HOSPITALS: 
 
 HISTORY, ORGANIZATIOJ(, AND COXSTRUCTIOX, 
 
 BOTLSTOX PKEE-ESSAY OF HARVARD UXIYERSITY FOR 1876. 
 
 W. GILL WYLIE, M.D. 
 
 "an o^^■CE OF peetentiox is woetii a pound of cube." 
 
 KEW YORK: 
 D. APPLETON AND COMPANY, 
 
 549 & 551 BROADWAY. 
 1877.
 
 BOYLSTON MEDICAL PRIZE QUESTIONS. 
 
 The Botlston Medical Committee, appointed by the President and Fellows of 
 Harvard University, consists of the following physicians : 
 
 J. B. S. Jackson, M. D., Henry J. Bigelotv, M. D., 
 
 D. H. Stoker, M. D., Richard M. Hodges, M. D., 
 
 Morrill Wyman, M. D., Calvin Ellis, M. D. 
 
 Samuel Cabot, M. D. 
 
 At the annual meeting, held June 7, 18 75, it was voted that no dissertation 
 worthy of a prize had been offered on either of the subjects proposed for 1875. 
 
 The following are the questions proposed for 1876: 
 
 1. Civil Hospital Construction (not of Lunatic Asylums) ; Location, Materials, 
 Arrangement, Warming, Ventilation, Drainage, Lighting ; with Designs. 
 
 The author of a dissertation on this subject, considered worthy of a prize, will be 
 entitled to a premium of Three Hundred Dollars. 
 
 Dissertations on the above subjects must be transmitted, postpaid, to J. B. S. 
 Jackson, M. D., Boston, on or before the first Wednesday in Api-il, 1876. 
 
 Each dissertation must be accompanied by a sealed packet on which shall be 
 written some device or sentence, and within which shall be inclosed the author's 
 name and residence. The same device or sentence is to be written on the disserta- 
 tion to which the packet is attached. 
 
 The writer of each dissertation is expected to transmit his communication to the 
 President of the Committee, J. B. S. Jackson, M. D., in a distinct and plain hand- 
 writing, and with the pages bound in book form, within the time specified. 
 
 Any clew by which the authorship of a dissertation is made known to the com- 
 mittee will debar such dissertation from competition. 
 
 Preference will be given to dissertations which exhibit original work. 
 
 All unsuccessful dissertations are deposited with the Secretary, from whom they 
 may be obtained, with the sealed packet imopened, if called for within one year 
 after they have been received. 
 
 By an order adopted in 1826, the Secretary was directed to publish annually the 
 following votes : 
 
 1. That the Board do not consider themselves as approving the doctrines con- 
 tained in any of the dissertations to which premiums may be adjudged. 
 
 2. That in case of publication of a successful dissertation, the author be consid- 
 ered as bound to print the above vote in connection therewith. 
 
 At the annual meeting, held June 5, 1876, it was voted that a prize of three hun- 
 dred dollars be awarded to Dr. W. Gill Wylie, of New York, for a dissertation on 
 " Civil Hospital Construction." 
 
 It was also voted that a dissertation on " Hospital Construction," bearing the 
 motto " Mille mali species, mille salutis erunt," was of such a high order of merit 
 that the committee recommend its publication by the author. 
 
 Richard M. Hodges, M. D., Secretary, 
 Boston, Mass. 
 
 CoPYKiGHT ET D. APPLETON A^'D COMPANY, 1S77.
 
 lOO 
 
 PKEFACE. 
 
 As tliere may be persons who consider the subject 
 of this essay, especially the chapter on " Construction," 
 somewhat outside the field of a practising physician's 
 work, perhaps a few words in regard to the circum- 
 stances which led to the Avriting of it may not be out 
 of j^lace. 
 
 More than five years ago, while a surgeon on the 
 Kesident House-Staff of Bellevue Hosj)ital, a large 
 pauper-hospital of this city, I had an excellent oppor- 
 tunity for seeing the bad effects of poor nursing and 
 defective construction on the welfare of patients. At 
 that time, with rare exceptions, the nurses were igno- 
 rant and in some cases worthless characters, who ac- 
 cepted the almost impossible task of attending to and 
 nursing from twenty to thirty patients each. There 
 were no night-nurses ; the night-watchmen — three in 
 number to a hospital of eight hundred beds — were ex- 
 pected to give assistance to patients requiring attention
 
 4 PREFACE. 
 
 during the niglit. Tlie liosj)ital-buildmg, originally an 
 old prison and almshouse erected sixty years ago, had 
 been added to, and was now a massive stone structure, 
 with three stories and a basement. The wards were 
 only separated from each other by the intervening par- 
 titions inclosing the water-closets and bath-rooms, which 
 were without ventilation, except as they opened into the 
 wards. In some instances there were only six windows 
 to wards of twenty beds. 
 
