HO SPITAL PLANS.
FIVE ESSAYS
RELATING TO THE
CONSTRUCTION, ORGANIZATION & MANAGEMENT
OF
HOSPITALS,
CONTRIBUTED BY THEIR A UT/IORS
FOR THE USE OF THE
JOHN       NSOI    OSPITAL
OF BALTJ IM ORE.
NEW YORK:
WILLIAM WOOD & CO., 27 GREAT JONES STREET.
1875.




JOHN F. TROw & SON,
PRINTERS AND BOOKBINDERS,
205-213 East I2ttz St.,
NEW YORK.




CONTENTS.
PAGE
NAMES OF TRUSTEES...................................................                       V
ADVERTISEMIENTS.........................................................     vii
LETTER ADDRESSED TO THE AUTHORS OF THE  ESSAYS.....................                        ix
LETTER OF JOHNS HOPKIINS TO TIIE TRUSTEES............................    XV
EXTRACTS FROM JOIHNS HOPKINS' WILL AND THE CODICILS THIERETO.......    xix
ESSAYS ON HOSPITAL CONSTRUCTION AND ORGANIZATION.
JOHN S. BILLINGS,
Bvt. Lieut.-Col. and Assist.-Surg. U. S. A..............................            1
NORTON FOLSOM, M.D....................................................                    47
JOSEPEH JONES, Ml.D.,
Professor of Chemistry and Clinical Medicine, Medical Department University  of Louisiana;  Visiting Physician  of Charity  Hospital, New
Orleans; Formerly Surgeon in the Provisional Army of the Confederate
States..............................         105
CASPAR MORRIS, M.D........1............................................   173
STEPHEN  SITH, M.D.................................                                      269
APPENDICES.......29..........,..........................   329








NAMES OF TRUSTEES.
FRANCIS T. KING,                 FRANCIS WHITE,
JOHN W. GARRETT,                 LEWIS N. IIOPKINS,
GEORGE W. DOBBIN,                ALAN P. SIIrH,
GALLOWAY CIIESTON,               CEtARLES J. AM. GWINN,
THOMAS M. SMITH,                 JOSEPH P. ELLIOTT,*
WM. HOPKINS,                     GEORGE aW. CORNER.t
* Elected in the place of Richard 1I. Janney, deceased.
1 Elected in the place of Joseph Merrefield, who was chosen Treasurer.








ADVERTISEMENT.
THE occasion which has called forth the following essays is
made sufficiently plain by the letter addressed to their distinguished authors; but the reason of their publication may justify
a word of explanation.
That motive will be found in the fact that so valuable a mass
of information as is embodied in these instructive papers, though
intended for the personal use of the trustees of " The Johns Hopkins Hospital," ought not to be withheld from the whole public,
now so much alive to the important questions therein discussed.
Hence, they have considered it in entire consonance with the beneficent designs of the founder of their charity, whose enlarged
views embraced the relief of human suffering wherever found,
that the essays should be published without stint of illustrative drawings, and at a cost not probable to be returned by any
expected sale of the volume. Besides the good likely to be done
by this publication, the philanthropic subject to which it relates
will be further benefited by the intelligent and liberal criticism to
which the special views of the essays may be subjected by learned
medical writers. The subject will thus be fully developed, and
all who seek the alleviation of suffering disease through the
instrumentality of the well-constructed and properly managed
hospital, will find in the result as sure guidance as the present
state of knowledge will afford.
To these essays, which treat the subject in the light of medical
learning and experience, it has been thought expedient to append
a sketch of a pavilion from an architectural point of view;
and they have accordingly presented a study of an octagon
plan, embracing some features of novelty and probably of
merit.
From the diversity of views which these plans present, it will




viii                 ADVERTISETIENT.
be obvious that the trustees of The Johns Hopkins Hospital are
lnot yet committed to any of them, but that, like the reader,
they are seekers after knowledge, and that their search is further
accompanied with a high sense of their responsible duty to find
and to execute the best plan they can.
Besides the duty of building a hospital, the trustees have had
also confided to them the task of providing a home for destitute
colored orphan children. As, in many respects, such an institution demands the observance of sanitary rules of construction
and the application of the principles of hygienic management,
in common with hospitals, they have thought it not inappropriate to publish, in the same appendix, the plan of separated
buildings they have provisionally, and will probably finally,
adopt. In the meantime it is open to such well-considered modifications as its publication may call forth.




LETTER  ADDRESSED  TO  THE AUTHORS OF THE
ESSAYS.
OFFICE OF THE JOHNS HOPKINS HOSPITAL,
BALTIMORE, March 6, 1875.
DEAR SIR: —The late Johns Hopkins, a rich citizen of Baltimore, bequeathed to trustees a munificent foundation for the
building and support of a hospital, mainly intended for the
benefit of the indigent sick of the City of Baltimore and its
environs.
The letter which, some time before his death, ble addressed to
his trustees, will best describe the object he had in view, and a
copy of it accompanies this conimunication.
The execution of this munificent charitable purpose has been
entrusted to a body of trustees, none of whom, with a single
exception, belongs to the medical profession, and, apart from
the injunction which the founder's letter imposes upon them,
" to obtain the advice and assistance of those at home and abroad
who have achieved the greatest success in the construction and
management of hospitals," they would have distrusted their own
ability to cope with a subject so strictly scientific and professional, without first resorting to the best sources of information
within their reach.
To this end the Board of Trustees has authorized their Building Committee "to confer with five distinguished physicians,
chosen from different parts of the country, who have made hospitals their special study, and obtain from them such advice as
they may need, and to compensate them for it."  It-is in execution of the authority thus conferred that this communication is
addressed to you, and you are invited to make such response to
it as your fulness of information, stimulated by the importance
to humanity of the subject, may prompt you to.
Besides the information afforded you by the letter, some addi



X                LETTER OF THE PRESIDENT.
tions are needful to be made, and some corrections which altered
circumstances require.
You will observe that the site of the proposed building is there
designated; and, as we assume that you are not acquainted with
it, it is proper to add, that it consists of an eligible piece of
ground situated in the eastern part of the city; that it is fourteen acres in extent, in the form of a parallelogram, 709 x 856
feet; that it is very elevated above the general level of the city,
and commands an extensive view in. all directions; that it is
healthy, with complete surface drainage, whilst underground
drainage may be accomplished to tide water; and that it is easily
accessible by street railway and by paved streets, which bound
the four sides of it.
It is also proper to state that the endowment, which in the letter is spoken of as amounting to two millions of dollars, is now,
by subsequent additions made to it by the founder, at least three
millions of dollars, yielding an annual revenue of $180,000.
Out of this income, the hospital building proper, an establishment for convalescent patients, and a honie for colored orphans
are to be erected, after which the income will be applied to their
support, as indicated in the letter. The means thus available we
believe will be ample to execute the trust with as much speed as
a due regard for doing it carefully will justify.
You should also be told more fully than is done in the letter,
that the founder of the hospital, by his will, provided for the
establishment of a university, upon a site also devised by him,
distant about a mile from the hospital. To the uses of this institution he has also dedicated over three millions of dollars of his
fortune, and he looked to the hospital as furnishing a most desirable aid to medical education in the university.
These preliminary statements are made in order that youl may
have a full view of the subject about which we now seek your
advice.
It will readily occur to you that the subject most prominent
at this day, in the professional consideration of the Hospital
question as applicable to cities, is the choice between the pavilionz system, which admits buildings of two or more stories in
height, permanently constructed, of which the Herbert Hospital
in England and several in this country may be considered good
modern types; and the barrcatck system of one story structures,




LETTER OF THE PRESIDENT.                Xi
destructible in whole or in part, which were so successfully used
in the late war, but of which no extensive and prominent example
is now in operation. In determining the claims of these systems
respectively, as applicable to us, careful regard should be had
to the character of patients intended to be the subjects of our
nursing, so as to avoid the error of building an institution which
shall prove not to meet the requirements demanded in the care
and cure of women and children, and the generally enfeebled inhabitants of the sheltered lanes and alleys of a city, however
much such a structure may have been a success when applied to
the uses of hardy men in the field.
We presume there must be sonme general principles of hospital
hygiene and of hospital treatment fixed and immutable in their
character, the discovery and proof of which are the result of
close, careful recorded observation and judgment. If these principles can be best applied through the agency of the pavilion
system, we wish to adopt that; if by the barrack system, then
we will avail ourselves of that form of construction, and if the
true rule for our guidance shall be found in the selection of tile
good features of each, and the combining of them all into a harmonious middle course, then we desire to make that selection
and combination.
In whatever plan may be adopted, we presume there will be no
departure from the now very general method of a central administration building, with wards for the treatment of the sick as
carefully separated therefrom and from each other as practicable. To the details of this building we especially invite your
attention:-the objects to be accommodated in it, the amount of
room to be given to each, and their location with respect to each
other for convenience of use.
Comprehended within these details will be the consideration of
the accommodations needed for the training school for nurses,
and whether they should be within the Hospital building or
separated from it; and as the Hospital will be used for clinical
teaching to the medical classes of the University, it will be needful to consider what accommodations that subject will require,
and how and where they should be provided.
As closely connected therewith we should be glad to have your
advice as to the most judicious location of the medical school
buildings of the University; that is, whether they should be in




xii             LETTER OF THIE PRESIDENT.
close proximity to the Hospital, or whether they can, with equal
profit and convenience, be erected with the other buildings of the
University, a mile distant.
In the same general category of things to be provided would
be included suitable appliances for promptly and efficiently caring for accident cases, so numerous in a large city, and a dispensary for out-of-door relief, both by the dispensing of medicines and the giving of medical advice.
In the treatment of these subjects, it is not to be expected that
you will present architectural drawings, but if your views can
be illustrated by such suggestive sketches as your pen or pencil
can throw off in aid of your thoughts, they will be gratefully
received and placed in the hands of our architect for more elaborate expression.
Certainly not second in importance to any of the matters you
are invited to instruct us upon, are those of ventilation and heating, and the kindred subjects of light and sunshine, as curative
agents. The various methods of heating, combined with ventilation, form professional problems about which the most experienced and best informed medical minds seem to be far from
being united.  Whether heating should be accomplished by
steam or hot water pipes radiating their heat directly into the
room, or by the same agency imparting heat to air in chambers,
to be thence sent into the apartment to be warmed; or by open
fires in the angles or sidewalls; or by ventilating stoves in the
centre of the ward, or by a combination of these methods, are subjects upon which opinions widely differ; —and whether vtenilationz
should be accomplished by what is called the natural method,
through doors, windows, and unavoidable leakages;-or through
flues and ducts acted upon by the differing temperature of the
outer and inner air, or by enforced currents set in motion by
fans, blowers, or other mechanical contrivances, are points which
have equally learned advocates and opponents. To solve for
ourselves these difficult problems, we invoke the aid of your
experience and thoughtful judgment.
The location of the kitchen and its appurtenant offices is a subject of great practical importance, upon which new and, so far
as we know, hitherto untried suggestions have been made.
Whether it should be in a separate building from those devoted
to administration or to the nursing and care of patients, or in




LETTER OF THE PRESIDENT.              xiii
the basement of some one of them, or in the upper story of any,
are points open to discussion and to be carefully considered.
Upon the subject of matnagement, with its numerous details
of medical attendance, resident and occasional, nursing, domestic
service, police regulations, etc., etc., we should be glad of any
advice, and, indeed, with reference to the whole matter, our wish
is to put you in our place so far as to learn from you how you
would execute the trust we are now seeking to be instructed
about, if it were confided to you.
We beg you to consider what has been said as mere suggestions of some of the topics to be considered, and not as limitations either upon the subjects to be treated or upon your mode
of treating them, and we ask your zealous co-operation in this
humane subject to which it is understood vou have given great
attention.
It is right that you should also know that besides the request
now made to you, a copy of this letter has been addressed to
four other distinguished members of your profession, whose
communications in reply, together with yours, will be printed in
a volume for our private use, and for such useful distribution as
so valuable a contribution to medical literature will be well
entitled to.
It only remains for us to add, that if you will kindly serve us
and the cause of suffering humanity, in the way we have indicated, we shall hope to receive your paper by the 1st of May.
Please acknowledge the receipt of this, and oblige
Very respectfully yours, etc.,
FRANCIS T. KING,
President of Board of Trustees.








LETTER OF JOHNS HOPKINS TO THE TRUSTEES.
BALTIMORE, IMarch 10, 1873.
To FRANCIS T. KING, PresidZent, ancd JOIIN W. GARRETT, ionz. GEORGE W. DOBBIN,
GALLOWAY CHESTON, THOMAS A. SMITH, WILIARm HOPKINS, RICHARD M.
JANNEY, JOSEPIr MERREFIELD, FRANCIS WHITE, LEWIS N. HOPKINS, ALhAN P.
SMITH, and CHARLES J. M. GWINN, 1r)ustees of "' the Johns Hopkins Hospital."
GENTLEMEN: —I have given you, in your capacity of Trustees,
thirteen acres of land, situated in the city of Baltimore, and
bounded by Wolfe, Monument, Broadway and Jefferson streets,
upon which I desire you to erect a Hospital.
It will be necessary to devote the present year to the grading
of the surface, to its proper drainage, to the laying out of the
grounds, and to the most careful and deliberate choice of a plan
for the erection and arrangement of the buildings.
It is my wish that the plan thus chosen shall be one which will
permit symmetrical additions to the buildings which will be first
constructed, in order that you may ultimately be able to receive
four hundred patients; and that it shall provide for a Hospital,
which shall, in construction and arrangement, compare favorably
with any other institution of like character in this country or in
Europe.
It will, therefore, be your duty to obtain the advice and assistance of those, at home and abroad, who have achieved the greatest success in the construction and management of Hospitals.
I cannot press this injunction too strongly upon you, because
the usefulness of this charity will greatly depend upon the plan
which you may adopt for the construction and arrangement of
the buildings.
It is my desire that you should complete this portion of your
labor during the current year, and be in readiness to commence
the building of the Hospital in the spring of 1874.
It will be your duty, hereafter, to provide for the erection,
upon other ground, of suitable buildings for the reception,
maintenance and education of orphan colored children.




xvi              JOHNS HOPKINS' LETTER.
I direct you to provide accommodation for three or four hundred children of this class; and you. are also authorized to
receive into this asylum, at your discretion, as belonging to such
class, colored children who have lost one parent only, and, in
exceptional cases, to receive colored children who are not orphans, but who may be in such circumstances as to require the
aid of the charity.
I desire that you shall apply the yearly sum of twenty thousand dollars, or so much thereof as may be necessary, of the
revenue of the property which you will hereafter receive, to the
maintenance of the Orphan's Home intended for such children.
In order to enable you to carry my wishes into full effect, I
will now, and in each succeeding year during my life, until the
hospital buildings are fully completed, and in readiness to receive patients, place at your disposal the sum of one hundred
thousand dollars.
In addition to the gift, already made to you, of the thirteen
acres of land in the city of Baltimore, upon which the Hospital
will be built, I have dedicated to its support and to the payment
of the annual sum1 provided to be paid for the support of thle Orphans' Home, property which you may safely estimate as worth,
to-day, two millions of dollars, and from which your corporation
will certainly receive a yearly revenue of one hundred and twenty
thousand dollars; and which time and your diligent care will
make more largely productive.
If the Hospital and Orphans' Home are not built at my death,
it will be your duty to apply the income arising from the property so dedicated to their completion. When they are built the
income from that property will suffice for their maintenance.
The indigent sick of this city and its environs, without regard
to sex, age, or color, who may require surgical or medical treatnment, and who can be received into the Hospital without peril to
the other inmates, and the poor of this city and State, of all
races, who are stricken down by any casualty, shall be received
into the Hospital, without charge, for such periods of time and
under such regulations as you may prescribe. It will be your
duty to make such division of the sexes and patients among the
several wards of the Hospital as will best promote the actual
usefulness of the charity.
You will also provide for the reception of a limited number of




JOHNS HOPKINS' LETTER.               xvii
patients who are able to make compensation for the room and
attention they may require. The money received from such persons will enable you to appropriate a larger sum for the relief of
the sufferings of that class which I direct you to admit free of
charge; and you will thus be enabled to afford to strangers, and
to those of our own people who have no friends or relations to
care for them in sickness, and who are not objects of charity, the
advantages of careful and skilful treatment.
It will be your especial duty to secure for the service of the
Hospital, surgeons and physicians of the highest character and
greatest skill.
I desire you to establish, in connection with the Hospital, a
training school for female nurses. This provision will secure the
services of women competent to care for the sick in the Hospital
wards, and will enable you to benefit the whole community by
supplying it with a class of trained and experienced nurses.
I wish the large grounds surrounding the Hospital buildings
to be properly enclosed by iron railings, and to be so laid out
and planted with trees and flowers as to afford solace to the sick,
and be an ornament to the section of the city in which the
grounds are located.
I desire that you should, in due season, provide for a site and
buildings, of such description and at such distance from the city
as your judgment shall approve, for the reception of convalescent
patients.
You will be able in this way to hasten the recovery of the sick,
and to have always room in the main Hospital buildings for other
sick persons requiring immediate medical or surgical treatment.
It is my especial request that the influences of religion should
be felt in and impressed upon the whole management of the Hospital; but I desire, nevertheless, that the administration of the
charity shall be undisturbed by sectarian influence, discipline,
or control.
In all your arrangements in relation to this Hospital, you will
bear constantly in mind that it is my wish and purpose that the
institution shall ultimately form a part of the Medical School of
that University for which I have made ample provision by my
will.
I have felt it to be my duty to bring these subjects to your




xviii            JOHNS HOPKINS' LETTER.
particular attention, knowing that you will conform to the wishes
which I thus definitely express.
In other particulars I leave your Board to the exercise of its
discretion, believing that your good judgment and experience in
life will enable you to make this charity a substantial benefit to
the community.
I am, very respectfully, your friend,
JOHNS HOPKINS.




EXTRACTS FROM JOHNS HOPKINS' WILL AND THE
CODICILS THERETO.
"I give, devise, and bequeath unto' The Johns Hopkins Hospital,' a corporation formed at my instance, under the laws of
Maryland, by Certificate recorded among the Records of Baltimore City, all the real and leasehold estate, not hereinbefore
specifically disposed of, and wheresoever the same may be situate, of which I may die seized, or possessed, and also all the
Bank stocks, owned by me, at my death, in Banks located, or
doing business within, or beyond the limits of this State, to be
held, used, and applied by the said'The Johns Hopkins Hospital,' in and for and to its coroprate purposes, in accordance
with the provisions of its existing Certificate or Charter of Incorporation, or with the provisions of such Act, or Acts of Assembly,
amending its Certificate or Charter of Incorporation, as the Trustees thereof, acting upon my recommendations hereinafter made,
may see fit to procure to be passed and accepted.
And as I aml of the opinion that the ward, or building, to be
under the control of the said Hospital, which is to be erected
for the reception and care of colored orphan children, ought also
to be opened for the reception and proper training of destitute
colored children, and that said ward ought, moreover, to be separated wholly, and built at a distance from, the wards, or buildings in.tended for sick poor white persons, or sick poor colored
persons, I do recommend the trustees of the said'The Johns
Hopkins Hospital,' to apply to the Legislature of Maryland for
authority to build the ward, or building, intended for the reception and care of the orphan colored children, in a locality different from that selected for the use of the wards for sick poor
white persons, or of sick poor colored persons; and also for
authority to receive and care for destitute colored children, in
such building, erected for the reception and care of orphan colored children; but it shall be the duty of the said trustees of the




XX                 JOHNS HOPKINS' WILL.
said'The Johns Hopkins Hospital,' to supervise the concerns,
interests, and wants of all the several wards, or subdivisions, of
the said'The Johns Hopkins Hospital,' wherever the said
wards, or subdivisions, may be located, in such manner that the
interests and wants of each of said subdivisions, or wards, may
be fully and impartially protected and promoted.
"And I desire that the said trustees of the said'The Johns
Hopkins Hospital,' shall make ample provision out of the property, real and personal, by this my last will and testament
devised and bequeathed to the said' The Johns Hopkins Hospital,' not only for the ward, or building, intended for the use of
sick poor white persons, and for the care of such inmates, but
also for the ward, or buildings intended for the use of sick poor
colored persons, and for the care of such inmates, and for the
ward, or building intended for the reception and care of colored
orphan and destitute children, as aforesaid."
*   %   %    * *        *   %    +   %   *   *
"I do further declare that it is my wish that the trustees of'The Johns Hopkins Hospital' shall apply to the Legislature
of Maryland for such additional authority as they may require
to enable them to educate the orphan and destitute colored children by them received into their charge, and shall use and employ
such portion of the nett income of the property (not exceeding
one-fourth part thereof, however) devised and bequeathed to them
by me, as may be necessary to enable them to perform the duty
of receiving, caring for and educating such orphans and destitute
colored children; and I do further direct that, when such authority is obtained, the same trustees shall expend such portion of
the said one-fourth part of said income as may be necessary in
the reception, care, and education of said orphan and destitute
colored children.
"'And I also declare it to be my wish that my said trustees shall
also apply for such additional authority as they may require, to
enable them to provide proper and respectable employment for
such orphan and destitute colored children so by them received
and cared for, when such children shall arrive at a suitable age."
"Now I do hereby revoke the said devise and bequest so made
of all the rest, residue and remainder of my estate, and I do
hereby give, devise, and bequeath all the said rest, residue, and




JOHNS HOPKINS' WILL.                 Xxi
remainder of the estate, real and personal, of which I shall be
seized, or possessed at my death, of whatsoever nature and
description the same may be, to' The Johns Hopkins University' and to'The Johns Hopkins Hospital,' as tenants in common, and not as joint tenants, to be equally divided between
them, share and share alike; the share of each corporation in the
said rest, residue, and remainder of my real and personal estate
to be held, used, and applied by such corporation in, for, and to
its corporate purposes, in accordance with the provisions of its
existing certificate, or charter of incorporation, or with the provisions of such Act or Acts of Assembly amending its certificate
or charter of incorporation, as the trustees thereof may procure
to be passed and accepted."








HO SPITAL CONSTRUCTION
AND  ORGANIZATION.
JOHN S. BILLINGS,
Bvt. Lt.- Cot. and Asst. Surg., U.S.A.




CONTENTS.
PAGE
I. RELATIONS OF THE MEDICAL SCHOOL TO THE HOSPITAL................. 3
II. ORGANIZATION AND GENERAL PLAN OF MANAGEMENT.................... 6
III. ON  THE  CAUSES OF HOSPITALISM, OR  THE HURTFUL INFLUENCE OF
HOSPITALS......1...........................................11
IV. TEMPORARY VERSUS PERMANENT HOSPITALS............................ 15
V. HEATING AND VENTILATION.............................................19
VI. BUILDINGS............................................................ 26
ADMINISTRATIVE BUILDINGS................................... 33
VII. GENERAL PLAN OF HOSPITAL....................................... 39
METEOROLOGICAL RECORD OF THE WEATHER AT BALTIMORE, MARYLAND................................................................ 44




HOSPITAL CONSTRUCTION
AND ORGANIZATION.
JOHN  S. BILLINGS,
Bvt. Lt.-Col. angd Asst. Surg., U.S.A.
I. RELATIONS OF THE M1EDICAL SCHOOL TO THE HOSPITAL.
IN attempting to prepare a plan for the organization and construction of a Hospital at Baltimore, under the provisions of the
Johns Hopkins' Trust, it is necessary first to consider the probable organization of the Johns Hopkins' University, for the reason
that the plan of the Hospital must depend upon the extent to and
the manner in which it is to be used as an instrument of medical
education, and upon the more or less intimate connection which it
is to have with the Medical School.
If the course of medical education proposed is to be that usually given in this country, and to the class of students which
form the majority of those now attending our medical colleges, it
will be extremely difficult, if not impossible, to devise a Hospital
which shall equally subserve the best interests of the patients and
the convenience and wishes of the students and professors.
I am decidedly of the opinion, however, that we have at present in the United States not only enough, but too many of the
ordinary sort of medical colleges, and that the opportunity which
is now presented of forming an institution for medical instruction
which, being entirely independent of students, can therefore
afford to consult their welfare instead of their wishes, is one of
which an attempt should be made to take the fullest advantage,
and such, I have reason to believe, is the intention of the trustees.
It seems to me that this school should aim to produce quality,




4                BILLINGS.-PLANS FOR THE
and not quantity; and that the seal of its diploma should be a
guarantee that its possessor is not only a well-educated physician, in the fullest sense of the word, but that he has learned to
think and investigate for himself, and is therefore prepared to
undertake, without danger of failure from not knowing how to
begin, the study of some of the many problems still awaiting solution.
It is not desirable that the classes should be large. In fact, as
the results of such a school become manifest and the value of its
diploma is understood, they may become too large for convenience
in practical clinical instruction. A class of half a dozen such as
I would wish the graduates of this school to be, would be a more
satisfactory result for a year' s labor than as many hundred turned
out on the ordinary pattern.
The means of attaining this end are sufficiently well known: a
high standard for admission; a four years' course; rigid and impartial examinations, preliminary, intermediate, and final; and
practical work in the laboratory and apothecary's department,
the microscope and photograph rooms, and the dispensary and
wards of the Hospital.
If this be the sort of Medical School intended, there are no difficulties in connecting the Hospital with it. It would really belong more properly to the Hospital than to the University, and
while, for hygienic and business reasons, the school building
should not be on the hospital grounds, it should not be far away.
An important feature of the school should be a first-class Physiological Laboratory, with ample facilities for chemical and microscopical work. This should be connected with the Pathological
Department of the Hospital, and the assistance rendered will be
great and mutual. If we are ever to advance in accurate knowledge of the laws of health and disease, it will be by the application of instruments of precision and of graphic measurement to
the secretions and motions of the body, healthy and morbid, and
for this purpose we must have the apparatus and the patients
near each other.
The Professors of the Medical School should furnish the medical and surgical advice required for the Hospital and Dispensary;
the Resident Physicians should be graduates of the Medical
School, selected by competitive examinations (the Physician-inCharge, of whom I shall speak presently, should be a member of




JOHNS HOPKINS' HOSPITAL.                5
the Examining Board, as the representative of the interests of
the Hospital); and the students should be employed as much as
possible in the Pharmacy, Dispensary, Wards, and Pathological
Department.
The true interests of the Hospital and of the Medical School
seem to me to be not only perfectly compatible but inseparable.
The objects of the Hospital as indicated by its founder are,
first, to properly care for the sick poor; second, to aid in the
education of Physicians and Nurses. Such an institution may
have a third object, to which I wish to call special attentionnamely, to promote discoveries in the science and art of medicine,
and to make these known for the general good. In this country
it is too much the case that scientific and medical men who
are qualified and have the desire to make original investigations,
and thus increase our stock of knowledge, want either the means
or the time to do so, and it is to young and energetic men, qualified and selected as I have above indicated, and working under
the direction of such men as it is hoped the Professors of the
school will be, that we must look for the scientific observation
and information so much needed to increase our power of healing
or comforting the sick.
I must remark, however, that if the Attending Physicians, or
the Resident Physicians, or both, be expected to attend to, and
advise as to the hygienic management of the Hospital, the result
will probably be a failure. Their thoughts and studies will be
for the most part directed to other subjects, and the minute supervision which is necessary to insure the continued healthfulness of the institution cannot be obtained from them.
The supervision I refer to must not be occasional and partial,
but must include an almost daily inspection of the entire establishment, with power to remove and remedy nuisances and evils
promptly and effectually.
I consider this more important than almost anything connected
with the Hospital, and the plan of the institution must depend
upon its probable presence or absence. If the management of
the details of such an establishment is to be entrusted to nonprofessional hands, or to physicians who have, or ought to have,
other duties and interests, it is desirable to prepare a plan in
which the evil results which may be expected shall be as little
permanent and expensive as may be.




6                BILLINGS.-PLANS FOR THE
II. ORGANIZATION AND GENERAL PLAN OF 3MANAGE3MENT.
I recommend that the organization of the Hospital shall be on
the Military or Railroad plan, i.e., that it shall have one head,
and only one, who shall receive his directions fronm, and be responsible directly to the Board of Trustees, and that all orders
and instructions which the Board may make relative to the discipline and internal management of the Hospital shall be issued
through him. This Officer should be a competent medical man,
and a man of executive ability. He should have charge of the
Hygiene of the Hospital in general and particular, should assign
and prescribe the duties of the employees, assign patients to
their places, and remove them to other places as he may deem
necessary. The subjects of temperature, light, air supply, and
disinfection should be his special charge; in short, he should be
the Health-Officer of the Institution, as well as its official head.
He should not appoint employees, or make purchases, nor should
he be connected with the Medical School. All requisitions for
supplies of any kind should be approved or signed by him, and
all accounts should pass through his hands. I shall call this
Officer the "Physician-in-Charge. "
I further recommend that this Officer shall be selected as soon
as possible in order that he may advise during the construction
of the Hospital as to the many details concerning which questions will arise, and all of which cannot be foreseen. He should
confer with the Managers and Superintendents of the principal
hospitals in this country, and prepare a plan for the management
of the Hospital, including a full set of rules and regulations, to
be submitted to the Board with all the information he may obtain on the subject. It would also well repay the Board to send
this Officer at such time as he could best be spared, prior to the
completion of the Hospital, to personally examine the various
systems of management and discipline of the principal hospitals
of this country and of Europe, and while in Europe he should
select certain instruments, books, and apparatus for the institution, and should make a complete collection of the rules, regulations, blanks, records, etc., in use in the various hospitals.
If a suitable man be obtained, the plan which he will submit to
the Board, with the accompanying documents, will be of much




JOHNS HOPKINS' HOSPITAL.                   7
more practical value than any set of rules which can now be presented.
Nevertheless, it is necessary to refer to some details under this
head, in order that the plan for the construction of the Hospital
may be understood.
I would recommend, then, that there be one Resident Physician
to every fifty (50) patients, one or two for the Dispensary for Outdoor Relief, and one in the Pathological Laboratory. To each of
these physicians I would allow two students, to be changed in
rotation according to the number available.  The Apothecary
should also have two students. When the Hospital is completed
there would thus be 22 students employed, and it will probably
be some time before the school will have a much larger graduating class than this.
The separate branches of administration will require a steward,
charged with purchases and property responsibility; a wardmaster, charged with the execution of orders relative to disinfection,
isolation, etc., and with the supervision of Inale employees; a superintendent of female nurses, an engineer, an apothecary, and a
chief cook. All of these report to the Physician-in-Charge, or
through him to the Board.
Inasmuch as the Training School for Nurses is to be connected
with the Hospital and will be controlled by the same authority,
the greater part of the nurses should be females. They should
have a separate building, which may be on or near the hospital
grounds. -Y
A number of clerks, messengers, ward orderlies, and laborers
will be required, for whom accommodation must be provided.
As a very important part of the training of a nurse consists in
teaching her how to prepare and serve food properly, it may be
a question how far they should be employed in the main kitchen
of the Hospital. If a suitable woman can be obtained for chief
cook, the main kitchen would be a valuable aid to the TrainingSchool. I have never seen such a woman, and my personal experience in large hospitals is that it is better to employ as chief
cook a first-class man, in which case the instructions of the nurses
in cooking will be mainly given in the diet-kitchens attached to
the wards.
* [NOTE.-Attention is invited to an account of the Dresden Nursing Association by
Dr. Fleming, in the Glasgow Medical Journal for April, 1875, and especiallyto the mode
of instruction there indicated for female nurses.]




8                BILLINGS.-PLANS FOR TIE
I recommend that no Chaplain be appointed, although a chapel
should be provided.
We now have to consider the rules and regulations which
should govern the admission of patients.
By the terms of the letter of Mr. Hopkins explaining the design of the trust, it appears that patients of all colors, both sexes,
and all ages are to be admitted, provided in the case of any applicant that his admission shall not imperil the other inmates. It
is probable that this last phrase was intended to apply to cases
of specific contagious disease, such as Scarlatina, Small-Pox, etc.
But what shall be done in cases of Diphtheria, Erysipelas, Gangrene, Typhoid Fever, Puerperal Cases, and others, of the danger of which there is little doubt, under certain circumstances?
To reject all cases which might possibly be a source of danger to
the inmates would greatly restrict the usefulness of the charity,
and would leave unassisted precisely those which have the greatest need of aid, not only for their own sake, but for that of the
health and welfare of the community.
It should be remembered that not even the most careful selection will entirely prevent the appearance of contagious disease in
the Hospital, and if Erysipelas or Diphtheria appear the cases
must be provided for. If we could be assured that no contagious
or infectious diseases would occur in the Hospital, it might be
worth while to consider the question of excluding all applicants
affected with them, for the problems of construction would be
greatly simplified by so doing. As we cannot have this assurance, we must make provision for such cases, and, having done
this, I would recommend that they should be received in all cases
where it shall appear that suffering to the patient and danger to
the community will result from rejecting them. I advise this
without hesitation, because I am well satisfied that it is possible
to receive and treat such cases without special danger to the inmates of the Hospital, as will be explained hereafter.
It will probably be found desirable that the Board shall have a
Central Office in the city, where orders for admission can be
granted. This Office should be connected by telegraph with the
Hospital. There should be two ambulance-wagons at the Hospital, or, if convenient, one may be kept, at least during the day,
near the Central Office. The bodies of these ambulances should
be iron skeleton frames, with linings of wood and leather which




JOHNS HOPKINS' HOSPITAL.                 9
can be easily removed, being divisible into several parts. The
litters should be woven wire mattresses.  Whenever an ambulance is used for a doubtful case, the whole lining of the vehicle should be taken apart and passed through the disinfecting
chamber.
The Physician-in-Charge, or in his absence the Medical Officer
of the day, should have the power to admit cases of emergency,
or such as may be selected from the dispensary patients.
Upon his arrival at the Hospital the patient should be examined by the Medical Officer of the day, who in case of doubt will
call upon the Physician-in-Charge for decision.
After the patient has been assigned to a numbered bed in a
ward, he should be subjected to a bath and be furnished with a
suit of clean hospital clothing before being taken to his bed.
When I say "subjected to a bath " I mean that in most cases
a nurse, male or female, as the case may require, shall superintend the giving of the bath and see that the cleansing is
thoroughly performed. At the same time the attendant should
note the condition of the skin, especially as to the presence of
sores, ulcers, or disease of any kind, for the information of the
physician.
The patient's clothing should be disinfected, and cleansed before being placed in store, or be at once destroyed by fire if it
seem proper to do so. Provision must be made for furnishing
clothing in place of that destroyed, when the patient leaves the
Hospital.
For the accommodation of pay and private patients special
accommodations are to be provided. These should be of several
grades.
For patients of means, who desire privacy and who are willing to pay for it, several suits of rooms should be provided,
entirely separate from the wards, and near the administrative
building.
Others of a lower grade are to be provided in connection with
the wards.
The system of records of the Hospital, financial, historical, and
professional, should of course be as complete as possible.
A perfect system of records should show not only the history
of each patient, but of each ward and each bed. For instance,
giving each bed a number and the furniture of that bed a corre



10              BILLINGS. —PLANS FOR THE
sponding one, if two successive cases of septicaemia or erysipelas
occurred in the same bed we should have some clew as to the
causes of such diseases.
I recommend that as soon as the Hospital is completed and
organized, there be undertaken the publication of an annual
volume of reports similar in character and plan to those issued
by Guy's and St. Bartholomew's Hospitals. This volume should
contain accounts of the more interesting cases treated in the Hospital and Dispensary, and records of original investigations made
by the Resident Physicians and Students.  If every student
graduating in the, Medical Department were required to prepare
a thesis which should contain some original observations or investigations, this volume would be a proper means of their publication. It should be edited by a committee of the Professors of
the Medical School, to which should be added the Physician-inCharge of the Hospital.
The Dispensary for Out-Door Relief should be connected with
the building designed for the instruction of students, which
should be entirely separated from the main administration building.
If the Medical School be organized upon the plan which I have
indicated, the greater part of the clinical instruction will be
given in the Wards and in the Dispensary; and not in the Amphitheatre which will be used mainly for surgical operations
and for walking cases, that is, patients not confined to their
beds.
It is very seldom that it is desirable to bring a patient confined
to his bed into the Amphitheatre except for a surgical operation,
and the Physician-in-Charge of the Hospital should have the
power of preventing the taking of any given patient to the Amphitheatre.
For surgical operations it is usually much better that the patient should be taken to the Amphitheatre, not on account of the
students so much as because of the special facilities of room,
light, and apparatus there provided for such purposes.
For the Dispensary for Out-Door Relief there will be required
two or three waiting-rooms for the patients, and several rooms
for the Physicians' use. The more subdivision is made in this
Department, by affording facilities for special branches, as for
diseases of the Eye and Ear, the Throat, the Skin, diseases of




JOHINS HOPKINS'S  HOSPITAL.              11
the Nervous System, etc., the better will be the results, and space
and conveniences should be provided for such classification.
The only objection to removing the Dispensary from the administration building is that it makes it desirable, although not
absolutely necessary, to have two Pharmacies. As this gives a
place for another student or two, selected from those who have
received a sufficient training from the Hospital Apothecary, and
as the Dispensary Pharmacy will not require a large stock of
drugs, or fittings, I do not think this objection of much weight.
It is moreover desirable that the accounts of expenses for the
Dispensary should be kept separate from those of the Hospital,
which will be made easy by the arrangement proposed.
In connection with this part of the institution, though not permanently in the same building, I think it is most important that
there should be a Pathological Laboratory, with facilities for
microscopic and photographic work.
The value of the Hospital with regard to the welfare of the
patients, as an aid to the Medical School, and as a means of promoting improvement in the science and art of Medicine, will depend largely upon the perfection with which this part of the institution is equipped and organized, and upon the regulations
which govern its use, and especially the recording of the work
performed in it.
III. ON THE CAUSES OF HIOSPITALISI, ORn THE HIURTFUL
INFLUENCE OF HOSPITALS.
The air in a hospital ward is made. impure and hurtful in two
very different ways.
First, it is contaminated with gases derived from the lungs
and bodies of the patients, fromn the decompositions of their secretions and excreta, and from  the products of combustion.
These gases are carbonic oxide, and carbonic acid, sulphurettedl and phosphuretted hydrogen, and ammonia and its compounds and substitution products.
These gases seldom exist to a dangerous amount, and their sufficient dilution with fresh air prevents them from being injurious
to health.
The second kind of contamination in a hospital consists of
minute particles of solid or semi-solid insoluble matter, derived




12                 BILLINGS.-PLANS FOR TTHE
directly or indirectly from the bodies of the patients, of which
they once formed a part. Some of these particles, if placed in
contact with a living surface, as of the mouth or lungs, or of a
wound, will either grow and reproduce themselves, or they will
change the mode of action of the part with which they come in
contact, or they may do both, and in either event will affect the
blood, and weaken or alter the natural process of life; in other
words, they will cause or aggravate disease.
It is to these particles, known as disease germs, contagia, microzymes, micrococci, bioplasm, germinal matter, etc., according
to the different theories which are held as to their nature and
mode of action, that are supposed to be due the majority, if not
all, of the contagious and infectious diseases, including those
specially prevalent in hospitals and referred to in the term
"Hospitalism."
In certain diseases of the skin and in a peculiar affection of the
ear, we have strong reasons for believing that the causes or conveyers of the disease are certain minute fungi, but the majority
of the contaoia are probably rather animal than vegetable in their
nature.
If subjected to warmth and moisture they rapidly decompose
and lose their specific powers, but if partially dried, they retain
their vitality (if the term may be -used) for a long time, very
much as dried yeast does, and after the lapse of weeks —or in
some cases of years-will act in the presence of moisture and
warmth very much as they would in the hour of their first separation from the body.
I am satisfied that I have seen scarlatina produced by some of
these particles which had been preserved in a blanket carefully
packed away for four years. They resist the action of cold and
of weak alkalies, such as soap and water, to a surprising degree,
indeed in some cases they seem to gain new powers in the latter
fluid, which is not a desirable cleansing agent in a hospital.
They are destroyed by a sufficiently high temperature, or if
moist, by chlorine, sulphurous acid, and ozone; and by a number of agents known as disinfectants.
Whatever may be the opinions held as to the nature of these
diseased germls, and their mode of origin and propagation, they
are what we have to fear and to provide against in the construetion of a hospital. They are on and i the dressings, thhe sponges,




JOHNS HOPKINS' HOSPITAL.                   13
the instruments and apparatus, the bedding and clothing of the
patients, the persons and clothing of the physicians and attendants. The finger-nails of the latter are full of danger. Wherever
there is a ledge, or projection, or crack in the ward, these invisible particles are liable to lodge, and becoming dried, to be displaced by currents of air.  Under certain circumstances it is
probable that a single one of these particles is sufficient to set up
a morbid process if brought in contact with the living body.
For some of them, as in Small-Pox, the results are the same, or
nearly the same, no matter where or in what succession they are
applied; for others, as in Erysipelas and septicaemic poisoning,
or inflammations of mucous membranes, the results vary according to locality of affection, and to modifications of the germs
by their parents.  That is to say, an Erysipelas germ  may
give rise to puerperal fever, and this again to fatal septicmmia
if inoculated through a scratch on the finger of the attendant.
It is very desirable that this subject of contagiim  should be
clearly understood in this connection, and that the above statements should be considered not as theories, but as an account
of facts which it is easy to verify.
It is particularly necessary to remember that one of these
particles cannot be diluted.
We may by diluting the air remove a certain number of the
germs, with the effect that in a cubic foot of air there shall be
but ten. instead of one hundred, and that therefore the probabilities of coming in contact with one are correspondingly diminished; but if it chances that one particle falls on the wound, the
results will be nearly the same as if no dilution had been made.
If you are standing on a plain across which a file of men are
firing, your chances of escape are of course better if there are
but ten men shooting instead of one hundred; but if one of the
ten does chance to hit you, the practical difference will probably
not be appreciable.
The experiments of Chauveau, on the effects of dilution of the
Virus of Sheep-Pox, show that when this is diluted with ten
thousand (10,000) times its bulk of water, about one inoculation
out of twenty will take effect, and the results will be the same
as if undiluted matter were used (showing conclusively that
the contagion cannot be soluble, but must consist of extremely




14                 BILLINGS.-PLA~NS FOR THE
minute particles suspended in the liquid).  I commend for
special attention in this connection a most valuable paper on this
subject by Dr. Burdon Sanderson, " On the Intimate Pathology
of Contagion," in the twelfth Report of the Medical Officer of the
Privy Council, 1869, and his supplementary Report on the same
subject in the Report of the following year.
During the years 1867 and 1868 I was engaged in a series of investigations on the minute fungi, bacteria, and microzynmes of
various kinds as causes or carriers of disease; and I can from
personal experience and observation confirm the majority of Dr.
Sanderson's observations with regard to these minute organisms.
No system of diluting the air of an hospital ward will give absolute security from the action of contagion, and we can therefore understand why it is that the usual mode of ventilation can
never afford perfect security against the hospital diseases, not
even if we double the cubic space, and triple the air supply
-sually considered sufficient.
Furthermore, the ordinary processes of disinfection will not
certainly destroy all these contagia under the conditions in which
they are found in a hospital ward. The gaseous disinfectants,
such as sulphurous acid, chlorine, and ozone, probably have
little action on dried albuminoid matter such as forms a pseudomembranous investment of these organic particles after a brief
exposure to, warm dry air. If a good, but dry vaccine crust
were placed. in. a room, and that room were filled with slpilhurous acid or chlorine gases in the ordinary way, I do not think
that the specific vitality of the crust would be materially injured
except by a very long exposure.
Andt if liquid disinfectants be used it is very difficult to apply
them so thoroughly and. universally as to give the desired security.
We know by experience that if a number of men affected with
rheumlatism, disease of the heart, organic disease of the stomlach,
paralysis, etc., are placed together in a ward, the danger of Hospitalism and infection arisingamong them is exceedingly small,
not greater probably than would be produced by placing- a like
number of well men under the same circumstances. But if we
place in that ward cases of fever, or of inflammnatory disease of
any of the mucous membranes, as of the throat, lungs, intestines, etc., we have introduced an element of Halnger. By vyen



JOHNS HOPKINS  HOSPITAL.                 15
tilation and thorough scientific cleanliness this danger may be
almost wholly averted, and this is the theory of good hospital
management as usually taught.
-It will no doubt occur to any one reflecting on this matter that
it would be well to isolate these dangerous elements, and that
the old proverb about the "ounce of prevention," etc., may be
properly applied in such a case. And there is no doubt that it
would be well, so far as the patients are concerned at least, to
carry their classification and corresponding separation to a much
greater degree than is done in the majority of.hospitals.
IV. TEMPORARY VERSUS PERMANENT HOSPITALS.
A number of large, carefully planned, and costly hospitals
have been erected within the last twenty years, in which all the
recommendations of those who have given most ~ attention to the
subject have been carried out, including isolated wards or what
is called the pavilion plan, with impervious walls and floors,
abundant air space, and careful provision for ventilation.
But with all this, it is believed by many, and is confidently
asserted with appeals to statistics, that the results given by these
institutions have not been commensurate with the labor, money,
and ingenuity expended upon them.
After a time in many of these Hospitals,, and in some of them
very soon, some of the ill effects which physicians usually attribute to impure air and contagion, such as Erysipelas and puerperal diseases, or a tendency to slow and imperfect recovery in
ordinary maladies, have made their appearance, -:in which case
attempts at purification and disinfection have not: always been
successful.
The results of the experience of military surgeons with Wooden
Barracks and Tent-Hospitals, especially in the late war in this
country, and in the more recent contests in:Europe, led to the
recommendation that similar structures should be adopted for
all hospitals, not only for the reason that such structures are
more easily ventilated and disinfected, but on the ground that
any building continuously occupied by sick or wounded men
will become contaminated, that its walls and floors will themselves become sources of infection, that it will be,better to
destroy or abandon them when this occurs, and therefore, for




16                BILLINGS.-PLANS FOR TIHE
economical reasons, that they should be built cheaply with reference to such destruction.
A formulization of this doctrine was given in a "Report on
the Barracks and Hospitals of the Army," Circular NTo. 4, WTar
Department, Surgeon-General's Office, Washington, ID. C., 1870,
4to, pp. XXII.-XXIII., in the following words: " Our hospi"tals approach more nearly in size and character the so-called
" Cottage-Hospitals of England than any others. They are satis"factory in one respect, that they are almost all temporary hos"pitals. This I consider a decided advantage, as I believe that
"no hospital should be constructed with a view to its being used
" as such for more than fifteen years. If the money required to
"put up such structures as the New York Civil Hospitals, the
"Rhode Island Hospital, or the Cincinnati Hospital were divided
"into two equal parts, one-half being used to erect frame hospi"tals of the same capacity as the stone and brick hospitals
"actually built, and the other half being put out at interest at
"six (6) per cent., a complete new hospital could be furnished
"every twelve years for an indefinite period to come."
At the time when I wrote this, i.e., during the years 1869-1870,
I was on special duty in the Treasury Department, advising with
regard to the reorganization and reform of the Marine Hospital
Service, which at that time was in bad condition. One of the
reforms which was most urgently needed in that Department
was in the mode of constructing hospitals, which up to that
time had been very expensive, and with one exception, the new
Marine Hospital at Chicago, were built on very improper plans.
I was therefore urgent and persistent in recommendations to
the Secretary and to the Architect of the Treasury in favor of
the temporary plan, using especially the argument for economy
given above.
I have given this brief history in order that the motives which
prompted the recommendation of this temporary plan may be
understood.
It is certainly one way of solving the problem, and for certain
kinds of hospitals I believe it to be the best plan which can be
pursued.
But the statement that this temporary character should be
adopted for all hospitals, and especially all parts of hospitals,
was, I am now satisfied, too sweeping. That is to say: I do not




JOHNS HIOPKINS'  HOSPITAL.                    17
think it necessary that all the buildings of an hospital should be
destroyed or removed at certain regular intervals, in order to
prevent infection, and there are some things to be taken into account in favor of more permanent structures under certain circumstances to which I did not give sufficient consideration.
Barrack Hospitals are best suited for Government purposes,
for contagious and infectious diseases, and in general where
much subdivision of patients is unnecessary, where number
of attendants and cost of fuel is not taken into account, and,
as I have above remarked, for hospitals which are liable to be
mismanaged.
It must be remembered that Military Hospitals can usually be
placed where there is ample room  for separating the numerous
buildings which are essential to the Barrack plan, they receive
adult males only, and these of a better class than those entering
Civil Hospitals, in their management the interests of no AMedical School or other institution need be consulted, and above all
they are under the direct charge of a medical man selected for
the purpose, whose responsibility for and interest in their proper
condition is direct and personal, and whose power is very great.
It is an error to suppose that a Barrack Hospital will prevent
Hospitalism.'  Certainly in our large Army Hospitals we had
the Hospital Diseases, as every surgeon of experience knows, and I
have myself emptied a Barrack ward, and placed the men in tents,
on account of the appearance and persistence of septic disease.
I have seen a decided tendency to erysipelas and pysemia appear in a most characteristic Barrack ward, an unplastered building, with excessive ridge ventilation, within six weeks after it
was first occupied. The weather was warm and for a week there
was little wind, so that the process of natural ventilation was
unsatisfactory.
And I think that the experience of most Army Surgeons will
agree with my own, that for cases of wounds or acute fesvers
Tents are better than Barracks, and in warm weather that open
sheds are better than closed tents.  The great advantages of a
(1) Dr. Day (Australian Med. Journ., Aug., 1874) considers that wooden structures are
directly disinfectant by reason of their action on the Oxygen of the Air, producing
" Peroxide of Hydrogen." (Ozone?)-Such power of this kind as they may specially
have is due to the resins in the wood, and must be very small.




1.8                BILLINGS. —PLANS FOR TIHE
Barrack Hospital are: First, that it costs less, and will therefore be abandoned, destroyed, or modified with less hesitation
than a more costly structure; second, that the wards being but
of one story, it is easier to arrange the ventilation.
The question as to the number of stories is, however, totally distinct from that of the permanence of the structure, and will be
considered hereafter.
All the arguments in favor of a Barrack Hospital apply with
still greater force to one composed mainly of Tents.
There is little doubt that if all the wards of the proposed
Hospital be made temporary structures the result would be satisfactory in all respects except as to cost and appearance. There
need be no fear as to the possibility of properly warming and
ventilating W~ooden Barracks or even Tents in the coldest
weather; the real difficulty in ventilation will occur in warm, still'weather.
Two Barrack wards have been in use, winter and summer, at
St. Petersburg since 1871, and the results have been entirely satisfactory, so far as warmth and fresh air are concerned.  The
secret of properly heating such structures, or tents, consists in
placing the heating apparatus not in the room to be warmed, but
below it.
The objections to such hospitals are their inflanmmability, the
large space and increased number of nurses, attendants, and laborers which they require, the amount of fuel necessary, and the
difficulty of enforcing proper discipline among and supervision
of the employees and the patients, especially in the location proposed.
These objections are serious ones, and their full force can only
be appreciated by those who have had practical experience in the
management of such hospitals.
I am of the opinion that all the good qualities of a Barrack or
Tent Hospital can be combined with those of a permanent structure, in such a manner as to secure both the healthfulness of the
one and, to a considerable extent, the convenient and economical
administration of the other, and such a plan I will attempt to
indicate. I shall again refer to the temporary plan, and give a
sketch of how it may be arranged, after describing the several
buildings which will be required under either system of construction.




JOHNS HOPKINS' HOSPITAL.                19
V. HEATING AND VENTILATION.
With regard. to heating, it is necessary to keep in view the
peculiarities of the climate of Baltimore.
I append a- table (A) showing the average annual temperature
of Baltimore, with maxima and minima, for the last 45 years;
also a table (B) showing the monthly means, maxima and minima, for the last five years. Also table (C) giving the mean direction of the winds for the same period..
From these tables it will be seen that we have to provide for
temperatures varying from zero to about 100~ F.
For at least three months in the year special provision against
cold will be needed, and this, if ventilation is allowed, can only
be effectually secured by warming the air before it is admitted.
into the wards, which can best be effected by the use of hot water
or steam, in what is known as the method of indirect radiation.
The use of hot water on the low pressure system as a means of
heating is specially satisfactory in hospitals, for the reason that
the air is warmed by a large surface at a comparatively low temperature, which in the heating coils rarely need be over 150~ F. in
this locality, and air thus warmed is much more agreeable and
salutary than when heated to over 200~ F., as it must be by furnace or steam radiators. The principal objection to the hot-water
apparatus is that in the rapid changes of temperature which occur in this climate in spring and autumn, amounting sometimes
to 40~ F. in a few hours, it is less manageable than steam, requiring a much larger timle to heat and to cool.
In the plan of hospital which I shall recommend, an essential
feature of which is that the pavilions shall be totally separated,
and therefore cover a larger space than is usual, it is a question
as to whether it will be advantageous or possible to centralize the
heating apparatus, especially if hot water is used, so that the
supply may all come from  one or two boilers, or whether it
will not be better that the heating apparatus shall be divided
into several sections, even to the extent of giving one to each
building.
* [For these tables I am indebted to the courtesy of the Chief Signal Officer of the
Army.]




20                 BILLINGS.-PLANS FOR TIIE
The use of open fireplaces in hospitals has been strongly recommended as being a very effectual means of providing for the
exit of air, as giving a cheerful appearance to the room, and because the direct radiant heat which they afford is specially agreeable, since it does not raise the temperature of the air directly,
and it is better that the heating beyond a temperature of about
45~ F. of the air inspired should be effected in the lungs. When
cool air is breathed transpiration from the lungs goes on rapidly,
thus favoring the removal of effete organic matter, for air
breathed at 45~ F. and expired at 950 F. will take up 50% more
vapor than air inhaled at 600 F., if the previous relative saturation is the same.
If, however, the moisture in the air at 60~ F. is not increased
over that at 4.5~ F. it will take up the same amount of watery
vapor in rising to 95~ F. through the action of respiration, but
with this important difference, that the moisture in the former
case will be largely derived from the lining membranes of the
nose, mouth, and windpipe, while in the latter it will be taken
from the smaller cells of the lung's, and with it certain organic
matters and products of their decomposition which if not removed
will produce discomfort, and if in excess, disease.
The objections to fireplaces are that they waste fuel, increase
labor, cause noise and dust, and are somewhat dangerous. There
is also always a liability that smoke and irritating gases will be
driven in the room in certain conditions of the mind.  The
greatest objection is that a large room like a hospital ward cannot be heated satisfactorily by fireplaces alone when the outside
temperature is near the freezing point, and any attempt to supplement their action by warming the fresh air supply in any
way, destroys at once their special advantage and reduces them
to ventilating shafts.
The usual intention in placing them in the wards of permanent
hospitals, is that the general temperature of the ward shall be kept
low to suit the febrile cases, while the convalescents and those
who require special warmth can gather around the fireplaces.
As for reasons already given it is proposed to separate the
febrile from the non-febrile cases, this reason for the use of fireplaces has no special weight.
The action of a fireplace in a corner of a ward as a means of
exit for foul air, which is the only advantage it has worth con



JOHNS HOPKINS' HOSPITAL.                  21
sidering, can be as well obtained if a coil of hot water or steampipes be substituted for the open fire, and this in my opinion
would be much more satisfactory. As ventilating shafts give
better results in the centre of the room than in the corners,
partly because the air-currents to them do not cross patients'
beds, and partly because the air in the shaft is kept at a higher
temperature, I should prefer to have them in the centre.
In the smaller rooms intended for one or two beds, fireplaces
may be used to much greater advantage, and especially in the
room intended for febrile cases.
We have next to consider the difficult question of ventilation.
In the letter requesting the preparation of this paper it is stated
that "The various methods of heating, combined with venti"lation, form professional problems about which the most ex"perienced and best informed medical minds seem to be far
" from being united."
The truth of this statement is unquestionable, and it is due in
part to the fact that while the knowledge of what it is desirable
to effect in heating and ventilation may be possessed by the physician, he has usually no practical knowledge as to the means of
doing it, and in part to the fact that an attempt is almost always
made to combine three things which are incompatible, namely:
satisfactory heating, ventilation, and economy. We can obtain
without much difficulty any two of them, but I have not yet seen
any plan which combines the three, if the word economy be understood in its usual sense.
A theoretically perfect ventilation implies that a man shall inhale no air or suspended particle which has previously been in
his own body or in those of his companions. If, for instance, each
patient were placed in a case open at the ends through which
fresh air were drawn from his head to his feet at the rate of
about one inch per second, and passed directly into the foul air
duct, his ventilation might be said to be perfect, and if these
cases were four feet square this would require 4,800 cubic feet of
air supply per man per hour. All the usual systems of ventilation aim, not at this theoretical perfection, but at rapidly diluting the foul air.
I have already explained that while this is satisfactory for the
gases it is not so for the suspended particles, and therefore have
proposed that as far as possible there shall be no source of infec



22                 BILLINGS.-PLANS FOR THE
tion in the majority of the wards, and therefore no necessity for
special and costly appliances for their ventilation.
Much as has been written on the subject of hospital ventilation, and many and diverse as have been the modes of obtaining
it, which have been tried, there is singularly little positive information to be obtained as to the relative efficiency and cost of the
different methods.
It will be found that those who have written on the subject
usually give no positive data, and I have sought in vain in the
large hospitals in this country for any precise information as to
the amount of air heated and supplied, and as to the cost of
effecting it. I can only say that I have never been in any large
hospital ward, either in barrack or permanent structures, in
which, when the ward was full, there was not a very perceptible
and peculiar odor to one coming in from the fresh air-and while
this test has, of course, none of the precision which an accurate
air analysis would give, it is the only one which has been practically available.
As I have never seen a system of hospital heating and ventilation which was entirely satisfactory, the recommendations which
I shall make must be to some extent founded on theory, and as
the means of producing the effects desired and tile question of
cost pertain rather to the architect and engineer than to the
physician, I cannot pretend to propose a system which shall be
perfect in all respects, and as this Hospital must be considered
as an experiment, to a certain extent, I should endeavor to so
arrange it that the system first tried need not necessarily be a
final one, but should admit of modifications as found necessary
by careful, practical trial in the first one or two pavilions erected.
It must be remembered that to ventilate a ward, even in the
ordinary sense of the phrase, it is not sufficient to pass into and
out of it a large quantity of air. A thorough distribution and
mixing up of the air must also be secured.
The mode of ventilation must differ in cold and warm weather.
For winter use the methods may be classed as follows: first, introduction of fresh warm air at the bottom and its removal at
the top of the room. On this plan, to secure satisfactory distribution, it is necessary that the fresh air should be introduced
through numerous apertures at the floor and taken out at the
ceiling, in the manner employed by Mr. Reid in the ventilation of




JOHNS HOPKINS' IIOSPITAL.               23
the House of Commons, and by Mr. Winans in his private residence in Baltimore.
This method aims to secure an uninterrupted flow of fresh
warm air upwards with sufficient rapidity to remove impurities
as fast as produced, and theoretically it is the most perfect system of heating and ventilation, if no regard be paid to cost, since
the temperature at the floor is kept at least as hiogh as in the
upper part of the room, and since an enormous amount of fresh
air can be passed through without perceptible current.  The
objection to this mode of ventilation is its cost, which would
probably be not less than double that by the ordinary methods.
The second mode of ventilation is to introduce the fresh warm
air at the top and draw it out at or near the bottom. This is the
most economical method, and by proper arrangement of apertures
secures a thorough mixing up of the fresh and foul air. The objections to it are that it is a system of dilution rather than of removal, that the upper parts of the room are kept warmer than
the floor, and that it is extremely difficult to insure the proper
working of the aspirating apparatus in all conditions of wind and
weather.
A variation of the second method is to introduce the fresh,
warmn air at the bottom, and also to remove it at the bottom, the
apertures of exit and entrance being placed near to or remote
from each other. Barker's patent ventilator, in use in the new
University Hospital at Philaclelphia, works on this principle.
During cold weather this plan is satisfactory as to amount of
air, though not, I should think, as to distribution. During
moderate weather it is not satisfactory for hospital use. Better
distribution and stronger aspiration would be obtained by carrying the tube for fresh warm air up inside the foal air flue, to the
top of the room, and there making the opening into the room.
This second plan is the one ordinarily used, and the main
point to be attended to in it is the mode of aspiration to be employed. This may be effected by fireplaces in the corners or centres of the ward, by flues passing upwards, or by flues passing
downwards to a larger flue which is connected with an aspirating'
or ventilating chimney which may be warmed either bv the waste
heat from the boilers and furnaces connected with the administration, or may have a separate fire for that purpose. The placing of upward ventilating flues in outer walls does not, so far as




24                BILLINGS.-PLANS FOR THE
my experience goes, give satisfactory results in very cold weather,
and they will vary in action with the direction and force of the
wind. Other objections to them in point of view of construction,
are given by General Morin, and will be familiar to the Architect.
To rely entirely upon fireplaces placed in the corners of the ward
as means of ventilation, will not, I think, be satisfactory, and so
far as regards ventilation, I should prefer to have them in the
centre and to use heating coils instead of open fire.  But if a
satisfactory aspirating shaft can be constructed which will take
the air from  the sides and corners of the room near or through
the floor directly downwards to a horizontal duct beneath the
ward, and thence to an aspirating chimney, I should prefer it to
any other mode of effecting ventilation on the second plan.
Whatever be the plan adopted for heating and ventilating in
cold weather, if a satisfactory temperature and amount of air
supply be attained it must be at a comparatively large expense,
and the amount of fuel consumed will appear excessive.  This
is a universal complaint as regards hospitals, and the surprise
and disapproval which are usually expressed by those who have
to pay the bills are due to the fact that they compare the cost
with that for heating other buildings of about the same size.
In this Hospital, when completed, the fuel consumed must not
only heat the buildings, but must do mechanical work to the extent of lifting more than one ton weight of air per minute, to a
height of from 50 to 100 feet.r'
So long as proper ventilation is secured, no matter by what
means nor what form of heating apparatus is employed, it will
take between two and three times as much fuel to keep the wards
comfortable in cold weather, as would be required for the same
rooms furnished with only the ordinary amount of window space
and used for ordinary purposes.
To secure proper ventilation of a ward in warm weather, by
what is called the natural system  of ventilation, it is desirable
that the ceiling shall not be fiat, and it is owing to the fact that
an arched or peaked ceiling can be so much more readily obtained
* A cubic foot of air at temp. 60~ and 30' Bar. weighs about 532 grains if perfectly
dry, and 528.6 grains if saturated with moisture. In the first case, 13,157.9 cubic feet
will weigh about 1,000 lbs., and in the second, 13,242.5; or as a mean result, one
pound of air measures 13.2 cft.. and a ton of 2,000 lbs., 26,400 cft.




JOHNS IIOPKINS' HOSPITAL.               25
in a room which has not another over it that is due the superiority of one-story over two-story buildings for hospital wards
during warm weather. On the other hand, rooms with high or
peaked ceilings are much more difficult to heat, and in our onestory barrack hospitals with ridge ventilation, it was found
necessary to take extra precautions to close all apertures, in order
to keep thlem moderately comfortable, with the outside temperature at or below the freezing point.
Natural ventilation, as I ha.ve said, cannot be relied upon in
warm, still weather. The use of a fan under such circumstances
will be found to give powerful assistance, and admits of cooling
the insufIlated air to a certain extent. It is also a valuable
means of regulating and controlling the supply of fresh air and
of supplementing defective action of the aspirating flues in certain conditions of the weather; and I recommend its employment
in this Hospital. The maximum amount of air to be supplied
may be estimated for the ordinary wards at one cubic foot per
man per second. The fan should have a capacity of about 600
feet per second.  It will be seen that the selection of the mode
of heating and ventilation is largely a question of money.
For instance, the increased cost of the first over the second
method of ventilation above described, if applied to all the
wards of this Hospital, may roughly be estimated at $10,000
per annum, and as it seems to me that this amount of money
can do better service in other ways, I recommend the employnlent of the second method, except for a few of the smaller
wards, or perhaps for one pavilion, for purposes of comparison
and experiment.
The sizes of the ventilating flues and chimneys required may
be readily calculated by the formula given by General Morin in
his " ]tudes sur la ventilation," and his " MAanuel du chauffage
et de la ventilation," using his maximumn  air supply of 100
cubic metres per hour. If one large central aspirating chimney
is to be employed, it must be about 8 feet in diameter at the
top, and not less than 130 feet high. An aspirating chimney
for one pavilion must have a flue of not less than 8 square feet
area.
I think that the most satisfactory results will be obtained by
giving to each pavilion its own heating and ventilating apparatus.




26              BILLINGS.-PLANS FOR THE
VI. BUILDINGS.
I give in Figures 1 and 2 (Plate I.), floor plans of such a pavilion as I would recommend:
Plan No. 1 is intended for a two-story pavilion, and an essential
feature of it is that the two floors are entirely cut off fromn each
other, as the stairs, dumb-waiter, and lift open only to the outer air.
If the pavilion has its own heating and ventilating apparatus
the main flue would come between the dining-room and kitchen,
and should have about 8 square feet area, with extra grate surface below.
Plan No. 2 is the same applied to a one-story pavilion, and also
shows a variation in the number of windows. I do not think it
desirable to have one window to every bed in two-story buildings,
as it increases the difficulty of heating and ventilation in cold
weather, without giving corresponding benefit.
There are no dust flues or clothes shoots in the pavilion. I
would have galvanized iron boxes with tight-fitting covers to be
moved about the ward on cars with large, rubber-tired wheels.
~When bedding is to be removed, one of these boxes should be
taken to the bed, the clotlhing placed in it, the cover fastened,
and the box wheeled off to be sent down the lift to the basement,
and thence on another car to the centre building, where its contents can be treated as may be desirable.
The small wards D and E are for patients who maty require
separate rooms, not on account of acute or dangerous disease,
but because of nervousness or irritability, weak eyes, etc., etc.
TWhen not occupied, and in certain wards, D would be used by
the physician as an examining-room,   etc.
L is a ward for acute, febrile, and doubtful cases, in whllich
special modifications of light and temperature are desirable. No
case of contagious disease is to be admitted to any part of these
pavilions, and if any case appear it is to be promptly removed,
with bed and bedding. If a second case appear soon after the
first, the ward is to be emptied and disinfected.
The plan given is not intended to apply literally to all the
pavilions, but only to give a general outline of arrangement.
I have placed the width of the main ward at 26 feet. If it be
made wider, up to 30 feet, it will be better, but the length must
not be diminished.




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JOHNS HOPKINS' HOSPITAL.                27
In the plan each patient has a little over 100 feet of floor space,
and each bed has about 8 feet wall space. This last must not be
diminished, so that if the ward is made 28 feet wide each bed
must have 112 feet floor space.
In some of the pavilions it will probably be desirable to have
the main ward shorter, i.e., for 18 or 20 patients, and the isolation
wards increased.
The one-story pavilion for surgical cases should be larger, for
each patient should have 10 feet of wall space.
These pavilions are to have basements about 9 feet high,
entirely above ground, and floored with asphalt, which are to
contain nothing but heating and ventilating apparatus, and are
to communicate with the central building by a closed corridor 10
feet wide. The top of this corridor may be an open corridor
leading to the ward floor.
It is to be noted that with the pavilion thus elevated, and by
the use of iron gates, etc., a very considerable amount of control
is given over the movements of patients, and of visitors to them.
The corridors leading to the central building divide the grounds,
while, being entirely below the level of any ward, they do not
interfere with ventilation.
The question as to the relative advantages of one and two-story
pavilions is totally distinct from that of permanence, and no
authoritative answer can be given as to the advantages of onestory structures, for the reason that there are no trustworthy
observations as to their relative healthfulness.
The arguments in favor of one-story pavilions are sufficiently
well known and are well summed up by Dr. Geo. Derby in a
paper on Hospitals, in the Fifth Annual Report of the State
Board of Health of Massachusetts for 1874, the main reason being
that it is easier to secure good ventilation in them.
Although the most satisfactory wards which I have seen practically tested have been in one-story barrack structures, I must
say that I have not found any reliable evidence as to the unhealthfulness of two-story buildings, on account of their height,
even as usually constructed, and I have never seen a two-story
pavilion, or a plan of one, in which the upper story was entirely
cut off from the lower, which can be easily effected, and removes
one of the greatest objections to this plan.
WTith the limitations of classification of patients which should




28               BILLINGS.-PLANS FOR THE
be made, I do not think that the employment of two-story pavilions to contain about 75 per cent. of the patients would produce
any difference in results so far as healthfulness is concerned,
while in economy of construction and management, and in the
control of patients which they afford, two-story pavilions present advantages which should not be overlooked.
It must be remembered that, in an institution of this kind, we
have to provide not only for the care of the sick, but to some
extent for the restraint of the vicious.
Aluch of the disease which will be treated in this Hospital will
be due directly or indirectly to Alcohol and Venery, and it-is desirable to prevent patients with depraved appetites from perpetuating or renewing their maladies by recourse to the original cause.
It is also very desirable to make the wards inaccessible to visitors and to patients and attendants from other wards who have not
proper authority to enter them. This is much easier to effect in
two-story buildings than in those of one, which last would occupy
nearly the whole ground.
I advise, therefore, although not without hesitation, that a
part of the pavilions be constructed of two stories, but the decision of the question must turn upon the manner in which the
buildings are to be arranged with reference to each other, which
will be considered hereafter.
I doubt very much the advisability of attempting to make the
walls and ceilings of the wards impermeable, by the use of cement,
silicates, paint, or paraffine. The amount of transpiration which
goes on through an ordinary brick and plastered wall is very
considerable, and to make it impermeable is somewhat like varnishing a man's skin to keep his underclothing from being soiled.
VWhile not prepared to speak positively on this subject until the
results of the two processes can be compared, which will be done
in a hospital now in process of construction near this city, I
should prefer a good ordinary hard finish, with the space between
the plaster and the wall, or in the hollow wall, so constructed
that it can be filled with a disinfecting gas such as chlorine or
sulphurous acid, when desirable, as suggested by Dr. Stephen
Smith, bearing in mind that moisture must precede the application of the gas; and to rely upon this, periodical scrapings and
whvllitewashings, leaving the room empty occasionally, etc. One
soiled blouse of an attendant, or stuffed chair, or baize screen, is




JOHNS HOPKINS' HOSPITAL.                   29
more dangerous as a source of infection than many square feet
of plastered wall. All corners in all wards should be made segments of circles instead of right angles.
All gaslights in the wards, water-closets, and bath-rooms
should contribute to the ventilation, the products of combustion
passing off through tubes connected with the foul air ducts.
Doors should be as plain as possible.  Those in the new ward
of the Presbyterian Hospital in Philadelphia are the most satisfactory I have ever seen. The window-sills should be of slate or
marble, and the windows should be in three parts, with square
tops, and be glazed with plate glass. The woodwork of the
pavilions should be picked hard pine, all joints, including floors,
to be put together with white lead saturated with oil and resin,
but not painted or varnished.
The general plan of heating and ventilation recommended is
shown in Fig. 1.
A.  Side, showing ventilation.
B.   "''   heating.
1/, N. Fresh air register.
0, P. Ridge ventilation.
L.  Foul air closet.
C, D. Foul air ducts.
E, 7F. Fresh air ducts.
3,,G.  Heating coils.
E                 FI 3
A          B
An arrangement for a two-story pavilion is shown in Fig. 2.
What are called foul air closets in the above will be better
understood by reference to Fig. 3.
The upper compartment B, is to be used to contain a spit-cup
or other thing which might be offensive, but which it is desirable
to keep near the patient. These closets should be made of iron,




90                BILLINGS.-PLANS FOR TIIE
be movable, and be passed through the disinfecting process about
once a month.
During cold weather the fresh air passes from  the fresh air
duct upwards over the heating coils and thence through large
flues into the ward.  These flues should extend to within one
foot of the top of the room, and should have two openings, one
just above the floor, the other at the top, which openings should
have tight-fitting registers.
A.  Foul air. ducts.
B.  Fresh air ducts..
C.  /Fresh air flues outside of coils.
D.  Lower register.
E.  Upper register.
F, G. Valves.
H.. Foul air closet.
I.  Foul air duct.
K.  Ridge ventilator.
O.. Heating coils. 
F          F
1G~~-P~ c   G  
FIG. 2.
During warm weather, or when desired for local purposes, the
fresh air is made to pass outside the heating coils. By this
arrangement the fresh air can be introduced either above or
below, and by the lower registers, through which in cold weather
warm or cold air can be obtained at pleasure, and by the use of
screens of varnished wood or glass, a very considerable amount
of local variation in temperature and amount of moisture of air
supply can be obtained for any given bed.  The foul air is to be




JOIHNS HOPKINS' HOSPITAL.                         31
removed by aspiration downward, either by means of one central
aspirating chimney or by smaller ones for each building, which
A, foul air closet, 
20 inches high, 
and about 12 x                                  A
18 inches in
surface, divid- 
ed by a shelf
into two com-                                      Li n  of     oo.
partmeits  B...
and C, the upper  one  of
which has a
door, D. The  /
top, front, door
perforated reg-      
isters, through
which the foul
air is drawn
down to the 
foul air duct
D'.
FIG. 3.
last will be the most satisfactory.  In warm  weather the windows and ridge ventilation are to be used. If a fan is employed,
this will be found satisfactory at all times; but if the fan is not
available, aspiration  will be desirable  occasionally, in  warm,
damp, still weather.
The difficulty which exists in ventilating the lower ward of a




32                BILLINGS.-PLANS FOR THE
two-story pavilion is seen in the above sketch. This will occur
more especially in summer from  the flat ceiling and dead airspace at the top of the room, and the only remedy would be to
carry shafts from the ceiling of the lower story straight up through
the roof. About four of these, each 18 inches in diameter, wouldl
be desirable.  They would appear as pillars in the upper ward,
and would not be in the way or unsightly. If they are used,
special precautions must be taken to make their junction with the
ceiling of the lower room absolutely air-tight by elastic packing.
By the use of Dr. Sternberg's automatic valves, or by the
apparatus employed by Mr. Winans, the temperature and air
supply of a ward may be made self-regulating, or if these are
allowed to vary it is possible by galvano-electricity to register
their variations either at regular intervals or continuously.
It would not be difficult to arrange in the Central Office a series
of dials which should show at a glance for any given ward or
room, or for all of them, the temperature and the amount of air
passing through either the fresh or foul air ducts, or both.
I need hardly point out the interest and value of such an apparatus, and I recommend its trial in one  pavilion.
The ventilation of the single and two-bed wards is to be indepen dent by fireplaces in winter, and from the ceiling by air-shafts
passing on the inside walls to the ridge in summer.*
The ventilation of the water-closets and bath rooms is also to
be independent by the central flue shown in the floor plan of the
pavilion. (Fig. 1.)
The motive-power in this flue is to be given by a stove in the
basement, which is to furnish the hot-water supply by means of a
circulating boiler.
The water-closets and slop sinks are to be arranged around this
flue, and are to ventilate downwards.  The majority of the waterclosets should be fitted with a Bidet attachment, and this is especially desirable in the female wards.
Over each bath-tub should be placed a shower not over five
feet six inches above the bottom  of the tub, and this shower
should be fitted with both hot and cold water supply.  Arrangements for special baths are to be provided in a separate place.
* It is in these small wards that the experiment of direct upward ventilation can be
best tried. It can be arranged in any of them, but most easily in the ward L, where
also it would be most advantageous.




JOHNS HOPKINS' HOSPITAL.               33
ADMINISTRATIVE BUILDINGS.
As already indicated, the advantages of dividing the administrative building into three distinct parts appear sufficient to warrant the recommendation of such a mode of construction.
The first building, which may be called the Administration
Building, should contain the offices, reception-rooms for patients
and visitors, apothecary's establishment, sleeping and dining
rooms for medical officers and students, and store-rooms for mnew
articles of furniture, bedding, and clothing. The rooms required
in such a building are shown in Figures 1, 2, 3 of Plate II.
The plans of this building given are simply rough sketches,
intended to indicate in a general way only, the number and
relative size of the rooms which will be required.
It will be observed that a large number of bath-rooms are
provided.  This is done for the purpose of inducing all who
have direct communication with the sick or with their bedding,
clothing, etc., to bathe frequently, and for this purpose every
convenience should be provided. I would remark in this connection, that the usual mode of fitting up a bath tub with a
shower bath placed eight or nine feet above the tub is unsatisfactory. The shower should be placed not more than five feet
six inches above the bottom of the tub, should be supplied with
both hot and cold water, and should be so constructed as to swing
aside and be out of the way when not in immediate use.
Taken in connection with the pavilions on each side intended
for private patients, this building admits of such variations as
the taste and skill of the architect may dictate, as will be more
plainly seen by reference to the general plan of the Hospital
given hereafter.
As lateral wings to this building are to be placed pavilions
containing rooms for private patients and for special cases, which
pavilions may be of either one or two stories.
A floor plan of one of these pavilions is shown in Fig. 4.




34               BILLINGS.-PLANS FOR THE
A  I  B      C          DF
T -
L   m   O'"J~l   I              -      -I t 
-.  *,  - - --    -*-b-  - - * -----
_- -1r~-.- L —-------    122 ft.  ----— L -------- -
FIG. 4.
E, F.; K, L.   Sets of two rooms with water-closet and bathroom, N, P, to each.
D, J, C, I, A, B. Patients' rooms.
H.              Nurses' room.
GC.             Dining-roomn.
O.              Kitchen.
AL.             Water-closet and bath-room.
The new isolation ward of the Massachusetts General Hospital
is also a good general modlel for these buildings, and their ventilation, like that of all buildings with a central corridor and inside
walls in which flues can be carried and -false ceilings placed in the
intermediate passage, is easy to arrange for both summer and
winter.
The second building required is to be detached from all others,
and is to contain the main kitchen, laundry, store-room, etc.
If it is considered desirable to centralize the heating apparatus,
and to employ one large central aspirating chimney, these should
be placed in connection with this building.
If hot water be used as the heating medium-and I strongly
recommenl its employment-it will probably be better not to attempt centralizing, either for heating or aspirating, for the reason that it will increase the cost too much.
I give in Figures 1, 2, 3, and 4 (Plate III.) a sketch of the arrangements of such a building, on the supposition that the heating will not be centralized.








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l  FIG.I1''                    TE 11  2 I —-2 --- _IG.3                                                  SKETCH PLAN OF RRANGE 3.  ENT. i-                      * I          i  >          OF CENTRAL BUILDING
FOR KITCHEN, LAUNDRY, E.T.C.
{lz           -ic                                                                                   FOR JOHNS HOPKINS HOSPITAL.ae      _     rN BY DR.J.S.B[LLINGS. U.S.A.
S         | ]  >1'0077-t, i         i            n       D      i          * /g~eZZ  l ]    +z+#                                       11
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I~' STORY                        24 STORY...                            4STOR
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[!   rl,2-;_r:=2 




JOHNS HOPKINS' HOSPITAL.                35
PLATE III.
Fig. 4. —Boiler House.
A. Boilers.
B. Engineer's room.
C. Engine.
D. Fan.
E. Disinfecting chamber.
The question as to the desirability of placing the kitchen and
laundry on the upper floors may here be considered. The usual
recommendation is that they should be in detached buildings to
prevent the heat and odor from becoming a nuisance.
Where hospitals are in such a limited space that outbuildings
are inconvenient, I have recommended that vertical be substituted for horizontal distance. This is especially desirable with
regard to the laundry, which is a source of peculiar danger and
nuisance in a hospital.
WVhere steam power is to be employed, the use of lifts is easy,
and does away with all inconvenience in placing these rooms
above, and by connecting their furnaces with the central chimney
we gain powerful aid for ventilation the year ro and.
An additional recommendation is, that they are thus less
readily accessible to patients and visitors.
In this Hospital I recommend that they be placed as I have indicated.
There may be a question as to the advisability of having large
central dining-rooms for convalescents and patients able to walk
to their mrieals. The advantage of this plan is that it effects a




X36              BILLINGS.- — PLANS FOR THE
saving in labor and to some extent in space, to have the diningrooms as near the kitchen as possible.
The classes or subdivisions of patients in this Hospital are
more numerous than usual, and probably four (4) central diningrooms would be required if this plan were adopted.
By the use of felt boxes and other well-known contrivances,
there is no difficulty in serving the food hot at any distance, and
as a certain amount of food must be carried to the wards it takes
very little more time and labor to serve the food for all the
patients in a dining-room attached to each ward.
There should be no communication from  the kitchen and
laundry on the same floor.
The ceilings of the kitchen, laundry, and drying-room should
slope upwards towards the central chimney into which they are
to be ventilated.
One lift for the kitchen is for coal, ashes, and slops, the other
is for food; one lift for the laundry is for soiled and the other
for clean articles. All these lifts should be ventilated at the top
into the Inain chimney.
The mattress-room is for the hair mattresses and for remaking
them, which should be often done.
Thin hair mattresses on others of woven wire will be found
most satisfactory.
The clothing and bedding should be stored in slatted racks,
detached from the wall, and all these store-rooms should have good
ventilation by the central chimney. New clothing and bedding
are to be stored in the basement of the administration building.
The building for boilers, engine, and fan is disconnected from
this building, is but of one story, and it may be desirable to
place it entirely under ground, in order to obtain the proper level.
In this building may be placed the disinfecting chamber, which
is a most important feature in connection with the hospital, and
should be carefully arranged and made much of.  It is intended
for the application of hot steam, disinfecting gases, and hot, dry
air, to articles of bedding, clothing, and furniture, and is to be
connected with the flue from the boilers into the main chimney.
It should be made as nearly air-tight as possible, and have a
cauldron or iron box in it in which a small quantity or a single
article of clothing can be disinfected by itself.




