenot, M., on, i, 68. ,, ,, Toilet, M., on, ii, 149. ,, ,, Wards, ii, 149. I Purification of air by earth containing organic matter, in India, i, 30. Pyaemia,) Deaths from, in London Hs., Table of, iii, 34. RADIATING H., by Desgadets, i, 18, 38. Rateable value of London, iii, 19, 38. Reception Room, ii, 249. Receiving Ward, ii, no, 232, 267. Records of Hs., i, 15. ,, Husson on, i, 17. ,, Imperfect Nature of, i, 16, 17. ,, Lawson Tait on, i, 16. ,, should contain, i, 16. ,, Value of, i, 17. Registration Districts in London, H. accommodation in, Table of, iii, 11. ,, ,, in London area, and number of persons in, Table of, iii, n. General Index. 57 Registration Districts in London, Number of Hs. and beds in each district, Table of, iii, ii. ■ • i. in London, Population in 1881, Table of, iii, ii. •• .1 in London, Ratio of beds to population, Table of, iii, ii. • > >i Table of H. accommodation in, iii, ii. Relief of sickness by State aid, iii, iq. Religious organization and teaching, i, i, 13. Religious control in Hs., Husson on, i, 14. Richardson, I)r. B. W., on purification of contami- nated air, ii, 274. Riga Town H., Russia, general description, ii, 236. the sick wards and their offices, ii, 238. I. •> Regulations and list of, ii, 236, 237. ti >• Summary of, ii, 278, 279, 280. ■■ .. elevation, plan, and section (plate) ii, 236. Rome, Hs. at ( see S. Spirito in Sassia, SS. Mo Salvatore ad Sancta Sanctorium, St. James in Augusta, S. Maria in Portico, S. Maria delle Granzie, S. Maria and S. Galiicano, S. Maria della Consolazione, S. Rocco, St. John Calibita, Poor Priests (H. for), S. Francesca Romana, Druggists’ H., Bakers' H., Prince Torlonia's Room for Eye Diseases, and the Spanish H.) ,, Proposed new H. at, ii, 230. Room for Drunkards, ii, 2G8. Rotunda H., Dublin, i, 65. ,, „ table of cases, i, 65. Royal Infirmary, Edinburgh, general description, i. 50; ii, 34 - ,, n ,, the sick wards and their offices, ii, 37. ,, ,, ,, Number of patients and deaths in, i, 50. ,, .. ,, Summary of, ii, 278, 279, 280. ,, ,, ,, plan and section (plate) ii, 34. • ■ 11 view (plate) ii, 33. Rudolf-Stiftung H., general description, i, 40. Rumsey, Dr., and Sir William Blizard on Over- crowding, i, 36. Russia, Regulations of Hs. in, ii, 236. Russian Hs. (see Nativity H., St. Petersburg, and Riga Town H.) ST. ANDREW THE APOSTLE, H.of, Genoa, Italy, general description, ii, 228. ,, the sick wards and their offices, ii, 23 3 - ,, Summary of, ii, 278, 279, 280. ,, view (plate), ii, 228. ,, plan and section (plate), ii, 233. St. Anne H., Paris, Number of beds in, iii, 5. St. Antoine H., Paris, Number of beds in, iii, 5. St. Denis H., France, general description, ii, 175. 11 ii the sick wards and their offices, ii, 178. • I ii Summary of, ii, 278, 279, 280. •I ■■ plan and section (plate), ii, 175. St. Eloi H., Montpellier, general description, i, 45, ii, 191. if n the sick wards and their offices, i, 48 ; ii, 193. 11 ii Summary of, ii, 278, 279, 280. 