 The sanitary condition of the hosj)ital was shocking, 
 notwithstanding the fact that to the visitor the wards 
 presented a clean and orderly appearance. I saw, while 
 on duty in the wards, patients die from septic diseases 
 contracted in the wards after the slightest surgical 
 operations or injuries. From forty to sixty per cent, 
 of all amputations of limbs proved fatal ; and I saw a 
 strong, healthy man die from pyaemia following an am- 
 putation of a great-toe. 
 
 From the twelfth official annual report of the hos- 
 pital I take the following : 
 
 January 1, 1872. 
 
 Number of patients remaining in liosj^ital 779 
 
 " " admissions during the year 1871 6,859 
 
 " " births " " " 1871 376 
 
 Total number of patients " " " 1871 7,514 
 
 Number of deaths " « " 1871 1,102 
 
 Which gives 1 in every C.8, or 14.7 deaths in every 100. 
 In a total of 1,102 deaths we find —
 
 PREFACE. 
 
 30 cases are recorded as caused by pyaemia. 
 
 1 
 
 case 
 
 is 
 
 1 
 
 
 
 1 
 
 
 
 1 
 
 
 
 1 
 
 
 
 1 
 
 
 
 33 
 
 cases are 
 
 pyaemia and delirium tremens. 
 
 " " pneumonia. 
 
 " " necrosis of sternum. 
 
 " " morbus coxarius. 
 
 " " tertiary syphilis. 
 
 " " resection of elbow, 
 puerperal peritonitis. 
 
 From tlie above we get in 1,102 deaths 69 caused 
 by hospital-poisons, or 1 in every 15.95, or G.02 in 
 every 100. 
 
 Takiug the number of births as representing the 
 number of women delivered during the year: In 376 
 confinements, 33 died of puerperal fever, or 1 in every 
 11.30; or 8.7 in every 100 of all the women confined 
 died of puerperal fever. Since the introduction of 
 trained nurses, the removal of the lying-in patients, 
 the reduction of the number of beds from eight to 
 six hundred, and the use of Lister's antiseptic dress- 
 ings, the condition of the hospital has baen very much 
 improved, but the faults of the buildings remain the 
 same. 
 
 Becoming, in the spring of 1872, a member of the 
 standing Committee on Hospitals of the New York 
 State Charities Aid Association, I devoted my sj^tare 
 time to studying the subjects of trained nursing and 
 of hospital-construction, spending a summer abroad for 
 the purpose. 
 
 A paper read by me before the Association, Decem- 
 ber, 1873. gave substantially the same 2:>lan for a model
 
 6 PREFACE. 
 
 ward wliicli is described in this essay. The Association 
 requested the publication of the paper, but I felt that 
 the subject required more study. In February, 1876, 
 the chapter on " History of the Origin and Develoj^- 
 ment of Hospitals : their Progress during the Century 
 of the American Republic," was read before the New 
 York Academy of Medicine, after which, deciding to 
 compete for the Boylston Prize, I wrote hurriedly, dur- 
 ing March, the rest of the essay, and forwarded it to 
 Cambridge, in accordance with the conditions, 3d of 
 Aj)ril, 1876. Since then I have withheld it from the 
 press, in hopes of gaining time to rewrite it, but profes- 
 sional engagements have prevented a full revision. 
 
 I do not present this book as a complete work on 
 hospitals. For the best statement of all the details of 
 internal management, I refer my readers to the " Hand- 
 book for Hospital Visitors," Document No. 13, of the 
 
 State Charities Aid Association. 
 
 W. G. W. 
 
 New York, ]\Tarc7i 1, 1877.
 
 ooi^te:nts. 
 
 CHAPTER I. 
 
 PAGE 
 
 History of the Origin and Development of Hospitals : their Progress 
 
 DURING THE CeNTPRY OF THE AMERICAN REPUBLIC. — CONCLUSION AS TO 
 
 THEIR Origin . . . . . . . . .9 
 
 CHAPTER II. 
 
 Relations of Hospitals to Pauperism. 
 
 Necessity for Hospitals. — Increase and Cost of Charities. — Education to replace 
 Alms. — Personal Relations to Charity.— Objections to Hospitals. — Pro- 
 posed Plan for governing Charity . . . . . .56 
 
 CHAPTER III. 
 Organization and Management. 
 Boards of Managers and Medical Boards. — Value of Hospital Appointments. — 
 