JOHNS HOPKINS' HOSPITAL.                37. In connection with this building large underground coal vaults
should be constructed.
The open corridors (A, B, Fig. 1), ten (10) feet wide, are intended to be on a level and have direct communication with the
basement corridors leading to the several pavilions, and to admit
of the easy access of small hand-cars to the several lifts.
The third building required is to contain the amphitheatre, outdoor dispensing-rooms, dead-house, and pathological laboratory.
I give a sketch plan of an arrangement for this building which,
however, admits of much modification, and for which many
special fittings and contrivances will be desirable which I shall
not attempt to indicate.
L~~C  D' E  F
~N                                KB~,.  J
_M                                    L
FIG. 5.
First story:
G.              Apothecaries' room.
N.              Laboratory.
M.              Bath-room and water-closet.
J.              Waiting-room.
K.              Dead-room.
O.              Lift.




38:BILLINGS.-PLANS FOR THE
~ — _
H C  L *  LB.   L
FIG. 6.
Second story:
A.         Amphitheatre for clinical lectures.
B.         Amphitheatre for pathological lectures.
C, D, E, F. Chloroform and waiting rooms.
IH.        Physicians' room. I. Post-mortem room.
L, M.      Photograph-rooms.
G, J.      MIicroscope-rooms and Laboratory.
K, N.      Bath-rooms and water-closets.
O.         Lift.
WVhen the Hospital is completed to its full capacity, and the
Medical School is in successful operation, it will be preferable to
have the pathological department in a separate building, but
I would recommend the above plan as a temporary one, to serve
for the first ten years, at the end of which time experience will
have shown just what is required.
WTith regard to other buildings I recommend that the Physician-in-Charge have a separate house, either on or in the
immediate vicinity of the grounds.
The chapel may be either a separate building or be connected
with the administration building. I should prefer it separate,




JOHNS HOPKINS' IHOSPITAL.                39
that it should be so arranged as to separate the sexes, and that
it be used as a reading-room during the week.
Tanks or cisterns will be desirable to serve as reservoirs in
case of any accident to the water supply from the city pipes. I
do not recommend that the water from rain-fall should be collected and preserved. The amount of water which will be required by this institution will be about 22,500 gallons per day,
and storage for at least 50,000 gallons in underground cisterns
would be desirable.
VII. GENERAL PLAN OF HOSPITAL.
Keeping in view what has been stated with regard to the causes
of the unhealthfulness of hospitals, I propose to prevent these
causes from being present in the greater part of the buildings,
and to confine them to certain structures, which may be purified
or destroyed when necessary.
This is to be effected by a careful classification of the patients,
by a methodical system of isolation, and by destruction of the
causes of disease as they occur.
Referring to the closing remarks on the subject of the causes
of Hospitalism, it is to be observed that an additional reason for
a greater subdivision of patients than is usually employed, is
that different patients, and the same patient at various stages
of his malady, require very different degrees of heat and light.
A man suffering from acute fever, whether specific, such as
typhoid, or due to local lesions, as from injury, cerebral rheumatism, etc., requires a much lower temperature than a case
of chronic rheumatism, or diarrhcea, or of simple debility, as in
convalescence, and it is difficult to furnish the proper conditions
to these two classes of patients, if they are to be placed in the same
room, because the apparatus necessary to effect it requires intelligence and constant supervision to produce the results required.
The same is true, though not to so great an extent, with regard
to light.  In the acute stage of most diseases bright light is
unpleasant, and the instinctive desire of the patient is to have it
greatly diminished.
Light is a powerful tonic and stimulant agent, with peculiar
powers and modes of action, which as yet cannot be said to be




409               BILLIhNGS.- PLANS FOR THE
well understood.  Nothing can compensate for its absence or insufficient supply in health, in many cases of disease, and in convalescence; bnt I am satisfied from  observation that in many
cases of acute disease the glare of a large, white-walled, manywindowed hospital ward does harm very much in the proportion
in which it inflicts discomfort.
I therefore propose to separate acute from chronic and convalescent cases, and this being done, the question of mode of
construction of wards for the latter class will not present special
difficulties.
The first thing to be decided is the size and the number of the
wards, bearing in mind that the larger the ward the more difficult it is to secure the isolation and classification of patients, and
the smaller the ward the greater is the labor and cost of supervision and attendance.
For each sex of each color it is desirable that there should be
at least two wards, viz.: medical and surgical, and children must
also be provided for.
I give the following estimate of the proportion of patients in
each class to be provided for, based upon the statistics of several
institutions of a somewhat similar character in Baltimore and
elsewhere.
White, Miale, Medical............................  75
White, lMale, Surgical.............................  75
Black, iMale, Medical.............................. 25
Black, Male, Surgical..............................  25
White, Female, Medical...................0....... 30
TWhite, Female, Surgical.......................... 30
Black, Female, Medical....................... 2.5
Black, Female, Surgical.........................
Children, Male...................................25
Children, Female.................................25
Private Patients..................                  40
Total..............  400
In view of the above figures, 24-bed wards should be the largest
to be made use of in this Hospital, and numerous smaller wards
will be desirable.




JOHINS IIOPKINS' IHOSPITAL.               41
A maximum estimate of the number of acute cases at any one
time requiring more or less isolation, is about 25 per cent.-that
is, excluding the private patients, about 90 beds, when the Hospital is completed.
As each ward should be emptied in rotation, so that there may
always be one vacant with the windows open, undergoing Nature' s
process of purification, the general distribution of beds may be
represented by something like the following scheme:
12 24-bed wards, for chronic and not dangerous
cases.....................................288 beds.
2 24-bed wards, accident and surgical, dangerous 48  "
14 2-bed wards, acute cases, not contagious.......   23 - 
14 2-bed wards, for not specially dangerous or acute
cases, but for which special temperature, light,
etc., is desirable.............................  28
20 beds, acute, contagious, and dangerous diseases,
in tents....                                  20
Private patients, special rooms..................16  "
Total.......................428...........  "
The above is a maximum estimate, and under no circumstances
are more than 400 beds to be occupied at one time.
The Convalescent Institution to be connected with the Hospital
should contain about 100 beds, divided into at least six wards.
On account of the prevailing wind, and to secure equable exposure to light, it is desirable that the long axis of the pavilions
should run nearly north and south.  It is also desirable that the
pavilions should be totally disconnected from each other and
from the administration buildings.
If two-story pavilions are used, they should be not less than
100 feet apart; if one-story pavilions are employed, they should
be not less than 50 nor more than 75 feet apart.
I furnish herewith ground plans showing an arrangement of
the Hospital with two-story and with one-story pavilions.  In
either case, the pavilions connected with the amphitheatre should
be of but one story, and as with the growth of the Medical
School it is probable that increased accommodations many be required in this building in future years, I should recommend that




42               BILLINGS.-PLANS FOR THE
the amphitheatre building and the pavilions connected with it be
at first cheaply constructed and temporary in character.
The relative merits of the plans submitted can be appreciated
only by reference to the probable cost; either of them  can be
carried out on the temporary or permanent plan, and either of
them will, in my opinion, be satisfactory, so far as the healthfulness of the institution is concerned.
Taking the plan of Plate IV., if the buildings be made of
brick, I should estimate the cost as follows:
14 one-story pavilions, brick, at.$14,000 each....... $196,000
Administration building..........................  60,000
Central building and machinery.................  90,000
Amphitheatre and one-story pavilions, wood.......  40,000
Total..........................             386,000
If all the pavilions in this plan were made temporary structures they would cost about $8,000 each, the cost of the other
buildings remaining the same. This would make the total cost
$302,000.
On plan of Plate V., the cost may be estimated as follows:
6 two-story pavilions, brick, $27,000 each..........$162,000
Administration building..........................  60,000
Central buildings and machinery.................  90, 000
Amphitheatre and one-story buildings attached..... 40,000
3 pavilions for private patients, $20,000 each....... 40,000
Total....................................... 392,000
Taking all things into consideration, I should myself prefer the
plan given in Plates V. or VI., as I think with proper administration it would give results the same as No. 1, while the cost of management would be not less than $10,000 per annum in its favor.
As the main approach to and view from the Hospital is to the
west, the buildings are arranged with reference to that fact, and
the architect will see that by breaking the lines of the administration building, either by central or end projections, or both,
and repeating the composition in the lateral pavilions attacked,








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Z i ow,                                                                                  val~02l&-2 ~tory
J,91%VC6 - Ra~tteztt~        IzziBit                       fa~r~mits'
No. 5.
SCALE ONE INCH TO 100 FEET
SKETCH  PLAN OF ARRANGEMENTL
FOR JOHNS HOPKINS HOSPITAL,
WITH TWO STORY PAVILIONS,
BY DR. J. S. BILLINGS  U.S.A.                                                  b
73f                                                                                                                       7 e  ird7i7
Pky)siciwri Ic~i zazye.                                                                                                  reniaht ~  J~rses.








Jaiwo2'riZioi
No. 6.
SCALE ONE INCH TO 100 FEET
MODIFICATION OF PLAN  SHOWN  IN PLATE V.
PROPOSED BY'
BY DR.J. S. B, LLiNGS  U.S.A.








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L~~~~~~
U-                    i
I'                                                ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~_
I- 1         I__ __ J                                                1     _r —-_  _ —-- -- 
-I_ _1J......... -L_ _  I___   ]uF 
|                                        ~~~~~~~~~~~~~~~~~~~SCALE ONE INCH TO 100 FEET||
a                               ~~~~~~~~~~MODIFICATION O.F PLAN SHOWN IN PLATE V.                                    l
2PL~yt~Ol~-i2                                                                                                 l~ory-  ____  j1
F-"7                                                                    -...                  L__I'~~-H
jI             I                     
i~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~F —1,___J           -L       J..                                                      -I I' t_ _     d ___~   — L_
No. 7.
SCALE' ONE' INCH TO 100 -EET
MODIFICA~TION 0.F PLAN 5H-OWN IN PLATE. V.
PROPOSED BY
BY DR. J. S. BILLINGS U.S.A.




JOHNS HOPKINS)  HOSPITAL.               43
the effect, in connection with the end towers of the other pavilions
and the tall chimney of the central building, may be made very
satisfactory.
At the commencement, any four of the two-story or eight of
the one-story pavilions may be omitted.
Plate VII. is a variation of Plate V., which permits of more
satisfactory arrangement with reference to constructing but part
of the buildings at first.
In a hygienic point of view there is little difference, but in final
appearance the plan of Plate V. would probably be preferable.
Whatever may be the plan adopted, I strongly recommend that
about 15 hospital tents, United States army pattern, be kept constantly on hand, and made methodical use of as isolation wards.
Each of these tents is 14 by 15 feet; height at walls, 4- feet;
in the centre, 11 feet. French floors and heating apparatus for
these tents should be kept ready. The heating may be either by
stoves, on the plan used in our tent-hospitals during the war,
or by a connection with the hot-water apparatus of the nearest
pavilion.
Where a tent is vacated it should be thoroughly disinfected,
first as it stands, and then again in the disinfecting chamber.
Each tent, as it would be used in this Hospital, would last between two and three years, and would cost, complete, not over
$100.
The location chosen for the Hospital is such that there will be
no difficulties as to drainage and sewerage.
Care must be taken to ventilate the sewer by one or more
shafts passing to a height above the buildings, but these shafts
should not be connected with any of the aspirating chimneys.
There are many contrivances and pieces of apparatus which I
should wish to see provided for in the plan of this Hospital, such
as for the use of compressed and rarefied air, sun baths, electricity in all forms, a bathing-house in which all forms of baths
can be administered, etc., etc.; but I have not thought it desirable to describe or provide for them, as their position and arrangement depend so much upon the plan which shall be finally
adopted.
So far as I can judge from my own experience and that which
is recorded of others, no matter what plan is adopted, when the
Hospital is completed and put into practical operation, it will




44                      BILLINGS.-PLANS FOR TIlE
appear that it can be improved in some particulars, and a certain
amount of funds should be reserved for this purpose.
The general principles which I have tried to state in this
paper are in accordance with the present condition of our
knowledge on the subject, but that knowledge is imperfect, and
too much of the teaching of books on the subject of hospital construction is theoretical only.
I have endeavored to point out the effects which it is desirable
to produce, but the means of obtaining these effects, so far as the
construction of buildings and the apparatus for heating, etc., is
concerned, come more within the scope of the studies of the Architect and Engineer than of the  Physician, and I do not doubt
but that there are better ways of planning both the individual
buildings and their combination into one general plan than
those I have indicated.
I sincerely hope, that whatever plan may be adopted will prove
by  its practical results that a hospital can be built and managed in such a way as not to produce any of the evils which are
usually attributed to such institutions, and which have brought
them into disrepute.
Meteorological Record of the Weather at Baltimore, AMaryland,
for 1871, 1872, 1873, and 1874.
Temperature.
Mean Monthly.                    Highest and Lowest.
1871. 1872. 1873. 1874.   1871.      1872.      1873.       1874.
January...... 36.1  35.0  34.0  39.1  64~  11~   56~  11~  58~ -4~   69~  13~
February..... 40.8 36.0  35.5  37.3  67   8    61   14    62   2    78   15
March......   49.7 37.0  40.3  43.7  71  29    65   9    68   5    72   23
April......... 58.9  56.0  51.9  46.9  85  40    88  38    75  38    68    27
May......... 66.0 68.0  62.3 (63.1  92  47    89  48    89  44    89   41
June....      74.7 75.2  73.9  75.9  93  59    94  58    95  49    97.5  54
July........  75.3  81.2  79.4  77.3  93  60    97  68    96.5 62    95.5  62.5
August.......  77.7  79.3  76.3  72 8  92  63    96  62    94  57    97   52
September... 63.7  69.5  68.0  69.9  83  45    94  50    93  40    90   53
October......  59.0  58.3  54.8  56;.6  78  40    80  38    73.5 30    78   35
November... 45.0  43.6  41.0  45.3  69  28    63.5 17    64  22    71   24
December... 33.0  32.2  40.4  39.0  53    5    55   8.5  66.5 22.5  67   21
Yearly Mean.. 56.6  55.9 54.8 155.5  78.3 36.2  78.2 35.1  77.8 30.6  81    35




JOHNS HOPKINS' HOSPITAL.                                 45
Moisture.                         Wind.
Mean Monthly.                   Mean Direction.
1871.   1872.   1873.  1874.   1871.   1872.  1873.  1874.
January..........  65.6   62.8   65.5    72.9    N.E.  NW.  N. W.   W.
February.........  66.6   60.3    61.1    71.3    N.E.   N.W.  N.W.  N.W.
March............  82.4   58.6    55.6    67.2    S.E.   N.W.  NW.  N.W.
April.............  65.3   47.4    57.3    66.5      W.      W.       N.    N.E.
May............. 65.9    51.5   65.5    59.7    N.E.  N.W.    E.    S.E.
June.............  69.0    61.3    64.8    64.8    S.W.   S.W.    S.    S. E.
July............. 66.1    62.6   62 9    64.5    N.W.   S.W.   W.    S.W.
August...........   72.6    66.1    78.5    61.4    S. E.   S.W.  N.E.    N.
September........  67.8    66.6    76.8    72.1       N.      N.      N.   E.S. E
October..........  68.8   62.5   75.1    65.4    N.W.  N. W.  N. W.  N.W.
November........  66.7   57.0   70.6   63.5    N.W.  N.W.   W.    N.W.
December........  65.0   58.4   71.6   63.6    S.W.   W.    N. W.  N. W.
Yearly Mean......  69.3   59.6   67.1   66.1    N.W.  N.W.  N.W.  N.W.
Rain-Fall (for 50 Years).
Number of           __                             TemperaDays on which Rain fell.                                  ture.
Extreme Fall.
1871.  1872.  1873. [1874.   Mean.    Max.        Min.      Mean.
January......    5       8     13     12      2.85      6.10     1.02       32.0"
Fetbruary.....   7      8    12       7      3.23     4.90      0.94       34.0
March......... 10    14         8      8      3.71      6.30     1.70       42.0
April........     7    10    14    15         2.20      9.10     0.41       52.5
May........      6.6         1 4    10     3.65      5.77      1.19      63.0
June........     8      9      8     10      3.66      9.20      0.60      71.5
July.......     15     10    11       9      3.85      6.89     1.26       76.5
August.......    1. 2    18    21     10      4.30      9.10     0.31       74.7
September.....-   4      9    14    11        4.45     10.50     0.50       67.5
October......    10      8      1      2      2.98      7.35     1.30       55.5
November.... 8    10 10 8                    3.20      7.90     1.06       45.0
December....    10     11     11    14       2.90      8.80     1.50       35.0
Total for the_     I                                               _   -..
year.......  104   122    147   116    40.98                            54.1
Mean of Spring.9.56....        9....... 52.5
"  "  Summer............ 11.81........      74.23
"  "  Autumn...........   10.63........      56.00
"  "  Winter.............    8. 98...            33.66




46                     BILLINGS.-PLANS FOR TIIE
Rain-fall.                     Temperature.
Inches.            Max.            Min.          Mean.
1817            48.55               92             -4
1818            32.60               94             -2
1819            28.75               98              10
1820            42.50               98             -2
1821            50.20               95             -6
1822            29.20               92               8            53.3
1823            44.55               93              18            55.2
1824            42.28               90              11            56.4
1825            24.45               94              10            53.5
1826                                96            Zero.           53.9
1827            26.39               98               9            52.1
1828            23.55               94              16            55.7
1829            43.09               92               8            52.6
1830                                98               4            54.9
1831            54.15               93            Zero.           53.7
1832            53.05               91             Zero.          53.9
1833            55.24               94              10            53.7
1834            55.68              100              10            54.6
1835            52.99               91            -10             53.6
1836            51.55               92               1            51.0
1837            45.00               98               5            53.1
1838            47.10              102              10            53.1
1839            51.70               96               4            54.5
1840            37.50               91            Zero.           52.9
1841            43.90               95            Zero.           52.1
1842            35.10               92              10            54.0
1843            48.79               92               3            52.9
1844            32.46               94               5            53.3
1845            28.39               97               9
1846            46.66               95               8            53.6
1847            33.01               98              10            54.6
1848            34.42               99              12            56.2
1849            30.63              100               6            55.2
1850            44.80               92              12            56.4
1851            38.10               92               7            56.2
1852            51.50               89             -5             53.9
1853            36.00               91               9            55.3
1854            59.02               98              14            55.6
1855            29.03               95               4            54.84
1856            22.09               92             -6             53.09
1857            38.04               92             -6             53.97
1858            40.10               94              10            55.78
1859            51.45               96               5            55.10
1860
1861                                90                            55.66
1862
1863
1864                                97               8            56.27
1865                                96               5            57.16
1866
1867                                92              10            54.66
1868                                97               5            54.33
1869                                95              19            55.46
1870                                95              12            57.53








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HOSPITAL CONSTRUCTION
AND ORGANIZATION.
NORTON FOLSOM, M.D.




CONTENTS.
PAGE
GENERAL  CONSIDERATIONS............................................              49
CLASSIFICATION  OF  PATIENTS...............................................   51
RELIGIOUS  MINISTRATION..............................................    52
CONNECTION  WITH  MEDICAL  SCHOOL........................................   53
COUNTRY  WARDS........................................................                                               54
PROXIMITY  OF  MEDICAL  SCHOOL...........................................                                              56
TRAINING   SCHOOL  FOR   NURSES.............................................    57
ONE-STORY   WARDS........................................................  58
SCHEME  OF  ORGANIZATION..................................................   60
EXPLANATION OF PLATES:
General Plan...........................................................                                         63
Grounds and  Pats.....................................................   67
Administraction Building...........                                                                              71
Cobnmon  Wards........................................................   75
isolating  Ward.......................................................   84
Private  Ward.d..........................................................                                      88
Kitche................................................................   91
Operating  Theatre and  Out-Patient Building.........................   93
Autopsy Building..................................,    95
LIST OF FURNITURE FOR A WARD OF TWENTY-THRREE BEDS........... 98
Contents of Medicine  Closet.............................................. 101
Contents of Dressing  Closet............................................ 103
LIST OF PLATES.......................... 104




HOSPITAL CONSTRITCTION
AND ORGANIZATION.
NORTON FOLSOM, M.D.
I PROPOSE first to consider the subjects brought to notice in the
letter addressed to me as nearly as imay be in the order in which
they are there mentioned, adding what I can on matters which
those subjects will lead to; and then to describe the Hospital as
I think it should be constructed, with the aid of such drawings
as time will allow me to supply.
If I enter at times into detail which seems disproportionate
or trivial, it will be either because I feel especially sure of my
ground from experience, or because I rate high the practical importance of the particular matter in hand.
I do not intend to discuss purely architectural matters, except
so far as is necessary to give practical shape to my ideas. I believe, however, that ornament, and even to some extent symmetry in construction, should be subordinate, in a hospital, to
usefulness and convenience; and that that building or part of a
building which best serves the purpose it is designed for will
look the best in the end; and that, indeed. the "'finishing "  or
slight elaboration of the nzecessa)ry parts of a building will usually prove more satisfactory than any amount of extrinsic or superadded ornamentation.
Simplicity has a beauty all its own; and the economical considerations, both as to original construction and inevitable subsequent repair, which would be likely to influence the adminis



60                FOLSOM.-PLANS FOR THE
trators of a charity, are here most strongly re-enforced by the
teachings of science andl experience, especially with regard to all
buildings permanently occupied by patients.
AMy attention has been early directed to the letter addressed to
the Trustees by the honored founder of the Hospital; and I hope
it is not unsuitable for me to express here my sense of its remarkable character. It evidences not only benevolence, but wisdom.
It shows not only solicitude for the welfare of the poor and suffering, but a keen appreciation of their necessities, and discriminating skill in planning their relief. It is marked by liberality
of views in the highest sense; yet its provisions are so pertinent
as to seem almost to imply actual experience in administration
of a hospital.
If any incentive to earnest effort, further than they already
had, were needed by those chosen to aid the committee with their
counsel, it would be found in this truly admirable instrument.
One of the first desires expressed in this letter is that the plan
adopted may be one to allow symmetrical additions to the buildings first constructed; and this has been borne in mind by the
present writer. But umnderstanding that there is, at present, no
free hospital in Baltimore, it seems probable that little delay will
be desirable in completing the Hospital to the full capacity contemplated by the founder-namely, 400 beds. And in any case,
true economy would seem to require the erection of all the admninistrative portions of the Hospital, and those for general use,
at once, and of the full ultimate size. On passing them in review,
I do not think the delay of any of these portions advisable. But
it will be entirely practicable to erect the warlds by degrees, and
nearly symmetrically.
The size of the lot of land provided is ground for congratulation; and according to the English estimate of 80 patients to the
acre, it would seem unnecessarily large; but I esteem it especially
fortunate that the opportunity is thus given for a degree of lateral expansion seldom attainable in a metropolitan hospital. I
have not failed to avail myself of so remarkable and advantageous an opportunity to expand, in making the plan which I submit.
A limit of a very few hundred has been suggested for the total
capacity of civil hospitals, and if the models of past time were
to be followed, certainly the smaller the hospital the better. But




JOHNS IIOPKINS' HOSPITAL.                51
with lateral expansion, free as I propose, I do not think any limit
is necessary on sanitary grounds.
CLASSIFICATION OF PATIENTS.
The expansion to which I allude will render easier and more
complete the classification of patients, which will need to be especially elaborate to fulfil the expressed wishes of the founder.
Provision is to be made for those who can pay for special room
and attendance, as well as for the indigent-not that the latter
class are to lack for anything requisite for their restoration or
their comfort, but there are certain refinements, such as privacy of
apartments and special service, which from force of habit are
necessary to persons in easy circumstances.
It is certainly not less desirable to supply these special opportunities for restoration to health to persons valuable to society,
by reason of their culture and means, than to provide for those
whose places could be more easily filled. The founder' s letter presumes that the receipts from those who can pay for especial privileges will aid in providing for those admitted free; and if this
does not prove to be the case, it can at least be arranged that they
do not increase the expenses of tile Hospital by their presence.,ale andfemale wards require to be entirely separate. The element of age does not necessarily enter into classification, as boys
of tender years can be placed in female wards. Tahe age of seven
is a convenient place to draw the line. But if the number of
children in the HIospital should be considerable, separate wards
would be preferable for them. Afedical and surygical patients
can be treated in the same wards without serious inconvenience;
but it is more satisfactory to a visiting officer to have entire wards
assigned to him than to share them with others, so that these two
classes would usually require separate location. There is to be
no restriction as to color in admissions to the Hospital, and this,
I presume, implies the assignment of separate wards for colored
persons.
The only class of cases excluded from the Hospital by the language of the founder's letter is that of contagious diseases.
These will sometimes arise, however, in the Hospital, and temporarily require accommodationl; and as casualty always brings a
certain number of cases of unpleasant character, either from the
odor of sloughing wounds or from delirium, and as there are a




01-2             FOLSOMI.-PLANS FOR THE
certain number of medical patients who, from similar causes, are
offensive to others, separate wards are needed to provide for these
elenments. But as these wards will consist of an aggregation of
separate single-bedded rooms, there is nothing to prevent their
being held common to various classes, except with regard to sex.
The following is a recapitulation of the different kinds of
wards required:
Private rooms, male, female, medical, and surgical, in common.
Male medical wards.
Female medical wards.
Mtale surgical wards.
Female surgical wards.
Colored male wards, colored female wards; both probably
common to medical and surgical service, if, as I suppose, the
number of colored patients will be relatively small.
Male isolating wards, female isolating wards; common to Inedical and surgical service so far as circumstances require.
One of these wards of the ordinary capacity could readily be
made available for colored patients of both sexes, by very slight
modification.
Wards for children, when their numbers justify the appropriation.
RELIGIOUS MINISTRATION.
The founder's letter provides for the improvement of the portions of the grounds not occupied by the buildings; and I shall
make other suggestions on this point further on. A garden will
not only be a source of refreshment and pleasure to people in
health, within and without the Hospital, but likewise will be a
remedy to the sick, some of whom will be carried out to enjoy
its beauties, while others are cheered by the presence of flowers
in the wards.
The idea has occurred to me, of a chapel for religious worship
in this portion of the grounds; but I have abandoned it for the
following reasons. The fulfilment of the founder's wishes in regard to the influences of religion in the Hospital does not require that there should be stated gatherings of the inmates for
worship. The general character of the institution will be such
that but few patients would be physically able to attend; and




JOHNS HOPKINS' HOSPITAL.                53
in view of the diversity of religious beliefs, they and the enmployees would naturally go to the various churches of their
choice in the vicinity. It is different in institutions whose inmates remain for longer periods, not confined to bed, and away
from the city.
Every facility, compatible with the welfare and comfort of
others, should be given, for the ministrations of religion according
to individual belief, to those patients desiring it. I may here
remark, however, that I have sometimes witnessed the mistaken
zeal of ladies and gentlemen, who, with the highest motives,
urged religious instruction and conference upon patients who
were indifferent, or who lacked the strength to profit by it. This
tends to bring what should be revered into contempt. The rules
of the Hospital should define the relations between patients and
religious visitors, and protect them from unwelcome interference.
CONNECTION WVITHI M3EDICAL SCHOOL.
The Hospital will never fail to obtain the services of attending
officers of the highest professional standing. One of the guarantees of this is the connection contemplated by the founder between the Medical School of the University and the Hospital. I
am convinced, however, that the desire expressed at the close of
his letter, that the Hospital shall form a par-t of the Medical
School, should be so interpreted that this may be the case only
so far as will conduce to the best interests of both institutions.
I am ready to admit that the Hospital may be regarded as a
very essential part of the College in furnishing the opportunities
for clinical and pathological teaching, absolutely and fundamentally necessary to medical education. But I believe it to be exceedingly important to both that nomninally and in organization,
they should be distinct.
In the Hospital organization the first consideration is the welfare of the patients. In the College, opportunities and advantages for the students are the main objects of solicitude. To
harmonize, or rather to prevent all conflict of these interests, will
be among the most delicate and important of the functions of the
Boards of Management.
A certain prejudice exists among the uneducated, and indeed
among those who have had better advantages, against going to a
llospital. A fear of being "experimelinted on," and a sensitive



FOLSOM3. —PLANS FOR THIE
ness about having their ailments openly investigated and spoken
of freely before others, actually deters patients from applying
for admission, who might obtain relief. It is necessary to deal
with such prejudices very gently, and to avoid so far as possible
any appearance which might justify them.
The whole Hospital should be imbued with the feeling that the
interests of the patients are paramount; that the students are
only allowed to visit as a privilege, dependent upon their orderly
and considerate demeanor; and that even Professors, as such,
have no absolute rights which patients are bound to respect
against their will.
This will really work to the benefit of both Hospital and College, by doing away with the prejudices alluded to; bringing
applicants for relief in larger numbers, and more promptly;
gieatly increasing the opportunities of the classes for observation
of disease; and, by refining the relations between students and
patients, doing something to prevent the relapse into scientific
coarsenzess which is apt to temporarily obscure the progress of
every young man in the profession.
COUNTRY WARDS.
The letter of the founder does not limit the scope of the Hospital to providing for acute or curable ailments; but I think a
general rule should be established by the Trustees, limiting the
stay of patients to a certain number of weeks, subject to modification in individual cases, on recommendation of the medical
officers in attendance.
It is a question for the deliberate consideration of the Trustees,
how far they will feel called upon to provide a home for disabled
persons who cannot be cured, and who do not need the daily
ministration of a physician, and skilled nursing. Certainly such
persons should not be suffered to remain long in the Hospital in
the city.
Since provision is to be made for convalescents at a distance
from the city, presumably at less expense than will be necessary
in the Main Hospital, I would recommend that chronic and incurable cases, not requiring much immediate treatment,-such
as consumptives, for instance,-should be provided for, temporarily at least, at the same time.
There are other cases, of which scrofulous disease of the hip is




JOHNS HOPKINS' hIOSPITAL.              55
an example, where ultimate benefit or cure is probable, but where
good food, fresh air, and rest are the principal remedies to be
used. These cases should also be transferred to the country
wards, returning temporarily to the Main Hospital when symptoms arise (such as the supervention of an abscess) requiring irmmediate treatment.
It will be desirable in arranging for these country wards,
(which will prove to be a very important feature of the Hospital,)
to make them readily accessible, by easy roads, at all seasons,
so that no delay may arise in the transfer of patients. If they
are many miles distant from the city, it will be well to place
them near a railroad; and easy wagons or ambulances can be
fitted with mattressed litters of a size to go through -the door of
an ordinary railroad car, so that a patient can be transferred
from a country bed to a city bed, or vice versa, without change
of position.
Economy of management would suggest the establishment of
these country wards in connection with the Orphan Asylum,
but this is a matter beyond ily province to discuss. The buildings should be of simple construction, roomy, well warmed and
ventilated, and might be of more than one story without detriment. Ordinary country houses with large rooms, with open
chimneys or special ventilation, and furnace heat in addition,
to secure a full supply of air, would serve the purpose. Waterclosets would be needed on each floor, and might be added in a
tower built at the corner or side of the house, connecting with
each story by means of a little ventilated stem or lobby, which
would keep the air of the house from contamination. A farm
would be a natural appurtenance of such wards, where convalescents and others might profit by light labor in the open air,
the products of which would partially supply the other parts of
the institution.
A resident medical officer would be required, and the position
might be filled by the house officers of the Main Hospital in rotation, a month or two at a time. If the distance from the city
should be considerable, it would be desirable that one or more of
the physicians in practice in the vicinity should be invited to act as
visiting or consulting physician on call by the resident officer, in
case of emergency. But cases requiring attention would be transferred promptly to the city; and there should be visits of inspec



56               FOLSOI. -PLANS FOR TIIE
tion and examination at least as often as every week, by the
Resident Physician of the Main Hospital, or his representative.
PROXIMITY OF MEDICAL SCHIOOL.
The advantages derived by a hospital from connection with a
medical school are comparatively few, and I have already alluded to the possibility of detriment, to be avoided by careful
management. The careful, thorough, and exact, even laborious
methods of investigating and treating disease necessarily employed by a professor in presence of a class of students, are,
however, not only advantageous to the individual patient concerned, but the standard of thoroughness and care is raised for
the whole institution, and every employee can be made to profit
by the example.
But instruction in a hospital is an indispensable part of thorough medical education; and the advantages to the medical
school of the connection are manifold, and would be much increased by close proximity of the institutions. Very few of the
exercises of other departments of the University would be regularly attended by medical students under any circumstances;
while hospital instruction will be likely to be given repeatedly
during the day, and sometimes unexpectedly, on short notice.
Besides the stated clinical lectures, illustrated by the cases of the
inmates and out-patients of the hospital, the visits to the medical and surgical wards, and the attendance at surgical operations at regular times, there are accidents and emergencies sometimes occurring, such as cases of poisoning, or the rarer dislocations, whose treatment is so specially instructive as to justify
the interruption of stated exercises to allow the students to witness it. The study of the appearance of the diseased organs of
the body, after death, and microscopical investigation of their
stracture, is a branch which receives constantly increased attention in the medical curriculum. The opportunity to pursue this
study must be seized at the time it occurs, often without reference to convenience of hours.
These matters are of the greatest importance to the students,
but unless they can reach the hospital easily, they will neglect
their opportunities; and apart from this, the time to get to the
hospital, and back to the next exercise, must be taken from the
busiest part of the day.




JOHNS HOPKINS' HOSPITAL.              57
I have no hesitation, therefore, in recommending that the
Medical School should be separate and apart from the Hospital
grounds, but within a few minutes' walk. A mile, in my judgment, would prove to be an injurious distance, even with constant facilities for transportation by horse-cars.
TPRALNING SCIOOL FOR NURSES.
The training-school for female nurses, to which the founder
alludes, is a matter to which I have given special thought.
The varying success which has attended the efforts of sincerely
philanthropical persons in establishing these schools in this country, has been largely due to the difference of the ground which
they have invaded. In any field where reform in nursing is
much needed, the managers of such a school, by devoting time
and money to raising the standard of the service,-engaging a
better class of women than were previously employed, and employing more of them to do the same work,-would be more
likely to win the encomiums due to successful change, than where
change was less needed. I am inclined to think little of didactic
instruction for nurses, and much of practical experience; and
that their duty should be so systematized as to bring each nurse
into relation with the different classes of cases in the Hospital,
successively, but without changing rapidly, or until entire familiarity with all details has been acquired in each situation.
I am strongly of opinion that the ]Hospital should be the
Trlaining School, and that a separate organization and management in a well-regulated hospital is more or less detrimental to
the economies of the latter, and to the excellence of the nursing.
The esprit de corps should be that of the Hospital, not of a, separate educational body.
It must not be forgotten that the best hospitals in this country
atlzcals have been training nurses, and although the number
leaving the hospitals to do private nursing has not been large,
the esteem and demand in which they have been held is proof
positive of the value of the training received.
The first care of any hospital must be to supply itself with
skilled nurses, and the amount of what can afterwards be done
to supply the community outside can only be determined by
trying. This would probably depend on the amount of money
devoted to this particular end.




FOLSOMI. PLANS FOR THE
I am not aware of any advantage pertaining to the name of
"Training School" in connection with a hospital, except, perhaps, that it would attract a greater number of applicants for
places, and among them, presumably, more of the better class.
I am inclined to think, however, that judicious advertising,
directly from the Hospital, would be quite as effectual and better on other accounts.
The instruction of nurses should proceed from the officers of
the Hospital, and should grow out of the daily experience of the
wards, care being taken, as above stated, to secure variety of experience to each nurse. The Matron, nnder the authority of the
Resident Physician, is the natural supervisor of nursing —and in
a large hospital this duty might well be in the hands of a special
subordinate. There are various matters in which systematic instruction is necessary, and this should be given by the Head
Nurses of wards to the Assistant Nurses, as they come under
their control, under the general direction of the Matron. The
medical officers should also be expected to instruct the nurses
so far as their demands and directions to them lead to it, and
especially by holding them individually responsible for duties
done in connection with particular patients.
Holding these views, I have made ample provision in my plan
for the comfortable living of all the nurses likely to be employed
or taught at one time in the Hospital, within the institution.
ONE-STORY WARDS.
While I am not prepared to deny that sick people will get
well rapidly in buildings of several stories, I am strongly of
opinion that one-story wards are better, and that these should be
detached so far as circumstances will admit.  I do not know
that there are any statistics in existence which show that more
patients recover, or that recovery is quicker, other things being
equal, in such wards; but I believe it to be true. Economy of
administration requires us to treat twenty or thirty patients in
one room. That room should be high enough to allow a great
body of air to be constantly entering and leaving it, without creating " a draught," or, in other words, chilling the skin
of any patient by passing over it too rapidly. If another room
of the same height is placed above, the whole building is so
high that the next pavilion has to be placed at an inconvenient




JOHINS HOPKINS' IIOSPITAL.              59
distance to avoid mutual shade, and to securefree external circulation of aire.  The desirability of the latter is so universally acknowledged that I shall not discuss the merits of wards placed
side by side in a continuous building, where light and air are
necessarily partially excluded.
One-story wards are very convenient of administration. By
omitting thresholds, and providing simple trucks with rubber
tires to the wheels, one attendant can do the work of two in
transporting patients and supplies; and wo7at can be done easily
woill be done pronmptly.
The arrangements which I consider best, and have adopted in
my suggestions for heating and ventilation, preclude the idea of
a second story to any building occupied by sick. One of these
features, ridge ventilation, modified to suit altered conditions,
is derived from army hospitals. It was thoroughly tested and
widely adopted during the war, and its excellence is acknowledgedl. I think the main dependence should be placed, in heatinq, upon very low pressure steam apparatus, with, almost inva.ricably, indirect radiation. In this way, to give heat, you must
give fresh air, and good ventilation is insured. Open fires are
specially useful in mild weather, and are very efficient ventilators;
and in their appropriate places special fireplaces are advisable,
which supply fresh warm  air, besides removing that which is
foul. It will be seen that no special system has limited my suggestions; and though the "natural method " of ventilation may
be relied on in some weather, when doors and windows are freely
open, efficient means of constant supply and change of air of
equable temperature has been provided for, both in winter and
summer.  Mechanical forcing by a fan has not been resorted
to, as the application of the necessary amount of heat directly
to supplying and ventilating shafts is simpler and more economical.
I do not consider destructible barracks, which are so excellent
for military hospitals, at all suitable for a private, civil institution. I believe that careful administration will make permanent structures at least equally healthful with them, and, in a
temperate climate, physical comfort is greater in a building with
comparatively thick walls. I should consider the moral effect
of barracks in a civil hospital, unless for temporary and exceptional use, positively prejudicial. If we provide for the renewal




60                FOLSOM1I.-PLANS FOR TlIE
or refreshment of the inner surfaces of wards, their entire destruction becomes unnecessary.
The character of the lot of land provided for the Hospital is
exceedingly satisfactory, and it is needless to dwell on some
matters which would demand early attention in selectiing a site.
Its elevation secures the free access of air to all the buildings, if
care is taken not to obstruct it unnecessarily.  No difficulty is to
be anticipated about drainage or water supply. If the streets
immediately around the Hospital can be paved with wood, it will
prevent annoyance and detriment from the noise of passing teams.
The difference of grade in these streets is not such as to interfere
with any plan for building; for it would be practicable to make
the greater part of the lot level.  In the plan which I submit,
however, the present general conformation of the land is respected.
SCHIIEE  OF ORGANIZATION.
The following scheme of organization is proportioned to the
full capacity of 400 beds:
Officers elected anneually by the Board of Trustees.
A Resident Physician-the executive officer; in constant and
confidential communication with the Trustees, and in professional sympathy with the medical and surgical staff, he is better
able to regulate action, and harmonize various interests, and to
control subordinates of varied position and character, than a nonmedical superintendent.  His duties include those of a steward,
and admitting physician; but he should have an assistant, and
one or other should be always at the Hospital. Under the direction of the Trustees, he has control of the Hospital in all respects, except the treatment of patients.  Ile makes all purchases for the regular needs of the Hospital, and receives all
moneys paid for board or otherwise, and his accounts are settled
monthly with the Treasurer. His decisions as to the admission
of patients, and their rate of board, shape the whole character of
the charity.  He appoints and discharges all employees not
elected by the Trustees. He is responsible for the proper warnming, ventilation, cleaning, and repair of the Hospital, and for the
discipline of house officers, employees, patients, and visitors.
He provides the diet and remedies ordered by the physicians and




JOIINS HOPKINS I-IOSPITAL.                61
surgeons, and keeps records of applications, admissions, discharges, etc. He has custody of all property at the Hospital.
In case of emergency, in the absence of the visiting physicians
and surgeons, he acts for them in regard to treatment, and discharges patients if discipline requires it. He assigns patients to
the proper ward and bed, and directs removal or change, when
necessary.  He orders all autopsies in writing, under rules made
by the Trustees. Ite makes an annual report to the Trustees of
the doings of the year, and the state of the Hospital.
A Boalrd of Consultting Physicians and Surgeons.
Eight Visiting Ph7fysicians and eight Visiting Surgeons, two of
each serving at one time, for a term of three months. They have
entire charge of the treatment of patients.  They order, through
the house officers, the medicines and stimulants required, and
direct what grade of general diet the patients shall receive. If
extra articles of diet are needed, they order them from an extra
diet list, cdaily. They daily report to the resident physician,
the names of patients suitable for discharge or removal to country wards. They dictate to the house officers the medical and
surgical records.
Four Physicians and four Szrgeons to Out-Patients, who
shall also act as assistants to the visiting officers when required.
An 02JOpthalmic and an Aural Surgeon, who attend to cases in
their special departments, whether out-patients or in the wards.
A Dentist.
A Pathologist, who makes all autopsies, preserves specimens
of morbid structure in a cabinet, and examines diseased growths
and secretions, of which he keeps record.
An Assistant Physician, the constant aid of the resident physician, and his representative when absent.
Sixteen Hrouse Officers-medical students or recent graduates,
eight medical and eight surgical, eight resident and eight nonresident —to serve in all two years, and eight to be elected each
year. The first year to be passed in the Out-Patient Department, and as junior ward officer, six months of each.  The
second year to be passed in the house, as senior ward officer, six
months of male and six months of female service. They carry
out the orders of the visiting officers. The non-resident officers
only assist in making autopsies.
The importance of the practical eficiency of these officers in




62               FOLSOM. —PLANS FOR THE
the care of the patients is very great. An examination before
appointment may be useful to secure a certain standard of
scholarship, but it should not be competitive. They should be
elected on the joint nomination of the visiting officers and resident physician, after thorough investigation, regard being had
to general qualifications, maturity, and practical ability, as well
as scholarship.
The Apothecary, who aids the Resident Physician in the purchase of drugs, etc., manufactures preparations, and dispenses
the remedies ordered by the physicians and surgeons.
The Matron, who aids the Resident Physician in the purchase
of household articles, supervises the housekeeping, cool]ing,
and cleaning, and especially the nursing and training of nurses.
Persons employed by the Resident Physician.
A Clerk, to aid in book-keeping and correspondence.
An Apothecary's Assistant.
An Engineer, in care of all apparatus.
Two Firemen.
A Store-keeper, who regulates the kitchen, and receives and
gives out supplies of food.
A Kitchen Jlan.
Five Crooks.
Four Kitchen Maids.
A Head Laundress.
A Laundry Mfan.
Eight Laundry Maids.
Four flousemaids.
Two Parlor zMaids.
Four Porters, one to serve also as coachman, one for OutPatient Depaartmzent.
An Assistant Matron and Librarian.
Two Seanzstresses.
Twenty Head lutrses.
Forty Assistant Nurses.
Twenty Nfight N21trses.
Five male Ward Tenders.
The aid of patients who are not physically disabled will be
necessary in the care of the wards; and the moral effect of this is








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JOHN-IS HOPKINS) HOSPITAL.              63
good; and it will be found that the payment of board proportionate to their means, be the amount ever so small, will cause
patients to better appreciate their advantages.
The manner in which this organization is proposed to be
accommodated can be better considered in connection with the
drawings accompanying this paper.
EXPLANATION  OF PLATES.
GENERAL PLAN.
Plate No. 1 is a block plan, showing all the buildings proposed.
Two ideas have been adhered to in this general plan of the Hospital:
First, that the wards should be all on the same floor, connected by low corridors with the first story of the other buildings;
so that passage from one part of the Hospital to another might
be unobstructed by steps; and no thresholds being used, trucks
with rubber tires to the wheels, before alluded to, might pass
everywhere without jolt or obstruction.
Second, that every room occupied by patients should receive
direct sunlight during some part of the day.
The value of the convenience and cheerfulness thus secured
can hardly be over-estimated.
The administration building occupies the centre of the obvious
front,-the westerly end of the lot,-fifty feet from the street, a
position of average grade, as regards the rest of the lot, and sufficiently accessible from all other parts of the Hospital.  It is
joined by two cross-corridors to the main or connecting corridor,
twenty-five feet to the rear, on the east side of which are several
low buildings, appurtenant to administration. This central region would at first glance seem to be the proper place for the
source of steam-heat, and the kitchen and laundry; but the lowpressure boilers are to send steam to every part of the Hospital,
by pipes which rise to the ceiling of the corridors, and descend to
the various radiators, and the water resulting from the condensation of the steam is to constantly return to the boilers, by the
force of gravity, through pipes beneath the surface of the ground;
therefore, the place for the boiler house is at or near the lowest
part of the lot, as near as may be to the main corridor, but also
accessible from the street, so that coal can easily be put in.




64                FOLSOMf.-PLANS FOR THE
The position fulfilling these conditions is found at the southerly
part of the lot, and is convenient in every way. The kitchen and
laundry, which are to be supplied with steam from a boiler of
higher pressure in the same room and under the same managenment as the heating boilers, are placed as near the boiler house as
is practicable.  These points being settled, the other buildings for
general use have been so placed as to have ready access to the main
corridor, and yet not to obtrude unpleasantly upon the wards.
The beds of the Hospital are distributed as follows:
In one private ward of 20 separate rooms............  20 beds
In fourteen general wards containing 23 beds each.. 322 "
In four isolating wards of 16 separate rooms, with
one bed in each................................  64"
Total.............................. 406  "
The general wards are alike, and would be assigned to such
various uses, at different times, as circumstances might require.
The four isolating wards are also alike.  Ample means of classification of patients are thus afforded, and the details of their distribution would be determined by the proportion in which different classes of patients would be found to present themselves.
The corridors are all to the north of the wards which they connect, and therefore do not interfere with the southerly exposure
of the buildings.
The private ward is placed at the north-westerly corner of the
lot, out of the thoroughfares of the Hospital, on a high level, accessible from the front street, but fifty feet from it, near the
house of the Resident Physician, with pleasant look-out from all
the patients' rooms. It is reached by a corridor which leaves the
northerly end of the main corridor, running first north-west, then
north, to the entrance of the ward.  From this corridor branch
off two of the four cross-corridors which go to the other wards.
Of the other two, one leaves the main corridor at its middle, the
other at its southerly end.
As much distance is allowed between the wards as the size of
the lot permits, reserving a moderate space for garden and airing
ground at the easterly end.  This distance between wards is
sixty feet from  east to west; and from  the southerly wall of
each ward to the cross-corridor of the row of wards to the south




JOHINS IIOPKINS' HOSPITAL.               65
of it, seventy feet. The wards, in each row, are placed opposite
to the intervals in the next row, to facilitate the free circulation
of air around them. The corridors are not necessarily level, but
follow  ihe slope of the ground, which is to be graded so that the
foundation of the isolating ward at the north-east corner of the
lot is a little higher than that of any other building.  It follows
that the wards are vertically eyt echelonz, and will the mlore
readily catch the prevailing winds.  The isolating' wards are
placed one at the easterly extremity of each cross-corridor, so as
to be the most out of the thoroughfares.
At the southerly end of the main corridor, a branch leads
south, past the out-patient building to the operating theatre.
Froln the same point two branch corridors side by side, with a
thin partition between, with doors in it, lead to the corner of the
laundry.
Here the most northerly branch itself becomes double, the
north half being one of the cross-corridors leading to wards, while
the south half leads to the kitchen, passing the following
three rooms:
A goods-receiving room, ten feet by twenty-four, where bulky
articles are received, nunpacked, examined, and repacked, or conveyed by trucks to any part of the Hospital.  Attached to this
room is a lavatory, and a water-closet, for nmale employees.
A dust-room, ten feet square, containing receptacles for sweepings, paper, and dry rubbish.
A garbage-room, ten feet square, with water-tight receptacles
for swill. The floor should be perfectly tight, and dished, with
a trapped drain and strainer, and supplied with a water-tap and
short hose; and the receptacles should be thoroughly cleansed
after each emptying.
These three rooms open on the corridor, and also, by double
doors, on the kitchen yard, where the teams drive in. The garbage-room also opens on the kitchen.
The most southerly branch corridor, at the corner of the laundry, turns south and runs between a row of horse-sheds, and the
laundry, and rinsing-room, and beneath the seats of the autopsy
theatre, to the dead-house.
The horse-sheds, for the convenience of the visiting staff, open
on the corridor.
The laundry, about forty feet square, is fitted with soap-stone




66               }FOLSOM3.-PLANS FOR THE
tubs, boilers, rotary  washing-machines, and  a centrifugal
wringer. It has a tight floor and drain. It communicates with
the ironing-roolm, twenty feet by forty; which contains a mangle,
stoves for heating irons, and a steam-heated drying-closet.  In
the corner is a water-closet, for. female employees. aNext this
room is the rinsing-room, twenty feet by forty, containing a large
number of ventilated boiling and washing tubs, and Ca dryingcloset; where all specially foul linen, bandages, etc., are conveyed from  the wards, at the dressing hour, placed at once in
water to soak, and thoroughly rinsed and deodorized before being
conveyed to the laundry for final cleaning.
A steam engine will be required to carry the machinery.
Over these rooms and reached by stairs, is a bell-deck or roof
arranged to be walked on, surmounted by a roof of glass and iron,
supported by pillars and surrounded by a railing, but having no
sides to obstruct the free passage of air. Here the clothes are to
be dried in fair weather. A lift for raising them could be connected with the steam-engine.
Twenty feet from the kitchen, and fifteen from the autopsy
building (from which it is separated by a covered way with gates
at each end), is a building eighty feet square, comprising a boiler
house, coal-shed, and wood-shed; also a small stable, where are
kept a horse and ambulance, and a vehicle to send for the attending staff in case of emergency. The use of the telegraph from
various points in the city in connection with these vehicles will
need consideration.  Over some part of this building is a loft,
where mattresses and pillows are aired after the departure of
patients, before being used again. There should be a sufficient
supply of these articles in the hospital to allow of their remaining in the open air a week.
A bed-room with a bath and water-closet attached, for the engineer, is also placed in the second story of this building.
The walls of all these buildings are recommended to be constructed of brick, with a closed air space, except in the corridors,
where a single eight-inch wall will be sufficient; and painted outside to insure dryness.  If stone trinmmings are used, they
should project as little as possible from the surface, as any irregularity interrupts the free sweep of air, and gives opportunity
for dust to collect. Especially in those buildings occupied by
patients, relief to the eye should be attained by variation in color,




JOHNS HIOPKINS' IIOSPITAL.              67
rather than by projections or depressions in the walls. There is
obvious opportunity for architectural effect in the front buildin(s.  The adlministration building will be likely to vary in
height in different parts. The private ward is in a commrnanding
position, and a tower or cupola on it would afford a magnificent
view. The out-patient and operating' buildings are of sufficient
size and height to balance the front symmetrically.
The inside of the walls should either be plastered directly on
the brick work, and so prepared as to be hard, smiooth, and impermeable like stone, so that they can be freely scrubbed; or, if
this is impracticable, very thin furring should be so attached as
to be easily removed and replaced; and this renewal should be
made in the buildings occupied by patients at least as soon as the
plaster becomes cracked or marred.  WThere the plaster remains
smooth and sound, a thin coat of paint applied every year probably renders it perfectly healthful.  However constructed, the
walls should have all corners and angles rounded to prevent accumulation of dust, and allow of ready cleansing.  This is especially desirable at the junction of the base-board and the floor,
where a broom is apt to leave more or less dust in spite of care.
(See figure on next page.)
All floors should be made of strips of hard wood, not over two
inches wide, tongued and grooved and blind nailed.
On the whole, the application of boiled linseed oil is believed
to be the best way of treating the floors.
The finish, especially in wards, is advised to be perfectly plain,
without mouldings; and where projection is necessary, as in the
casing over a door or window, the upper surface should slope
towards the floor at an angle of forty-five degrees, to facilitate
cleansing.
GROUNDS AND PATHS.
Plate No. 27 shows on the block plan the course of the paths
about the grounds. A driveway, fifteen feet wide, surrounds the
whole, and from this lead off paths ten feet wide, which will allow
the passage of carts if necessary. A row of trees is placed along
the outer side of the driveway, and on the inner side wherever the
buildings are not so near as to be shaded by them. In planting
the double rows, the trees should be placed opposite, rather than
alternate, to insure the formation of.a vista of gothic arches.




68                FOLS03. —PLANS FOR TIIE
The front or business entrance to the Hospital, to which all
patients should be directed, is opposite the southerly front door
of the administration building.  Close to the gate is the lodge,
where the gate-porter lives night and day. He sees every one
who enters, inquires the errand of all newcomers, and directs
them accordingly.  Applicants for admission and visitors to the
wards go to the door opposite the gate. Vehicles conveying
persons injured by accident, or cases of severe sickness, unable
to walk, are driven to the door at the southerly end of the
administration building.  Out-patients are directed by the next
path to the south to the front door of the out-patient building.
Students pass by the path still further south to the entrance to
the operating theatre, which should be their regular place of assembly, except when, under special instructions, they are to meet
the visiting staff at the wards, or the Pathologist at the autopsy
theatre.
9BASE BOARD
SECTION OF CORNER STRIP OF FLOORS.
CORNER PIECE
FLOOR
i
A path leads around the southerly end of the administration
building directly to the middle of the short corridor which passes




JOHNS HOPKINS' hOSPITAL.                69
across to the main corridor. At this point a cut and arch-way,
with a catcdh-basin at the bottom, might be mlade, so that a cart
could pass beneath the corridor and reach the court-yard behind
the administration building, which is the only space about the
Hospital entirely enclosed by buildings.
At the northerly end of the administration building is the
private entrance, which serves for visitors to the Resident Physician' s famlily, and to the patients in private rooms. The grounds
about the private ward are made as attractive as possible, and in
the centre of the space to the east of it is a fountain.
The rear entrance to the Hospital is close to the boiler house,
and is under the charge of the muan on duty there, so far as
necessary. Teams bringing stores and ice, drive up to the easterly side of the kitchen building. Those bringing other goods,
and the scavenger-carts, pass SOulth and west of the kitchen to the
goods-receiving room door, and to the dust and garbage rooms.
The driveways and the yard around the kitchen are mlacadamlized.
The wood-shed is reachled fronm the kitchen yard. 1Here waste
boxes, barrels, etc., are broken up to be utilized for fuel. Here
also broken furniture, and badly soiled bedding are placed while
waiting for repairs and cleansing. The roof of the covered way
between the coal-shed and autopsy building projects over the
northerly gates, to protect persons passing across from  the
weather, so that, through the wood-shed and boiler-room, the
stable can be reached from the main buildings without exposure.
Teams bringing coal for the boilers turn to the left on entrance
at the gate, drive into the coal-shed by a southerly door upon a
bridge of plank supported by brick piers, from which the coal is
dumped on the floor below. They then leave the shed by a
westerly door, comling out through the covered way between the
shed and the dead-roolm. Undertakers pursue the same route,
pass the coal-shed, and back into the covered way through the
southerly gates, which are then closed. After the remains are
placed in the wagon or hearse, the gates are reopened and the
vehicle passes out; in this way being entirely out of view of the
patients, on some of whoml the associations connected with such
matters would have a depressing effect.
A driveway to the horse-sheds for the visiting staff, just to
the east of the operating theatre, can be reached by either the
front or rear entrance. Coal for use in the wards is carried to a




70                FOLSOM.-PLANS FOR THE
small coal-cellar in each building, by the cart-paths which run
along their northerly aspects. The same paths conduct those
patients who are able to go out of doors, or who are carried out
in baskets and litters, to the garden.  A sunmmer-house, or rustic
arbor, shaded by trees, is readily accessible from the end of one
of the corridors, and an uncovered inclined plane might readily
be constructed for trucks or wheeled chairs to pass to and fro
upon.  Most of the garden or airing ground had better be smooth
turf; any irregularity of level and any trees now existing on
that portion of the lot being preserved, if suitable, and flowerbeds and shrubs disposed at angles and near the paths, so as to
give as much expanse of green as the limited space allows. A
fountain is suggested at a central point.
As has been stated, the most north-easterly building, an isolating ward, is to stand a little higher than any other building.  It
follows that the general downward slope of the lot should be made
to be towards the south-west, as indicated by the grade of the
surrounding streets; but this slope need not be regular.  The elevation now existing near the centre of the lot might be lowered
to about the level of the north-easterly building, and from this
plateau the slope would be more rapid to the south and west.
To insure dryness, the various buildings, especially those occupied by patients, are immediately surrounded by gravelled
paths a few feet in width, beyond which the turf slopes quietly
away from the buildings.  The surface water is thus directed to
points intermediate between the cross-corridors and the row of
wards to the north of each, and as the downward slope is to the
west, there will be a lowest point between each two rows of wards,
somewhere near the main or connecting corridor.  At these lowest points, and at intermediate points, if slight irregularity or
any other cause makes the surface water collect, catch-basins are
placed, which overflow into brick drains.  These drains, and the
earthen pipe or other drains from the various buildings and from
the fountains, empty into a main drain running south, probably
diagonally, intersecting the cross-corridors, but avoiding passage
beneath any large building, to reach a sewer beyond the boundaries of the estate.'
1 If, as has been intimated, this sewer is located in Ann Street, the main drain would
follow a diagonal line drawn from the north-easterly corner of the private ward to a
point near the rear entrance of the IHospital.








N                                                                               S
RPL   O  ArA                                                                  L
INROOM SEWINGROOM   MATRON                                           L                                   WAITINGOM
Yo,_I                             ftj                              ACCIDENT
I.T TE  [                                    r                   E111 AMINATION'-,TRUSTEE PARLOR:         SE OFFICERS,              WAITING ROOMT. ADM'TT'NG
RES. | | PHYE*S&ST"WAPD                                  LT
RESIDENT PHYSICIANS HOUSE-.                                                   __                                                                                        l
PLAN O F ADM INISTRATIOC I'LDING.                                                        O
FIRST FLO01                 ~ SCALE,32 IN.- I FT,
Dr. Folson-fs Sug e sti olLs
i J      H NS H  O PKI NS    H OS PI TA   L.




JOHNS HOPKINS' HOSPITAL.                71
Cesspools, if required in connection with the smaller drains,
-would be placed near the paths, to facilitate the necessary annual
emptying process.
ADMINISTRATION BUILDING.
Plate No. 2 is a plan of the first story of the administration
building and its appurtenances.
The main building is 250 feet long and 50 feet wide, divided
longitudinally by a hall, 12 feet wide, intersected by three equidistant cross-entries. The central cross-entry, 12 feet wide, opens
on the front veranda, 100 feet long and 8 feet wide, by the front
door of the building; and at the opposite end of the entry, the
central rear door leads by a few steps to the courtyard behind
the building, and opposite to these, other steps lead to the centre
of the main or connecting corridor.
The northerly cross-entry, 10 feet wide, passes from a door in
front, seldom used, to a short cross-corridor of the same width,
leading to the northerly end of the main corridor.
The southerly cross-entry, also 10 feet wide, passes froln the
principal business entrance, opposite the front gate, to a short
cross-corridor of the same width, leading to the main corridor,
which is also 10 feet wide. The corridors leading from this main
corridor to the wards are 7 feet wide. All the corridors are to
be very low studdedc; allowing about 7 feet below the steam and
water-pipes, which are recommended to be wrapped in asbestos,
covered with canvas and painted, and hung along the corridor
ceiling, in plain view.
Trhe northerly end of the building, beyond the cross-entry, is
appropriated to the Resident Physician and his family. It opens
on the cross-entry by two doors with a small lobby between. A
projection or ell at the north-east corner gives opportunity for a
south window. The situation of a kitchen (more for serving food
than for cooking) and a dining-room are indicated, but further
details are left unsettled. If it were found that all the room in
the upper stories was not needed for the Resident Physician, the
partition wall could be placed further to the north in those stories,
without departing from the idea of a dwelling for him, separate
from the Hospital, yet readily accessible. A speaking-tube at
the door onl the cross-entry should communicate with his bedroom.




72                FOLSOMI.-PLANS FOR THE
Opening on the northerly cross-entry are two closets, and a
lavatory and water-closet for the use of officers.
Between the northerly and central cross-entries is, in front,
the business office or counting-room of the Resident Physician,
about 22 by 19 feet, including a strong room for account-books,
records, and valuables.
1Niext is a room for meetings of the Board of Trustees, about 29
by 19 feet. On the other side of the main hall are a dining-room
for the officers of the Hospital, about 20 by 15 feet; a sewingroom and a matron's office, each about 15 feet square.
Between the central and southerly cross-entries is, in front,
a small parlor or reception-room, for general use, about 19 by 12
feet. [Next is the office of the house officers, about 29 by 19 feet,
containing eight desks, and in the corner, not indicated on the
plan, a ventilated cupboard and sink for the examination of urine.
One window is arranged for the convenient use of the microscope.
A small medical library of books of reference should be placed
in this room, in the custody of some one house officer; and a
glazed case should be provided for certain surgical instruments
and apparatus liable to be needed suddenly. Next to this room
is the porter's office, about 19 by 10 feet, where the head porter
remains by day, and where he sleeps by night. On the other
side of the main hall, next to the central cross-entry, is a library
room, about 15 feet square, containing entertaining books for
patients' use. A catalogue of the library should be kept in each
ward, and there should be a stated time for the nurses to procure and change the books for the patients. In the corner of
this room, and also accessible from the central cross-entry, is a
wvater-closet for the use of the females employed in this part of
the institution. Next the library is the room, about 19 by 15
feet, appropriated to the visiting staff. Here consultations would
often be held.  Adjoining is an exalining-room, about 6 by 15
feet, and beyond it a lavatory and water-closet. Next to this,
and opening on the southerly cross-entry, is a lavatory, with a
housemaid's closet, and two water-closets, -one to be kept locked
for the use of male employees, the other for the use of persons
from the waiting-rooms near by.
The portion of the building south of the southerly cross-entry
contains in front a double waiting-room, about 36 by 19 feet,
for applicants for admission, and other persons calling on busi



JOHINS HOPKINS' IIOSPITAL.                 73
ness.  Beyond is the admitting  office of the Resident Physician,
about 16 by 12 feet, and leading from it an examination-roolm,
about 16 by 6 feet, which also gives access to thle main hall, and
thence to the acciclent-roomr on the opposite side, about 15 by 20
feet; where are several beCds covered with rubber sheeting, for the
temporary reception and examination of "accidents" and persons too sick to sit up.  Here are kept tourniquets and dressings,
for the prompt arrest of hemorrhage, and a tray containing ether
and restoratives.  A sink and a bath-roonm are placed in the corner, the latter being only for exceptional use in emergencies, or
when patients are unable to go to the regular bath-house.  Next
the accident-room  is a waiting-room  for visitors to patients,
about 15 by 32 feet.  There should be a regular hour for the admission of these visitors, arranged so as not to interfere with the
visits of the physicians and surgeons.
In the rear of the main building, on the easterly side of the
main or connecting corridor, are three low, one-story buildings.
The most northerly of these, about 52 by 18 feet, is appropriatecl
to household supplies —bedding, crockery, utensils, etc. —which
are given out as needed, under the direction of the Matron, a
regular time being established for issuing, and the head nurses
of wards being made to account for all deficiencies in their supplies of articles.  It opens on the corridor by two doors, one of
which is double.
Immediately to the south of the most central cross-corridor is
the bath-house.  The portion appropriated to females, about 19
feet square, opens on the cross-corridor.  On the right of a central entry are three ordinary bath-rooms, about 6 feet square.
On the left of the entry is a room 7 by 8 feet, for shampooing
and douche bathing.  From this open two hot-air or vapor closets, of different temperatures, and a, specially ventilated closet
for sulphur baths.  The other half of this building, exactly similar, is appropriated to males, and opens on the main corridor.
This building, as drawn, is of the smallest dimensions consistent
with usefulness.  More space might well be allowed for it.  It
should be under the charge of an assistant nurse, who shoulcl
keep both portions clean and in order, and who should be instructed in rubbing and applying electricity to female patients,
ward tenders doing the same for male patients.
Ten feet south of the bath-house, the interval being left for




74                l'FOLSO.t. —PLANS FO01 TIIE
light and air, is the dispensary, about 38 by 18 feet —opening on
the corridor by two doors, one of them double, and a central window-devoted to the preparation and dispensing of drugs. The
orders of the attending staff in respect to medicines and stimulants
are transmitted in writing to the apothecary by the house officers, and the head nurses receive the remedies prescribed at the
window, every bottle being distinctly labelled with the patient's
name, the number of the ward, and the nature of the preparation. Articles for external use should be dispensed in bottles of
peculiar shape or color; and poisons, besides having a special
label, should be put in phials having small projections from the
surface, and hence distinguishable in the dark. These phials are
obtainable as a regular article of trade, and their general introduction and use is very desirable.
Opposite the dispensary, on the corridor wall, would be a series of knobs, with a directory, governing electric bells placed in
every ward and in the principal other buildings, stummoning the
nurses and other employees. This place is sufficiently central,
and, as the apothecary uses the ward-bells more frequently than
any one else, they are placed near him.
South of the dispensary are three branch corridors before
alluded to, the most westerly one leading directly from  the outpatient building. Out-patients will enter this corridor for two
purposes only: to go to the dispensary for remedies prescribed,
or to reach the admitting-room, when sent, to the Resident Physician with a recommendation for admission from the physician
or surgeon to out-patients. It is proposed that a recd stripe on
the right-hand wall should serve as a guide to the dispensary,
while a blue stripe on the left-hand wall, leading around the
corner into the main building to the front waiting-room, would
enable the patients to find their way to this point, verbal instruction being given them to follow the 9red or the blue line, as
required.
No chimneys have been drawn in the administration building,
but open fireplaces would be desirable in many of the rooms, for
ventilating purposes if nothing more.  The basement, reached
by stairs immediately beneath the main stair-cases, should contain steam-radiators sufficient to thoroughly heat the building;
flues, with registers, conducting the warm air to every room, and
especially to all water-closets, which should each have a special








( j j )1 j  i   I i j7   j j j j, I
li;.~ —--- Ill                   I                        Ii
No. 3.
PI,AN  OF COMMON  WARID.
SCALE 16 IN.- FT.                  )
DR.FOLSOM'S SUGGESTIONS, 
JOHNS HOPKINS HOSPITAL                     -,i  ~~~~fnyi~ ~ ~




JOhNS IIOPKINS' HOSPITAL.               7D
outlet behind the seat, leading to a chimney or to a flue in the
outer wall, opening beneath the eaves.
The second story, of which no drawing is presented, would be
appropriated to officers and female employees. Two of the crossentries, required in the first story, would serve no useful purpose
on this story, as sufficient light could be supplied by sashes over
the doors. The central one, to which the central stair-case leads,
might be retained. Narrow cross-entries might be desirable at
other points, to afford more private access to water-closets, etc.
The two series of rooms, opening on the long entry, would be
appropriated as follows:
For the assistant physician, a room with a bed-room and bath
adjoining. For the matron and the apothecary, the same. For
the eight house officers, four double bed-rooms, with a bath-room
and lavatory between each two. A speaking-tube leading from
the entry below to the bedside of each house officer, would enable the night nurses to communicate with the particular officer
whose services might be required, without rousing all.
The southerly portion of this story, separated from the rest by
a partition across the hall, would give ample room for dornlitories for the assistant nurses, with bath-rooms and water-closets,
and one or more sitting,-rooms. The assistant matron should
room among them, and maintain discipline without interfering
with proper relaxation and cheerfulness.
A third story would probably be required only at the centre
and at the ends of this building. Room should be reserved for
a series of water-tanks, supplied from the street, connected with
each other by pipes with valves so arranged that the supply of
the institution could be taken from any one tank, or from all, at
will. They should have capacity for at least three days' supply
for the whole Hospital; or say 50,000 gallons.
The remaining portions of the third story would furnish rooms
for all female employees not provided for in the second story;
and there should be bath-rooms and water-closets for their use.
COAIDION wARDS.
Plate No. 3 is the ground plan of a common ward.
The room for patients, about 56 by 43 feet, is calculated for 23
beds. A central chimney-stack, 6 feet square, gives opportunity
for two large " Franklin stoves" or detached fireplaces, for soft




76               FOLSOM3.-PLANS FOR, TIIE
coal, wood, or coke, made of soapstone, placed on the northerly
and southerly sides, the flues of which are cast-iron pipes 10
inches in diameter. On the easterly and westerly sides are two
large drums or registers, with grated fronts and ends, which
supply fresh, warm air to the ward. The distance between beds
is 4' feet. In wards occupied by patients with suppurating
wounds or active fever, the three corner beds might be removed,
or kept empty; but it is believed that the system of ventilation
and air supply herein suggested would prove ample for the full
capacity of the ward.  In practice, convenience requires that
there should be at least one vacant bed in a ward, at all times,
for facility of change.
The shape of this room for patients differs from that usually
adopted in pavilion wards. The advantages of a nearly square
room with a central stack are the privacy of each bed, as compared with its situation in a long hall without obstruction to the
view; the absence of drac7ghts, the fireplaces and warm  air
supply being nearly equally distant from all parts of the ward,
and the chimlney-stack by its volume and position interrupting
and mixing accidental air-currents; and the ease of administration; the beds being nearly equidistant from the supplementary
rooms of the ward.
This fornl of room was suggested by the late Mr. George M.
Dexter, and adopted by the trustees in enlarging the Maissachusetts General Hospital in 1844; and, in constructing a pavilion
ward in 1872, described and figured in the report of the trustees
for the year 1873. I do not think that the attractive, home-like
character of such rooms, in comparison with long, narrow wards,
can be appreciated without seeing both in occupation.
A veranda, 7 feet wide, extends around the southerly half of
the ward, so that shade or sunshine, as required, in the open air,
can be obtained at all times of the day. A szun-roomn or glazed
porch, 13 by 6 feet, for use in cold weather, occupies the centre
of the south veranda.
The ward is entered by a double door-way 6 feet wide, over
which is a large window, shown in Plate No. 6, which, with
the window in the gable shown in Plate No. 5, gives light and
free circulation of air in mild weather, to the entry and northerly
part of the ward. The entry is about 72 feet wide, and, as shown
in Plate No. 6, is 17 feet high; and the rooms which lead




JOHNS HOPKINS' HOSPITAL.                 77
from it are 11 feet high. These rooms are as follows: The
nurses' room, where the head nurse sleeps at night, and where
any private examination of patients is made; 17 by 9 feet, with
two closets, one large enough for trunks; heated by a stack of
steam-radiators beneath, with the arrangement shown in Plate
No. 15; with a ventilating flue in the wall, with an opening
near the floor, and an outlet beneath the eaves.
Next this room is a small closet for brooms, dust-pans, etc.
Next is an entry, 3 feet wide, with shelves on one side, leacing
to a linen -room, about 11 by 8 feet, lined with shelves made of
narrow slats, for linen, pillows, etc., and with a set of tight
drawers to hold blankets.  This room has a cold fresh air duct,
and an outlet beneath the eaves.
Next this is a closet about 8 by 4 feet, opening on the corridor,
for patients' clothing, provided with shelves and hooks, with a
cold fresh air duct, and an outlet beneath the eaves.
On the easterly side of the entry are three closets, respectively
for medicines and stimulants, dressings, and for patients' hats
and outer clothing, the latter closet having a ventilator beneath
the eaves. The medicine closet is kept locked, under control of
the head nurse. The dressing closet is the receptacle of articles
of daily use, placed here to avoid having any cupboard, case, or
closet, ill the main ward-room. A shelf at the top of the head of
each bedstead, and a drawer in the small wooden table beside
each patient, should be the only places where anything can be
" put away" in the ward-room, and these should be frequently
inspected by the nurses. A list of the contents of the medicine
and dressing closets, and of the furniture required for a general
ward, is appended to this paper.
On the easterly side of the entry, next the corridor, is a scullery, about 14 by 11 feet, containing on one side a dresser, where
food is prepared and carved, and a sink and drain-board; on the
other, a china-closet, and a small portable range, for preparing
gruel and light diet, and keeping food warm.
The flue of this range is a cast-iron pipe, which occupies the
centre of a chimney two feet square, the outer space of which
ventilates the water-closets and bath-room  adjoining, and, by an
opening at the top of the room, the scullery itself.
The three water-closets occupy a space or room, entirely surrounded by a wall of brick from the foundation, so as to make




78               FOLSOM. —PLANS FORP THE
it practically a separate building, about 9 feet square. The floor
should be tiled.  Access is gained from the ward by two sets
of double doors, swinging both ways, and closed by springs.
The space between the doors is ventilated by a window. The
construction of the water-closets is shown in Plates No. 24,
25, and 26.  The most easterly one is for patients' use. The
middle one would be commonly used for emptying and cleaning bed-pans, and should have a short hose at the side for
this purpose. Opposite it is a sink for washing spit-cups and
dressing basins.  The third water-closet is especially for the
nurses' use, and can be reached through the bath-roomn; and a
blind-door separates it from the others.  Opposite it is a receptacle for the ordinary soiled linen and clothing of the ward,
which should be carried to the laundry  frequently; the
badly soiled linen, dressing cloths, etc., being conveyed to the
rinsing-room  in pails, as soon as removed from  the patients.
The water-closets are heated by a steam  radiator beneath,
arranged as in Plate No. 15.
Next the water-closets is the bath-room, about 9 by 6 feet. On
one side is a soapstone sink, supplied with tin basins, for patients' use. On the other side is a movable bath-tub, on wheels,
with a drain-pipe in the floor under the outlet, and hot and cold
water faucets in the wall, for filling it. It can be used iBn situ,
or rolled to the side of a patient' s bed if required. It would be
used comparatively infrequently, as all patients able to go to the
regular bath-house should do so. This roomu would be heated
and ventilated like the water-closets.
On the north side of the corridor, opposite the entry, is a dining-room for the use of patients when able to leave the ward, 20
by 10 feet, and about 7 feet high, with windows all aroulnd, to
be kept open in summer; heated, like the corridors, by direct radiation. At one end, a staircase affords access to a small coalcellar beneath; the cellar of the main building being devoted entirely to the heating and ventilating apparatus.  The cellars
should be paved with asphaltum throughout, and the windows,
being supplied with wire nettings to keep out cats and vermin,
should stand open in all moderate weather; the steam pipes being wrapped with asbestos to save waste condensation.
Plate No. 4 is a west side elevation, and No. 5 a north elevatiol of a common ward. No. 6 is a longitudinal section, and No.








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I,.,~~~,.I,  4.
S DO  E LEVATION           Scale Y n EcA =TI  Ff. 
O COMX0   WAARDD
D)r. FolsonYs Sug.estions
JOH  NS  H O PKIN S   HOSPItAL.'  -''~"




J OHNTS HOPKINS' HOSPITAL.               79
7 a cross-section of the same. The relative height of the different parts of the building are shown in the elevations.  At the
apex of the main part, the roof is continued out, north and south,
about 8 feet, to form louvered gables.  The roof of the northerly
lower portion is truncated, and the flat part is tinned.  From this
level runs out the narrow gable for the north entry window. The
roof of the dining-room is nearly flat, and but little higher than
the corridor roof.  All the roofs have projecting eaves.  The
corridor is drawn 7 feet high inside, but would need to be a little
higher, to accommodate the steam pipes, etc. All corridors should
be kept loao so as to obstruct air-currents as little as possible.
The room for patients is 14 feet high at the wall, and is finished
into the roof so as to be about 20 feet high at the centre. The
superficial area, provided for each bed is over 100 feet.  The
cubic space for each bed is over 1,600 feet. The purity of the
air of a ward depends rather upon the rapidity with which it is
chlanged than on the capacity of the room, but in a large room,
to say nothing of the cheerfulness of its aspect, a free supply of
air does not create perceptible draughts, and temporary emanations frotm patients give rise to little annoyance.
Between the beds, on three sides of the ward, are windows 3
feet wide, 3 feet from the floor, and 10 feet high; with ordinary
sashes below, and the upper two feet, above a transom, having a
sash hung on hinges at the bottom, opening inward to a limited
extent, and provided with wings or sides of sheet copper, which
convert it into a sort of hood when open; so that the entering
air is directed upward to the sloping ceiling instead of sinking
downward directly on the patient below. These windows are
protected by the projecting eaves. (See figure on next page.)
It is worthy of consideration whether all sashes should not be
doubly glazed, with an air-space between the panes to make
them better non-conductors of heat; which would be desirable in
both hot and cold weather.  The only objections would seenl to
be the slight additional expense and weight. As a substitute
for the outside sashes sometimes applied to exposed windows in
winter, their merit seems obvious.
Corresponding to the ridge ventilators in an army pavilion are
two large openings in the ceiling of the ward, controlled by
valves and cords, and leading into the ridge-space around the
chimney shown in Plate No. 6.