11 n Perspective view (plate), i, 46. n it plans, sections, and elevation (plate), ii, 191. St. Francesca Romana II., ii, 230, St. George's Union Infirmary, general description, ii, 220. .1 1. I. the sick wards and their offices, ii, 223. • 1 .. ,, Summary of, ii, 278, 279, 280. ■ 1 ,i ,, elevation, plan, and section (plate), ii, 220. St. James in Augusta H., ii, 229. St. John Calibita H., ii, 230. St. Louis H., Paris, Number of beds in, iii, 5. S. Maria and S. Galiicano H., ii, 229. S. Maria in Portico, S. Maria delle Granzie, and S. Maria della Consolazione united H., ii, 229. St. Marylebone Infirmary, general description, i, 63 ; ii, 58. „ ,, the sick wards and their offices, ii, 61. ,, .. Summary of, ii, 278, 279, 280. „ ,, perspective view (plate), ii, 58. ,, ' ,, plan and section (Plate), ii, 60. St. Petersburg (see Nativity H.) S. Spirito in Sassia, H. of, Rome, ii, 228. S. Rocco Lying-in H., Rome, ii, 230. St! Thomas’s H. , general description, ii, 22. ,, ,, the sick wards and their offices, ii, 29. ,, ,, Building Committee, ii, 23. ,, ,, Cost of furuiture, ii, 28. ,, ,, Estimates for building, ii, 27. ,, ,, failure in construction, i, 19, 32. ,, ,, Negotiations for new site, ii, 22. ,, ,, Nursing in, i, 14. „ ,, Objections to, i, 39. ,, ,, Pay Wards, ii, 24. ,, ,, Summary of, ii, 278, 279, 280. ,, ,, general view and plan (plate), ii, 22. ,, ,, plan (plate), ii, 26. Salisbury, Lord, on overcrowding in London, iii, 4. Sanderson, Dr. Burdon, proposed H. ward, ii, 274. ,, ,, on ventilation of wards, ii, 274. 58 General Index. Sanderson, Dr. Burdon, Evidence of, before Com- mission on Fever Hs., ii, 274, Sanitary arrangements, Supervision of, ii, 52. SS. Mo Salvatore ad Sancta Sanctorium H. of Rome, ii, 229. Sarazin, Dr. Ch., on Bourges Military H., ii, 186, 188, 189. ,, on H. construction, i, 72. ,, ,, on temporary Hs., i, 39. Schools and classes in H., i, 60. Scotch Hs. (see Glasgow Western Infirmary and Royal Infirmary, Edinburgh). Separation, Advantage of, i, 25. ,, Wards, i, 50, 58 ; ii, 15, 31, 41, 48, 56, 67, 69, 86, 97, no, 112, 117, 122, 135. 139, 140, 149, 167, 173, 176, igo, 195, 204, 216, 219, 226, 235, 239, 249, 255, 2C2, 273 - ,, Wards, Summary of area and contents per bed, ii, 280. Sickness and Destitution, Separation of, i, 8; iii, 16. Site, Selection of, i, 21, 22, 63. ,, Area of, per bed, Summary of, ii, 278 (see also Area of Site). ,, covered per bed, Summary of, ii, 278 (see also Area covered). Skin Diseases, Hs. for, in London, Number of Beds in, iii, 13. Slop Sinks, ii, 9, 15, 20, 31, 40, 47, 67, 86, 96, 109, 166, 226, 234, 262, 269. Small Pox Hs., in London, i, 71. ,, ,, in London, Number of Beds in, iii, 13. ,, ,, Dr. Power on, i, 71. ,, ,, Dr. Thorne on, i, 71. ,, Pavilion, i, 43, 45. ,, and Fever Hs., Evidence of Dr. J. Burdon Sanderson before Com- mission on, ii, 274. ,, ,, ,, Requirements,- and general arrangements for, i, 70 ; ii, 70 Soldiers' Home at Washington, i, 54. Sources of Income, Decline of, iii, 18. Space required in Wards, Report of Government Committee on, ii, 68. Space surrounding H., i, 21, 22, 23. Spanish H., Rome, ii, 230. Special Hs., Requirements and general arrange- ments for, i, 75. 1, Dr. Oppert on, i, 75. Staff, Superintendence and control of, i, 11. Staircases, i, 43, 53 ; ii, I0 , 15, 2 r, 32, 41, 48, 57, 67, 75, 86, iii, 121, 123, 139, 140, 149, 167, 173, 185, 227, 235, 255, 263, 269, 272, 273. State Control of Hs., i, 9 ; iii, 20, 36. State relief of sickness, iii, 19. Statistics, Bristow and Holmes on, iii, 28. , of disease and death in Prussian Hs., iii, 32. ,, as to patients and mortality in London Hs., iii, 29. Steam Elevators, i, 52, Steam Pipes, Heating by, ii, 145, 171, 208, 215, 218. Steele, Dr., on H. mortality, iii, 33. Stone and Urinary Disorders, Hs. for, in London, number of beds in, iii, 13. Stores, i, 43,45,48, 51, 52,53; ii, 4, 17,25, 35 . 