 Influence of Women in Hospitals. — The Superintendent . . .68 
 
 CHAPTER IV. 
 The Construction of a Civil Hospital. 
 Excuses for Faults of Construction. — Location. — Preparation of the Grounds. — 
 Character of the Buildings. — Classification of the Patients according to 
 their Diseases. — The Ward ; Comparative Costs of Construction. — Shall 
 the Buildings be permanent or temporary in Character ? — Disease-Germs 
 and Disinfectants. — Character of the Ward.— Number of Beds to Each 
 Ward. — Cubic Air-Space to Each Bed. — Shape and Size of Ward. — Posi- 
 tion of the Ward in Relation to Points of the Compass. — Position of the 
 Service-Rooms. — Connection of Service-Rooms with the Ward. — Founda- 
 tion of the Ward. — Objections to Basements and Cellars. — Material for the 
 Walls of the Ward. — Permeable or Impermeable Walls ? — The Floors of 
 the Ward.— The Windows.— The Doors and Roof.— The Piazza.— 77ie Ser- 
 vice-JRoom B uil din ff.—BimensioTis. — Basement. — Wash-Room and Water- 
 Closets. — Bath-Room. — Day and Dining Room. — Nurse's Room and Linen- 
 Shelves. — Reception and Examining Room. — The Main Corridor . 86
 
 8 CONTENTS. 
 
 CHAPTER V. 
 Warming and Ventilation. 
 
 PAGE 
 
 Different Methods of Ventilation. — Aspiration versus Propulsion. — Different 
 Methods of Warming. — Ward Heating and Ventilation. — Proposed Method 
 of Warming. — Proposed Method of Ventilation. — Foul-Air Escapes. — 
 Lighting the Ward. — Ward-Furniture. — Heating and ventilating the Ser- 
 vice-Room Building . . . . . . .117 
 
 CHAPTER VI. 
 
 Pay-Patients in Charitable Institutions. 
 
 Provident Dispensaries. — Pay- Wards ...... 133 
 
 CHAPTER VII. 
 Special Isolated Huts for Certain Important Cases, such as Ovariotomy and others 
 extremely sensitive to Infectious Matter. — The Plan of the Hut. — Position. 
 — Dimensions. — Floor. — Height from Ground. — Walls. — Roof. — Windows. 
 Door. — Warming. — Lighting. — Ventilation. — Furniture . . .138 
 
 CHAPTER VIII. 
 
 Administrative Buildings and Arrangement of the Buildings on the Grounds. — 
 Separation of the Ward-Pavilions. — Position of the Ward-Pavilions. — Ad- 
 ministrative Building. — Bath-House. — The Apothecary-Shop. — Operating- 
 Theatre. — Accident-Ward. — Stable. — Autopsy and Pathological Building. 
 — Out-Door Dispensary. — Laundry. — Water-Supply. — Sewers and Drain- 
 age. — Cultivation of the Grounds ...... 148 
 
 CHAPTER IX. 
 
 Relations of the Medical School and the Training-School for Nurses to the Hos- 
 pital. — Professors and Students. — Reception-Hospitals. — Organization of 
 the Training-School . . . . . . .157 
 
 CHAPTER X. 
 
 Improvement of Hospitals now in Use. — Small Hospitals. — Lying-in Hospitals. 
 
 — Hospitals for Convalescents. — Army-Hospitals. — Insane Asylums . 165 
 
 CHAPTER XI. 
 
 Hospital Buildings now in Use. 
 The Old Conglomerate. — Extemporized and Irregular Hospitals. — The Old Block 
 Plan.— The Corridor Plan.— The Pavilion Plan.— The One-Story-Pavilion 
 Plan. — Hospitals of America, England, France, Germany, Italy, and Spain, 
 with Plans and Descriptions . . . . . .182 
 
 Appendix ......... 221
 
 HOSPITALS. 
 
 CHAPTEK I. 
 
 HISTOEY OF TIIE OEIGIX AXD DEVELOP:\rEXT OF HOS- 
 PITALS : THEIR PROGEESS DUEES'G THE CEXTUEY OF 
 THE AilEEICAX REPUBLIC. 
 
 It is tlie common belief that hospitals, for tlie treat- 
 ment of tlie sick poor, are the offspring of Christianity ; 
 that, previous to the Christian era, no such institutions 
 as our hospitals ever existed. The best encycloj^aedias, 
 both English and American, make no reference to the 
 fact that hospitals were known previous to the coming 
 of Christ, and not infrequently we hear men in public 
 addresses making the same mistake. Beyond question, 
 hospitals for the purpose of treating the sick poor were 
 founded in India, among the Buddhists, several hun- 
 dred years before the advent of Christ. 
 
 During the reign of Asoka, who died 226 years b. c, 
 the Buddhists cut on rocks their edicts on hospitals, 
 one of which, dated 220 b. c, can be seen to-day. It 
 directs that along the routes of travel hospitals shall 
 be erected, that they be " well provided with instru- 
 ments and medicines consisting of mineral and vege- 
 table drugs, with roots and fruits," and also that
 
 10 H08PIJALS: 
 
 " whenever tliere ' is no provision of drugs, medicines, 
 roots, and lierbs, are to be supplied and skillful physi- 
 cians are to be aj^pointed to administer tliem, at the 
 expense of the state." ' 
 
 In Wise's "Review of the History of Medicine" 
 (vol. i., page 392) there is a quotation from Tounour's 
 translation of the " Mahawauso," stating that " Buddha 
 has aj)pointed a j^hysician for every ten villages on the 
 high-road, and built asylums for the crippled, the de- 
 formed, and the destitute. His son, Upatiso, built hos- 
 pitals for cripples, for pregnant women, and for the 
 blind and diseased, and Dhatusend built hospitals for 
 cripples and for the sick." 
 