80                FOLSOMf.-PLANS FORI TIIE
The ends of this space are the louvers, shown also in Plate
No. 5, behind which are valves worked from below.  In cold or
COPPER
SIDE  PIECE 
WOODEN   STRIP  WHICH  BRINGS  UP _ON  CASING
SASH
DIAGRAM OF TRANSOMA WINDOW WVITH SIDE PIECES.
stormy weather the louver to windward would be closed, to prevent a downward dra-ught unimportant in mild and pleasant
weather, when all the orifices would be freely open. In very cold








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JOHNS IIOPKINS' IIOSPITAL.             81
weather, this ceiling ventilation would be used only when, as at
the dressing hour in surgical wards, rapid change of air would be
desired; the usual and principal means of ventilation being the
central chimney.
The upward draught of the chimney is secured in weather cool
enough to call for any artificial heat, by the passage through it
of the two cast-iron flues of the Franklin stoves, shown in Plate
No. C.  These are intended to be used in preference to the
steam-heat, when both are not needed, as, for instance, on many
spring and autumn days.  These fireplaces and iron fnlues are, of
course, themselves active ventilators by their own draugthts. At
the bottom of the chimney is seen a basket-grate of iron, hung
in the middle of the main shaft. In weather so warm that arti
ficial heat is objectionable, but when the air seems heavy and
stagnant, as in the "dog-days, " a coal-fire is to be made in this
grate through a door in the cellar, and, smouldering all day, it
will keep the air moving steadily up the shaft, while no heat
reaches the ward. The ashes which fall through the grate are
removed by another door below.
For this suggestion I have to thank my friend, Mr. A. C. Martin,
architect, of Boston, whose authority in the matters of ventilation and heating is well recognized, and to whom I am indebted
for many hints and criticisms during the preparation of this
paper.
The ventilating ducts leading to the shaft are shown in Plates
Nos. 10 and 11. Arising by twelve vertical. grated openings
in the side walls, these ducts descend to below the level of the
cellar floor, and directly seek the chimney, which they enter
above the floor by two openings on the east and west sides, 4 by
2g feet each. These openings are proportioned.to the size of the
ducts, which are each 1 by 2 feet. Near the ceiling are two
openings from the ward into the main shaft, controlled by valves
worked from below, for exceptional use-like those leading to
the ridge space-when it is desired to rapidly evacuate the air at
the top of the ward.
The steam heating apparatus and ducts supplying fresh air to
the ward are shown in Plates Nos. 8 and 9. To insure a rapid
supply of cold air, whichever way the wind blows, we have two
ducts to each stack, the one to windward being opened, and the
one to leeward closed by valves worked from above. The ducts,




82                FOLS03I.-PLANS FOR TIIE
each 3 by 2 feet, run from  grated openings just beneath the
veranda, along the ceiling of the cellar to, reach the stacks of
steam-heated radiators which, enclosed by a non-conducting
wall of brick, are placed at the corners of the chimney. At the
junction of the air-duct with the enclosure of the radiators is a
mixing valve, similar in action to that shown in Plate No. 15,
controlled from the ward above. This valve directs the air either
downozard, so as to pass up again through the radiators and be
strongly heated and then reach the ward through the dreum
above; or, the valve being lowered, the air passes laterallZy over
the top of the radiators and reaches the ward through the drum
very slightly tempered; or again, the valve being placed at the
proper intermediate position, part of the air goes one way andl
part the other, and can be made to enter the ward at any temperature desired.
The air-ducts pass immediately beneath the Franklin stoves,
and a register might be placed under each, connecting with the
duct, to be opened when the stoves alone should be in use; so as
to bring the entering current of air, which is supposed to be conistant in all weath7ers, directly in contact with the stoves, which
are made double, to allow the air to pass up between the layers
of soapstone and be heated.
In warm weather all windows and orifices in the ward would be
freely open, so that the patients would conme as near to living in
the open air as is desirable, and much nearer to it than would be
possible in a two-story building. It is my belief that telzts, so
extravagantly lauded by some writers for hospital purposes,
iwould be inferior to this pavilion in comfort and healthfulness,
in any weather.
In weather requiring the great body of the air supply to be artificially warmed, the windows and top ventilators would be
closed most of the time, and the general course of the air would
be as follows: A large volume of very slightly heated air would
enter the middle of the rooln, and, rising by virtue of its less specific gravity to the upper part of the room, would be diffused
equally and, cooling somewhat, descend at the walls. The central fireplaces would draw  a certain amount of the lower
strata of air in their direction, but the greater portion would
leave the ward by the peripheral vertical openings which are beneath the patients' beds. Thus the emanations from patients








II ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 1
COMMON WARD.
RADIATOR
COLD AIR BOX
COLD AIR BOXX 
IAD I ATOR
mNo.. I; I0.1~1 1                          No.8.
PLAN OFVENTILATING DUCTS.   PLAN OF HEATING APPARATUS
V-V-MIXING VALVES
4~~~~CMO WARD                                  Y.MiNVAV5
Dr~s_. Folo~    Snhet i
SScale Ytr Inch =1 Ft.=
IOU                        P, E  Lo    FM. 
becd                          bed                                    be
JOHNS HOPKINS  EL                                 S    SHOT LTI 
C OM MONL WVAR D.             *C -vV.Y. InlXING YALV4E.
i fL    D)r. Fol s o z]s    S u cige sti olls
r ~      0 t O N-S   H-OPKIIYS      HO SPITAL......:-.rL 




83
will be, to a greiat extent, -ra~win from  the War& at once, by a
short path, instead- of be1Uiia     de- td-ed- for
-tiff nseat
T le  t   sInsartea  of. enom i,  seen in the sectioiS, to allow tho
ai St asfelYbo  them. This Ieight is recis ae
xi- vo 1'""" ire~l'  bclo\Y tlle! t, lm
lostbl         -,Asteads, on accont  of te great facilitY for t
hospitaly bed           and-for t he appication  of
fir to Vass ireeoy theo. fh iatieigt5
1physical eatnrtio    of Ptiets,  o be                   i
e e.ich it od. The Cpatients elUoY  btter ys W
dressings,    etc., wl-il it tff ~or'  from low bedste a
of the world, Owithin and  withov~, th  fomi low bed    tts Get -
in I    a wit,~ ~~i tlze           achl ~ ta s
The pattern in use for many years   the
of t  -\A7'01  -use for 1-1 1ally  e a figure, 1i'
eral  tospitl is so satisfatory that I give a figure of it, as spied by the Tucker    aacturi  CompanY   It is made of
vr~ought iron. Its lerngth is 0  leet, its width  3 feet, its hleiglht
nieabrly 2 eet; andt on te iron straps, which by a simple contrivnearly a iret;'J-"d,Which by a Si' RV1 -10ane are allo wed to spring a little, goes a pa-hlef ud I-erm-attress, 6 inches thick, and on this a firm- hair mattress, rounded up
d-re     to     for
at thle mdlet  to allow~ "o iift.teniing, 6 inches thiel;   so that tle
ltes   inhes   feetabvt.The  ea  of the bedstea
rise h  higt  of    feer, and- has a shelf of hard wood-, 6a
-le~~    u  rnseicrle, or a t~l fof I  pepniuar
pat ti ente    r               o               head —curtaii, atinches wide.  An ironsmi-cirle, for a tester ort be
tacelies here, and-wetted- c  be raised to a perp ica
positi on,   out of the  w ay, wheon deired-    h   oi' 7e utal rod
byt ther aid, as they d-o constantlY. The whole is weled toget.r  nd mnae so strong n  heavy  as to be very firm. It does




84               FOLSOM3.-PLANS FOR TIIE
not vibrate when touched, like an ordinary iron bedstead, and
never needs repair.
ISOLATING WARD.
Plate No. 12 is the plan of an isolating ward.  It corresponds in most respects with a pavilion lately erected at the
lMassachusetts General Hospital, described. and figured in the Report of the Trustees for the year 1874.
The access to this building is by the eross-corridor, common to
several wards. The possibility of communication by aerial currents between different wards should be precluded by partitions
across the corridors made almost entirely of glass, with spring
doors swinging  both ways, with glass panels.  These partitions
are not shown on any drawinga, but there should be one at the
northi-west corner of each isolating ward, anld another between it
and the next ward. The corridors are warmed by direct radiators
placed along the wall as required. No attempt would be made
to keep the temperature up to that of the wards in cold weather,
but the air would be, constantly tempered. The ventilation is by
the windows, which should be wide open in all moderate weather;
and in each space between the isolating partitions two windows
would be provided with sashes hung from the top, swinging freely
both in and out. These would move so readily as to allow the
ingress and egress of air when the doors open and close, thus preventing the forcing of the air onward through the second pair of
doors when the first pair are swinging.
In cold weather, the lower sash of the corridor windovs should
be raised two inches; and a board, with a spring in the end to
]old it in place, fitting the window-casing in front of the sash,
occludes the opening. The air then enters betweein the sashes,
without creating a draught. This contrivance, very simple and
inexpensive, is recommended wherever it is desired to apply a
regulator to the draught of a window, and will be useful in other
parts of the Hospital.
The isolating partitions would hardly be needed, considering
the distances between the pavilions, except for the isolating
wards, and for such surgical wards as it might be desirable to
separate from all others. A number of the partitions might be
made, and stored, to be put up when required.
The isolating ward is about 113 by 37~ feet, and has 16 rooms








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PLAN OFI OI$ATING WA-RD.
I            8          [ii3r       n3                      uz         =                                1
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No. 13~ —I --— rLEfI 1
_!~~~~~~~~~~~~~~~~~~~~.3'  - " ~                 
EAST ELEVATION OF ISOLATING WARD
SCALE, IN.I FT.
I'   O NDr. Fol s ons S   cestiols
JOHNS HOPKINS HOSPITAL.
_,....
J.   b| _                                                           _ dop1  ~s    ospr? 




JOHNS HOPKINS' HOSPITAL.                85
for one patient each. An entry, 7 feet wide, divides the building
longitudinally, and opens at the southerly end on a porch, froml
which access may be had to the garden. At the northerly endl
are double doors closed by springs. Opposite them is a baywindow in the corridor; and access to the garden is provided at
this point also, for general use. A cross-entry, 4 feet wide, at
the middle of the ward, opens on two verandas, about 34 by 8
feet, with sun-rooms or glazed porches at the centre of each.
The administration of the ward is provided for at the centre.
Two rooms, about 13 by 10 feet, with a closet in each, serve for
the nurse and lnale attendant, the latter of whom officiates also
in the adjacent common wards.  Opening on the cross-entry by
two wide doors each are two closets, with cold air ducts and
ventilators beneath the eaves, for the trunks and clothing of
patients. Opening on the main entry are a medicine-closet and
a dressing-closet like those already described, and behind them
a ventilated linen room about 10 by 8 feet. Next this is a room,
about 8 by 5 feet, for the use of the nurses, with a bath-tub and
water-closet, and in a small lobby a soapstone sink.  Next
is the patients' bath-room, about S by 7 feet, with a tub on
wheels, as described in the common ward. Access to this room
is through a lavatory about 8 by 5 feet, with a soapstone sink
and tin basins, and opposite it an unlocked closet for patients'
hats and outer clothing.
Opposite this room is the stairway leading to the cellar; and
next this are the two water-closets-one usually devoted to bedpans —which are enclosed by a thick wall from the foundation,
as in the common ward building. The floors are tiled. Opposite
the water-closets is a sink for washing spit-cups and dressingbasins, and beneath this a receptacle for moderately soiled linen.
The water-closets have a lobby, with a closet for brooms, etc., at
one side. Thus there are two doors between the water-closets and
the entry. The next room is the scullery, about 13 by 10 feet,
arranged as in the common ward, the chimney to ventilate the
water-closets.
The patients' rooms are each 13 by 8 feet, with an open fireplace, 2 feet wide, in the corner of each, next the door, and a
window opposite, 3 feet wide, like those in the common ward.
Plates Nos. 13 and 14 are the east elevation, and the crosssection of the isolating ward. The longitudinal entry is 24 feet




86               FOLSOM.-PLANS FOR TIlE
high, and has a separate monitor roof, with windows beneath the
projecting eaves, which gives ridge ventilation for the whole
building, when the rooms are suffered to communicate with the
entry. A narrow gable at each end gives opportunity for a large
arched window over each door. The rooms are 13- feet high at
the walls, and 14~ at the centre. Over the doors are windows
opening to the height of the ceiling.  When these windows
and the doors are opened, the circulation of air is free throughout the building, and the rooms ventilate into the entry; but
each room is arranged to be heated and ventilated as a unit
when occupied by a case requiring more complete isolation, in
which event the door and window would remain closed. The
fireplace in each patient's room, arranged to burn soft coal,
has a cast-iron pipe for a flue.  The space in the chimney,
around the iron pipe, closes in at the level of the ceiling, and
fresh air being supplied to it by a duct in the cellar, a register,
shown in the cross-section, gives passage to the air, moderately
heated by contact with the iron pipe, into the room. An airsupply is thus provided for in such weather as does not necessitate the use of steam; and even in sumnmer a very small fire
can be made, for ventilating purposes, radiation being prevented by an iron screen. A duct leading from an opening in
the middle of each ceiling, controlled by a valve, opens into the
space in the chimney around the iron pipe, above the level of thle
ceiling, which is thus utilized for ventilatinllg.
The linen-room is not warned, but has a cold air supply duct,
and a ventilator beneath the eaves. Every other room in the
ward is supplied with fresh, warm air, in weather requiring the
use of steam-heat, by a register opening beneath the window, the
supply being regulated by the contrivance now to be described.
Plate No. 15 shows a contrivance for regulating  the temlperature of the air admitted to the rooms of the isolating ward, or for
any room having an independent stack of radiators beneath.
The radiators are hulng  from  the floor-tinmbers by iron rods,
and are enclosed in a wooden box lined with tinned sheet-iron,
iwithl a door at the side for the removal of dust.
The air is admitted through the top half of the cellar window,
whichl is lihung on hinges at the top, and opens outward, and the
amount of air admitted is regulated by a crank in the room
above, which connects by a rod, with a quarter circle attached to








r-_ —— = —-~~____ _.li~ _  L                                                  -                   a_' 11" _'  I- -
IL
j,7l1j
lP 0
No,14.
CROSS SECTION OFISOLATING WARD.
Dr. V;olsornis Siig estiol-ts
JOHNS HOPKINS  HOSPITAL.                                         S
scale _!_nch_  Ft.




N oA, 5.DETAIL OF MIX`ING VALVE FORM O LATING  IAY
///                ~~~~~~~~SCAL:E AMINH.7  7i~~~~~~~~~~~~~~
O "                                        -----          
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JOHNSHOPKNS HOPITA








JOHNS HOPKINS' IHOSPITAL.                87
the window-sash. The movement of the crank opens and closes
the window; but, opening to the f ull extent represented by
dotted lines in the plate, would be desirable at all times unless during a very high wind.
The direction of the air thus admitted is determined by a valve
made of a strip of board, suspended by hinges from below the
front of the radiators, the position of which is regulated by a rod
connected with a second crank in the room above. The stability
of the crank in the position given it by the hand of the attendant, is insured by a set-screw, with a bit of rubber or leather beneath the tip.
When the valve is in the horizontal position, all the air is directed to the radiators, and is fully heated by rising through the
stack, after which it passes up through the space in the wall,
beneath the window, shown also in Plate No. 14, to the vertical register just under the window-seat.  When the valve is
placed in the vertical position, indicated by dotted lines in the
plate, all the air is directed upward away from the radiators;
but is tempered by mingling somewhat with the air circulating
in the space over the radiators, and then reaches the room by the
register above. Wh]en the valve is placed in an intermediate
position, the air-current is divided, part of it only is heated by
passingo through the radiators, andl this then mingles with the ascentding cold portion before it reaches the register and enters the
room.
it is apparent that the temperature of the room can thus be
regulated to suit varying conditions, without interfering with the
fresh air supply, and without modifying the access of steam to
the radiators.  If the room gets too warnr, the nurse, instead of
closing the register, and so shutting off the oxygen, simply turns
the crank a little upward. If the thermometer, which hangs near
the door, falls below the standard directed by the attending
officer, the crank is turned downward. If a sudden general
atmospheric change has taken place, and the temperature still
falls, the stpp7ly of air may need to be temporarily diminished,
till the engineer, who watches the thermometer out of doors as
well as his gauges, has time to restore the suddenly fallen steam
pressure.
The proper use of the contrivances described requires intelligence and faithfulness on the part of the attendant, but no more




SS               FOLSOM. —PLANS FOR TIIE
than would be required to properly regulate temperature in any
other way.
Besides the cases which can properly be treated in the rooms
of the isolating ward, by closing the doors and the windows over
them, cases will arise of exceptional character, needing, temporarily, more complete isolation than the ward affords. Although
contag'ious diseases are excluded by the admittingl physician.
cases of variola and scarlatina are liable to develop after admission, and their immediate removal may be impossible. Odors
are sometimes developed in disease, of such peculiar intensity
that they permeate everything near. Surgical complications may
be such as to demandl that the case should be absolutely in a
building by itself.
To supply this exceptional want, it is proposed that there
should be kept, in the cellar of each isolating ward, one or more
sectional btiltdingqs, made of pine wood, the different parts of
which fasten together by hooks and bolts, so that one can be
erected in an hour without the aid of a carpenter. Such a building might be   by 7 feet, and 7 feet high at the eaves, with a door
in one end and a window opposite. The floor should be raised a
foot above the ground. A frame with slats, resting on cleats,
would supply the place of a bedstead, and a bed-tick filled with
hay would be used instead of a hair mattress. In one corner
would be a hole througth the roof, protected by a piece of soapstone, for the funnel of a small stove, which would have a cold
air register opening beneath it. After use, the building could be
taken apart, exposed to the sun and air for a sufficient time,
painted or varnished a thin coat, and put away in the cellar
again. All the bedding should be boiled or baked before being
used again. In hot weather, a canvas tent-fly could be used in
the usual way to protect the building from the heat of the sun.
PRIVATE WARD.
Plate No. 16 is the plan of the private ward.  It is so arranged that none of the rooms for patients front to the north;
and this, together with its position in the lot, have given the
building its shape, which is that of the letter L. The entrance
to the ward from the main corridor is at the north-easterly end.
iNear it is the corridor leading to the most northerly series of
wards, but this opens in such a way that passers will not look




JOHNS HOPKINS EHOSPITAL.                   89
down or invade the private entry. The northerly portion of the
ward is about 132 by 42 feet.  An entry 8 feet wide runs east and.
west the whole length of it.  The southerly portion of the ward,
about 80 by 48 feet, is placed at right ang'les with the other portion, near its westerly end.  It is bisected by an entry 8 feet wide,
running- north and south, which crosses the other entry to reach
the northern wall, where a window gives it air and light. A crossentry, 4 feet wide, runs east and west between the two portions
of the ward.
The roo'ms for administration are all on the north side of the
northerly entry.  There are two sets of water-closets; each set
of two enclosed in a room, with brick walls from the foundation,
about 12 by 9 feet, including a lobby with a sink in it, for washing spit-cups, basins, etc.  These are situated at opposite ends
of the entry, one set for ladies, and the other for gentlemen. The
easterly pair are ventilated into the chimney of the scullery, which
is 24 by 12 feet, placed convenient to the corridor, with a ralnge,
sink, and dresser, into which open a cool pantry with a window,
and a china-closet, each about S by 6 feet.  Next is a bath-room,
about 12 by 6 feet, with a movable tub, as described in the common ward, and a wash-bowl in the corner. Nlext is a room 12
feet square, with a closet, for the male attendant.  Next this is
the linen-closet, 12 by 10 feet, and next this again, a room 12 feet
square, for patients' soiled linen, with a closet for brooms, pails,
etc., in the corner.  Next comes the northerly end of the south
entry, and beyond it is a second bath-room  like the first, one
being for ladies and the other for gentlemen.  Sitz-baths, on
vwheels, with rubber tires, coulcl be filled in the bath-roolms, and
readily moved to the patients' rooms.  The westerly pair of
water-closets are ventilated into the chimney of the nurses' room,
which is about 18 by 12 feet, placed at the north-west corner of
the ward, a sufficiently central position, having a closet and an
open fireplace or stove.
All these rooms, except the linen-closet and soiled clothing
room, which have cold air supply ducts, are warmed l by radiators beneath, arranged as shown in Plate NAo. 15.  All the
rooms, except the water-closets, have ventilators beneath the
eaves.
On the southerly side of the north entry are six rooms for
patients, each about 18 by 12 feet, and about 14 feet high, rising




90                FOLSO3f. -PLANS FOR THE
to 17 at the centre, with a mullio-ned window 41 feet wide, and a
hooded top sash over a transom.  Over the doors are windows,
extending nearly to the ceiling-. Each room has an open Franklin soapstone stove, for soft coal, and likewise a radiator beneath,
arranged as shown in Plate No. 15. A cold air duct leads to
the double back and sides of the Franklin stove, and a large
ventilator opens into the chimney near the ceiling, for exceptional use.
An electric indicator placed at the intersection of the entries is
operated from the various patients' rooms, and from the bathrooms and water-closets. In the patients' rooms a handle is attached to a wire cord, so that it can be put by the side of the patient's pillow wherever the bed is placed. A light touch on a
knob in the handle rings the bell, and indicates the number of
the room to the nurse. A similar system, with knobs in the
wall, would be desirable in the isolating wards; and by arranging couplings for the attachment of wire, a few minutes would
serve to connect one of the sectional isolating buildings with
the indicator in the ward, where a signal would be reserved
for it.
The southerly portion of the building contains twelve rooms
for patients similar to those just described.
The two rooms at the centre of the building are larger than the
others, which will prove a convenience when relatives are permitted to remain with patients at the Hospital. This should
generally be discouraged in the interests of the patients themselves, but circumstances sometimes render it necessary.  These
rooms are about 22~ by 17- feet, arranged like the smaller rooms,
except that the windows, placed in the south-east and south-west
corners respectively, are bays, are bays, 4 feet wide, the side panes looking south, east, and west, the whole being carried up nearly to
the ceiling. Opening on the north entry, north of one of these
rooms, is a closet for trunks and clothing, about 22~- by 4~~ feet;
and north of the other room, the closet for dressings, splints,
etc., about 9~- by 42 feet, including the medlicine-closet, which
opens separately ona the entry. At the intersection of the entries
are the cellar stairs, where coal is brought up; and above them is
a staircase leading to a second story of limited dimensions, devoted to sleeping-rooms for a second head nurse and one or two
assistant nurses. A small billiard and reading room for patients'








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JOHNS HOPKINS' HOSPITAL.                91
use could be placed here to advantage. Above this is a tower or
cupola, carried to as great height as taste will allow, and commalnding not only a view of the whole Hospital, but a magnificent
prospect all around.
The advisability of having a water-closet and bath-room
attached to each private room  has been considered; and it
would add much to the convenience and elegance of the ward.
But comfort does not require it, as movable bath-tubs and conlmodes can be supplied for such as need them. It would seem
desirable to avoid. in rooms which are intended to offer absolutely
no drawback to recovery, the possible source of impure air which
the opening of a soil-pipe or drain-pipe affords. For this reason
no set basins have been placed in the rooms. The furniture is
to be of hard wood, finished with as few irregularities of surface
as possible. Instead of carpets, rugs are to be used. The only
piece of stuffed furniture to be allowed is a lounge, with a linen
cover which can be readily removed and washed. On the departure of a patient, the room is to be closed from the entry, and
swept, aired and dusted; the rugs to be shaken and sunned;
and the windows left open for some days, unless the weather is
stormy.
Double doors at the south and west ends of the building give
access to a veranda, 8 feet wide, which surrounds the building,
excepting on the north side. The narrow cross-entry also opens
on it. Steps lead to the grounds at the south and west ends, and
from the corridor at the north-west corner. The south door is
the entrance for visitors.  Sun-rooms or glazed porches might be
constructed at both the double doors if desired.
The cellar is devoted to the heating apparatus, etc., with coalbins at the north-easterly corner.
KITCHEN.
Plate No. 17 represents the kitchen, about 50 feet square,
including the store-room, about 26 by 22 feet. A wide door leads
from the corridor to the kitchen proper. Against the walls are
shelves and dressers as needed. There are three sinks with tables
adjoining-the largest of which is for the preparation of vegetables, and is therefore near the kettles. The brick oven, about 14
by 12 feet, is in the corner. It is heated by a small hard coal fire
in the front corner, the fuel being put in at the front door, and




92               FOLSOM.-IPLANS FOR THE
the ashes removed by a door beneath. The oven has two flues;
one over the fire, the other diagonally opposite; both controlled
by slides. When the oven is heating, the flue over the fire is
closed and all the gases pass across to the further corner. When
it is hot, the flue over the fire is opened and the other closed, so
that the oven is free from gases while baking. A slide over the
door can be opened to take the heat and gases when the door is
open. An iron shelf or hearth is hinged to the front, just under
the door, with a catch to keep it horizontal, for basting meats,
etc. If the Hospital were to employ a baker and bake its own
bread, a small room for kneading and raising the dough would
probably be built at one side of the oven. This piece of apparatus is the cheapest and most efficient means of cooking meats, as
well as other articles. Adjoining the oven is the broiling range,
about 9 by 2 feet, where a shallow fire is continually kept for
broiling and toasting. It is arranged to draw the smoke downward and-backward away from the meat. Next comes a French
range of ordinary construction, about 19 feet long. The chimney, 2 feet square, is common to the three pieces of apparatus
last described. Next the range come ten steam-jacket-kettles,
each cast in one piece; and beyond them automatic tea, coffee,
and water urns.
The store-room opens into the corridor, and also by two doors
into the kitchen proper.  It is lined with shelves, bins, and
places for barrels. A spiral staircase leads to the vegetable cellar
below. Double doors at the side admit the supplies, and the
storekeeper's desk and the scales are near them. All goods are
ordered in writing, on cards inscribed: " Please deliver the following articles, and return this card with the goods."  The
weight or quantity, etc., is verified on the spot by the storekeeper, the card marked "correct " and transmitted to the office,
and the tradesman is then credited with the goods on the supply
book. When the monthly bill is presented, it is readily verified
by reference to this book. In the corner of the store-room is the
ice-room, which is filled from the outside. A small door in the
corridor furnishes the supply for the wards, etc. On one side of
the ice-room is the room lined with shelves, for milk, butter,
etc., and on the other, the meat-room, supplied with hooks all
around.
A staircase in the corridor leads up to two dining-rooms in the








Dr. Fols onis  Si ig g esti ois
JOHNS HOPKINS  HOSPITAL.
No. 18.
PLAN  OF OPERATING  iTHEAT 1RE
AND OUTT PATIENTS' BUItDIN G.                  P f]11S) i   g/L    I.P9e 
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JOHNS HOPKINS' HtOSPITAL.             93
second story, one for the nurses and one for the other employees.
The food is raised by dumb-waiters, not shown in the drawing.
The ventilation of the kitchen would be partly into the chinmney, by means of a hood over the range and boiler, and over
the kettles and elsewhere by means of large ducts passing up
through the rooms above, terminating in Emerson's ventilators
above the roof.
OPERATING THEATRE AND OUT-PATIENT BUILDING.
Plate No. 18 is a plan of the operating theatre and the outpatient building. It is desirable that one should be accessible
from the other, and yet that patients brought from the wards for
operation should not be under the observation of the out-patients.
The doorways opening from the out-patients' room on the corridor should therefore have two sets of spring doors, and there
should be a general understanding that out-patients should not
be sent through the corridor during operations.
The out-patient building is about 75 by 50 feet. The main
room, about 50 by 40 feet, is provided with seats for about 200,
so as to avoid the crowding which produces unsavory results in
most such places. The front door, at the west side of the building, is provided with a porch, where wet umbrellas may be left,
and where an attendant meets the patients and directs them to
the part of the room appropriated to the particular ailment of
each. Here they sit, facing the doors of the rooms of the physicians and surgeons, until summnloned to go in, by the passing
out of the preceding patient, and by a signal at the side of the
door, on a level with the eye, which displays the words, " Come
in," when the medical officer presses a handle on his desk. This
device is suggested to avoid the confusion of bells sounding from
the different rooms. At the east side of the room are two waterclosets, for males and females, with a sink in the lobby of each.
These are ventilated into the flues shown next to them, the
draughts of which are reinforced by their relation to the fireplace.  This fireplace, made of iron castings, is the principal
means of heating the main room, and has a large cold air duct
leading to the space around it, from which registers eight feet
from the floor open into the room. Above the level of the registers, the water-closet flues come into relation with the cast-iron
pipe which forms the smoke-flue above. This fireplace does not




94               FOLSOM.-PLANS FOR THE
differ in principle from those suggested for other parts of the
Hospital, but it is intended to be more on the scale of a furnace.
Two stacks of steam radiators are placed under the westerly part
of the room, for use in extremely cold weather. Four ventilating ducts, controlled by valves, open at the ceiling and terminate
in Emerson's ventilators above the roof.
On the northerly side of the building are four rooms for the
treatment of medical cases, and on the southerly- side are three
for surgical cases. The rooms are connected with each other, and
with the corridor, so far as possible, and the details of their use
would vary with the development of the out-patient department.
Each room is provided with a closet and sink, and each is heated
by steam radiators beneath, and has a ventilator beneath the
eaves.
The main room is fifteen feet high, and the side rooms thirteen
feet. Over the central part of the building is a second story,
reached by the staircase of the operating theatre, and appropriated to rooms for the male employees, numbering 8 or 9, not
provided for elsewhere. One water-closet and one bath-room,
near the chimney, would be required on this story.
The operating theatre is about 82 by 60 feet. The operating
room is about 64 by 16 feet, with smaller rooms mostly walled
with glass, at the ends. One of these is for operations requiring
privacy, or side light. The other, having a closet and watercloset adjoining, is for the surgeons' use. Near the folding doors
leading to these rooms are two sinks. The seats rise from a
semicircle of 10' feet diameter, to within 7 feet of the rear wall.
They are 2 feet and 4 inches from centre to centre, and the capacity of the theatre is about 500. Although this number of persons would seldom be present, it would seem that there ought to
be some one place in the hospital grounds where members of
the medical profession and all connected with the institution
and the university could be gathered, when occasion should
arise.
Beneath the seats is found abundance of room for, on the west
side, an etherizing room, about 19 by 12 feet, with a closet, and
a water-closet near it; a square entry containing the stairs by
which the seats are reached; two waiting-rooms, 15 and 10 by 12
feet, where patients are brought from the wards or from the outpatient department, before being etherized; and a male and




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LongitudTinal Section of AUTOPSY BTUILDING.
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JOHNS HOPKINS' HOSPITAL.               95
female recovering-room, about 28 and 18 by 12 feet, where
patients are put to bed temporarily, after operations, while recovering from ether. The entry behind is divided by glass doors,
and the doors of the rooms have glass panels, so that light may
be supplied, while sound is obstructed. A sink in the corner of
the entry serves for both recovering-rooms. South of the entry
behind are large closets with sloping ceilings for storing surgical
apparatus, etc.
Plate No. 19 is an elevation of the operating theatre.  It
shows the method of lighting, by central sky-lights above; and
a large north window above the seats. There will be no glare of
direct sunlight from this window, and, as it is the nearest source
of light, operators will not be likely to intercept the view of the
audience by standing before the patient. More distant ground
glass windows on the east and west sides will add to the general
lightness of the room.
The theatre is heated by steam radiators beneath, the vertical
registers being in the wall of the operating-room, under the seats,
one on each side, about 7 feet from the semi-circle. It is ventilated by a chimney, 5 by 2 feet, in the middle of the south wall,
containing a basket grate, in which a fire is made at the moment
the room is to be used. The duct leading to this chimney has
a narrow opening at the floor around the semi-circle, where the
chairs of the surgeons are placed, and also beneath the first and
second rows of fixed seats, and from the two water-closets at the
sides of the building.
AUTOPSY BUILDING.
Plates Nos. 20 and 21 are the plan and longitudinal section
of the autopsy building and dead-house. The whole building is
about 52 by 42 feet, and the auditorium is about 42 by 31 feet.
The access to the autopsy-room is by an entry, opening from the
corridor, leading beneath the seats to the stairs by which the
seats are gained. At the foot of the stairs is the door for the
pathologist, leading through a lobby which serves for a clothes
closet, to the space where the autopsy is performed. Beyond
this is a room for more detailed pathological investigation, with
a sink and table; and from this stairs lead to a room above,
about 42 by 21 feet, for the preservation of specimens. The two
dead-rooms, measuring together about 29 by 21 feet, are reached




96               FOLSOM.-PLANS FOR THE
by a separate passage from the corridor. They contain tables of
stone for the reception of the dead; and the remains of those
dying in the hospital should be conveyed here at once.
The dead-rooms are kept as cool as possible. The autopsyroom is warmed by steam, the registers opening vertically in the
wall of the room below the seats.
The ventilation of the dead-rooms is into a chimney about 3 by
2 feet, the draught of which is reinforced by making a fire in a
basket-grate when an autopsy is to be made. An autopsy table,
contrived for the Massachusetts General Hospital by Dr. Henry
J. Bigelow, is shown in Plates Nos. 22 and 23, and has proved
extremely successful at that institution. I quote his description
of it:
"The autopsy table is supported upon a single hollow iron leg,
"intended to insure ventilation and drainage. For this purpose,
"the downward draught is concentrated upon the trunk of the
"subject, from which alone objectional odors emanate. Air, to-' gether with water and other fluids, are drawn through a nearly
"central opening in the table, which is fitted with a grating into
"the iron leg. Here they are separated. The water falls verti" cally to a trap in the cellar, while' beneath the floor the air is
"drawn laterally to a special chimney. The air-tube, where it
"leaves the table-leg, inclines upward for a short distance, to ex" dude water. The table-top is dished, and made of tinned copper.
"The hollow leg is cylindrical at the floor, but expands above
" into an oblong square, which closely fits the table around the
"grated opening; the flaring part being a single casting lined with
" porcelain, like a sink. To the top of this casting an iron flange
" is bolted, which supports the whole edge of the copper table.
"Near the floor the leg is halved, to allow rotation. The
"upper half is received into the lower half, and rests upon a
" square shoulder, lubricated by a cup on the outside, which de" livers oil slowly through the joint into the interior of the leg. A
" small rubber hose is attached to a water-cock in the floor near
" the leg."
DIMENSIONS.
"Length of table-top,................ 6 feet 10 inches.
I' Width "' I.                    2 " 6 
"Length of grating,................... 2  " 5  "
"Width 6"  II........i.......... 1 foot 9  "








Dr. Folso onYs  SuP p    estiotns
JOH NS HOPKINS  HOSPITAL.!\\:...per   7a'p  /                                                                                        I
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LONGITUDINAL SECTION OF AUTOPSY TABLE.
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|l                      t >  _A j il__ _1_ _ 
7 42  17 -                                              j _ _ _ _ _ _ _ _ _ _ _ _ _ _  __  /_vNo.22. 
VIEW O AUTOPSY T/ABL E.'v t'; BIGELOW,'
BY H.J._BIGE




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JOHNS HOPKINS? IIOSPITAL.                97
"Distance from head of table to grating, 2 feet.
te"    "   "  foot   "                2 "  5 inches.
"Height of table,.................... 2  "      "
"Depth of dish from ends,..............      2..     sides...   1 4
"Inside diameter of cylindrical leg,.    foot 4  "
"Diameter of air-tube,................1 "   6 
"At the rear of the theatre a soapstone sink with a steep incline' and draining slab at the end, provided with hot and cold water,
"is enveloped by a glass hood, or chamber of glazed sashes, like' that in a chemical laboratory. Ventilation is secured by a large
" exhausting duct, with an enforced draught.
"With these appliances, an autopsy is almost, if not quite,
" odorless."
A refrigerator for the temporary preservation of specimens is
also seen at the rear of the theatre.
The floors of the autopsy and dead-rooms are water-tight, and
arranged to be washed with hose.
Plates Nos. 24, 25, and 26 give respectively a view of the
open top; of the front when closed; and a vertical section, of
the top arrangements proposed for all water-closets, as a substitute for " leading" them in the ordinary way. Urinals, as heretofore constructed, cannot be kept free from odor, and are not
as well. adapted for hospital use as a water-closet with the seat
raised.  Every water-closet requires daily washing with soap,
and sometimes with sand, to keep it clean.
In the pattern proposed, the top of the porcelain bowl, instead
of being round or oval, is a square shallow tray or sink, the
edges thickened for strength,  but rising only half an inch all
around.  The usual oval oval opening of the bowl is in the middle of
this slightly shelving sink, and the verge of the opening is perfectly smooth. The fan-jet of water is in its usual place in the
bowl, which is of the usual shape and construction below, to
secure the playing of the fan-jet around the circumference.
The front edge of the square sink comes forward flush with the
face of the wood-work.
The seat, hinged at the back, is raised when the water-closet is
used as a urinal or slop-sink, or while washing bed-pans; and,
thoulghl there is no play of water over the square part of the sink,




9  FOLSOMI. —PLANS FOR, THE
except from the hand-hose, there is every opportunity to wash it
thoroughly.
TVhen the seat is down, it rests, not on the sink, but on sepa-.
rate wooden cleats at the sides, one inch higher than the top of
the sink, so that there is always an interval of an inch between
seat and sink, even when the cover is shut down; and through
this interval the air constantly passes horizontally from the front,
backward over the sink to the ventilating duct behind.
As the bowls are not made in this country, it may be necessary
to use one of the usual kind, and fit a tray of glass or lead to the
top of it.
The wood-work in front slopes in at the bottom three inches,
to give standing room.
LIST OF FUIRNITURE FOR A WARD OF TWVENTYTHREE BED S.
COST
ARTICLES.                        NO.  OF EACH.
Wooden Trays.........................   3    $2.00
Coal Hods..............................   2       3.00
Coal Hods (small).......................  1   1.00
Shovels.............................. 1           1.50
Shovels (small)..........................  2        16
Match Safes............................   1         20
Oil Lamps (Britannia)...................   6      75
Oil Cans................................   1      1.00
Lamp Fillers...........................   1         33
Lamp Shades (tin)...................... 2           75
Spit-Cup Covers (tin)..............       36        06
Wooden Pails..........................   4          25
Keelers, or Dish-Tubs..................   1         42
Brooms................................  2           33
Floor Brushes..........................    2        92
Dust Brushes..............                 2    37
Window Brushes.........1...........   1           1.00
Mop Handles...........................   2          21
Mops...................................    2  29




JOHNS HOPKINS' HOSPITAL.                                          99
COST
ARTICLES.                                          NO.   OF EACH.
Dish  Mops..............................                          1         $0.12
Scrubbing Brushes......2.......   2                     25
Soup  Tureens (tin)......................         1          5.00
Vegetable Dishes (tin)...................                          3            75
Coffee-Pots............................                           2             75
Tea-Pots...............................                           2            61
Wash-Bowls........................... 12                                        30
Poultice  Dippers.......................    2                   43
Tin Dippers...........................    2      18
Tin Cups........                                                  2   29
Dust Pans...........................                            2    16
Graters.............................    1                                      03
Tunnels............................. 12
Strainers.............................    1                                     12
Sugar Boxes...........................    1            1.19
Bread  Boxes...........................                         2          1.28
Tea Trays..............................   12                                  60
Chamber Pails.........  1  95
Casters................................   1                                  2.00
Corkscrews.............................                                         85
Poker.................................    1                                     50
Tongs..................................    1                                1.00
Steps for Linen  Closet...................         1          4.00
Card-Frames (tin)......................      23              30
Cambric-covered Screens...............   6                                    4.26
Clocks...............................   2                 3.50
Thermometers..........................        2          1.00
Clothes-Brushes........................                            1            21
Baskets, for carrying Bottles............   I                                   50
Bandage Winders......................    1                                   4.00
Nail Brushes...........................    2                  30
Combs.....                                       6    10
Trucks, for Litters...................                            1   10.00
Litters................................    1                                 6.00
Basket Litters...........................    1                              6.00
Rubber Sheeting, yds............... 20   2.25




100                FOLSOM.-PLANS FOR THE
COST
ARTICLES.                        NO.   OF EACIH
Rubber Pillow-cases.................... 12       $1.35
Lamp Scissors..........................   1         50
Scissors..............................  1  1.00
Shears.................................    1      2.50
Copper Heaters (to fill with water)......   4      5.00
Knives.............................  23            56
Forks...............................  23            75
Carving Knives and Forks..............  6           33
Large Spoons..........................  6           13
Table Spoons.........23..................  3       31
Tea Spoons.........12................... 1          14
Blankets..............................  60         1.24
Quilts................................. 46   1.40
Sheets...............................   200         93
Pillow Cases........                     200        28
Half Sheets............................ 100         34
Mosquito Nets.........................  30          16
Shirts...............................     50        50
Table Cloths...........................   6        1.55
Table Covers (Turkey Red)..............   3        3.81
Dressing' Towels (diaper)................ 200       13
Toilet Towels (crash)..................   150       18
Rollers (crash)..........2............... 1         44
Towels (coarse crash)..................   12         15
Toilet Towels (huckabuck)..............  50         23
Table Covers (one for N!urse)............  2        2.35
Spit-Cups........................ 36   13
Bed Pans..............................   3        1.42
Soap Dishes...................             3    15
China Wash-Bowls and Pitchers.........   2       1.50
Plates..........................  30        12
Small Plates............                 30   11
Bowls............                         30  15
Mugs..................................    30    13
Medicine Mugs............                  30    05
Drinking Ducks.........................   6          20
Cups and Saucers............              30    11
Dishes................................   6          67




JOHNS HOPKINS' HOSPITAL.                 101
COST.
ARTICLES.                        No.  OF EACH.
Platters..............................   2    $0.95
Water Pitchers.........................  2         83
Small Pitchers..........................   6       39
Very Small Pitchers..................      6       31
Sugar-Bowls............................   2        57
Ice-Jars.............................   1        1.99
Tumblers...............................    12       7
Salts.................................  24          1
Hair Mattresses....................... 28    13.51
Husk AMattresses........................  25     3.31
Husk Bolsters.......................   5           61
Hair Pillows...................        25      1.66
Feather Pillows.........................  60     1.96
Small Wooden Stands..................  23          90
Reclining Chairs................... 1  27.00
Arm Chairs (with cushions).............  23      4.80
Small Wooden Chairs...................  16         92
Long Tables...................            3       18
Towel Stands.........................   2       1.00
Looking-Glasses...................       3     4.50
Boxes for Soiled Clothing...............  1      3.00
Bureau and Glass (for Nurse).........    1    20.00
Square Table        "    "..1                   2.00
Rocking Chair   "  cc..       1   3.75
Small Chairs        "    "                 4      1.40
Iron Bedstead            "..              1    15.00
W~ash-Stands        "    "                 1      3.00
Lounge              "    ".                1    20.00
Wheeled Chairs....................    1    40.00
Iron Bedsteads...........             23    30.00
Total cost................    $2,486.15
CONTENTS OF 3MEDICINE-CLOSET.
8 oz. Solution of Iodide of Potassium, 40 grains to 1 oz.
12 "             Bromide of   "        "   "      1':




102              FOLSOM1.-PLANS FOR THE
4 oz. Solution of Sulphate of Morphia, 1 grain to 1 oz.
12 "    "           "      Magnesia, 2 drachms to 1 oz.
8 "    "       Chloral Hydrate, 4 grains to 1 oz.
4"  Tincture of Opium.
4 " Deodorized Tincture of Opium.
4 "  Spirit of Nitrous Ether.
4 "  Solution of Acetate of Ammonia.
12 " Cod-Liver Oil.
8 " Castor Oil.
4"  Fluid Extract of Senna.
8 " Mustard.
1 pint of Lemon Syrup.
4 oz. Compound Tincture of Gentian.
4"      "        "        Cinchona.
2 " Tincture of Chloride of Iron.
8 " Solution of Sulphate of Quinine, 8 grains to 1 oz.
4 "  Oil of Turpentine.
1 pint of Lime Water.
2 oz. Aromatic Spirit of Ammonia.
2,"    "    Sulphuric Acid.
2 " Essence of Peppermint.
2"  Tincture of Ginger.
1 doz. Compound Rhubarb Pills, 5 grain.
1 C"     "      Cathartic  "  5  "
1 "  Dover' s Powders, 10 grain.
1 "     "      "       5 "
1 "  Powders of Sub-Nitrate of Bismuth, 10 grain.
1 "      "''         "'                5 S
4 oz. of Seidlitz Mixture.
2 "    Tartaric Acid.
4 "    Bitartrate of Potassa.
4 "    Compound Licorice Powder.
1 doz. Pills of Sulphate of Quinine, 2 grain.
1 "   "        "                1  "
1 "   "      Opium,             1  "
1 One-ounce Graduated Glass Measure.
1 Minim Glass.
1 pint of Brandy.
1 "    Whiskey.
1 "    Gin.




JOHNS HOPKINS' HOSPITAL.               103
1 pint of Sicily Madeira.
1 "    Tarragona or Port Wine.
1 quart of Dilute Alcohol or Rum, for bathing.
CONTENTS OF DRESSING-CLOSET.
5 yards of Cotton for Compresses.
5  "      Poultice Muslin.
2 doz. Assorted Roller Bandages.
1 yard of Sheet Lint.
~ lb. of Scraped Lint.
2 oz. Tincture of Iodine.
1 Camel's Hair Pencil.
2 oz. of Olive Oil.
2 doz. Sponges.
2 lb. Simple Cerate.
1 yard Adhesive Plaster.
1 Eight-inch Spatula.
1 Four  I" "I
1 yard Oiled Linen.
1 Pincushion.
12 Sheets Cotton Batting.
I lb. of Charpie.
Assorted Splints.




LIST OF PLATES.
No. 1. Block Plan.
2". Plan of Administration Building.
"  3. Plan of Common Ward.
4. (West) Side Elevation of Common Ward.
"  5. North Elevation of Common Ward.
6. Longitudinal Section of Common Ward.
7. Cross-Section of Common Ward.' 8. Plan of Heating Apparatus of Common Ward.
9. Cross-Section of Heating Apparatus of Common Ward.
" 10. Plan of Ventilating Ducts of Common Ward.
" 11. Cross-Section of Ventilating Ducts of Common Ward.
" 12. Plan of Isolating Ward.
" 13. East Elevation of Isolating Ward.
" 14. Cross-Section of Isolating Ward.
" 15. Detail of Heating Apparatus, with Mixing Valve, of Isolating Ward.
16. Plan of Private Ward.
" 17. Plan of Kitchen.
" 18. Plan of Operating Theatre and Out-Patient Building.
" 19. Cross-Section of Operating Theatre.
" 20. Plan of Autopsy Building and Dead-House.
" 21. Longitudinal Section of Autopsy Building and Dead-House.
" 22. View of Autopsy Table.
" 23. Longitudinal Section of Autopsy Table.
" 24. Plan of Water-Closet.
" 25. Elevation of Water-Closet.
" 26. Section of Water-Closet.
" 27. Diagram of Paths, showing possible Trees, Shrubs, etc., on Block Plan.




HOSPITAL CONSTrtUCTIO NA
BAND ORGANIZATION.
JOSEPH  JONES, AM.D.,
Professor of Chemzistry and  aliic6n Jleldicise, Medical Depacrtwnent University of Loitisianac;'Vi-siting Physician of charity Hospital, New Orleeans,;'Formerly
Surgeon in the Provisional Army of the confederate States.




C ONTENTS.
PAOGE
LETTER  TO  THE  TRUSTEES...............................................  107
GENERAL REMARKS........................................................  109
LOCATION...1....................................................... 110
DRAINAGE  AND  SEWERAGE............................................... 110
WATER..................................................................... 111
ARTIFICIAL LIGHT.......................................                                                 112
SUNLIGHT  AND  HEAT.......................................1............... 112
BUILDING  MATERIALS....................................................... 112
METHOD OF COMBINING THE ADVANTAGES OF TEMPORARY AND PERMANENT
HOSPITALS.........................................................  113
FOpRn, SIZE. AND ARRANGEMENT OF HOSPITAL BUILDINGS.................. 114
HEAT, REGULATION OF TIE TEMPERATURE OF THE WARDS.............. 118
DISINFECTION............................................................. 123
DISTRIBUTION OF PATIENTS AND CLASSIFICATION OF DISEASES AND ACCIDENTS. 127
HOSPITAL ADMINISTRATION.................................................. 130
EXPLANATION  OF PLATES.................................................... 163




495 ST. CHARLES STREET, NEW ORLEANS, LA.,
April 8, 1875.
FRANCIS T. KING, ESQ.,
President, " The Johns Iloplcins' Iloslital," Baltimore, Md.
iD)EAR Sin: -Your kind favor of the 3d inst. has been received
and carefully considered; and whilst feeling great hesitation in
accepting the important trust of renderingo counsel in the execution of the noble bequest of the late Johns Hopkins, of Baltimore,
and whilst distrusting the extent of my qualifications and experience, to which you have been pleased to allude in such generous
terms, allow me to say that I will endeavor to present a practical view of the more important subjects which will be involved
in the erection and operation of a great Hospital.
I gather from your letter, that the objects and uses of "The
Johns Hopkins' Hospital" will be —
1st. The relief of human suffering; the recovery of health;
recovery from sickness in the shortest time; with the smallest
possible mortality.
2d. The establishment of a Medical School, where pupils shall
be taught the ways of nature in the recovery from  diseases
and casualties, and in whic]l the daily experience of the medical
staff shall be enlarged, perfected, and preserved for the use of
future generations.
I will endeavor to present concise and practical observations
on the following points: —
1st. Hospital Construction.  Form and size of Hospital Buildings. Building Material. Size and arrangement of W~ards.
Ventilation.  Light.  Heat.  Disinfection.
2d. Distribution of Patients.
Classification of Diseases and Accidents.
3d. Administration.
Medical and Surgical Staff.
Duties of Physicians, Surgeons, and Resident Students.
4th. Nurses and Attendants.
5th. Arrangements for Cooking.
Diet.




108               JONES.-PLANS FOR THE
6th. General Police.
7th. Clinical Instruction.
Proper Location and Structure of Amphitheatre and Lecture Room.
Disposal of Dead.
Structure and Conduct of Dead House.
Post-Mortem Examinations.
8th. Laboratory for Chemical, Microscopical, and Pathological
Investigations.
9th. Library.
Duties of Librarian.
Preservation of Hospital Records and Works of Reference.
Museum.
Duties of Curator of Museum.
Preservation of Anatomical and Pathological Specimens.
10th. Hospital Dispensatory.
Duties of Druggists.
Preparation and Dispensation of Drugs and Medicines.
11th. General Dispensatory for Out-door Patients.
12th. Regulations relating to Students attending Clinical Leetures and General Dispensatory; and Visiting, Obstetrical, Surgical and Medical WVards.
13th. Observation and Registration of Cases.
I shall endeavor to make the observations under each head as
explicit and practical as my experience may permit.
In conclusion, allow me to request, that if I have not fully
comprehended the nature of the subjects to be discussed, I may
receive further instruction at your earliest convenience.
With great respect and high esteem,
I have the honor to be
Your obedient servant,
JOSEPH JONES.




HOSPITAL CONST RUCTION
AND ORGANIZATION.
JOSEPH  JONES,. D.,
Professor of Chemistry and Clinicat Jedicine, Medical Department University of Louisicna; Visiting Pliysicia of Charity lospital, New 0rlecans; Formerly
Surgeon in the Provisional Army of the Confederate States.
495 ST. CHARLES STREET, NEW ORLEANS, LA.,
May 10th, 1875.
To FRANCIS T. KING, President, and JOEN NV. GARRET, HoN. GEORGE W. DOBBIN,
GALLOWVAY CHESTON, TIHOIIAS MI. SMITH, WILLIAM HOPKINS, RICHARD M.
JANNEY, JoSEPH IF ERRIFIELD, FRANCIS WII1TE, LEWIS N. HOPKINS, ALAN P.
SMNITHI, MI.D. 6and CHARLES J. AI. GWINN, ilTrustees, of "'72ee ohnls Hlop/kinzs':lospital," acl7timore, Mcaryland.
GENTLEEMEN:-In accordance with the request contained in
the letter of your honorable President, bearing date April 3d,
1875, I have the honor to submit the following observations,
which I shall endeavor to conform to the order of subjects indicated in my letter of the 8th of April.
In presenting the results of my experience, I desire to avoid as
far as possible controversy and criticism; and it will be my
effort to express my views and apply well established principles
in such a simple, practical, and concise manner, that suggestions
may be furnished worthy of the consideration of your honorable
and learned body.
If sauch charity as that which actuated the late Johns Hopkins
of Baltimore, and which has been regarded as the most benign of
all the virtues, " the very bond of peace, and of all virtue," was




110                JONES.-PLANS FOR TIHE
universally diffused, there is not a disease that can afflict human
nature, nor a'want which the varying condition of man can
require, nor any of the manifold visitations of adversity in poverty or distress, but would find an open asylum, prepared with
every useful accommodation. The founder of this noble charity
evidently held, that one of the first duties is to feel for q2man.
The most distingiuished ability and the greatest success in life
are valueless when that duty is neglected.
A.llbw me to say, that I regard. the letter of your honorable
President as calling, not for an elaborate treatise on the history
and construction of hospitals in this and other countries, nor
for a detailed account of my personal experience in Civil and
Military Hospitals; but rather for the expression of a definite
opinion, and the unfolding of a definite plan of hospital construction and organization, which may be compared with those
furnished by distinguished members of the Medical Profession,
and which may be subjected to direct discussion. with a view to
adoption, mod'ification, or rejection.
LOCATION.
It is not necessary to discuss the location of a great hospital,
as this subject has been decided beyond controversy, and in the
most enlightened manner, by the terms of the bequests of the
late Johns. Hopkins.
Thus President King says in his letter of the 3d of April, 1875:
"The site of the proposed building'  "consists of an eligible
piece of ground situated in the eastern part of the city."  "It is
fourteen acres in extent, in the formn of a parallelogram, 709 by
856 feet"; "it is very elevated above the general level of the
city, and commands an extensive view in all directions'"  "it
is healthy, with complete surface drainage, whilst underground
drainage may be accomplished to tide-water''; and "it is easily
accessible by street railway, and by- paved streets which bound
the four sides of it."
DRAINAGE AND SEWERAGE.
The first attention should' be paid to the sunface and underground drainage, which should be of the most ample and effective character, so as to rendier the Hospital grounds dry and




JOIINS HOPKINS' ITOSPITAL.            111
porous, and prevent the accumulation of any water, either on
the surface or in the soil.
The sewers should be ample in size, simple in structure, and
capable of easy examination and repair; and they should be constructed upon the most approved and efficient plan.
The question of the drainage and sewerag'e appertains to
Engineering Science.
Two main sewers should run across the Hospital grounds, one
in the front, and the other in the rear of the buildings; and all
minor sewers should discharge into them. The large sewers
should be not less than four feet in diameter, and the smaller
sewers not less than two feet in diameter.
The sewers should be properly ventilated.
iTVo setwer should run under any.ward or HIospital bulilding.
The water used in the Hospital bath-rooms, kitchen, steamlaundry, dispensatory, laboratory, etc., should be used to cleanse
out the privy vaults, flowing into and through them, and emptying into the main sewers.
As water is the best disivfectant, and tkUe best means of remnoving filth and noxious gases fromn the sewers, the supply
should be large and practically unlimited.
The free flow of the fecal matters in the sewers may also be
promoted by a system of founltains, located at stated intervals
in the Hospital grounds, the waste water from which should
flow continuously and at stated intervals into the sewers. The
fountains, whilst thus adding to the beauty and attractions of
the grounds, and to the comfort of the patients, may be made
of the greatest practical benefit in flushing out and cleansing the
sewers.
VWATEPR.
The supply of water is of the greatest moment. The Hospital
grounds, buildings, and wards should be furnished with ample
supplies of pure potable water, and the pipes should be constructed of such materials as to preclude the contamination of
the water by lead, or any other deleterious agent.
Each ward and building should have its own system of water
pipes.
The main administrative building may be so constructed as




112               JONES.-PLANS FOR THE
to be surmounted by large iron tanks, to which the water may
be elevated by engines, located in the Hospital grounds or buildings, if the water-works of the city of Baltimore have not sufficient force to accomplish this result.
ARTIFICIAL LIGHT.
The Hospital grounds and buildings should be supplied with
the ordinary gas, which is the safest, cleanest, and most efficient
means of illumination.  The gas-pipes and gas-meters should be
so arranged as to adimit of frequent and efficient inspection.
SUNLIGHT AND IHIEAT.
The axis of the wards of the Hospital should be so located as
to secure the largest possible amounts of the sun's light and
heat. The location of the Hospital should also to a certain extent be regulated by the direction of the prevailing winds.
BUILDING MATERIALS.
Permanent hospitals should be constructed upon the most
substantial principles.
The materials for the foundation, walls, and floors should be
either brick, stone, or iron, or a comlbination of each.
Of all building materials, granite is the most durable.
The materials and plan of construction should be such as to
render the Hospital buildings fire-p2roof.
The walls should be of impermeable material, such as Par)ian
cemzent, or of colored tiles, or large porcelainz or glazed eart-henware slabs, joined perfectly by a good cement. It is impossible
that any absorption of poisonous animal matters should occur,
with walls formed of glazed tiles or slabs.
The floors should be constructed of fire proqf materials, and
covered with glazed tiles or slabs, which may be covered with
good oil-cloth, or material of the like kind, which will not absorb
organic matters and gases, and which will lessen the necessity of
washing the floors, and which imight be frequently removed and
washed.
Vitlhout doubt, wooden buildings serve an excellent purpose,
in time of war, and in great emergencies; but the objections to
the construction of permanent hospitals of wood are:




JOHNS HOPKINS' HOSPITAL.                113
1st. Danger of destruction by fire.
2d. Perishable nature of wooden buildings, necessitating constant repair and renewal.
The chief objections which have heretofore been urged against
permanent hospitals, are more correctly applicable to the evils
of faulty construction, overcrowding, and the neglect of periodical evacuation and disinfection.
METHOD OF COMBINING THE ADVANTAGES OF TEMPORARY AND
PERMIANENT HOSPITALS.
An important principle in the construction and conduct of
permanent hospitals, which has not yet been recognized and
adopted, is that each permanent hospital should never be filled
to its utmost capacity, biut t7hat at least one-towefth of the entire woard space should at all limes be vacant.
Thus: If a permanent hospital consists of 12 wards, only 11
wards should at any time be occupied; the twelfth or vacant
ward should be fully ventilated, cleansed, disinfected and aired;
and to accomplish its complete renewal or regeneration, so that
it shall in fact constitute a newv ward, one mllonth should be devoted. Each ward should thus be treated once in twelve months.
Each ward may be annually evacuated, cleansed, ventilated and
disinfected with chlorine, carbolic acid and burning charcoal and
sulphur, syTstematically and regularly, in rotation, so that all
inconvenience and confusion would be avoided.
If the Hospital consists of twenty-four wards, then two wards
should always be vacant; if of thirty-six wards, three wards;
if of forty-eight wards, four wards, and so on.
At such times, as when contagious or infectious diseases are
prevailing, the cleansing, evacuation and rotation may be performed at shorter intervals.
By ventilation, evacuation, cleansing, disinfection and renewal
of bedding, the permanent hospital is perpetually undergoing
the process of renewal and reconstruction, and thus attains the
advantages of the destructible wooden pavilion hospital, without
its defects.
By complete renovation of the vacated wards, we mean not
nmerely disinfection of the floors, walls and space, by the fumes
of burning charcoal and sulphur, chlorine and carbolic acid, but




114               JONES.-PLANS FOR TIIE
the thorough cleansing and varnishing of all furniture, and the
thorough renewal of the bedding.
It is probable that the chief source of the propagation of contagious and infections diseases is to be found in the stuffing
(moss, hair, straw, cotton, wool, etc.) of the beds. Absolutely
new material, or material which has been subjected to thorough
disinfection, by means of steam and other agents, should be used
at stated intervals in the construction of beds. It is unfortunately too true, that the materials employed in the construction
of beds are used, over and over again, in large hospitals, without
proper cleansing and disinfection.
The hygiene of a hospital should commence with the bed,
upon which the patient passes the greater portion of his time.
As beds are constructed of porous materials, they without
doubt act as sponges for the absorption and retention of deleterious organic matters and gases.
No attention to ventilation, temperature, food and cleanliness
of the wards and patients will avail, if the beds are used for
indefinite periods.
By this principle of rotation in the ward service, we secure for
the permanent hospital the advantages claimed for temporary
wooden hospitals, which may be destroyed or removed at will.
With propUer drainage ancd sewerage, it is impossible that
the grounds of the permanent hospital should ever become saturated with organic matters.
FORM, SIZE AND ARRANGEMENT OF IOSPITAL BUILDINGS.
In permanent European hospitals constructed on the Pavilion
system-the Lariboisiere at Paris, the Herbert Hospital at WVoolwicll, the Blackburn Hospital near Manchester, England, the
Hospital of Saint Louis at Turin, and the Military Hospital at
Malta; and in American permanent hospitals-the Boston Free
Hospital, the Pennsylvania Hospital, the Blockley Alls House
and Hospital, the Pennsylvania University Hospital and the
Episcopal Hospital of Philadelphia, and the Charity Hospital of
New Orleans, furnish plans worthy of careful consideration.
In temporary Military Hospitals —the Confederate Hospitals
of Camp Winder, Camp Jackson, Richmond, Virginia, of Gordonsville, Charlottesville, Staunlton, Lymnchburg, Petersburg, anmd




JOHNS HOPKINS' IOSPITAL.                115
the large temporary hospitals attached to the Army of Tennessee,
located at various times at Chattanooga, Tennessee, Rome,
Atlanta, Miarletta,:Nacon, Georgia, and other points, which were
erected dluring the recent civil war, under the enlightened dlirection of Surgeon-General S. P. Moore, C.S.A.; and the great
Federal Hospitals-of W~est Philadelphia, the iMower General
Hospital, Chestnnut Hill, the McClellan Hospital, Philadelphia,
the Hammond General Hospital, Point Lookout, the Lincoln
Hospital, Washington City, the Hospital at Fort Schuyler, New
York, furnished plans worthy of the consideration of Army
Medical Officers.
The Hospital should consist of a Central or Administrative
Department, the buildings devoted to the reception and treatment of Diseases and Accidents, and the necessary rooms for
Clinical. Instruction and Pathological Investigation.
Hospitals, however necc.;sary and exellent in themselves,
and however they may to a certain extent reflect the civilization
and charity of a community, as they relate only to the cure of
disease and the necessities of mankind, must. be regarded as
holding only a subordinate station in the body politic of medicine, the science of which in its noblest extent aims not only at
the cure of disease, but the eradication of the causes of disease,
and the preservation and prolongation of the life of maln, in
every country and climate, and in every condition and occupation.  If, therefore, the crowding of healthy men has its danger,
the collection of many sick persons within the confined area of
the hospital is far more perilous; and from the imperfection of
the arrangements, as well as the contamin —tion of the ill-ventilated and crowded wards with morbid substances, hospitals have
frequently becomn3 pest-houses, and effect-e- more harm than
good.
The risks of aggregation are encountered in the hospital, in
order that medical attendance and nursing may be moret easily
and perfectly performed; otherwise it would be more humane
and more productive of good results to tret; the sick at their
own houses and homes, or in separate apartments, scattered over
a great area, permiting of complete isolation.
Whilst it may be admitted that the many advantagscr3  of hospitals more than counterbalance the continual sacrifice of life
from  diseases arising fro:m  aotual contact, and  the rapicily




116               JONES.-PLANS FOR T-IE
changing and putrlefying substances emitted by the sick, or
aggravated by impure air; at the salme time it is well established,
that the risks of conta(gion and aogoravation of disease is the
least in the best const ructed and ventilated hospitals.
The followinog rules, governing the construction of hospitals,
have met with strong support by many who have had the greatest experience in the erection and management of Civil anld Military Hospitals:
1st. An unlimited supply of air is the cardinal consideration
in the erection of hospitals, and should govern the construction
of the buildings.
2d. The sick should be placed in detached and perfectly ventilated buildings, so disposed as to get the freest air and the
greatest light.
3d. The sick should be distributed over as large an area as
possible, and each sick man should be as far removed from his
neighbor as possible.
4th. Not more than from 80 to 100 sick should be in the same
building, under one roof, and there should be no possibility of
the polluted air of one ward passingr into another.
5th. In the wards, each man should have not less than from
1800 to 2200 feet of cubic space.
6th. A much more efficient, and at the same time much less
costly ventilation, may be obtained by natural than artificial
means: therefore, it should be dependent upon the movement
of the outer air, alid on inequalities of weiglht of the external and
internal air. In a properly constructed ward, sufficient ventilation can at any time be obtained by open doors and windows.
The windows in the wards should be numerous, opposite to
each other, and should reach from the ceiling' to the floor. Additional openings may be made, so as to secure as far as possible
a vertical movement of the air from below upwards. And this
will best be accomplished by the method recommended by Dr.
Edmund A. Parkes, in his valuable lffcnuczz of Practicccal Hygiene, which is as follows:
A tube opening at once to the external air should run transversely along the floor of the ward to each bed, and should end
in a box placed under the bed, and provided with openings at
the top and sides, which can be more or less closed. In the box,
coils of hot-water pipes should be introduced to warm the air




JOHINS HIOPKINS' IIOSPITAL.             ].17
when necessary. The area of the tube should be not less than 72
square inches to each bed; and the area of the openings in the
box at least four times larger. The fresh air, warmed to any
degree, and moistened, if necessary, by placing wet cloths in the
box, or medicated by placing chlorine, iodine, or other substances, will then pass under each bed, and ventilate the space,
so often left unaired; and then ascending round the sides of the
bed, will at once dilute and carry up the products of respiration
and transpiration to the ceiling. It would be possible to arrange
the hot-water pipes, so as to cut off all or some of the pipes
under a particular bed from the hot-water current, if desirable,
and so to give a fever patient air of any temperature, from cold
to hot, desired by the physician. In the low and exhausted
stages of fever, warm air is often desirable. By this simple plan,
the physician could deal effectually with the atmosphere rounnd
his patients, as to warmth, dryness, humidity, and medication:
and at the same time the open fire chimney and open doors and
windows are preserved. For the exit of the foul air, channels in
the ridge should be provided, warmed witlh gas if possible.
7th. In order to preserve the purity of the air, by immediately
diluting and rapidly carrying away the morbid substances evolved
from the bodies and excretions of the sick, it must be continually
changing: for persons in health, at least 2,000 cubic feet per
head must be supplied per hour; and for sick persons, not less
than from 4,00( to 5,000 cubic feet per hour. At the same time,
the mlovement of the air should be as far as possible imperceptible, in order to avoid the sensation of draught or chill. The rate
at which the mlovemenlt becomes imperceptible, varies with the
temperature of the air, a very considerable velocity being not
perceived at high temperatures.
8th. Every ward should be amply supplied with hot and cold
water; and baths, both simple and medicated, should be attached
to each ward.
The supply of water for all purposes should be at least 65 gallons per head daily; to be expended, if necessary, daily as follows: for cooking, including cleansingl of kitchen, 5 gallons; for
baths and personal washing, etc., 25 gallons; for laundry washing', 10 gallons; for washing and cleansing hospital and utensils,
10 gallons; for water closets, 15 gallons per head daily.
9th. The wards should be erected upon arches, so as to allow




1.18              JONES.-PLANS FOR THE
of free ventilation of the lower floor. The lower corridor, upon
which the wards are erected, may be used as a general highway,
with a central tramway or railroad, for the conveyance of the
food, medicines, patients, clothing and dead.
10th. Each ward should be connected with the lower arched
corridor by means of lifts and stairways, so as to permit of the
ready distribution of patients, medicines, food, etc.  By this
means, all unnecessary noise and bustle about the wards will
be avoided, and the service rendered by the nurses and attendants will be more efficient. The patients of each ward will
thus also have free and ready access to the Hospital grounds.
Open-air exercise is an important mode of medical treatment,
and open verandahs, on the sunny sides of wards, and also gardens and quiet walks, will conduce to the comfort and health of
the patients.
11th. The wards should not be constructed too large nor too
small. Only two rows of beds should be permitted; they should
be arranged so as to allow the attendants a general view of each
patient; every contrivance, as lifts, shafts, tramways, and speaking tubes, to save labor, should be employed, in order that the
time of the attendants should -be expended as far as possible in
nursing, and not in other duties.
12th. The water-closets should be arranged in nearly detached,
well-ventilated lobbies, at one end of the ward, and separated
front it by a thorough cross ventilation.
iNo urine or other excretion should be retainecl in vessels, but
should immediately be discharged by the -urinal.
All excreta shouldl be removed by water; and the water-closets
should have continuous and unlimited supplies.
I have drawn up the following plan, based upon the preceding principles, for a permanent hospital, capable of accommlodating 800 patients.
HEAT, REGULATION OF THE TEMIPERATURE OF THE WARDS.
The arrangements for heating the Hospital should be ample to
meet all sudden changes of temperature, and also to maintain
the degree of heat and moisture, best adapted to the proper treat-l
ment of certain diseases.
The temperature of hospitals should be regulated in accordance with that of the climate in which they are situated, and the




JOHINS HOPKINS' HOSPITAL.                 119
class of patients by which its wards are supplied. Patients
depressed by poverty and privation should manifestly be treated
in a different manner from well-nourished and vigorous men in
the prime of life and within the military ace.
During a period[ of eight years, 1817-1824, the mean monthly
temperatures of Baltimore were as follows: January, 30.9~ Fahr.;
February, 33.0~; March, 39.2~; April, 52.1'; MIay, 60.6~; June,
70.9~; July, 75.2~; A-ugust, 74.7~; September, 66.6~; October,
54.9~; November, 44.3~; December, 34.4~. Mean temperature
for spring, 50.6~; summar, 73.G~; autumn, 55.3~; winter, 32.8~.
Alean for the year, 53.1~.
The following  table  (see p. 120) furnishes the monthly
extremes of temperature in Baltimore during a series of years
1841-1852.
Of all exciting causes of disease, there are none more common
thfan extremes or sudden transitions of temperature.  It is evident from the preceding record of the changes of temperature in
Baltimore during a series of years, that buildings designed in
this city for the efficient treatment of the sick should be so constructed as to shield the inmates effectually from  the extreme
cold, and the suddcen changes of the months of December, January, February and March, and the elevated temperature of
June, July, August and September.
It is probable that external cold excites internal disease by
deranging the circulation and condition of the blood, particularly
in the capillaries.
Cold checks the perspiration, contracts and obstructs the
vessels of the skin, and thus throws more blood inwardly, so that
internal congestions are produced, which impair the functions of
the affected organs, especially if they are such as are concerned
in excretion: and in other ways lays the foundation of disease.
It is well known that this intropulsive effect of cold takes place
more rapidly and in a more injurious degree when the capillary
circulation is weak and sluggoish, whilst on the other hand the
injurious effect of cold is lessened or prevented by a vigorous
state of the capillary circulation and healthy concition of the
blood.  It is evident,, therefore, that the poorer classes are
peculiarly liable to the injurious effects of cold, and require in
sickness a higher and more uniform degree of heat, than strong,
well-fed individuals.
However, huts and wooden buildings may have served a use



Afonthly Extremes of Temperature in Baltimore, Maryland, during a period of 12 years,
1841-1852.
January.  February.   March.     April.      May.      June.      July.     August.   Sept'ber.   October.   Nov'ber.   Dec'ber.
Y e a r.   _ _ _    _  _  _  _  _  _     _  _   _  _  _  _     _  _  _  _  _  _      _   _      _  _  _  _  _  _     _
Mlax. Min.  Max. Min. Max. Min. Max. iMin. Max. Thin. Max. Mlin  Max. Mi   Max.. Max. Mn. Max. Thu. Max. Mm. Max. Thu.
lFahb.
H-l     1841    50"  0   64    5   7019    66  30   82                34   94    59   95 62    84   65   88  55   67  25   6722    5515
0       18       5716   66  13   76  24  8032   78                   42I85   47   92  62   86  53   90           35   76  34   58   15   4910
r/L    ~1843    6 0  1 0   51   10   53   63   72   26   78  45   85   52   92   65   88  68   88  43, 73  32   64   25   50   17
i:      1814    48    5   55    6   63  25    78           28   83   52   87    50   94   55 89    55   85      42   6938    64   24   49   19
1845    56  20   61 13    7h i24   80             27.84839   94  45   97  55915785    43  79   276 3 19  42                         9
1846    63  14   57   87316    82  33   88  40   89  52  95   55   93   58   91   45  85   30   69 20  5 6   20
1847    54   10   5218 64 20    841  26   89   46 I9752    9858    94   57   94                         51   81  32   7816    60613
1848  59 1 2  52 24  7415'8 82 35 9 3 45  995097 60 95 6092 42 81  40 6 7 26  71 t26
1849    56    6   46  1 1    72  26   78  28   87    44 10055    93   59   89   60   89  51   74  42   76  34   5516
1850    65  1 2    64   13   70  27  72    32   81  48  9 2, 52    89  68    89   62   82   52   70  46  61   36   56  26
1851    50   15   52   1    73   33   69  40   85   43 I 90  52   92   63   90  53   93   54   80  34   65  30   56    7
1852    50  -5   58  15    70 22 2 69  32   83  42   94   50   96  63   91  57   95   46 1 8636  62 28   6025
_                                                                                              _
l~l-_____________                                                                            ____        ____    ______   ____




JOHNS HOPKINS' HOSPITAL.               121
ful purpose during periods of excitement and war, in the treatment of the sick of armies, who as a general rule have been well
nourished, well clad, and in the vigor of manhood and in robust
health, at the time of the attack of disease, and the supernation of wounds, they are not adapted to the treatment of the
destitute sick of large cities.
One of the first requisites in the treatment of the sick poor, in
permanent hospitals, is the power of controlling the temperature
of the wards and maintaining a uniform and sufficiently warm
temperature during the severe cold of winter and spring.
The temperature of each ward may be regulated to a certain
extent by open fire-places, and by this means also efficient ventilation is promoted; but the temperature can only be regulated
with efficiency by a central heating apparatus, attached to each
Hospital Pavilion, or located so as to supply the entire Hospital.
Tie degree of wcarwnth s7ho0cd vary in accordance witlh the
ayge and condition acnd the class of diseases treated in tghe dcifferent woards.
It is well established, that the lowering of the external temperature, especially when rapid, acts injuriously upon the very
young and old; and that both infants and old persons require
mnuch artificial warmth, in addition to warm clothing and nutritious food. On the other hand, the degree of temperature of the
house does not appear to be so material to well-fed and wellclothed men in a state of health.
While for new-born children and old people a temperature
of froml 65~ to 735 F. may be necessary: on the other hand, for
well-fed and well-clothed adults, any temperature over 48~ up to
60~ may be comfortable.
For sick persons, it appears to be generally held, that the air
of the sick-room or hospital should be about 60~ Fahr.; but no
arbitrary rule of this character should be enforced in the conduct of a large hospital, in which a vast number of different
diseases in different stages are received.  One advantage of
gathering certain diseases in certain specific wards, is that we are
thereby enabled to regulate with greater accuracy the temperature inr accordance with the nature of the diseased states.
fMuch has yet to be accomplished in the investigation of the
influence of the external temperature on the progress and results
of disease.




12                JOINES.-PLANS FOR THIE
In acute febrile diseases and in the active stages of pneumonia,
and even in some cases of phthisis, a temperature of air as low
as 40~ to 55~, is not only well borne, but even appears to be beneficial; on the other hand, spasmodic affections of the larynx and
bronchial tubes, and chronic diseases of the heart and kidneys,
attended with pulmonary congestion and difficult respiration,
require a certain degree of both warmth and moisture.
In convalescence from  fever and other acute diseases, the
forces having been reduced by the active chemical changes and
rapid metamorphosis of the blood and tissues and organs, sudden
changes of temperature, and especially cold, act injuriously.
The rule, therefore, established by the results of the observations in both Civil and Military Hospitals, that convalescents
fron fever and acute diseases must be kejpt warm, should be
rigidly enforced.
A well-constructed hospital, therefore, should have wards
of different tem peratures, and the proper regculation qf the heat
sh7ould be considerecd as equally iimportant with the regular
angd abundant suppZly of light, fr'esh air, pzure water, and whvolesomnefool and efficient remedies.
The plan of ventilation proposed by Dr. Edmund A. Parkes,
to which we have already referred, viz., heating fresh air under
each bed, by hot-water pipes (the passage of hot water through
certain of which can be stopped, if desired), offers the means of
giving a certain temperature to a bed even in a large ward, or in
a small ward, of bringing the whole air in the ward to any desired
temperature.
By supplying each ward with two large, well-constructed, open
fire-places, we obtain the advantages of radiant heat, which, so
far from adding any impurity to the air, promotes wholesome
and efficient ventilation. But from the limited amount of heat
which can thus be supplied to large wards, other measures, as
those of conduction and convection, must also be employed; it
will be found that the open air fire-places will add greatly to the
cheerfulness and comfort of the patients in cold weather.
The radiating grates should be constructed upon the rules indicated by Desaguliers, and applied by Count Rumford:
The width of the back of the grate should be one-third the
width of the hearth recess; the sides should slope out to the
front of the recess; the depth of the grate from before backwards




JOHNS HOPKINS'  HOSPITAL.               123
should be made equal to the width of the back. The sides and
back should be made of non-conducting material; the chimney
throat should be constructed so as to lessen the draught, and
ensure more complete combustion. The grate should be brought
as far forward as possible, but still under the throat.
Of the various means of heatincg, water appears to be the best,
as it is more under control; and in the low-pressure system, in
which the water is not heated above 200~ F., and in which there
is a central boiler, from which the water circulates through the
pipes and returns again, outlets being provided at the highest
points for the exit of the air, the danger of explosion is avoided,
and the supply of heat is mluch more regular.
Steam furnishes an equally efficient supply of heat, but it is
more expensive, less under control, subject to greater variations,
and when water at high temperatures, rangying from 250~ to 310~
F., is employed, the pipes are subjected to great pressure, and
destructive explosions may occur.
If the low-pressure system is employed, with water at 200~
Fahr., the relation of the tubing to the capacity of the ward
should be carefully calculated.
According to Hood, if the pipes be four inches in diameter,
and the water be at 200~, then divide the cubic contents of the
room by 200, and the quotient will be the number of feet of
pipe, in length, to keep the room at 55~ F., when the external
air is 32~ F.
The plan proposed by Deosaguliers, one hundred and forty
years ago, may be applied to the open fire-places in each ward;
viz., to have an air chamber round the back and sides of the radiating grate, and to pass the external air through it into the
room, thus securing the passage of a considerable quantity of,gently warmed air into the ward, and effecting a great economy
of heat.
The Meissner stove of Germany acts upon this principle, but
it is without the open, cheerful fire, alnd on this account is inferior
to the open grates.
L ISINFECTION.
If the floors, sides, roof and walls of the wards be constructed
in the manner which we have advocated, and covered with glazed




124               JONES. —PLANS FOR THE
tiles or slabs, it is impossible that they should ever absorb or
retain organic poisons and impurities.
When the wards are periodically evacuated, not only the floors,
but the windows, walls, roof and furniture, should be well
washed and cleaned, and cleansed with a solution of carbolic
acid.
The fumes arising from burning sulphur and charcoal (mixed),
as well as from chlorine gas, generated either from black oxid e
of manganese and hydrochloric acid, or from black oxide of manganese, common salt and sulphuric acid, and also a solution of
carbolic acid, injected into the confined space, in the form of
steam or spray, appear to be the most efficient means of disinfecting vacant wards at stated intervals.
Carbolic acid alone should not be relied on, to the exclusion of
such destructive agents as sulphurous acid and chlorine gas; for
the first agent, whilst destroying animal and vegetable life, and
arresting putrefaction, may at the same time preserve the organic materials, which may, after a certain time after the carbolic
acid has been dissipated, again enter into putrefaction.
As the organic matters exhaled by the lungs and skin tend
to form a coating, in the form of dust or mould, upon the furniture and walls of inhabited rooms, careful cleansing at stated
intervals is important; and furniture after being cleansed may
be rendered practically new by a coat of varnish, which is itself
a preservative and disinfectant in virtue of the turpentine, shellac
and resin which it contains.
The vapors arising from ordinary tar, obtained from the pitch
pine, may be daily employed in the wards with benefit.
A heated mass of iron is plunged into a metallic vessel containing the tar, and the smoke thus generated is allowed to ascend, under and around each bed.
I have found by repeated experiment in those Civil and Military
Hospitals with which I have been connected, that the volatile
matters, and finely divided matters and carbon, thus arising from
tar, not only do not irritate the lungs, but may, when judiciously
applied, benefit certain diseased states of the pulmonary apparatus.  Any extensive disinfection of a ward by chlorine, sulphurous acid, or carbolic acid, whilst it is occupied by patients,
is manifestly impossible.
Tar, with its results of distillation, is a complex product;




JOHNIIS HOPKINS' HOSPITAL.              12.5
wood tar gives out creosote, and coal tar gives out carbolic acid
and cresylic acid. These substances differ in composition, but
their actions are very similar.
Carbolic acid has acid properties, but its composition is analogous to that of the alcohols. A saturated solution destroys
plants rapidly; coagulates blood; is hurtful if allowed to touch
the eyes; leeches and fishes die in it without convulsions;
animals dry up without decomposing; weak solutions of gelatine are not made turbid by it, but strong are; albumen it
coagulates to a mass, soluble in excess of albumen.
According to Mr. Crookes, it does not affect the oxidation or
action of inorganic substances; meat steeped in a one per cent.
solution of carbolic acid and then dried, preserved a fresh odor.
Similar results were obtained with skin, gut, size, glue and albumen; a few drops added to half a pint of fermented sugar and
yeast stopped the action; the solution of one per cent. stopped
the activity of yeast, but produced no change in its appearance;
caterpillars, gnats, cheese mites, fish and infusoria were destroyed.
There is neither life nor decay without motion. Tar acids
arrest that motion which takes place in decay; they therefore
antisept, and are antiseptic; as soon as the decay ceases, the
putrid gases cease to rise, and they are therefore disinfectant.
Pettenkofer finds that although carbolic acid arrests fermentation, the ferment preserves its power, and acts when the carbolic
acid is gone; if this be true, the disinfectant must be used continuosly, and the ipure matter must be cleared away continuouasly.
It is difficult to use enough of any disinfectant to destroy
organic poisons, when human life must be preserved; but the
tar acids render fermenting matter inert, and this is the great
object to be first attained in hospitals.
Creosote is found in the products of distillation of wood, and
of benzoine resin used in fumigation; and the tar-barrels burnt
in the time of epidemics, from the earliest date, give out this
body, and would give out more, if the flames were suppressed,
and distillation only allowed, as in the method proposed for the
fumigation of the hospital wards with tar smoke.
Gmelin says that water, impregnated with 1 part of creosote in
10,000, smells of smoke. Its most wonderful property is its pre



126                JONES.-PLANS FOR THIE
servation of flesh: it stops flow of blood, and kills and preserves
beasts, fishes, insects, infusoria, fungi, and plants.  Liebig says
that it was used long before Reichenbach discovered it. As
aqua Binelli, kept a secret in Italy. The atua emnjpyreuma tica of
Silesia contained some of it, made by distilling crude vinegar
with lime.
Speaking of the great value of tar as a disinfectant, Dr. Robert
Anlgus Smith says:
"The world has admired this substance without knowing its
existence, and sought it in every corner, using various names to
express it, wrapping it in bundles to carry around them, burning
it in pastiles for fumigation, and sometimes in public in great
bonfires.  Savages use petroleum  for their wounds and their
cattle, and the most civilized of old times kept in products of tar
the dead that they desired to preserve to a joyful rising. Bishop
Berkeley tells us that it was usecd as tar-water in America, the tar
being merely stirred up with water, and the water drunk, a glass
at a time. He himself had tried it in many diseases, and tells us
of small-pox, erysipelas, skin diseases, and ulcers being cured
by it; quotes the pitchingr of wines by the Romans as a proof of
its value, and Jonstonus, in his Dendrogracphia, as saying that it
is wholesome to walk in groves of pine-trees which impregnate the
air with balsamic particles. The learned writer then goes on to
say, that although he may be ridiculed, he suspects tar-water is a
panacea; and as the old philosopher cried aloud from the housetops to his fellow-citizens,'Ecduceate your childre)n,' "so I confess, if I had situation high enough, and a voice loud enough, I
would cry out to all the valetudinarians upon earth, drink tarwater."  What, then, is the wonderful agent, after which men
have hunted, in tar-water  Like all such hopes of men, it bec:olnes less when it is found, but it is still of great value.  It is
not one thing only, there are many things to be found. We
have the tar-acids and turpentine, benzole, aniline, acetic acid,
and imany other things from tar, and each has its place."
Absolute cleanliness, the immediate removal of all excretions,
offensive matters, and soiled clothing and bedding, together with
free ventilation, are the great measures for the preservation of
the purity of the atmosphere, and the prevention of any injurio0us effects arising from the exhalations from  the sick themselves.