44 . 45 . 53 . 59, 82, 92, 101, 125, 143, 162, 163, 169, 177, 182, 187, 188, 195, 199, 200, 201, 212, 221, 232, 249, 259, 270, 272. Strasburg University H., general description, ii, 137. ,, ,, the sick wards and their offices, ii, 138, 139. ,, ,, Summary of, ii, 278, 279, 280. ,, ,. plan and section (plate), ii, 137 - Sturges Pavilion, Bellevue H., N.Y., i, 55. Subsoil, ii, 4, 12, 16, 25, 34, 44, 53, 59, 91, 101, 115, 142, 162, 168, 176, 187, 199, 200, 206, 210, 220, 231, 248. Summary of Construction of various Hs., ii, 278. 279, 280. Summer Sick Pavilions, ii, 201. Superficial or floor space (see Wards, size of). Supervision of sanitary arrangements, ii, 52. Surgical Society of Paris, on construction and position, i, 21. Surgical Wards, Limit of patients in each, i, 37. Swedish plan of payments from patients, iii, 26. Syphilitic Hs. in London, Number of beds in, iii, 13. ,, wards, ii, 35, 73, 92, 211, 238. TABLE of Co-efficients of Aeration, i, 26, 27, 28, 78. ,, Date of erection, size, and general ar- rangement of buildings, ii, 278. ,, Date of foundation of Hs., i, 1. ,, Death rate, Farr and Lawson Tait on, i, 34. ,, Diseases treated at Moabite Barrack H., ii, 205. ,, Mortality in relation to number of inmates, *. 34 - ,, Deaths from Pyaemia in London Hs.,iii, 34. ,, Area, population and H. accommodation in London Districts, iii, 10. ,, H. Accommodation in London Parishes, iii, 9. ,, Hs. in England and Wales, iii, 6. „ Mortality in Lying-in Wards at Rotunda, H., i, 65. ,, Number of beds in various H., classified, iii, 12, 13, 14. ,, Patients in London Hs. discharged, cured, died, &c., Table iii, 31. ,, Rate of air contamination, ii. 51. ,, Relative mortality in Hs., 34. ,, Space required in wards, ii, 73. ,, Summary of construction of various Hs., ii, 278, 279, 280. ,, Lighting and ventilation of wards, ii, 279, 280. ,, Tenders for St. Thomas’s H., ii, 27. General Index. 59 Tait, Lawson, on H. mortality, i, 15, 34 ; iii, 33. „ table of death rate, i, 34. Takhtsingji H. p general description, ii, 271. ,, the sick wards and their offices, ii, 272. ,, view (plate), ii, 271. ,, plans (plate), ii, 272. Temperature of wards and offices, ii, 106, 251. Temporary Hs., i, 39, 73 ( see also Hut Hs.). ,, Dr. Sarazin on, i, 39. ,, materials in construction desirable, i, 39. Tenon H., Menilmontant, Paris, general description, i, 43 ; ii, 168. ,, ,, the sick wards and their offices, i, 43 ; ii, 171. ,, ,, the Maternity, i, 43 ; ii, 173. ,, ,, Overcrowding at, ii, 170. ,, ,, Summary of, ii, 27S, 279, 280. ,, ,, plan (plate), i, 44 ; ii, 148, 170. ,, ,, view (plate), ii, 168. Tenon on management, i, 8. ,, on Hs., ii, 264. ,, proposed H., general description, ii, 264. M ,, the sick wards and their offices, ii, 269. lt ,, M. de Cardocet on, ii, 264 ,, ,, plan (plate), ii, 264. Tent Hs. i, 71, 74 (see also Hut Hs ). Theatres, i, 50 ; ii, 35. 3^. 45. 