 Scavoneur, in his "Voyages" (vol. ii., page 489), 
 gives an account of the Banian hospital, which still 
 exists at Surat, at the time of his writing, about one 
 hundred years ago : 
 
 " This curious institution was supported by the one 
 anna per cent, on the rupee of the merchant's clear gain, 
 to which were added the fines of certain venal offenses, 
 under the supervision of the chief Banians. In 1770, 
 when trade had decayed, the revenue was upward of 
 six hundred pounds a year, and so careful were they of 
 the animals that bread-and-milk was provided for two 
 which could not croj) grass. The hos23ital consisted of 
 twenty-five acres, surrounded with a high wall, divided 
 into courts and defended by sheds and yards for the 
 accommodation of the animals." 
 
 Not far distant on a rock, in Guzerat, are the edicts 
 of Asoka, cut on it more than two thousand years ago. 
 Hamilton, in his "Hindostan" (vol. i., page 718), tells 
 of an old tortoise, that w^as seen in one of these hos- 
 
 * Eeview of the History of Medicine, by Thomas A. Wise, London, 1867.
 
 TEEIR OBIGIF AND DEVELOPMENT. 11 
 
 pitals, that had been there for seventy-five years. There 
 are, more or less, in all Buddhist countries, hospitals for 
 incurables, lepers, and such as are afflicted with elephan- 
 tiasis. 
 
 " In the city of Bangkok there is, in addition to 
 these, a hospital for poor lying-in women ; and all the 
 male and female physicians attached to the court are 
 obliged to give their services gratuitously to each one 
 of these establishments. 
 
 "According to the 'Shah Nameh,' a collection of 
 heroic poems on the ancient histories of Persia, the fire- 
 worshij)er3 from the earliest times were obliged by 
 their laws to provide suitable houses for the suffering 
 poor of their community, and the king to furnish the 
 best medical treatment for the inmates free of all cost. 
 In Bombay the noble hospital connected with Grant's 
 College is the princely gift, to the sick poor, of the well- 
 known fire-worshiper and Parsee knight. Sir Jamsetja 
 Jejeeboy. In 1869 his wife and children erected a 
 very magnificent hospital for incurables near it. In the 
 same year an ophthalmic hospital was oj)ened by an- 
 other munificent fire- worshiper, Mr. Cowlesjee Jehhaug- 
 heer." ' 
 
 It is said that the sick were treated in the temples 
 of ^sculapius, 1134 years b. c, at Titanus, a city of 
 Peloponnesus, but there is no evidence that these tem- 
 ples were used for the purpose of treating the siclr poor ; 
 still they were in some respects similar to our hosj^itals. 
 
 Dr. John Watson, in his "Anniversary Discourse 
 before the New York Academy of Medicine," says: 
 " As asylums, these temples bore no inapt resemblance 
 
 * Information from Mrs, Leon Owens, who for many years was a resi- 
 dent of India.
 
 12 HOSPITALS: 
 
 to tlie liosjiitals and infirmaries of modern times ; into 
 which, in fact, some of tliem were ultimately converted. 
 The temples of JEsculapius, Cos, and Tricca, according 
 to Strabo, were always filled with patients, and along 
 their walls the tablets were suspended, upon which 
 were recorded the history and treatment of the indi- 
 vidual cases of disease." 
 
 The valetudinariums of the Komans, referred to by 
 Seneca and other writers, and which are defined by An- 
 drews, Ainsworth, Cooper, and other authorities, as 
 places where men lie being sick, sick men's lodgings, 
 infirmaries, or hospitals for sick folk, a sick-room, must 
 have been institutions somewhat similar to hospitals. 
 As they are not described by any of the many Roman 
 historians as public institutions, they were ^^robably 
 something like our private hospitals — water-cures. 
 
 There was a public building on an island of the 
 Tiber at Rome to which slaves were removed when 
 sick, and one at Delos used as an asylum for aged 
 women, and near some of the temples houses were 
 erected for those sick while visiting them. 
 
 In the East caravansaries or resting-places for trav- 
 elers have existed from time imi5iemorial. In all of the 
 early pilgrimages some such resting-places were cus- 
 tomary, and were usually found near the shrines and 
 temples. 
 