JOHNS HIOPKINSS' IOSPITAL.              127
The water-closets and urinals should  b3 cleansed at least once
a day, with a solution of sulphate of iron and carbolic acid, and
when such a disease as cholera is prevailing, the miixture of carbolic acid and sulphate of iron should be freely used, and all
the dejections from the bowels should be received into vessel-:
containing sufficient quantities of the solution.
\Then a cheap process for the manufacture of the peroxide
of hydrogen has been devised, it will without doubt prove to be
one of the most valuable, pleasant and innocuous disinfectants.
W~hen the peroxide of hydrogen, which resembles water, is
poured on the filthiest substance, the smell of putrefaction ceases,
and in many cases is replaced by a fragrant perfume.; it has
given up its oxygen, and only pure water remains.
If water could be compelled to take up 100 volumes of oxygen
in combination, it is probable that no impurity could resist it;
but the great objection to the peroxide of hydrogen for hospital
use is its cost.
It is well known that Air is one of the greatest disinfectanits
but it should be remembered that mere filling of a room with
fresh air is not sufficient to render it pure: it seems necessary
that air should be filled and refilled repeatedly. This is explained upon the supposition that a very small portion of the
oxygen of the atmosphere is in that active state which favors the
destruction of the organic matters adhering to the walls and
furniture. When, therefore, wards are periodically evacuated,
all the windows and doors should be left open and a sufficient
time should be allowed for the frequent and comrplete renewal
of the air of the ward.
TlVcater, next to air, is the greatest disinfectant, and the supplies for cleaning and cleansing the Hospital, the patients, the
clothing and the water-closets should be unlimited.
In disinfecting the water-closets and urinals, one pound of
sulphate of iron, dissolved in half a gallon of the solution of
crude carbolic acid, as it is most generally obtained from the
gas-works2 should be employed daily in each ward.
DISTRIBUTION OF PATIENTS AND CLASSIFICATION OF DISEASES
AND ACCID)ENTS,
In the Plan of Hospital Construction which we propose,
tihe Surgical Wards should occupy the central portions of the




128               JONES.-PLANS FOR THE
Hospital, in order to secure the most efficient treatment and
attendance and the most prompt surgical aid.
On the other hand, the fevers and other so-called contagious diseases, as erysipelas, hospital gangrene, pyTemia and puerperal
fever, should be treated in the wards removed from the central
portion of the Hospital.
The observations on the relations of temperature to certain
diseases have shown the propriety of grouping together certain
diseases. It will be admitted that venereal diseases should be
isolated as far as possible, and that separate wards should be
devoted to children. By placing the male wards on one side and
the female on the other of the executive central building, the
efficiency of the service as well as the discipline of the Hospital
will be promoted.
Special attention should be devoted to the nonmenclatnre of
diseases, in the wards and in the general records and reports of
the Hospital.
The R-esident Surgeon, Resident Assistant Surgeon, and the
Attending Physicians and Surgeons, should be required to
record the diseases, wounds, etc., in the classification and provisional nomenclature of the Royal College of Physicians of
London.
The Annual Reports of the Hospital, as far as they relate to
the nature of diseases and deaths, should be drawn up in accordance with the classification of the nomenclature of diseases
prepared by a Joint Committee appointed by the Royal College
of Physicians of London, England.
The importance of a uniform  system of the registration and
classification of diseases is best shown by the following quotation from the Preface to the Original English Edition:
"For perfecting the statistical registration of diseases, with a
view to the discovery of statistical truths concerning their history, nature and phenomena, the want of a generally recognized
nonenclature of disease has long been felt as an indispensable
condition.  The advantages accruing from accurate statistics of
disease are likely to be the greater and the surer, in proportion
as the field of investigation is the wider. The statistics of a
single town may be instructive; but more instruction will be
obtained from the compared statistics of various and many
towns. This is alike true of different districts of the same coun



JOHNS HOPKINS' HOSPITAL.                129
try and of different countries and climates; and the most instructive sanitary statistics would be those which relate to the
whole of the inhabited portions of the globe.
"For the registration of such statistical facts, it is clearly
requisite that there should be a uniform nomenclature of diseases
coextensive with the area of investigation, and taking  the
largest area, the universal globe, the nomenclature would need
to be one that can be understood and used by the educated
people of all nations.
"Among the great ends of such a uniform nomenclature must
be reckoned that of fixing definitely, for all places, the things
about which medical observation is exercised, and of forming   a
steady basis upon which medical experience may be safely
built.
"Another main use of the statistical registration of diseases,
on a wide scale, is that it must tend to throw light upon the
causes of disease, many of which causes, when duly recognized,
may be capable of prevention, removal, or diminution.
" When a general and uniform  nomenclat ure of diseases has
once been carefully framed, when we are sure that medical
observation is occupying itself everywhere with the self-same
diseases, the value of statistical tables becomes very high, as representing the course of events in disease under various circumstances of time, place, season, climate, manners and customs,
age, sex, race, and treatment....
"The Committee appointed by the Royal College of Physicians
of London have prepared a nomenclature, suitable to Englanc
and to all countries where the English language is in coimmorn use.
For each name they have supplied the corresponding' Latin term,
which is the language of ancient science, and probably the fittest
languaoe for a nomenclature common to all the world; and also
the equivalent term in the three modern languages which are
the richest in medical learning and literature-the French, the
German and the Italian languages; and in this way they hope
to have laid the foundation for a nomenclature of diseases in any
lainguage extant on the earth."
In America this nomenclature was adopted in the classification of diseases; in the statistics of mortality of the ninth census
of the United States; it has been practically adopted by the
Medical Department of the United States Army, and it has been




130               JONES.-PLANS FOR THE
officially adopted by the United States Marine Hospital Service;
it has been endorsed by the profession through the action of the
American Medical Association; and its provisional adoption
~was formally recommended by the American Public Health Association in 1873.
The office of the Clerk, and of the Resident Surgeon and Ptesident Assistant Surgeon, as well as each ward, should be furnished
with printed copies of this system of nomenclature.
As this work has been recently published, for the use of the
medical officers of the United States Marine Hospital Service, by
Dr. John M. Woodworth, supervising surgeon, it is probable that
the necessary number of copies could be readily obtained from
the bureau of the United States Marine Hospital Service.
HOSPITAL ADMINISTRATION.
PRESIDENT AND BOARD OF TRUSTEES.
The entire organization and conduct of the Hospital shall be
in accordance with the rules and regulations established and
promulgated by the Board of Trustees, through their executive
head, the President.
All officers and employes of the Hospital shall be responsible
for the proper discharge of duty to the Board of Trustees, through
the President.
All irregularities, all grievances, and all violations of law and
order, or discipline, and all subjects of disagreement among the
medical officers, if such should arise, must be referred to the
President for arbitration and settlement.
All estimates for expenditures in the different departments
must be submitted to the President and Trustees, for their final
adoption and execution.
In all important questions of administration and discipline, the
final appeal must be to the Board of Trustees.
The President and Trustees shall have the power of suspending
and discharging any officer or employe, for neglect of duty or
improper conduct injurious to the interests of the Hospital.




JOHNS IIOPKINS' HOSPITAL.              131
All reports from  the various officers must be made to the
Board of Trustees, through the President.
It shall be the duty of the President to make monthly reports
to the Board of Trustees, setting forth all matters of importance
relating to the financial, hygienic, and medical condition of the
Hospital.
The President shall also present an annual report to the Board
of Trustees, embodying the reports of the Treasurer, Purveyor,
Secretary, Resident Surgeon, Resident Assistant Surgeon, and Attending Physicians and Surgeons, with the classified surgical and
medical and mortuary statistics of the individual wards, and of
the entire Hospital, and the meteorological register, with all
matters and cases of interest relating to hygiene, medicine and
surgery.  If such reports should be published, an exchange
might be established, with similar reports from all the leading
hospitals of the world, and thus an important measure might
be inaugurated for the extension and perfection of the Library,
and the gradual concentration and preservation of the most practical and important contributions to the hygiene and conduct of
hospitals.
The President shall cause a copy of the most important rules,
governing the officers and employes, to be framed and suspended
in each ward, in the Library, Museum and Dispensatory, and in
the offices of the President, Treasurer, P sident Surgeon, Resident
Assistant Surgeon, and Clerk.
Success in the management of a large hospital will manifestly
depend upon a just distribution of labor, and the absolute subordination of officers, employes and patients to just law, the
ultimate end of which shall be the efficient relief of human sufferm
ing, and the speedy cure of disease.
TREASURER.
The Treasurer shall keep careful and accurate accounts of all
the moneys, property claims and revenues, and secure and preserve the same for the benefit of the Hospital.
The Treasurer shall make all necessary payments authorized
by the President and Board of Trustees, and not otherwise.
He shall preserve vouchers for all moneys expended.
The Treasurer shall make full monthly and yearly returns of




132                JONES.-PLANS FOR THE
the receipts and expenditures, to the President and Board of
Trustees.
The reports of the Treasurer shall contain a minute account
of all the individual items of expenditure, including the moneys
expended for drugs, chemicals, surgical instruments, supplies
and fixtures of all kinds, and salaries of officers and employ6s.
The books of the Treasurer shall be at all times open to the
examination and inspection of the President and Board of
Trustees.
It is desirable that the Treasurer should be distinguished for
financial ability, thorough business training and habits, and irreproachable integrity.
PURVEYOR.
It shall be the duty of the Purveyor to make all the purchases
of drugs, medicines, instruments, chemicals, disinfectants, wines,
liquors, and hospital supplies of me~at, flour, sugar, vegetables,
clothes, bedding, etc., under the direction and in accordance with
the orders of the President and Board of Trustees.
The Purveyor shall present monthly and annual reports to
the Trustees of all the supplies consumed, and those remaining
on hand.
The Purveyor shall exercise due diligence in gathering information as to the market price, as well as to the quality of all
articles of food or clothing required for the use of the Hospital.
The mental and moral requirements of the Purveyor should
be similar to those of the Treasurer.
SECRETARY.
The Secretary shall keep in substantial volumes duplicate
copies of the records and transactions of the Board of Trustees.
One copy shall remain permanently in the office of the Secretary,
and the other be deposited in the Library so as to be at all times
accessible to the examination of the President and Trustees.
Tihe Secretary shall, under the direction of the President, conduct the correspondence of the Board of Trustees. He shall
also, under the direction of the President, superintend any publications ordered by the Trustees.




JOHNS HOPKINS' HOSPITAL.                133
The preservation, classification and consolidation of all official
records and correspondence of the Trustees and Hospital shall
devolve upon the Secretary.
It shall be his duty carefully to preserve at least fifty copies of
all published documents, over and above those distributed to the
officers of the Hospital, and to other institutions.  At least five
copies of each published report shall be annually bound in substantial Russia binding, and deposited in the Hospital Library,
under the care of the Librarian.
It is unfortunately true that the statistics of many large hospitals are not accessible, on account of the neglect to file and preserve the annual records.
CLERK.
The Clerk shall record the name, occupation, age, nativity and
disease of each patient entered into the wards of the Hospital;
also of all patients prescribed for in the "out-door" dispensatory.
The Clerk shall preserve the records of each ward separately,
in books devoted to this purpose.  In these books shall be
entered all facts likely to be of importance to the friends of
patients, as well as the causes of death.
The Clerk shall prepare monthly and annual reports, containing a classified record. of the diseases and deaths, and such other
information relating to the different branches of the service, as
the President and Board of Trustees may direct.
In the discharge of the preceding duties the Clerk shall be
entitled, if necessary, to the aid of two assistant clerks, to be
appointed by the Board of Trustees.
RESIDENT SURGEON.
The general medical and surgical management, the classification and distribution of patients, and the general direction of the
hygiene and nursing of the Hospital shall be entrusted to the
Resident Surgeon.
The entire time and attention of the Resident Surgeon shall be
devoted to the discharge of his official duties; and he shall be
directly responsible for his acts to the President and Board




134               JONES.-PLANS FOR THIE
of Trustees. He must reside pezmianently in the central executive building, and act upon all emergencies requiring medical or
surgical aid, in the absence of the Visiting Physicians and Surgeons. Together with the Assistant Resident Surgeon, he shall
have charge of the pay wards, and be responsible for their proper
conduct.
AWhen a consultation is deemed necessary in any medical or
surgical case, the Resident Surgeon shall constitute one of the
Consulting Physicians or Surgeons.
The general managemient of the Dispensatory, both Hospital
and "Out-door," and of the Resident Students, Nurses, and
employes, shall devolve upon the Resident Surgeon.
The Resident Students land Nurses shall report directly to the
Resident Surgeon, and receive their instructions from him.
All cases of difference between the Resident Students shall be
referred to the Resident Surgeon, and his decision shall be subject only to the approval of the President.
The Resident Surgeon shall make monthly and annual reports
to the President and Board of Trustees, which shall include the
reports of the Assistant Surgeon and Visiting Physicians and
Surgeons, and embrace the medical and surgical statistics of
each ward, and all matters relating to the hygiene, and medical
and surgical history of the Hospital.
ASSISTANT RESIDENT SURGEON.
The Assistant Resident Surgeon sharl aid the Resident Surgeon in the discharge of his official duties, and shall perform
sucnh labors as may be assigned to him in the general medical
and surgical management of the Hospital.
In the absence of the Resident Surgeon, the Assistant Surgeon
shall be clothed with his authority and act in his place.
He shall reside permanently in the central executive building,
and be ready to meet every emergency which may arise amongst
the medical and surgical patients.
It shall be the duty of the Assistant Resident Surgeon to
inspect each ward at least once a day, and report their condition
to the Res-ident Surgeon, whose inspections shall be at such times
as may be necessary to the proper regulation of the Hospital.




JOHNS IIOPKINS' tIOSPITAL.             135
In the temporary absence of any Visiting Physician or Surgeon
the PR sicdent Surgeon and Assistant Surgeon shall provide for
the medical attendance of the patients.
The President and Board of Trustees shall elect to the offices
of Resident Surgeon and Assistant Surgeon men  eminent for
both surgical and  medical attainments and administrative
ability.
The successful conduct of the Hospital will depend to a large
extent upon the admzinistrative acbility of the ]Resident Surgeon.
As the Resident Surgeon and Assistant Surgeon should be
required to reside permanently in the Hospital, and to be ready
to meet all emergencies, by daty or by night, with the assistance
of the Resident Students, these officers should be either unmarried, or if married, without the encumbrance of a family of
young children.
RESIDENT STUDENTS.
N'ot less than fourteen Resident Students shall be appointed
by the Board of Trustees, to serve for a period of not less than
twoo years.
The applicant for the position of Resident Hospital Student
must be twenty-one years of age, and must have attended two
full coueorses of medical lectures in a "first-class," reputable,
recognized, regular Medical College or University.
The position of Resident Hospital Student shall not be confined to the natives of Maryland, but shall be open alike to all
the States and Territories of the Union, and the appointments
shall depend solely upon medical and surgical acquirenments and
moral worth.
The applicants for the position of Resident Hospital Student
shall be subjected to a rigid written examination, embracing
Chemistry, Pharmacy, Materia  Medica, Therapeutics, Anatomy,
Surgery and Obstetrics.
The questions relating to the respective departments must be
printed, and all the answers written out by the applicants, in a
room in which there can be no access to printed books nor any
communication with each other.
The Resident Students shall be assigned to wards; two wards
or one pavilion being assigned to each student.




136               JONES.-PLANS FOR THE
The remaining four students shall be assigned as follows:- 
One student to the Dead-House, for the performance of postmortem examinations; ohe student to the Dispensatory, to act
as assistant to the Druggist; one student to the Chemical and
Pathological Laboratory, to act as an assistant to the Chemist,
Pathologist and Microscopist; and one student to the Museum,
to act as an assistant to the Curator of the Museum, in the preparation and preservation of anatomical and pathological specimens.
Rotation shall be established in these different positions, so
that each Resident Student shall serve at least six months in
each position, and thus the great advantages afforded for the
acquisition of a thorough practical knowledge of the science and
art of medicine be shared equally by all the Resident Students.
The entire time and attention of the Resident Students shall
be directed to the discharge of their duties, except such intervals
as may -be necessary for meals and recreation.
They shall sleep in the building and be at all times ready to
assist the Resident and Assistant Surgeon, and the Visiting Physicians and Surgeons, in the discharge of their medical and
surgical duties.
The Resident Surgeon shall assign the Resident Students to
the different Wards and to the different Visiting Surgeons and
Physicians, in regular rotation.
Each Resident Student shall accompany the Physician or Surgeon to whom he may be assigned in his morning and evening
visits, and shall write down in a book preserved in each ward all
the directions with reference to treatment, Tmdicines and diet,
and see that the medical and surgical treatment is properly carried out by the Nurses.
They shall, in accordance with and under the direction of the
Physicians and Surgeons, perform  all the minor operations, as
bleeding, cupping, blistering,  leeching, bandaging, and the
dressing of wounds, stumps, fractures, etc.
The Resident Students shall keep in each ward an accurate
register of the cases, in which the following particulars shall be
entered:




JOHNS HOPKINS' HOSPITAL              137
Name of patient.
Age.
Nativity.
Occupation.
Race.
Sex.
Number of ward.
Number of bed.
Name of Attending Physician or Surgeon.
Nature of disease or injury.
Prognosis.
Previous diseases.
Date of present disease or injury.
Supervening diseases.
Result, death or discharge.
Date of death.
Date of discharge.
Condition at date of discharge or transference.
Results of post-mortem examination.
Treatment.
General remarks.
All important cases, which may be indicated by the Attending
Physician and Surgeon, must be carefully reported by the Resident Students.
Such reports should embrace the following records:
Pulse........ morning and evening.
Respiration..  do.       do.
Temperature.  do.        do.
Symptoms...   do.        do.
Treatment...  do.        do.
Diet.........  do.      do.
Results of treatment or operation.
Observations upon urinary and other excretions, and upon the
blood. Record of post-mortem examination.
Each ward should contain two or more large case-books, upon
which the Resident Students should be required to enter all cases
and matters of medical and surgical importance indicated by
the Attending Physician or Surgeon.




138               JONES.-PLANS FOR THE
No student shall be permitted to remain in the Hospital for a
longer period than three years, nor for a shorter period than two
years.
The Resident Students shall be under the immediate control
and direction of the Resident Surgeon, who shall assign them to
their respective positions and wards, and instruct them in the
perf-.rmance of their duties.  They shall report all cases of
neglect or insubordination, on the part of the nurses, employes
or patients, to the Resident Surgeon.
The Resident Students shall not be allowed to leave the
Hospital, except at such times as may be specified by the Resident
Surgeon, and they shall be ready at all times to respond to the
calls of the Resident Surgeon, Resident Assistant Surgeon, and
Visiting Physicians and Surgeons.
No Resident Student shall prescribe for any patient in the Hospital; neither shall it be lawful for the Resident Students to prescribe for out-door patients, nor to attend any cases in "_private
practice," out of the Hospital.
Attention to cases out of the Hospital will surely tend to demoralize the Resident Students, and, sooner or later, lead to the
neglect of official duty.
The Resident Students shall be furnished with sleeping apartment in the central administrative building, as indicated in the
plan; and they shall also be furnished with board, fuel, light,
and washing, by the Hospital, free of expense.
Upon the completion of their term of service, each student shall
receive a diploma, setting forth in general terms the nature and
period of service, and advantages enjoyed, and bearing the broad
seal of the Hospital, and the signatures of the President, Trustees,
Resident Surgeon, Assistant Surgeon, and Visiting Physicians
and Surgeons.
The position of Resident Hospital Student is one of honor and
trust, and will furnish superior advantages for the acquisition
of thorough knowledge in the art and practice of Medicine in all
its branches.
DRUGGIST AND ASSISTANT DRUGGIST.
The Dispensatory shall be in charge of a thoroughly educated
and accomplished Druggist, — a graduate of a regularly chartered
School of Pharmacy.




JOHNS IIOPKINS' hIOSPITAL.            139
The requirements shall be the same for the Assistant Druggcrist.
Applicants for these positions should, as in the case of the
Resident Hospital Students, be subjected to a rigid written examination. One of the Resident Students shall act as an Assistant
to the Drugg'ist in the preparation of medicines and compounding of prescr'iptions.
All prescriptions for the Hospital, as well as for "out-door
patients," shall be filled at the Dispensatory. The prescriptions
froml the various wards of the Hospital shall be delivered to the
Druggist, by the nurses or appointees charged with this duty, at
an hour each day not later than 10 A..r. During the evening
visit, the Physicians and Surgeons shall prescribe only those
remediies which are actually needed during the night.
The Druggist shall as far as possible manufacture all the
standard preparations in the laboratory, and he shall also keep
on hand, ready prepared, such mixtures and compounds as may
be agreed upon by the Resident Surgeon and Attending Physicians and Surgeons; and the formulae of these standcard house
prepc)arations shall be carefully preserved in the Dispensatory
and in each pavilion or ward.
The Dispensatory shall be under the immediate direction and
control of the Resident Surgeon.
The Drugg(ist shall make his requisitions for drugs, chemicals
and disinfectants through the Resident Surgeon, upon the Purveyor, subject to the approval of the President and Board of
Trustees.
The Druggist shall preserve an account of the drugs used by
each Ward; and he shall present to the President and Trustees
weekly and monthly and annual reports of the amounts consumed and of the stock on hand.
PATHOLOGICAL CHE[MIST AND MICROSCOPIST.
A competent Chemist and Microscopist and Histologist, who
has devoted special attention to Orranic Chemistry in its application to Physiology, Pathology ancd Toxicology, shall be placed
in charge of the Chemical and Pathological Laboratory.
It shall be the duty of the Chemist to examine morbid products, secretions and excretions submitted to him by the Medical
Officers of the Hospital, and to report the results in writing.




140               JONES.-PLATNS FOR TIE
He shall also keep a daily record of the state of the weather:
changes of temperature, barometric pressure and moisture, direction and force of the wind, variations of ozone and of electricity,
and rainfall; and he shall be provided with the necessary apparatus. He shall make monthly and annual reports to the Resident Surgeon, and through this officer to the President and
Trustees, of all chemical work of importance performed in the
Laboratory, for the elucidation of the chemistry and pathology
of disease.
He shall have as his assistant one of the Resident Students.
A limited number of students may be received into the Laboratory by the Chemist, upon such terms and for such length of
time as may be determined by the President, Resident Surgeon
and Chemist.
LIBRARIAN.
The Librarian shall be a graduate of a regular medical college or university, and shall be appointed by the President and
Trustees in consideration of his learning, ability and devotion to
the literature of the medical profession.
He shall have charge of the Library, and carefully preserve
the works, establish exchanges, and report from time to time to
the President those works which will be of the greatest value to
the Medical Officers and Resident Students in the discharge of
their duties.
The Library shall be kept open at such times and under such
regulations as the Board of Trustees may adopt.
It shall be unlawful for any book to be taken out of the
Library. But the Medical Officers of the Hospital and the Resident Students, as well as members of the medical profession
generally, shall have free access to the library, for purposes of
research and study.
CURATOR OF THE MIUSEUM.
The Curator of the Museum shall be a graduate of a medical college or university, and shall be selected by the Board
of Trustees in consideration of his proficiency in, and devo



JOHNS HOPKINS' HIOSPITAL.             141
tion to the studies of Physiology, Anatomy and Pathology.
It shall be his duty to inject, prepare and preserve all pathological specimens placed in his hands by the Mledical Officers. He
shall label all specimens, and classify the entire lMuseum, and
preserve accurate catalogues, with full descriptions, for the reference of the MAedical Officers and Students of the Hospital. The
Curator of the Museuml shall, when practicable, institute exchanges with similar institutions.
NURSES.
Twenty Head Female Nurses and Forty Assistant Female
Nurses (or in the ratio of one Head Female Nurse and two Assistant Female Nurses to each ward) shall be appointed by the
President of the Hospital.
The Assistant Female Nurses shall be under the direction and
instruction of the Head Female Nurses.
The Head Female Nurses shall occupy the rooms attached to
each ward, with a window commanding the entire ward; and the
Assistant Female Nurses may be quartered in the detached portions of the pavilion across the corridor, occupied by the messroom, lift and stairway. If the dimensions in the plan do not
allow of sufficient room, those buildings might readily be increased in length front 5 to 10 feet.
If possible, each Head Nvurse and her assistants shoutld be
permanently attached to a specific ward, and limited rigidly to
the disc7harge of specific ditties.
The rooms occupied by the Nurses should be comfortably and
pleasantly furnished.
The association of the Nurses in large dormitories is to be condemnedcl, as it tends to corrupt the good and to make the bad
worse.
In many cases the convalescent patients may be made available as assistant nutrses.
The administration of the diets and medicines, the making of
poultices, and the management of the ventilation and warming
of the ward, should be in charge of the Head Nurse, whose room
should be so situated as to command a view of the interior of
the ward, and also of the entrance.
The cleanliness of the ward, bed, be'ding and utensils of the




142               JONES.-PLANS FOR THE
patients, as well as their personal cleanliness, the fetching of
diets, the warming and ventilation of the wards, and the watching ill patients during the night, are to be attended to by the
Assistant Nurses, under the Head Nurse's superintendence ancd
superveillance, and she is to have power of reporting disobedience
on their part to the Resident Surgeon.
All provisions, food, poultices, dressings, medicines, clothing,
bedding, utensils, fuel, etc., should be as much as possible
brought into the wards or to the doorways by lifts, and nothing
should be fetched by the nurses; in order to enable the nurses to
do their duty more effectively, and also to obviate the inconvenience and demoralization consequent on the congregating together in numbers of the nurses, patients, and men servants.
Whilst the patients should be made as useful as possible,
consistently with their capacities inside the ward, they should
not be sent out upon missions of any character whatever; and
nothing in the way of food or drink or clothing should be
brought into the ward, nor any visitors allowed, without the
knowledge and approval of the Head Nurse.
There should be one Head Female Nurse to every 40 patients
(one ward), and one Assistant Female Nurse to every 20 patients
(two to each ward).
The proper place for the instruction of Nurses in the discharge
of their duties is in the ward and with the patients, and no
separate school for nurses appears to be needed.
If, however, the President and Board of Trustees should deem
special instruction necessary, the Resident Surgeon, and one or
more Attendant Physicians anlld Surgeons of the Hospital, might
instruct the nurses by lectures and practical demonstrations, at
regular appointed hours, in the Amphitheatre of the Hospital.
Such practical course of instruction should be accompanied by
examinations, to test the capacity of the nurses.
No Assistant Nurse should be kept on duty each day in a
ward more than twelve hours altogether.
Twelve hours each dclay is not too much for rest and recreation;
and if the health and strength of the nurses be not carefully husbanded, their efficiency will sooner or later be impaired.The nurses who sleep before and after a night watch should
be enabled to do so quietly.
A night ration should always be provided for night-watchers.




JOHNS HOPKINS' HOSPITA-L.              143
The Head Nurses should be responsible for the bedding, clothing and utensils of their respective wards.
All irregularities amongst the Nurses, Assistant Nurses and
patients must ba reported diractly to tthe Resident Surgeon, who
will at all times issue the necessary orders and instructions, to
the Head Nurses.
The wards must be cleaned and placed in order, and every
patient be required to be at his bed, before the morning and
evening visit of the Physicians and Surgeons.
The Head Nurse of each ward must accompany the Physician
or Surgeon-in-Charge in his morning and evening visits, and receive his orders.
Specific hours of rest and recreation for the nurses shall be
devised and promulgated by the Resident Surgeon.
The Head Nurses and Assistant Nurses shall wear such dresses
and distinctions as may be prescribed by the President.
ITNurses should be of not less than twenty-five nor of more than
sixty years of age, of strong, active habits and sound health, and
of established unblemished character.
W\Ve have advocated the employment of fenale and not male
nurses, without entering into any argument, but simply presenting the results of our experience.
Sir J. Ranald Martin, Examtziing fMe ical Of/ ier to the Seeretary of Statefor Inzdia in Counzcil, has well said:
"It should seem obvious enough that the virtues which in all
ages and all countries have ruled the domestic circle; that'she
who looketh well to the household, and eateth not the bread of
idleness;' that she whose'tongue is the law of kindness,'
should have a natural and a large share in the tending, of the sick
and maimed. To the natural care of the sick and wounded we
must add the natural care of the infant and the aged, along with
the household cares and the rearing and trainingo of children.
"Requirements of so extended and important a character,
capable of such infinite development, cannot be limited to the
household affairs of common life. They must be brought systeimatically in aid of the sick in hospital, for purposes of nursing
and of general administration.
"One of these ends, whether in private or public relation,
would appear to be thie care of the sick —an occupation for which
woman, whether taken from the instinctive tuitions of the sanc



144               JONES.-PLANS FOR TIHE
tuary of home, or from the trained service of the Hospital, possesses unequalled aptitudes and capabilities. Everywhere and
at all times the number of nurses to be employed in a hospital
must be regulated by the nature of the prevailing diseases,
whether epidemic, acute or chronic."
Miss Nightingale, who is one of the highest authorities in all
that relates to the conduct of hospitals, thinks that the woman
is superior in skill to the man in all of sanitary domestic economy,
and more particularly in cleanliness and tidiness. Sanitary civil
reformers will always tell us that they look to the woman to
carry out practically their hygienic reforms. She has a superior
aptitude in nursing the well, quite as much as in nursing the
sick.
CONDUCT OF PATIENTS.
The patients shall be governed by such rules and regulations
as may be devised and promulgated by the President and Resident Surgeon.
Regular hours shall be fixed for exercise and recreation in the
grounds of the Hospital.
CONVALESCENT PATIENTS.
If the Hospital be constructed in the manner indicated, with
elevated, well-ventilated and well-lighted pavilions, with verandas at the sides, oie or more wards may be devoted to convalescent patients, and a separate building will be unnecessary.
VISITING PHYSICIANS AND SURGEONS.
Not less than four surgeons, and not less than six physicians,
shall, in conjunction with the Resident Surgeon and Resident
Assistant Surgeon, constitute the Surgical and Medical Staff of
the Hospital.
The Visiting Surgeons and Physicians shall be elected by the
Board of Trustees, to whom their written applications and testimonials must be addressed, through the President.
The Visiting Surgeons and Physicians shall be selected in accordance with and in consideration of their known and well



JOHNS HOPKINS' HOSPITAL.                145
established ability and professional attainments, and enlarged
experience in the treatment of diseases and injuries, and in clinical teaching.
One or two wards (not exceeding two wards) shall be assigned
to each physician or surgeon, and the treatment shall be conducted in attendance with his direction.
The Visiting Physicians and Surgeons shall have nothing to do
with the administration of the Hospital, but their duties shall be
strictly confined to1st. The treatment of the sick and wounded.
2d. The clinical instruction of the Resident Hospital Students.
3d. The clinical instruction of the Students of the Medical Department of the University founded by the late Johns Hopkins,
of Baltimore.
The Attending Physicians and Surgeons shall visit their wards
at least twice during the twenty-four hours, and shall spend at
least four hours, each day, in the examination of and prescribing
for the patients, and in the impartation of clinical instruction to
the medical students, by the bed-side; viz.: from  9 A.rf. to 11
A.-Il., and from 5 P.ir. to 7 P.r.
They shall cause their prescriptions, as well as all directions
as to diet and treatment, to be written by the Resident Student
assigned to the wards by the Resident Surgeon, in a book specially devoted to this purpose. The Head Nurse and the Resident student shall be guided by these written directions; and it
shall not be lawful for the Resident Student to prescribe or in
any manner alter or add to the directions dictated by the Attending Surgeons and Physicians.
During at least six months of the year, the Visiting Physicians
and Surgeons shall lecture clinically to those medical students
who may be assigned to them  during the morning visit; and
they shall also, at such time as may be determined by the President and Board of Trustees, deliver lectures and perform operations before the entire medical class assembled in the Amphitheatre.
It shall be the duty of each Visiting Pllysicianl and Surgeon to
preserve careful records of all important cases and operations,
and also a record of all the cases, giving nature of diseases, results of treatment, and post-mortemn examinations, in their
respective wards.  And they shall, at such intervals as may




146               JONES.-PLANS FOR TIIE
be determined by the Board of Trustees, present a written report,
containing the medical and surgical statistics of the ward, together with all matters of importance relating to the science and
art of medicine, which may be illustrated by the cases under
their charge.
Each Visiting Physician and Surgeon shall have the privilege
of appointing a medical assistant, who shall act as his chief of
clinic, and aid in the clinical instruction of the students.
The Attending Physicians and Surgeons should receive liberal
and just co;zmpensationfor their services, and should be held to
a rigidc accountability for the discharge of their official duties.
If from any cause a physician or surgeon should be absent
from his wards, the Resident Surgeon shall appoint some one to
fill his place temporarily.
OUT-DOOR PATIENTS, AND DISPENSATORY FOR OUT-DOOR
PATIEiNTS.
The out-door patients shall be prescribed for in the central administrative building, alternately by the medical officers of the
Hospital-, two of whom shall perform this duty in rotation for
the period of two months. The hours for prescribing shall be
fixed so as not to conflict with those assigned to ward practice
and clinical instruction; viz.: from 11 A.Mt. to 1 P.Ar.
A careful register of the name, age, sex, occupation, nativity,
residence, and disease of each patient, shall ba. kept. The prescriptions should be filled at the general Hospital Dispensatory,
and a careful record should be kept of the amount and cost of
the medicines used.
CLINICAL INSTRLUCTION.
The Medical Students attending the Medical Department of
the Johns Hopkins' University shall be divided into sections,
and assigned respectively and in rotation to the Visiting Physicians and Surgeons.
Each student assigned to a special ward for clinical instruction
may have one or more beds placed in his charge for observation.
The student to whose observation cases are confidedl should be




JOHNS HOPKINS' IHOSPITAL.              147
required to record histories, noting accurately the pulse, respiration, temperature, characters of the urine, etc. Each report of
an individual case should be submitted to the examination and
inspection of the attending medical officer of the ward, and if
deemed worthy of preservation, should be entered upon the casebook of the ward.
Every facility should be afforded by the Attending Physicians
and Surgeons to perfect the students in auscultation and percussion, and in the operative procedures of Surgery and Obstetrics,
and in a practical knowledge of the symptoms and pathology of
various diseases.
Clinical Lectures at appointed times should also be delivered
in the Amphitheatre, to which all students should have access
free of charge.
IMEDICAL DEPARTMENT OF UNIVEIrITY: ITS LOCATION AND
DIDACTIC LECTURES.
The Lecture-room  within the Hospital grounds, which we
have designated as the Anmphitheatre, should be devoted to the
illustration of clinical medicine and clinical surgery, and the
diseases of women and children.
The clinical instruction, by the bedside, and within the walls
of the Hospital, whilst constituting one of the most important
branches of medical education, should not by any means supersede the regular didactic lectures delivered in a building  or
medical college, especially adapted for this purpose.  This
building should be located as near as possible to the Hospital,
and if space permitted upon the same square or upon an adjoining square.
This building should contain not less than two large, wellventilated lecture-rooms, in which the didactic lectures, on
chemistry, anatomy, physiology, materia medica, pharimacy,
therapeutics, practice of medicine, hygiene, surgery, alnd obstetrics should be delivered.
The Professors connected with the Medical Department may
at the same time fill the positions of Visiting Physicians and
Surgeons in the Hospital.
The Hospital MIuseunl and Library may serve for the Medical
College also.




118                JONES.-PLANS FOR THE
OBSERVATION AND REGISTRATION OF CASES.
Each ward should be provided with three Record Books, as
follows: —
1st. Prescription and diet book.
2d. General record of all the cases.
3d. Case-book, or record for cases of special interest.
In the book devoted to the general recordc of all the cases, the
following particulars should be entered, and the pages of the
book should be ruled and headed accordingly.
Cases treate.d in Ward N~o. —, Johns Hopkins' irospital, 3fedicat Service of    -, T.D., ftrom         to   -, 187-.
Recordced by     —, Residcent Student..                              Result.. S
The cases  of special i nterest should be reported fully, and
reorded in the special case-book.,
-H. C).   44i      Results of
44  0  R    55 ~  ~    Post-morta >6~             0               -R L~3 ~C)4  teu, etc.
The cases of special interest should be reported fully, and
recorded in the special case-book.
The cases recorded in the special case-book may be registered
in accordance with the following general plan:




JOHNS HOPKINS IH-IOSPITAL.                                          149
Number of Case.
Number of Bed.                     C
Date of Admission.
cc, or...
Morning.              _
Evening.
Morning.
E|vening. 
Mdorning.          I S c
Evening.  o
Gq1
Amount of Urea
Specific;racityd.
Chlof rine.
Reaction.
Chlbuonen or other
ResuAbnoal   rodts.    Q
eatmo ent of Uea
excretecl in 24 hours.     
Phosphoric Acid..<
Sulphuric Acid.1      a
Chlorine.
Chloridle of
Sodiunm, etc.
Rtesults.
Treatment.
~~' t~~ ~T?       c.'




150               JONES.-PLANS FOR THE
DISPOSAL OF DEAD, STRUCTURE AND CONDUCT OF DEAD-HOUSE,
POST-MORTEM EXAMIIINATIONS.
The dead should be quietly removed from the wards to the
dead-house at the earliest practicable moment.
In the removal of the dead. the lifts and the central railroad in
the central basement corridor should be employed. After being
washed in a solution of carbolic acid, and subjected to the fumes
of a burning mixture of charcoal and sulphur, the dead should
be laid upon lead-covered or marble-covered tables in the deadhouse.
The dead from the "p'ay Bwards " should be placed in a special
division of the dead-house, and should receive such burial as
their means and the wishes of their friends may indicate.
The dead from the charity wards shall be allowed to remain
in the dead-house for six hours, or longer, as the Trustees may
direct; and at the end of the specified time, if the bodies be not
claimed by any friend or relation, it shall be lawful for the
Attending Physician or Surgeon of the ward in which the death
took place, to hold a post-mortem examination. Medical students
attending the F-ospital, and pursuing clinical medicine and surgery, shall have free access to these post-mortem demonstrations;
and it shall be the duty of the medical officer present to illustrate and explain as far as possible the character of the anatomical lesions.
The bodies destined for post-mortem examination shall be
removed, by means of a lift, from the general dead-house to the
upper dissecting or post-mortem room.
Those bodies which have not been used for post-mortem exanminations, and which have not been used for coroners' inquests,
nor been claimed by friends, shall be devoted as far as possible,
and as far as nmay be necessary, to the study of practical anatomy in the medical department of the Johns Hopkins' University. To serve this purpose in the most efficient lanner, the
bodies should be carefully injected and conveyed to the dissecting rooms.
The Attending Physician and Surgeon shall have the first and
chief right to the post-mortem examination of any body from the
vard under his charge.




JOHNS HOPKINS' HOSPITAL.               151
No dead body shall be examined by any medical officer until
a certificate of death has been furnished to the clerk.
The Visiting Physicians and Surgeons shall have the right to
examine or cause to be examined in the chemical laboratory, any
organ, tissue or fluid which they may believe to have been involved in the diseased process.
All specimens illustrating clearly the nature of diseased processes, and which may be deemed worthy of preservation, shall
be delivered to the Curator of the AMuseum, for injection and
preservation.
Careful records of all post-mortem examinations shall be made
in books preserved in the post-morteml room and in the Museum,
according to the following plan (page 152).
If the medical staff be well chosen, the credit of the institution and the welfare of the inmates will be best promoted by a
generous trust on the part of the governing power towards the
executives; whilst an intelligent and chastened zeal in the discharge of duty is thus secured in the medical staff, the great
curse of interference and intermeddling-a cold performance of
duty-will be avoided.
By a wise and generous system of administration, it will be
possible to secure in the medical staff cheerful subordination, a
deep sense of personal responsibility, and such a union of dispositions and pursuits as to make the talents of the medical
officers co-operate to the greatest advantage for the public
good.
In the administration of the Hospital there should never be
any medium between confidence and the want of it; and should
any medical officer forfeit the confidence of the Trustees, he
should at once be withdrawn.
Mr. Fonblanque observes, that " it is not the personnel, but
the?noralcae, upon which a sound administrative system hinges;
a system based on the personal integrity of its agents2"
And Sir J. R. Martin has wisely remarked, that the objects
and ends to which everything in an hospital should tend areeconomy in expenditure, ease and expedition in labor, and exactness in the results. These great objects are attained by regulating
the order of labor, and by dispensing with useless labors which
consume precious time, obstructing and postponing the results;
by the establishment of a system, in fact, in which economy and




152                             JONES. — PLANS FOR THE
Number of Case.            (r
1                                     i Age.                                    cZ
|  Ward.,
Name.                            Q ~' 
Disease.
Exterior.
Head-Brain.
Spinal Cord.           a        ~  
Sympathetic
System.
_ _ _ _ _ _   -  b Q7
Mouth, Throat, etc.  I                   b
Stomach.
Small Intestines.
Large Intestines.
Lymphatic System..
r Liver.
- Spleen.                            C Z
hkidneys.
Circulatory System —Heart,            C~
etc.
Respiratory System- 
Lungs, etc.
Characters of Osseous System —Blood, Urine, etc.  
IID+
~cc                      *




JOHNS HOPKINS' HOSPITAL.               153
humanity shall be equally respected. The success of the treatment of the sick in hospitals depends less on the remedial means,
than on the care, the vigilanc3, the reagularity, and the order
with which lservice is performed.  Without that order, the sick
run the greatest risks, even in the hands of the most able and
the most practised. By a perfect administration-by proportioning the number of trained servants to our wants, by regulating
their various functions, by uniting economy with success, in fact
we may in some measure overcome imperfections in structural
arrangements. But on the other hand, when administration is
ill-orderedcl, and the hospital building ill-constructed, it is death
to the inmates. Borne down by such overwhelming dcisadvantages-odds of our own creation —the highest talents and the
best exertions of the physician and surgeon are set at nought.
HOSPITAL COOKING AND DIET OF THE SICK.
The kitchen should be furnished with the best and nmost convenient stoves and ranges, in order that economy of fuel andc
labor, and at the same time the most efficient means of preparing food, may be secured.
It would be foreign to our purpose to enter into any critical
examination of the many excellent forms of cooking stoves and
ranges which have been invented and perfected during the
present century. The officer charged with the arrangement and
fllrnlishing of the culinary department will, without doubt, receive from the learned directors of the Hospital the necessary
instructions and facilities for testing the relative merits of the
various arrangements for cooking.
W~e will simply remark in passing, that the Charity Hospital
of New Orleans is fitted with a range of the manufacture of
Bramhall, Deane & Co., of New York, at a cost of about two
thousand dollars. The apparatus does all the cooking for the
thousand inmates of the Charity HIospital, and keeps a constant supply of hot water for kitchen use and similar purposes.
It has been estimated fromn actual experiment, that the daily
cost of the fuel consumed in this range does not exceed sixty
cents.
The kitchen, as well as the supplies, should be intrusted to




154               JONES.- PLANS FOR TIE
the immediate care of an intelligent and responsible female head
cook and f emale housekeeper.
The culinary department, as well as the Hospital food supplies,
should be under the general direction and control of the Hospital
Purveyor. Careful tables of diet should be constructed by the
Hospital Purveyor, by and with the advice and direction of the
President and Resident Surgeon.
Absolute cleanliness and thorouogh order should be enforced at
all times in the culinary department, and the best mechanical
arrangements be adopted for the rapid and efficient distribution
of food to all parts of the Hospital, at such times as may be determined by the President and Resident Surgeon.
It is believed that the location of the kitchen in the basement,
near the centre of the Hospital, and its free connection with all
parts by the central railroad and lifts of the central basement
corridors, will be adapted to the regular, efficient, and rapid and
almost simultaneous supply of all parts of the Hospital with
food, at any hour that may be indicated.
With reference to the diet of the sick, an elaborate volume
would not exhaust this important subject, and in the limited
time and space at our command, nothing more can be accomplished than the presentation of a general outline drawn up from
the experience of the best observers, which may furnish materials
for definite calculation and final action.
If the original deduction of Prout be accepted, four great
classes of elements are necessary for perfect nutrition; viz.:
1st. Nitrogenous substances or albuminates (including albumen, fibrin, casein, hlmatoglobulin, legumen, gluten, etc.),
which contain also sulphur and phosphorus.
2d. Fatty substances (including animal and vegetable oils).
3d. Carbo-hydrates (including starch, sugar, pectin, and allied
substances).
4th. Salts (potash, soda, magnesia, lime, iron, chlorine, phosphoric acid, fluorine, and water).
The albuminates, fat, and salts are indispensable, and the
carbohydrates are so universally taken and so eagerly sought
after, that no diet should be considered as perfect without them.
In addition to these classes, the accessory foods or condiments
are useful in giving flavor and aiding digestion.
These classes should not be confounded together, and are not




JOHNS HOPKINS' HOSPITAL.              155
convertible, as they serve different purposes in the animal economy.
The albuminates nourish all the tissues which give rise to
mechanical force of any kind, and probably also those connected
with mental action.  It has been announced by physiologists,
that the mechanical force evinced by the human machine, either
in carrying on its internal movements, or in acting on external
objects, is proportional to the amount of albuminates which can
be digested, absorbed, and properly applied to nutrition. The
digestive power in the stomach and intestines, the formative
power in the nitrogenous tissues, and the eliminating processes
in the after stages, have to be balanced so that one shall equal
the other, otherwise health is destroyed.  Acute diseases are
not only attended with derangement of digestion, but also by increased chemical change of the blood and tissues, and even under
the most favorable system of diet the waste of tissue and the loss
of force is greatly in excess of the supply.
Lessening the supply of albuminates leads to a decline of force,
and if the supply is entirely cut off the decline is very rapid,
affecting the muscular system first, including the heart, and
at a later date the nervous system and mental powers. This result may to a certain extent be delayed by an increase in the
supply of fat and starch, which limit the disintegration by absorbing oxygen and developing heat, and also by perfect rest.
These principles have been applied in treatment, and the albuminous tissues and the blood itself brought under control by a
judicious adaptation of diet and exercise alone, without the employment of drugs.
By oxidation, the nitrogenous elements also contribute to animal heat, after they have formed parts of tissues.
Fatty aliments, like the nitrogenous, are both plastic and heatgiving, being essential to the formation of both muscular and
nervous tissues, and to the production of heat and mechanical
force. Starch and sugar are supposed by many physiologists to
be entirely heat-giving, and not formative.
The salts and water are equally essential; lime, chiefly as
the phosphate, is absent from no tissue; both lime and magnesia
are essential for bone growth and repair; potash and soda in the
forms of phosphates and chlorides, form parts of almost all tissues; and iron, sulphur and phosphorus appear to be essential




156              JONES.-PLANS FOR THE
to the proper constitution of certain constituents of the blood and
tissues.
The preceding well-established facts render it evident, that tile
diet of the sick as well as of healthy individuals should have
due proportions of the four great alimentary classes.
A complete consideration of the important subject of diet, as
applied to the inmates of a large hospital, embracing men, women
and children, would embrace the determination of the quantity
of the different classes of alimentary substances required for
persons of different occupations, different sexes and ages, during
and after the period of growth and pregnancy, and under all the
varying conditions of disease, convalescence and health, and variations of climate; the determination of the best articles of food
in each class, their digestibility, and the best mode of cooking
them.
Some approximation to the supplies required by the sick in
hospitals may be made by an examination of the quantity and
composition of food which has been found by long experience
and by experiment to be necessary for healthy men, and espe —
cially for soldiers between the ages of 20 and 40 years.
WThilst it is true that it is not possible, in the absence of direct
observation and experiment, to determine how much food is sufficient for the maintenance of the highest health and physical and
intellectual power, in any particular person, at the same time it
is of importance to fix the caverage amount, as in a hospital fixed
quantities of food must be supplied and issued, to a great
extent in accordance with the number and character of the
patients.
It has been calculated that a man of average size and activity
will, under ordinary conditions of moderate work, take in twentyfour hours, in solid and liquid food, from -tth to I-th of his own
weight. As solid food contains a certain percentage of water,
if this be eliminated, the average amount of anhydrous food for a
healthy man in twenty-four hours varies from 19 to 25 ounces,
which in its ordinary state combined with water would range from
34 to 46 ounces. The water consumed during the twenty-four
hours, on the other hand, ranges from 50 to 80 ounces. Therefore from 80 to 120 ounces of both solids and liquids are ingested
by a healthy man in 24 hours.
A man will take on an average, in twenty-four hours, when nearly




JOHNS HOPKINS  HOSPITAL.                               157
at rest, 18.5 ounces anhydrous solid food, 70 to 90 ounces water;
when in moderate and  usual exercise, 23  ounces of anhydrous
solid food, 70 to  90 ounces water;  under great exertion, 26 to
30 ounces anhydrous solid food, and 80 to 100 or more ounces of
water.
A  man of mean height, weight, and activity requires in twentyfour hours from   250 to  350  grains of nitrogen, from   3,500  to
5,000 grains of carbon, and about 400 grains of salt; during rest,
about 198 grains of nitrogen and 4152 grains of carbon.
A working-man of average height and weight requires daily,
in avoirdupois ounces and tenths of ounces, nitrogenous substances (dry), 4.2; fat, 1.4; starch, 18.7; mineral matters, 0.71.
Dr. Edmund A. Parkes has given the following  Table for the
Calculation of Diets.
In 100 Parts.
Articles of the Soldier's Diet.
Water.  Albumen.   Fats.   Carbo-    Salts,
rydrates.
Uncooked meat of the kind supplied
to soldiers, beef and mutton.  Bone
constitutes one-fifth of the soldiers'
allowance........................   75.        15.        8.4               1.6
Uncooked meat of fattened cattle. Calculated from Law's and Gilbert's experiments.  These rumbers are to
be used if the meat is very fat....   63.     14.      19.                 3.7
Cooked meat; roast, no dripping being
lost. Boiled assumed to be the same.   54.     27.6    15.45                2.95
Bread; white wheaten of average
quality..................40.          8.        1.5    49.2       1.3
Flour, average quality..14.....    14.          14.6       1.2    68.6       1.6
Biscuit........................... 15.6               1.3    73.4       1.7
Rice.......10.....................       5..8    83.2       0.5
Oatmeal...........12...........     16.        6.8    63.2       2.
Maize..13.5                                      10.       6.7    64.5       1.4
Peas (dry)...5...................           22.        2.     53.        2.4
Potatoes.......................   74.            1.5.1    23.4       1.
Carrots (cellulose excluded).........   85..6.25    8.4.7
Cabbage.91..2.5      5.8.7
Butter...6..3      91.                2.7
Egg (10 per cent must be deducted for
shell for the weight of the egg)...  73 5     13.5    11.6                 1.
Cheese......    36.8    33.5    24.3                                          5.4
Milk (sp. gr. 1030 and over).           86...7.4      3.7.5       6.
Do      "'" 1026...........0....   90..3      2.5      3.9      5.
Sugar.............................     3.                        96.5       5.




158                JONES.-PLANS FOR TIIE
The mode of using the table is as follows: The quantity of
uncooked meat or bread being known, and it being assumed or
proved that there is no loss in cooking, a rule of three brings out
at once the proportion.  Thus, the ration allowance of meat
being 12 ozs., 2.4 ozs., or 20 per cent., is deducted for bone. The
75 x 9.6
quantity of water in the remaining 9.6 ozs., will be  100  -- 7.2,
and the anhydrous solids 2.4 ozs. In the case of salt beef or
pork, it is not certain how their value should be calculated, as
many of the important nutritive constituents have been partially abstracted by the brine; perhaps salt beef may be reckoned
as equal to two-thirds the quantity of fresh beef.
The English soldier on home service receives: meat, 12 ozs.;
bread, 24 oz.; potatoes, 16 ozs.; other vegetables, 8 ozs.; coffee,
0.33; tea, 0.16; salt, 0.25; sug'ar, 1.33; milk, 3.25; total, 65.32
ozs.; total value Sd.
The French infantry soldier of the line, in time of peace,
receives: munition bread, 26.5 ozs.; white bread for soup, 8.8;
meat uncooked, 8.8; vegetables, 5.6; salt, 0.5; pepper, 31 grains;
brandy, 13 ozs.; total, exclusive of brandy, 50.27 ozs.  In
time of war the French soldier receives: meat without bone, 7
ozs.; bread, 26.5; rice, 2; dried vegetables, 2; salt beef or pork,
8.75; salt, 1 oz.; wine, I pint; beer, 1 pint; brandy, ~ oz.;
sugar, 1 oz.
The Prussian soldier in time of peace receives: bread 25.5 ozs.;
meat without bone, 5.5 ozs. On the march: bread, 33 ozs.; meat,
8.25.  In time of war: bread, 29 ozs.; fresh meat, 8 ozs.; rice,
3 ozs.; barley, rye or buckwheat, 3 1 ozs.
In calculating sick diets, two modes may be employed: 1st.
The average diet of healthy men may be halved or quartered,
the relations of the different classes remaining the same, but the
amount is lessened.  Tables can be kept of the nutritive value of
the diet, to avoid trouble in calculation, and the physician can
know at once the exact amount his patient is taking.  2d. The
relative proportions of thel several classes may be altered; the
nitrogenized substances may be increased or lessened; or the
fatty or starchy substances or salts may be thus dealt with, and
certain tissues may be fed or brought into a state of inanition, at
the option of the-physician.
In malny cases of disease, the point of digestibility of the food




JOHN-S HOPKINS' HOSPITAL.                            159
is the one mainly to be considered, as the nervous and muscular
powers of the stomach and thle supply of gastric juice are often
lessened.
It must be remembered tllat the numerous wants of the sick
cannot be met by  rigid  scales, however numerous; and they
must be used  in  hospitals for convenience  and  be  subject to
changes, according to the age, disease and  stage of disease, and
varied according to the power of the patients.
In the British army there are altogether ten diets-tea, spoon,
beef-tea, milk, low, chicken, half, fish, roast, entire.  The following  table shows the quantity, in the chief diets of the English
military  hospitals, and  the  proportions  of carboniferous  and
nitrogenous aliments, as calculated by Dr. De Chaumont:
NuXtritive  Va~le  of _Eaglis7h Afilitary Hospital Diets, as fixed
by JReg'ylation.
Amounts of different constituents in ounces and tenths of ounces.
Nalbmen   Fats.   Carbo-   Salts.   ater, fre   ater    Total
Albume n.   Fats.   ydrates.       weight.           weight.
Tea Diet.............880.342   6(. 648.153    8.023    8.477    17
Spoon Diet...........960.342    8.288.173    9.763    8.737     181
Milk...............  3. 620   2.446   12. 517.557  19.140  57.850     77
B3ef-tea.............  2.400    1.074    7.(65t.828   11.9,53   16.047  281
Low................  3.503    2.792   11.531   1.004   18.845  31.450    490
Half................ 3.072   2.112  12. 966   1.306   19.446  27.607      471
Entire..............  3.792    2.446   14. 838    1.450  22. 52)  306.267  591
Chicken............  3.411    1.554   10.603    1.279   16.847  18.403    351
Fish................ 3.134    2.384  12.475    1.394  19.387  24.863      441
Aliss Florence Nightingale has given some practical, commonsense views on nursing, from  which we quote the following:
"In laying down rules of diet by the amounts of solid nutriment in different kinds of food, it is constantly  lost sight of
what the patient requires to repair his waste, what he can take
and what he cannot.  You cannot diet a patient from  a book;
you cannot make up the human body as you would make up a
prescription-so  many  parts'carboniferous,' so  many  parts'nitrogenous,' will constitute a perfect diet for a patient.  The
nurse's observation  will here materially  assist the  doctor, the
patient's' fancies' will materially assist the nurse. Organic chem



160                JONES.-PLANS FOR TI-IE
istry is useful, as all knowledge is, when we come face to face
with nature; but it by no means follows that we should learn
in the laboratory any one of the reparative processes going on in
disease. Chemistry has as yet afforded little insight into the
dieting of sick. All that chemistry can tell us is the amount of'carboniferous' or nitrogenous elements discoverable in different
dietetic articles.  It has given us lists of dietetic substances
arranged in the order of their richness in one or the other of
these principles; but that is all. In the great majority of cases,
the stomach of the patient is guided by other principles of selection than merely the amount of carbon or nitrogen in the diet.
No doubt, in this as in other things, nature has very definite
rules for her guidance; but these rules can only be ascertained
by the most careful observation at the bedside.  She there
teaches us that living chemistry, the chemistry of reparation, is
something different from the chemistry of the laboratory."
The quantity and quality of food should be varied in hospitals
in accordance with the nature of the disease, whether acute or
chronic, sthenic or asthenic; age; sex; previous habits of life;
employment; season and weight and endowment of body.
In acute diseases, the activity of the functions of digestion and
atbsorption are impaired; whilst at the same time there is a great
change in the chemistry and vital acts of the blood and tissues,
attended with elevated temperature, aberrated  nervous and
muscular action, and rapid waste of the tissues.  In this state
the nutriment should be capable of easy digestion and ready
absorption; and it has been observed that milk, beef-tea, wine and
alcoholic stimulants will most readily sustain life and at the
same time repair the waste of tissue.
As far as my experience extends, in many cases of acute disease, attended with high temperature, rapid pulse and great
muscular and nervous prostration, alcohol acts not only as a
food, and is destroyed in the blood and tissues, and by its oxidation diminishes the waste of tissue, and thus preserves the
strength, but it also reduces the animal temperature to a marked
degree.
The great objection to the use of alcohol in the treatment of
disease is that it may lead to intemperance. This danger may
to a great extent be avoided by givinog the alcohol in combination with milk, and also by ceasing the remedy as soon as the




JOHNS HOPKINS' HOSPITAL.                 161
patient is so far convalescent as to be able to subsist comfortably
without it.
In the treatment of Bright' s disease of the kidneys and of chronic
dysentery, milk appears to be absolutely essential, and of the
greatest value.
The so-called extracts and elixirs of beef are practically valueless, except for the salts and small quantities of soluble nitrogenous matters which they contain.  They may support life for
limited periods, when the digestive functions are greatly impaired,
but they can never take the place of fresh beef-tea, milk, softboiled eggs, etc.
The claims set forth by the inventors and vendors of the socalled extracts of meat have not been sustained by clinical observation.
The multiplication of dietaries in a hospital is to be avoided.
The surgeon should write on the ward book when special articles
are required, as milk, milk punch, soft-boiled eggs, etc.
The dietary should be constructed in accordance with the age,
sex, and diseases of the patient; and various minor changes may
be made in accordance with the changes of the season.
In acute cases, where the digestive function is so impaired as
to preclude the use of solid food, the breakfast may consist of
half pint of milk or beef tea, 4 ozs. of bread, and one fourth of
a pint of tea; the dinner and supper should not vary materially
from this, except that when necessary milk punch and beef-tea
may be given in small quantities at regular intervals (every two,
three, or four hours).
As soon as convalescence has been established, one or two
eggs, with toast and butter, may be added to breakfast and
dinner.
WVhen convalescence has been fully established: breakfast — 1
pint fresh milk, 10 ozs. bread, 6 ozs. hominy or oatmeal, 2 softboiled eggs, tea, coffee or cocoa, with sugar. Dinner-6 ozs. meat,
6 ozs. bread, 4 ozs. rice, 4 ozs. potatoes, sweet or Irish, 4 ozs. fresh
vegetables, 1 pint of soup or broth, 1 oz. cheese, 4 ozs. dried
fruit.  Supper -- pint fresh milk, 8 ozs. of bread, 3 ozs. hominy,
tea or cocoa with sugar.
In hospital service, the quality of the meat is even more illportant than the quantity.
Whenever fresh vegetables and ripe fruit can be obtained at




162                 JONES.-PLANS FOR THE
reasonable prices, they should be served to the convalescents and
chronic cases.
Moderate supplies of vinegar and light wine or ale will prove
beneficial in many cases.
I have thus endeavored to present to your honorable body a
definite outline of my views with reference to the construction
and administration of a hospital, destined to receive chiefly the
sick poJru of a large American city.
The time to which my reply was limited by your learned President was so short, that many of the subjects have not perhaps
received that elaboration which their importance demands.  I
may be permitted, however, to hope that the preceding suggestions may prove worthy of your consideration, and at least lead
to the discussion of definite lines of action in the execution of
your most honorable and responsible trust.
3With great respect,
Your obedient servant,
JOSEPH  JONES, M.D.,
Professor of Chznistry and Clinical Mledicine, 1fedical Department University of
Louisiarna; Visiting Physician, Charity Hospital, iNe7w. Orleans; Formerly
Surgeonz, Provisional Army, Confederate States.




J 
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i't  Y66:'"of                        "      &DR. JOSEPH JONE:S SUGGESTIONS,
FOR
JOHNS HOPKINS HOSPITAL.








JOHNS HOPKINS' HOSPITAL.                              163
EXPLANATION OF PLATE I.
GROUND PLAN OF HOSPITAL, FRONT VIEW.
Total length of Hospital, 675 feet.
Total breadth of Hospital, 440 feet.
Total capacity of Hospital, 800 beds.
A. Central Administrative building, 195 feet in length, 75 feet in breadth.
Height of basement, 12 feet.
Height of corridor, 12 feet.
cl. Room for Hospital stores, blankets, sheets, towels, etc., 30 x 30 feet.
c. Room for storing Hospital beddingc, 30 x 30 feet.
f. Room for Hospital beds, 30 x 30 feet.
b c. Central hall or corridor dividing the basement at right angles.
Height of basement, 12 feet.
Height of corridor, 12 feet.
g h i. Rooms for storing coal, wood and fixtures, 30 x 30 feet.
j k l. Rooms for Hospital stores of male, female and children's clothing, 30 x 30 feet.
mn. Room for storing wines, cordials, etc., 30 x 30 feet.
n. Room for Hospital stores,-d-ltugs for Dispensatory, 30 x 30 feet.
o. Room for chemicals, acids, etc., for Dispensatory and Chemical Laboratory, and for
the manufacture of disinfectants, 30 x 30 feet.
p. Store-room, for meats, vegetables, etc., for Hospital, 37~ x 30 feet.
q. Store-room for flour, sugar, tea, coffee, etc., 37~ x 30 feet.
v. Kitchen, 75 x 30 feet; height, 12 feet.
s. Room for apparatus regulating supply of water to Hospital, 75 x 30 feet
t. Room for engine, 40 x 17j feet.
t. Roo:n for heating apparatus and artificial ventilation, 75 x 30 feet; height, 17 feet.
v. Room for engine, 40 x 17~ feet.
b b, be cc c. MiIain corridors, running through the executive building and Hospital
at right angles, and connecting all parts by means of a central railroad provided with turn-tables.
All the business of the Hospital, such as the conveyance of sick and wounded to the
different wards; distribution of food, medicine and clothing, removal of the dead, etc.,
should be accomplished by means of the central railroad in the basement corridor.
B B. Basement of wards.
The basement of the wards should be arched, with open sides, and railroad or tralmway in centre.
Height of basement of wards, 12 feet.
Width of basement of wards, 30 feet.
Length of basement of each ward, 1.50 feet, exclusive of central transverse
corridor and addition beyond corridor for lifts and stairway.  Total length,
180 feet; breadth, 30 feet. If verandas be erected along the sides of each
ward 10 feet in width, then the total breadth would be 50 feet.
Height of basement of wards, 12 feet.




164                      JONES.-PLANS FOR THE
C C C. Vaults, or receptacles of water-closets.
D D D. Bath-room vaults or receptacles, the water from which should be directed into
and through the privy vaults.
E E. Stairway for wards.
F F. Lifts and shafts for wards.
G. Steam laundry for females, 60 x 171 feet.
H. Steam laundry for males, 60 x 17~ feet.
I. Dead-house for females, 30 x 17~ feet; 12 feet high.
J. Dead-house for males, 30 x 17~ feet; 12 feet high.
K. Stable for horses, etc.
L. Workshop for refitting beds, repairing furniture, etc.
M M. Fountains. The waste water of the fountains should be conducted by sewers to
the vaults of the water-closets, as shown by the red lines, 1 1 1 1 1. The
arrows indicate the directions of the various currents in the sewers.
NT N. Grass and flowers.
0 0. Main arched corridor, connecting all the Hospital wards.
Length of main corridor, 675 feet; breadth, 15 feet; height, 12 feet.
The main corridor should be appropriated to the business of the Hospital —removal,
transference of patients, medicines, supplies of food, clothing, bedd.ing, dead bodies.
etc.
P P. Spaces between the wards, 30 x 30 feet.
The wards being arranged alternately on each side of the central corridor, the distance between opposite wards on each side will be 90 feet.  If verandas 10 feet in
width be built on the side of each ward, then the distance will be 70 feet. This distance
will be ample for perfect ventilation; and the sunlight will fall fully upon each structure.
Q Q. Main sewer, running in front of Hospital.
The front main sewer should receive all the water and fecal matters from the
water-closets, bath-rooms, etc., of wards 2, 4, 7 and 9, and of the main central executive building, dispensatory and kitchen. In the plan, six fountains are connected with
the main front sewer.
The diameter of the main sewer should be not less than four (4) feet, and the diameter of the smaller tributary sewers connected with the fountains, privies, water-closets
and bath-rooms should range from one to two feet.
R R. Main sewer, running in the rear of the Hospital.
The rear main sewer should receive all the water and fecal matters, etc., from wards
1, 3, 5, 6, 8 and 10, and from the laboratory, steam-laundry, dead-house, dissectingroom, work-shop and stables.
It will be observed, that in the preceding plan no sewer cpasses under arny ward or
Vortion of the Hospital buildings.
It will also be observed that the central portions of the Hospital are occupied by the
kitchen, and the arrangements for heating and supplying the Hospital with hot and cold
water.
The dead-house is removed 35 feet to the rear of the steam-laundry, but is accessible
to all parts of the Hospital by the railroad or tramway.
The following is the plan of the first floor of the Hospital.  (Plate II.)




No.2.
PLAN   OF1' F  It, -1L  Opt
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1-0 WARDS, 4-0  PATIENTS   EACH   4-00 PATIENTS.  TOTAL  LENGTH   OF  FRONT   675  FT.
DR.JOSEPH JONES SUGGESTIONS,
FOR
JOHNS HOPKINS HOSPITAL.








JOHNS HOPKINS' HOSPITAL.                               165
EXPLANATION OF PLATE II.
PLAN OF FIRST FLOOR OF HOSPITAL.
A. Central Administrative Building, first floor.
b b, c c c. Central corridor or passage-way, dividing the central administrative building at right angles, and communicating with library, museum, dining-hall, and
amphitheatre, operating rooms, dispensatory, and the pay, surgical. obstetrical
and medical wards.
Width of central corridor, 15 feet.
Height of central corridor, 18 feet.
d. Office of president, 30 x 30 feet; height, 18 feet.
e. Office of treasurer, 30 x 30 feet; height, 18 feet.
f. Office of resident surgeon, 30 x 30 feet; height, 18 feet.
g. Office of assistant resident surgeon, 30 x 30 feet; height, 18 feet.
I7. Office of clerk, 30 x 30 feet; height, 18 feet.
i. Reception room for patients, when they are examined for admission into the various wards, 30 x 30 feet; height, 18 feet.
Out-door patients may also be examined and prescribed for at certain hours in this
room, by the resident surgeon and assistant surgeon, and attending physicians and surgeons.
The three rooms, g h7 i, should communicate freely with each other, and especially
during the examination, admission, and registration of patients.
The recepti3n room for patients should communicate freely with the corridor of the
basement, by a lift and stairway.
In like manner, the offices of the president, surgeon and treasurer should communicate directly with the central corridor in the basement.
j. Library, 30 x 90 feet; height, 38 feet.
The Library should extend up to the roof of the building, through the second story,
and in addition to the windows at the side, may be lighted from above.  Galleries should
run around the walls, at intervals of 12 feet, so that the whole space may be utilized
for the preservation of the Hospital records, and works of reference.
k. Laboratory of dispensatory, for the manufacture of medicinal preparations: tinctures, syrups, extracts, etc.
Dimensions of dispensatory laboratory, 30 x 30 feet; height, 18 feet.
I. General dispensatory for entire Hospital, and for the out-door patients, where all
medicines, prescriptions, etc., shall be prepared, in accordance with the rules of
the Hospital, by competent druggists, and dispensed according to the directions
of the resident surgeon, assistant surgeon, and attending surgeons and physicians.
Dimensions of general dispensatory, 60 x 30 feet; height, 18 feet.




166                      JONES.-PLANS FOR THE
mn. Dining-hall for officers and resident students of Hospital, 30 x 60 feet; height,
18 feet.
n. Museum for the preservation of anatomical and pathological specimens.
Dimensions of museum, 75 x 30 feet; height, 38 feet.
The museum should extend up to the roof of the building, through the second story,
and in addition to the windows at the side, should be lighted from above by a dome,
or otherwise, as in the case of the library.  Two galleries, at intervals of 12 feet,
should run around the walls of the museum, so that the entire space may be utilized,
and ample room afforded for the gradual growth and perfection of the anatomical and
pathological collection.
The museum is located near the great amphitheatre or lecture room, so that the professors charged with the conduct of the medical and clinical lectures may avail themselves of the specimens, preparations, dissections, models, and drawings, in the illustration of their cases and lectures.
o. Room  for the preservation of surgical instruments, bandages, appliances, etc.,
15 x 30 feet; height, 18 feet.
In like manner, this room should occupy a central position, in order that the appliances may be readily available to the entire Hospital, and also to the surgeons, when
performing operations before the class in the anmphitheatre.
p q. Operating rooms, 30 x 15 feet; supplied with operating tables, gas, hot and cold
water, ether, chloroform, diffusible stimulants, and surgical appliances for reducing fractures, etc. In these rooms the patients to be operated on may be prepared before being introduced into the amphitheatre. These rooms may communicate, by means of lifts and stairways, with the lower basement corridor, so
that at all times they may be used in the reception and immediate treatment of
patients, when they are brought to the Hospital, with wounds or accidents.
B. Amphitheatre, or central operating and lecture room. Diameter, 75 feet, height,
40 feet.  The seats should be so arranged as to accommodate at least 400 students.
1. lIMain entrance from central hall or corridor. 2. Lecture and operating table and
bed for surgical and medical cases. The amphitheatre should be supplied with gas and
hot and cold water, and be well lighted by a dome above.
C. Chemical, pathological and microscopical laboratory, 40 x 50 feet; height, 18 feet.
The chemical laboratory should be devoted to the microscopical and chemical examination of the blood and urine, and of the morbid products of disease, and should be
supplied with water and gas, and should be well lighted at the sides and above.
The chemical laboratory should communicate freely with the amphitheatre, in order
that the results of the processes, instituted in the investigation of disease, may be immediately available to those delivering clinical lectures in the amphitheatre, for the illustration of the pathology and therapeutics of the various diseases brought before the
medical students.
The laboratory should be furnished with two or more microscopes of standard power
and accuracy, together with those reagents and apparatus which are specially adapted
to the investigation of physiological and pathological chemistry, and to pharmacy and
toxicology.




JOIINS tIOPKINS' THOSPITAL.                          167
D. Laundry. -Drying-room for clothing of females and children, 60 x 25 feet; height,
18 feet.
E. Laundry. -Drying-room for clothes of males, 60 x 25 feet; height, 18 feet.
The laundry building should be situated at least 35 feet in the rear of the laboratory
(C). The basement of the laundry should be fitted up with the most approved machinery for washing by steam, and the most effective and improved methods should be employed in drying the clothes.
F. Dissecting and post-mortem room, attached to dead-house, and situated immediately
over the basement, in which the dead are received and prepared for burial,
and which communicates with all parts of the Hospital, by means of the central railroad in the central basement corridor. The bodies should be raised
by a lift to the upper post-mortem and dissecting room. Post-mortem examinations should not be permitted in the lower rooms. The post-mortem and
dissecting room should be freely ventilated by side windows, and should also
be lighted and ventilated from the roof above. The floor should consist of
colored tiles, and the dissecting and post-morteml tables should be covered with
lead or zinc.
In all large hospitals, situated in or near large cities, many cases may demand the
presence and investigation of the coroner, and the room now indicated would be the
proper place for such inquests, where they might be conducted quietly, thoroughly,
and without any interruption.
In cases of poisoning, demanding medico-legal investigation, the laboratory (C) would
furnish all the necessary facilities.
The dissecting-room should be supplied with water, and every arrangement should
be made to attain and preserve the utmost cleanliness.
It is impossible to over-estimate the value of careful post-mortem examinations to
the progress and perfection of medical science.
Thorough clinical instruction is impossible, without post-mortem examinations, and
chemical and microscopical investigation of the pathological products.
Dimensions of dissecting and post-mortem room and dead-house, 50 x 30 feet; height,
18 feet.
The dead-house should be surrounded by a substantial iron railing, enclosing a small
space around, and no patient should be permitted within or around this enclosure.
G G.'Male and female surgical pay ward, situated on the right and left of the central
administrative building.
Length of ward, 150 feet; breadth, 30 feet; width of veranda, 10 feet; height
of ward, 18 feet. Capacity, 40 beds.
H H. Male and female surgical wards, situated on the right and left of the amphitheatre,
and contiguous to operating rooms, 150 x 30 feet; 18 feet high.
I. Male ward for treatment of diseases of nervous system, 150 x 30 feet; 18 feet high.
J. Male ward for treatment of diseases of skin, 150 x 30 feet; 18 feet high.
K. Male ward for the treatment offevers, 150 x 30 feet; 18 feet high.
By this arrangement the ward devoted to the treatment of fevers will be as far as
possible isolated from the remainder of the Hospital.
L. Female obstetrical ward, 150 x 30 feet; 18 feet high.
M. Female medical ward, 150 x 30 feet; 18 feet high.
N. Ward for children, 150 x 30 feet; 18 feet high.




168                       JONES.-PLANS FOR THE
0 O. Nurses' rooms, attached to each ward, with window commanding ward, 10 x 10
feet; 18 feet high.
P P. Ward library and reading room for preservation of case books, small test chest,
instruments, also books for patients, 10 x 10 feet; 18 feet high.
Q Q. Stairway communicating with basement and with second story, 5 x 15 feet.
R R. Mess-room and scullery, 15 x 15 feet.
S S. Press-room for clothing, etc., 5 x 15 feet, arranged with shelves, etc.
T T. Lift, or elevator, extending from basement to second floor. If it should be practicable to arrange the lift and stairway together, in the space indicated on
either side, or in the centre, and so as to occupy not more than 15x5 feet, then
the other space might be made available for the assistant nurses, as a dormitory.
U U. Privies, or water-closets, and ward sinks, with entrance and windows.
Dimension of water-closet and ward sink, 10 x 10 feet; of ventilated lobbies connected with water-closet, 5 x 5 feet.
V V. Bath and ablution rooms, 10 x 10 feet; ventilated lobbies connected with bathrooms, 5 x 5 feet.
Total length of detached building or Hospital pavilion, including central corridor,
and extension beyond corridor for mess-room, etc., 180 feet.
Length of each ward, 150 feet; breadth, 30 feet; height, 18 feet; capacity, 40
beds; cubic space per bed, 2250 feet; 20 beds on each side of ward.
Ten windows on each side of ward and two windows at each end.
Breadth of windows, 5 feet; height of windows, 17 feet. One window to two
patients.
W WV. Piazza, or open gallery or veranda, on each side of ward: length, 140 feet;
breadth, 10 feet; height, 18 feet. The verandas may be used for the exercise
of the patients, and also for sitting and reading.
Capacity of first floor of Hospital, 10 wards, 40 beds each: total, 400 beds.
The following is the plan of the second floor of the Hospital:




No.3.
PL-AN  OF SECON-D FLOOZE!,
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10  WARDS, 40 PATIENTS  EACH. TOTA.L  PATIENTS    4-00.
DR.'JOSEPH JONES SUGGESTIONS,
FOR
JOHNS HOPKINS HO.SPITAL.








JOHNS  HOPKINS' HIOSPITAL.                           169
EXPLANATION OF PLATE III.
PLAN OF SECOND FLOOR OF HOSPITAL.
A. Central Administrative building, second floor.
b b, c o. Central hall or corridor, connecting all parts of Hospital: width, 15 feet;
height, 18 feet.
d ej k m n o p s t u v w x. Sleeping apartments of resident students.  Dimension of each
student's room, 30 x 15 feet; 18 feet high.
g. Sleeping apartment of resident surgeon, 30 x 30 feet; 18 feet high.
h Sleeping apartment of assistant resident surgeon, 30 x 30 feet; 18 feet high.
f. Sleeping apartment of treasurer, 30 x 30 feet; 18 feet high.
g. Sleeping apartment of druggist, 30 x 30 feet; 18 feet high.
1. Library.
r. Museum.
B. Dome of amphitheatre, 75 feet diameter.
C. Male medical pay ward, 150 x 30 feet; 18 feet high.
D. Female medical pay ward, 150 x 30 feet; 18 feet high.
E. Male eye and ear ward, 150 x 30 feet; 18 feet high.
F. Female eye and ear ward, 150 x 30 feet; 18 feet high.
G. Male ward, diseases of heart, lungs, kidneys, etc.
H. Female ward, diseases of heart, lungs, kidneys, etc.
I. Male ward, skin affections and venereal diseases.
J. Female ward, skin affections and venereal diseases.
K. Male ward, fevers.
L. Ward for children.
Of course the relative distribution of the patients and diseases to different wards
must depend to a great extent upon the number and character of the prevailing diseases.
O O. Room for ward nurse, 10 x 10 feet; 18 feet high.
P P. Room for ward library, etc., 10 x 10 feet; 18 feet high.
Q Q. Stairway communicating with basement, 5 x 15 feet.
R R. Mess room and scmllery, 15 x 15 feet.
S S. Press room for clothing, etc., 5 x 15 feet.
T T. Lift, or elevator, extending from second floor to basement, 5 x 15 feet,.
U U. Water-closets, 10 x 10 feet.
V V. Bath and ablution rooms, 10 x 10 feet.
W W. Verandas, 140 x 10 feet.
Large iron tanks should surmount the central administrative building for the distribution of water to all parts of the Hospital, in case the water-works of the city are
without the necessary power.
The apparatus and engines for the regulation and circulation of the hot and cold
water should be situated centrally under the amphitheatre and laboratory, as indicated
in the preceding plans.
The plan of each ward in the entire Hospital is represented in the following Plate,
No. I V.:




170                     JONES.-PLANS FOR THE
EXPLANATION OF PLATE IV.
PLAN  OF EACHI WARD IN  ENTIRE HOSPITAL.
Length of each ward, 150 feet.
Breadth of each ward, 30 feet.
Height of each ward, 18 feet.
Capacity of each ward, 40 beds.
Cubic space per bed, 2250 cubic feet.
Two open fire-places in each ward.
Twenty beds on each side of ward.
Two beds between each window.
Ten windows on each side.
Two windows at the end.
Breadth of windows, 5 feet.
Height of windows, 17 feet.
The windows should extend from six inches of the floor to six inches of the ceiling
of the ward.
Nurses' room, 10 x 10 feet.
The nurses' room should command a view of the entire ward by means of a window.
Ward library, 10 x 10 feet. If deemed desirable, this room may also be used for
one or more assistant nurses.
Water-closet, 10 x 10 feet.
Bath room, 10 x 10 feet.
Ventilated lobby leading to privy or to bath-room, 5 x 5 feet.
Length of ward veranda, 140 feet; breadth, 10 feet.
\Vidth of central corridor, 15 feet.
Length of addition to ward beyond corridor, and devoted to mess-room, pressroom, lifts and stairway, 15 feet; breadth, 30 feet.
See also explanation accompanying Plate IV.
The following Plate V. gives a profile view of each detached building or pavilion:




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I~  I2.  Z7ySW/4iO/li/10,   l"K    ek     I/c('/f'd/; ft't/it V/s/dl(      ~DR.JOSEPH   JONES   SUGGESTIONS
IMS  0l/M,    l"                   r                                                                                                                                   FOR,Ii.r <(l'd,"                (1 i/        / /ai                          i I          OIL 6' l   /''l                                                 JOHNS   HOPKINS   HOSPITAL.
%~~~. 