192 (see also Operating Theatres) . Thermhydric Hot-water Grates, ii, 55, 62, 224, 261. ,, ,, description and plans of (plates), ii, 62, 64, 65. Thevenot, M., on Puerperal Fever, i, 68. Thomas and Laurens' System of Ventilating and Heating, ii, 145. Thorne, Dr., on Small Pox Hs., i, 71. Throat and Ear Hs. in London, Number of beds in, iii, 13- Toilet’s, M„ System, Hs. built on (see St. Eloi H. Montpellier, H. Bichat, St. Denis I-L, Bourges Military H.). ,, Letter from, on his System, ii, 196. M on construction, i, 20, ii, 196. ,, System, i, 20, 47, 49, 72; ii, 175, 181, 186. ,, Puerperal Fever Wards, ii, 149. Training Kitchen, ii, 249. Training of Nurses, i, 54. Trelat on aggregation of patients, i, 33. Tyndall, Professor, on dust, i, 29. Utrecht H, Holland, the sick wards and their offices, ii, 199. ,, ,, summary of, ii, 278. ,, ,, elevation and plan (plate), ii, 198. VAN HECKE'S system of ventilation, ii, 147. Vaulting under Hs., Objections to, ii, 217. Ventilating Shaft, Danger of, i, 31, 45. fan, ii, 131, 275. Ventilation, lighting and warming (sre Warming). Amount of power required for, ii, 253. Artificial (see Artificial Ventilation). Amount required for each adult, i, 28. and warming, Dr. Billings on, ii, 250, 232. Dr. Burdon Sanderson on, ii, 274. by Capt. Douglas Galton's stoves, ii, 8. by Thermhydric Hot-water Grates, ii, 55, 62, 64, 65, 224, 261, by windows (see Window Ventilation). Captain Douglas Galton on, ii, 55, 71. Conditions of, i, 29, 48 ; ii, 108, 253. Cost of Duvoir-Leblanc system, ii, 146. Cost of Thomas and Laurens’ system, ii, 146 Dr. C. Waldhauer on, ii, 239. General Morin on, ii, 254. Husson on, ii, 147. in Circular Wards, i, 56. M. Grassi on, ii, 147. of Drains, i, 32. Prof, de Chaumont on, ii, 51, 55. Thomas and Laurens’ system of, ii, 145. to gas burners, ii, 71. Van Hecke's system, ii, 147. window (see Windows). with reference to size of room, &c., i, 25. Venereal Wards, ii, 35. 73. 92. 211, 238. Verandahs, ii, 31. 4 1 * 5®. 97> 1 10, 135. I 8o, 184, 194 216, 218, 219, 239, 273. Vesinet Convalescent H., Death rate in, i, 78. Vincennes and Vesinet Convalescent Hs., i, 77. Vivisection Room, ii, 213. WALDHAUER, Dr.C., on ventilation, ii, 239. Walls, Floors and Ceilings (see Floors). Wall or bed space (see Wards, size of). Wards, Aspect of, i, 58, 64 ; ii, 7, 14. 16, 29, 37, 46, 55 61, 95, 104, 120, 121, 125,126, 127, 132. 138, 139, 144, 165. 171, 178. i8 3. 189. 193. 202, 215, 217, 219, 223, 233, 238, 250, 260, 272. ,, Summary of, Aspect of, ii, 278. UNIVERSITY College H., Objections to i, 39, Urinals, ii, 9, 20, 30, 47. 86, 109, 120, 194, 216, 234, 255, 269. Urinary Diseases, Hs. for, in London, Number of beds in, iii, 13. Utrecht H., Holland, general description, ii, 198. Annular, ii, 87, 275. Aural, ii, 212. Children's, i, 32 ii, 21 1, 259. Circular, i, 56 ; ii, 80. infectious, Destruction of contagious matter in, ii, 274. 6o General Index. Wards, Furniture of, i, 22. ,, Lying-in, i, 43, 56, 69; ii, 73, 142, I 4^, 173 - 176, 192, 199, 212^ 238. ,, Limit of patients in, i, 22, 40, 64. ,, Isolation (see Isolation). ,, Operation ( see Operation). ,, Ophthalmic (see Ophthalmic'. ,, Periodical evacuation of, i, 22 ; ii, 52. „ Receiving, ii, no, 232. ,, Separation (see Separation). „ Separation of cases in, ii, 72, 266. „ Size of, i, 7, 14, 19, 32, 41, 58 ; ii, 7, 14. 