 After the birth of Christ, when his words began to 
 reach the hearts of men and lead them to acts of kind- 
 ness, and when Jerusalem and the roads a23proaching 
 it were crowded with pilgrims, sjDecial accommodations 
 for the use of those taken sick were established in con- 
 nection with these caravansaries. Afterward, when 
 monasteries and convents were established, they were
 
 TEEIR ORIGIN AND DEVELOPMENT. 13 
 
 tlie resting-places of pilgrims, and in these we find there 
 were special apartments arranged for the sick. In the 
 East, in the time of the Emperor Julian, these apart- 
 ments for strangers and pauj^ers in the monasteries were 
 • called xendochia. Amonsj the Komans it was the ens- 
 tom to set aside apartments in their houses for guests 
 which they called liospitalia — and it is from this that 
 our word liospital is derived, and it was from the spirit 
 of charity taught by(Christ^ stimulated by the necessi- 
 ties of the pilgrims, that our first hospitals originated. 
 
 As early as a. d. 300 it is said that several hospitals 
 were established for the use of sick pilgrims near Beth- 
 lehem, under the direction of St. Jerome, in whose writ- 
 ings the term "hospital" first appears in connection 
 with curative establishments.* 
 
 Besides the necessity of providing places of shelter 
 for sick pilgrims, another cause that influenced the 
 founding of hospitals and other charitable institutions 
 was, that the barons of the middle ages did not distrib- 
 ute corn among the poor, as was the custom with the 
 Romans ; and when Christianity was introduced into 
 the Roman Empire many slaves were set free and be- 
 came helpless paupers. % o ff^^'^"^^-'')^^ I'^Wt'^f 
 
 "To either St. Ephraim, who died in 381, or St. 
 Fabiola, is due the credit of founding infirmaries, which '^ 
 
 were supported by charitable contributions for the ex- 'J 
 
 elusive purj^ose of treating the sick." ,$ 
 
 Hospitals were spoken of " in the Council of Nice, < 
 
 A. D. 325, as institutions well known and deserving sup- 
 port and encouragement." "" 
 
 The famous Hosj^ital of Cesarea was founded a. d. 
 
 ' Dr. Toner's " Contributions to the Annals of Progress in Medicine.''
 
 14 HOSPITALS: 
 
 370. The Hotel-Dieu, perhaps the oldest hospital in 
 Europe now in use, was founded about a. d. 600 by 
 St. Landry, Bishop of Paris, for all sick and destitute 
 persons of whatever sex, age, or condition. Its motto 
 was " Medicus et Hospes " — sick pilgrims and mendi- 
 cants all were received. 
 
 The first hospital built in England especially for 
 the sick was erected at Canterbury by Archbishop Lan- 
 franc. Id 1070 and in 1208 the Hospital of the Holy 
 Ghost and St. George's Hospital were established in 
 Berlin. After this a hospital was considered requisite 
 for eveiy city to afford shelter to the poor and sick. 
 
 The introduction of the leprosy during the Cru- 
 sades, and later epidemics of small-pox and cholera, 
 necessitated the separation of the sick from the well, 
 and to accomplish this many lazarettos were built. 
 Lamothe, in his book, " Charitable Legislation," says 
 that, in 1226, there were two thousand such institutions 
 in France alone. 
 
 In 1048 a school of medicine was established at 
 Salerno, and the same year an order, called the " Breth- 
 ren of the Hospital," for the care of the sick in Jerusa- 
 lem, dedicated to John the Baptist, was organized, and 
 in 1118 knightly vows were added. After this broth- 
 erhoods of Hosj^italers were formed and extended 
 through Europe. As the Crusaders increased, the 
 brotherhoods became richer and more numerous; and it 
 was not uncommon for wealthy persons, when dying, to 
 bequeath theii' property to the hospital in which they 
 had been relieved while away from home. The hos- 
 pitals established by these brotherhoods were always 
 near and connected with a monastery or cathedral. Of 
 their internal arrans-ements but little is kno^vn. It
 
 THEIR ORIOm AXD DEVELOPMENT. 15 
 
 seems that tlie kniglits or hrotliers bound ' up tlie 
 wounds, and acted as pliysicians. The earliest account 
 of physicians or surgeons being connected with a hos- 
 pital among the Templars was under John de Lastic, 
 who in 1437 defined the duty of the physicians and 
 surojeons.' 
 
 In 1456 the Grand Hospital of Milan was opened. 
 This remarkable building is still in use as a hospital, 
 and contains usually more than two thousand patients. 
 The buildings stand around scpiare yards, the j^rincipal 
 one being much larger than the others, and separating 
 the hospital into two parts. The main wards on either 
 side of this large court form a cross, in the centre of 
 which is a cupola, with an altar beneath it, where 
 divine service is performed daily in sight of the 
 patients. These wards have corridors on both sides, 
 which are not so lofty as the ceilings of the wards, and 
 consequently there is plenty of room for windows above 
 these passages. The ceilings are thirty or forty feet 
 hio-h, and the floors covered with red bricks or flao;s. 
 The outside wards are nothing but sj)acious corri- 
 dors.* The wards were first warmed by open charcoal- 
 braziers. 
 