JOHNS HOPKINS' HOSPITAL.                          171
EXPLANATION OF ELEVATIONr,
OR  PROFILE  OF  EACH  DETACHED  PAVILION  OR  HOSPITAL
BUILDING  AS IN  PLAN  NO. 4.
Each detached pavilion or Hospital building, including the central corridor and messroom, would present the following dimensions:
Total length, 180 feet.
Breadth without verandas, 30 feet.
Breadth with verandas, 50 feet.
Length of wards, 150 feet.
Breadth of wards, 30 feet.
Breadth of corridor, 15 feet.
Length of detached portion for mess-room, etc., 15 feet.
Breadth of detached portion for mess-room, etc., 30 feet.
Capacity of each ward, 40 beds.
Capacity of each detached building or pavilion, 80 beds.
Capacity of first floor of entire Hospital, 10 wards, 400 beds.
Capacity of second floor of entire Hospital, 10 wards, 400 beds.
Total capacity of entire Hospital, 20 wards, 800 beds.
Height of basement, 12 feet.
The basement beneath the wards should be entirely open, so as to admit of the freest
circulation of the air.
The basement of the wards should be used for communication as specified, and also
for exercise of patients in hot and wet weather. The basement of each pavilion should
communicate directly with the central executive building.
Height of first floor of wards, 18 feet.
Height of second floor of wards, 18 feet.
Total height of each pavilion or detached Hospital building, including roof and
floor, 60 (sixty) feet.








HOSPITAL CONSTRUCTION
AND ORGANIZATION.
CASPAR MORRIS, M.D.




CONTENTS.
GENERAL  REMARKS,....1........................... 175
GENERAL  CONSTRUCTION...........................................  193
WARD.................................................................... 206
CORRIDORS  AND  VERANDAS...................................... 214
BASEMENT, AND  ITS USES.............................................  220
DRAINAGE.................................................................. 222
HEATING  AND  VENTILATION................................... 224
FOOD; ITS PREPARATION AND DISTRIBUTION............................. 236
ADMINISTRATION.......................................................... 239
NURSES...............24.....2......................................   242
THE  SUPERINTENDENT...................................................... 245
ARRANGEMENTS  FOR  TEACHING........................................  247
DISPENSARY................................................................  250
TRANSPORTATION OF THE SICK AND WOUNDED...........................  253
RELIGIOUS  SERVICES........2.......................................  254
HOME  FOR  CONVALESCENTS................................................. 257
DESCRIPTION OF DRAWINGS................................................. 263




HOSPITAL CONSTRUCTION
AND ORGANIZATION.
CASPAR MORRIS, M.D.
TRIE subject of hospital construction is one which has recently
claimed great attention, yet not so great as its importance
demands. There has been much discussion of theoretic principles, and many buildings have been erected in which these have
been brought to the test of practical experiment; not always
with successful results.  The interests at stake, the expenditure involved, and the irremediably injurious influence of errors
in construction, give rise to a sense of serious responsibility, assumed in the expression of opinion and suggestion of plans, especially at a period when views are so unsettled as at present;
when one who had devoted much time to its consideration, and
enjoyed unusual advantages for the accumulation of knowledge
on the subject, declares that no permanent or costly building will
ever be erected hereafter for the treatment of disease, except as
a monument to the pride of some aspirant for posthumous fame;
when we are told by competent and honest observers that the
massive and costly buildings erected within a few years in Paris,
for the Hotel Dien, will never be occupied; and that the extensive and imposing structures put up., without any restriction upon
the money expended, for St. Thomas's, in London; those constructed by the commissioners of the British nation at Netley,




176              MORRIS. —PLANS FOR TIIE
and those under private local auspices at Leeds, have each some
serious defect in arrangement or construction. Yet the growth
of population requires that additional accommodation shall be
provided; advance in social science demands that the improvements in architecture and economy shall be made available for
the benefit of the sick; and the dilapidation of old. structures
requires that new ones should be substituted for them.
It becomes necessary to take a survey of a wide field before
determining on any plan of action, and one cannot indulge the
expectation of avoiding all error in conclusions, or hope that in
the experiments of improvement there may not be some point in
which change may fail to be an advance; and it is certain that
our experience will afford a fresh starting point for progress, and
that future improvements will be based on our failures. The
problem to be solved, in this as in all other human interests,
is, how the largest amount of good may be secured with the
smallest amount of disadvantage for any given expenditure of
power: and here, as in most cases, money is the representative of
power.
It is not my design to engage in debate upon the principles involved, nor to enter into scientific discussions or statements; knowing only too well my want of qualification or ability
for either. Having been conversant with the inception, construe
tion, and development of a hospital, which, within fifteen years,
has grown from a few beds in a private house to a structure with
a capacity for three hundred beds; having participated in the
conferences over the plans adopted, and watched the practical
working in conformity with them, it is my simple purpose to
offer to you these plans, with some suggestions of change in
accordance with the requirements of the position in which you
are placed, and others which present themselves as probable
improvements.
I have myself as an individual no claim to any originality.
The plan presented as the basis of this paper is essentially that
of the Hospital of the Protestant Episcoptxl Church of Philadelphia, which plan was the result of much laborious thought
and consultation between the accomplished and experienced architect Mr. Samuel Sloan and the committee to which was entrusted the construction of that building. Messrs. John Welsh
and John C. Cresson brought to the service the benefit of intelli



JOHINS HIOPKINS' IHOSPITAL.            177
gent and cultivated minds, with great practical ability and clearness of perception, and much experience in detail of building; to
which Professor Cresson added rich scientific stores, accumulated
during a life devoted to such pursuits. Bishop Stevens, then
Rector of St. Andrew's church, and retaining still his interest in
the medical profession, in which he had acquired eminence
before entering holy orders, was also an earnest fellow laborer.
Dr. Edward Hartshorne added to similar endowments and acquirements the advantage of many years' experience as physician to the Eastern Penitentiary, and one of the surgeons of the
Pennsylvania Hospital and the Wills' Hospital, and contributed
also the results of much study of the subject of hospital construction, and very extensive observation of the buildings of
Europe devoted to the service of the sick, and of the modes of administration. Nor was it only in the original preparation of the
plan on which fifteen years ago the central building for administration was erected with one pavilion of two stories with an attic,
that these gentlemen manifested their ability. The experience
of those fifteen years of actual use was brought into service in
the construction of the pavilion now in process of erection.
The result of those many years of trial suggested but few
modifications; and those not essential. The changes in the detail
of that plan, which are here proposed, are such as approve thenmselves to my own judgment, as improved application of the principles on which that hospital was undertaken, and the extension
of the application of the same principles to the wider service required in the present case. The object has been to present
a plan which should combine simplicity of arrangement, with
adaptation to the various services to be performed; solidity and
durability with lightness and and airiness of construction; compactness, with enough of extension to secure the combination of ease
of administration with ample space; and to avoid everything
which should promote vitiation, or contamination of the atmosphere, or afford points at which there might be possible any
accumulation or concealment of foul or refuse matter to become
a cause of depravation of the air.
Dr. Robert S. Knight, who has devoted many years to the practical working of the Hospital of the Protestant Episcopal Church,
as Superintendealt, has kindly furnished Imany valuable hints,
the result of his intelligent and careful observation.




178               MORRIS.-PLANS FOR THE
With these preliminary remarks we are prepared to enter into
the consideration of the questions propounded in your letter of
inquiry.
The first question proposed in your letter, requesting opinions
on the best plan for the construction of a hospital for city service,
"is the choice between thepavilion system, which admits build"ings of two or more stories in height permanently constructed,' of which the Herbert Hospital in England, and several in this
"country, may be considered good modern types, and the bar"rack system of one story structures, destructible in whole or in
"part, which were so successfully used in the late war, but of'which no extensive and prominent example is now in operation."''
Two subjects, not necessarily connected, are included in this
question. A building of only one story may be easily destructible, and designed for only temporary use, or may be more permanent in its character; and some of the arguments advanced in
favor of the single story do not of necessity involve the question
of its being destructible; while the most permanent two-storied
structure is susceptible of removal of the plaster and floors
whenever necessary, and is thus made virtually a new building.
One answer to both is spontaneously suggested by the term
"City" in the proposition.
A city hospital must be adapted to the requirements of city
life, and must be constructed on the same principles as the city
itself.
Light, air, and space are essential to life; and a certain
amount of each is absolutely necessary to existence.  The more
ample the supply of air and light and the wider the range of
space enjoyed by each individual, the more robust the health
and the greater the enjoyment; provided in securing these, one
does not sacrifice other interests, each also important, though
not in the same degree.
The healthy residents of a city are well aware of this, and as
they possess the ability, avail themselves of the advantages of
wider space to secure increase of light and air, and only abandon
it to obtain other advantages.
But the necessity of concentrating action, and combining  in
concerted effort for business purposes, compels a majority of
them to sacrifice the comfort, and elegance, and superior advan



JOHNS HOPKINS' hOSPITAL.               179
tages in relation to health, of villa and suburban dwellings, and
to mass their houses on the smallest area which furnishes the
requisite amount of light and air, in order to economize time and
strength in the co-operative pursuit of common purposes. So
must the sick and wounded of such a population submit to similar concentration in order to secure advantages which cannot be
had without such sacrifice. As this concentration is necessary
for the business of life during health, so is it equally in times of
sickness in order to secure the greatest amount of provision of
means for recovery of health. The supply of medical and surgical attendance and nursing is limited, and cannot be spread
out indefinitely in proportion to the increased demand consequent upon this aggregation of the population in masses for the
sake of convenience in the transaction of business.
As in active life, wide spaces between dwellings and large sized
apartments promote the comfort and health of the occupants, but
the necessities of business convenience, and economy of labor and
expenditure, require the surrender of all that is not absolutely
essential, and the construction of houses which occupy a smaller
extent of surface, and are placed floor above floor; and the
mutual benefit derived from this compression of population into
the smallest space compatible with health, more than compensates
for the sacrifice of other advantages which it involves; so in the
city of the sick it is necessary to submit to as much concentration
as can be secured without an undue abandonment of that which
is of fundamental importance, the proportion of light and air,
and space essential to the restoration of impaired health.  It
were as impracticable to distribute the number of sick and
wounded accumulated within the densely populated precincts of
a city, with its proportionably increased causes of disease and
accident, over such an area as would provide for each the amount
of space they would enjoy in a rural district, as it would be to
carry on the mercantile op.erations of a great emporium of commerce, or the labors of a great mechanical or manufacturing
centre, with a similar disregard to the requirements for concentrated action. It is readily granted that a village of cottages,
with commodious arrangements, and airy, large apartments appropriated to the use of the sick, with a nurse for every half
dozen cases, and proportional supply of medical and surgical
skill, would return a per centage of mortality vastly less than




180 SMORRIS.-PLANS FOR THE
that supplied by crowded wards; just as a rural district or village does less than large towns. Utopian in the highest degree
as such a suggestion is recognized to be, it is scarcely less practicable than the plan of one-story barrack buildings for city
hospitals. But concentration and crowding are not synonymous
terms, and no argument is presented for crowded wards. NVlhen
the ample floor and air space of properly constructed wards in
modern hospitals, and the convenience, and appliances for the
comfort and nursing of the sick collected there, are placed in
contrast with the dark and illy ventilated rooms and houses to
which the poor, for whom these hospitals are provided, are accustomed, and in which they are compelled by the necessity of their
occupations to dwell, it must be acknowledged that they are
furnished with advantages in them, which, in comparison, are
almost as great as those of the imaginary village.
Carefully conducted observations, made in a wide field and
through many years, by numerous and unconnected persons
well qualified for the task, have furnished us with data on
which to found our calculations; and these have been adapted,
not to the production of a minimum, providing for every patient
the smallest amount of comfort compatible with existence, but
to the provision of the largest amount consistent with due
economy of labor and expenditure. In wards such as are proposed the most ample supply of light, air, and space is afforded.
The economy practised is only in the grouping the patients in
common wards, in order to diminish the number of nurses required, and lessen the labor; and by grouping many wards
together to curtail expense.  Every bed in a well-constructed
hospital is provided with at least 100 square feet of floor space,
in order to furnish ample room for the comfort of the patient
and for the convenience of the nurses in rendering the necessary
services; and from 1,200 to 1,600 cubic feet of air space for each
patient is believed to be no more than sufficient for the maintenance of the proper purity of the air, with the best arrangements for constant change.
From twenty-four to thirty is the number of patients that it
is found proper to place under the supervision of one head nurse,
and this number is collected in one ward; while in conjunction
with the various apartments accessary to such a ward, room for
ten more may be found wTitlhin the area necessary. Every such




JOHNS HOPKINS' IIOSPITAL.              181
ward is in truth a hospital in itself; and every general hospital
is but an aggregation of such, each being repeated till a sufficient
number of structures is provided for the patients it is designed
to accommodate. The question now before us is, shall the number of wards necessary be spread out upon the one level, each
ward separated from the other by a space at least double its
height? or shall the same amount of floor and air space be
furnished by superimposing one ward upon another?
"It has been laid down as an axiom by the Chirurgical Society
of Paris in 1864 that the clear space in which a hospital should
stand, should not afford a less area than nearly 540 square feet
to each patient, that is to say, that a hospital for eighty patients
should stand in the centre of an acre of ground; and they
further said that the proportional area should be greater as the
number of patients increases."
This calculation has reference to the usual system of manystoried buildings. It cannot be conceded that surface covered
by buildings occupied by sick, even though they be of only onestory, can be reckoned as vacant space. The same proportion of
space unoccupied must be allotted to one-story structures as to
those of greater elevation, and thus an acre of ground would be
required for every separate building.  The original outlay for
land, always a very important item of expenditure, must therefore be double for one-storied structures to that which would be
necessary for two. The consideration of the question of pelrma
nent or temporary buildings is distinct from that of one or nlore
stories, and will claim attention hereafter. In the case of the
Johns Hopkins' Hospital the land having been already acquired,
the cost of purchase need not be taken into consideration.
But in grading of grounds, excavation for-foundations and
sewerage, provision for conveyance of heat and artificial light, for
the distribution of food, and nearly all the various forms of service, and for roofing, the cost is the same for the building of one
story as for that of two. The cost of nursing and support might
almost be said to increase with the square of the distance, and
the difficulty of supervision and administration in the same proportion.
The safety of the surrounding neighborhood, and the probability of restoration of patients themselves, should not be
placed in jeopardy bay any considerations of economy in expend. -




182              MORRIS.-PLANS FOR T-IE
ture either for land or building, or in subsequent administration;
but if it is possible to secure the requisite floor and air space for
any given number of patients without the disadvantages connected with this diffusion over an unnecessarily wide extent
of surface, and without incurring the risk of injurious results
from position or crowding, it is certainly proper to do so.
There can be no justification of undue crowding; but this
may be effected as certainly in one-story buildings, placed side
by side, as when wards of the same capacity are built the one
above the other. No greater number of patients can be received
into the samle sized ward in the one position than in the other;
and the fact that two wards are supported by the same foundation and sheltered by the same roof, is no objection, provided
they are properly separated from each other. Isolation is the
object aimed at; and, if this be secured, economy, in construction and convenience of service, may be perfectly justifiable.
The objection to placing one ward above another is founded
chiefly on the supposed increased facility for the transmission
of foul or contaminated air from one to the other in this position; and on the increased freedom of ventilation afforded by
ridge openings, which cannot be had in the lower wards of twostoried buildings.
The transmission of miasmal influence, whatever that may
be, is not any more in an upward than in a lateral direction.
It is carried by currents of air, or on the persons and clothing
of those exposed to it, and in sponges, and dressings, and
instruments; and if these pass laterally from the source of contamination, the effect will be transmitted by lateral passages
as surely as by vertical.  In illustration of this, it may be
proper to refer to the fact asserted by good authority, that
at the Royal Victoria Hospital at Netley near Southampton,
England, where the wards and corridors are so improperly constructed as to favor communication, the opening of an abscess
filled with a peculiarly offensive fluid in one ward was promptly
recognized in another on the same floor at the distance of onethird of a mile.  If the corridors are made sufficiently long,
wide, high, and open, and the system of ventilation in the wards
is properly arranged, all the currents will be from the corridors
into the wards, and thus there will be no communication from




JOHNS HOPKINS' IHOSPITAL.             183
one ward to another, whether they be placed above or beside
each other.
This arrangement of currents is the only available mode of
preventing diffusion. Even with the most perfect arrangement
it is impossible to secure absolute immunity.  An incident,
occurring within my own knowledge, will exhibit the potency
of the cause of contamination and the facility of diffusion.
A passer on the street heard a tap at a window, and, pausing,
it was thrown up, and a gentleman, seated within, said: " Are you
afraid of varioloid  " the passer replied: "Yes, but draw down
the sash and I will talk to you." It was done immediately, yet
in due time to prove the source of poisoning, he sickened with
the disease. This was lateral diffusion; and while it shows the
subtle nature of the miasm, and the necessity for adopting every
guard against it, proves that all that can be done is ineffectual to
annihilate the influence. The outer air rushing into the room,
that from within escaped by a counter current through the same
opening.
There should be no channels of communication between wards,
which it is possible to dispense with, whether the connection be
lateral or vertical, and the warming and ventilation of each should
be entirely independent and isolated. In proportion to the freedom of escape of the air of a ward, by combustion in open fires
with vertical chimneys, and through properly adjusted flues,
will be the necessity for the supply of an equal amount of that
which is fresh and pure, which will flow in by every opening.
With such currents setting strongly toward the fire-places and
ventilating flues, the products of respiration and cutaneous
exhalation and other contaminating influences will be carried by
them to these points, and will have no opportunity for escape to
other wards by corridors or other channels of communication.
When the subject of heating comes under consideration, it will
be found that the difficulty of supplying properly warmed air to
one-storied structures, with ridge openings, is much greater than
to wards of the same area with appropriate substructions to
afford accommodation for the arrangements to furnish moderately heated pure air from without; while the open fire-places,
with tall chimneys in two-storied pavilions, create a demand for
this fresh supply more uniform in its operation and more subject to control, and less disturbing to the sensations of the occu



184             1MOPtRIS. —PLANS FOR TIE
pants than ridge openings. With the arrangements which are
proposed, and which will be described when the construction
of the ward is under consideration, it is believed that the flow
of air outward will be through the chimneys and fire-places
and flues; and thus the air which has been exhausted of its
vitalizing principles, and contaminated by the exhalations of
the sick, will be carried off by them without transmission to
other wards, whether above, below, or at the one side.
The experience not only of private dwellings but of public
institutions, in which many persons are brought under one
roof, is very strongly in favor of the superposition of one
story upon another.  Not only are the upper' rooms more
light, and cheerful, and airy, but they are also more healthy.
Army experience confirms this also. In buildings provided for
troops, even in miasmatic districts, those men who occupy the
upper floors, are less subject to disease than those on ground
floors, which would not be the case if that malarious influence
ascended; and travellers are aware that in foreign cities the upper
floors of hotels are appropriated to the best apartments; those
on the two lower floors being considered less healthy than those
above. It is a well established fact that prisoners confined in
upper stories, enjoy better health than those on ground floor
apartments.
We thus come to the investigation of the second point in the
question proposed.
Within the last few years there has been much discussion
whether permanent structures for hospital purposes, or temporary buildings erected at comparatively slight cost, and easily
removed and replaced, are to be preferred.  The controversy
is still actively urged; and you reasonably ask for an opinion.
The question has yet been brought to the test of actual experience only in military hospitals, except so far as the percentage of death in old hospital buildings, proves that when well
conducted they are equal to new. There is no doubt about the
fact that walls improperly constructed, floors imperfectly laid,
furniture allowed to become dilapidated, and clothing and bedding allowed to become foul from the effluvia and discharges,
the result of disease and emanations from the persons of the
sick, become themselves contaminated; and thus render the
atmosphere within and around them unhealthy; and give rise




JOIINS HIOPKINS' HOSPITAL.            180
to modifications of the symptoms of all cases subjected to their
influence; and render them more difficult of cure, or may even
give origin to special diseases.
Such results can be averted only by the exercise of unceasing
vigilance in the maintenance of the integrity of structures; and
by cleanliness; and the prompt removal of all secretions and
discharges; and articles imbued with them; even though their
injurious influence should not be attended by offensive odor.
This is not the measure of their poisonous power.  A lethal
influence may lurk in the atmosphere and no sensible odor
betray its presence, while a foul and offensive smell may give
rise to nothing more serious than nausea or disgust.  "Vigilance essential to success" should be the motto of hospital
management.  It embodies a principle applicable equally to
the professional treatment of the sick and injured, the nursing
of the patients, and the police of the establishment. Upon this
more even than upon construction, arrangements, or age of
buildings-it might almost be said more than upon the skill
of professional attendants-depends the result of hospital treatment. Without it the most judicious plan of buildings which
can be suggested, with the largest expenditure in original construction, will be rendered valueless; and the newest hospital
will yield the largest percentage of unsuccessful and fatal
results.  With intelligence, vigilance, and energy on the part
of the various officers in charge, an old building in which purity
and neatness are maintained, is greatly to be preferred to a
new one without such care. A close ill ventilated corner, an
accumulation of foul clothing, or careless slopping of floors,
or the obstruction of a drain, would contaminate the atmosphere of the best planned and best constructed building, however recent. Captain Galton of the British Army, in his admirable address on the construction of hospitals, quotes from a report of Mr. Simon, the medical officer of the Privy Council of
Great Britain, the following clear expression of these views:
"That which makes the healthiest house, makes likewise the
healthiest hospital; the same fastidious and universal cleanliness,
the sanme never-ceasing vigilance against the thousand forms in
which dirt may disguise itself, in air, and soil, and water, in
walls, and floors, and ceilings, in dress, and bedding, and furniture, in pots and palns and pails, in sinks and drains and dust




186               nORRIS.-PLANS FOR THFE
bins. It is but the same principle of management, but with immeasurably greater vigilance and skill; for the establishment
which has to be kept in such exquisite perfection of cleanliness,
is an establishment which never rests from fouling itself; nor are
there any products of its foulness, not even the least odorous of
such products, which ought not to be regarded as poisonous."
It must not be assumed that all the peril of what is termed
hospitalism rests lurking in old buildings; much less can it be
admitted that it is found only there, and can be escaped or annihilated by adopting barrack buildings of one-story and of cheap
construction, easily erected and quickly destroyed.  Hospital
gangrene, the mlost formidable malady supposed to originate
peculiarly in old, illy ventilated, and over-crowded wards, was
found in one-story newly constructed barracks during our late
war. Cheapness of construction and facility of removal may
lead to a want of vigilance, both in original construction and subsequent administration, which will be productive of the worst
consequences. In truth, cheapness of construction inlvolves the
use of inferior materials, and less care and skill in building.
Such a barrack after three or four years' use, may have more
cracks in illy plastered walls, more open seams and fissures in
badly laid floors of inferior wood, more pockets for the accumnulation of fomites, and be more saturated with poisonous influences, than a solid structure which has resisted the storms of
centuries and been kept in proper repair, and has afforded relief
to the sick and wounded of successive generations.
This is not a mere conclusion deduced from theoretic principles, but the result of actual observation. In one of the great
London hospitals the largest death rate was furnished by the new
wards recently added to the older structure; and the most satisfactory practical refutation of theoretic arguments against permanent hospital buildings, is furnished in the highly interesting
and intelligent paper of Dr. WVilliam  Hunt, contributed to the
Medical Times of Philadelphia, for Nov. 20, 1874, in which he
furnishes the statistics of the Surgical Mortality of the Pennsylvania tfospital, for the year 1872-3, as follows: "The entire
number of cases treated, during the twelve months in the house,
2,155: of whom there died, 172, or 8.59 per cent. Of these cases,
768 were medical, and 1,387 surgical. The whole number of
Surgical deaths was 90. Ofr these there died within 24 hours




JOHNS HOPKINS' HOSPITAL.                  187
(that is were killed by the accident for which they were brought
to the hospital) 35; within two days, 7; within three days, 4;
within fonr days, 1; within five days, 2. Of troubles inevitably
fatal, as spine and brain injuries, burns, wounds, etc., there
died in periods from  six to ninety-three days, 9; of cancer, 3;
tetanus, 2; cases fatal in themselves, in or out of hospital, 63,
leaving a mortality of 27 to account for, of whom 4 are put down
to pyiemia.  The others were made up of very severe cases, snch
as compound fractures, exhaustive suppurative troubles, necrosis, etc; and it is certainly fair to presume from  the social
status of most of them, that their lives were prolonged and their
sufferings ameliorated as well within, as they would have been
without, a hospital."  WTell may Dr. Hunt propose the question, " Ilow mlany of these cases died of hospitalism U"
Now the wards in which the male patients of the Pennsylvania
Hospital are treated (and a very large proportion of the surgical
cases are nmales), are in the oldest part of the building, bearing on
its front the date 1755; and those parts of most recent construction were erected in the last century.  The entire interior was
replastered, and new floors were laid about twenty years ago.
It were unwise to claim for that building the merit of perfection of arrangement; those most famuiliar with it, are most
ready to recognize its defects, and are constantly renewing efforts
to remove them.  But if with reasonable vigilance, such results
of treatment can be obtained in a hospital which has been
occupied more than a century, notwithstancling the defects in.
construction, which grew  out of the imperfect knowledge of
tile period at which it was built, it is only reasonable to claim
that it is safe to build hospitals with all the improvements the
result of modern progress, with the design and expectation that
thley may be safe still when they shall have been in use by as
many generations, only let them  be as solid in construction.
There is moreover, as has been already noticed, actual experience that exemption frol diseases supposed to be especially
cattached to old hospital structures, cannot be claimed for those
of most recent construction.  Hospital gangrene, that most
formidable of them  all, has not only occurred in the onestory temporary barracks of our military  hospitals, but is
found also in private, isolated dwellings.  Two patients sufferingl with it were recently brought from  different quarte.rs to the
Z __)                      t )~L LI\\II I    I~V




188               MORRIS.-PLANS FOR TilE
hospital of the Protestant Episcopal Church, in this city, for
treatment, where they were received and treated successfully
without injury to other patients.  Then, again, cheapness of
construction and facility of renewal, so far from guaranteeing
exemption from hospitalism, may favor its prodnction.  Slightly
built barracks must be liable to early decay, and a degree of
dilapidation productive of the most injurious influences on the
sanitary condition of a hospital, might be reached in a few
years, which would not result from a prolonged occupation of
buildings carefully constructed of good materials, in which the
knowledge they were to be perpetuated would add an additional
motive for care in present administration.
The rate of mortality in the hospital of the Protestant Episcopal Church in Philadelphia, which furnishes the basis of the plan
herewith submitted, has been remarkably small. In a note furnished for the preparation of the annual report, it is stated that
in 1873, it was 7 per cent. of all admissions, including a large
number of cases confessedly incurable when brought there, either
from the violence of the injuries received, or the nature or stage
of the disease with which they were afflicted. An endowment
for the special support of incurable cases, and another for a ward
for diseases of the lungs, brings to it a larger proportion of cases
seeking only care, not cure, than is found in most hospitals.
"The death rate of Philadelphia (one of tile healthiest cities
"in the world), is about 2, per cent. If it be assumed that one
"fourth of the population of the city, are during the year subject
"to disease or injury, as all are who are received into hospitals,
"then the rate applied to that part only would be ten per cent.,
"which is largely in excess of the hospital rate."
Granting all that is claimed by the advocates of cheap structures and frequent renewal, the application of the principle to
the case of hospitals for large cities is attended with grave if not
insuperable difficulties. AWhile the reasons which render proper
the use of shelter-tents and temporary barracks for troops in the
field, or encamped for limited periods in given localities, with the
constant expectation, and strong hope of a speedy termination
of the combination of events which causes them to be collected,
justify also the resort to similar arrangements for the reception
of the sick and wounded of an army; by a parity of reasoning
permanent locations and substantial buildings, are demanded for




JOIHNS HOPKINS' HOSPITAL.             189
the proper reception and treatment of the sick and wounded of
a settled permanent population, as that of a great city must
always be. Succeeding years only increase its density at a given
point, and spread still more widely the causes of disease, while
they increase the number of claimants for hospital relief, who are
stationary and if they receive hospital relief at all must have it
of easy access. An army hospital changes its location necessarily
with the removal of the troops; a military hospital, though it
may remain longer in one place, ceases to be needed when the
return of peace renders it no longer useful.
Such hospitals should be temporary, and can be and are, more
conveniently and better located at a distance from great towns,
where ample space can be procured at, comparatively small outlay, and appropriate sites abound. Even in the event of pro
longed war, creating prolonged need; and granting that consequent dilapidation, or the invasion of disease renders renewal
necessary, it is an easy affair to remove such an hospital. New
sites are readily found; but they must be in immediate proximity
to the forces for the accommodation of the sick and wounded of
which they are designed. The troops themselves would be moved
also; new sites would be sought for the army as well as for the
hospital. Such territorial migration for a city, may be compatible with the savage tyranny of Central Africa, it is impossible
for us; and as the army hospital must follow the troops when
moved, so must the city hospital retain its relative position to
the population which needs its relief, and is permanently fixed.
It should secure such ample space around it as will prevent the
encroachment of growing numbers; but it cannot be removed
from the heart of the town because the population becomes dense
around it. That very increase of density creates an additional
need for hospital service. The sick and the wounded cannot be
transported to inldefinite distances in the hour of sickness and
accident. Such transportation would in many cases, and those
of a character most urgently requiring hospital treatment, and
susceptible of restoration to health, result in inevitable death.
The suggestion of temporary receiving wards in centres of population with rural or suburban hospitals is not practically available. Neither grave cases of disease nor serious injuries would
bear the changes necessary in such an arrangement. They must
remain at whatever inconvenience where they are first taken.




190              M3ORRIS.-PLANS FOR THE
The hospital nmust be in immediate proximity to the population
it is designed to relieve, surrounded by as large a space of open
ground as can be secured for it. This population is fixed; so
must the hospital be: for suitable sites in such near vicinage are
rare and costly. To purchase a new one every ten years (the
termn fixed by some of the advocates of temporary structures
as the utmost limit of safe occupation of buildings,) would
involve a very heavy outlay of funds which could not be raised
by the sale of the ground already occupied; nor would it be
possible to erect new wards on the site of the old without
serious detriment to the sick occupants, even granting that
there were space enough to permit; while the arunument for
necessity of change is as fully applicable to the soil on which
the building stands as to the structures themselves.  To rebuild
the whole group of wards at the same time would be impossible, without an entire abandonment of the hospital service
during the time; and to renew them one by one would perpetuate the confusion, disorder, and uncleanliness, necessarily connected with the work of constrLuction. WAith proper vigilance
and constant care both buildings and land may alike be kept
free from contamination; and solid walls, and good roofs raised
on substantial foundations, permit the entire renewal of floors
and plastering and other interior parts of the structures, whenever age has caused dilapidation, or other influences call for
renovation; and thus all the practical advantage of new structures is actually obtained.
While thus advocating the erection of solid buildings for permanent use, it is not right to overlook the fact that there are certain cases in which it is desirable for the advantage of some
patients themselves that they should be withdrawn frotm the
general wards, and enjoy the benefit of exeimption from the vitiation which is unavoidable notwithstanding the utmost vigilance
and care.  Temporary structures may be pitched for such cases,
to which they can be removed.  Such are used in some European
hospitals, with great advantage for patients after amputation.
There is another class of cases which should be removed from
the general wards, consisting of such as have offensive dischiarges,
which pollute the air and render it disgusting to others.  One
such case interferes with the comfort of a whole ward. A neat
ward in the attic of each two-story pavilion, around the central




JOHNS HOPKINS' HOSPITAL.               191
chimneys, would furnish ample and convenient accommodation
for such cases, greatly to the relief of those left in the genera]
wards. Burns with large suppurating surfaces are peculiarly
offensive, and so are cases affected with incontinence of urine. A
" foul ward'" for the reception of such, might well be placed in the
position indicated; and the removal of such cases from the general
ward would greatly promote the comfort of all others. The room
need not extend beyond the square formed by the central projection; and its immediate and close connection with the stack
of chimneys and flues would insure it the greatest freedom of
ventilation.
The attention to hospital construction which the experience of
recent events in our late civil war has excited, was anticipated
by nearly a century, similar causes producing similar results.
There is in the library of the College of Physicians of Philadelphia, vol. 2576, 0. a copy of a pamphlet printed at Wlilmington,
Delaware, in the year 1813.  " Econoemical observations on MfMilitary HMospitals, and the?prevention cand entre of diseases i-,)cinlent
to an ArQzmy, etc., by James Tilton, I. D., Physician and Snrgceon
in the Revolutionary army of the United States."  Dr. Tilton
was one of the first graduates in medicine of the University of
Pennsylvania, and was a gentleman of great moral worth, and
high social standing, and attained  an enviable eminence as
one of the leading medical men of his day.  His account
of the overcrowding of the general hospitals, during the war of
the Revolution and the consequent mortality among the inmates,
is very sad. He asserts that "in 1777 and 1778 at least half
our army was swallowed up owing to a fatal tendency to throw
all the sick of the army into general hospitals where crowds gave
rise to infection and consequent mortality too affecting to mention."  (page 13).
Dr. Tilton describes the expedient to which he resorted to
remedy the evil; and is fairly entitled to the honor of having
been the first to introduce the system of temporary hut hospitals, as distinguished from  large and permanent buildings for
general hospital purposes.
Dr. Tilton says (page 47), "As to the construction of hospitals
"' I would observe that wood above all other materials of which
"' they are made, retains infection most permanently. Wooden
"' houses therefore, and especially  wooden floors should be




192              MORRIS.-PLANS FOR THE
"avoided.  Earthen floors are best, and tents are better than
" sheds or wooden houses......  The surface of a tent floor
"may be scraped off, or a new covering of fresh earth may be
"spread over it, as often as occasion may require, or, what is
i' still more expedient, a tent may be removed to a fresh surface
"as often as you please. The walls of a tent may be sluiced' with water and thus freed from all infection as often as you
" shall think it necessary. A wooden building can not be so
"cleansed. The best expedient hitherto discovered for cleansing
"wooden buildings is founded on the Mitchillian doctrine, by
"whitewashing.  This may serve for the walls, but wooden
" floors once infected are irreclaimable. The more you wash
" theim  with water, the worse they are. You must abandon
"them. Tents I should suppose would be particularly proper
" in warm climates, as well as in our warm seasons. They may'be opened at pleasure so as to admit the most free current of
"air. It is much easier to pitch the number of tents necessary
"than to prepare houses. The number of tents also may be
" proportioned to the number of sick so as to run no risk of
"crowding them. I have used common horsemen's tents, and
"long tents formed like the roof of a house prepared expressly
" for hospital purposes. But in cold climates and winter seasons,
"some better protection than tents afford, may be necessary.
"In such cases the best hospital I have ever contrived was
"upon the plan of ar Indian hut. The fire was built in the
"midst of the ward without any chimney, and the smoke circu-' lating round about, passed off through an opening about' four inches wide, in the ridge of the roof.  The common
" surface of the earth served for the floor.  The patients laid
" with their heads to the wall round about, and the feet were
"all turned to the fire.  The wards were thus completely
"ventilated. The smoke contributed to combat infection, with"out giving the least offence to the patients, for it always
" rose above their heads before it spread abroad in the ward,
"and more patients could be crowded with impunity in such
"wards, than in any other I have ever tried.  This was the
"expedient I employed in the hard winter of 1779-80 when the
"army was hutted near Morristown, and I was well satisfied
"with the experiment."
Dr. Tilton gives rude wood-cuts of these hospital huts. Three




JOHNS HOPKINS' HOSPITAL.               193
pavilions are connected together, a larger one with two smaller
crossing it, one at either end, each having its own entrance and a
separate fire-place.  "All the air and light are let in from the
" south front.
"The walls were built of rough logs, without hewing. The
"chinks were daubed with mortar made of common clay and
"water only. The middle or main ward, 311 by 191 feet in the
"clear, was assigned to febrile patients, and the smaller end" wards, 351 by 16 feet clear, were occupied by the wounded, and
" other cases of topical affection."'We may claim for these rough structures, adapted only to the
rudeness of those "times which tried men's souls," the merit of
being the prototypes of the temporary barracks and hut hospitals, for which some are disposed to claim advantages over wellbuilt and properly contrived structures of permanent character.
Better adapted to the advance and comfort of our own times,
even these are suited rather to the circumstances of armies, than
of settled centres of population.
Dr. Tilton' s experience with regard to overcrowding, and buildings improperly arranged, was similar to that which must everywhere follow such ill-directed efforts; and his description of the
French hospital at Williamsburgh in Virginia, exhibits a condition which of necessity rendered unavailable all the science and
skill of the surgeons of those forces. There was a total disregard
of the first principles of hygiene, and one cannot wonder that the
ravages of disease were more dreadful than those of the most
deadly conflict; and that, as Dr. Tilton states, the proportion of
surgeons who sacrificed their lives in the cause of their country,
was greater than that of officers in the field.
GENERAL CONSTRUCTION.
Having thus presented the grounds on which a preference for
permanent buildings and pavilions of two stories elevation is
based, it will be proper to advance to the consideration of the
detail of construction and administration.
The site has been determined for you by the intelligent and judicious selection made during his life by Johns Hopkins himself
-a site which combines in a preeminent degree the advantages
most essential to the purpose entertained: facility of access from




194               MORRIS.-PLANS FOR THE
all parts of your rapidly growing city;  elevation which lifts it
above all possible future encroacIhmuent by surrounding buildings, even though the district immediately adjacent should become densely populous; proximity to that part of your city occupied by those whose pursuits and habits render them specially
liable to injuries and diseases requiring hospital relief; easily accessible for those to whose professional care the beneficiaries are
committed, as well as to those who are entrusted with the supervision of the administration; while the beneficent and wise direction of the munificent founder of the charity, that you shall provide in the country an appendage to the hospital proper in a retreat for those who are convalescent, will relieve you from a great
embarrassment which oppresses kindred institutions, obliged to
limit the number of their patients suffering under acute disease,
on account of the difficulty of discharging such as no longer require active treatmuent, but who would lose much if not all the
benefit gained, if returned prematurely to the crowded apartments
and inadequate diet and attendance of their own homes or lodging-houses; and who are themselves retarded in their progress to
health by the surroundings which are appropriate and necessary
for those who are still sick and suffering.
It is important to secure all the advantage of elevation you possess. High as is your location, overlooking a wide extent of territory in every direction, the lots immediately east of you, separated from you only by a street of 60 feet between the curb,
have for a short distance a slightly higher level. It is therefore
essential that you should secure all the advantages of your own
elevation, by placing the front of your central buildings *on the
level of your highest point, and maintain that level for all the
extension of the structure.  This highest point is found at the
northeastern corner of your grounds, from which the descent, at!
first gradual, eventually becomes rapid as it approaches the
southwestern corner, where a retaining wall, embankment, and
terraces will be required.  The entire area occupied by the buildings, except that on the south line appropriated to buildings for
heating, and laundry, and other kindred purposes, which should
be sunk to the level of the street, should be graded by an uniform
slope, if it can be accomplished; though one terrace on a line
with the southern end of the front pavilions may be admissible,
or even desirable.




JOHNS HIOPKINS' IHOSPITAL.             195
To secure the utmost available freedom of circulation of air
for the hospital, diminish the liability to intrusion from without,
and at the same time give to the neighborhood a participation in
the benefit of the open space by which the buildings are surrounded, the grounds should be enclosed by a wall not more than
three feet in height, surmounted by an open iron railing; the
ground within being graded to the level of the top of the wall,
thence rising by slopes and terraces to the highest level. The
streets bounding your lot on the north and south and east are all
of reasonable width, while the noble avenue lying beside your
western limit has a grandeur in its breath, as well as in its extent,
which renders them in comparison contracted. If possible without encroaching on the space necessary for your structures,
MIonument Street, which forms your northern boundary, and on
which your buildings should front, should be widened to correspond with Broadway on the west. Such an abandonment of
ground on the part of the hospital would not diminish the air
space of the institution and might invite the erection on the opposite side, of buildings of such character, as would be attractive
if not imposing. Every effort should be made by means of enclosure, grading, planting, and embellishnment, to render the
hospital grounds attractive in appearance, not only to the patients
within but also to the neighlbors surrounding; and thus to enhlance the value of adjacent property and keep as far removed as
may be, all sources of contamination, moral as well as physical.
It is essential to secure all the advantages possible with regard
to light and air.  WVith this view not only should the buildings
be placed on the highest level of the ground but should be themselves elevated above it by a lofty basement.
The greater the elevation above the surface, the more cheerful
and healthy will be the wards. This consideration renders useless the direction that the rooms in the basement shall not be
used for the sick. They should be, however, to whatever use
they may be put, as well-lighted, as well-ventilated, and as wellfinished as any other part of the building; and no wooden floor
should be allowed even in those parts which may have vaults or
cellars beneath them. NVhere there are such vaults they should
be furnished with brick arches, and all the floors should be of
artificial stone or well laid and smoothly dressed flags. Whether
used for heating arrangements, storage purposes, or left unoc-ee




196               MORRIS. -PLANS FOR TIHE
pied, the windows should be large, and if left open as they should
be in suitable weather, they will secure for the wards above all
the advanta(ges claimed for such as are built on open arches while
they afford valuable space for various useful purposes. By closing the windows in stormy weather the warmth and dryness of
the ward floor is secured.
The generous founder having with great wisdom and justice
directed provision to be made for the reception of both sexes
without regard to color, it is necessary, in order to meet this requiremlent, that there shall be at least four separate pavilions,
each containing a surgical and a medical ward. Equal convenience and comfort must be secured for all; and yet economy and
ease in administration demand that these buildings shall not be
scattered over an unnecessarily wide extent of surface, and shall
be as nearly as possible equi-distant fronm the centre. It is hoped
the plan on which this paper is founded may meet these demands; neither crowding the buildings so closely as to impede
the fullest admission of light, and circulation of air; nor rendering administration and supervision more difficult and costly by
unnecessarily wide dispersion; nor giving to any one part superior advantages.
There are certain principles universally conceded which must
be kept continually in view while considering any plan for the
construction of a hospital; and of these the most important is
that light and air are essential to life. Health cannot be maintained without either; much less can it be restored when lost,
without an abundant supply of both. The freest access of both
is there —fore a fundamental necessity to every hospital, and other
things being equal the pereentage of recovery of health will be in
proportion to o the perfection of the arrangements for the supply
of these. Tis the great problem to be solved is the proper exposure,
and adjustment to each other and to the offices for administra,ionc, of those parts of the building which are appropriated to
the use of the sick, in such manner that they may all enjoy the
due amount of exposure to sunlight, and receive a properly graduated quantity of fresh and pure air, uncontaminated by emanations from  other sick persons; and yet be so congregated
as to economise labor and time in service, and thus diminish
expense.
Climatic considerations are of the very highest importance in




JOHNS HOPKINS' HOSPITAL.                197
this relation. A structure perfectly adapted to the tropics, or to
the heated term of our own sunl erf s would be wholy unsuitable
to the rigor of higher latitudes, or of our winter season. The
variations of climate in the temperate zone require that all
dwelling houses and other buildings should contain arrangements
adapted to both extremes. This is preeminently necessary in hospital structures.
Observation teaches us that even plants, except those of the
lowest organization, do not flourish in positions which are deprived of sunlight, and of air in mzotion; and that the conditions
which favor the development and promote the growth of these
are inimical to animal life. On the north exposure of buildings
and of trees, these growths flourish, and the higher order of even
vegetables perish.
During the winter months in this latitude the sun is wholly to
the south; and the period of the year in which his rays reach
the northern side of a building at any hour of the day is very
short.  During the cold months of winter, and the damp and
uncertain vernal season, the only breezes which can be admitted
into our dwellings, whether for invalids or persons in the enjoyment of health, with comfort and safety, are those which blow
from the south; while during the rigor of winter the northern
winds must be carefully excluded by every precaution that can
be adopted. Ntorth walls, even if wholly impermeable to air, become so chilled by wintry blasts that it is difficult to heat apartments bounded by them. No apartments for the sick, requiring
as do all such that there should be frequent changes of the atmosphere, and the maintenance of an equable and regulated temperature, should have such an exposure, unless they have also a
large southern opening. In prisons it is found that the health of
those who are confined in ranges of cells which have the northern
exposure, is not so good as that of those in the southern ranges,
and those on upper-floors are better than those on the lower.  It
is therefore laid down as an established principle in hospital
construction, in this latitude, that the wards shall be so placed
that the greatest possible proportion of their surface shall be exposed to the south, and thus receive all the benefit of the direct
rays of the sun, and that even with this advantage there shall be
as few cul de sacs, in which the freedom of circulation of air is
impeded, as is possible; and that the spaces between parallel




198               MOPRRIS.-PLANS FORT TIHE
buildings shall have as great width as is compatible with proper
concen tration.
The various rooms necessary for the purposes of general adlninistration and the residence of officers may easily be placed in a
central structure, and so arranged that each shall receive a share
of those influences, so essential to the life and comfort of those
who occupy them, ample for those in health, engaged in active
employment, and able to seek refreshmelnt by out-door recreation.
To these, therefore, the considerations so essential to the proper
provision of accommodatiois for the sick. do not apply.  It, is
only necessary to provide space, light, and air, in proportion to
their number. The southern exposure is of less importance.
Sonime general remarks on the subject of construction should
precede the consideration of the specific details of the parts of the
building.  The style of architecture is a matter of taste; the
interior arrangements and adaptation of the several parts to the
purpose designed, and to each other, is the point of essential importanee.  Still some regard to appearance and effect is due to the
community; and any violation of the rules of proportion of the
parts, or of the canons of taste in ornamiilent, should be avoided.
Prisons and police-stations should be made forbidding  and repulsive in appearance, even though regard for the sanctity of life
demands that there should be nothing detrimental to health in
the interior arrangements.  School-houses and college-buildings
should be spacious and cheerful-looking; and so, preeminently,
should be the structures designed for the reception of the sick.
A hospital should have an expression of comfort inspiring a
sense of repose, and tranquillity, and hope of restoration of
health. The very exterior should be attractive to the approaching
sufferer.  WVounded men, brought to the hospital of the Protestant Episcopal Church in Philadelphia, from the terrible diseomforts of field exposure, declared it was "like the approach to
paradise."  Too great display of ornament is out of place, not
only as involving a needless expenditure of money better appropriated to provisions for the comfort of the patients, but as repugnant to the inherent sense of propriety.  The style of architecture must of course be accommodated to the material used in
building, and that will vary of necessity with locality, and be
determined by convenience and cost. If stone be used, it should




JOHNS HOPKINS' HOSPITAL.                199
not be so white as to be glaring to the eyes of the sick, nor so
dark as to be gloomy. Whatever be the exterior, the inner walls
and the lining of the outer should be of well-burned brick, well
laid with strong mortar; and in order to secure entire freedom
from dampness, and check the transmission of heat, cooling the
wards in winter and heating them in summer, an air space of
some inches should be interposed between the outer and the inner
walls. The greatest vigilance should be exercised, dluring the progress of the building, to guard against the carelessness of workmen, who will, unless watched continually, fill this space with
rubbish and mortar, thus defeating the object. The same vigilance over the construction of flues is absolutely required.  The
neglect of it has entailed serious inconvenience, and endless expense in the removal of obstructions which may impair the action
of the best-contrived plans for heating and ventilation. The ignorance of somej and the indifference of others, require the unceasing oversight of an active and intelligent superintendent during
the whole progress of construction. It does not do to commit this
to contractors or master builders, too often careless about minor
matters of detail.  Obstructed flues, or wooden joists improperly
placed in contact with heated flues, are too often the result of
the ignorance or covetousness of builders, and can be guarded
again.st only by the unceasing watchfulness of those who will be
interested in the future success of the institution.
The greatest solidity of construction is necessary. To secure
this and guard against the results of settling, the foundations
should be deep, broad, and heavy, and of such material as will
bear the superincumbent weight. This cannot be too seriously
urged. Time should be allowed for the necessary settling before
the superstructure is laid upon them.
Grading of grounds, excavation, substructures, construction
of sewers and drains should be the work of one season, leaving
them well protected during the winter. Another building season
will be required for erection of walls, roofing in, and laying of
floors.  During the second winter much indoor work may be
done, and preparation made for the plastering, which should be
done so soon as the weather permits. This should be applied
directly to the walls; be of the best materials and have what is
known as the hard polish for the finishing coat. All joints and
projections should be rounded.  Wooden mouldings are wholly




200              MORRIS.-PLANS FOR THE
inadmissible, as shrinkage will allow or form cracks and fissures,
harbors for vermin and pockets for the retention of the morbid
emanations and exhalations from the sick. Similar objections
apply with equal force to all cornices and ornament to the ceiling, of moulded plaster. The base where the wall and floor join
should be guarded by a projection of cement, and not by a
wooden base strip. No projecting points or ledges, or mouldings, whether for ornament or use, can be allowed in any part of
the buildings.
Proper fymmetry of proportion will render ornament unnecessary. It is impossible to lay too much stress on the necessity of
avoiding, in every part of the building, everything which shall
have a tendency to catch dust, conceal dirt, or afford a harbor
for vermin of any kind. The disgusting results of want of precaution in this respect are indescribable; to say nothing of the
injurious influence on the sanitary state of the hospital.
The material and construction of the floors should command
primary attention, and, to avoid shrinkage, should be purchased
and subjected to the proper means to promote seasoning before
the foundations are laid; and window and door frames should be
put together at the same time.  Soft woods, or those easily
frayed or splintered, are wholly unsuited. They are defaced by
the pressure of the feet of bedsteads or chairs, and liable to be
scarred by the thoughtless dragging over them of a bedstead or
other heavy article of furniture; so that the indiscreet act of a
moment may produce permanent and irreparable mischief. Every
such bruised or frayed spot becomes a pocket for the reception
and emission of pestiferous contamination. The hardest and
closest grained wood accessible should be secured without reg'ard
to cost; and the utmost accuracy in the adjustment of joints
should be demanded. Costly and otherwise well constructed
buildings will be rendered unfit for hospital purposes if this be
neglected. One open seam or splintered edge of a joint, may become an irremediable source of contamination, in a ward otherwise without objection; and thus render useless all the expenditure of thought in contriving, and money and labor and material
in construction, and make unavailing the vigilance and neatness
of service.
When thus laid and carefull y planed smooth, the floors
should be imbued with oil colored with some material of a sub



JOHNS HOPKINS' HOSPITAL.                201
dued tone.  No rugs, or floor cloth, or covering of any kind,
should ever be allowed.  They will, of necessity, become foul,
no matter how m-nuch care is exerted to guard against it.  The
naked floor should therefore be made attractive in appearance.
The natural color of the wood, it is true, is more pleasing to
the eye, but is liable to grave objection. The remark just ventured as to the impossibility of guarding against the soiling
of rugs and carpets is equally applicable to the floors.  The
accidental overturning a cup containing medicine, or some
excretion, a wash or a liniment, which cannot, always be avoided
in the hurried movements often necessary, or a jet of blood
from a, divided vessel before it can be tied, not only produces a temporary soil, but leaves a permanent stain on a light
colored floor, to offend the eye at least, even if free from other
evil influence. The effort to remove the soil or efface the stain
by scrubbing, diffuses an unhealthy dampness through the entire
ward, especially pernicious to the occupants of the adjacent beds.
All wet cleansing is ivjux'ions, and the necessity for it should be
guarded against. Floors made of hard wood, and then rendered
impermeable by being imbued with colored oil or wax, may be
kept perfectly clean by dry sweeping, and occasional mopping
with an absorbing moistened cloth, without the necessity for
scrubbing, which, in careless hands, leads inevitably to the slopping pools of water on the soiled spot, every moment absorbed
by the floor only to be emitted in a. more subtle form of vapor
contaminated by the foulness of the source of the soil to remove
which the water was applied, thus diffusing more widely the evil
influence. Varnish and paint, while equally effectual with the
oil in preventing the absorption by the wood of whatever may
be spilled upon it, are liable to objection on account of the facility with which they are worn off by the attrition of feet: not only
giving an untidy appearance to the floor, but leaving the portions
thus exposed unprotected, to imbibe whatever may be spilled
upon them. The colored oil is more deeply imbibed by the wood
than the varnish or paint; the application lasts longer without
requiring renewal; and the eye is not offended by the strongly
marked lines of wear.
Before any floors are laid, or plaster put upon the walls, all
fines, and pipes or tubes for gas, or bell, or telegraph wires, should
be fixed carefully, that there may never be occasion to raise a




202              1MOPRIS.-PLANS FOR THE
board in the floor or break the continuity of the wall. It is impossible ever to re-adjust a board once raised, or to repair perfectly
the fracture of the plaster coat. Applicable to every part of the
building, these remarks apply with still greater force to the
wards directly appropriated to the sick.
The windows should be large and rise high toward the ceiling,
and descend so low toward the floor as to permit a patient lying
in bed to look out of that before him without being compelled to
assume any constrained position.
Some have suggested that they should open down to the floor.
There are many objections to such windows. It is difficult, if not
impossible, to make them so close as to exclude draughts, which
are always undesirable, and under such circumstances, falling so
directly on the beds, would be very injurious. While it is impossible to exclude the outer air, and most improper if p)ossible,
its admission should be under control, and not through crevices
or cracks. The sashes of windows descending to the floor and
rising near the ceiling, are too heavy to be easily moved, and the
glass is too liable to be broken. The ward windows should be
double glazed, with a space between the inner and outer panes;
thus interposing a stratum of air, to interrupt the rapid transmission of heat during the cold weather. All the windows should
be furnished with inside, slatted shutters, divided transversely
midway in the height, and folding in several divisions longitudinally.  The slats should be short and narrow, and lie well
over each other, and turn in compartments on pivots.  These
are absolutely necessary in order to moderate excess of light,
and to prevent the falling of the sun's rays directly on the beds,
or even faces, of the patients.
Outside awnings of canvas, such as are used in tropical countries and are now beingo introduced in our own, placed during the
summer at the windows of the wards, would contribute greatly
to the comfort of patients.  They shade the windows effectually, while they afford free access to the air. They must be
removed at the approach of winter, during which all the sunlight available is required.   The window  seats everywhere
should be of slate, polished. Wooden seats expand and contract under the drying influence of heat, and crack the plaster
where it rests upon them, thus not only giving rise to an unsightly appearance, but affording harbor for vermin.  They




JOHNS HOPKINS' HOSPITAL.               203
should be wide, so as to afford suitable resting-places for flowerpots containing living plants, which enliven the appearance of
the ward, and cheer the hearts of the patients.  They are not
liable to the objection so justly made to flowers which have
been cut and formed into bouqaets.  These decay promptly,
and commulnicate to the water in which they are placed vegetable juices, which undergo putrefactive fermentation and render
the air impure.
One of our most distinguLished surgeons in charge of a large
hospital half a century ago, expressed his opinion that no hospital was complete which was not provided with a green-house,
from which flowering plants should be placed about the wards and
rooms of patients.
The main central building should contain all the apartments
necessary for the comfortable accommodation of the various resident officers, professional and executive, and these should be
provided with such liberality as shall promote the cheerfulness
and health of those who, in the discharge of their arduous duties,
are subject to influences depressing to the feelings, and injurious
to the health. No useless expenditure upon ornament or furniture should be indulged. Here, as in the other departments of
the hospital, there should be nothing requiring extra service to
preserve cleanliness; nothing to occasion needless expenditure,
or the employment of more servants than are absolutely necessary. The greater the number of these, the more to be fed and
lodged, the greater the difficulty of preserving order and discipline and cleanliness.
The warden or superintendent, and the matron and resident
medical officers and apothecary may well form one family, having
one parlor and one dining-room in common, while the other enmployes and servants will have similar apartments in the central
basement, or near as may be to the kitchen, but without being
allowed access to it, except for service there. They should not
be allowed to gather there to gossip and idle. A sitting-room
should be provided near the refectory to which they can resort
when not engaged in active duty. Ample provision should be
made in the basement of this central building for the accommodation of the servants; with arrangements for ablution, bathing
their persons, and for water-closets, etc. These should all be
light and airy. This should be firmly impressed on thie minds




204              MORRIS.-PLANS FOR THE
of all in any way connected with hospital buildings. There
should be no dark corner or closet or hole of any kind anywhere.
Every brush, and pot, and pail should be kept in an open and
airy room, subject to inspection at any moment. Even the closets
in which clothing is deposited should have open shelves, otherwise foul articles will be shut up in them to elude observation.
Dark or illy ventilated water-closets are as exceptionable in the
centre building, and for the use of servants, as they are about
the wards themselves. They should be abundantly provided
everywhere, of easy access, and always subject to observation,
that they may be kept pure. Elements of disease engendered
there may be transported on the persons of officers or servants to
the wards themselves and be productive of the most disastrous
results.
There are four services essential to the hospital administration,
each of which requires accommodations entirely detached from
the wards, for which especial buildings must be provided, all as
nearly central as possible. Two of these-the general supervision
and the preparation and dispensing of medicines-may very properly be placed beside each other, in the main central building.
The other two must each have a detached building.
The kitchen for the preparation and distribution of food must
be placed as nearly as possible at the centre of the entire group
of buildings to be served from it, but entirely detached from them
all.
The building appropriated to the generation and distribution of
heat should be placed on the central line, but beyond the extreme
southern end of the most southern pavilion, on the line of a
street, by which it can receive its supply of coals, and get rid of
its ashes without trespassing on the grounds appropriated to the
patients. It should open on the level of the street, and should
have coal-bins so arranged as to permit carts to drive above them
and dump the coal directly into them.
In the same building the laundry should be placed. It should
have a flagged floor, and be furnished with a revolving wringer
and a drying-room, for use in bad weather; but there should be
also an enclosed yard, well exposed to the sun, in order that all
clothing should be hung in the open air, and receive the direct
rays of the sun whenever the weather permits. This purifies the
clothing much more than mere washing, however thoroughly




JOHNS HOPKINS HOSPITAL.              205
done, and drying in a closed, heated chamber. Machines for
saving manual labor in washing should be used, but not to the
exclusion of direct application of human hands to the removal
of the soils and stains. This cannot be dispensed with, however
much it may be assisted by other agencies. In the same building
there should be a close apartment, communicating by' a flue with
the furnace chimney, in which clothing, and bedding, and bedsteads may be subjected to a high degree of heat, for their purification. All these processes of purification should be conducted
at this point, the furthest removed from the wards of the sick.
The laundry especially, with its damp vapors charged with the
foul matter removed from soiled garments and bedding, should
be thus detached.
That all patients received into a hospital do not recover their
health, is only in conformity with the law of mortality, to which
man is subject. Some disposition must be made of the bodies
of the dead.  They should be removed from the presence of
the living sick as speedily as possible after death has been
rendered certain. A decent room should be provided in which
they shall be kept till claimed by friends; and another where
friends may assemble to pay the last tributes of affection and
respect.
The proper place -for this is in the building appropriated to
heating and laundry purposes. Detached from those parts of the
hospital occupied by the sick, and fronting on a street which
affords ready access, it is yet withdrawn from general observation, and the bodies may be taken to it from any part of the hospital, without exposure, through the basements and tunnel connecting them with the building. Two rooms would be proper, as
from so large a number of patients more than one might be lying
dead at the same time. The front of this structure on the street
should have nothing repulsive in its aspect.
To trace the results of disease in the bodies of the dead, and
from them to seek for causes and means of prevention and cure
is always an object of much interest, to every intelligent medical
man, and the opportunities for doing this furnished by hospitals
has always been regarded one of the great benefits they confer on
mankind. Properly conducted, such investigations have in them
nothing repulsive, and are generally recognized as proper.  The
friends of those who die in hospitals have as much claim to con



206               MORRIS.1 —PLANS FOR THE
sideration of their feelings in this respect, as any other class.
These feelings should always be regarded.  But when properly
informed of the grounds which render important such an examination, friends rarely refuse it.  Some place properly constructed and furnished for the purpose is essential to every hospital. No more appropriate place can be found than immediately adjoining the rooms provided for the reception of their
friends. Such rooms should be lighted in such manner as will
screen the interior from  the inspection of idle curiosity, and
have ample provision to secure perfect cleanliness in all its
details.
WARD.
Having thus gone hastily over the general arrangement and
construction of the buildings required, it is proper to enter into
more specific detail.
The ward into which the patients are received, and in which
they are cared for, is, strictly speaking, the hospital; and a
general hospital is but the apggrecgation of as many structures,
each formed on the sanme type, as may be necessary to furnish
the requisite accommodation for the number of patients the income enables it to support.
There is a limit to the size of a hospital; and the number of patients to be accommodated fixed by Mr. Hopkins himself, is the
largest which it is wise to collect in one place and under one management. Better three or four such, scattered in different parts
of a large town, than a larger number aggregated in one common
institution.
These wards may be quite detached, united together on the
same level, or superimposed, the one upon the other; still each
is perfect in itself, and should be provided with every arrang'emnent for the comllfolrt and convenience and proper treatment of its
inmates, as thonugh there were no others. In describing, therefore, the plan of one, that of all is given, however many there
may be.
The size and shape, and adjustment of the various parts to
each other, are not subject to arbitrary arrangement, but are developed by the necessities to be provided for. They are the natural outgrowth of the demands of the institution, as decidedly
as the form and structure of any living organism is the result of




JOHNS 5HOPKINS' HOSPITAL.               207
its nature and wants, and provide the means of supplying them.
Hence it will be found that a peculiar shape of the ward is comnimon to all hospital plans of modern date. The variation is in the
adjustment of them to each other and to the administration offices.
As the aggiregated wards which compose a general hospita!
must be placed under the control and supervision of one warden ol
superintendent, and must, therefore, be grouped in such relation
to each other as most promotes convenience in supervision; so, in
the same manner and for the same reason, each separate ward
must be under the charge of one executive officer-the nursewho, being held responsible to the physician and superintendent
for the faithful execution of all orders, must be able to observe
with convenience tihe condition and progress of each case, in order
to render such service as each may require, and to report such
changes as are constantly occurring. To secure this, the arrangement must be such as brings every part, of the ward into proper
relation, so that each patient may be under constant observation;
and while every one has a due supply of light and air, they may
be so concentrated that each is ready of access.
The first act of creation, preceding the existence of living creatures, was the provision of light; and it was not until God
"breathed into his nostrils the breath of life," that man " became
a living soul."   Life and health are, therefore, dependent on
ighzt and air; and the supply of these, with the amount of
space in which they may be enjoyed, is the fundamental point
arounld which all ward arrangements cluster.  Life may be
maintained without fresh supplies of food during many days,
while only a few minutes' withdrawal of air is fatal; so important is this to our being; and it should nmever be forgotten that,
in proportion to the vitiation of the purity of the air and the
withdrawal of light, is the loss of life-sustaining power.
The size of the ward depends on the number of the occupants,
each requiring a given extent of space and a given amount of air;
and the number of occupants depends on the ability of one person, with proper assistants, to nurse them.
Under this term -nursinlg  are included all the various services
performled for the sick under the direction of the surgeon or physic ian in charge. The nurse not only applies the remedies and
gives the food, but regulates the temperature, and the supply of
air and light, and ministers in every way to the mitigation of snf



208               MORRIS. —PLANS FOR THE
fering and the promotion of the restoration of health. In order
that this may be properly done, it is necessary that all the patients allotted to the care of one nurse should be placed in one
apartment, and not more widely dispersed than hygienic principles require; and that they should be so distributed that all shall
be in sight at the same time from every point, yet not so crowded
together as to encroach on the share of light and air appropriate
to each, thus gendering disease instead of restoring health.
The result of most careful observation has been to lead to the
conclusion already stated, that 100 square feet of floor space is
necessary for every patient in a hospital, in order to secure sufficient room for the various services of attendants; and. that not
less than from 1200 to 1600 cubic feet of air space is required,
with all the arrangements for frequent removal of the air which
can be made available.
The mnultiplication of nurses and assistants involves not only
increase of expenditure, but, what is still more to be guarded
against, division and, therefore, diminution of personal responsibility.  To prevent this, each ward should be capable of receiving just so many patients as can be properly cared for by one nurse.
It would be impossible for one person to attend to many cases
of extremle illness; nor is it desirable for the sick themselves that
many severe cases should be collected together.  It is more
difficult to maintain the requisite cleanliness; and the exhalations
from  the bodies accumulate in larger quantities and are more
injurious; as is proved by the higher death-rate in wards where
they are thus grouped. It is therefore on every account better to
distribute the more serious cases in the same wards with those of
less gravity. Thus in every ward there will be collected cases of
disease of various forms and different degrees of gravity, in every
stage of advance and decline, and affecting persons of every
variety of character, requiring varying degrees of attention, some
even capable of rendering assistance to each other by minor acts
of service. No fixed rule can be laid down as to the amount of
attention any given case shall require, nor is it possible to divide
the finite power of the nurse amid an infinite variety of demands.
But of such an average of cases, experience has taught that a
good nurse, with suitable assistants under her control, can care
for about thirty patients.  This determines the size and capacity
of the ward. It must have at least thirty times the 100 square




JOHNS HOPKINS' IHOSPITAL.              209
feet of floor space, and this must be so arranged as to give also
not less than thirty times the 1200 cubic feet of air space; these
figures giving the minimum of each. Each patient must have an
equal access of light and amount of air. To furnish these, there
must be appropriate windows for every bed, and no corners or
recesses for concealment.
A parallelogram of greater length than breadth presents the
most eligible shape. This, therefore, has been adopted as that
best suited for a ward, and the size must be such as affords the
necessary space.
But there are certain adjuncts and offices which are essential
to the performance of necessary services to the sick which cannot
be performed at the bedside nor in the ward; and rooms for these
must be so appended as to bring theim into the most convenient
relation to the ward proper and to each other.
To permit space for some of these, the structure of the parallelogram must be still more elongated, the addition being separated from the ward, and divided into rooms; and, in order to
give the sick, especially those confined to their beds, the best advantages of light and air, they must be allowed the southern end
and these offices must be added to the northern end. For other
purposes, also, suitable appendages must be provided zohoily o)n
th/e exterior, yet opening out from the ward.
A nurse's apartment is of prime importance for every ward.
except those appropriated to children.  In those, the nurse
should sleep in the common ward, and thus have them directly
under notice at all hours of the night and day.
The nurse's room should be large, light and cheerful, so that
every opportunity for the recuperation of forces exhausted in
duty, should be afforded in the hours of relaxation. This room
should be immediately adjacent to the ward, and should have a
window for observation opening into it. Next to this, further
removed from the ward, should be a kitchen for the preparation
of gruels, tea, coffee, toast, or messes of various kinds of special
diet, to be furnished at irregular hours, and which cannot be provided for in the central kitchen. There should be in this a good
cooking range with circulating boiler so as to supply hot water
constantly for washing purposes. There should be also a sink
for washing plates, and cups, and bowls, and other vessels used
in supplying diet, not medicine.  Those used for the latter




210               MORRIS.-PLANS FOR THE
purpose, should never be allowed to be taken there for any
purpose whatever.  There should be simple open shelves on
which the vessels used in conveying food to the patients should
be arrancged when clean. There should be no closet with doors
in which anything soiled could be put out of sight for even a
moment, no drawers or other places for the concealment of
articles imperfectly cleansed. The remark, made when treating
of general construction, upon the importance of avoiding everything which should afford harbor for vermin, is especially applicable here. No fixed table nor shelf should rest against the
wall.  The wall behind the sink should be guarded from soil
and the slopping of foul water by a slab of glass. The floor
should be of slate, or artificial stone of such composition as will
neither absorb fluids spilled upon it, nor wear by attrition. If
laid with slate, the flags should be joined accurately, and they
should be laid securely, or they will work loose and afford holes
for dust and dirt.
Adjoining the kitchen is a space in which a lift for patients
may be placed, if it is thought desirable. If not used for that
purpose, this affords a most appropriate position for a closet for
keeping a supply of clean bed linen, which should be always at
hand, and the supply should be abundant. Then comes the stairway by which the ward communicates with its fellow above or
below. It must be large and well lighted and of easy grade, each
step having a tread of twelve inches and a riser of six. An iron
handrail attached firmly to the wall by stays at proper intervals,
not let into the wall, should be provided in order to furnish support to the feeble in ascending or descending. These stairs should
be of stone. Solid slate affords the best material, as it does not
polish and become smooth as'metal steps do, nor wear away
under the tread and become uneven, as sand-stone and marble
do. It has also the great advantage of having little or no capacity for absorption of water or other fluids spilled upon it.
WVhen the stairway is made with a broad tread and easy rise,
and the buildings of only two stories, patients of every kind,
whether sick or wounded, may be carried up or down on stretchers, or in chairs suspended on a fulcrumn between bearing-poles so
that they adjust themselves to tbe level, with less inconvenience
and suffering than by an elevator. These stairs may be made
to open on the veranda, instead of into the corridor or passag'e,




JOHNS HOPKINS' IHOSPITAL.             211
and thus if there be no shaft for a lift, there will be no channel
of direct communication between the ward below and above.
W~hen not in use the shafts are shut up and the air in them becomes stagnant, and the machinery must be kept oiled and thus
promote foulness. If possible, they should be avoided. Properly
constructed stairs supersede the necessity of an elevator.
These several divisions occupy the entire space on the one side
between the inner or northern end of the ward proper, and the
south line of the corridor by which it is connected with the other
pavilions.  The corresponding space on the opposite or outer
side of the passage leading to the ward from the connecting
corridor, affords room for a subsidiary ward capable of receiving some eight beds, which may very properly be used, in connection with the surgical ward, as a private operating room;
and, in connection with the medical ward, for those cases which
require a little more seclusion than can be found in the long
ward.  There should, however, be in every ward an ample
supply of light mnovable screens, with good bases and covered
with a well glazed material, which can be placed around any bed
in order to secure privacy for the occupant at any timle it is
desirable to do so without removal.
On the north side of the connecting corridor are two rooms,
separated from each other by a passage, having a window opening to the north. That on the inner side, should be used ais the
ward refectory, and should communicate with the basement by a
small lift, to be ztsed oullyforfood.  All patients who can leave
their beds should be required to take their meals in this refectory,
not only in order to avoid the soiling of the ward by the careless
slopping of liquids or scattering of crumbs, but because it is better
for themselves that they should take their meals out of the ward
atmosphere. The other apartment should be fitted up as a reading or recreation room, and furnished with books and games for
amusement in order to draw out of the wards all who are able to
leave it.
In describing the adjuncts of the ward it still remains to speak
of those exterior to it, the rmost important of them all-waterclosets, urinals, receptacles for slops, bath-rooms, lavatories, etc.
The spaces appropriated to these purposes must be large
enough to prevent any crowding; and the accommodation so
ample that there shall be no necessity for the detention of any




212              MORRIS. — PLANS FOR TIHE
patient waiting for an opportunity of relief. In this part of the
arrang'ement there should be no stint-want of largeness of provision in the beginning will entail endless trouble. No patient
should have anlly apology for not going to the water closet, who
is not confined absolutely to the recumbent position. WVhen the
closets are placed at one end only of the ward the distance to be
travelled fromi the other end is too great for a weak patient, and
affords an excuse to the indolent for the needless use of vessels
about the bed.
They must be so placed as to afford the most ready access from
the beds, and yet be as much shut out from the area of the ward
as though they had no connection with it.
To accomplish both purposes towers should be built projecting from one side of the parallelogram at either end of that part
which constitutes the ward proper, shut off from the ward by
light door frames covered with highly glazed impermeable material, such for instance as that known as imitation morocco, closed
by springs, the doors double, with an intervening space, one door
opening either way, so that one shall close as the other is opened,
and that there shall never be an unbroken communication between
these apartments and the ward. These should receive their light,
air, and heat, each in ample abundance from sources entirely independent of the ward supply. Placed thus at either end of the
ward, each range of water closets should contain at least three
seats, and for each pan there should be a separate compartment
furnished with a door closed by a spring.  This door should be
attached to the water pipe, so that the mere act of opening it
shall cause the pan to be flushed freely with water, independently
of the volition of the patient, who may be too weak, too ignorant,
or too careless to give proper attention to this necessary act.
No part of the construction of hospitals, or of dwelling-houses,
is more important, or should receive more thought in arrangement or more care in supervision than this. From defect in original construction, or neglect in subsequent attention, palaces
have been converted into seats of pestilence, and hotels have sent
their guests to the grave, or entailed upon them months of painful
sickness or permanent valetudinarianism. In hospitals this care
is especially required. The inmates are perpetually changing,
and are drawn from that class of society absolutely ignorant of
the necessity for care on such subjects, and reconciled by habit




JOHNS HOPKINS' HOSPITAL.                213
to uncleanliness and foul odors.  It is practically difficult, if
not impossible, to convince them of the injurious influence of that
to which they are accustomed; and the constant change of patients requires the unceasing repetition of the same lesson, and
extension of the same care. Economy and security from obstruction is consulted by the provision of suitable material for abstersion in proper size; otherwise the pipes will be obstructed by
needless quantities of paper, or insoluble masses of rags, oakum,
cotton, or whatever comes most conveniently to hand.
Two separate urinals should be provided in each tower. These
should be of porcelain, and not of the usual rounded shape, but
so formed that the person using it must stand directly over it,
and thus have no apology, indeed no opportunity, for soiling
the floor. There is no odor more pervading, and few  more
offensive, than that due to the decomposition of the secretion
from the kidneys of even healthy animals; and the urine in disease becomes charged with effete material, the putrefaction of
which renders the odor insufferably abominable. No wooden
floor is permissible for these apartments.  Artificial stone, or
well-laid slate flags, affords the best material  The wall adjacent
to the urinal should be sheathed with solid glass slabs, and the
floor beneath should be guarded with the same.*  This is absolutely non-absorbent, but the surface of it should be frequently
cleansed by a good sponge. There must be a separate receptacle
for slops, lined with porcelain, of globular shape-not conical or
square-provided with an ample supply of water, hot and cold,
so that all vessels used to receive sputa, or other excretions or
secretions, or discharges at the bedside, shall be readily cleansed,
and the receptacle itself flushed freely afterward.
In an adjoining room-properly separated by a screen-should
be placed the necessary arrangements for washing. Three or
nore basins excavated in a marble block, each furnished with a
water-cock and grated outlet, are necessary at each end of the
ward. There should be sufficient space between the basins to
allow them all to be used simultaneously without inconvenient
crowding; and the wall behind should be sheathed with glass to
* For the Lose of this most appropriate material for such purposes we are indebted to
the architect of the Presbyterian Hospital.




214               MORRIS.-PLANS FOR TIHE
prevent the absorption of the foul water splashed against it.
There should be also a fixed bath-tub, lined with planished
copper coated -with tin; and a movable bath-tub to be taken if
necessary to the bedside of any patient unable to bear being
carried to the room. The apartments appropriated to these purposes must be well lighted by windows independently of the
ward; and ventilated by a separate stack of flues to be heated
either by fire in the basement or by steam coils properly placed
within them, or connected by horizontal flues with the furnace
chimney. Every seat in the water-closet must have an opening
beneath it conducting to a heated flue, so as to furnish a strong
downward current beneath every pan.
Similar arrangements for the subsidiary ward should be made
in the tower at the north end; which should be made so capacious as to furnish space for this independently of that appropriated to that end of the main ward. In the upper part of
each of these towers there must be a room, heated by steam coils
in the cold weather in order to prevent freezing, containing irontanks capable of holding a supply of water ample to meet the
draught necessary for these several services. It is estimated
that at least 4,000 gallons is necessary to meet the requirements
of the eighty patients it is proposed to provide for in each
pavilion.
CORRIDORS AND VERANDAS.
Wards thus constructed must be united to each other and to
the main building by passages to facilitate the access of the
officers from part to part, and the proper performance of the
various services.  Patients in various stages and degrees of
sickness will also require transference from one ward to another.
There must, therefore, be means of communication, and in our
variable climate it is important that these shall be capable of
being warmed in winter, and kept airy in the sulnmmer; and
screened from the sun, and protected from the weather at all
seasons. There is no difficulty in securing the fulfilment of all
these purposes, without risk of obstruction of the freest circulation of air. The corridor should be wide and lofty, and the
doors should be large, and open opposite to each other; and
tile arches should correspond in the same way, and be lmade as
highl and wide as is compatible with strength of the walls.