19 . 2 9 . 37, 46, 50, 55, 62, 73, 84, 95, 98, 105, 120, 121, 132, 138, 140, 142, 144, 165, 171, 175, 178, 184, 189, 193, 202, 207, 215, 217, 219, 223, 233, 239, 242, 250, 252, 260, 265, 269, 272. ,, Summary of size of, 280. ,, Small Pox, ii, 238. ,, space required, ii, 73 ; Report on, ii, 68. ,, Summer and Winter, ii, 201, 204. ,, Temperature of, ii, 106, 196, 251. „ Syphilitic and Venereal (see Syphilitic). „ Warming, lighting and ventilation of (see Warming). Warming, lighting, and ventilation, i, 24; ii, 7, 8, 14, 19,29, 38, 47, 51, 55. 62, 78, 85, 95, 105, 114, 120, 122, 130, 132, 138, 140, 145, 165, I7I, 178, 184, 189, 202, 208, 215, 224, 234, 239, 2 4 2 . 2 43. 250, 252, 2G1, 272. ,, Burdon Sanderson on, ii, 276. ,, de Chaumont on, ii, 55. „ Duvoir-Leblanc System of, ii, 145. „ Captain Douglas Galton on, ii, 8, 55. „ Grouvelle's, M., system of, ii, 145. „ by hot air, ii, 85, 95, 138, 165, 171, 202, 234. „ by Ijot water, ii, 47, 62, 105, 130, 145, 178. 184. 224, 234, 239, 242, 250, 261, 276. ,, Experiments on, ii, 105. 145. „ Advantages of and objections to, ii, 105, 251. ,, by open fires, ii, 7, 14, 19, 29, 38, 47, 62, 85. 179. 184. 189. 224, 261. ,, Advantages of and objections to, ii, 105, 251- ,, by steam pipes, ii, 145, 171, 208, 215, 218. „ Experiments on, ii, 105, 145. ,, by close stoves, ii, 78, 122, 189, 202. by Thermhydric Grates, ii, 55, 62, 224, 261. Warming Stoves, Comparison of, ii, 64. ,, and Ventilation, Thomas and Laurens' system of, ii, 145. ,, ,, Dr. Billings on, ii, 250, 252. ,, ,, Toilet on, i, 47. Wash-house and laundry (see Laundry). Washington, Soldiers' Home at, i, 54. Water closets and baths (see Baths and w.c.’s.). Water closet ventilating lids (plate), ii, 225. Water supply, i, 31 ; ii, 6, 13, 18, 27, 36, 45, 54, Or, .83,93, * 03 . 117, 125, 128, 143, 1O4, 170, 178, 188, 201, 207, 214, 222, 233, 238,243, 269. ,, Modes of softening, i, 31 ; ii, 6. Precautions as to, i, 32. Westminster H., Objections to, i, 39. Windows, Size and amount of light and ven- tilation of, i, 43, 50; ii, 7, 14, 19, 29, 38, 46, 55. 62, 74. 84, 95, 98, 105, 122, 133, 145, 165, 171, 178, 184, 189, 194, 202, 208, 215, 217, 219, 223, 233, 242, 250, 2O0, 272. ,, Summary of, ii, 279. ,, sashes, Special recommendations as to, ii, 62, 224, 260. Winter sick wards, ii, 204. Women, Ms. for, in London, Number of beds in, iii, 13. Woolwich (see Herbert H.). Workhouse I-Is., Furniture and fittings for, i, 22 ; ii, 75. ,, infirmaries, ii, 58 ; iii, 17. ,, ,, fittings and medical appli- ances, ii, 75. ,, ,, Infectious diseases in, ii, 70. ,, ,, Local Government Board Regulations as to, ii, 08 . ,, ,, Metropolitan, Separate num- ber of beds in, iii, 13. Workhouse Hs. and Infirmaries, List of Plates — St. Marylebone Infirmary, view, ii, 58. ,, ,, plans and section, ii, Go. ,, ,, Thermhydric Stoves, ii, 62, O4, 65. St. George's Union ,, plans, elevation and section, ii, 220. ,, ,, Construction of w.c.’s, ii, 225, 22G. Workhouse lying-in wards, Cubic space in, i, 67. ,, ,, Death rate in, i, 67. Women, Hs. for, i, 64. ZONE of Aeration, i, 21, 23. ERRATA. Section I. Page 7, lines 23-4, for "an appendix ’ read “ Section III.” Pages 26, 27, 28, headings of No. 4 columns, for “litres" read " milli-litres." Page 