 This hospital, built at the time when the Chui'ch of 
 Rome was at the height of her power, and but a short 
 time before the Reformation, is a good example of what 
 had been attained toward the development of hospitals, 
 and it shows how much a part of the Church the insti- 
 tution of hospitals was. We undoubtedly owe much 
 to the Church of Rome. For centuries she was the 
 only home and protector of the Christian religion. By 
 
 * Beckman's "History of Inventions." 
 
 * Hospitals, Intirmaries, and Dispensatories, by F. Oppert, 1867.
 
 16 HOSPITALS: 
 
 the devotion of her adherents, and the comjoleteness 
 and vitality of her organization, she successfully re- 
 sisted the devastations of the barbarians, and preserved 
 through the darkness of the middle ages vs^hat knowl- 
 edge we have of the Greek and Eoman civilization. In 
 youth all is growth and progression, and change brings 
 strength and power ; but with age change means death, 
 and length of life depends upon the power to resist 
 change. The Church did not prove to be an exception 
 to this law, for since the sixteenth century she has re- 
 sisted all changes in hospitals. A close study of all 
 hospitals built subsequent to this period for two hun- 
 dred years on the Continent of Europe and about one 
 hundred years in England, in fact just as long as the 
 Church of Rome had control of the hospitals, shows 
 that no progress in their construction was made. 
 
 In all of these hospitals the first idea in the erection 
 was to make the hospital a church institution, and on 
 this account the wards were clustered about the chapel. 
 Add to this idea of making the hosj)ital a cliurcli insti- 
 tution that of economy and convenience of administra- 
 tion^ and take the j^lan of the Grand Hospital of Milan 
 as a model, and we have the source of our modern block 
 plan and corridor hospitals ; nor do we find that this 
 hospital, built in 1456, was to any extent improved 
 upon until science became an important factor in prog- 
 ress and civilization. 
 
 About the first of the sixteenth century another 
 cause began to influence the establishment of hospitals, 
 namely, the necessity of providing for the care of the 
 large numbers of sick and wounded incident to war. 
 From the earliest ages it seems to have been the cus- 
 tom to have a surgeon or physician. in attendance on
 
 TEEIR OEIGm AXD DEVELOPMENT. 17 
 
 an army, but, previous to tlie times of Ambrose Pare 
 (1560), tliere is no evidence tliat tlie physician or sur- 
 geon was considered a necessity, or as being of mucli 
 consequence in military affairs. 
 
 As tliere was no special provision for the wounded 
 after a battle, tliey were distributed in the nearest 
 towns and quartered upon the inhabitants. There are 
 one or two references by ancient historians, showing 
 that the wounded were sometimes placed in tents, but 
 there is no account of such a thing as a military hospi- 
 tal. The soldiers were taught to dress their wounds 
 with oil and wine, and in many cases left to take care 
 of themselves when wounded. 
 
 The Italians were the first to produce writers on 
 military surgery about the beginning of the thii'teenth 
 centuiy. Early in the fourteenth century the study of 
 surgery was introduced into the Universities of Mont- 
 pellier and Paris, but we find no account of a military 
 hospital being erected until 1575, when, at the siege of 
 Metz, through the influence of Ambrose Pare, the first 
 famous military surgeon, one was built.' 
 
 Thus we see that the spirit of humanity without 
 the aid of science did not make proper provision for 
 sick and wounded soldiers. Three hundred years later, 
 when science had developed into such proportions as to 
 divide the control of the world with religion itself, we 
 shall find the experience afforded by the large number 
 of sick and wounded incident to wars to be by fiir the 
 most important influence of all others in bringing about 
 reforms in hosj^itals. 
 
 In 1670 Louis XIY. beo-an to build the Hotel des 
 Invalides. Beckman, in his " History of Inventions," 
 
 ^ " On the Establisliment of Army Hospitals," by Edward A. Crane, M. D. 
 3
 
 18 HOSPITALS: 
 
 speaking of this liospital says, " The extravagant mag- 
 uificence of wliicli is rather a proof and monument of 
 the profusion and joride of that sovereign than of his 
 care for meritorious soldiers." This is one of the first 
 instances of this personal monumental idea showing 
 itself in the construction of hospitals. 
 
 One of the first houses established for the sick poor 
 was that built at Rome by Fabiola, a Roman lady, the 
 friend of St. Jerome.* But this and all other hospitals 
 founded by individuals were made church institutions 
 until the beginning of the eighteenth century, when 
 several hospitals, such as Guy's, were founded in Eng- 
 land by individuals, and the monumental idea began to 
 show itself in the style of building. Since then many 
 have been built, and in almost all the idea of making a 
 monument has been the first and most important con- 
 sideration in selecting the style of building, and has 
 lately done much to hinder the adoption of the best 
 plans, so far as the welfare of the patients is concerned. 
 