JOHNS HOPKINS' HOSPITAL.               215
These should be merely strong pillars, occupying as small space
laterally as possible. The arches should be glazed, with sashes to
open so that the sashes of opposite windows being thrown up
when the weather renders it proper, there may be a current
through, and a freedom of circulation as entire as though there
were no obstruction; while the closure of the doors and sashes,
when necessary entirely, excludes the rain or snow. A partial
opening or closure, adjusted to the temperature, is always under
the control of the officers. The advantages of connection and protection may thus be secured with entire freedom of circulation.
There is still another necessity for the patients to be met. Some
escape from the ward musc be provided for those who are able to
leave their beds; some arrangement by which they can breathe
the outer air at intervals; some place to which they may resort
for exercise, and where they may indulge in cheerful conversation and merriment without disturbing the repose of those who
are so ill that these cannot be permitted in their immediate
presence.  For this purpose in some hospitals galleries have
been constructed running parallel to the wards.  *This is an
exceedingly objectionzable position. They exclude the light and
air from the wards, and not only impair the ventilation, but,
opening out of the wards, receive all the impure atmosphere,
and retain it; so that the patients who frequent them breathe
the same air as that of the ward, only somewhat diluted. The
prevalence of the habit of tobacco-smoking is also so general
that the appetite for it must be indulged, and the smoke will
be carried into the wards through open windows and doors,
which transmit also the disturbance of noise from  conversation and heavy footfalls.  All these are serious objections,
and render such galleries entirely inadmissible.  Open verandas
on the south side of the connecting corridors present every
advantage required, and are not liable to  these objections.
On the same level with the ward floor, they are easily accessible
for the feeblest who can walk, and by wheeled chairs for those who
cannot but are able to leave their beds. Facing the south, they
receive the full benefit of the warm sun in the winter season, and
are screened from the cold winds by the closed satshes and doors
of the corridors; while, during the warm  season these, being
thrown open, invite of course, the utmost freedom of the breezes
from whatever point they blow. At all seasons, in every state of




216              MORRIS. —PLANS FOR THE
the weather, except the most inclement, they are favorite places.of resort, and patients unable to rise may be gratified in their
desire to be carried there on their beds. There is no adjunct of
the ward which contributes more to the comfort of the sick, or is
more important in promoting the restoration of health.
A similar veranda may be provided at the south end of each
ward, with a large central window opening to the floor. In this,
however, smoking should be prohibited, as the fumes would be
drawn directly into the ward.
A tower at the side of the south end of the pavilion, corresponding to that in which the various offices are placed, and like it
occupying the space beyond the corner chimney, furnishes a
small apartment, with a fireplace in the corner and a window at
the one side, well adapted to receive a patient in such condition
from any cause as to make it desirable to remove himl from the
general ward.
The wards thus constructed should be made as attractive as
possible. The walls properly finished with a hard plaster, well
polished, will retain their purity of color for many years, and
can at any time receive a coat of paint of some subdued tone.
The spaces between the windows and over the fireplaces may be
made attractive by cheerful pictures or appropriate sentences of
comfort and encouragement.
In furnishing, nothing should be allowed which is not absolutely necessary; and above all other considerations, the utmost
care should be taken to exclude everything which may be pervertecl into a receptacle of any soiled garment or other source of
impurity.
The bedsteads should be of iron, closely riveted and strongly
but lightly framed, affording the least harbor for vermin that
can be. Constantly introduced with patients brought from chambers teeming with such pests, nothing but the most extreme caution against the provision of harboring places, and vigilance in
subsequent care, can protect the wards from their presence and
disgusting prevalence. There should be no lockers for any purpose whatever. They cannot be kept free from insects.
The mattresses should be of the best curled hair, capable of
being purified and renovated frequently; and the warmth of the
patients should be secured, not by what are known as " comfortables," wadded with either cotton or wool, but by good woolen




JOHNS HOPKINS' HOSPITAL.              217
blankets. These afford a much more healthy cover, and may be
washed with more ease and less injury. Sheets and pillow-cases
should be white; not unbleached, which never look clean and
afford an excuse for neglect of change. Each bed should have a
white overspread, not colored or checked. Every patient should
have a comfortable chair with arms; and the width of the ward
should be such as leaves a wide passage between them placed
one at the foot of each bedstead, while at the same time each bed
is drawn at least two feet from the wall, thus leaving a good passage at the head also. This not only facilitates access for the
performance of the various acts of service, but also withdraws
the patients from the influence of the currents of air which circulate around the walls, and fall from the ceiling by them. Every
bed should be so placed as to afford the occupant an outlook
through a window to the open sky.  Windows placed opposite to each other afford this opportunity to all with their feet
turned toward the middle of the ward, except those placed
where the central chimney stack interferes.  These should be
reversed, and have the heads toward the stacks and the feet
toward the windows. The grates being placed only in the north
and south sides of the stack, will allow this without inconvenience.
It is important that the feet of the bedsteads should be finished
with smooth rounded knobs, or be set in turned wooden receptacles. They must not be mounted on castors, which allow them
to roll improperly under the movements often necessary in rendering various services to the patients; and, if not thus mounted,
rough feet fray the floor. Castors coupled in pairs by bars the
length of the width of the bedsteads, and well guarded by rubber
tires, should be provided to slip on the feet of bedsteads, when
it is desired to roll a patient from one part to another of the same
ward, or to another. Such an arrangement renders useless the
more complicated and troublesome apparatus sometimes provided
for such purposes. The less complicated the various appliances
are, the better. They are more easily kept clean and in working
order, and are less disturbing to nervous invalids.
All vessels of every kind and for whatever use should be of
porcelain or glass. They are more liable to breakage, it is true,
and more costly; but it is impossible to prevent the indentation
of metal vessels by careless handling, and the consequent break



218              3MORRIS.-PLANS FOR THE
ing of the coat of tin; exposing some portion of the iron to corrosion, and rendering cleanliness impossible.
There should be a liberal provision of movable screens which
can be adjusted at will around the bed of any patient for
whom it may be desirable to provide privacy for any purpose for a short time, or whose condition may be such that
the sight of it would be injurious to others, such, for instance,
as hemorrhage or convulsions. A dying patient may thus be
withdrawn from  general observation with no shock to his own
sensibility, and great relief to the feelings of others. Attendant
friends may be thus protected from needless exposure of their
feelings, and religious rites may be performed for which privacy
is required.
These screens should be light but strongly framed, and covered with the same material mentioned in connection with the
doors.
If the purity of the atmosphere be, as is confessed by all, the
one essential for success in the treatment of the sick, every means
for the preservation of this purity is of the highest importance.
In the language of Mr. Simon, Medical Officer to the Privy
Council of Great Britain, already quoted but worthy to be
repeated here:
" That which makes the healthiest house, makes also the
" healthiest hospital; the same fastidious and universal cleanli"ness, the same never-ceasing vigilance against the thonsand
"forms in which dirt may disguise itself in air, and soil, and' water, in walls, and floors, and ceilings, in dress, and bedding,
"and furniture, in pots, and pans, and pails, in sinks, and'drains, and dirt-bins. It is but the same principle of manacge"ment, but with immeasurably greater vigilance and skill; for
" the establishment which has to be kept in such exquisite per"'fection of cleanliness, is an establishment which never rests
"from  fouling itself; nor are there any products of its foulness
" —not even the least odorous of stach products-which ought
"not to be regarded as poisonous."
The removal of soiled garments, bed-linen, and dressings is
therefore a subject preeminently entitled to attention. I shall
never forget the expression of a WaTard Sister in a London Hospital, whose ward presented a pattern of purity, who in reply to
the question how often changes were made, answered with a




JOHNS HOPKINS' HOSPITAL.               219
smile of astonishment at the simplicity of the questioner, " as
often as they are required."
How shall the soiled garments be disposed of? No place
should be allowed in the construction of a ward in which
they can be deposited even for a moment. They become "a
stercoraceous heap," as offensive and pernicious as that collected at the outlet of a sewer. In connection with that watercloset of each ward nearest to the laundry, and most removed
from the lift by which food is supplied, there should be a
shaft, the walls of which should be glazed with the most solid
and impermeable plaster coat and painted, in which a lift shall
descend from the ward to the basement. Each ward should be
furnished with a box lined with copper, and provided with a
closely-fitting lid, mounted on wheels or castors shod with vulcanized or rubber tires, which can be run to the foot of each bed
at the time changes are made, in which soiled articles shall be
deposited and drawn at once to the opening of the shaft, and
the box with closed lid sent to the basement, and thence immediately to the laundry. They should not be allowed to tarry a
minute by the way. The rmetal-lined box can be scoured and
exposed to the air and sun for purification, as is done with dairy
vessels, where similar causes demand similar attention to the
absolute removal of every particle which can produce contamination. The usual mode of gathering the soiled garments in
baskets or in the arms, and carrying them through the wards and
down the stairways, diffuses the foulness and disseminates the
seeds of disease. But even this, disgusting and improper as it
is, is preferable to the sluttishness of throwing them loosely
down a shaft, contaminating the walls by their contact in descent, and then lying at the bottom  to undergo at least the
incipient stages of putrefactive change, and send the poisonous
influence through the shaft back to the ward.
The same shaft and lift will afford conveyance also for coal
and ashes to and from the ward, thus separating all crude and
refuse as well as all foul material as far as possible from the
ward kitchen and the lift to the ward refectory, and saving the
stairways from soil and the atmosphere from pollution.




220               MORRIS. —PLANS FOR THE
BASEMIENT AND ITS USES.
A lofty, enclosed, well-lighted and well-ventilated basement
should underlie every part of a hospital. Where the necessity
of keeping the proper level requires that any portion of it should
be sunk below the surface, it should there be surrounded bv a
wide area, bounded, not by a perpendicular wall, but by a sloped
embankment; and the drainage from  this area to the sewer
should be such that no pools of water could be collected during
rains, and that the foundations and walls of the building shall
be kept perfectly dry. No wooden floor should be allowed in
any part of the basement. Good flags, or artificial stone made
not with asphalt but Portland cement, that which is imported,
well laid on a good foundation bed of furnace clinker or other
dry material, should be used; and the walls should be plastered
with hard polish, and finished with as much care as those of the
-wvards.
Though the basement, however elevated and dry and welllighted, and even when provided with vaults beneath it, is'unsuited for use for general disease, there is one class of cases,
continually presenting themselves in hospitals, which can be
treated with more safety to themselves, as well as with less disturbance to others in rooms placed there.  AMania a potu, a
disease frequently developed in those of inebriate habits by the
shock of injury, requires some arrangement for seclusion, not
only for the sake of the other patients in a ward who are disturbed by such cases, but for the protection of the poor victim
himself. Under the influence of the wild apprehensions of the
delirium they not infrequently throw themselves from windows;
a terrible catastrophe which is averted by placing such patients
in a basement room. A general hospital must have such provisions for security, or render itself liable to the penalty due to
neglect of proper care.
Rooms are also necessary for vapor and other forms of medicated baths, which cannot be administered either in the wards
or bath-mroons without annoyance to the other patients.  The
basement affords the proper place for these also.
Store-rooms for the preservation of splints, and implements of
various kinds for the use of the sick, when not in actual. service,




JOHNS HOPKINS HOSPITAL.              221
are necessary, and will be more conveniently placed in the zasement than in any other part of the buildings; and closets for
the reception of the clothing of patients, which must not be
allowed to accumulate in the wards, provided with receptacles
in which those of each, properly marked, can be kept separate,
will demand much roonm which cannot be given elsewhere. Store
rooms of various other kinds are necessary, and offices in which
many duties may be performed.
The kitchen and its appendages, though not placed under any
part of the buildings, should be on the level of the basement,
which should extend from it as from a central point beneath
every pavilion, in order to allow the most prompt and convenient distribution of food to each, without the deteriorating influences of delay or exposure. The requisite stores of various
kinds find their most appropriate receptacles and channel of
distribution here. The bNksement should also communicate by an
outlet separate from that through the kitchen, with the laundry
and ash-pit, thus allowing the removal of soiled clothing or bedding to the one, and of offal of every kind to the other without
being transported through wards filled with sick, or corridors
communicating with them, or across grounds designed for recreation, and exposed to general observation from without.
Another sad necessity is met by the provision thus made for
the removal of the bodies of the dead to the place provided for
their deposit, in the same building with the laundry, till claimed
by friends. They should be carried to it by the same passage as
the soiled linen, bedding, etc. The grounds around the wards
are thus kept free from every cause of offence to the eye or imagination of the patients, for whose use they should be made and
kept as attractive as possible, while by the same arrangement
everything which should prove unpleasant to the eyes of neighbors is kept out of sight.
All these advantages are sacrificed, and with no compensating benefit, where wards are raised on arches open at either
side. If properly supplied with windows and doors such basements may be kept as perfectly ventilated as though the winds
blew through them unchecked, while the floors of the wards
are not unnecessarily chilled by the cold blasts of winter; and
banks of snow driven by them, will accumulate there during the
continuance of storms at least. The same attention to neatness




222              MORRIS. —PLANS FOR THE
which is required to keep the open spaces under the wards
pure and unincumbered with odds and ends of lumber, will
keep the enclosed basement equally so; and in an institution
superintended by a faithful warden and inspected by an active
board of trustees, no accumulation of refuse material would
be allowed there more than in the offices, corridors, or wards
themselves.  W~hile the basement itself thus constructed communicates directly with the kitchen, a well-built, well-lighted
tunnel should be constructed from the southern end of that
under each pavilion, through which communication shall be
maintained with the laundry and heating arrangements, and
through which shall be carried all the steam-pipes, water-pipes,
and gas-pipes. All these should be so laid in trunks beneath
the floor of the basement that they shall be readily accessible at every point for repair or renewal; yet none of these or
of the drainage-pipes, conducting to the sewer, should be laid
in such a manner as will make it necessary ever to break
the flagging for any possible repair. This should be guarded
against in the original construction by openings at suitable
places.
These basements are of the greatest value in the heating
arrangements. In them should be placed the air-duct and airchambers in which the air is heated by the radiators or coils of
pipe, though this air should not be drawn from them. These
chambers must be outside the wards, and nowhere but in an
enclosed basement can they be properly placed.
In our climate a basement is an absolute necessity for this, if
for no other reason. Practical experience will soon demonstrate
its necessity for every civil hospital at least.
DRAINAGE.
Startling experiences have aroused attention to the importance
of the arrangements to effect this.
A building provided with everything money can supply for
elegance and general comfort, may be rendered uninhabitable by
defective drainage, or an unsuspected communication with a foul
sewer or cess-pool; and the purposes to which a hospital is
devoted, renders this service in connection with it, one which
should be provided with the most judicious and thoughtful pru



JOHINS HOPKINS' HOSPITAL.              223
dence, and maintained and watched with the most jealous care.
If the excremental discharges of healthy action are capable of
producing poisonous influences when not properly removed, how
much more deleterious must be the morbid products of such
various diseased organs and functions as are collected in a large
hospital.
Every water-closet should be separately trapped. All drains
and sewers should be laid outside the walls; and connectingpipes, while they need the protection of walls to guard them
against freezing in the cold season, should be carried to the outside drain at the nearest point.
Every pipe should be properly furnished with traps to secure
absolute exemption from liability to the return of the air of the
drain or sewer; and these should be so placed that access to them
may be had without difficulty in case injury or obstruction of
any kind should render repair necessary.
The first step toward the erection of the buildings of the Johns
Hopkins Hospital should be the construction of a sewer, not
within the grounds, but in the street to the south of the lot. In
order to secure absolutely exemption from danger from any reflux
of gases from this sewer into the drains, and to ventilate it thoroughly, a connection should be made between it and the furnace
of the steam boiler in the heating apparatus, which it is proposed
to place in the centre of the southern line of the lot in inmllediate
proximity to the sewer, by which arrangement a strong draught
from any point through the sewer to the furnace would be established, so that nothing could escape in any other direction. To
this main sewer smaller tributaries should be laid directly from
each pavilion and from the kitchen and laundry, each welltrapped. These should all be well constructed with hard brick
well cemented, or good terra-cotta pipe, so that there shall be no
leakage into the soil; and with such a grade as shall secure a
rapid current to what flows through them.
Every possible precaution should be taken to prevent any
reflux of the air from  the sewer or drains into any part of the
building.  This is not always sufficiently attended to, and
unhealthy dwellings are often caused by such neglect.
The spouts which collect the wat:er from the roofs should discharge into the sewers. These being open at the top allow the
escape of gases there at all times, except when the flow of




224               MORRIS.-PLANS FOR THE
rain through them  obstructs it. Other drain-pipes should be
so connected with flues, opening above the roof as to supply
similar means of escape when the falling rain interrupts it
through the spouts. No part of the construction is more important, and none should secure more watchful care.  The
whole system  of drainage should be fully planned and laid
out before any flurther progress is made in the arrangement of
the buildings. The smallest negligence or oversight may render
useless the utmost cost and care elsewhere. We are told that in
one of the best constructed and best managed hospitals in London, it was found that every successive occupant of two beds in
one of the wards, was attacked by erysipelas. The beds, etc.,
were changed, but still the same result continued. On close investigation a dust-bin was found beneath these windows outside.
The removal of this remedied the difficulty. After some time
the disease recurred in the same location, and it was found that
the dust-bin was again in use.  Its permanent closure restored
the salubrity of those beds-erysipelas no longer infested that
spot in the ward. If the dry dust-bin outside thus contaminated
the air, how much more active would be the pestiferous influence
from a damp drain opening within the ward.
From neglect and oversight of such influences colleges have
seen their most hopeful students consigned to the grave when
just prepared to diffuse the blessings of the culture received in
their halls; outbreaks of mortal illness among the children of
schools have been found to arise from the contamination of the
air due to imperfect drainage; and palaces have been converted
into pest-houses.
In order to cut off all possible reflux of air from the general city
sewers into which the main sewer of the hospital conducts, it
should be doubly trapped at the point of connection.
Each pipe and drain being thus protected by a special trap,
the principal sewer being ventilated by a connection with the
furnace, and having also an opening to the outer air, there can
be no introduction from the drains of any foul air to any part of
the buildings.
HEATING AND VENTILATION.
The most important of all arrangements remains still to be
considered.  The proper size, shape, and capacity of a ward




JOHI-NS HOPKINS' IIOSPITAL.             225
admits of little debate; so that variations, and discussions about
hospital plans turn more on the combination and connection
of any given number of such wards, than on any modifications of the wards themselves. The temperature must be kept at
the proper point, and the atmosphere must be kept pure. Miss
NIiglhtingale has expressed in terse terms, and most appropriate
words, this most important truth:
"The very first canon of nursing: the first and last thing upon
"which a nurse's attention must be fixed; the first essential for
"the patient, without which all the rest you can do for him is
"nothing; with which I had almost said you may let the rest
alone, is this, to keep the air he breathes as  pare as is the ex"ternital air, without chilling him."  Heating and ventilation
are thus inseparably connected; and every arrangement for the
one must be made in due proportion and adjustment to the other.
In those regions where the climlate is mild and temlperate, where
there are no vicissitudes, and open windows and doors allow access to genial breezes which waft off exhalations, these questions
have no importance.  In cold regions and seasons if temperature could be maintained at the proper point without change of
air, it might be done without difficulty.  But the mlere congregation of healthy persons in a closed apartment renders the atmosphere impure and incapable of sustaining life.  It is not
necessary in order to prove this to refer to experiments on lower
animals confined in vessels from which air is excluded, nor to the
fearful histories of the Black Hole of Calcutta, or the betweendecks of slave and coolie ships; results due not to the mere remloval of the oxygen absorbed by the vital processes connected
with respiration, and the substitution for it of the carbonic acid
gas thrown out in return, but still more to the accumulation of
the various emanations, exhalations, and secretions which are
being thrown off unceasingly from every part of the surface, internal and external, loaded with the excremental results of vital
chances in the tissues. No one need seek for illustrations beyond the range of one's personal observation. If one enter an
apartment of the best regulated family with all tile neatness
and attention to purity belonging to the highest refinement, in
which several persons have slept with closed windows and doors,
the air is found to be stifling and oppressive from the accumulation of these exhalations.  Their retention within the system  is




226               MORRIS.-PLANS FOR TIIE
even more fatal than the exclusion of air from the lungos. Animals coated with an impermeable varnish perish, though there is
no interruption to the respiration; a burn or scald, however
slight, destroying the functions of the skin of two-thirds the
surface is fatal; and we are told that, a child gilded to take part
in a pageant, perished from this cause before the metallic coating could be removed.
Greatly as these normal discharges vitiate the air, and terrible
as are the poisonous influence they exert, when concentrated
resulting speedily in fatal issues, and when less concentrated
causing entire destruction of the health of those long exposed to
them, as is seen in the cases of persons employed in crowded,
badly ventilated apartments in various manufactures, not in
themselves unhealthy; they are harmless when compared with
those froml the diseased organs of the sick, and the foul and
putrescent sloughs and discharges from the unahealthy wounds
and ulcers of the patients in a hospital ward. The prompt removal of air so contaminated, and the introduction of that which
is pure is, therefore, the first consideration in its construction.
The escape of heat fron any apartment, where the temperature without is lower than that within, must be the necessary
consequence of thle chlange of air; which, to maintain its purity
where the contaminating influence is unceasing, must be without
interruption; and as the supply of heat must be in proportion to
its withdrawal, it must therefore be continuous also. Tlhe two
are inseparably connected by mutual reaction.  In our own
climate during the warm  season, there is comparatively little
difficulty about ventilation.  When the outer air can be freely
admitted there is none. Curreints created by natural forces generally supply a sufficient motive power throlugrh  windows and
doors, which can be thrown widely open. But there are times
when the temperature without, or the incleumency of the weather
even when the temperature is genial, demands the closure of all
openings. During the summer aand autulmn months, especially
the latter, we suffer from  an oft-recut1rring condition of atmosphere in which the opening of windows and doors produces no
relief; when there'"is not a breath of wind" to carry off exhalations, and the air is saturated with.moisture, a(nd refuses to imbibe it from  the skin, producing a sense of stifling, distressing
even to those in full health, almost fatally oppressive to the sitck




JOHNS HOPKINS' HOSPITAL.                227
and feeble. Open windows and doors do not of necessity put air
in motion; and without this movement of the air, the exhalations and emanations unceasingly produced by the vital processes in animal bodies, as are the odors of plants and flowers,
accumulate around them and vitiate the air. The various states
of the weather, and the vicissitudes of temperature necessarily
associated with our varying climatic influences, require different
methods of relief. When the temperature permits windows and
doors to be kept open, and natural agents produce currents,
these passing through the ward maintain its purity.  When
heat is required, or when fires can be tolerated, the most effective ageney for the purification of the air and consequent motion clan be put into operation. But the conditions vary greatly,
and the methods of pronmoting change of air must be adapted to
the varying circumstances.  We cannot rely on any one exclusively. A well constructed hospital mYnust be prepared to meet
all chang'es by the various appliances adapted to each. Air,
air in motion, air constantly renewed, air moderately heated,
pure air, is the one central life-giving influence around which all
hospital arrangements cluster themselves, and to which all are
subservient.
The condition which should first, claim attention is that which
ocecurs when the temperature requires the closing of windows
and outside doors. How shall the circulation of the air and its
removal froum the ward be then accomiplished most effectually,
and with least disturbance to the sensations of the patient 2
One simple expedient, that earliest resorted to, and longest
tried, supplying both heat and ventilation, is at the same time
most effectual, and most easily applied; and when its proportions have been properly adjusted to the area to be kept pure,
has always proved satisfactory.
Combebzstion in open fire-places connected with ascending
shafts, creates a demand by the consumption of the air which is
necessary for its support, which must be supplied, and causes
an upward draught in the flue by the ascending force of the
heat, which passes off'so largely in that direction, carrying with
it in addition a large volume of air.  This irresistibly sets in
mlotionr that of the apartment, and causes an afflux toward the
point at which it is going on of currents converging from every
direction on its own plane toward the focus. The circulation of




228               MORIS. —PLANS FOR THE
air in an apartment thus heated has been established by actual
observation conducted in a chamber the atmosphere of which
was filled with floating particles which were visible so that their
course could be distinctly traced.
The air is drawn along the floor toward the point of combustion.  It is there warnled by radiation fromn the incandescent
mass in the grate, and whilst one part is consumned in supporting
the combustion, a very large volume is carried up the chimney
under the influence of the strong draught created by it, and
another portion is carried upward by the rarefaction produced
by the heat, along the breast of the chimney toward the ceiling,
before entering the fire. It there diffuses itself, and as it passes
toward the walls, both lateral and opposite, loses some of the
heat, and by the time it reaches the outer walls is chilled, and
descends t to the floor to be again subjected to the draught by
which it is carried toward the fireplace.  The observation on
which this statement is founded was made in the closed chamber of a manufactory of lampblack.  lNow this is just what is
needed, provided it can be adjusted to the area of the apartment,
the air of which is to be purified; and provided a supply of fresh
air equal to that which is thus consumed (and carried away, can
be furnished.  This constitutes true ventilation, which should
not be confounded with " draugllhts," which are not essential to it.
WIhile there is no stagnation anywhere to afford a nicuts for the
propagation of the germs of disease, there is no sensible current,
unless it be at a point so near the throat of the chihnlley as to be
harmless. In a very able paper on hospital construction presented to the British Medical Association at its meeting at
Leeds, in 1869, by Capt. Douglas Galton, of the British Army,
he says "''the most powerful engine for ventilation for drawing
out the air is the open fireplace.": "'' * "Nearly seveneighths of the heat generated by the coal in an ordinary fireplace
passes with the smoke up the chimney, and carries with it out
of the room a large quantity of air, amounting in even moderatesized rooms, when the chimney is heated, to as much as from
14,000 cubic feet to 20,000 cubic feet in an hour."  No statement
could prove more satisfactorily the value of the open fireplace in
the hospital ward. It is the remnoval of this amount of contaminated air to be replaced by that which is fresh and pure.
Any apartment without an open fireplace is unprovided with




JOHNS HOPKINS' HOSPITAL.                229
the most important arrangement for the health of its occupants.
A hospital wvard without it, is radically and essentially imperfect. Other agencies for the preservation of the purity of the air
may properly be brought into associated action, but this is the
one without which all others fail. It only requires sufficient
afflux to be secured from a healthy and pure source of supply
through channels in which it is not vitiated in its course, and the
object aimed at is satisfactorily accomplished. If the temperature permitted this constant maintenance of fire, and the size and
position of the fireplaces and chimneys were properly adapted to
the area of the ward of a hospital, no other agency would be
needed.  It possesses this most important advantage, and one
peculiar to itself, that while it keeps currents in motion through
every part of the air space of the ward, the final course of the
air is to the point of combustion and extraction in the grate,
sweeping in its progress along the floor, and about and beneath
the bodies of the patients, and the beds on which they lie. The
air thus carried up the chimney, must be replaced; and the
supply will be drawn fromi corridors as well as through flues,
and thus currents setting into the several wards and finding their
outlet by the fireplaces will prievent the escape from the wards
into the corridors of the poisoned atmosphere.
In order to secure the certainty of a sufficient draught into the
ward to prevent any flow from it into the corridors, chimneys
with open fireplaces should be placed in each corner of the long
ward, and also a central stack in the middle of the floor of each,
having a grate near the floor on the north and south faces of the
central stack, and fires should be kept burning in the grates
whenever the temperature permits. But the air from the corridors or other source must not be cold, or the heat diffused by
direct radiation from the open fires will not be sufficient to keep
the temperature of the ward at such a point as is congenial to
the feelings or conducive to health. It must be warmed moderately before admission to the wards, and must be drawn from.
an uncontaminated source. The best mode of doing this will
claim  notice hereafter, attention at present being limited, as
closely as the necessary connection of the topics will admit. to
ventilation only.
But powerful as is the agency of the open fireplaces, we are
lnot necessarily liimited to this alone.




230               MORIRIS. —PLANS FOR TIIE
Other flues may well be introduced rising perpendicularly
through the outer walls, and in the east and west faces of the
central stacks of chimneys, having openings at the floor and
near the ceiling, and each entering separately into a horizontal
duct in the attic, and throug'h it communicatingo with a shaft
discharging throlughl a ventilator in the roof around the central
chimneys. These flues will be necessary in addition to the chimneys at those times when fires cannot be kept burning in the
open fireplaces. Those near the ceilings must be closed when
they are, and those near the floor should be constructed on the
admirable plan introduced by iMr. Barker, of Germantown, Pa.,
in immediate connection with the flues for.the supply of suppleienCutal heat.  Coils of pipe to be supplied with steam when
there are no fires in the central chimneys, may be so placed, in
connection with both the chimneys and tile flues for ventilation
beside them, as to secure upward currents through them at all
times, and aguard against descending currents.  These flues in the
central stack will also have the advantage of being exempt from
the influence of the temperature of the out-door air, as those in
the outer walls confessedly are, sometimes to the extent of producing draughts downward into the ward. To guard against
this each should be furnished with a register.
3ut while the action of open fires thus secures entire freedom
of ventilation during those periods of the year in which fires can
be kept burning without inconvenience to the feelings of the
patients, and the necessary additional heat can be added byv
warme.d air admitted through chambers heated by steam coils
or radiators, and ventilating flues communicating with heated
chimneys lend their assistance in the maintenance of the purity
of the air, other expedients are necessary to do this when fires
are intolerable.
Open windows and doors, and gas jets lighted in chimneys to
ensure upward draughts through them, are sufficient when the
natural forces without keep the air in motion, and create currents
between opposite windows or through open doors. But there are
many days during the warai season when the air is perfectly still
and scarcely an aspen leaf trembles in the breeze; and others, in
the autumun  especially, when loaded with moisture and heated to
a degree that is almost ins-upportable, it appears stagnated, with
no motion to carry off the excremental exhalations and secre



JOHNS HIOPKINS' IIOSPITAL.                231
tions, and too much moisture to absorb them, and they hang
around the person producing them with a stifling tenacity. Such
days are hard to bear for the healthy and strong; to the sick
and feeble tllhey are terribly distressing.
Some method of relief for this condition nmust certainly be provided in every well-organized hospital.
Various expedients for producingl forced ventilation have been
triedl-some dependent on suction, drawhing the air out; and others
on pressure, forcing  it into the apartmlent in which it is to be
breathedl, and driving out before it what has been used.
Experience has proved them all to be unsatisfactory, with the
single exception of the fan for propulsion of air through a duct
communicat, ingT with the several air chambers in which the air
thus propelled is warmned by the steam-coils or radiators, when
heat is required, while flues in thle walls and central chimneys
provide a draft on the air already in the ward; such a fan
should be provided in the basement.  Its use would probably be
unnecessary, except in the condition just described; but if it will
afford relief at such times it is a most valuable apparatus.  It
will be readily conceded that the preservation of the purity of
the air in an asylum for the insane is a most difficult unldertaking.  Yet by this agency Dr. Kirkbride has secured it in that
department of the Pennsylvania Hospital with such unquestionable success that it is proposed to add it to the otlher arrangements in the generall wards of that institution.  It is true that
there are instances in which such fans, provided when tlhe hospitals were constructed, have never been used. They stand idle,
but there is the apparatus ready for service if it should be needed.
If needed and not provided the loss is a serious one. There are
times when the fan will be of the utmost value.
W7e may now pass to the consideration of the methods of
heating, which will involve of necessity some repetition.
Introduced into the wards primarily for their influence in
consuming the air, and by thus creating a demand for a fresh
supply promloting ventilation, open fireplaces are not less valuable also as themselves sources of heat, communicated by direct
radiation so far as that reaches.
This is the most natural and acceptable mode of heating.
Every one instinctively draws toward the source of heat that
one may experience the gratification of feeling its direct impres



232              MIORRIS. —PLANS FOt TIHE
sion, and even a low general temperature may be born with
pleasure when direct heat falls upon some part of the sensitive
surface.  As the fires can be approached by those patients
who are able to leave their beds who gather in clusters around
the heartllhs for the sake of the enjoyment of the sensation of
direct heat; and as those who are unable to leave their beds can
be kept comlfortable by blankets, or if necessary by warm appliances under them, the general temperature as supplied fromn
other sotrces of the ward in which there are open fires may be
kept at a lower degree than that which is demanded when there
is no direct source of radiation accessible, and no cheering influence of the blazing hearth.
This is not an unimportant consideration. Miss Nightingale
most justly condemns what she describes as a process of
"under-cooking'" to which too many persons are subjected
by modern arrangements for heating houses without open fires,
and still more frequently witlhout any channels for the escape of
heated and impure air. Bad enough for those in health and in
common dwellings, it is especially injurious to the sick and
feeble inmates of a hospital ward. The maintenance of an unbroken, uniform  high temperature, is exhaustive of the vital
force. Some fluctuations are not only congenial to the feelings,
but productive of a healthy stimulus to the nerve force when
kept within reasonable limits and not too prolonged or too often
repeated, and regulated with discretion. These variations are
most easily secured by an open fire, to which one may approach
or from which one may withdraw.
Miss Nightingale says: " Natture affords air to both sick and
healthy of varying temperature at different hours of the day
and night and season; always apportioning the quantity of
moisture to the temperature and providing continuous and free
movement (of the air) everywhere. We all know how necessary
the variations of weather, temperature, season, are for maintaining health in healthy people. Have we any right to assume
that the natural law is different in sickness? In lookling solely
at combined warming and ventilItion to ensure to the sick a certain amount of air at, 60 i'.,* paid for by contract, are we acting
in accordance with physiological lawv  Is it a likely way to
* This point, always assumed as her standard by Mliss N., is much too low.




JOHNS HOPKINS? HOSPITAL.              233
enable the constitution to rally under serious disease, to undercook all the patients day and night during all the time they are
in hospital at one fixed temperature? I believe not. On the
contrary, I am strong'ly of the opinion-I would go further, and
say I am certain —that the atmospheric hygiene of the sick-room
ought not to be very different froln the atmospheric hygiene of
a healthy house."
There is great wisdom in these views, which should be borne
in mind not only in the construction of wards and the arrangements for heating and ventilation, but should be kept unceasingly before the attention of those engaged in the administration of the wards while in use. An occasional reduction of
temperature by the judicious admission of a body of fresh unheated air is not only agreeable to the sensations, but when not
too violent or too long continued, and guarded by proper protection of those exposed to it, gives tone and vigor to the skinrelaxed by too long exposure to a high temperature —and promotes the healthy action of that most important organ and thus
invigorates the entire system.
Such changes cannot be provided for by permanent arrangement, but must be controlled by the medical adviser of the sick,
and effected by the discretion and under the watchful care of a
prudent nurse. They are not to be confounded with draughts
or imprudent exposure without proper protection. Open fires,
under direct observation, facilitate the control of such changes.
But direct radiation from open fires is not sufficient to afford
the warmth necessary for a large hospital ward. There must be
other sources of supplemental supply, which must next claim
attention.
Captain Douglas Galton, in the appendix to the essay previously referred to, describes what he calls "ventilating fireplaces, constructed on the principle of those used in military
hospitals and barracks. These fireplaces are constructed in such
a manner as to utilize a portion of the heat generated by the fire,
and which would otherwise pass away by the chimney, in warrning fresh air which is admitted into the ward; and they are,
besides aiding ventilation in a remarkable degree, very economical of fuel." This fireplace consists simply of an ordinary lowdown grate fixed near the hearth with the common protection of
fire bricks at the back and sides. Behind this is an air chamber,




234              MORRIS.-PLANS FOR TIIE
into which pure fresh air is admiitted from without through a
duct under the floor. An iron back above the point to which
the coals are heaped, and an iron pipe passing through the airchamber to convey away the products of combustion and the
smoke, use the heat which would be carried up the chimney in
warming the air in the chamber, which is then discharged into
the ward through an opening in the breastwork of the chimney
about halfway between the top of the grate and the ceiling. The
air cannot be scorched and over-heated, as is done in hot-air furnaces and by stoves, which parch the air and not only rob it of
the necessary moisture, but deprive it of its vitalizing properties.
"The limit to which the heat from the fire can be so utilized
will be the point at which it cools down the chimney so as to
check the draught in combustion of the fuel."  It is self-regulating; too large a supply of air into the air-chamber will cool
down the flue and check combustion, while on the other hand, the
more active the combustion the greater the amount of air thrown
out through the opening into the ward, and the more active the
ventilation. The warm air thus thrown out into the ward, mingles
with that which ascends in front of the breast of the chimney,
under the rarefying influence of direct radiation from the fire,
and with it sweeps around the upper stratum of the air of the
ward, is cooled as it approaches the ceiling and walls. descends
by these to the floor and is again drawn toward the open fire,
thus sweeping along the floor and carrying with it the exhalations and other contaminatinlg matters held in suspension
gathered around the beds, to be consumed in the fire, or carried
with the products of combustion and other unconsumed matters
with the smoke from the chinmney-top.
But there must be still other channels through which air must
be admitted to meet the demands created by the draught through
the fires and up the flues; and when the outer temperature is
low, it cannot be allowed to enter the ward unwarmed. It must
Ibe supplied through air chambers heated by steam coils, and
these should discharge themselves into the ward near the floor,
about midway between the central fireplaces and those in the
corners of the wards, and also in the middle of the projection
thrown out laterally opposite the central stack of chimneys.
The currents thus created do not mingle, but maintain an uninterrupted circulation.




JOHNS HOPKINS' HOSPITAL.               285
The mode of supplying the heat to the radiators or coils of
pipe in these chambers, whether by hot water or steam, and, if
by steam, whether by high or low pressure, is now being vigorously discussed. Hot water may be dismissed at once as not
adapted to hospital use. The circulation cannot be maintained
at sufficient distances from the point at which the heat is generated, and too much time is necessary in effecting changes,
whether of reduction or elevation of temperature. The character of the heat supplied by steam, whether by high or low
pressure, and the facility for transmission and for change are
the same. The discussion therefore turns chiefly on economical
points, and falls rather within the province of engineers and
machinists.
The high pressure, it is believed, will furnish the requisite
amount at the most distant points with the most certainty and
speed, and can be regulated and altered with greater promptitude.
The advocates of the low pressure claim  that it consumes less
fuel in the production of a given result; a most important consideration, since one of the largest items in the enormous expenditure in hospital management in our own climate is that for
coals. It is well suited to private houses, where the area to be
warmed is small.  Placed immediately beneath the area to
be warmed, and the heat which is supplied through air chambers and generally diffused supplemented by direct radiation
from coils of pipe or other radiating arrangements fixed in the
room to be heated, it supplies all that is required, and is admirably adapted to the service of banking houses, railroad depots,
and other offices fop similar purposes, where the doors are
being opened continually, and persons coming and going may
retain extra clothing if they require it.  Ventilation is there
imaintained through the opening of the doors, and such apartmlents in modern structures contain so large an air space in
proportion to the number of persons at any one time in them,
that it does not become contaminated, and there is not the
necessity for the circulation created by direct combustion in
open fires, which has been demonstrated in hospital wards.
But direct radiation, whether from coils collected in different
positions or radiators of other construction, or from tubes carried
1Laround the walls, is wholly unsuitedrl to ward service; especially
tile latter mode. Heat is diffused, but irregularly, and without




236               MORRIS.-PLANS FOR TIHE
the corresponding consumption of foul air. Ventilating flues do
not furnish sufficient certainty of draught, and whatever other
escape may be provided, whether by ridge openings in onestory wards, or elsewhere, sufficiently capacious to carry off
the vitiated air, creates too great a dispersion of the heat, and
reduces the general temperature to an uncomfortable degree.
To meet this, the local temperature in the immediate vicinity
of the radiator must be proportionately elevated, thus giving
rise not only to great inequality in the temperature of different
parts of the same ward, peculiarly unconmfortable to patients
confined to their beds, but occasioning also strong draughts
through every opening whether of inlet or outlet.  To check
these, and equalize the temperature, the outlets will be closed
under any other than the most rigid military discipline, and
the foul air will be retained, loaded with all the poisonous
effluvia.  The ward will be converted into the closed air chamber
of the heating apparatus. These are not mere theoretic speculations, but the results of actual observation.  The " problems,
to solve which you invoke the aid of experience and thoughtful judgment," are important. The solution of them is "difficult"' indeed. The combination of open fires in the wards with
heated air diffused through air chambers warmed by coils of
steam pipes or radiators, and carried off by chimneys and ventilating flues, provides all that is required where fires can be bornfe.
Through a large portion of the year, natural ventilation through
open doors and windows is all that is required.  There are
periods of longer or shorter duration when a fan is necessary.
One should therefore be provided. While direct radiation from
steam pipes in the wards is thus positively condemned, it may
be used with great advantage, and perhaps with economy, in
corridors, basements, and offices not frequented by the sick.
FOOD; ITS PREPARATION AND DISTRIBUTION.
Diet is as important as drugs, and the proper form and mode
of preparation should be as entirely under the control of the
medical adviser. Both are therapeuta, and in both it should
be required that the best material should be provided, the most
skilful agents employed in the preparation and concoction (to




JOHNS HOPKINS' HOSPITAL.               237
which the most convenient arrangements are essential), and that
they should be presented to the patients in the most attractive
guise.
Those who have visited the well arranged and well conducted
kitchens of some of the oldest hospitals in the world will not
soon forget the attractiveness of their bright array o0f culinary
implements, nor the delicate and appetizing appearance of the
various articles of diet prepared by careful hlands specially
devoted to this good work; the truth being there fully admitted
that in many cases mnore depends on the proper presentation of
suitable nourishmlent to the exhausted frame than on the farragos of medicaments which, during the dark ages of medical science were so persistently thrust upon the debilitated organs and
deranged functions of digestion. There should be no possible
connection or facility of communication between the offices for
the preparation and distribution of food and medicine, yet
Doth should be central, and furnished with easy access to all the
wards.
The necessity for this central position of the kitchen is universally conceded; while the apprehension of difficulty in preventing
the dissemination of the vapors and odors generated in the processes of preparation of various articles of food, not only to the
discomfort of the sick, but vitiating the atmosphere of the wards,
has led to the suggestion of the impropriety of placing it in the
basement of even the administration buildings, and that it should
be transferred to the upper story. There are many and grave
objections to this change of location. An apartment adapted to
such purpose for such an institution must be large, and it should
be fire-proof. The prime cost of the erection of such a system of
arches and masses of wall as would be necessary to render it safe
would be great, and should not be needlessly incurred. But in
the daily service also the labor and cost would be much increased.
The Consumption of fuel is great, and some mechanical contrivance for hoisting this and lowering the ashes would be requisite.
All crude articles of food must be carried -up and the refuse matter brought down, and the food itself when prepared must first
be taken down and then distributed; and if there be wards on the
second floor, raised again to these; thus increasing the labor and
time occupied in its distribution after the preparation, and deteriorating its quality in the most objectionable manner, and -to a




238              MORRIS.-PLANS FOR TILE
great degree; and rendering it less attractive to the appetite made
fastidious by weakness or disease.
The basement position should therefore be retained, while careful arrangements for carrying off vapors and odors should be
skilfully made by hoods over the ranges, collecting the fumes
and vapors, and discharging them into the chimney.
In the plan proposed this is done by placing the kitchen
beyond the south end of the central pavilion, where it has ready
access to the store of fuel, and to the sewer for drainage; and
from which point food can be distributed through the basements
by lifts to the refectory of each ward. To facilitate this, a railway should be laid; on which a car provided with compartments
surrounded by hot water, in order to retain the heat of the food
should be run to each lift, and a bell in each ward refectory
should be connected by a wire with the lower end of the lift, by
pulling which the servant in the refectory should be apprized
that the meal is ready for that ward. The vessels in which the
food is placed should have covers; be made of a size and shape
to correspond to that of the compayrtments in the car; each ward
having its own, to be returned to the central kitchen for washing
and scouring so soon as emptied, and should be kept scrupu]ously clean and bright.
Attention to food and cooking is regarded by too many as a
servile office, and any interest taken in it as derogatory to human
dignity. This is a most unwarrantable judgment. The healthy
performance of the functions, whether moral or bodily, depends
on the proper nourishment of the organs; and this upon the
supply of food. If this be deficient in quantity, bad in quality,
or improperly prepared, both must suffer. To attach more ilmportance to the taste than to the nutritive properties of food is
contemptible and destructive to health. Yet taste is an important function in the process of digestion, and may not be disregarded with impunity; and nothing can be more disgusting and
repulsive to the appetite, and therefore injurious, than the sodden, badly prepared messes too often provided for sick and well,
taken, if at all, with disgust: and when swallowed under the demnand of the system for supply of its waste, disturbing its
power by the violence done to the central organ of digestion and
its numerous dependents. The care of the coo7Xi-?g of a, hospital
should ever be regarded as an /.onoi-alde position, which should




JOHNS tHOPKINS' hIOSPITAL.             239
secure the services of one well skilled in the art of cookery, with
a sufficient number of suitable assistants, to secure the faithful
and efficient performance of its duties.
AD3MINISTRATION.
This resolves itself into three departments, each of essential
importance, each to be conducted by independent chiefs, and yet
all to be harmonized not only by consent of action, but by some
recognized union as well as limitation of power.
These departments are the professional, executive, and nursing.
It will at once be conceded that no individual man can be
found competent as house resident to the proper professional
care of the large number of patients for whom the charity is provided, and the great variety of forms of disease which will be
collected there.
If such a man existed, his talents would honestly earn, and
certainly receive, a pecuniary reward far beyond any salary even
the munificent foundation to be inaugurated could afford.
Whether wisely or not this is not the place for discussion, the
usage has assumed the sanction of established law, that surgical
and medical advice and service shall be rendered to hospitals
without such compensation; and the honor of such posts is
earnestly coveted, and sought after by the best qualified and
most ambitious and distinguished members of the medical profession. This is surely highly creditable, since the time, thought,
labor, and sense of responsibility thus devoted to the service of
humanity, are taken froml  other fields of labor which would
yield quite as large a harvest of honor with the addition of
great pecuniary emolument. There is no abatement in the ranks
of the profession of this disinterested desire to serve the sick
and suffering; or of ambition for the renown and eminence
which are the reward of well-directed hospital service.  There
will undoubtedly be a large force of physicians and surgeons
ready to volunteer their co-operation in carrying into effect
the benevolent purposes of the founder. Such service cannot
be overestimated, and should not be brought into a position in
which it is measured by a money standard.  In a hospital of
the size proposed, the duties are too onerous and demand too




240               MORRIS.-PLANS FOR THE
great a sacrifice of time and power, to commit their performa.nce to a smaller numnber than that which experience has proved
practically tie best proportioned; four of each branch. They
are thus able to divide the service as is most agreeable to
themselves.  Some prefer a longer period of service with a
snmaller number of cases; and two together take service for six
months and divide the wards: while others prefer the shorter
ternm of three months and the undivided charge of all the cases
presenting during that period. There are valid reasons in favor of
each arrangement; but it is a matter of detail which may properly
be left to the wishes and judgments of the officers themselves.
However it may be arranged, the entire control and responsibility for professional treatment must rest on the surgeon or
physician having charge at the time, subject only to such rules
regulating consultations as shall be established in concert with
the professional officers by the board of trustees.
The appointments should be made annually, with the implied
understanding that changes are not to be made except by resignation, unless for some neglect of duty or other cause which
should be ample to justify the attaching  so grave a stigma to
character as would result from such change. The occurrence of
the annual elections affords opportunity for change if any good
reason require it, but should never be allowed to furnish occasion
to exhibit either personal favor or disfavor on any other ground
than professional merit.
WThile the entire responsibility for the treatment of the patient
must rest upon the shoulders of the attendants-in-chief, there
must be subordinates to execute orders, and have charge of the
mnedical and surgical treatment during the intervals between the
visits of the physician or surgeon-in-chief, and to superintend
the nursing. There is no part of the hospital service more important than this, since the efficiency of any treatment depends
wholly on the faithfulness and accuracy with which it is applied.
The charge of the whole could not be committed safely to one
salaried officer. The duties are too arduous and conflicting; and
the difficulty of accommodating himself, and distributing his service among the many cases, and under the direction of different
chiefs, is too great. It would be impossible so to arrange the
hours of service that one resident only should be able to attend
on each physician and surgeon-in-chief in his daily visits to the




240               MORIRS. —PLANS FOR THE
great a sacrifice of time and power, to commit their performance to a smaller number than that which experience has proved
practically the best proportioned; four of each branch. They
are thus able to divide the service as is most agreeable to
themselves.  Some prefer a longer period of service with a
smaller number of cases; and two together take service for six
imonths and divide the wards: while others prefer the shorter
term of three months and the undivided charge of all the cases
presenting during that period. There are valid reasons in favor of
each arrangement; but it is a matter of detail which may properly
be, left to the wishes and judgments of the officers themselves.
However it may be arranged, the entire control and responsibility for professional treatment must rest on the surgeon or
physician having charge at the time, subject only to such rules
regulating consultations as shall be established in concert with
the professional officers by the board of trustees.
The appointments should be made annually, with the implied
understlding that changes are not to be made except by resignation, unless for some neglect of duty or other cause which
should be ample to justify the attaching so grave a stigma to
character as would result from such change. The occurrence of
the annual elections affords opportunity for change if any good
reason require it, but should never be allowed to furnish occasion
to exhibit either personal favor or disfavor on any other ground
than professional merit.
While the entire responsibility for the treatment of the patient
must rest upon the shoulders of the attendants-in-chief, there
must be subordinates to execute orders, and have charge of the
inedical and surgical treatment during the intervals between the
visits of the physician or surgeon-in-chief, and to superintend
the nursing. There is no part of the hospital service more important than this, since the efficiency of any treatment depends
wholly on the faithfulness and accuracy with which it is applied.
The charge of the whole could not be committed safely to one
salaried officer. The duties are too arduous and conflicting; and
the difficulty of accommodating himself, and distributing his service among the many cases, and under the direction of different
chiefs, is too great. It would be impossible so to arrange the
hours of service that one resident only should be able to attend
on each phTysician and surgeon-in-chief in his daily visits to the




242               MORRIS.-PLANS FOR THE
one year, and should be required to give some pledge to continue the full term.  The time at which the service of each
should expire, should be so arranged that there should always
be two in office who have had six months service; and never less
than two should be in the house at any moment, as patients may
be brought at all hours requiring the service of more than one.
Telegraphic connection with the central police station, or a
district telegraph office, should be established to facilitate the
instantaneous summoning of the surgeon or physician-in-chief
in case of emergency.
An honorable certificate of the fact suitably engrossed and
signed by the president and secretary, should be the meed of
those residents who serve faithfully the entire term for which
they were appointed.
NURSES.
In this connection as subservient to the same interests the arrangenments for nursing may properly claim attention. No proficiency in science, nor skill in its application by the possessor,
can dispense with faithful, intelligent nursing. This faithfulness and intelligence is to be brought to bear on the case, not by
proficiency in medical knowledge, but simply by that peculiar
qualification which is known as " tact;" which gives superiority
to those who possess it in whatever sphere of life they move. A
nurse possessed of common sense and faithfulness in the performance of duty, with this tact, is greatly to be preferred to
one instructed in the principles of medicine, never so thoroughly,
without these.
The establishment of a "school for training female nurses" is
one of the objects provided for by Mr. Hopkins. It is an important adjunct to the hospital; and if properly conducted will
furnish invaluable assistance for the proper cure of the patients,
and it should certainly be in the building. There is much need
for practical training in the art of nursing, even in the case of
those possessing a natural adaptation for the service. Gentleness and tenderness of manner may be cultivated; the proper
mode of exercising control and manifesting firmness may be
taught; the mode of administering medicines, of making application of dressings of various forms and kinds, of attending to
the wants; of relieving the suffering produced by weariness, by




JOHNS HIOPKINS' HOSPITAL.              243
uncomfortable postures, or other causes; of changing postures
and removing clothing, without exertion on the part of the patient; of simply turning or adjusting a pillow (no one who has
not known by experience can conceive how much depends on
the slightest properly effected change); even the bestowal of
a look of sympathy or word of encouragement, are all subjects of education. Habits of personal cleanliness may be cultivated, and the best modes for preventing the necessity for too
frequent changes of bedding, often attended by great suffering,
or even peril to the patient, may be acquired. The more intelligent the person who is to perform the arduous and responsible
duty of nursing the better. Some possess a natural intuitive
"knack" for nursing; even such are not beyond improvement
by instruction. They only make the best subjects for it. The
worst are those who are self-opinionated, self-sufficient, and presumptuous.
To every ward there should be one good, intelligent, efficient
head nurse who alone should be held responsible for the administration of remedies and the general neatness of the ward,
and for the care of everything in it.  She should be supplied
with such assistants as are necessary; and the necessity should
be determined not by the number, but by the character of the
patients. It is impossible to say that one nurse is sufficient for
any given number of cases, so greatly do they vary in the
amount of attention each may absolutely require. The necessity
is not always to be estimated by the gravity of the symptoms or
the peril of life. The varieties of temper, and of susceptibility
to suffering, create as much variety in the need for attendance,
and cannot be disregarded. The querulous tempers of the sick
are often the result and expression of the diseased condition as
much as the vitiated secretions, and require not toleration only
but ministrations for their cure.
The head nurse should not be required or even permitted to
perform any of the rougher work. This should be done by those
in training, and in some of the more offensive details by those
not capable of cultivation, but possessed of physical strength.
Even these should always be sober, good-tempered, and quiet.
The supervision of the nursing of all the wards should be committed to one superior, responsible to no one but the board of
trustees.  She should also be the principal of the training school




244               MORRIS. —PLANS FOR THE
for female nurses directed by the letter of Mr. Hopkins. This
should be in the hospital building, where its pupils will receive
practical training as well as theoretical instruction, and will form
a body, subject to the orders of the principal, from which assistants to the head nurses of the several wards can be detailed as
need demands.
The selection at an early period of a suitable person to fill the
important position of principal of the training school for female
nurses and head of the nursery departmlent, thus affording her an
opportunity for receiving personal training in the performance of
the duties she is to superintend in others, in the schools connected
with St. Thomas's Hospital in London and Bellevue Hospital,
New York, and other kindred institutions, would be a very
important step toward securing efficiency in action at the first
opening of the Johns Hopkins' Hospital. It is exceedingly difficult to effect changes in long continued usages.  Such changes
are always met by obstructions in the prejudices or habits of
incumbents in possession. The need of thorough radical change
in the nursing department of hospitals is generally acknowledged, and the difficulty in effecting it loudly lamented.
The chief nurse of each ward should be required to wait upon
the visiting physician or surgeon, attended by the resident, in
their daily visits to the bedside of every patient; there to receive
and note in a tabulated book, provided with proper distribution
of spaces ruled and headed for the purpose, the directions for
diet and for the administration of remedies, or applications of
such dressings as are delegated to the nurse's care. But in all
these matters she should be subject to the authority of the resiclent physician in charge of the ward during  tile intervals
between the visits of the physician or surgeon-in-chief.  She
shlould communicate with the attending physician or surgeon
o i7y through the resident in charge of the ward; and all directions to her should pass through this officer. The fact that the
nurse has been present at the time they were given to him, and
heard the directions thus given, should not be considered sufficient for her, nor be presumed to render either unnecessary or
inopportune the directions of the resident to the nurse personally.
Blank forms should be furnished to the nurse for each patient,
and every day, in all cases of acute disease requiring regular and




JOHNS HOPKINS' HOSPITAL.                245
frequent administrations of doses of medicine or food. At the
time of the visit of the attending physician or surgeon, the resident should be required to inscribe on this schedule, opposite
to each hour, the direction for that hour, and, at the subsequent
visit, the nurse should be obliged to exhibit it with a checkl
placed at each dose given, or sign of omission if -not given.
Spaces should be provided in which the nurse shall rectord any
changes in condition or synmptoms which occur. These schedules,
thus filled up, should be placed on file, to furnish materials for
the history of the case should any development in its progress
render it important to consult them. It is an important point,
and if properly attended to would be productive of good results.
Night nursing is as important as that during the day, and
should never be intrusted, as is too often done, to anl undisciplined attendant.  The number of cases requiring attention at
night may be small, but they are those of gravest character, at-.
tended by the greatest risk, involving the greater responsibility,
and demanding the better care. But it should be committed to
other hands than those exhausted by service during the day.
The health and comfort of the nurses should be as much an object
of consideration as that of the patients.  No labor of mind
or body, or exhaustion of feeling, should be demanded which
shall impair their own health.  A good and faithful nurse is too
valuable to be sacrificed even to her own impulse of good. The
interests of the patients, too, demand this care of the nurse on
the part of the managers. Weariness and consequent weakness
develop nervous excitability, the influence of which is especially
injurious to the sick.  A cheerful, happy temper is one of the
highest qualifications for nursing, and this cannot be maintained
where the physical strength is overtasked and exhausted.
THE SUPERINTENDENT.
The executive department of such an institution requires a
head of no ordinary endowment and culture, and the efficiency
with which it is conducted will depend more upon hiln and his
mnode of carrying into action the rules they may frame, than upon
the wisdom of the trustees, or the perfection of the rules themselves.  Minuteness of perception and accuracy of observation
must be combined with readiness to recognize the obstacles to be




246              MORRIS.-PLANS FOR TIIE
encountered in the preservation of the purity of air, and of neatness and cleanliness in all the surroundings, which must be
maintained at whlatever cost of labor, though all the tendency of
the normal action of every part of a hospital is to the production
and accumulation of foulness. He must above all things possess the power of self-control, without which he will never be
able to exert the command over those employed which is necessary to subordinate them to his authority. He should have such
a degree of mental culture as shall render him an acceptable
companion to the cultivated officers associated with him in the
application to its purpose of the end6wment;
and yet he must be so familiar with the detail of domestic service, that he can enter with a full comprehension of what is necessary into the provision of the requisite supplies. He should have
delicate sympathy with those engaged in different departments
of service in the difficulties they must encounter, and yet with
it firmness and decision to demand and require the faithful discharge of the respective duties of each in his several department.
With no control over the treatment of the patients, he must be
so far familiar with it, and appreciate its importance, as to provide intelligently whatever is required to carry out the practical
application of the means necessary to accomplish the purposes of
those who do have charge of the ministration of the remedies, and
see that nursing is faithfully performed; he must have sufficient
sympathy with the sufferings of the sick to listen to their conlplaints, and provide for the relief of any remediable inconveniences; and yet have coolness and firmness of feeling enough
to resist unreasonable demands and turn a deaf ear to querulous
complaints, the natural offspring of unhealthy functions, and to
discriminate between those which are the result of natural imlperfection of temper, and those which are the consequence of
disease.
To equalize conflicting claims, to harmonize conflicting feelings, to control and bring into properly adjusted cooperation
conflicting duties, to overcome difficulties as they arise unexpectedly, to suggest modes of accomplishing objects, and yet be
the cheerful agent in carrying out the suggestion of others
whether coincident with his own or opposed to them, requires a
character combining opposite qualities in no ordinary degree.
If in union with these qualities he should have received a




JOHNS HOPKINS' HOSPITAL.              247
medical education, he would possess an unquestionable advantage. But in that case he must lay aside all aspirations after
professional honors, strictly speaking, and have no disposition
himself to enter on practical duties, or criticise the manner in
which those duties are performed by those to whom they are confided. The duties belonging inherently to the office of warden or
superintendent would absorb all the capacity of one most perfectly qualified. It would not be in the power of any one mind
to discharge them faithfully and take any part in the medical
and surgical service of the house. That would be a vain attempt
to serve two masters, each fairly entitled to undivided devotion
of all the faculties, and like all such efforts, would result to the
satisfaction of neither.
A matron or chief female officer will be necessary in addition,
who should have no connection with the nursing nor responsibility for that service.  She will find full occupation in the
supervision of the stores of bedding, the proper performance of
laundry service and repair, and the maintenance of perfect cleanliness and order in those parts of the establishment not embraced
in the wards properly speaking, which should all be under the
control of the head of the nursing department. There need be
no conflict, the duties are distinct, and each department would
tax fully the capacity of one person without combining with it
those of another. The care of the kitchen and the attention to
the economical provision of varieties in diet, and the proper
preparation and distribution, would fall in the province of the
matron; and, if well performed, would demand much skill, time,
and labor. It is an important and honorable service, on the
proper discharge of which very much depends, and might well be
coveted by a lady, in the strictest sense of the term, possessed of
culture and refinement, but with an aptitude for household
duties.
ARRANGEMFENTS FOR TEACHING.
It is not necessary that hospitals as such, should be used for
purposes of medical instruction.  They may be founded and
endowed, or supported by voluntary contributions, witll tlhe
proviso that they shall not be so used. That such a protection




'248               MORRIS. -PLANS FOP TIIE
is an advantage to the sick, no one can deny; nor that the disturbance of the tranquillity of the patient caused by making one
the subject of remark of the teacher, and object of investigation
by the student, is in many instances injurious, even when condclucted with the most delicate address on the part of the teacher,
and responded to on the part of the class by a similar regard to
the feelings of the individual.  On the other hand, the mode of
investigating disease, the manner of making the necessary inquiries, the relations of symptoms to causes, the various details
of the relations between the medical adviser and patient, can
never be so well taught as by practical illustration at the bedside; and are best acquired under the guidance of an experienced
practitioner.  Indeed, no one, however well instructed in the
theory of medicine by books andl study and oral teaching, is
qualified to put the principles thus acquired to practical use,
without some such instruction in the art of investigating the
nature of disease, and detecting its diagnostic marks, and tracing
tihe influence of remedies applied.  Very few medical students
are favored with opportunities for acquiring such knowledge and
cultivating the necessary tact, except as they are afforded by
clinical instruction in hospitals. It is necessary that the3y should
have it; and this necessity is recognized by the judicious founder
of the hospital, who, including a medical school in the plan -of
his university, directs that the hospital he endows shall be thus
imade subsidiary to the advancement of medical science. He thus
requires that, in return for the benefits he confers on the sick, and
the blessings he provides for them, they shall contribute, somewhat to the good of the common humanity.  This he was certainly enutitled to stipulate; and every patient who accepts his
lnunificent provision for his own personal advantage is bound,
by the very act, to return the service required for the benefit of
others. It is but a smlall tribute in acknowledgment of a great
boon.
The relations thus established should be guarded on the one
side from  offensive and oppressive intrusion, and on the other
from unnecessary and selfish vvithholding of an opportunity for
doing a great good, not to the mlere student only, but through
him to fellow-sufferers without limit.  The teacher who would
disregard the proper delicacy, or ig'nore the feelings of a patient,
in presenting a case to a, class, or subject one to fatigue and




JOHNS HOPKINS' IHOSPITAL.               249
injurious exposure in order to exhibit the symptoms or progress
of disease, or the advantage derived from  treatment, is not
worthy to be called an instructor, and would not receive an
appointment by any body of men right-minded themselves on
such subjects. He could not teach nor exhibit what he did not
himself possess or practise, the proper mode of treatment of the
sick. It is not for a mlonment to be supposed that such an one
would ever hold a post on the staff of the Johns Hopkins' Hospital.
It is not to be denied, however, that there are grave difficulties
in the way, recognized by every properly qualified teacher, and
from which he would himself desire to be protected. A class of
students of medicine must embrace men of every grade of intelligence and of every variety of character. Most if not all of thenm
are unused to consideration of the feelings which belong to sickness, and, if earnest in the pursuit of their object in life, are
bent only on using every opportunity for the acquisition of the
knowledge which is essential to success. Many, with the reckless indifference of the period of life at which such studies are
pursued, think only of the present gratification of curiosity.
To allow such motley companies to throng the wards filled with
patients in every stage of disease; cluster around the beds of
those whose extreme illness renders them especial objects of interest; hustle each otlher for places; chaff each other in sport; or
weary the sick by repetition of questions to satisfy their own
desire for information at tilhe expense of the suffering of the sick,
were a mortal wrong. Such invasions are also destructive of the
police of the hospital. It is impossible under such circumstances
to maintain order or cleanliness.
Some mode must be devised to meet the emergency; to guard
the sick from improper intrusion; to afford the students the advantages which are so essential to themselves, and so important
to the interests of humanity; and to save the hospital from a disturbance which is so objectionable.
The plan here proposed embraces a lecture room and operating
theatre, the access to which by the medical class is entirely without, the hospital, and yet so placed with regard to the general
wards, that patients can be taken to it without injury to thenmselves; with small waiting wards attached in which they can rest
till needed for illustration, or where they can remain for a time




290              [MORRIS.-PLANS FOR THE
after an operation. To the general wards only the more advanced class of students should be admitted; and those only in
small bodies, properly adjusted by the attending physician or
surgeon whose service they are following, so as to give them opportunities for observation without injury to the patients. The
details of this arrangement should be committed to the medical
and surgical staff of the house, and lie under their control, subject to such modification as they shall find expedient.
The question as to the location of the medical department of
the university does not belong to the consideration of hospital
arrangements, and cannot be properly discussed in connection
with it.
DISPENSARY.
In considering the question of dispensary service it must first
be determined whether it is to include visits at the homes of the
sick, or only giving advice and furnishing medicine to those who
are able to leave their homes in quest of it. It is in this latter
form that it is generally connected with hospitals, leaving the
other to district or general associations specially instituted, and
by which it can be more properly conducted. It is in this view
that it will claim attention.
It is an associated agency rather than an integral part of the
hospital itself, and it would be imposing too.great a tax on the
time and labor of the regular staff to expect them, in addition to
their ward services, to devote the necessary time and thought to
the number who are drawn by the reputation of the institution
to seek relief at its doors.
The abuse of charity by the resort to public institutions for
gratuitous advice and assistance on the part of many who are
able to make moderate compensation for the service they receive,
and who by doing so lose their own sense of self-respect and
become accustomed to dependence and learn to rely on it, is a
subject which has demanded and received much attention in
Great Britain as well as in our own country, both from  the
members of the medical profession and the managers of hospitals. A ready and partially justifiable apology is presented in
favor of those who thus place themselves needlessly in the
position of beneficiaries, in the confidence inspired in the superiority of the advice of gentlemen who have established for




JOHNS HOPKINS' HOSPITAL.              251
themselves a reputation which has led to their receiving hospital
appointments.
This ought not, however, to be accepted without careful limitation, since such parties can receive the same advice at the
private offices of the same skilful practitioners, who are entitled
to compensation for the toil and anxiety by which they have
qualified themselves and acquired the reputation which they
thus transmit to the institution they serve. Nor should the
claims be disregarded of the large number of aspirants for fame
and the just pecuniary reward of their exertions, who crowd the
ranks of the junior members of the profession, and are entitled to
a fair field in which to cultivate and exhibit their powers. The
general interests of humanity are promoted by the recognition of
diverse claims and due regulation of their relations to each other.
There are rights to be maintained on both sides, and evils to be
avoided which will attach themselves to every course of human
action.
The out-door dispensary should therefore be under the charge
of an entirely distinct staff of medical and surgical officers, and
the access to it should be by a separate entrance; and while
medicine may be drawn from the same stock, and manufactured
in the same laboratory, the compounding the prescriptions of
the physicians and surgeons should be the duty of a separate
apothecary. The duties of the laboratory and the compounding
and dispensing to the wards, will furnish full employment to the
apothecary of that part of the institution, andl where there is a
large number of patients in the out-door dispensary, the attention to them interferes with hospital duties.
It is proposed to devote the basements of the two southern
pavilions on the plan herewith submitted, to this dispensary
service, with access across paved yards on the level of the street
b)ounding the hospital on the south, entirely distinct from that to
the hospital.
These basements will be elevated above the level of the ground,
and will contain ample area to be subdivided into waiting-rooms
for patients and dispensing-rooms, and allow a separate examination-room for each specialty into which the general service
may divide itself.
It would be impossible to enter upon the discussion of the
question of "specialties" in practice or in teaching. Such divi



252               MORRIS.-PLANS FOR TIHE
sions are pushed by some to an extreme which is not only absurd,
but very injurious to the interests of medical science as well as
those of patients. When once the medical man is thoroughly
instructed in the general principles of the science of medicine,
lie may, and probably will, acquire greater proficiency in the
application of these to one form of disease than another, and
therefore, in public service or in private practice, acquire distinction in the treatment of some special form of disease. He
will naturally under such circumstances turn his attention esp,-~cially to that class of diseases, and this fact will in turn bring a
larger number of such cases to his consulting-room. Out of this
grows eminence in a peculiar line. MEen who have thus acquired
proficiency and reputation in the treatment of special disease,
will desire appointments which will afford them a wider field of
observation and a larger harvest of renown.  Appointment of
such men on the dispensary staff will secure proper attention to
the patients seeking advice, and add largely to the efficiency of
the institution. But it should not be allowed to degenerate into
a position in which aspiring ambition shall seek reputation in a
special plan of treatment, a mere stepping-stone to personal notoriety; to which it is quite possible to pervert it. The character
for ability in the treatment of some special form of disease should
have grown out of previous study and consequent aptitude.
The surgery of the eye, and of the ear, may each well be made
a specialty; and so may the peculiar diseases of women, and
those of children; but the great body of cases should be treated
on general principles by general practitioners. Four physicians,
and the same number of surgeons, should have care of these
general groups of cases, one of each rendering service at stated
hours daily, while one to each of tire special subjects enumerated should also give daily attendance at some other hour, not
only to avoid confusion among the applicants themselves, but to
enable them to receive such as shall have been referred to the
specialist by the general physician or surgeon. Opportunity
should also be afforded to the officers on the dispensary staff, of
making their cases the subject of clinical instruction to the
medical class, in the amphitheatre of the hospital, on such days
and at such hours as will not interfere with the lectures of the
hospital staff proper.




JOhINS HIOPKINS' HOSPITAL.             253
TRANSPORTATION OF THE SICK AND VWOUNDED.
This is one of the important subjects on which you solicit suggestions.
One or more vehicles, properly shaped to receive a mattress
or stretcher, hung on springs adjusted to the varying weight it
may be required to carry, and provided with all the appliances
to limit motion, and prevent its transmission to the sick or
wounded occupant, should be held in readiness; with the horses
required to draw them. These should be used only when the
distances are great or the weather inclement. For moderate or
short distances stretchers, carried by men, may be substituted
not only on account of economy of expenditure, but, what is
much more important, to the great diminution of the suffering
of the patient. The rude extemporized resort to the unhingedc
window-shutter, or door, or hard settee, properly guarded by a
small mattress or folded quilts, is often to be preferred to the
wheeled carriage, however carefully driven over illy paved
streets, swayed from side to side in the unavoidable jostle of a
crowded thoroughfare. Bearers can generally be secured with
but little difficulty.
The modern application of telegraphy has provided conveniences for summoning assistance, which cannot be too highly appreciated, and of which hospitals have not been slow to avail
themselves.
The hospital office should be put into immediate connection
with the central police station; with the understanding that messages should be promptly  rnsmie transmitted through it from  every
part of the city, whenever an accident has resulted in injury
requiring the subjects to be sent to the hospital. One of the
resident surgeons should be detailed for duty in taking charge
of the case, and superintending the transportation to the hospital. The well-intentioned but ignorant officiousness of benevolent spectators often suggests remedies or actions not only inappropriate, but positively injurious; and the meddlesome interference of some who claim the privilege of doctors without the
qualification, is often more pernicious still.  When we think
of the evil effects too often resulting from such ignorant or presumptuous interference, we cannot estimate too highly the value
of the timely and authoritative interposition of one who comes




254              MORRIS. —PLANS FOR THE
prepared to take prompt measures suggested by knowledge and
experience.
All the instruments required for stanching hemorrhage, or
supporting an injured limb, should be despatched with the ambulance in charge of the surgeon. Limbs or lives which would
be sacrificed by delay in the transportation to the hospital, or
through injudicious treatment, would thus be saved.
RELIGIOUS SERVICES.
The importance of this branch of hospital arrangement cannot
be over-estimated.
Considered from the lowest point of view it is evident that
man's spiritual nature is as much a part of his being as his corporeal, and its appetites and disordered conditions require as
decidedly supplies and remedies. Temples to the god of healing
were probably the hospitals of the civilized nations unenlightened by Christian revelation. They were certainly the tokens of
a sense of dependence on a higher power than human art for the
relief of sickness and pain: and among all Christian people hospitals for the relief of disease have been an outgrowth of religious philanthropy. It were irrational, to say the least, to pass
without consideration the intimate relation between the body
and the soul, and to overlook the influence which the one exerts
upon the other, and while providing for the cure or relief of the
morbid states of the body to neglect the claims upon our sympathy of feelings which disturb the bodily health, and upon that
ground alone, if on no higher, are entitled to demand consideration.
Religious instruction and consolation can be neither rejected
nor neglected with impunity, however much the injudicious obtrusion of it may be condemned. The proper adjustment of
this influence is a delicate affair, and is entitled to much thought.
Even those who under the exciting and all-absorbing influence
of active pursuit of temporal business and pleasure have been
most successful in banishing from their minds the thoughts of
another state of existence, find that in hours of weakness and
sickness, with their enforced exclusion of customary pursuits
and excitements, the soul naturally realizes and dwells upon the
shortness and uncertainty of the present life, and that the thought




JOHNS HOPKINS' HOSPITAL.               255
of another state of existence will intrude, however much it may
be repelled. The judicious direction of such thoughts, and the
supply of the consolations of revealed religious truth, are therefore as much a humane duty as the provision of proper remedies for bodily disease, and support for bodily weakness; and
the proper control over action designed to meet this state of the
mind and heart of the patients is as legitimate an exercise of
judgment, as that which provides and regulates the application
of remedial agencies to bodily diseases. It would be as unwise
to leave this without provision as it would be to open the wards
for the reception of cases of disease without control over the
mode or character of the treatment to be employed for cure or
relief.
The importance of the subject was properly appreciated by
the founder, who in his letter of instructions to the Trustees
says: "It is my especial request that the influences of religion
" should be felt in, and impressed upon, the whole management
"of the hospital; but I desire, nevertheless, that the administra"tion of the charity should be undisturbed by sectarian influence,
" discipline, or control."
The religion of Jesus Christ, in whose divinity and offices he
himself professed his faith, is beyond doubt that which he desired
should permeate with its healing influence the institution he endowed; committing the control of the means by which that influence should be disseminated to the board, excluding sectarian
teaching and attempts at proselytism, at the same time that he
provides for the extension of the benefits of the charity to all
without regard to creeds or the want of them.
The character and known views of the members of the board
of trustees selected by Mr. Hopkins himself, and to whom he
entrusted the carrying into application his "especial request,"
-men with whom he had been intimately associated for years
before the selection of them for this duty,-may be looked upon
as the expression of his purposes in this respect.
Some rules for the regulation of this important matter must be
adopted.
That which is simplest of all, requiring no argument for its
support, is, that every patient in the hospital shall enjoy, as an
unquestioned right, the privilege of receiving the visits and religious services of any one he or she may select, whether a regcu



256               MORRIS.-PLANS FOR THE
larly ordained or appointed minister of any Christian church or
not; subject, however, to the consent of the medical or surgical
attendant, who alone can determine how far the state of the
bodily health of the patient may render such. visits improper
or injurious; and provided also that such visits shall not be
made at times which would interfere with the discipline of the
hospital.
The second rule is equally incontestable, and of universal aplication.
No service thus rendered to or performed for any one or more
patients shall be conducted in such a manner as shall interfere
with the comfort, or disturb the quiet of, or in any way incommode other sick persons in the ward.
The propriety of these rules will not be questioned.
The next step is on more debatable ground, and must be taken
with due caution.
The interruption to the usual current of thought and employment of mind occasioned by bodily injury or sickness, presents
an opplortunity which should not be neglected, for the presentation to the attention of subjects of eternal interest to the soul.
How shall this be done, and by whom?
The supply of Bibles, and of books of devotion, and of instruction in those points of religious belief held in common by the
great body of professed Christians as represented in the board
created by the founder, should be encouraged in conformity
with his " especial request. "
But this silent and unobtrusive influence does not meet fully the
requirements of the case, and as no one authorized teacher is
appointed, other agencies must be invoked for vocal instruction
and ministry, and some restraint established, or irregular and
antagonistic teaching will lead to improper excitement, or even
give occasion to injudicious and reprehensible controversy.
In a hospital conducted on the principles of that founded and
endowed by Mr. Hopkins, there can be no written law on this
subject. It must be left to the discretion of the board of trustees, which should be represented in this relation by a committee
appointed to superintend and direct this special subject. This
committee should, either directly or by delegation of authority
to the superintendent, regulate and control the time at which
and the persons by whom visits for this purpose, may be made.




JOHNS HOPKINS' HOSPITAL.               257
This authority to be final and without appeal, unless to the
board in session.
The same committee, or its deputy, should make arrangements
to secure for the benefit of the inmates, the performance of some
form of public service and instruction on the day appropriated to
Divine worship; such services to be held in a chapel in some part
of the buildings easily accessible, and at such hours as will not
interrupt the necessary routine of daily service; due notice being
given to all able to attend, without the exercise of any control or
improper influence, the character and duration of the service to
be subject to the control of the committee, who shall have power
to exclude any ministrations they may believe disturbing or injurious to the sick or convalescent.
The rules for the government of the institution relating to this
subject should be well considered, and adopted before the opening of the institution, and once decided should not be allowed to
become subjects of discussion.
HOM{E FOR CONVALESCENTS.
To a superficial observation the addition of such an appendage
to the arrangements for the relief and cure of the sick appears a
simple matter indeed. The more careful thought is given to the
subject the more formidable becomes the array of difficulties
which present themselves.
The location of such an institution is itself of vital importance.
It must be on some route of public travel which shall furnish
conveniences for easy access to the feeble and those in delicate
health, or just emerging from the perils of acute disease. Water,
with steamboats running frequently, presents the most available
channel of communication, and the influence of the breezes and
currents of air which follow water-courses is desirable, if a suitable and healthy site can be found on the shore.
It should be high, and there should be no marshes in the
neighborhood to poison the air by the exhalations.
The distance, even by water, should not be so great as to involve fatigue in transportation, and it must be at a point with
which communication is open during the cold season as well as
during the summer, and must not be so remote as to render
inconvenient occasional visits fron the physician or surgeon who




258               MORRIS.-PLANS FOR THE
has had charge of the case in its acute stages. The miasmatic
influence which prevails on the shores of the Chesapeake and its
tide-water tributaries, precludes the resort to them. Next to
water, railroad communication is to be chosen. But this must
be by a route affording frequent trains and stoppages, and the
site selected on this must be near a station.
If a common road affords the only avenue of approach, the
distance from the hospital for the treatment of acute disease
must be so limited, that the probability of procuring a suitable
site is proportionally diminished.
The site itself is as important as the location, and the selection
of it is surrounded by as many and as great difficulties. It must
not only be in a salubrious district, free from the contaminating
influences of imperfect drainage and neighboring swamps, but
must not be in the vicinage of any of the numerous establishments inimical to health which cluster around the suburbs of
every great city. It should have a good elevation and perfect
drainage, an ample supply of water, sufficient area to furnish
space for outdoor exercise and amusement, with unobstructed
air, and ready access to market for supplies.
The site determined, a second question at once presents itself
scarcely less perplexing. Will it be proper to collect convalescent
invalids without regard to age, sex, or color in one building? All
are certainly included in the provision made by the founder.
During acute sickness the collection of all in one common institution is unattended by any difficulty. Is there not, however, a
change in circumstances connected with returning health and
vigor, which renders indiscriminate and unrestricted communications in hours of constrained idleness liable to very serious objections 2-objections which would not be obviated by the interposition of territorial lines of division, nor even by the obstacles
interposed by separate buildings on the same grounds. This is
a subject which demands careful thought and investigation, and
on which there is yet no experience in this country to guide one
in forming an opinion. The separation of the sexes in detached
buildings would alone involve greatly increased labor in administration and supervision, and enhance largely the cost of main
tenance, which would be doubled by the distribution into separate
buildings. Distinct homes for the white and colored must, of
course, be designed.




JOHNS HOPKINS' EHOSPITAL.             259
There is a limit to human responsibility, and if one waits till
some plan for doing good is devised, which shall be free from all
contingencies which may result in evil, one may abandon every
effort for the relief of the suffering which abounds in the world.
Responsibility terminates with the exercise of reasonable care
to provide guards against the evils inseparable from the reception
of both sexes in one house; and the same intercourse which is
proper in social life, in lodging-houses and other homes for the
healthy population, may well be recognized as allowable in the
home for the convalescent; the cost of building and expense of
support being thus greatly diminished, and the benefits proportionably extended to a larger number. Still, it is a very serious
difficulty, and the only effectual barrier against the evil consequences which are inseparably connected with one common home
would be the establishment of two, entirely distinct in govern.
ment, and remote from each other. The original cost would be
double, and that of maintenance nearly so; but it is only by this
that the evils resulting from association can. be wholly avoided.
The same principles of construction would apply whichever
course is taken.
It is difficult to determine the proportion to the general hospital which such an appendage should bear. The percentage of
recoveries to admissions would not afford even an approximate
estimate. Various influences will induce a large proportion of
those thus restored to desire to return to their own homes so
soon as they are able to leave the wards for the sick. Duties to
be performed, however imperfectly, will draw heads of families;
and the indescribable charm which finds its centre in the home
of the lowliest, will cause a large proportion of those who possess
homes -to prefer to return to them even though the material comfort, to a disinterested observer, be beyond comparison less than
that offered in the convalescent home. There is in the mental
and moral association a charm which may be more powerful in
its attraction, if not in its health-restoring influence, than sunshine and pure air and good diet without its aid.
Then again there may be many patients discharged cured from
the wards, to whom for various reasons it would not be desirable
to extend further benefits. At the moment of an accident, or in
the hour of sickness, all are welcomed; the profligate, the pro
fane, and the unworthy and ungrateful.




260              MORRIS. —PLANS FOR THE
Bad and good, incorrigibly evil, and those unwilling to submit
to control, as well as those who respond cheerfully and gratefully
to that which is necessary for proper order, are all collected in a
hospital provided for the sick poor. To some of these it may
not be proper to extend any aid, beyond that which humanity
and Christian love teaches -us should be extended to the unthankful and the evil as well as to the good.
Designed only for the reception of " convalescent patients," it
should not be filled with chronic invalids and incurably sick,
whose presence would materially interfere with the comfort and
diminish the advantages of those for whose special benefit the
provision is designed. Great care will be necessary to guard
against this.
When these several classes of cases are eliminated, but a small
percentage remains to claim the privilege of the home for convalescents. All these are considerations which claim attention,
and the decision upon the questions they present must rest with
the board of trustees. It is sufficient to indicate them and invite
attention to their essential importance.
Perhaps twenty per cent. of the cases of admission would be
a liberal estimate of the proportion for which it would be necessary to make provision in the home for convalescents, unless it
be thought within the scope of the purpose of Mr. Hopkins to
extend its benefits to others than those who have passed through
the wards of the hospitals so generously endowed.
The requisite capacity, the location, and site having been determined, the character of the buildings next claims attention.
The same principles which govern the construction of the hospital proper are equally applicable here. Sunlight and air are
the great agents whose influences are to be provided; and this
must be done without stint, though with as much regard to
economy of ori;ginal cost of construction, and expense in permanent management, as is consistent with this provision. Should
the plan of one home only, be adopted, a solid parallelogram of
sufficient size to furnish the required room is the most economical form of building, the sexes being provided with separate
dormitories and parlors, but being thrown into association in the
chapel, refectory, and the open grounds. Any disposition to
improper association would overleap whatever barrier could be
interposed by placing them in different wings or even detached




JOHNS IHOPKINS IIHOSPITAL.            261
pavilions, with common centre building for administration offices,
and the restraint afforded by mutual observation and the more
nlinute circumstantial supervision of the officers of the institution which would naturally result from such concentration, would
be the most effectual.
The detail of arrangement of such a structure should be the
subject of careful thought. It is only necessary to present the
general principles which should govern the selection of the plan.
The kitchen, laundry, and heating apparatus should be in detached buildings, their location in relation to the main building
being subject to the nature of the grounds chosen. The kitchen
must be brought into as close proximity to the refectory as possible, and the laundry be as much detached.
There should be commodious and well-aired and lighted, apartments for the use of the inmates in such weather as forbids outdoor amusement; and every inducement should be presented to
encourage some agreeable employment of strength and occupation of time. Miss Nightingale says: "A little needle-work, a
little writing, a little cleaning, would be the greatest relief the
sick could have if they could do it. These are the greatest relief
to you though you do not know it.     * * * *    Bearing in mind
that you can have all these varieties of employment which the
sick cannot have, bear also in mind to obtain for them all the
varieties which they can enjoy."
The dormitories should be large and airy, and heated on the
same principles as those advocated for the hospital wards. They
should be common, not isolated. One convalescent should not be
left alone during the night, lest there should be some need for
assistance which could not be summoned. Two only should
not be placed in the same apartment, lest incongruity of temper
or dissimilarity of habits should involve risk of disturbance. A
few private apartments should be provided for special cases
whose presence in the common dormitories would interfere with
the comfort of others, or for such as could pay for extra accommodations. Even these should have communicating doors, so as
to permit the summoning of assistance; and there should be galvatnic connection with the apartments of the nurse by which she
could be summoned in case of necessity.
Refectory, dormitories, and rooms for amusement and occupation in weather which does not admit of out-door pursuits, are




262              MORRIS.-PLANS FOR THE
all that will be required. Food, air, and appropriate occupation are the influences which promote convalescence. No part
need be set apart for the apothecary. The requisites for the
comfort of a well-ordered lodging-house are all that are needed
for such a home.
The objection to corridors or verandas surrounding the wards
of the hospital, does not apply to such an institution, and wide
piazzas or galleries should be provided, so arranged as to furnish
shade during the warm season, and warmth with shelter from the
wind during the cold.
No dark corners or recesses should afford opportunity for
concealment; or for the accumulation of dust and dirt. Every
part should be well lighted, well aired, and open to observation.
The entire charge of the administration would be most properly committed to an intelligent and experienced physician,
who would be able, with the assistance of a judicious matron
and proper nurses, to conduct the medical treatment, as well as
the general economy of such an institution.




r-   [I  II Ir~                     -?                                   No. I.
ROEOMROUAE
r — =SUSE                                    96 FEETT THE INGH.
DR. MORRIS  SUGGESTIONS,
JOHNS  HOPKINS HOSPITAL                                  A TA=R====  — Y            LAVATOR 
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Nob~Al- I                                                            1 1 E.t~             ~~ NING L 
PLAN OF EISEMENT.