28, lines 17 and 23 from bottom, for "part-48’' read respectively "pint — 46," and bottom line, for "sanitair" read “ sanitaire." Section II. Page 19, lines 9 and 10, for “56,408, 68,364, 2,136," read respectively " 56,414, 66,670, 2,083." ,, 27, line 9, for “ 267 ” read “ 268.” ,, 37, line 6, for " 100" read " no”; line 24, for “577" read "587;" lines 33 and 34, for “east and west” read "north and south," and for “ north and south ” read “ east and west ; " also note the latter alterations on the compass point of plate opposite to page 34. ,, 38, line 16, for " 16” read " i6J." ,, 40, line 2 from bottom, for “ 16" read “ 17." - ,, 46, line 17 from bottom, for "108" read " 106.” „ 95, line 11 from bottom, for " 2iJ ” read “ 21.” „ 97, line 11, for 1,296" read "1,288.” „ 98, lines 17 and 18, for "19*, 244 "read re- spectively " 19I, 24,” bottom line, for “8 feet ” read “ 7 feet 2 inches." „ 99, line 13, for " 9 feet ” read " 8 feet 2 inches.” ,, 105, line 4, for " 107 " read " 108." ,, 107, line 18, for "XX" read "pp.” ,, no, line 10, for "22*” read " 20J." „ in, line 2 from bottom, for “ 107 " read " 108." „ 116, lines 18 and 23, for “E” and “F” read respectively “ F " and " E." ,, 1 19, bottom line, for " 197" read " 198." ,, 122, lines 2 and 4, for " 465, 29, 487, 30 feet 6 inches” read respectively "360, 22 5, 375, 23J ; " line 22 for “ 116 " read ” 120; ” line n from bottom, for “28*” read “ 141.” ,, 139, lines 12 and 13, for “16, 192, 8" read respectively "26, 312, 12." „ 140, line 20, for “ 1,279” read " 1.272." ,, 144, three bottom lines, for “3,695, 62,815, 59,030, 1,963, 1,845” read respectively “ 3,699, 62,886, 59,186, 1,965, 1,850.” „ 145, top line, for " eight feet ” read “ 7 feet 10 incnes.” Page 165, lines 20 and 21, for “57,866, 54,108, 53,357. 2,223" read respectively "57,854, 54,098, 53.34 6 . 2,222." „ 167, line 7, for " 13* ” read " 21." ,, 176, line 27, for " 7 ” read " 28.” ,, 178, lines 15 and 29, for “ 1,271, 1 " read re- spectively “ 1,245, 2." ,, 184, line 10, for 52,974, 2,207 "-read respectively “ 52,916, 2,205." „ 187, line 21, for “59,800, 17, 277” read re- spectively "537.920, 16, 2,490." ,, 189, lines 25 and 26, for " 89, 47,678, 1,703 ” read respectively " 85, 47,405, 1,693." ,, 193, lines 16, 18, and 42, for " 372, 114, 65, n8 " read respectively "371, 113, 65, 184.” ,, 194, line 7, for “ 16* " read “ 16*.” ,, 199, lines 1 and 2, for " 35,080, 133 " read respectively “341,129, 1,292." ,, 202, the divisions of the scale on plate beneath the " transverse section " arc drawn twice the proper size. ,, 206, line 26, for "800,670, 8. 10 "read re- spectively "800,672, 18, 20." ,, 214, line 2, for " 494 ” read " 496." ,, 215, lines 2 and 3, for "334, 44, 378” read respectively "333, 41, 374.” ,, 217, line 10 from bottom, for " 3,368, 142, 53,046, 2,210" read "3,363, 140, 52,967, 2,207." ,, 223, line 7 from bottom, for " 177 " read “ 354." ,, 239, line 9 from bottom, for " 13 " read “ i2f." „ 248, line 21, for "14 acres” read "13 acres, 3 roods, 26 perches,” and for "1,689" read " 1.679” ,, 250, line 27, for “ 104 ” read " 105.” ,, 260, lines 2, 21, 22, 24, and 25, for "128, 562, 18J, 20J, 669, about 22 j, 22J” read re- spectively "129, 529, 17 63, 197, 633, 2IT, 21*." ■ ■’ vr 9 ■