 Before the Reformation in the sixteenth century, 
 hospitals, lazarettos, and all other charitable institu- 
 tions, were completely in the hands of the ecclesiastics, 
 and had become a useful part of the machinery of the 
 Church of Rome, which then in a great measure directed 
 all the affairs of Europe. Until this time the knowl- 
 edge of medicine and pretty much all learning was con- 
 fined to the priesthood. In fact, until the eighteenth 
 century almost all hospitals were more like our poor- 
 houses than the hospitals of to-day. At this period 
 positive science was established, but the practical adap- 
 tation of science or inventions was only just fairly be- 
 gun. Curative medicine was hardly in advance of the 
 
 ' Beckraan's "History of Inventions."
 
 THEIR ORIGIN AND DEVELOPMENT. 19 
 
 time of Hippocrates, and sanitary science was in its 
 infancy. 
 
 Early in tlie seventeentli century, it is said tliat 
 Gustavus Adolplius of Sweden established the first 
 regular military sanitary service, but we have found 
 nothing to show that sanitary science to any extent in- 
 fluenced the construction of hospitals, certainly not 
 civil hospitals, before the eighteenth century. After 
 the Reformation, during the reign of Elizabeth, the age 
 that produced the founder of Inductive Science, efforts 
 were made, on account of the prevalence of the plague, 
 to bring about -improvement in dwelling-houses, by lim- 
 iting the number of inmates in each house, etc. ; and in 
 the seventeenth century the fearful ravages of both the 
 cholera and jail or typhus fever excited a general inter- 
 est in efforts to prevent the spread of these contagious 
 diseases. 
 
 Toward the latter part of this century, the writings 
 of Sydenham did much to improve the science of medi- 
 cine, and early in the eighteenth century we find several 
 authors treating of air intelligently. Among these were 
 Hoffman and Beucrus. Arbuthnot wrote a valuable 
 treatise on air, arguing from the laws of physics. 
 
 In 1713 Cardinal de Polignac wrote "Le mecanique 
 a Feu," in which he treats of ventilation, and makes use 
 of the laws of physics in giving plans for the construc- 
 tion of fireplaces, and to him is due the credit of invent- 
 ing the first machine for forcing ventilation. He says : 
 " It is not the warmth of a room, but its inequality of 
 temperature and want of ventilation., that is the origin 
 of numerous maladies ; we cannot, therefore, be too cau- 
 tious of living in those in wliich this dangerous impu- 
 rity of heat and motionless air exists, nor. remain too
 
 20 HOSPITALS: 
 
 long in rooms into wliicli temperately warm fresh air 
 is constantly flowing and diftused." ' The cardinal's 
 method of heating the air before it enters the room, by 
 ducts and chambers behind the fireplaces, is most scien- 
 tific and ingenious. 
 
 In 1715 Jean T. Desaguliers, a French refugee then 
 residing in London, translated the work of Cardinal de 
 Polignac (M. Ganger) into English. In 1723 Desagu- 
 liers was requested to improve the ventilation of the 
 House of Commons, which before that time had been 
 ventilated by means of four holes in the ceiling con- 
 nected with hollow pyramids to take off the foul air — 
 but often cold air would descend instead. 
 
 Desaguliers very ingeniously arranged a fire with 
 flues to heat the air in the pyramids or shafts, and thus 
 ventilate the room. In 1727 he designed a machine, 
 which by means of pumps forced the fresh air in, and 
 the foul air out, of mines. In his " Cour de Physique," 
 vol. ii., page 474, he describes a ventilator which he 
 had proposed to the Royal Philoso23hical Society for 
 " changing the air of the rooms of sick people in a little 
 time, either by drawing out the foul air or forcing in 
 fresh air, or doing both successively without opening 
 doors or windows," which he thought would be of great 
 use in all hospitals and prisons, and also serve to con- 
 vey air into a distant room.'' The motion was given to 
 the air and the current established by means of a num- 
 ber of fans revolving in a circular case — the exact prin- 
 ciple of the fan-ventilator of to-day. 
 
 It was not altogether original, but was the ajDplica- 
 
 * Bernan's "History and Art of Warming and Ventilating," vol. ii., 
 p. 3, London, 1845. 
 
 * Philosophical Tranaactions, and Bernan's "History of Ventilation."
 
 THEIR ORIGIN AND DEVELOPMENT. 21 
 
 tion and improvement of the plan proposed by Cardinal 
 de Polignac, and was something like Popin's Hessian 
 bellows. This centrifugal wheel- ventilator was applied 
 to the Ilouse of Commons in 1736, and used for seventy- 
 five years. In 1741 Samuel Sutton published a i:)lan 
 for drawing off the foul air of ships by means of pipes 
 passing through the fires and connecting with the flues, 
 thus by suction forcing out the foul air. And about 
 the same year (1741) Stephen Hales published the 
 description of a ventilator that worked on the j^rinciple 
 of the bellows. 
 