JOHNS.HOPKINS' HOSPITAL.             263
DESCRIPTYON  OF DRAWTINGS.
The entire group of buildings is composed of pavilions, the
long axis of each running north and south, connected by lateral
corridors running east and west, and so placed as to throw all
those portions of the pavilions appropriated to sick wards to the
south side; other adjunct apartments being projected on the
north side.
They are so placed on the lot of ground, that the extreme
south building (the heating house and laundry) shall be on the
line of the street bounding it on the south, and at the grade of
that street; and the southern end of the south range of ward
pavilions shall be on the line of the north side of this building
and its yard; thus providing that the north or main front of the
group of buildings shall recede as far as possible from the north
line or Monument Street, leaving space for widening said street
anld for ornamental grounds.
The entrance is by a gateway at the middle of the Monument
Street front. At the one side of this gateway is a one-story
building, containing two rooms for the gatekeeper; and at the
other, two rooms of corresponding size to be used as waitingrooms for applicants for admission; one appropriated to each
sex.  At either side of these buildings east and west, glass
houses, fronting to the south; the one for the conservatory and
the other a grape-house.
The central building is distributed to three services. The
north end, constituting the main front of the building, is of two
stories thrown into one, surmounted by a dome or other arrangement for lighting the operating apartment and lecture-room; and
may be finished with flanking towers or any architectural arrangement adapted to give it character as the most prominent feature
in the building. This position is important to it as the only one
which affords a north light, which is that best adapted to an
operating room.
The front entrance in this main central building is for the
exclusive use of students and others attending at lectures and
operations. The entrances to the hospital proper are placed in
the main corridor, at either side; and should be provided with
porticos or porches corresponding in style with that in the
centre of the front of the main building. The front entrance,




264               MORRIS.-PLANS FOR THE
appropriated to students, has no communication with the other
parts of the hospital, in order thus to guard against any intrusion into the wards except under the restriction of rules to be
adopted by the board of trustees.
The main portion of the central -pavilion, immediately in the
rear of the amphitheatre for lecturing, has three stories: the
two lower appropriated to offices and the residences of officers;
and the upper to the accommodation of the training school for
female nurses, required by the plan of the founder. The rear of
the central pavilion is of only two stories, corresponding with the
four interior ward pavilions, and contains on the first floor two
wards for children, and on the second private apartments for
pay patients and for resident physicians. The main floor of
the central pavilion is divided by a central passage running
north and south its entire length from the north end, where
it enters the lecture-room and operating apartment, on the
level of the arena of the amphitheatre, to the south end,
where it opens upon the corridor connecting with the two
southern ward pavilions; and is crossed at right angles by the
connecting corridor running east and west.  It thus affords
easy communication with all the wards, from  which patients
can be brought as illustrative cases for lectures or for operation. On either side adjoining the lecture-room are suitable
apartments, lighted from  the side, in which  patients can
wait till required to be taken in; or rest after operation till
sufficiently recovered to justify removal to their respective
wards; and also smaller rooms for the use of the lecturer or
operator, containing cases for instruments, splints and apparatus, and conveniences for washing, etc. This central passage,
running north and south, is intersected by the main corridor
running east and west, upon which are strung the several warcl
pavilions hereafter described. To the south of this, on the nmain
floor, on the one side is the apothecary's dispensing room, connected by magnetic wires and speaking-tubes with each ward;
and on the other, the business office of the warden or superintendent. Adjoining these rises the main stairway; beyond
which are parlor and dining-room for officers; and still beyond,
wards for children, opening on a veranda across the south end,
from  which passes the gallery connecting this building with
the south pavilion wards. The ward on one side being appro



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JOINS HOPKINS' hIOSPITAL.              265
priated to white, and on the other to colored children. The connecting gallery passes over the roof of the central kitchen, which
is thus placed at the very centre of the entire group of buildings
to be supplied from it, on the level of the basement, through
which it communicates with them all, without exposure of the
food after preparation to the deteriorating influences of vicissitudes of weather, or delay during transportation.
In the basement, under the operating and lecture room, are
well-lighted apartments of the same area as those above, communicating with them directly, which are suitable for purposes
of pathological investigation; withdrawn from unnecessary observation, yet having easy communication with other parts of
the building through the basement passages. The other portions
of the central basement are occupied as storerooms for general
purposes under the warden's apartment, while beneath that of
the apothecary is a laboratory, to be made fire-proof, with a
detached fire-proof storeroom for keeping ethers, alcohol, and
other highly inflammable articles used in the preparation of medicines, and also wines and liquors for direct administration, which
should be held as medicines and dispensed as such by physicians'
prescription.
On the second floor, immediately in the rear of the upper part
of the amphitheatre, the entire space occupied below by waitingrooms and hall is thrown into one apartment, to be used as a
chapel, lighted from either side, east and west, and also by windows to the north opening into the amphitheatre over the upper
range of seats. It is divided from the corridor by an open screen
of glass, so that this may be thrown into it if necessary.
The area on this floor south of the transverse corridor is appropriated to the various apartments for officers, and a board room
and library, and to apartments for the use of pay patients and
resident physicians; and the central passage terminates on a veranda running across the breadth of the pavilion. The central
part of the main building has a third story in which are the accommodations for the training school for nurses.
The entrance to the hospital proper is, as before mentioned,
by separate doors, protected by appropriate porticos ow porches,
opening into the main corridor on either side of the main central
pavilion, half way between that and the two-story ward pavilions
which lie parallel to it, at the distance of 140 feet on either side.




266              MORRIS. -PLANS FOR THE
The female patients and their friends will enter at the side connected with the wards set apart for that sex, and the males and
their visitors on the other, being directed to the one or the other
by the gatekeeper, persons having business with the warden or
superintendent being directed to that nearest his office.
Each pavilion, except the central one, is a separate and distinct
hospital, perfect in itself in the accommodation furnished for the
treatment of the patients. But, as all are to be brought under
the administration of one common central power, it is necessary
that there should be some channel of communication, which in
this climate must be provided with arrangements to adapt it to
use in all the vicissitudes to which we are liable of heat and cold,
sunshine and storm. If the temperature were uniform and genial, there need be no covered communication, and each pavilion
might stand entirely detached from all others. But some protection is required against inclement weather and extremes of
temperature, whether high or low. The construction of these
corridors is therefore such as to provide against both' extremes.
They should have the smallest breadth of wall consistent with
solidity, allowing the widest possible space in the intervals, to
furnish the freest currents of air when suitable, and be provided
with glass sashes, by which the weather can be excluded when
the necessity for protection requires this to be done for safety.
The windows should open to the ceiling, and the doors should be
large and wide, and they and the windows should be placed directly opposite to each other, that thus there may be, during the
warm months, the utmost freedom of circulation of air, while,
even then, protection from the sun is needed by sick and well in
passing to and fro.
The pavilions next the central building on either side are two
stories, those beyond but one. The corridors are, therefore, of
corresponding height, those connecting the outer pavilions being
only one story. On the south-side of each corridor is an open
veranda of the same width. These are found by experience to be
most valuable adjuncts. Sheltered from the north winds during
the winter season, they receive the warm rays of the sun, and
afford exercising galleries for those patients able to walk or move
themselves about in wheel chairs, while morning and evening in
the summer months they are shaded from the direct rays of the
sun, and furnish pleasant resting-places in the open air. On the




PLAN OF SECOND  FLOO R.                                                                                                                                  No.3.
SCALE 64 FEET=INCIDR. MORRIS' SUGGESTIONS, 
JOHNS HOPPKINS HOSPITAL
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JOHNS HOPKINS' IHOSPITAL.             267
same level with the wards, they are easily accessible from them;
and yet do not serve, as galleries around them would, to exclude
the light and confine the air of the ward, nor are they subject
to the deleterious influence of the poisoned air of the ward.
Patients congregate there for pleasant chat and lively amusement, without interfering with the repose or disturbing the
tranquillity of the sick in the wards to which they belong. If
connecting corridors were of no other service they would be
valuable as affording opportunity for this arrangement of verandas, instead of placing them parallel to the wards.
It is not necessary to repeat here the description of the detail
of arrangements in the several wards, as they correspond accurately with the plan proposed in that part of the essay in which
the principles of construction are explained. Each ward with its
adjuncts is but a duplicate of the other. The outer pavilions are
made one story only, in order that they may thus be drawn so.much nearer the general centre, and not exclude light and air
from the inner ones; and also because the required number of
beds is provided with only one floor. A larger number of patients
than is thus provided for should not be gathered in one hospital.
For the same purpose of concentration the two south pavilions
are placed in the position they occupy, by which they are
brought near the central administration, the heating power, and
the kitchen. As they can be placed on a somewhat lower level
than those in front, the gallery of communication between them
and the transverse corridor uniting these may have a slight inclination, and if exception should be taken to a second story of
this transverse corridor as obstructing the access of air to the
northern pavilions, it may be made only one story with an open
veranda on the flat roof; though the distance south from these
pavilions, and the wide space between them renders such an
objection of little force.
The basement of these southern pavilions is appropriated to
the out-door dispensary service, having separate entrance on the
street bounding the hospital on the south, across paved yards,
interposed between the street and the south end of the pavilions;
these have no outlet at that end.  The space between these
pavilions is wide-176 feet.
On the level of the street, on the south line of the lot quite
beyond the terminal line of the southern pavilions, is placed a




268              MORRIS.-PLANS FOR TIHE
building of only one story, containing the heating apparatus,
with coal-bins adjoining on the one side, and the laundry on the
other, having attached to it a yard, also on the level of the
street, but sunk below that of the hospital grounds, in which
clothes shall be dried in the open air and sunshine whenever it
can be done, thus receiving the purifying influence of light and
air. The drying room only to be used when the weather forbids
out-door drying.
The kitchen is placed at the most central point of the entire
group of buildings, and perfectly detached from them all, on
the level of the basement, by which it has communication with
every part by railway and lifts.  The central chimney, with
its perpetual fire, will afford opportunity to connect with it
flues for ventilation of various parts more accessible from this
point.  The isolation of the kitchen from all other buildings
will prevent the diffusion of fumes and vapors arising from
culinary processes, as effectually as though it were placed on
the upper floor.
It will be seen also that an underground passage, well-lighted,
connects the kitchen with the coal-bins and ash-pit, and affords
opportunity to bring in provisions and stores without any connection with the hospital or any of its adjuncts, and that
similar tunnels convey the various pipes and tubes connected
with the arrangements for heating and lighting and the supply
of water, to the basements under the several pavilions; and these
passages also afford conveyance for soiled clothing to the laundry, and for the bodies of the dead to the apartment appropriated to receiving them and delivering tliem to friends.
An area of twelve feet wide at the bottom and easy slope to
the surface surrounds every part, which is in the least sunken
below the surface.
It will be noted that in each of the wards the lateral walls are
broken midway, thus forming external projections corresponding
with the end towers. This provides the same amount of floor and
air space as that for which the plain parallelogram is calculated,
and which is encroached upon by the central stacks of chimneys.
No representation on the drawings is made of the hut or tent
rooms, which should be provided for any cases requiring absolute isolation, these not being permanent structures, and easily
placed on any part of the grounds, as occasion demands.




HOSPITAL CONSTRUCTION
AND ORGANIZATION.
STEPHEN SMITH.




CONTENTS.
INTRODUCTORY  STATEMENTS.......................2......1......... 271
I. SITE OF THE HOSPITAL..............................................  273
II. THE GENERAL HOSPITAL.............................................           282
III. BUILDINGS ADAPTED FOR THE CARE AND TREATMENT OF THE SICK OF
A GENERAL HOSPITAL......................................                 290
IV. HEATING AND VENTILATING......................................... 308
V. ADMIINISTRATIVE BUILDING...........................................          314
VI. THE MEDICAL SCHOOL.......................................... 317
VII. THE  CHAPEL.................30... 320
VIII. TRAINING SCHOOL FOR FEMALE NURSES............................... 322
IX. ADMINISTRATION................................................. 325




HOSPITAL CONSTRUCTION
AND ORGANIZATION.
STEPHEN SMITH, M.D.,
OF NEW YORK.
INTRODUCTORY  STATEMENTS.
FROM the letter of Mr. Hopkins to the trustees we learn that he
contemplated the establishment, upon the grounds selected, of1. A General Hospital;
2. A Training School for Female Nurses;
3. A Part of the Medical School of the University.
It is evident from this letter that it was his desire that the
general hospital should be the central feature of this great
charity.  The "Training School for female nurses" and the
"Medical School" were to be accessories which would both
promote the best interests of the hospital, and enlarge and
greatly extend its usefulness. We have therefore to develop
the plans in detail by which these three institutions may be so
grouped together in one harmonious whole, as will best secure
the highest interests and greatest success of each.
It is important to notice, also, that one of the important eleients which enters into the study of hospital foundation is
eliminated from the proposals of the Trustees of "The Johns




272           STEPHEN SMITH.-PLANS FOR THE
Hopkins' Hospital." The site for the hospital is already selected, and the necessary land obtained.
The questions to be determined are, therefore, limited to the
preparation of the site, and the arrangement and construction
of the several buildings required to fulfil the objects and purposes of the donor.
In the discussion of the several questions raised, the author
has aimed to establish general principles, without entering into
the consideration of details.  The plans submitted are, therefore, rather in outline, the duty being left to the architect and
engineer to complete the design according as their judgments
may dictate. This course has been pursued in compliance with
the instructions of the trustees, and in deference to the experience of those officers who are immediately responsible for the
success of this great charity.  The proper construction of a
general hospital of the dimensions contemplated, involves a
knowledge of the special wants of a large community of people,
sick of a great variety of diseases, and the proper methods of
care in each case. Such knowledge can be gained only by long
experience in the care of the sick, combined with a practical
acquaintance with hospital construction and management. The
architecture of a hospital differs, also, from all other structures
in almost every particular, and these peculiarities can be
thoroughly appreciated only by those who have given to this
branch long and patient study.  It is necessary, therefore, in
order to the proper development of hospital plans that the
physician and architect should combine their knowledge and
experience, the former in establishing general principles, the
latter in reducing those principles to form and practice. And
it may not be improper to add that whatever general plans are
adopted, their success will depend upon the perfection of
details.




I.
SITE OF THE  HOSPITAL.
"I have given you in your capacity of trustees thirteen acres
of land, situated in the city of Baltimore, and bounded by
Wolfe, Monument, Broadway and Jefferson Streets, upon which
I desire you to erect a hospital." —lr. Hopkins' Letter to the
Trustees.
"It consists of an eligible piece of ground, situated in
the eastern part of the city,... fourteen acres in extent, in
the form of a parallelogram, 709 by 856 feet;... very elevated above the general level of the city, and commands an extensive view in all directions;... is healthy, with complete surface drainage, while underground drainage may be accomplished
to tide-water;... it is easily accessible by street railway,
and by paved streets which bound the four sides of it." —Letter
of Instruction of Trustees.
PREPARATION OF THE GROUNDS.
Whatever may be the nature or condition of the soil of the
site selected, two important objects are sought to be attained in
its preparation for permanent occupation by a hospital. These
are: 1. Imnmunity from the evils of ground air and ground
water. 2. Surface grading and cultivation.
Both objects involve the necessity of sanitary works of the
highest importance to the future healthfulness of the hospital,
and demand the most careful and painstaking execution.
1st. Immunity from the evils of ground air and ground water.
-Every soil contains in greater or less quantity air and water.
The proportion of these elements in different soils varies very
much, depending for the most part upon the density of the
individual soil. But in some proportion they always exist in
soils, and may become active factors in the causation of un



274           STEPHEN SMITH.-PLANS FOR THE
healthfulness to dwellings, unless adequate preventive measures
are adopted.  It is the combination of these elements which
renders a soil damp.
1. Ground air.-It is found by actual experiment that gravel
contains 35 per cent. of air. It has been well stated:  "This is
certainly a great quantity of air; but for all that, this ground,
as far as it is dry, consists to the extent of one-third of air.
In building on gravel, we build as well on air, just as we build
on water when we build on piles driven into a swampy soil, and
cut off under water." * What is true of gravel is also true of
other soils, as sand, clay and even of stony and rocky soils.
Sandstone is nearly as porous as loose sand. The rock of Malta
was found by experiment to take up one-third of its volume of
water, which shows that when dry it must contain air to the
same extent.t This ground air is generally very impure.  It is
found to contain a large amount of carbonic acid, and other
impurities derived from the soil, the amount and kinds varying
with the composition of the earth. Pettenkofer found, in sterile
lime-rubble, a few feet under the surface, as much carbonic acid
as in the worst ventilated human dwelling-places. The amount
of gas increases in proportion to the depth to which we penetrate, within given limits, and to the proximity of the ground
water, except in the months of June and July, when the upper
stratum  contains the greater proportion.  But the ground air
may contain other impurities than carbonic acid.  It may be
charged with the emanations of any organic matters in the soil
undergoing changes. The air in burying-grounds is thus heavily
loaded with the gases arising from the decomposition of bodies
buried deeply in the earth. Another feature of this soil air is,
that it moves from point to point under the influence of the
same laws which govern the movement and diffusion of gases.
Difference of temperature of the free and ground air leads to
" exchange and motion." These fluctuations occur constantly.
Again the rise of temperature of the ground in a given locality
is followed by a movement of the surrounding ground air towards
this point, thus establishing currents through the earth.  It is
evident, therefore, that the ground air is a most important ele* PETTENROFER. Air in Relation to C'othing, Dwelling, andc Soil. London, 1873.
f PETTENKOFER, op. Cit.




JOHNS HOPKINS' HOSPITAL.                          275
ment to be considered in the soil of the site of dwellings. If the
soil near or more remote from  buildings contains organic matters
which  are  emitting  deleterious  gases,  these  emanations  are
readily  carried  by  underground  currents and  discharged  into
any receptacle to which the air is drawn by difference of temperature. *   These  receptacles may  be  the  heated  basements  of
dwellings, and thus the dwelling may become a foul air shaft
for the discharge of the ground air, loaded with carbonic acid
gas and other dangerous impurities. t
The effects of these emanations from the soil upon the health
of residents is most disastrous.  The malarial poisons may be of
a kind which insidiously impair the constitution, and cause permanent ill-health, and premature decay and death, without even
a suspicion of their source. Persons thus chronically poisoned
fall an easy prey to other exciting causes of disease, intensified
by these existing agents of ill-health, or convalesce with great
difficulty.:
Or again, the ground air may convey into dwellings the active
germs of diseases which, in due time, produce their legitimate
fruits.  There is reason to believe that typhoid fever, cholera,
and diarrhceal diseases may be introduced from the soils to the
interior of dwellings, and their local origin escape detection. ~  It
is evident, therefore, that too much importance cannot be
attached to those measures which protect dwellings from the
evil effects of ground air.
*'" Remarkable testimony as to the permeability of the ground, and of the foundation
of our houses, has been given by gas emanations into houses which had no gas laid on.
I know cases where persons were poisoned and killed by gas, which had to travel for
twenty feet under the street, and then through the foundations, cellar-vaults, and
flooring of the ground-floor rooms."-PETTENKOFER, op. cit.
" [Thus our heated houses ventilate themselves not only through the walls but also
through the ground on which the house stands. If there is any gas or other smelling substance in the surrounding ground air, they will eonter the current of this ventilation. I have witnessed a case in Munich, where not the least smell of gas could be
detected in the street, but a great quantity of gas found its way into the ground-floor
room of a house where no gas was laid On."] —PETTENKOFER, op. cit.
t "... They may (lodgers brought in by ground air), without betraying their presence in any way, become enemies, or associate themselves with other injurious elements, and increase their activity."-PETTENKOFER, op. Cit.
" In another case the gas (from pipes in the neighboring ground) penetrated into
the best heated room, and produced an illness of its inmates, which was taken for
typhoid fever."-PETTENKOFER, op. Cit.




276             STEPHEN SMITH. —PLANS FOR THE
2. Ground water.-Pettenkofer, who first called attention to
the sanitary aspects of ground water, thus explains the meaning
of the term: " The stratum, or surface of the stratum of saturation of porous ground, accessible and observed in wells in the
upper water-bearing stratum  of the ground in any locality." 
He regards this saturation surface of ground water as due to
underground lakes, ponds, or streams filled in with drifted soil;
such water surface being covered to a greater or less height, and
on which covering or soil people live and cultivate the ground.
This stratum of ground water varies very much in different seasons, depending upon the amount of rain-fall, evaporation, and
other conditions affecting soil saturation. With its rise the soil
becomes more and more saturated, and dampness ensues; with
its recession the soil becomes more dry. And as this water-line
fluctuates, so the amount of ground air varies, penetrating and
filling all the interstices of the soil as the water recedes, and
again escaping into the open air as the water rises to the surface.
The ground air is liable to become charged with deleterious gases
emanating from the soil, and to discharge them into the open air,
to the detriment of the people living in the vicinity.t
But a more serious danger from the fluctuations of ground
water results from the liability of the conveyance of the germs
of disease from one point to another. It is now well established
that cholera, typhoid fever, and similar diseases, spread widely
through the agency of the ground water, the infectious discharges of the sick being thrown upon the ground. The ground
water acts not only as a carrier of these so-called "ferments,"
but is itself fermentable under certain conditions, and thus beconies capable, at times, of enormously increasing the amount of
infectious materials.
It is apparent, therefore, that no hospital site can be regarded
* Report on Epidemic Cholera to the Bavarian Government, etc.
" " In a porous soil which easily allows the rise and fall of the water-line, an amount
of air finds entrance and exit equal in volume to the quantity of water which occupies the interstices of the earth.  If the soil is impure from cesspool soakage and
other sewage abominations, the air drawn into those interstices, as the water-line
falls, becomes naturally loaded with the results of sewage decomposition.  As the
water-line rises, this air is expelled, and adulterates the pure atmosphere above.  If
the area is inhabited, much of this finds its way into the basement of the houses built
upon such a foundation (it gets out more easily there), and the inhabitants naturally
suffer from the effects of foul air." —Di. CARPENTER, Pablic:1ealth, March, 1875.




JOHNS HOPKINS' HOSPITAL.                   277
as properly adapted to the construction of residences for the sick,
which is not thoroughly protected against the evils which arise
from a soil having a high saturation level. At no season of the
year is such a site healthy. Every fluctuation of the groundwater has its attendant sanitary evils.  With its rise bowel affections increase, and with its fall malarial poisons are developed.*
Remedial Measures.-Obviously the first effort should be to
secure purity of soil. All sites may contain, mixed with the soil
or collected in deposits of variable extent, animal and vegetable
matters of a putrescible nature, which may give off very deleterious gases.  If the grounds have previously been used for
yarding stock, for slaughtering, or for any offensive trades discharging liquid refuse, the soil is liable to be saturated with
putrescible matters which will render the ground air foul and
deleterious to the occupant of the dwelling located thereupon.
There may also be unseen deposits of organic matters which will,
if allowed to remain, impair the healthfulness of the site.
Great care should therefore be exercised in securing purity of
the soil of the entire area under control. All local collections of
filth should be scrupulously removed, and the places supplied with
earth, free from organic impurities, and largely composed of sand.
There should also be a thorough examination as to the existence and depth of the stratum of water-bearing soil, and the
fluctuations of the ground water.  And when these facts are
determined, a system of deep drainage should be perfected, which
should effectually prevent ground water from approaching within
at least six feet of the surface.
But our efforts to protect the site from the evils of ground
air and ground water should not be limited to the measures
suggested. However pure the subsoil may be, the ground air
may bring from  great distances and from  great depths noxious
gases and discharge them into heated basements, or into the
open air of the grounds. Nor will the subsoil drains always
prove adequate to convey from the site the impurities which
they may contain.  The drain and sewer pipes are also liable to
* " The rise of the water-line is attended by certain evils. Typhoid and its allied
diseases become prevalent, but as the water-line falls again another set of diseases
become prevalent also; the intermittent class-ague, neuralgia, rheumatic disorders
— are rife."-Dn. CARPENTER, Public Hlealth, March, 1875.




278            STEPHEN SMITH.-PLANS FOR THE
allow the escape of their contents into the soil, or to become so
closed that the sewer gases penetrate them, and thus reach the
basements of the buildings, or the open air.*
The most effective method of protecting the hospital against
these dangers is by a system of ground ventilation which will
withdraw constantly from the soil all foul air and all gases, and
discharge them at s.uch a distance from the ground as to prevent
their return.  This can be done by means of a heated shaft which
communicates by its base with drain pipes and conduits leading
to all parts of the grounds at various depths. This shaft may be
the chimney of the boiler and other heating apparatus of the
administration buildings. It should have an altitude of 150 feet
or more, and being the most conspicuous figure on the grounds,
it should be monumental in its design and appearance. The
superficial soil conduits should be very porous to enable the air
to enter them readily, while the deeper drains should be especially laid for drainage. If these soil drains are properly laid
and connected with the heated shaft, the air and gases in the
ground will be forcibly drawn into the shaft, and discharged into
the free air far above the buildings. The result would be that
instead of the constant escape of the ground air into the free air
of the grounds and into the basements of the buildings, the free
air would be drawn into the ground and thence escape through
the heated shaft. The process would prove to be one of constant
purification of the soil.
2. SURFACE GRADING AND CULTIVATION.
" I wish the large grounds surrounding the hospital buildings
to be properly enclosed by iron railings, and to be so laid out
and planted with trees and flowers as to afford solace to the sick,
and be an ornament to the section of the city in which the
grounds are located." —Ar. Hopckins' Letter to the Trustees.
In grading and cultivating the grounds, our aim should be to
* "If the subsoil is drained by sewer pipes, and the latter are not ventilated in
the most efficient manner, another evil also arises. The sewers which were pervious
and allowed leakage into the subsoil of both air and water, which passed downwards,
are now sealed to some extent (by the rise of ground water), and all sewer gases find
their way into the houses direct." —DR. CARPENTER, Public Hlealth, March, 1875.




JOHNS HOPKINS' HOSPITAL.              279
add to their beauty and healthfulness. Far too often hospital
grounds show no taste in their cultivation or care, and the impression which we receive at first sight is repulsive. But a plot
of ground of fourteen acres on which a large number of buildings
of approved architectural finish are grouped, ought to be so laid
out and cultivated as to prove inviting and attractive to the most
ordinary visitor.
In selecting the site of a hospital we give preference to an exposure or inclination of the grounds towards the sun at mid-day,
and towards that point of the compass from which the prevailing
winds arise. We thus secure the influence of two important
elements of healthfulness to the hospital-sunlight and heat, and
currents of wind. ~When the natural inclination of the ground
selected is not in the required direction, much may be accomplished in improving the surface inclination by judicious grading.
The site of the Johns Hopkins' Hospital affords an opportunity
of overcoming by grading natural defects in the inclination of
the surface. With but little effort and small expense the surface may be inclined towards the south, south-east, and west, so
as to expose every building on all its sides to the sun and winds.
In the cultivation of the plot the ultimate purpose should be
to secure a large supply of vegetation, and especially of trees;
for trees, judiciously selected and arranged, are not more essential to the beauty of the landscape than to the purity of the air.
Man and vegetation are the complements of each other in their
effects upon the surrounding atmosphere.  "Plants," says
Schacht, " imbibe from the air carbonic acid and other gaseous or
volatile products exhaled by animals, developed by the natural
phenomena of decomposition. On the other hand, the vegetable
pours into the atmosphere oxygen, which is taken up by animals
and appropriated by them. The tree, by means of its leaves and
its young herbaceous twigs, presents a considerable surface for
absorption and evaporation; it abstracts the carbon of carbonic
acid, and solidifies it in wood fecula, and a multitude of other
compounds. The result is that a forest withdraws from the air,
by its great absorbent surface, much more gas than meadows
or cultivated fields, and exhales proportionally a considerably
greater quantity of oxygen." *
* Les Arbres.




280          STEPHEN SMJITH.-PLANS FOR THE
Again, the foliage of trees has the power of absorbing and
rendering innocuous poisonous emanations from the earth. The
most dangerous marsh miasms are rendered harmless if a grove
intervenes between the resident and the marsh.
Finally, trees greatly modify the temperature and humidity of
the surrounding air. This effect is produced by the absorption
of the moisture of the air and earth, and its exhalation from the
leaves. Hales states that a sunflower with a surface of 5.616
square inches, throws off 20 to 24 ounces avoirdupois every
twelve hours, and a vine with twelve square feet of foliage
exhales at the rate of 5 to 6 ounces daily. Bishop Watson,
in his experiments on grasses, estimated that an acre of grass
emits into the atmosphere 6.400 quarts of water in twenty-four
hours. As this exhalation of vapor is a cooling process, and as
it proceeds more rapidly as the temperature rises, it is evident
that vegetation, and especially shade trees, tend powerfully to
equalize the temperature. They absorb the excessive moisture
of the air, and again give off clouds of vapor under the stimulus
of light and heat. Marsh says: "The evaporation that cools
the air, diffuses through it at the same time a medium which
powerfully resists the escape of heat from the earth by radiation."  The value of a single tree for these purposes may be
gathered from the estimate made of the amount of foliage on the
Washington Elm, at Cambridge, Mass., viz.: 7,000,000 leaves
exposing a surface of 200,000 square feet, or about five acres of
foliage.
As conservators of pure air over the grounds on which a permnanent hospital is located, shade trees are, therefore, invaluable,
and should be assiduously cultivated. In their selection care
should be taken to secure a large variety, including evergreens.
They should be so planted as most effectually to serve the purpose of intercepting foul air, of supplying needed shade, and of
modifying temperature. Around the entire margin of the grounds
they should be so selected and planted as to effectually screen
the air which enters the grounds of all impurities. In the large
area between the groups of pavilions on the northern and
southern portions of the grounds they should be so planted as
to furnish a grove which would thoroughly purify the air passing
from the pavilions on the south to those on the north side.
Between the pavilions there should be continuous rows of




JOHNS HOPKINS' IHOSPITAL.            281
shrubs, sufficiently high to intercept the possible lateral currents
of air.
In thus advocating a large supply of trees we do not propose
to create a shade so dense as to render the grounds damp. It
should be a fixed purpose of the architect that no part of the
grounds uncovered by buildings shall be.unsunned and unaired.
The cultivation of flowers should be an important feature in
the management of the grounds. These gardens or plots may
occupy the open spaces between the pavilions. They add greatly
to the beauty of the scenery, and afford great pleasure to the
sick.
Fountains, with one or many jets, add much to the scenery,
and, if numerous enough, tend also to purify the air by washing
out the floating impurities.




II.
THE GENERAL HOSPITAL.
1. CAPACITY OF HOSPITAL AND DISTRIBUTION OF THE SICK
OVER THE SURFACE AREA.
"IT is my wish that the plan thus chosen shall be one which
will permit symmetrical additions to the buildings which will
be first constructed, in order that you may ultimately be able
to receive four hundred patients." —Mr. Hopkins' Letter to
the Trustees.
In this statement we have the capacity of the proposed hospital given, when fully completed.
The first question which we have to consider is the proper distribution of the sick over the allotted area, so as by symmetrical
additions to accommodate, finally, the requisite number.
Distribution of Sick over Sug:fcace Area.-Two important principles in hospital construction are at variance in the consideration of this question.
1st. On the aggregation of the sick depends economy of construction and facility of administration. The more compactly
the sick are arranged the less house space is required; the nursing
is more readily supervised, the food supplied and all the details
of management are simplified and reduced to a minimum of expense. Thus a hospital having large wards, or several adjoining
wards, requires far less personnel and machinery than wards of
the same size divided or in separate buildings. It follows that
tile crowding of patients in wards and the aggregation of wards
is favorable to economy and efficiency of administration.
2d. But this aggregation of the siCk tends to unhealthfulness,
and thus to defeat the purpose for which a hospital should be
constructed.
It is a well settled principle in sanitary science, that beyond a
certain given number of square feet of surface or ground area,




JOHNS HOPKINS' HOSPITAL.               283
people cannot be healthfully aggregated together.  French
authorities limit the nunmber to 80 persons per acre, while
English writers allow 100 persons per acre. And especially is
this true of the sick. The morbid products constantly excreted
from their bodies, as from the skin and lungs, poison the surrounding air, and render the immediate neighborhood of the
sick unfit for the residence of other persons. Not only is the
surface area immediately around the sick rendered unwholesome,
but from the tendency of such emanations to ascend, the area
above it is contaminated to a much greater extent.
Again there are many varying conditions among the sick
which still further modify the rules of surface distribution.
Those suffering from  acute diseases require in general more
separation than convalescents, or those affected with chronic
complaints; surgical cases require larger areas than medical
cases; specific fevers than inflammations.  Thus we may multiply the conditions which would modify any fixed rules of surface population of the sick.  In a general hospital all these
varying conditions are found, and due consideration must be
given to them in the final distribution of individual diseases.
Finally, it is evident that the limits of healthful occupation of
surface area will depend upon the constancy and certainty of
the renewal of the air about the sick. It is possible to renew the
air surrounding an individual sick person so constantly and perfectly, that neither he nor his immediate neighbor can respire
the contaminated air. But the conditions by which such results
could be attained would be expensive and complicated, and
would require the most watchful supervision. ANTe must, therefore, attain the same results by means which are largely selfoperating and inexpensive.
To reconcile these conflicting principles and secure that degree
of isolation essential to the protection of the individual patient,
whatever may be his malady, with such aggregat;ion as will render administration effective, we must combine isolation with ventilation.
The distribution of the sick to surface area was very thoroughly
studied by the Chirurgical Society of Paris, and the conclusion
reached was, that every hospital should have a space of clear
ground of not less than 540 feet to each patient. This would give
to each building containing 80 patients one acre; or in other words,




284          STEPHEN SMITH. — PLANS FOR THE
a hospital accommodating that number of patients should stand
in the centre of an acre of ground. The proportional area was to
be greater as the number of patients increased. There can be
no doubt, however, that for permanent healthfulness a smaller
number of persons to the acre is desirable, for we thus more
effectually secure isolation. Where the grounds are ample, as
in the present case, there is no other reason why the number
should exceed 40 persons to the acre as a general average, than
that which grows out of administration.  And we believe it
possible, in the combination and construction of the ward and
administrative buildings, to fix upon 40 patients to the acre as
the basis of distribution of the sick to surface area.
2. THE CLASSES OF SICK TO BE RECEIVED.
"The indigent sick of this city and its environs, without
regard to sex, age, or color, who may require surgical or medical
treatment, and who can be received into the hospital without
peril to the other inmates; and the poor of this city and State,
of all races, who are stricken down by any casualty, shall be
received into the hospital, without charge, for such periods of
time and under such regulations as you may prescribe. It will
be your duty to make such division of the sexes and patients
among the several wards of the hospital as will best promote
the actual usefulness of the charity.
" You will also provide for the reception of a limited number
of patients who are able to make compensation for the room
and attention they may require." —Kr. Hopkins' Letter to the
Trustees.
"In the same general category of things to be provided, would
be included suitable appliances for promptly and efficiently
caring for accident cases, so numerous in a large city; and a
dispensary for ont-of-door relief, both by the dispensing of
medicines and the giving of medical advice." —etter qf I)nstruction of Trustees.
From these instructions it appears that all classes of persons,
and all forms of disease, are to be admitted to this hospital,
excepting such as would be perilous to the inmates. This latter




JOltNS HOPKINS' IIOSPITAL.              285
qualification obviously excludes known contagious diseases, as
small-pox, scarlet fever, etc. There is also no exception to the
social condition of the sick. The poor and the rich of both
sexes and of all ages are alike to be received, and suitable provision must be made for them.
The questions which arise under this head for our consideration relate to the special requirements of the sick: first, as
regards their diseases; and, second, as regards their social condition.
1. What provision shall be made for the care and treatment of
the great variety of diseases admissible to a general hospital?
Shall they all be provided with the same conditions, or do they
require to be classified and grouped accorling to their peculiarities in buildings arranged for their special necessities?
Heretofore this question would have been decided in favor of
entire uniformity in the provision for the care of the sick. Diseases would have been indiscrimintately intermingled in the salme
wards (excluding known contagious affections), even to the extent of mixing medical with surgical cases, typhus and typhoid
fevers with chronic diseases.   But the recent advances. in
our knowledge of the intimate nature of contagion, and of the
infectious nature of many diseases hitherto believed to be simply
inflammatory, inevitably leads to the conclusion that general
hospitals must hereafter be general only in the sense of admitting all diseases, but must be special in their methods of providing for individual groups.
There can be no doubt that that hospital will soon be regarded
as best arranged and managed which adapts its wards to the
cure of special diseases, and so classifies its patients that each
malady has its appropriate and designated wards. The policy
of mixing patients suffering from different acute diseases, in the
same ward, is wrong in theory and pernicious in practice.
There are certain conditions of temperature, isolation, food,
medicines, nursing, etc., which are peculiar to individual diseases, and which cannot be suitably provided in the aggregate.
Nor can we overlook the lesson as to the necessity of isolation
of many classes of diseases which recent studies of the methods
of propagation of acute affections by germs is teaching,. Though
the germ theory is still sub judice, yet so many important facts




286              STEPHEN SM3ITH. —PLANS FOR THE
have recently been placed on record, that it will be but an act of
prudence, if not wisdom, to give them  due weight in hospital
management.  By the germ  theory we understand that a particle of an infective nature may ble emitted from  the sick, and
give rise in another person who receives it to a disease, if not
altogether like that in the former, quite as dangerous.  Such
transference may take place through the mledinln of the air,
food, water, or substances used  about the  sick, as sponges,
linen, etc.  Formerly, the nulmber of diseases known to be propagated by a specific contagious principle was limited; smallpox, scarlet-fever, measles, etc., beingo types.    But this list has
been considerably extended lately, and at the present time there
are such evidences that a much larger nuimber of acute diseases
must be included, that we cannot be too cautious in our hospital
provisions for their care.  There is now no doubt that the blood
of persons sick of various acute diseases contains microscopical
organisms which do not exist in the blood of those in health, or
of those suffering from  chronic maladies; and those organisms
increase and diminish as such diseases increase or diminish in
severity.  If these so-called germs produce their like, as do ordinary seeds, it is evident thatthat all diseases which propagate temselves by means of germs should be classified and assigned to
special wards, with as much care as we should small-pox and
scarlet-fever.  Again, we have to  consider that it is a wellestablished fact, that infective emanations from  persons suffering from  many acute diseases not only injuriously affect  other
patients, but that they infect ward furniture and the materials
of which the ward is constructed.  AVe would not presume to
place persons sick of pneumonia in an uncleaned ward recently
occupied by persons sick of small-pox, for we know that the
* " Under the name infectious diseases we group together those affections which we
know, or at least believe, must originate through the infection of the system with cer-tai peculiar poisonous matters, and which are mainly distinguished from the ordinary
poisons by the fact that they can reproduce themselves under favoring conditions to an
endless degree. The classification of this group of diseases will, of course, be modified
from time to time, according to whatever theory of their etiology is maintained; and
yet it is easy to foresee that when investigations have been prosecuted further in this
direction, infectious diseases will be found to occupy a far wider field than now is commonly given them."-LIEBERIEISTER, Introducetiouo to the ilnfectious Diseases, in
Cyc/op. r'ac. JAIed.




JOIINS HOPKINS' IIOSPITAL.                      287
germs of small-pox are stored in the walls and furniture of that
ward, and  that they may escape again into  the air and infect
any susceptible person.  The same remark is true of erysipelas,
gangrene, pyenmia, septicemia, typhus, relapsing fever, and we
know not how many other acute diseases.  It follows, therefore,
tlhat in making permlp anent provision for the great variety of diseases which will fronm time to time enter a general hospital, we
nmust be able to group them  so as to prevent one class from
damaging another.
It may be stated, therefore, as a "general principle of hospital
hygiene," that in the care and treatment of the sick in a general
hospital miany and diverse conditions will be required.  As we
select remedies with reference to the special requirements of individual diseases, so, in a measure, we mlnust adapt the external
conditions of the sick to their special needs.  And one of the
special needs of the sick is that the ward shall be adapted to
their necessities.  One disease is blest treated in the open air,
another in a tent, and. a thlird in a dwelling'.  One recovers mlore
readily in the light, another in darkness; one requires larcge
superfliial alnd cubical area, another requires less.   To group
these widely different diseases in the sanme ward and subject them
to the same conditions, woulcl be as absurd as to give theim  all
the saime remledies.
Adopting the principle, that, in order to make suitable provision for the sick admitted to a general hospital, diseases must be
classitied  according to their special peculiarities, and isolated,
we have next to inquire as to tihe proper classification of diseases
for this purpose.  The principle of classification should, as already
noticed, be the same as that wh ich governs in the classification
of the diseases of special hospitals for contagious maladies, viz.,
the conztagyio?us and.infective natulre of the several cliseases.e
It is true that we cannot classify all diseases with absolute pre*... the conviction is growing stronger that, in the investigation of diseases,
the idea of causality represents the last point to be reached, and accordingly
the imost scientific rule of classification aimust refer to causes, i.e., must be ctiolo/fclal.
"The n most advanced position reached thus far is the one now held with regard to the
etiology of infectious diseases. This group rests upon an etiological basis, and there is
scarcely any difference of opinion respecting its value, as the best ultimate foundation
for classification in these diseases.'"-LEBEREISTER.l, Imttroduction2 to Injfectious Disecses, 0o). cit.




2S8           STEPHEN SMITII. —PLANS FOR TIIE
cision on this basis as we can small-pox, scarlet-fever, measles;
yet enough]l is now known of the infectious properties of large
numbers of the diseases, both medical and surgical, of a general
hospital to prove that the time has arrived when such classification must be recognized as the guiding principle in the distribution of the sick in wards.
In the first place, the sick must be grouped according to
the conditions of sex, age, color, etc.
Sex.-There should be two groups of wards for the purpose of
completely isolating the sexes, viz., northern and southern.
Age. -One or more wards in each group must be set apart for
children.
Uotor. —Separate wards can be assigned to persons of color in
each group, if it is found necessary.
Pay Patienzs.-One or two wards in each group may be arranged for those who pay, and who, on that account, expect and
are entitled to more care and attention than ordinary charity
patients.  Such persons require isolation, and many of the comforts and conveniences of home.  The interior arrangements of
pavilions devoted to this class should make it convenient for
family friends to remain with andl take care of the sick, and
enjoy the privacy of home life.
It would at first appear that diseases might be grouped in
accordance with the present classification in mortality returns,
which, to some extent, recognize etiology as the basis of classification, but practically such division would not accomplish the
purpose.  The following scheme woul.d be more nearly in accoidance with our present knowledge of the requirements of each
group.
1st Group. —Gangrene and  sloughing, erysipelas, pyeamia,
septictemia. These diseases are intensely infective, and require
isolation, with large areas of superficial and cubical space.
2d Group.-Diseases attended with much suppuration, fevers,
etc., but not complicated with the preceding conditions. These
affections are less infective, but require isolation.
3d Group.-Acute medical and surgical diseases, having but
slight if any infective properties.
4t7z Group.-Chronic  non-infective  diseases, convalescents,
etc.
Out-door Department.-The department devoted to out-door




JOHNS IIOPKINS' HOSPITAL.              289
relief and practiee should be connected with, and be provided in,
the buildings devoted to the instruction of medical classes. The
"Pathological Buil ding" or laboratory (so called on the plan)
should have its northern, basement portion provided with rooms
to accommodate the out-door poor service.  Access would be
directly from the street.




III.
BUILDINGS ADAPTED  FOiR  THE CARE AND  TREATMENT OF THE SICK OF A GENERAL HOSPITAL.
" IT is mly wish that the plan thus chosen... shall provide for a hospital which shall, in construction and arrangement,'ompare favorably with any other institution of like character
in this country or in Europe. " —r. Hopkins' Letter to Trustees.
" It will readily occur to you that the subject most prominent
at this day in the professional consideration of the Hospital
question as applicable to cities, is the choice between the pavilion
system, wlhich admits buildings of two or more stories in height,
permanently constructed, of which the Herbert Hospital in England and several in this country may be considered good modern
types; and the barrack system of one-story structures, destructible in whole or in part, which were so successfully used in the
late war, but of which no extensive and prominent example is
now in operation. In determining the claims of these systems
respectively, as applicable to us, careful regard should be had to
the character of the patients intended to be the subjects of our
nursing, so as to avoid the error of building an institution which
shall prove to not meet the requirements demanded in the care
and cure of women and children, and the generally enfeebled
inhabitants of the sheltered lanes and alleys of a city, however
match such a structure may have been a success when applied to
the uses of hardy men in the field. We presume there must be
some general principles of hospital hygiene and of hospital treatnent fixed and immutable in their character, the discovery and
proof of which are the result of close careful recorded observation
and judgment. If these principles can be best applied through
the agency of the pavilion system, we wish to adopt that; if by
the bar-rack system, then we will avail ourselves of that form of'onstllruction; and if the true rule for our guidance shall be
found in the good features of each, and the combining of them




JOHNS HOPKINS' HOSPITAL.                  291
all into a harmonious middle course, then we desire to make
that selection and combination." —Letter of Instruction of Trustees.
In providing a residence for a sick person with a view to his
prompt restoration to health, our first and chief concern would
be to secure him  an unfailing supply of pure and properlytempered air. Whatever other provision be made for his care
and treatment, to the wholesomeness of the air he breathed
we should attach chief importance.  For pure air is the best
restorative in all forms of disease which human agency can provide, while impure air will destroy health and life in spite of
every means which we may devise and provide.* Simple and
self-evident as is the proposition that the sick must have pure
air in order to prompt recovery, we are strangely liable to allow
it to lose much of its force when applied to the aggregations of
sick persons forming a hospital. With infinite care and patience
we select the residence of a single invalid, with a view to secure
pure air, sunlight, isolation from other sick persons, and every
condition essential to health; yet when we make provision for
large numbers of sick in one residence, we are not sufficiently
alive to the fact that we have increased the ratio of the importance of these conditions by the number of sick to be cared for.
Imlpressed with these facts as perhaps no other person ever
has been, Miss Nightingale, in the following concise and emphatic language, thus defines what she understands by a hospital
pavilion:
"By a hospital pavilion is meant a detached block of buildings, capable of containing the largest number of beds that can
be placed safely in it, together with suitable nurses' rooms, ward
sculleries, lavatories, baths, water-closets, all complete, proportioned to the number of sick, and quite unconnected with any
other pavilions of which the hospital may consist, or with the
general administrative offices, except by light airy passages or
corridors.  The pavilion is indeed a separate detached hospital,
which has, or ought to have, as little connection in its ventilation
with any other part of the hospital, as if it were really a separate
*'In modern hygiene nothing is more conclusively established than the fact that
vitiated atmospheres in our dwellings and their surroundings are the most fruitful of all
sources of disease."-RIGHT HON. LYON PLAYFAIR.




292           STEPHEN SMITH.-PLANS FOR THE
establishment miles away. The essential features of the pavilion
construction is that of breaking up hospitals of any size into a
number of separate detached parts, having a common adminisuration, but nothing else in common. And the object sought;that the atmosphere of no one pavilion or ward should diffuse
itself to any other pavilion or ward, but should escape into the
open air as speedily as possible, while its place is supplied by
the purest obtainable air from the outside." *
If there be " some general principles of hospital hygiene and
of hospital treatment, fixed and immutable in their character,
the discovery and proof of which are the result of close careful
recorded observation and judgment," those principles are embodied in the preceding statement. In this definition of a pavilion we have set forth the true principles of hospital construction.
Every hospital building devoted to the sick, whatever maladies
they may suffer from, should secure the conditions and the
results set forth in this description.   It will be noticed,
however, that no particular form of structure is here described.
The pavilion may therefore be a tent, or a barrack; it may have
one or many stories. Adopting the principles so concisely stated
in this definition, there is great latitude for the exercise of judgment in their application to the buildings of a general hospital,
as is illustrated by the variety of plans adopted by modern hospital architects. It would be unprofitable to discuss the merits
and demerits of these plans in this connection, and we proceed
to consider the special application of the principles of a hospital
pavilion to the proposed general hospital.
In the preceding sections we have arrived at two conclusions,
which have an important bearing upon the provisions to be
made for the sick.  The first is, that in the distribution of
patients there shall be a minimum number per acre; and the
second is, that the sick shall be classified, not only according
to sex, age, and their social condition, but also according to
their diseases. It is evident that in applying these principles
we are limited on the one hand to a given population per acre,
and on the other that we require the largest possible number of
wards, and the largest amount of ward space.  Both of these
conditions may be fully secured, however, by adopting a system
* Notes on Hospitals.




JOHNS HOPKINS'  HOSPITAL.                           293
of pavilions  which, while  it answers  every  requirement, will
admit of such  contraction  or expansion  as the  exigencies of
the service may demand.  The system  contemplates a series of
temporary  and  of permanent pavilions, of such  number and
capacity, and  so constructed, arranged  and distributed, as to
fully meet all the conditions, and secure all the results proposed.
To the consideration of these two classes of structures we now
proceed.
T'emporary Pavinions. —Temporary pavilions are buildings of
cheap construction, designed for temporary purposes and frequent renewal.  They are adapted for those diseases which are
most liable to infect the materials of the ward, and thus render
it unfit for occupation.  Hence  the necessity  of the frequent
renewal of these structures.
The simplest and least expensive structure yet devised for the
care of the sick is the tent.  And humble  as is such a ward the
results which follow  the treatment of the most dangerous accidents within them  are far more favorable than those which are
given by the more pretentious permanent hospitals.  The tent is
susceptible  of being converted into a mere shade for protection
froml  the direct rays of the sun,' and of being inclosed  so as to
be adapted to the most rigorous winter.  The tent admits also of
the most thorough  ventilation, both  in  summer and  winter.+t
* It is this open air condition of a tent that renders it so valuable in the treatment of
diseases attended by blood-poisoning. An eminent surgeon has said that the most successful treatment of pysemia was in the open air, under the shade of a tree.'" If most satisfactory results have followed the treatment of the wounded and sick
in tent hospitals, it has been principally because they are more completely capable than
any other hospitals of a constant and natural ventilation. Formed of a tissue permeable to air and gases, the vitiated air within them is constantly passing out, and is constantly being renewed by fresh air which enters, not only through certain openings, but
passes freely through the network of the covering itself. During a considerable portion
of the year the doors may be opened, and the walls of the tent so raised as to enable
the patients to pass many hours of each day in the open air. In the colder season,
when it may be necessary to warm the tents, the air within them may be maintained
even more constantly pure; since. whenever the temperature of the air within a tent is
raised to a degree above that of the air without, the air within the tent begins to escape,
or rather is forced into the surrounding atmosphere, from which, in turn, it is necessarily renewed; and the rapidity of the outgoing and incoming currents of air will
increase with the difference existing between the temperature within the tent and the
temperature of the atmosphere at large. In my opinion, where the difference between
the interior anld the exterior temperature is from 30~ to 6T0 Fah., most of the vitiated




294                STEPHEN  S3IITH —PLANS FOR TIlE
The tent may be a pavilion  erected  upon permanent foundations
with a permanent roof, and thus yield  the advantages of a temporary structure as far as the health of the inmates is concerned,
and of a permanent structure so far as affects the administration. *
The class of cases to be admitted  to the tent are included in the
first group.  These  diseases, beingo  highly  infectious  and  frequently  extremely  offensive, require  large areas of superficial
space and  the most ample supply of pure air.   The superficial
area per bed should be three or four times that devoted to  ordinary patients.
Wooden pavilions, or "barracks," are, next to tents, the least
expensive structures.   Though designed for temporary purposes,
they have all the essential features of permanent buildings except
in  material.   In  construction they  should  have the dinensions
and general internal arrangemlents of the permanent pavilions.
Pericmancent cPavilions. —There are two  general plans of constructing the permanent pavilions of a ge'neral hospital, to which
allusion should be made.  The first plan is that of aggregation
of wards in buildings of several stories; the  second is that of
air passes out through the tissue of the tent. However this may be, it is certain that
at our ambul:mce, where we maintained a constant temperature of about 60~ Fah. night
and day-when we had fuel-the atmosphere within the tents seemed to grow purer as
the weather became severe. Never at any time was a persistent odor to be perceived in
the tents, except that of tobacco smoke; and it may be interesting to observe, that
while this odor clunn  to the tents during the mild days of the winter, it rapidly escaped
whenever the weather was frosty.  I believe the greatest advantage, from a sanitary
point of view, to be derived from the general use of tents in the hospitalization of the
sick and wounded, depends upon the facility with which the atmosphere within them
may be kept pure and wholesome, and the common results of overcrowding avoided.
Another very probable cause of the excellent results obtained in tents, may be attributed to the circumstance of their occupants being constantly more or less exposed to
the influences of direct light. When the sick are treated in the open air, the influence
of light upon them must be very considerable.  How important a factor this agent may
be, among the several known to be indispensable in order to have the best sanitary condition, it is difficult to say. We know, however, that without light the maintenance of
health for any considerable time is impossible, and that its invigorating effects upon
organic life in general bear a constant relation to the directness or indirectness with
which the light may reach it. If it be true that the light within a tent is not at any
time, strictly speaking, direct sunlight, the light within a white cotton tent not only is
in great part direct light, but the light is stronger-the tent being in the sunshine —
than it generally is in any room receiving its light indirectly, and by reflection, as nearly
all rooms do.-DR. CRANE, 1Eistory of the Ailerincat Ambllance.
* For details, see i:Istory of thle Aniericata Anmbulance, etc., by TIIrOMAS W. EVANS,
M.D., London, 1873; also 5T/tt HIospitals, by J. FOSTER JENKINS, M.D., 1874.




JOIIINS IIOPKINS'  OSPITAL.                    2950
segreoation, or the entire separation of wards; each ward being
a hospital pavilion of one story, with all the accessories detailed
by Mliss Nig'htingale.  The objects sought to be attained by the
first method are economy of construction, and facility of admninistration.  But such aggregation of wards always implies many
things in  conlmon, as stair- and hall-ways, dining-rooims, day
rooms, and even attendants, and these conditions must result in
a conmmunity of atmosphere among wards and rooms under the
sa0mle roo1f. The second plan is designed to render the isolation of
the sick from all sources of foul air complete and effective. It sacrifices economy if there is economy in the construction and management of two or more stories of wards to the highest interests
of the patient.    i He is not only to be separated from the air of
the adim-linistrative'buildings, but as far as possible, also, from
the air.which has been contaminated by other sick persons.
WAhfile we do not doubt that the wards of pavilions of more
than one story may, by their construction and managemlent, be
preserved in a fair state of healthfulness, especially if the stairways are external to the building, yet we are persuaded that
the liabilities incurred by increasing the population to surface
area are so manifold as to render it very unwise to construct two
or more stories of wards for a permanent hospital.  Nor do we
believe that pavilions of more than one story of wards are more
economical in construction  and management.   The imposing
style of architecture which they are supposed to require renders
the buildings extremely expensive, while the labor of ascending
stairways is most exhausting.  But even if they were less expensive in every respect than one-story pavilions, but in any
degree less healthful for the sick, the latter should be preferred.+
The only plausible reason urged in favor of multiple stories of
wards is the want of adequate ground space, as in the location of
hospitals in the built-up portions of cities.  But it is question*"'The mode of construction in hospitals is, it is presumed, to be determined by that
which is best for the recovery of the sick. If any other consideration is taken, such or
such a percentage of mortality is to be sacrificed to that other consideration." — lrss
NIGIITINGALE, Op. cit.
{ "The objection usually urged is that hospitals in two floors cost more than in
three or more floors. But I submit that this is not the question before us, which is
ho-w to construct a hospital with the requisite facilities for ventilation, administration,
nursing, and health."-MISs NIGIITINGALE, C9I. Cit.




296            STEPHEN SAIITII.-PLANS FOR TIIE
able whether even  that excuse will much longer avail; all
modern scientific inquiries into the conditions under which the
sick recover, tends to prove that hospital sites should be selected
where there is ample area, and hence in suburban rather than in
urban districts.
In the present instance, from every point of view, we can but
regard the question as settled in favor of permanent pavilions of
one story of wards.*  On this plan diseases may be classified
and isolated to the greatest advantage, and those symmetrical
additions can economically be made to the buildings which will
eventually give the hospital the required capacity.  If, however,
buildinogs containing more than one story of wards are erected,
they should be occupied by those sick of non-infective chronic
diseases, and by convalescents.
Adopting the plan of one-story pavilions we proceed to consider the details of their arrangement and construction.  The
general features of the best constructed pavilions are now so
well established that it will be necessary to enter into details only
so far as to render the special features of these individual structures apparent.  They may all be constructed on the same plan,
with such internal modifications as will adapt them to particular
or specific purposes.
Architectural Features.-As permanent pavilions are erected
with a view to no other renewal than perhaps the interior wall,
it is important that they should be so constructed as to allow of
as little accumulation of filth as possible, and to admit of the
most thorough cleansing.  The architectural designs of the exterior of the pavilion must be largely left to the good taste and
judgment of the architect.  To what extent it is wise to lavish
money in mere ornamentation of the exterior of the wards, those
charged with the responsibility of the expenditure of funds must
determine.  We can only advise that nothing in the arrangements of the exterior should be allowed to interfere with the
* "The most healthy hospitals have been those on one floor only." —Mss NIGHTINGALE, Op. Cit.
It may be accepted as a rule that, so far as the sick are concerned, they
would be better placed in wards all on one floor, opening out of a common corridor;
and if land is cheap, and the site fairly level, it is probable that such an arrangement
might be more economical than building two-story buildings." —CAPT. DOUGLAS GALTON. Constructwon of Ilopitals. London.




JOHNS HOPKINS, HOSPITAL.                        297
largest possible exposure of the wards to the sun and air.*  But
we must assert in the strongest terms that the interior of the
ward shall be finished without ornamentation.  There should be
no jutting cornices, no projecting casings; in a word no surface
which, by its position and construction, naturally collects and
retains filth.  To this general statement we may add, that whatever materials are selected it should be borne in mind that the
interior surfaces whether of the wall, the floor, the ceiling, or
the furniture,  will require frequent cleansing by rtubbing to secure freedom from  accumulating  organic matters.  No substance
should, therefore, be employed which is not susceptible of cleansing by thorough rubbing..t
Dimensions.-The form  of the pavilion should be that of a
parallelogram, its width not exceeding 30 feet, and its length
varying with the number of patients to be accommodated.  We
should adopt as a standard for the distribution of the sick 20
patients to the ward.  There should be two rows of beds, and
each bed should have 8 feet of wall space.  This would give 120
feet of superficial space to each patient, including one window,
4 feet in width.  Each patient should have about 2,000 cubic
feet of air space.  The dimensions of the ward proper based on
these figures would be as follows: Length, 8() feet; width, 30
feet; height, 16 feet.  Each bed would stand in a space 8 feet in
width and 15 feet in length-removed 2 or 3 feet from  the wall,
and separated from  the foot of the nearest bed on the opposite
side by at least 12 feet.
These details can be modified to meet every contingency.  In
* "Hitherto we have studied too exclusively architectural effect, and in our zeal to
vie with other public buildings have lost sight of the humble, but sacred purpose to
which a hospital is dedicated.  If richly carved work, fanciful windows, imposing
towers, etc., were essential elements in the successful treatment of the sick, the former
style of hospital architecture would ordinarily fulfil the purposes of life saving.  But
when we recall the fact that the largest success in the treatment of the most dangerous and fatal forms of disease is in the simple tent on the open field, we fully realize how
vain, indeed how criminal, is the expenditure of money in efforts at mere architectural extravagance."-Princi2wpls of Hospital Consteruction, by the AUTHOR.
f "To purify rooms the air must blow long into them, or every part must have the
organic matter rubbed off by the hand.  This is a sufficient rule for both hospitals
and private houses.  Good rubbing will purify furniture, and this our housewives
know; long-continued currents of air are also known to be good, bat better as a sup.
plement to rubbing." —ANGUS SMITH, op. cit.




298            STEPHEN SM3ITH.-PLANS FOR TIIE
a temporary ward of the dimensions given, as a tent or barrack,
it may be advisable to diminish the number of patients to 3 or 4,
andl arrange but one row of beds.  In wards with chronic, nonsutppurating diseases a larger number than 20 may be safely distributed.
lTa7s. —The walls of permanent pavilions should be constructed of porous brick.  The walls should be hollow, and
should be plastered  on lath, with  a good hard-finish surface.  Such walls are porous, but they admit of thorough
cleansing and disinfection.  Impervious walls are not of easy
construction, and it is questionable if the amount of ventilation
secured through porous walls is not a material advantage to the
sick, provided such walls are properly cleansed.  Hollow walls
are much warmer, and less liable to dampness, than solid walls;
and there may be suitable arrangements m ade to disinfect the
entire walls by forcing powerful gases, as chlorine and sulphurous acid, into these hollow spaces, thence through the bricks and
plaster.
The interior wall surface constructed as proposed may be
washed down with disinfectants, or be treated by disinfecting
gases, or, finally, it may be entirely removed, and a new surface
applied with comparatively little expense.
Th/e Baseen. — The pavilions should have well-constructed
foundations, so arranged as to imeet the conditions necessary to
render the ward above healthy, and make the management successful.  The materials of the foundation or basement story may
be brick or stone.  They should be laid on a base so constructed
as to give a permanently dry foundation, not only of the walls,
)but of the entire area which the foundations cover.  The best
surface is that made of asphalt laid on concrete, the soil being
properly ulnderdrained.  The basement should be six feet in
height above the surface of the ground, and the arrangements of
the different portions should adapt them for their special purposes.  These purposes are as follows: —
1. An Air-Czamber. — All that portion of the basement directly
under the ward should be constructed into an air-chamber.  It
shlould have double walls, and be perfectly secured against dampness and against the entrance of air except through properly construtted openings like double windows for summner ventilation,
or with the air-shaft connected with the fan for winter ventila



JOHNS IHOPKINS IIHOSPITAL.            299
tion, if the fan is used. The coils of steam-pipe may be so arranged in this chamber as to distribute the heat to all parts of
the chamber. The ceiling should be the floor of the ward above
If this basement is used as a hot-air chamber, suitable openings
should be made in the ward floor like registers, and so arranged
as to properly distribute the heated air uniformly over the ward.
There may be valvular openings in the air-chamber communicating with the hollow space between the double walls, through
which hot or cold air, or disinfecting gases, may be so forced as
to heat, or cool, or disinfect the entire materials of the walls.
The floor of this chamber should be on a level with the surface of
the ground, and should consist of asphalt laid on concrete. The
dimensions would be 80 ft. length, 30 ft. width, 6 ft. height; total
cubical capacity, 13,440 ft.
2. Water-Closets. —One of the most difficult questions to settle
in ward arrangement is the location of these filth-accumulating
appendages, so as at once to make them conveniently accessible,
and yet harmless in their effect upon the ward atmosphere. To
make then accessible, they are generally grouped upon the same
floor as the wacrd, at the extreme end, and direct communication
with the air of the ward is intercepted by hallways, doors, and
counter and cross currents. These precautions have proved more
or less ineffectual. The air of the ward has too frequently been
contaminatted by the emanations from these adjacent rooms, and
no ward can be healthy the air of which is polluted by the effluvia from a permanent water-closet in constant use. The danger
does not so much follow from the recent dejecta of the sick, as
from those accumulations which undergo putrefactive changes,
and during that process evolve new and more dangerous infective
materials. It is of the first importance, therefore, that these permanent receptacles of the excreta of the bowels and kidneys
should be so placed and so managed, that their atmosphere can
never by any possibility reach that of the ward.
There is apparently but one method of entirely overcoming
this evil, and that is by the removal of the closet from the floor
of the ward, and locating it where it will be so separated from
all direct connection, that the air within it cannot penetrate the
ward.  This plan would require that it should be located in
the basement, or upon the grounds of pavilions devoted to a
class of the sick who are capable of walking up and down




300            STEPHEN SMITH. -PLANS FOR THE
stairs.   This number is always large in general hospitals,
amounting to at least one half of the inmates.* In the wards
in which some patients were unable to ascend stairs, it would
be practicable to provide for them  a small room  on the ward
floor, with dry earth-closets, a urinal, and a lavatory. These
conveniences would be adapted to the wants of the comparatively few who could not go down and up a flight of stairs,
and if properly located and thoroughly attended to, would not
be a source of foul air to the ward.
If this plan were adopted there should be a staircase of easy
ascent, relieved by a landing, and leading from a room adjoining
the hall on the ward floor to the basement, on the extremity of
the pavilion next to the corridor.  The water-closets should adjoin the basement on one side, and the corridor on the other; the
entire height being that of the basement at this extremity, or
twelve feet. These rooms would thus be placed entirely outside
of the pavilion, and could be provided with ample means of
ventilation independent of the ward. The part of the basement
inclosing the staircase should be separated from  the other part
by a permanent brick wall.
3. Service Rooms.-The remaining portion of the basement
next to the corridor should be devoted to the room or rooms necessary for the service of the ward.  There should be a stairway
to the ward floor, and an elevator to convey all articles to and
from the ward, except dirty linen, which should have a shoot
separated from all other communication.
T2'e Ward.-The special features of the ward which require
notice, are the windows, the floors, the ceilings, the free extremity, and the service rooms.
1. The Windows. —We have proposed to make the ward eighty
feet long, with ten beds on each side, having eight feet of wall
space to each bed, which includes a window four feet in width.
This plan would give ten windows upon each side, of four feet
* "The following census of the patients in Bellevue Hospital, New York, with reference to their ability to traverse a flight of stairs, was recently taken: —
Number able to traverse a flight of stairs..........................  242
Number able to walk only about ward............................. 101
Number unable to leave their beds................................ 99
Total................. 442"




JOIINS IIOPKINS' tHOSPITAL.             301
each in width. The location of the windows of wards upon the
opposite sides is generally opposite to each other, for the purpose
of favoring currents of winds across the ward. This result undoubtedly follows, but at, the same time the beds are not very
thoroughly flushed by the air which passes directly across the
ward from window to window. There is also a tendency to the
conveyance of the emanations from the patient of one side to his
fellow opposite.  WTe propose, therefore, to so place the windows that they shall alternate on either side, thus producing
cross-currents. The windows should have double sash for warmth
in the winter, and as a means of ventilation without currents,
and should extend to the floor. The plan on which the windows
are located necessitates the arrangement of the beds alternately
along the wall. The space which we have given to each bed,
viz., ten feet, with a window four feet in width, provides six feet
of wall space to each bed. It is evident that this plan gives two
advantages which have not been secured as yet in hospital construction, viz., 1st. The cross currents most effectually flush the
beds with fresh air, and 2d. The air of one bed is not conveyed
to that of the bed opposite. The diagram illustrates this plan.
2. Thze Floor.-The floors of the permanent pavilions should
be of hard wood, as oak, or ash, or of wood properly treated
with beeswax so as to admit of polish. The boards should be
tongued and grooved, and put together with white lead, or other
plastic material capable of solidifying, so as to prevent crevices
for the lodgment of filth. But a better floor is made of hard
wood, as ash and oak, arranged and laid in parquetry.  Such
floors are extremely durable, admit of the most thorough cleaning, and present the least facilities for the collection or retention of filth.
3. The Ceiiin/.-The ceiling serves the purpose of forming an
air-chamber above the ward which protects it from the extremes
of heat and cold, especially the former. It is contended that
high ceilings, by which is meant a height greater than sixteen
feet, are injurious, as they permit a larger stratum of foul air to
accumulate in the upper part of the ward, and diffuse itself
again over the ward. This undoubtedly is true, except when
there is free outward ventilation in the ceiling, as in the ridge
ventilation of the common barrack. If the outflow is large and
uninterrupted, as it should be in pavilions of one story, the




302           STEPHEN SMITH.-PLANS FOR TIlE
height of ceiling above seventeen feet is a matter of little importance.  With this provision supplied, the ceiling may be
laid upon the inside of wide rafters, giving an air-chamber of a
foot or more in depth, and a greatly increased capacity to the
cubical contents of the ward. An air-chamber of this size, with
a modified ridge ventilation, would amply protect the temperature of the ward from the direct rays of the sun upon the roof,
and from extreme cold. A roof for a pavilion has been suggested
constructed of iron arches and glass coverings, like a conservatory, or the New York Grand Central Depot, the glass being
double, with an interspace to prevent the condensation of moisture.  Such a roof, with suitable ridge and roof ventilation,
would give a very pleasant effect to the interior if the glass were
suitably colored.  Still we believe the common ceiling, constructed as above proposed, would be preferable as a permanent
arrangement.
The Extremrities of the Pavilion.-An important feature of a
pavilion of one story is the arrangement of the extremities.
The plan usually adopted is to locate the bath-room and waterclosets in one extremity, and the ordinary service rooms in the
other. In order to give sufficient space for these accessory
rooms, it has been deemed necessary to increase the width of
the extremities by adding projecting towers or sections. These
additions have a tendency to obstruct the free access of both air
and sunlight to the external wall surfaces of the ward, and
hence ought to be avoided. It would be much wiser to go to
the other extreme and make the extremities narrower than the
ward, so that the ward walls should be constantly flushed with
air and sunlight. This can be effected by removing as many of
the service rooms to the basement as practicable. If the bathrooms, ward-closets, scullery, etc., are located, as now proposed,
in the basement, there will be no practical difficulty in constructing the extremities of the pavilion on a scale of width sufficiently
less than that of the ward to fully expose the entire ward walls
to the sun and winds.
The plan we propose, however, is as follows: The extremity
of the pavilion connected with the administration, should be
connected with the ward by a hall diminished in width so as
to render the angles of the ward free, to the extent of 3 or 4
feet, in which windows can be placed. Large windows, or doors




JOHNS HOPKINS' HOSPITAL.               303
with steps leading to the grounds, should be placed at each end
of this hall. The other, or free extremity of the pavilion, may
be diminished much more in width, viz., 10 feet; and as there
are no service rooms required, the narrowed portion may be
completed as a bay window for flowers, with such architectural finish as may be deemed suitable; or it might be arranged
for a ward operating room.
Service JRoovms.-The extremity of the pavilion devoted to
administration should have provision for a hall way, clothesroom, stairways, water-closets, store-room and a ward diningroom.
Hffalloay.-The hallway may be narrow, not exceeding 4 to 6
feet, and may terminate in the stairways to the basement. It
should be closed at both extremities by doors.
1. Nurse's Roomn.-The nurse should have no separate room
in the pavilion. She will have her sleeping and private apartments, with her clothes, in the building devoted to nurses.
By this means she requires no room, nor bed and other
necessaries which tend to make the ward foul. Her retiring
room, where she can rest and yet overlook the entire ward,
should be the recess at the free extremity of the ward. When
relieved of duty, which should be frequent, the nurse should
retire then to the Home.
2. Clothes _Roon.- A small clothes room for ward linen should
have an exposure to the external air and to the sun. It is too
much the custom to have the ward linen shut up in a close,
dark, and unventilated room. The linen is often damp when
it is packed on the shelves, and if placed on the beds in that
condition, as it sometimes is, the effect is injurious to the
patients.
3. Water- Closet and Laccatory. —If these necessaries are located
on the ward floor, they should be as effectually separated from
the ward as possible. A convenient and very suitable place is
that given in the plan (see illustration), the ventilation being
provided for entirely separate from the hall way which leads to
the ward. The closet room has ample window space and opens
into the stair way, which naturally is a ventilating shaft.
4. Store-Roomns.-Store-roolmis should be set apart, one for the
medicines, instruments, and other appliances, and another for
the clothes of patients.




304          STEPHEN SMITH.IL-PLANS FOR THE
5. Ward Dining-Room. —Every pavilion should have a diningroom so entirely separated from the ward that it is impossible to
contaminate the ward atmosphere with the emanations from the
food. It should be sufficiently isolated from all other apartments to prevent the air ever penetrating to them. It should
communicate with the service-room of the basement by a lift.
Bath-Room. —We would exclude the bath-room altogether as
an appendage of the ward, and substitute a portable bath for the
ward, and a general bath-house for the hospital. The ordinary
bath of the ward is generally a receptacle of filthy linen, and is
rarely used for remedial purposes; even when it is so used it is of
no other value than what follows cleansing with hot or cold water.
This can be effectually done in the common portable bath. A
general bath-house should be erected and provided with every
facility for hot and cold, shower and swimming, sulphur and
electrical, and other medicated baths. This establishment might
be satisfactorily located in immediate contact with the laundry.
Day-Roonm.-In order to give proper effect to the external
appearances of the administrative portion of the pavilion, a
second story should be added, and in this we would arrange the
day-room of the ward, in addition to any similar provision made
at the free extremity of the ward. This room would be large,
well lighted and aired, and would afford facilities for a readingroom or gymnasium.
The preceding plan of a proposed permanent pavilion is, as
already stated, adapted to all the pavilions to be erected. Even
the tent would best serve its purpose if its foundations and roof
were permanently constructed in the form of the basement and
roof prescribed for a permanent pavilion. If it is necessary to
adapt any pavilion to special diseases or cases, the interior admits of any necessary changes.
We have to notice next the medium of communication between
the wards.
Corridor and Sub-way of Admninistration.-The medium of
communication between the pavilions, and between pavilions and
the administrative buildings, is a part of the general plan. These
passages are corridors, or perrons, and generally consist of enclosed walks variously arranged. The ordinary elevated and
enclosed corridor is seriously obstructive of the free circulation
of air over the grounds. In many instances it is so elevated as




JOHNS HOPKINS' HOSPITAL.               305
to present a permanent barrier to the passage of currents of air.
In order to obviate these objections, and yet secure all the advantages of the corridor, it is better to construct the passage-way
partly under ground, and convert the top or roof into an open
walk. This construction can be easily effected in the light soil
of the site selected. This sub-way should be so arranged as to
accommodate the gas pipes, the hot-air pipes, and the water
mains at the bottom, so that they may be readily inspected.
Above this chamber should be the floor of the sub-way for the
passage of a tram, and for a walk for officers in stormy weather.
The top should be an open walk for officers. It is desirable that
this sub-way should have at least four feet of elevation above the
surface of the ground, and that this part should be well supplied
with windows for light and ventilation.
Relation of the Pavilions to each other.-A great variety of
plans have been adopted of arranging the pavilions on the
ground. Of all the plans proposed, that best adapted to secure
isolation, exposure to sun and winds, and facility of administration will be pavilions parallel to each other.  They may be
arranged alternately on either side of a central corridor, or upon
one side. In the former plan the administration extremities of
the pavilions front alternately north and south; in the latter
they may all be located on the northern extremity. The advantage of the former is compactness, and hence facility of administration; of the latter, exposure of the free extremities to the
sun and winds, and freedom from contamination of the air of
the service rooms. The latter plan is preferable. (See illustrations.)
Arrangement of Pavilions upon the Grounds.-It is importanL
to separate as widely and effectually as possible the male and
female portions of the general hospital. The two sexes of
patients cannot safely be allowed to intermingle even on the
grounds. They should not only be as widely separated as possible, but there should be an effectual bar against their approach
to each other. We shall best accomplish this purpose by locating the pavilions for the different sexes on opposite portions of
the grounds. The plan proposed is as follows: Locate the pavilions for the males on the southern, and the pavilions for the
females on the northern section of the grounds. In order to
carry out the full purpose of Mr. Hopkins, of providing ulti



306          STEPHEN SMITH.-PLANS FOR THE
mately four hundred beds, there must be twenty pavilions or
their equivalents in each section-each accommodating twenty
patients. At the commencement but one or two pavilions need
to be built in each section, and the remainder can be added as
patients increase, or as circumstances require.
In arranging and distributing the single pavilions upon the
grounds regard must be had: First. To the largest exposure of
the wards to the sun and winds; Second. To the imost complete
isolation of one building from the other; Third. To convenience
and economy of administration.
Exposure to the Sun and Winds.-In order to expose all parts
of the ward most effectually to the sun, the long axis of the pavilion should run north and south, or as nearly in that direction as
the grounds will permit. This position admits of complete
exposure of the entire external part of the building, and of the
interior of the wards, to the rays of the sun every twenty-four
hours; and this direction of the long axis is most favorable to
the currents of air on this site. The prevailing south wind would
flush each side of the building, and the air escaping from the
ward would be borne away from the adjoining pavilions.
Isolation qf Pavilions.-The rule of separation of pavilions is
thus given by Miss Nightingale: "'The distance between the
blocks should not be less than double the height of the block.
-x- * A greater distance would be better, but this would involve
a greater cost for land, and a greater distance to be traversed by
the hospital staff. e   *   If the wards are raised on basements, the rule as to distance should apply only to the height of
the pavilion from the floor of the ground-floor ward." If separation of the pavilion is one of the most effective methods of
securing isolation, it should not be prevented by so unimportant
a consideration as the distance to be traversed by the hospital
staff. The site of the proposed hospital favors adopting to the
fullest extent every practicable method of protecting the sick
from sources of danger due to their aggregation. WVe believe
that the rule above given, and which has generally been followed,
does not apply in this case, and should be discarded. We propose, therefore, to separate the pavilions on the same side of the
corridor by a space of 100 feet.
NYumber of Pavilions of each class.-The last question which
we have to determine in this connection is the number of pavil



JOHNS iIOPKINS  I HOSPITAL.             807
ions which will be required of each kind to meet the several
classifications and conditions prescribed.  We will take as a
basis of calculation two hundred patients, such as are found in a
general hospital, which admits the indigent sick of all ages, but
limited to a single sex. There will be on an average twenty
patients suffering from infectious diseases, as erysipelas, septicamia, etc. For this number there should be provided two tent
pavilions of the size of the permanent pavilions, each containing, not to exceed, ten patients. There will be forty patients
suffering from acute medical and surgical diseases, attended with
more or less suppurative inflammations of a possibly infectious
character.  These cases require isolation in buildings which,
though well ventilated and cleansed, may require removal at
long intervals. Two wooden pavilions, admitting twenty patients
each, would accommodate this class. There will be 100 patients
suffering from chronic affections, or who are convalescents; these
cases require less area than any of the former, and could be
amply classified and distributed in four pavilions.  Finally,
there will be forty patients represented by children, or those who
pay, for whom two pavilions will be required. This system
would require for one section of the hospital, for example that
devoted to males, ten pavilions, as follows:2 tents accommodating.......................  20 patients.
2 wooden pavilions or barracks accommodating  40
4 permanent pavilions accommodating........ 100   "
2 permanent pavilions accommodating........  40
Total................  200
This arrangement is a number equal to one half of the proposed hospital. If the same provision is made for both sexes,
which is the rule in general hospitals, we have but to duplicate
the plan to meet the requirenlents of a general hospital having a
capacity for 400 patients.




IV.
HEATING AND VENTILATION.
"Certainly not second in importance to any of the matters
you are invited to instruct us upon, are those of ventilation and
heating, and the kindred subjects of light and sunshine as curative agents.  The various methods of heating, combined with
ventilation, form professional problems about which the most
experienced and best informed medical minds seem to be far
from being united. Whether heating should be accomplished
by steam or hot-water pipes radiating their heat directly into the
room, or by the same agency imparting heat to air in chambers,
to be thence sent into the apartment to be warmed; or by open
fires in the angles or side walls; or by ventilating stoves in the
centre of the ward; or by a combination of these methods,. are
subjects upon which opinions widely differ: and whether ventilation should be accomplished by what is called the natural
method, through doors, windows, and unavoidable leakages, or
through flues and ducts acted upon by the differing temperature
of the outer and inner currents, or by enforced currents set in
motion by fans, blowers, or other mechanical contrivances, are
points which have equally earned advocates and opponents. To
solve for ourselves these difficult problems, we invoke the aid of
your experience and thoughtful judgment."-Letter of Instruction of Trustees.
The problems of heating and ventilation have always been
difficult of solution, whether applied to hospitals or private residences. The methods which have been suggested and employed
are innumerable, varying from the common fireplace to the most
fanciful and expensive apparatus. And yet tile objects sought,
viz.: the constant remrovea of fonl aiir, and the constant supply
of properly tempered frJesh  air, witlhout noticeable currents,




JOHNS ItOPKINS' HOSPITAL.              309
does not seem to present any extraordinary difficulties. But
when we reflect upon the infinite varieties of apartments which
are constructed, their external surroundings, and interior arrangements of rooms, we comprehend the complicated nature of
the problem of their proper ventilation.
The different methods of ventilation may be reduced to three:
1. Natural ventilation, where the ordinary doors, windows, and
heated fireplaces are relied on; 2. Vacuum, or exhaustion of the
air of the room by heated shafts; 3. Plenul, or propulsion by a
fan. These different methods have their special merits, which
largely depend upon the circumstances under which they are
employed. Natural ventilation is the simplest and most effective method yet devised in small and isolated buildings having
proper inlets and outlets of air. It is not efficient in buildings
or apartments so inclosed as to obstruct the free flow of the external air. The efficiency depends upon the degree and steadiness of the heat in the fireplace; but this will vary with the
temperature of the external air, and so it will happen that at
certain seasons, as in the summer, the ventilation may come
to a standstill. If, however, the building has an unobstructed
flow of external air around it, the ventilation will still prove
efficient. The vacuum differs from the natural method simply
in providing a permanently heated chimney with a constant suction power applied to the air of the ward. It is more expensive
in construction, but when once completed is without further
cost, as the shaft is heated by the fires necessary in the administrative buildings. It can readily be employed to supplement and
make more effective the natural method. Plenum ventilation
differs entirely from the other methods. Instead of attempting
to draw the air through the wards by creating a vacuum, it seeks
to force the air through by propulsion. Its advantages are that
the air of the ward is constantly being agitated and finally
driven out, owing to the large and forced accessions of fresh
air.  The power of the fan to create that constant pressure
which insures movements of the air without sensible currents is
proved by the anemometer. Without the fan this delicate instrument generally demonstrates stagnation in many parts of the
ward, but when the fan is in operation, the rapidity of its movements shows the agitation of the air in every part. The value of
the fan is greatest in large buildings of multiple stories inclosedl




310            STEPHEN SMITH. —PLANS FOR T-IE
by other buildings, and in wards devoted to infectious diseases.*
The great drawback to its general use is its expensiveness, and
the want of means of diffusing the air properly.  The machinery
— a fan driven by steam-air tubes, air chambers for heating the
air, etc., etc., is costly in construction and expensive in management.
There are many methods of warming the air of the wards of a
hospital, but they are all more or less subservient to ventilation.
The purpose of all these methods is to supply the ward with
properly tempered air, free from all impurities, and with a due
degree of moisture.  That these objects are rarely fully attained
is but too well known to every one. The air is liable to be over
or under-heated, to be deprived of its moisture or of its proper
proportion of oxygen, and to be saturated with irrespirable
gases and other impurities. It is for this reason that all artificial methods of ventilation, which included the process of heating, have been so generally discarded, and the natural method
preferred.
When we attempt to analyze the different methods of heating,
we find they may be reduced to three: 1. The heating of the
building itself, as the walls, floors, etc.; 2. The heating of the
air of the building; and 3. The heating of air external and
forcing it into the building.
1. It requires but a small amount of heat to warm the air of
an inclosed room, provided the heat is properly diffused. A
room  is often comfortably warmed in winter by heated flues
communicating with the kitchen fire, which warm large areas of
the solid walls.  So also a room so situated that the floor is all
warmed by the heat in the room below, will be habitable in the
coldest winter without other sources of heat. The explanation
is very simple. The walls, floors, and other solid structures of
dwellings and apartments are capable of receiving and storing
up large quantities of heat, and of again imparting it to colder
bodies and to the surrounding air. It is a question whether we
do not overlook one of the most effective methods of warming
*.. "' in the case of infectious diseases, it would seem in the abstract to be of
the greatest importance that the patient should be in a current... Even in health
we poison ourselves, and in disease we tend more rapidly in the.. same direction. Infectious emanations may be collecting round a patient, and if so, the still air will
keep them more carefully near him." —DR. AUGUST SMITII, 6P. cit.




JOHNS HOPKINS' HOSPITAL.                             311
apartments, by neglecting so generally  the  simple processes of
heating the walls, floors, and other solid structures of the building.*  The best illustrations of this method of heating is seen in
large conservatories and in  the tent hospital.  In  the conservatory the ground is warmed by flues laid  in the earth  or under
the floors, heated by furnaces situated outside of the building.
In this manner a tropical climate is readily maintained in northern latitudes during the winter. In tent hospitals the hea-ting
apparatus is constructed on a similar plan: the stove, or fireplace, or furnace, is placed outside of the tent, and the ground,
or space, if there is a cellar, under the tent floor is warmed by
the flues leading from  the fire to the chimney.  By this arrangement the ground and the floors are maintained at a uniform temperature, and these impart their heat to the air of the ward. In
some instances registers are inserted in the floor, through which
the air beneath enters the ward. The records of temperature
made in large tent hospitals heated in this manner, show remarkable uniformity at all times, and in all parts of the ward.- t
The system   of ventilation  in these wards is evidently natural.
The egress and ingress of air is through the necessary openings,
and largely through the materials of the tent itself.:
* "Our methods of warming are very cumbrous, and we seem to be behind ancient
Rome and modern Russia. We warm the air, which changes in a moment, when a
door or window is opened, and we do not warm the house itself. Builders make the
walls thinner in these days, and we sit at a fire very much as s'svages over a blaze in
the open air."-AUGUST SMITr.
t "The thermometer out of doors standing at 290 Fahr., we found the following
temperatures existing within the tents, at five feet from the floor: At the entry of
the first tent (over the furnace), 57~; second, 59~; third, 61~; fourth, 89~; fifth
(farthest from the furnace), 55~. " —M. BREIIAN, T2he Am. Ambula-nce.
" I have many times myself been a personal witness to the fact, that during the
rigorous month of December, when the cold was ranging from 14~ Fah. to 10~ Fah.,
the temperature within the tents was maintained from 540 to 59~0 Fah., and that
without forcing the fire. "-M. JOLLY, Ambulance Americaire.
t"' A canvas tent within which the air is warmed by a fire, is the best illustration
which can be suggested of effective natural ventilation.  Neither special inlets nor
outlets for air. nor shafts, nor driving fans, are needed; the elevation of the general
temperature necessary for the comfort of those within the tent in the winter season,
with the free action of the wind without, is all that may be required to maintain a
ventilation in every respect satisfactory; satisfactory, not only because it is sufficient,
but because it is accomplished regularly and without draughts."-T/le Almerican
Ambulance.




312          STEPHEN SMITII. —PLANS FOR THIE
This method of heating through hot-air chambers under the
floor is capable of great extension. The pavilion may have all
that portion of the basement directly beneath it converted into
an air-chamber, in which are located the steam pipes. Thus,
the floor of the ward would be suitably warmed. Registers
could also be arranged in the floors, or the floors could be
largely perforated, and thus diffuse the heated air in the ward.
And again, the hollow wall space might be made to communicate with the air-chamber, and thus both walls and floor would
be warmed. Finally, the air-chamber and hollow wall space
could communicate with a space between the roof and the
ceiling, and the entire wall surface would then be warmed. In
this arrangement there would be great economy of heat, and the
ventilation of the ward would be very complete.
2. The air of the ward is warmed by radiant heat from fireplaces, stoves, steam-pipes, etc.  In this method of heating
natural ventilation is generally adopted. The fireplace is the
oldest method, and in many respects the most efficient. It provides both the means of heating and a powerfully drastic outlet
for the air of the ward. Though wasteful of fuel, yet within the
]imits that it properly warms the air, it is the mlostt efficient
nethod of warming and ventilation ever employed. One of its
best features is its self-regulating power. Heating by stoves,
steam-pipes, etc., are well calculated to economize fuel, but they
require great care in the regulation of the inlets and outlets of
air, to preserve the air of the ward from being overcharged with
impurities. There are many combinations of these methods, as
fireplaces and stoves with air-chambers, jackets, etc., which
answer a good purpose.
3. The method of heating the air externally, and forcing it into
the wards, is seen in the ordinary furnace located in the base
ment and in the hot-air chamber where the fan is employed.
The machinery necessary to effect leating and ventilation properly by this method is somewhat complicated, and requires not
only a nice adjustment of parts, but constant care in its management. Hence, while it is very efficient when properly employed,
it is more readily deranged than any other method. It is more
costly in its outfit, but very economical of the heat.
In appreciating these several methods of ventilation and heating, and their adaptation to the several parts of a general hospi



JOHNS HIOPKINS' HOSPITAL.              313
tal, it may be stated that natural ventilation is best and most
usefully applied in small buildings, standing quite alone, and
with a free circulation of air around them. It is the only method
which could be employed in a tent hospital. It can be made
efficient in any temporary wooden structure. It is only slightly
less efficient in permanent hospital-pavilions, which stand alone,
with free circulation of air all around them. In buildings aggregated together, with inclosed courts and projecting portions, it is
altogether inefficient.  On the contrary, vacuum  and plenum
ventilation become more powerful and less expensive in proportion to the aggregation of buildings. We are, therefore, readily
brought to the conclusion that natural ventilation should be
relied on in all detached one-story buildings, and the vacuum
and plenum ventilation should be adopted in two or more story
permanent buildings, whether pavilions or administration.
Of the several methods of heating, that should be preferred
which requires the least machinery and care on the part of ward
attendants, and does not in itself tend to vitiate the air. In a
temperate climate, where the thermometer fluctuates in winter
between 40~ F. and 25~ F., the weekly mean being rarely below
30~ F., no elaborate system of heating can be required. Either
the common fireplace, or the ventilating fireplace, or some combination which embodies the familiar principle of the fireplace,
should be adopted, or the ward should be warmed through the
Cair-chamber heated by coils of steam-pipe. The latter nmethod
would prove the most economical, as the floors and walls could
be so warmed as to be retentive of heat for long periods. It
would require less supervision also on the part of attendants
than any system which necessitated the frequent replenishing of
fires.




V.
ADMINISTRATIVE BUILDINGS.
"In whatever plan may be adopted, we presume there will be
no departure from the now very general method of a central
administration building, with wards for the treatment of the
sick as carefully separated therefrom  and from each other as
practicable. To the details of this building we specially invite
your attention; the objects to be accommodated in it, the
amount of room to be given to each, and their location in
respect to each other for convenience of use.
" The location of the kitchen and its appurtenant offices is a
subject of great practical importance, upon which new and, so
far as we know, hitherto untried suggestions have been made.
Whether it should be in a separate building from those devoted
to administration or to the nursing and care of patients, or in
the basement of some one of them, or in the upper story of any,
are points open to discussion, and are to be carefully considered." —Letter of Instruction of Trustees.
The buildings required for administration should be so located
as to be accessible to all branches of hospital administration,
and yet not obstruct light and air over portions of the ground
occupied by the pavilions. Nor should they be so situated that
by any possibility the air of the pavilions can be contaminated
by emanations from  the works necessarily carried on within
them.
Central Administr-ative Butilding.-One building must be devoted principally to offices and to the residence of officers.  It
should be so located as to be accessible both to the street and to
the general hospital service. It should be sufficiently large to
accommodate an apothecary' s department and store-roonms in the
basement, a reception room, superintendent's office and clerical
rooms, trustees' room, dining(-hall of officers on the first story,




JOIHNS' hIOPKINS IIOSI'ITATL.          315
and living apartments of the superintendent and resident medical
and other officers, on second and third stories.
Kitchen. —The location of the kitchen is made the subject of
special inquiry. Like the other administrative buildings, it is a
permanent structure, and too much care cannot be exercised in
placing it where it will best serve its purpose, without detriment
to the sick. The air of the kitchen is necessarily more or less
charged with the vaporized, gaseous, or other products of the
cooking process, and although these materials may not at the
instant be injurious to the sick, yet they are liable to take on
new forms, or enter into new combinations which are very deleterious. Three plans of locating the kitchen are mentioned, viz.,
1. in a separate building; 2. in the basement of a building; and
3. on the upper story of the administrative building. Of these
different locations, the first is preferable to the others in the present case. The reasons are: First, There is ample surface area for
the separate location and construction of the kitchen and its
appurtenant offices. Second, By thus giving complete isolation
to the kitchen, we relieve all of the other buildings of the possibility of contamination by its emanations. This relief cannot
be obtained when the kitchen is located in the basement of
another building. In the basement of the administrative building, where it is more often located, it generates an atmosphere
which penetrates the entire house, and frequently renders the air
of apartments on other stories highly offensive. Third, In the
position which we have selected, the kitchen is far more conveniently located for the service of the hospital than if removed
to the roof of the administrative buildings. The communication
with the street, with the sub-ways of administration, and with
the central administrative building is direct and convenient. As
there can be no other advantage of locating the kitchen in the
basement, or in an upper story of another building, than economy
of ground space, and perhaps in a limited degree of fuel, these
reasons do not apply in the present instance.
Lazrundry. -The laundry is peculiarly liable to contaminate the
surrounding air. The foul linen subjected to steam heat gives
off whatever products of animal excretion may be contained in
their texture. Hence this service should be isolated either in a
separate and special building, or be located on the upper floor of
the central administration building, as has been proposed in other




316          STEPHEN SMITH.-PLANS FOR THE
hospitals, and as is practised in certain hotels. Where the
grounds are ample, there is less necessity of locating the laundry
in or on the main administration building. In the present case
it would be better to erect a laundry, separate from the other
buildings, with an independent but thorough system of ventilation, by which the vapors and gases are drawn into the chimney
and discharged at a great altitude. The most favorable situation
on these grounds is on the central part of the eastern side. If
located here, in connection with the boiler-rooms, the laundry
will be convenient to all parts of the hospital, the ventilation can
be rendered very perfect, and the prevailing western winds will
remove all gaseous emanations and vapors from the grounds.
Batkh-llouse and Gymnasium. —In connection with the laundry,
a bath-house should be constructed. It should be of sufficient
capacity to supply every needed facility for bathing, for cleanliness, and for medication. It should be supplied with hot and
cold and swimming baths, hot air Turkish baths, and every
form of medicated baths.  In the same building should be a
gymnasium, supplied with all the apparatus required for a
general and special exercise.
Dimensions.-The dimensions of these various buildings and
apartments will determine the dimensions of the main structures
These are matters of detail which architects can best determine.




VI.
THE MEDICAL SCHOOL.
" You will bear constantly in mind that it is my wish and purpose that the Institution shall ultimately form a part of the
Medical School of the University." —Mr. Hopkins' Letter to the
Trustees.
* * *  " As the Hospital will be used for clinical teaching
to the medical classes of the University, it will be needful to consider what accommodation that subject will require, and how and
where it should be provided. As closely connected therewith
we should be glad to have your advice as to the most judicious
location of the Medical School buildings of the University, that
is, whether they should be in close proximity to the Hospital,
or whether they can with equal profit and convenience be erected
with the other buildings of the University a mile distant."Letter of Instructions of Trustees.
Not the least interesting feature of the University scheme of
education projected by Mr. Hopkins, is that which lays the foundation of a medical school in connection with a general hospital.
The organized methods of medical education in this country are
extremely imperfect, and practically yield little more than elementary instruction. The educating bodies are private corporations, empowered to fix their own standard of qualification, and
to bestow on whom they please the doctorate of medicine. As
these educating and licensing corporations are supported entirely
by the fees of students, and are irresponsible to any other authority it naturally happens that in their rivalry for patronage the
lowest possible standard of qualification obtains.
No school would presume to institute a preliminary examination of the students applying for admission to test their mental
or educational fitness for the course of study.




31.8         STEPHEN SMITHI.-PLANS FOR TIIE
In the lecture-room students of every grade of advancement
are assembled to listen to the same lecture, and no oral examination is made except at the option of the student. In the final
examination the student is required to answer a few technical
questions, and is then advanced to the highest rank known to his
profession. The consequence of this vicious system of education
is that the standard of medical qualification is extremely low, the
degree of Doctor of Medicine is a misnomer, and the country is
overrun with titled but unqualified practitioners.  In the munificence of Mr. Hopkins we have the prophecy and possibility of a
reform in medical education which will be general in its character
and permanent in its results. Incorporated into the University
as an integral part of its system of education, the Faculty of
Medicine will be required to subject their students to the same
tests as are required in the other departments, to grade the
course of instruction, and firmly to exclude all unqualified applicants for its degree of Doctor of Medicine. While there can be
no doubt that a school thus organized and conducted would at
first repel medical students who were pursuing their studies and
seeking graduation through the old channels, it is equally certain that in the near future such a school would be the centre of
attraction to the profession in all parts of the country, and would
assume a national character and importance.
Relations of a Hospital to a Medical School.-No medical
school can be regarded as properly endowed for instruction which
has not the advantages afforded by a hospital. It is at the bedside only that the student can be successfully taught the practical duties of his profession.  The hospital also furnishes the
basis of pathological or morbid anatomy, a branch of medical
education of the first importance.  Facilities can also be furnished for the study of practical anatomy. In these three particulars the hospital should be required to contribute to the
course of instruction pursued in the medical school.
To render the hospital available to the school, buildings should
be constructed adapted for the care of the dead, for an operating
room, for laboratories for the studies of practical and pathological anatomy, and for a museum.
Mortuary, Pathological Laboriatories, and   fauseurm. —One
building could be arranged for the care of the dead, for anatomical laboratories, and for the museum. It should be located on




JOIHNS HOPKINS' HOSPITAL.               319
the exterior part of the grounds. In its underground portion
should be constructed the vaults for the reception of the dead,
a well-lighted room for post-mortem examination, and conveniences for visitors of the dead. It should communicate with the
underground sub-ways for administration, through which the
dead should be transported in air-tight caskets. The first story
should have an entrance for students directly from the street,
and be constructed for a lecture room, and laboratories for pathological investigations.  The second story should contain the
museum, and if practical anatomy is pursued at the hospital, its
laboratories should be located on the upper story.
Operating Theatre.-The theatre for operations should be located on such portion of thle grounds as will most effectually
isolate it from the wards, from the kitchen and laundry, and
from the buildings devoted to the care of the dead, and instruction in morbid anatomy. It should also have attached to it accident wards for both sexes, to which the recently operated may
be removed, as well as accidents requiring operations.
In its arrangement care should be taken to prevent all unnecessary disturbance of the sick, before and after the operation.
It is very inconvenient to convey such patients up and down
stairs, and hence the ward and theatre should be on the same
floor. There should be a private room in which anesthetics are
administered without exposure of the sick to the gaze and often
ridicule of medical students.  Private rooms for consultation
with provision for instruments, and room for various surgical
appliances should be provided.




VII.
CHAPEL.
"It is my especial request that the influences of religion should
be felt in and impressed upon the whole management of the Hospital; but I desire, nevertheless, that the administration of the
charity shall be undisturbed by sectarian influence, discipline,
or control." —Mr. Hopkins' Letter to the Trustees.
The religious element is best impressed upon the management
of a hospital by the constant and consistent exercise of all those
virtues which belong to the Christian character by officers and
nurses in the daily discharge of their duties. This fact is strikingly illustrated in those hospitals which are entirely under the
administration of religious orders. Religious forms and exercises enter into the daily routine of management. But in a hospital, the administration of which is to be undisturbed by sectarian influence, discipline, or control, and yet the influences of
religion are to be felt and impressed upon the whole management,
there is need of a building or apartment set apart and dedicated
to religious worship and instruction.
The chapel should stand quite apart from all other buildings,
and should be devoted exclusively to worship and instruction.
The practice of using the operating theatre for religious and
other meetings should not be allowed, as the air is liable to
become foul and poisonous to freshly made wounds. Nor should
the chapel communicate directly with any of the pavilions, for
in such cases it becomes a foul air chamber, which ventilates
itself into the wards. It may very properly be located in one
angle of the grounds, and thus stand apart from all other structures. In architectural finish it can be made a highly ornamental feature of the group of buildings, but should be in bar



JOHNS HOPKINS' HOSPITAL.                321
mony with the structures occupying the several other angles of
the grounds.
A chapel thus situated, and used for the moral and intellectual improvement of the sick, is by no means a superfluous
building. It should be free to every denomination, and such
special appointments should be made in construction and furniture as different religious sects might require. It would thus
be in use almost daily for religious services.  There should
always be an organized school of instruction in the elements of
an English education, for the benefit of those who need sucL
instruction, and the number is always large in a general hospital.
This school should be regularly conducted in the chapel. And,
finally, there should be courses of lectures, concerts, and entertainments given for the amusement and instruction of the inmates. The importance of thus supplying the cravings of those
sick of chronic diseases, or convalescents for mental recreation,
can scarcely be overestimated.




VIII,
TRAINING SCHOOL FOR FEMALE NURSES.'I desire you to establish, in connection with the hospital, a
training school for female nurses. This provision will secure the
services of women competent to care for the sick in the hospital
wards, and will enable you to benefit the whole community by
supplying it with a class of trained and experienced nurses."AMr. Hopkins' Letter to the Trustees.
" Comprehended within these details will be the consideration
of the accommodations for the training school for nurses, and
whether they should be within the hospital buildings or separated
from it." —Letter of Instruction of Trustees.
Every general hospital should have a well-organized training
school for nurses as a part of its system of management. This is
a duty which it owes alike to itself and to the community. A hospital is a school for nurses in the very nature of its service. All
that is required to perfect such instruction is a well-devised plan
by which it shall be rendered systematic. And nowhere else can
a nurse be properly trained so as to acquire accurate knowledge
and valuable experience.*  Here she is under strict discipline;
she sees every phase of disease, and becomes thoroughly familiar
with every appliance in the care and treatment of the sick. The
value of "trained and experienced nurses" in hospital practice
* " With regard to an oft-disputed question, whether it is desirable to train probationers entirely in a publie hospital, I should say, without hesitation, that it is there
o!ly that they can be trained."-Mrss NIGHTINGALE, Notes o0b Nursing.




JOHINS HOPKINS'  HOSPITAL.                    323
can not be over-stated.*   However complete the hospital may
be in all its details, and whatever other provision we make for the
comfort and restoration of the sick, all will prove but of secondary value if those who have immediate care of the wards and of
the administration  are incompetent.  Remedies are not more
valueless administered by the ignorant than are the nicely adjusted provisions of ward details managed by unqualified and
irresponsible nurses. And these facts apply with greater force
to nurses in families, where the physician is not so constantly in
attendance, and where the appliances are not so abundant.t
Indeed, " trained and experienced" nurses, in the sense here
contemplated, are unknown outside of the training school. The
best nurses met with in families are totally ignorant of that elementary medical knowledge which is the basis of the intelligent
care of the sick. i  They are harmless, perhaps, in simple cases,
but in emergencies they are powerless to do good.  This is no
fault of nurses, for' hitherto  there has been  no opportunity
offered them  ill the general hospitals of this country to gain a
truly professional education.  In making the "Training School
for Female Nurses" one of the foundation stones of this charity
a service will be rendered to the public of great and ever-increasing magnitude.
The organization of the school should be part of the general
plan of administration, for its first object is to supply the hospital with " trained and experienced nurses."  In the first place, a
suitable building should be erected on a convenient part of the
grounds.  It should be located where the occupants would be
free from noise, and from contact with the routine of administration. It should be of sufficient dimensions to accommodate the
* " When the disease is formidable, and the result of the struggle doubtful, the success or failure of the physician will in a great measure depend upon the skill and
ability with which the nurse economizes and sustains the vital powers of the patient,
whose recovery or death will depend quite as much on the qualifications of the nurse
as of the physician."-SIR JOHN MCNEILL.
f " I am bound to say that I think more patients are lost by want of care and ingenuity in these momentous minutia (attention to diet) in private nursing than in public
hospitals. "-MiSS NIGHTINGALE.
t " The nurse's work is, in fact, a very important part of medical practice, and for
it's due exercise requires a considerable amount of knowledge, both of the laws of
health and disease."- -3MIs NIGIITINGALE.




324           STEPHIEN SMITH.-PLANS FOR THE
matron and the entire staff of nurses and assistant nurses with
dining, living, and sleeping rooms.  The grounds should be
ample for exercise and the cultivation of flowers. In this building all the nurses should have separate apartments, in which
they live and keep their clothes and all articles necessary for
their use.
Dr. W. G. Wylie e thus describes the quarters of the nurses
at St. Thomas's Hospital, London: —
"The building which has been erected for the accommodation
of the probationers (St. Thomas's Hospital, London), called the'Nightingale Home,' adjoins the house of the matron.... It
is entered from the main corridor of the hospital, and contains
on the ground floor a capacious dining-room, with adjoining
room for the sister in charge.  Above these are four floors of
bed-rooms, affording a separate room for each of the thirty-five
probationers, bath-rooms, and a day-room for convalescents."
The training school for nurses connected with Bellevue Hospital, New York, is organized on the plan of that at St. Thomas.
The apartments of the nurses are outside of the hospital, in a
building on an adjoining street.  When relieved of duty the
nurses retire to their "home," and are entirely free from care.
This school has proved a marked success in every respect.
* See Letter to State Charities Aid Association, New York.




IX.
ADMINISTRATION.
"It will be your especial duty to secure for the hospital surgeons and physicians of the highest character and greatest
skill." —Mr. Hfopkcins' Letter to Trustees.
" Upon the subject of management, with its numerous details
of medical attendance, residental and occasional, nursing, domestic service, police regulations, etc., etc., we should be glad of
any advice, and, indeed, with reference to the whole matter, our
wish is to put you in our place, so far as to learn from you how
you would execute the trust we are now seeking to be instructed
about, if it were confided to you." —Letter of Instruction of
Trustees.
Successful administration of the affairs of a general hospital
requires the most complete subordination of all departments to
the governing board or its representative, and the most perfect
harmony between these several departments. Governing boards
may not act judiciously, but as their will is supreme, their rules
must be implicitly obeyed. Every act of insubordination must
be promptly met and adequately punished. However arbitrary
such regulations may seem to be, all experience proves that civil
hospitals cannot be successfully managed without giving to the
administration something approaching military discipline. The
duties of administration of a general hospital may be divided as
follows:
1. The -Executive Duties;
2. The Medical and Surgical Care of the Sick;
3. The Nursing;
4. The 2Duties of TIWarden.




326          STEPHEN SMLTHI. —PLANS FOR TiIE
1. The Executive Duties.-There must be but one executive
head in a general hospital, and he must be held rigidly responsible to the governing board. He should be selected for his intimate familiarity with all the details of hospital administration,
and for his known executive ability. Experience has also amply
proved that he should be a medical man who has been thoroughly trained in hospital practice.  His title should be that
of "Superintendent," or "ifedical Superintendent," and he
should have general charge of the entire establishment.  It
should be his duty to enforce all rules and regulations, and all
officers and employees should be subject to his control under the
rules. He should have no direction whatever of the medical and
surgical treatment of patients except in cases of emergency.
2. Tlhe fedical and Surgical Care of the Sick. —The care and
treatment of the sick should be under the exclusive control of
the visiting and resident staff of physicians and surgeons. The
visiting staff should constitute a medical board. They should
prepare rules governing the resident medical staff and the nurses
in their duties in the wards, to be approved by the trustees.
The resident medical staff should consist of three grades, viz.:
house physician or surgeon, senior assistant, and junior assistant. They should have their living apartments in the administrative building, and should serve in each grade six months, or
at the longest, one year. The medical board should have no
other disciplinary power than that of suspension from duty of
an offender.
3. Tfhe )Duties of Nursing. —The entire charge of the nursing
should be under the matron, who should be the lady superintendent of the training school. She should be held responsible for
the rigid enforcement of the rules governing the corps of nurses.
The grades of nurses should be nearly as follows:-1-. Two
division nurses, who are the chief nurses of the male and female
divisions; 2. Ward nurses, two for each ward, and designed to
relieve each other both day and night; 3. Ward maids, two for
each ward, who are to do cleaning and render needed assistance
about the care of the patients.
In a hospital that has a well-organized training school as a
part of its management, there should be the most perfect system
of nursing. The candidates for nurses should be carefully selected, and the training should insure that intelligent subordina



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II DR.SMITHS  PLAN.'CINo.2.
No. 5.
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JOHNS HOPKINS' HOSPITAL.               8;27
tion of the entire staff to rules and duty which gives the necessary
discipline in the wards, and effectiveness to the service. Nor
should these duties be rendered onerous by too great confinement, nor by overwork. Nurses should be so frequently relieved
that they cannot become weary, and when relieved they should
be allowed to be entirely free from all care pertaining to their
service. They should sleep in their own apartments, and have
their own methods of recreation undisturbed.  By the proper
distribution of duty and recreation nurses will never flag in interest, nor allow the slightest breach of discipline to occur.
The -Duties of Warden. —The warden should have supervision
of the administrative department, and be responsible for the
proper management of all its details.








AP PE DICES.








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APPENDIX I.
DESCRIPTION OF THE PLAN ADOPTED FOR THE
"JOHNS HOPKINS' COLORED ORPHAN ASYLUM"
FOR 300 CIIILDREN, AT BALTIMORE, MD.,
BY
JOHN R. NIERNS]E, F.A.I.A.,
ARCHITECT TO THE BOARD OF TRUSTEES "JOHNS HOPKINS' HOSPITAL, CORRESPONDING
MEMBER OF THE AUSTRIAN INSTITUTE OF ARCHITECTS AND CIVIL ENGINEERS,
MEMBER OF THE U. S. COMMISSION OF SCIENCE AND ART, AND OF
THE JURY OF THE EXPOSITION OF VIENNA IN 1873.
THE building is designed in the simplest style of medieval
architecture-two stories in height for the wings, and three
stories for *the centre building. The third story of the centre
building is altogether devoted to the Infirmary, thus being out
of the reach of spreading contagion to the living part of the Institution, and located where most accessible to the greatest supply
of pure air and sunlight.
The whole group of the block plan consists of six isolated'buildings, connected by corridors with each other, a plan selected
by the Trustees as affording the best and largest supply of light
and ventilation from any side.
The space under the high pitched slate roofs is nowhere used
for occupation, but only for protection against the heat and cold
of the upper stories, and for the purpose of ventilation. At the
same time this feature adds to the character and impressiveness
of the style, and gives a pleasant effect to the beauty of the skyline of the building group. For general effect, the boldness of
the projections, the outlines of the various buildings of the
group, with their gables, ornamental chimney, and ventilating
shafts, high-pitched and band-coursed slate roofs, simple but
effective brick or galvanized iron cornices, a few colored brick




332                     APPENDIX I.
bands and arches to break up the dulness of the large brick
fronts around the group, and a central and useful belfry, are
relied upon for the external architectural effect, without a dollar's worth of mere embellishment.
Every apartment will be provided with large open fireplaces,
besides auxiliary hot-water or steam heating —both systems of
heating combined with large air-flues for ventilation on the
exhausting principle.
Liberal areas and cubic spaces have been provided for the
various departments, in accordance with the sanitary requirements of the best medical authorities.  Thus the school and
class-rooms furnish an average area of 20 square feet or 305 cubic
feet of space per head. The dormitories furnish 46 square feet
or 687 cubic feet per head, and the infirmary 80 square feet or
1,253 cubic feet per head.
The stairs and connecting corridors are proposed to be fireproof, all partitions to be of brick, and the floor directly under
the roof to be made fire-proof by cement concreting.  The north
windows to be double-sash or double-glazed, for economizing heat
and preserving a more uniform temperature in winter.
The double dormitories bordering on the corridor of the lateral
front building and the infirmary-rooms on the third floor will
have large transom ventilation over the corridor ceilings, lowered
for that purpose, and connecting with a large ventilator at the
centre space of the roof. Revolving, self-coiling outside shutters
are proposed for all the windows, to take the place of the ordinary outside Venetian shutter.  Ample accommodations have
have been provided for three hundred (300) children and the
necessary officers and attendants.
No. 1-Presents a front elevation of the buildings in the modified medieval style, with gables and belfry, banded or figured
slate roof and crestings, and large handsome central entrance
porch. The whole extent of the front is 329 feet. There will be
a basement of 11 feet in height througYhout the building; the
principal floor will be elevated from 6 to 7 feet above the ground;
each of the two upper stories will be 15 feet clear height, and the
central third or infirmary floor, 16 feet clear.  The material
employed will be brick, with colored brick bands and arches.
The sills and base of the building will be of granite or of "'Cheat
River" freestone.  The outline of the proportions and forml




JOHNS HOPKINS COLORED ORPHAN ASYLUM
PLAN 0 FBASEMENT                                      No
SCALE 33 FT=I INCH.
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PLAN OF FURNACE CELLAR IN EACH WLNG                            H 
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RA'ivilaoERNSEE,  RRCHITECn.








JOHNS HOPKINS COLORED ORPHAN ASYLUM
PLAN OF PRINCIPAL FLOOR.
SCALE 33 FEET TO I INCH.
I                                                          C             d   syb~~~~~~zZ~~~l/977r  |.S'107g,;'                                                                 l~~~I eli   I 
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JOHNS HOPKINS COLORED ORPHAN ASYLUM                                                                                  No.4.
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___________________1_ _________                                                               _           JOHN R.N   IERNSEE, ARCHITECTBALTI MO REM.
_~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~~~~~~I)1111~1....~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~








APPENDIX I.                      333
of the building will be mainly depended upon for its architectural effect, excluding as much as possible all merely
decorative features, for, while it is intended to construct the edifice with a pleasing and expressive external effect, the principal
effort will be to make it a well-arranged, pleasant, and healthy
home for the orphans, contributing at the same time to discipline
and instruction.
No. 2-Is a plan of the basement and furnace cellars of the
building.  2No living rooms are located in this basement, with
the exception of rooms for the engineer, firemen, and laborers in
the front part of the centre building, the floor of which will, however, be ventilated by a space and air-ducts below, and areas on
the outside walls. The engine-room and laundry will be on this
floor, in the extreme back-centre building, and so located on the
premises as to bring that floor entirely above ground.  The uses
of the various apartments on this floor are designated on the
plan.
No. 3-Plan of first or principal floor; the uses and sizes of the
various apartments are designated on the plan.  To the extreme
wing on the left is attached an ample terrace, directly accessible
from the infants' department for their exercise in fair weather.
At the back of the two main stairs for the children, indicated by
an arrow on the plan, the stairs lead down to a platform on a
level with the grounds outside, giving a direct connection with
the school-rooms by three large doors.  Side entries from  the
outside are also provided for direct access to the dining-room,
also outside access to the basement floor. Three dumb-waiters,
accessible from the basement, are provided for the convenience
of conveying food, etc., to the infirmary department on the third
floor. Besides the main front stair, a separate service stair connects the infirmary directly with the culinary department.
Clothes and dust shafts are also  amply provided.  Ample
kitchen, scullery, pantry, and store-rooms, besides a domestics'
dining-room, are embraced in the extreme back-centre building.
By means of rolled iron girders, the columns of the two upper
floors of the extreme front-wing buildings can be avoided if
judged desirable.
No. 4-Shows plan of the second floor; the uses of the various
rooms are all designated on the plan. The domestics' chambers
and sitting-room  in the extreme back-centre building afford




334                     APPENDIX I.
ample accommodations for from twelve (12) to fifteen (15) domestics, confined to their own building, but affording communication
with the whole group.
No. 5-Shows the detail of the arrangement of the beds in one of
the large dormitories for eighty-two (82) children; it will be seen
that the beds are perfectly isolated, the smallest space between
those on the piers being sixteen (16) inches, the larger space being
three and one half (32) feet, allowing for a single seat or locker
between the one, and a double one in the larger space. Ample
window space for air and sunlight is provided from all four sides
of the building. The smaller double dormitories, in the inner
lateral tract, are thoroughly ventilated by a series of large transoms in the corridor walls above the lowered corridor ceiling,
into and through the roof.
No. 6-Plan of the third story central or infirmary floor;
shows extensive accommodations for forty-four (44) patients,
divided into fever or contagious disease ward, boys', girls', and
infants' wards, convalescents' day and dining rooms, waterclosets, bath and sculleries each of the latter provided with a
dumb-waiter and service stairs, communicating with the lower
service and culinary department. There are also two terraces
over the side corridors, affording a fine airing-place for the convalescent in fair weather.
No. 7-Shows a block plan of all the buildings, separated from
each other by intervening corridors, as proposed, for proper and
efficient lighting and ventilation.
No. 8-Shows a block plan of the same group of buildings
standing close to each other. It must impress the observer at a
glance with the serious defects such an arrangement would prod~uce in the lighting and ventilation of the whole structure; for
although the latter form would naturally save a total distance of
sixty-four (64) feet length of walk and building, at a cost of
some eight thousand ($8000) dollars, yet it can stand no comparison with the other, as dictated by more modern and enlighteued sanitary requirements.




JOHNS HOPKINS COLORED ORPHAN ASYLUM
PLA-IXN   OF'IPT I Rx D  O-t I                    IIN III1iM0AIUY  FL 0 OT{.
No. 6.
SCALE 30 FuEET1 INCH.
/212'
6AV7  6                 6                        8
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W. lostv17- 2
___  _     Con vesrent
B\/                                                          B                        B
lL.0  0Ox~ 17Ba /~ilfMc
JOHN R. NIERNSEEACIET








BLOCK PLAN OFTHE JOHNS HOPKINS COLORED                         ORPHAN ASYLUM FOR 30-0 CHILDREN
AS PROPOSED WITH BUILDINGS SEPARATED                                                           F  OR LIGHT AND VENTILATION
No. 7.
10116"~.SCALE3  ft.to I                                                 IN CH.
N ~~~ ~~~ ~~~ ~~~ ~~~ ~~~ ~~~ ~~~ ~~~ ~~~ ~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~'~~~~~~~~~~~~~~0
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/~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~:
V~~~~~~~~~~~
~L,                                          ~z~,~g~~~~~~~~~~~~~~~z,9/~. "~ ~ ~~~~~~~~~~~~~~~JOHN R.N1ERNSE~E. ARCHITECT.._I








BLOCK PLAN OFTHE. JOHNS HOIPKINS COLORED ORPHAN ASYLUM FOR 300 CHILDREN WITH BUILDINGS STNIN'OE
19'~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~"
70                                             70.
JOHN R..NIERNSEAC~ET
11'14 o I e I  )n t, 261'  f e 








JOHNS HOPKINS COLORED  ORPHAN ASYLU
DETAIL OF LARGE  DORMITORY   FOR  82  BEDS.
nr n'                    C'    8'/'  /2     6'\.SCALE V6             J.R.NIERNSEE, ARCHITECT.
I                        O Co1rrthd or
ti
Itl
l  326'              6'
l _  SCALE                 JR.NIERNSEE, ARCHITECT.








APPENDIX II.
BALTIMORE, July 12, 1875.
FRANCIs T. KING, Esq.,
President of the Johns Hopkins' Hospital.
SInr:-I avail myself of the privilege which you granted n me, to
append to your published Essays upon Hospital Construction
and Management some studies of octagon pavilions for hospital
wards, either of one or two stories in height, as well as a brief
description of their construction and the principles developed in
connection with their heating and ventilation. I have not gone
into the general subject.
I have the honor to be, with great respect,
Your obedient servant,
JOHN R. NIERNS'E.
Before entering upon a description of the octagon plans herewith presented, I beg leave to mention briefly the motives which
caused me to investigate carefully, and try to develop, the full
capacity of the octagon plan of a ward for permanent pavilions.
I found in the best books on hospital construction that form
is but briefly alluded to, as " being best adapted  for convalescents;" if that be so, it must mean comfort, space, areage,
cheerfulness, and many other points which ought to be as desirable for the really sick as for those recovering from  sickness.
Having made hospital construction a close and careful study as
regards the various plans and the best authorities, and having
examined personally many of the best and latest constructed
hospitals in this country and in Europe, I am impressed with the
following facts:1st. That the old plan of collecting from 1,000 to 2,000 sick




336                    APPENDIX II.
in one block of buildings of several stories in height, whether
solid or embracing one or more enclosed courts, has been entirely abandoned and condemned, at least so far as the construction of new buildings is concerned.
2d. In the construction of every modern hospital, during the
past 20 years, the separation or more perfect isolation of the
various wards has been aimed at.
3d. The number of beds per ward has been materially dimninished, ranging from twenty-four to forty.
4th. More area and cubic space per bed has been allowed.
Sth. Better heating and ventilation have been attempted.
6th. That the axiom has been adopted by the best medical
authorities, that " natural ventilation" is both more efficient
and less costly than artificial; and open fires or radiators supplied with fresh and pure air are both desirable in connection
with ventilation as well as heating.
7th. That hot-water heating is the most desirable and effective
mode, as auxiliary in connection with open fires.
8th. That the most impervious material should be used for
inside construction of hospitals.
9th. That the baths and water-closets should be separated
from  the wards by well-ventilated lobbies, with independent
heating and ventilation, and no soil or water pipes should pass
under any part of the hospital buildings.  (See " Herbert Hospital Commission.")
10th. That the pavilion system, in various forms, for hospitals
has met with more favor and approval than any other.
While the foregoing main points met with strong support
from  the best medical authorities, the question of temporary
(barracks or even tents) or of permanent pavilions, their complete.separationL and absolute disconnection from  each other,
seems yet to be an open one, as well as whether these pavilions
should be one or two stories in height.
The military-mledical experience of the late wars, both at home
and abroad, shows a larger percentage of recovery in temporary
wooden buildings (tents and other frail and comparatively open
structures) than in more permanent and solid ones. When we
consider that the majority of the sick soldiers must not only
have been surgical cases, but as soldierks used to the open air,
and sleeping in tents or even without them during a campaign of




PLAN OF
ONE STORY OCTAGON PAVILION FOR TWENTY-FOUR BEDS.'oI,,c, /.~ I I,,, I(. /, C,     /, /
7  A r't9/'li  -ol
x
N~ oO'.   i.'
JI.NIERNSEE,
5~C   ~ ~~/(        A LE EH'~'T
ARCHITECT'.








LAN OF ONE STORY OCTAGON PAVILION FOR THIRTYNINE BEDS,/,  (   / //                        o ~ /,,; o  o;,....
7,,',,b, (J _     Z / 1.:
W. iC.'
_t 
7k~r.
i,ii  i,                               ^-'
lNo. o  y|iJ.'R.FNIERNS EE
CA.LE, 1ARCHITECT.;   C~3     7 ] $F








APPENDIX II.                      337
several years, the war experience is not so thoroughly applicable
to the civilian sick who occupy our town hospitals.
In regard to the question of building the pavilions one or two
stories in height, we have high authority for saying that "they
can see no reason why a two (2) story ward could not be so
arranged and constructed as to be equal-in its salubrity to a onestory building, provided the materials used are as imnpermleable as
can be obtained —the heating and ventilation being independent
for each story-and the stairs isolated, and separately ventilated
from the wards." *We assume that open fireplaces, or stoves,
should be chiefly relied upon for heating and ventilating hospitals (see "1Herbert's Commission," Oppert, and other high
medical authorities), and that apparently the only way of securing a fair average distribution of open fire-heating for the oblong,
or Herbert ward, is the patent stove-heating, by placing two or
more of them at equal distances in the central aisle of the ward,
as in the Herbert; or placing open fireplaces at the centre of
the length of the wards in the outer wall, or cutting off the four
angles at the end, octagon shape, and placing a fireplace in
each —all of which modes are very well adapted for ventilation;
but they distribute the heat to the various beds in a very unequal ratio-the parties nearest the stove or fireplace being
necessarily over-heated, while those at the extremities must be
uncomfortably cool, if not cold.
Therefore, the advantages of both the square and octagon
ward over the oblong shape in that respect are so apparent and
decided, that I was led to the investigation of the further developments and possibilities of the octagon ward, stimulated by the
inspection of IDr. Folsom's temporary one-story square pavilions, lately erected in connection with the Massachusetts General
Hospital in Boston.  Said wards are 45 feet square, with central
ventilator and chimney, two open fireplaces, and two projecting
Franklin stoves (one heater on each of the four sides of the central chimney), thus radiating the heat equally (or almost so) to
the four sides or quarters of the patients' beds, with central and
outer transom window ventilation, and auxiliary furnace-heating through registers in the floor-the service buildings being all
at one, or the entrance side, thus allowing three full sides open
to light and air instead of only two, as in the Herbert plan.
But as the beds in the corners range' irregularly, and the four




338                    APPENDIX II.
angles afford some dead spaces for stagnant air, I conceived the
octagon form as entirely avoiding those defects, placing all the
beds at equal distances from each other, and from the fireplaces
and ventilators.
By concentrating all the service building at the entrance side
with the acknowledged improvements of the Herbert plan of
baths and water-closets, we have more sides of the ward entirely
free for the largest possible amount of sunl,'igfht ancd hleat than
in any of the other forms.
Constructing the outer walls double or hollow, as in the Herbert Hospital, with floors and ceilings fire-proof, the whole
coated with Parian cement and polished, it will form an imperrmeable interior coating, and at a reasonable cost, with no joints
whatever.  The same effect may be obtained by a covering of
Dutch tiles, or glazed earthenware; but it should be used in
large slabs, as in the German stoves of that material; or the
walls could be lined with large sheets of 4 inch corrugated glass,
both of which latter materials would be absolutely impermeable,
but their cost would be materially greater than the Parian cement, which also can be tinted to any desired shade in the matelrial itself, before its application. The floors can be laid with
encaustic tiles, or plain hardwood parquete-tablets well impregnated with a, disinfecting solution (silica), or stained and
waxed, as in some of the French and German hospitals. All
unnecessary woodwork on doors, windows, and casings should
be avoided. Both the boxes and sashes of the windows can be
made of cast-iron at a small advance over the cost of hardwood
frames, and have the advantage of being less absorbent and
more fire-prdof.
The American sash window, double hung, and also double
sash, is by far the best in use. The double casement or French
window is almost universally used in France, Germany, and
Austria, but is only adapted to their very thick walls, which
admit the opening and fastening of one fold (or one-half the
width of the window) withihn the thickness of their walls, which
are generally from 2- to 3 feet. But we have either in the whole
or partial opening of that description of window always a direct
and distinct vertical centre streak or volume of air passing
into the room, running from top to bottom, and blowing directly
on the inmates.  For the correction of this defect, and to




No. 3.                   T                                                 SECTION  THROUGH
SCALE frc
WARD AND SERVICE ROOMS.
-/Vi i  1I  L-.Rrs   obby    - EBa-1 RNSEE  ARCHITECT.z'do -
3.R. NIERNSEE, ARCH ITECT.








APPENDIX II.                   339
secure partial ventilation, they open only one pane of glass, set
in a metal frame above the reach of a person's head.  This,
however, makes the whole contrivance both complicated and
liable to derangement-particularly in double windows.  By
double windows we mean both an inner and an outer one,
separated or standing from 8 to 12 inches apart.  These are
always used, even in private dwellings, to save the heat of the
room in winter, and as a protection against the scorching rays
of the sun in summer. Othels, like the new square pavilions of
the Massachusetts General Hospital, have adopted low transom windows above the ordinary window. These are moveable
(Louvre fashion) by rachets and pulleys. All of which is better
and more perfectly accomplished by the double sash (American
hoisting window).  This, with the double or hollow walls, accomplishes not only the great desideratum (in a hospital) of
keeping the rooms or wards at a more uniform temperature-not
affected by the frequent changes of the external one-but the
double windows also afford the simplest mode of window ventilation, without direct draught, dust, rain, or snow driving into
the wards. This is effected by opening the upper outer sash on
top and the lower inner one at the bottom, either more or less
entire, or vice versca, and thus affording either a top or bottom
ventilation. This may be yet further subdivided into any number of very minute air-streams by a perforated tin or wire screen
fastened horizontally to the meeting rail of the inner lower sash
between the double windows.
The necessity of doubling the windows in some way has
been felt and acknowledged by the almost universal employment
of the French casement double-window on the continent of
Europe; by the glazing of some of the more modern hospital
single windows woith plate-glacss three-eighths of an inch in
thickness; and also by the putting into single sashes two sheets
of extra thick (one-eighth inch) common glass, set half an inch
apart from each other. It requires great precaution in setting
the glasses in a dry and warm atmosphere.
As in large hospitals and other public buildings there is
always an engineer and fireman employed to attend to the
engine, and hoisting and heating apparatus (who can thus attend,
with little additional labor, just as well to a score of separate
fires as to two), I would propose to dispense with the usual




340                     APPENDIX II.
large and expensive heating apparatus concentrated in one place
(which requires an extent of pipes of over a thousand feet in
length, with a consequent expense and loss of heat), and place
instead a small boiler within the central chilney and ventilator
in the basement of each pavilion.  The smoke from the furnace
of said boilers, as well as froin the four fires in the wards
above, will be led by a cast-iron smoke-pipe into a highll chimney;
the annular space between said smoke-pipe and brick walls
forming a ventilation — shaft, in which the air is rarefied by the
heat fromn the smoke-pipe; a small extra fire-grate is also placed
at the other end of the boiler-grate to provide for summer
ventilation.
For a two-story pavilion, the same arrangement of smoke-pipe
and ventilator is doubled by an annular division within the ventiliting shaft on the second floor. By this arrangement an
entire insulated heating and ventilating system for each story of
a pavilion can be obtained, considerable economy in first cost of
apparatus and heat acquired, and the heat and ventilation better
regulated and graduated for the separate wants of eachl ward, or
entirely dispensed with, if any one ward is not in use, etc. The
employment of either the square or octagonal form of ward for
hospital purposes seems only to interfere in some degree with
one of the requirements of a sick ward, viz., "that the beds
should be so arranged as to allow the attendants a view of every
patient "; but as this does not imean the necessity of such minute
and close individual surveillance as in the workshops of a penitentiary or other penal institution, and as there is generally
more than one attendant present, it can amount only to a very
minor defect when we consider how many other iimportant requisites are accomplished by the adoption of that form of ward.
Finally, in considering the construction of hospitals, the relative position and connection of the various wards with each
other, and the central culinary and administrative buildings,
we find generally the basement and its connecting corridors used
for the transportation and distribution of food, patients, utensils,
furniture, clothing, etc.; and the upper connecting corridors,
whether for one or two-story buildings, used merely by the
attending physicians, visitors, and as a place of in-door exercise
for convalescent patients.  The upper corridors, if they are left
open on their sides, as in the Free Hospital of Boston, afford lit



-  X --   --------— __-__       --      — _- -  ------  -_      _-    -          ----------                   -    -        -        ---- I L
No. 4.
SIDE ELEVATION
OF
PAVILION  AND SERVICE BUILDING.
7  11iT                          i
I \\ 7                      ~ -  -;  I:C                   -                    -      - o   I!.,J. R. NIERNSEE, ARCHITECT. 
I'   *:/                 ~"~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.~








PLAN OF PRINCIPAL FLOOR OF TWO  STORY OCTACON PAVILION.
~oI~ ~~                                 I
O         nI- 9J Lilt
~,:               _ _BLT_._L=
Scullery             JV'rse.
11'               11'
No. 5.   
QCALE  F R*~~~~J.R.NIERNSEE,
ARCHITEC. 








APPENDIX II.                      341
tie protection aoainst rain, snow, or cOld,' and ilf closed, as in the
Herbert and most other new pavilion plans, they form (with the
enclosed basement corridor) a barrier to the circulation between
the respective pavilions of two (2) to three (3) stories in heiglht;
which must prove some obstruction to the perfect free, circulation of air around and between the blocks. -It was this
consideration, no doubt, which induced the authorities of the
great newh]ospital at Berlin to construct their two-story and
basement pavilions, culinary and administrative buildings entirely detach7ed froam  each other, while all the service'and
visiting  communication between the various buildings is accomplished merely by the out-door walks through the grounds..
In this last case of entire separation, the service and visitors
are exposed to the inclemency of the weather in all seasons; and
in the closed connecting-corridor system  of three stories high,
the free circulation of the outer air between and around the
various pavilions must be to some extent obstructed.  I therefore conceived the plan shown by Section ANo. 7, for either a one
or two-story pavilion'; that is, by forming the covered connecting link between the various buildings o?nly by closed baseentcorr-idors with sashes and.ventilators, available at all seasons,
and intended for the uses of all commuzn1ication between them,.
having a flat terrace roof on a level with the first floor, surrounded by a railing, or balustrade.e   This terrace can be used
for the exercise -of patients and general] communication in ftir
weather; thus the free circulation of air all around the wards
would be left enzti're~ly unobstructed above the firstflooar.
Besides this advantage, the saving' in cost Of construction of
some 900 feet of corridor (if one or two-story pavilions are
adopted), of iron and glass-wood being too perishable and unsafe
-would be a very material consideration.  The louvres of the
octagon ventilator,'opening on eight sides, will likewise allow a
majority of them always free from the direction of the prevailingwind. Even on the weather side, the down or return driaft can
be counteracted and entirely prevented by employing for each
of the eight openings the outside foot-valve, or 7Winans' valve,
which opens and closes with a very slight pressure of air from
either side. These valves are light frames covered with painted
linen, mica plates, or isinglass, hung freely on a centre-pin, so as
to move with the slightest pressure in either direction.




342                    APPENDIX II.
Explanation of the Octagon Plans herewith annexed.
Plan No. 1-represents a one-story octagon ward of 65 feet, outside diameter, for 24 patients, with central heating and ventilating
shaft, containing four open fire places; the service buildings are
all placed at the entrance side, communicating with the general
connecting corridor. The average space between the beds is 4
feet. The general details are visible on the plans and section.
No. 2-represents a one-story octagon ward of 75 feet, outside
diameter, for 39 patients, with variations of service building.
No. 3-shows a section through the ward, service buildings and
basement, central heating and ventilating shaft.
No. 4-shows a side elevation of a one-story octagon pavilion,
with basement and service building attached.
No. 5-represents the plan of a two (2) story octagon pavilion,
with basement staircase and connectinog basement corridor.
No. 6-shows a section through the same, with the central annular ventilating and heating shaft.
From the following table it will appear evident that in planning
hospital wards, where the largest area per bed for the minimum
ofi cost is desirable, it is certainly worthy of consideration not to
ignore entirely the axiom, " that the same length of line (ergo,
wall) encloses a larger area of space within the circle than in any
other form." Adopting the principle, as laid down by the Herbert
Hospital Commission, " that the great point to be considered in
a ward is to obtain the largest area per bed, as of more importance than mere cubic contents," we observe from  the above
table of comparison that the 61 ft. diameter octagon plan affords
122 sq. ft. of area per bed against 992 sq. ft. of the Herbert plan,
each for 24 patients, and that the octagon ward at 143 ft. height
offers the same cubic contents, viz., 1800 cub. ft. per bed, as the
Herbert plan at 18 ft. height. Ergo, more area by 22 per cent.
is gained at the same expense.
JOHN R. NIERNsE:E,
Architect to the Trustees of the Johns Hopkins' Hospital
and Orphan Asylum.




COMPARATIVE TABLE 1OF DIAGRAMS
OF
ALPPE  X-IX II.
J. R. NIERNSEE.




344                                      APPENDIX II.
Height of ward required for 1800
cubic ft. per bed.
Real cubic feet per bed for ward                                                 o
18 ft. high..                     m.
Cubic contents of ward 18 ft. high |
exclusive of centre shaft.. 
_s._
Cubic contents of ward 18 ft. high |s
inclusive of centre shaft.'
Square feet of window per bed.
Area of bed per ward, without the |                            us 
shaft.                                                              s 
Number of beds per ward.                       - __3 __
Area of ward, deducting  centre                                                  C =
shaft.. Area enclosed, in square feet.s                                    u                  s
Length of outside walls and centre            cv  oshaft.       fet                 0
k    Length of circumference in feet.,                 -.e'               ce
( 4
a,
0                                               4




No. 6.
SECTION OF TWO STORY PAVILION,
2 I iSfry'       - IWar d
ae                                                                        ll slllily W1/ar d  X/Uirse  Stair otluse  W  )1
SCALE *                                                                                        JOHN R.NIERNSEE, ARCHITECT.
~ ~CL',ON.IENE, _.~TECT








Dr. Folsom's Square Ward............................................ 200 23.6 2.500 2.400 24 100 60 45.000 43.200 1.800  18
Herbert Rtectangular Ward of 50 feet.....        22... 202.... 1.950... 20 97 40......100 1.75   18
do.      do.      do........        26..       92.....   24 994...... 43.056 1.794  18
do.      do.      do...... 286.... 3.051       2 940... 54.918.716  18
do.. 346.... 3.822       40 95-40... 796.720   18i
The principles laid down by the Herbert Hospital Commission are: 7 ft. 3 in. wall space for each bed. Height of ward, 14 ft., width 26 ft. Area for each bed, 87 sq. ft.
Cubic contents per bed, 1200 ft.  The largest superficial wirndow space per bed is 31 ft., used ill the Netley Hospital.                          C








INDEX.
[NOTE. — The letters B., F., J., M., and S., refer to the writers of the essays.]
Administration, of food and medicines, di- Basement, uses of the, B., 27; F., 78; M.,
rections for, M., 245.                    195, 220; S., 298
Adipinistrative buildings, B., 33; F., 71; Bath-house, F., 73; S., 316
J., 115; M., 203; S., 314          Bath-rooms, B., 32; F., 78. 85; J., 117;
use of upper stories of, F., 75                     Ni., 220; S., 304
Advertisement, v                                        ventilation of, B., 32
Air, amount of, required by each patient, B., Baths, B., 9, 32; F., 89
25; J., 116; M., 180, 208; S., 297          vapor and medicinal, M., 220
and light, utilization of, M., 196; S., Bedding, B., 36; F., 83; J., 114; M., 217
291                                 Bed-shelf, F., 77, 83
as a disinfectant, J., 127             Beds, renewal of, J., 114
circulation of. favored by one-story         separate record of, B., 10
wards, F., 59                             spaces between, F., 76; S., 297
contamination of, in hospital wards, Bedsteads, F., 83; M., 216
B., 11; M., 182; S., 282                        location of, M., 217
cross-currents of, S., 301                        moving, M., 217.
flues, B., 30                          BEEHAN on the heating of tents, 311
necessity for pure, S., 291            Bellevue Hospital, census of patients in, 300
pulmonary transpiration affected by BIGELOW, HENRY J., autopsy table, 96
different temperatures of, B., 20   Billiard-room, F., 90
weight of, at different degrees of hu- BILLINGS, JOHN S., on hospital construction
midity, B., 24                                            and organization, 3
Ambulance, B., 8; F., 55; M., 253          Boiler-house, B., 36; F., 63; M., 268
Amphitheatre, B., 37; F., 93; J., 147; M., Boxes for soiled clothing, B., 26; M., 219
263; S., 319                Building materials, B., 28; F., 66; J.,
Annual reports, B., 10; J., 128                        112; M., 119; S., 297
Apothecary, B., 7; F., 62; J., 138         Buildings, climate determines the nature
assistant, F., 62                            of, M., 197
room for, F., 75                           objections to temporary, J., 113;
Apparatus, special, B., 43                               M., 188
Appendix I., 330                                       sectional, for contagious disII., 334                                        eases, F., 88
Assistant matron, F., 75
Assistant physicians, B.,7; F., 61; J., 134; Carbolic acid as a disinfectant, J., 124
S., 326                          CARPENTER, DR., on ground water, 276
Atmospheric poisons, nature of, B., 12;                  on soil miasms, 277
M., 182; S., 286                         on ventilation of sewers, 278
Aural surgeon, F., 61                       Carpets, M., 201
Autopsy table, F., 96                       Cases, classification of, B., 40; F., 51; J.,
127; M., 208; S., 288
BAKER'S ventilator, 23                            registration of, J., 136, 148
Barrack hospitals, B., 17; F., 59; M., 186; Ceilings, S., 301
S., 294                          Central office, B., 8
Barracks, difficulties in  the heating  of, Cesspools, F., 71
B., 25                         Chairs for wards, M., 217
temporary, B., 15; F., 59        Chapel, B., 38; F., 52; M., 257, 265; S.,320




848                                  INDEX.
Chaplain, B., 8                            Creosote, preservative powers of, J., 125
CJTAuvEAU, on dilution of sheep-pox, 13    Curator of museum, F., 61; J., 140
Chief cook, B., 7
Children's ward, B., 40; J., 128; M., 264; Day-room, M., 211; S., 304
S., 288                         Dead-house, B., 37; F., 95; J., 150; 1M.,
Clerk, F., 62; J., 133                                    205; S., 318
Clinical instruction, B., 10; F., 53; J., 146 Dentist, F., 61
Climate of Baltimore, B., 44; J., 119; M., DESAGULIER'S plan of heating, 123
247                               DEXTER, GEORGE 1M., suggestions regardClosets, F., 77, 85; M., 210                                ing the form of wards, 76
Clothes-yard, M., 268                      Diagrams, comparative tables of, 343
Clothing, disinfection of, B., 9; M., 205  Diet, J., 153; M., 236
furnished to patients, B., 9           of British hospitals, J., 159
room, B., 36;., 221; S., 303   Dietary table, J., 157
Coal, storage of, B., 37; F., 67           Dining-room for nurses, F., 93
Conservatory, M., 263                                      patients, B., 35; F., 78;
Construction, general remarks concerning,                    M., 211; S., 304
B., 15; F., 49, 59; M., Diseases, caused or aggravated by atmos198; S., 290                           pheric poisons, B., 12
tendency to carelessness in            classification of, B., 41; J., 127;
the details of, 1M., 199               S., 287
Consulting staff, F., 61                   Disinfectants, J., 124
Contagion, carriers of, B., 12; J., 114; M.,             imperfect action of, B., 14
182; S., 286                 Disinfecting chamber, B., 36; M., 205
effects of diluting air of ward Disinfection, J., 123, 125
on, B., 14                    Dispensaries, abuses connected with, M., 250
mode of transmission, M., 182   Dispensary, B., 10; F., 74; J., 146; M.,
nature of, B., 12; S., 286                     250, 264; S., 288
Contagious diseases, provisions for the care           separate medical staff for, M.,
of, B., 8; F., 51;                 250
J., 128; S., 307     Doors, B., 29
sectional buildings for, Drainage, B., 43; F., 70; J., 110; M., 222;
F., 88                        S., 277
Convalescent's home, arrangement of, 14.,
Earth closets, S.. 300
constructison of, a., n g  Emergencies, ward for, B., 9; F., 73
difficulties  attending  the Eploys, B., 7., 62
establishment of a, 1M., Entrnce, F,   69; M., 263
Executive, S., 326
location of, B., 41. F., 54  Executive, 
J., 144; M., 257; S., 296
officers of the, M., 262   Fans, as a means of ventilation in warm
Convalescents, accommodations for, B., 41;         weather, B., 25
J., 144                         use of revolving, B., 25; F., 59; M.,
construction of wards for,          231; S., 309
F., 55                    Fireman, F., 62
medical attendance for, F., Fireplaces, B., 20; F., 59; J., 122; MI., 227,
55                                      233; S., 312
occupation for, M., 261     Floors, B., 29; F., 69; J., 112; M., 200;
Corners should be segments of circles, B.,          S., 301
29; F., 67                              perforated to permit passage of air,
Cooking, B., 7; J., 173; M., 238                    S., 299
Corpses, disposal of, F., 67: J., 150; M., Floor-space, for each patient, B., 27; F.,
205, 221; S., 318                             79; M., 180, 207; S., 297
Corridors, B., 37; F., 65, 84; M., 214, 266; Flowers, cultivation of, M., 203; S., 281
S., 304                      Flues, ventilating, B., 23, 32; F., 81; J.,
grade of, F., 65                        116; M., 230; S., 309
ventilation of, F., 84         Foliage, modification of temperature and
glass partitions in, F., 84             humidity of air by, S., 280
CRANE, DR., on the use of huts as hospitals, FOLSOM, DR. NoRTON, on hospital con293                                 struction and organization, 49




INDEX.                                      349
Food, nature of, B., 25; F., 74, 77, 81; J., Hospital administration, Miss Nightingale
154                                              on, 295
preparation and distribution of, B.,             uncertainty regarding the true
7; F., 91; J., 154; M., 236                      method of, I1., 175
quantity of, required, J., 156                  diet, J., 160
Foul air closets, B., 29                              endowment of the, viii
Fountains, J., 111; S., 281                           entrances, F., 69; 1\A., 262, 2(65
Furniture for ward, list of, F., 98                   for convalescents, xv; B., 41;
F., 54; -11., 257
Galleries, 41., 215                                   for temporary reception of cases,
GALTON, CAPTAIN DOUGLAS, on one-story                   M., 189
pavilions, 296                            gangrene, lA., 187; S., 288
on fireplaces, 228                          general plan of, B., 40; F., 63 
on hospital administration, 185              1;I., 263; S., 297
Garments, disposition of soiled, B., 26; M.,          income of, viii, xiv
219                                      limit to capacity of, xiii; F.,
Gas-lights, J., 112                                     50; 4M., 206; S., 306
ventilation of, B., 29                     objects to be accomplished by a,
Germ-theory of disease, B., 12; S., 286                 B., 5
Glass slabs for urinals, 4I., 213                     of the Episcopal Church of PhilaGoods, method of ordering and receipting                delphia, 176
for, B., 6; F., 92                           of the Episcopal Church of PhilaGrape-house, 1I., 263                                   delpia, mortality of the, 188
Ground air, S., 274                                   out-door department of, B., 10;
Grounds, arrangement of the, F., 68; M.,                F., 74; J., 146; 4M., 250; S.,
194; S., 273, 278                           288
enclosure  and  decoration  of,             proximity of medical school to
xv; F., 52, 69; M., 195                     the, F., 56
estimated number of patients to             requirements of a, ix
each acre of, F., 50; M., 180;           site of, xviii, F., 60; J., 110;
S., 284                                     1I., 193; S., 293
Ground-water, S., 276                                 supervision of the hygiene of a,
B., 5
HALES, on moisture evaporated by vegeta- Hospitalism, B., 11, 14; 41., 186
tion, S., 280                     Hospitals, general construction of permat
Hall-way, S., 303                                        nent and tempora:rr, B., 15;
Heating, B., 19, 29; F., 59; J., 118; 41,                F., 59; J., 113; il., 184, 189;
224, 231; S., 308, 310, 313                 S., 290
subordinate to ventilation, S., House officers, F., 61
316                                           rooms for, F., 75
HOOD'S formula for proportionate size of HUNT, DR. WILLIAM, on the surgical mot
heating pipes, 123                        tality of the Pennsylvania HosHOPKRINS, JOHNS, extracts from  will and             pital, 186
codicils, xvii        Hydrogen peroxide as a disinfectant, J.,
letters to trustees, xiii                       126
Horse-sheds, F., 65
Hospital administration, B., 60; J., 130; Ice-room, F., 92
41., 239                         Isolating ward, B., 43; F., 65, 84, 86; 41.,
Captain Galton on, 185                              216, 190; S., 307
barracks, B., 15
buildings, form, size and arrange- JOLLY, on the heating of tents, 311
ment of, B., 3'39; J., 114; M., JONES, DR. JOSEPh, on hospital construc181; S., 297                              tion and organization, 109
capacity of, B., 40; F., 50; M.,           letter to trustees, 107
206; S., 282
connection of the medical school Kitchen, arrangement of, B., 36
with the, xv; B., 3; F., 53; J.,           location of, B., 34; F., 64, 91; J.,
147; 1..  247; S., 318                       154; M1., 204, 221, 237, 268; S.,
construction and organization, B.,             315
6; F., 49; J., 109, 116; 4M., 175,
193; S., 271                     Laboratory for apothecary, M., 265




83D0                                  INDEX.
Laundry, fittings of, F., 66                NIGHTINGALE,  Miss, on diet, 159
location of, B., 35; F., 64; AM.,                on females as nurses, 144
204; S., 315                                   on heating hospital wards,
work, performance of, M., 205                      332
Lavatory, F., 78; M., 213; S., 303                         on heating and ventilation,
Lecture-room, B., 37; F., 93; J., 147; M.,                    225
249, 263; S., 319                          on hospital construction,
Librarian, F., 72; J., 140                                  295
Library, F., 72; -i., 265                                  on isolation  of pavilions,
LIEBERMEISTER,  on the nature of infec-                       106
tious diseases, 286                    on occupations for the sick,
Lift for soiled clothes, coal and ashes, M.,                  26t
219                                    on the air of hospitals, 291
Light, artificial, J., 112                                  on the training of nurses,
gas, J., 112                                           322
on the value of competent
Mania a potlf, accommodations for cases                      nurses, 323
of, M., 220              Nomenclature of diseases, J., 128
MARSII, on the cooling of air by evaporation Non-resident medical officers, appointment
from foliage, 280                             of, M., 240
MARTIN, A. C., method of ventilating, 81   Nurses, B., 7; F., 57; J., 141; M., 242;
MARTIN, J. RANALD, on women as nurses,                S., 326
143                          accommodations for, M., 264; S.,
Matron, F., 62; M., 247; S., 326                      323
room for, F., 75                           duties of, J., 141; M., 244
Mattresses, B., 36; F., 83; M., 216                 employment of, in kitchen, B., 7
room for, F., 66                        instruction of, F., 58
MCNEIL, SIR JOIIN, on the value of compe-           proportion of, to patients, M., 208,
tent nurses, 323               243
Medical school, connection with hospital of         rooms for, B., 34; F., 75; J., 141;
the, B., 3, 5; F., 53; J.,          M., 209; S., 303
147;  I., 247; S., 317            training school for, B., 7; F., 57;
desirability of small classes         J., 142; S., 322
in the, B., 4
duties of the professors in
the., B., 4; J., 147    Octagon pavilions, 334
thinluence.,of the4;  J.,  Oil as a filling for floors, Mi., 201
inluencey of the, F., ead   Operating theatre, B., 37; F., 65; M., 249;
necessity for an elevated              S. 319
grade of requirements in., 3
hgrae of re3uirementsi            warming and ventilation of, F., 93
Mthe,  Une       t        Operations, where to be made, B., 10
Medical schools in the United States, B._ Ophthalmic surgeons, F., 61
4; S., ) 7.                    Org3anic poisons, nature of, J., 125
Medical service in the hospital, nature of Ornaments, architecture of,., 49;., 198,
the, M., 239.                               200; S., 296
Medicine closet, F., 77,  2
Medicine  closet, F.,    10       Orphan Asylum, description of plans, 330
contents of, n, F.,     7                          proposed capacity of, xiv
mode of dispensing, F., 74                         revenue of, iv
MnEISSNER'S stove, 123                     Out-doo      r departmenue of, 10; F., 74;
MoRRIN, GENERAL, on ventilating flues Out-door  department,,   4; F., 7288 J.,
and chimneys, 25                          accots of, B., 2       8
MoRRIS,  DR. CASPA, on hospital con-                    separate pharmac for B.,    11
struction and  organization               separate pharmacy for, B., 11
175      a                   Out-patients, medical attendance for, F., 61
Mortuary, B., 37; F., 95; M., 204; S., 318
Museum, J., 140; S., 318                   Patient, area allowed for each, F., 79; M.,
181; S., 282, 284
NIBEnSIE, JOHtN R., description of plans            cubic air space for each, F., 79;
adopted   for the  Colored              J., 116; M., 180; S., 297
Orphan Asylum, 330                    wall space for each, S., 297
studies of octagon  pavilions,          floor space for each, S., 297
334                           Patients, bathino of, B., 9




INDEX.                                     351
Patients, character of, to  be admitted, PLAYFAIR, SIR LYON, on vitiated atmosxiv; B., 8; S., 284                           phere as a cause of disease,
classification of, F., 51; J., 127;             291
INI., 180; S., 285, 288         Police stations, telegraphic connection with,
control of, B., 28; J., 142, 144           M., 253
limit to number of admitted, M., Post-mortem examinations, F., 95; J.,150;
267                                           M., 206; S., 319
number of, in each ward, B., 40;               form for recording, J., 152
F., 75; Mi., 180; S., 297       Private wards, location of, B., 9; F., 64,
pay, accommodation for, B., 9;                     88; M., 211, 264
F., 88; MvI., 264; S., 288'PUlmonary transpiration, effects of differpayment of board to be in pro-                  ent temperatures on, B., 20
portion to means, F., 63        Purveyor, J., 132
term of residence in hospital, F.;
54
to aid, in care of ward, F., 62; Radiators, B., 19; F., 82, 86; M., 234
J., 141                         Ranges, J., 153
transportation of, M., 210, 253    Ration of European troops, J., 158
Pathologist, F., 61; J., 139; M., 265       Reading-room for ward, M., 211
Pathological building, location of, B., 11, Records, B., 9
37; F., 95; J., 150; lMI., 205, Registration of ventilation and tempera265; S., 318, 389                           ture, B., 32
PARKES, DR. EDMUND A., dietary tables, REID'S method of ventilation, B., 23
157                             Religious influences to be provided, xv
method of heating, 122            Religious services, B., 8; F., 52; M., 254,
system of ventilation, 116                          256; S., 320
Pavilions, arrangement of, upon grounds,B., Resident medical officers, B., 4, 7; F., 60,
41; F., 63; M., 195; S., 305               71; J., 133; M., 203, 241,
dimensions of, S., 297                         264; S., 326
estimated cost of, B., 42         Resident medical students, J., 135
exposure to sun and wind, S., Revolution, mortality in hospitals during
306                                            the, 191
extremities of, S., 301          Roadways, F., 67
isolation of, S., 306            Roofs, F., 79
number of, B., 15; F., 59; J., Rooms, for etherizing patients, F., 93
113; M., 188                            for examinations, F., 73
number of each class of, S., 306          for recovering from  etherization,
octagon, 334                                F., 93
of the  Massachusetts  General            insalubrity of northern, M., 197
Hospital, 336
of one and two stories, S., 295,
296; B., 27                     SCHIACdT, on the sanitary value of trees,
permanent, B., 15; F., 59; J.,                 279
113; M., 188; S., 294           Screens, M., 211, 218
relation to  each other of, S., Scrubbing, AB., 201
296                             Scullery, F., 77, 85
temporary, B., 15; F., 59; J., Secretary, duties of, J., 132
113; M., 188; S., 293           Service-rooms, S., 300, 303
Pennsylvania Hospital, surgical mortality  Sewers, J., 111; M., 223; S., 278
of, 186                            connection with boiler-furnace of,
PETTENKOFER, on ground-air and water,                 M., 223
274                                       escape into soil, of contents of, S.,
Philadelphia, death-rate of, 188                      278
Physician-in-charge, B., 4, 6                       ventilation of, 3B., 43; Mi., 223;
house for, B., 38; F.,             S., 278
60; J., 133; M., 239; Shoots for clothes and dust, B., 26
S., 326                Sick, medical and surgical care of the, S.,
Physiological laboratory, B., 4                    326
Plans, description of, B., 26; F., 63; J., SIION, TI[R., on tho essential cleanliness of
163; M., 263                               hospitals, 218
list of, F., 104                     SMSITH, AUGUST, on ai currents, 310




05)2~~ IN~IDEX.
SMixTIr, AUGUST, on cleanliness of rooms, University, endowment of the, viii
297
on heating, 311
ROBERT A., on tar as a disinfectant, Verandas, F., 76; M., 215, 266
126                          Ventilating ducts, B., 25; F., 74, 77, 81 
DR. STEPHEN, on hospital construe-             M., 230
tion and organization, 271                flues in outer walls, B., 24
Soiled clothing, disposition of, B., 26; F.,       shafts, location of, B., 21
78; Mx., 219                Ventilation, absence of positive data reSoil, gas emanations from the, S., 275                garding methods of, B., 22
medical measures for unhealthy, S.,            comparative expense of, B.. 24
277                                         complicated by heating and economiasms, Dr. Carpenter on, 277                    my, B.,
Speaking-tubes, F., 71; J., 118; M., 264           different methods required in sumSpecial branches, facilities for cultivating,         mer and winter, B., 22
B., 10; MI., 252                of gas lights, B., 29
Stable, F., 66                                     of single two-bed wards, B., 32
Stair-cases, M., 210; S., 300               Visiting staff, F., 61; J., 144; M., 240
Steward, B., 7
STERNBERG'S automatic valves, B., 3
Store-keeper, F., 62                        Walls, construction of, B., 28; F.1 66; J.,
Store-room, F., 73, 92; lai., 220, 265; S.,          112; M., 199; S., 298
303                                   disinfection of, B., 28; S., 298
Stoves for wards, F., 81; S., 312                  finishing of, F., 69
Stretchers, M., 2o53                               hollow, S., 299
Students; to be employed in the hospital, Wall space for each patient, B., 27; S., 297
B., 5, 6                          Ward-master, B., 7
Sub-way, lM., 2oS; S., 304                  Wards, advantages of square form of, F., 76
Summer ventilation of lower wards, B., 32           capacity of, B., 40; F., 75;  I.,
Sun-room, F., 76, So                                  180; S., 297
Superintendent, AiS., 24,5; S., 326                 connection between, J., 118; lx., 183
Superintendent of female nurses, B., 7              description of, B., 26; F., 75; J.,
Supplies, requisitions for, B., 6                     167; lI., 206; S.. 300
distances between, F., 64; M., 197;
S., 297
Table of temperature at Baltimore, J., 120          division of, F., 51
Tar as a disilnfectant, J., 1~4                     floor-space of, B., 27;   F., 79;  MI.,
Telegraph, B., 8; F., 66, 74, 90; iM., 242,           180; S., 297
253, 261, 264                        for children, B., 40; F., 52  J.,
Temperature, best degree of, for wards, J.,           121; lI., 264; S., 288
221; xi)., 232                     healthfulness of upper, lM., 184
Tents, B., 43; S., 307                              heating of, B., 19; F., 75, 81; J.,
as isolation wards, B., 43                     118, 121, 123; li., 224, 231; S.,
as hospitals, S., 293                          308, 310, 313
compared with barracks, B., 17               isolating, B., 43; F., 84; M., 216;
mode of heating, B., 43                         S., 307
TILTON, DR. JAMES, observations on mili-            of one-story, B., 27; F., 63;  i.,
tary hospitals during the Revolu-            182;., 295
tion, 191                                 registration  of  temperature  and
Training school for nurses, xv; B., 7; F.,            ventilation of, B., 32
57; J., 142; lI., 242; S.,          should be emptied in rotation, B., 4;
322                                   J., 113
Treasurer, J., 131                                  small, B., 26
Trees, arrangement of, F., 69; S., 280              special, B., 26; MI., 211
sanitary value of, S., 297                   superposition of, M., 182
Trustees, duties of, J., 130                        usefulness of temporary, lMi., 190
letter to authors of essays, vii          ventilation of, B., 19; F., 76, 81;
room for, F., 71                            J., 122;  *., 224; S., 308
Tunnels for passageway, Ixi., 268           Ward vessels, materials for, Mi., 217
for steam, water, and gas pipes, Warden, S., 327
MI., 222                        Water, J., 111




INDEX.                                      O53
Water, as a disinfectant,'J., 127          WATSON'S experiments on the moisture
Water-closets, B., 32; -F., 77, 85, 91; J.,        evolved by grasses, 280
118; Mi., 212; S.,  29, Weather at Baltimore, record of, B., 44;
303                                                J., 120
pattern of, F., 99                  Windows, B., 26; F., 79; J., 116; M., 202;
ventilation of, B., 32; F., 74; 1I.,            S., 300
214                  Wood-shed, F., 67
Water-tanks, location and capacity of, B., Woodwork, B., 29; F., 69
39; F., 75; J., 112, 214   WYLIE, DR. W. G., on nurses' quarters at
Wrater supply, J., 117                              St. Thomas' Hospital, 324
23