 During the first half of the eighteenth century, in 
 Great Britain there is but little to be found in medical 
 works having a direct bearing upon hospital reform, 
 but there were several important hospitals built; 
 among these was the Royal Infirmary of Edinburgh. 
 
 The medical school in connection with the univer- 
 sity, led by Alexander Munro, had grown in imj^or- 
 tance, and, as there was no hospital then in Edinburgh, 
 the professors and those interested in the school suc- 
 ceeded in establishing the Royal Infirmary in 1734. 
 The doctors took a deep interest in the erection of the 
 building, as they were at that time the most famous in 
 Britain ; the plan adopted by them will give a good 
 idea of the progress tliat had been made in hospital-con- 
 struction, and is interesting as being one of the first hos- 
 pitals erected with the design of subserving the inter- 
 ests of a medical school. 
 
 The original building is still standing; it consists 
 of a central administrative portion with wings two 
 stories high on either side, containing the wards ; the 
 whole hospital is one solid building, but the windows 
 are large and opposite, and the number of beds in each
 
 22 HOSPITALS: 
 
 ward is small compared with tlie old cliurcli liosj^itals. 
 In many respects it shows j)rogress, but it is evident 
 that the controlling ideas in the plan of construction 
 were economy and convenience of administration. 
 
 Early in the eighteenth century, through the wait- 
 ings and teachings of Boerhaave, the Medical School of 
 Leyden became the most famous of that period, and 
 held the position of the first medical school of Europe 
 for a generation. Boerhaave was a man of great erudi- 
 tion, and it is difficult to say to what extent his teach- 
 ings are original; at any rate, many of his aphorisms 
 will bear the light of science to-day, and show a com- 
 prehensiveness that extends to some of the latest scien- 
 tific discoveries and methods of treating disease. The 
 following two aphorisms have been selected as having 
 a direct bearing upon the subject we have in hand : 
 Aphorism 245 : " But it is more especially serviceable, 
 in the beginning of the cure, to make an exact closure 
 of the wounded lips while bleeding, and making the 
 dressings seldom, and very expeditiously, carefully de- 
 fending the parts in the mean time from everything too 
 moist, oily, or relaxing, and also from the cnV itself P 
 Aphorism 200, on wounds in general : " The air of the 
 patient's chamber should be always pure and free from 
 putrid exhalations ; that which is dry, and moderately 
 warm or temperate, is best ; and it should be frequently 
 renewed or changed." 
 
 We will not give our explanation of these words, 
 but that of one of his j^upils, Gerard van Swieten, 
 w^hich we find in Van Swieten's " Commentaries on the 
 Aj)horisms of Boerhaave," published more than a hun- 
 dred years ago. On page 181, vol. ii., after giving the 
 above aj^horisms, he says: "Where a great number of
 
 THEIR OEIGIN AN'D DEVELOPMENT. 23 
 
 wounded patients lie together in a liospital, tlie air is 
 filled witli putrid exhalations, whicli affect all of them, 
 and kill many who otherwise might have been pre- 
 served ; such places should therefore have the windows 
 often opened, and the air changed or blown out, to re- 
 move the putrid exhalations. It is indeed often ad- 
 vised to perfume the place for that purpose ; but chang- 
 ino; of the air is much more serviceable to the diseased." 
 
 " But, above all, those patients are observed to suf- 
 fer most for want of fresh air who have wounds in the 
 head, as we are assured from observation." Can any- 
 thing we have to say to-day express more clearly the 
 danger of foul air and the necessity of jDure air in treat- 
 ing wounds successfully ? If Boerhaave did not origi- 
 nate these ideas, he at least by his learning and wisdom 
 collected them, shaped them into living germs, and 
 planted them in the minds of his puj^ils who were des- 
 tined to become the first and prime movers in the de- 
 velopment and practical application of sanitary science 
 in treating the sick. 
 
 Among the pupils of Boerhaave, at Leyden, were Sir 
 John Pringle and Gerard van Swieten ; Donald IMunro 
 and Eichard Brocklesby were also students at Leyden ; 
 all four are noted as beino; amonar the first men who 
 wrote and taught the application of sanitary science in 
 the construction and management of military hospitals. 
 
 Of books that had a wide circulation we have been 
 able to find but a few that treat of the practical appli- 
 cation of sanitary science in caring for the sick and 
 wounded, before the publication of the writings of Sir 
 John Pringle, and none that will compare with the ad- 
 vanced views taught by him. In 1750 he published a 
 scientific essay on antisej^tic substances (probably the
 
 2i HOSPITALS: 
 
 first ou tliat subject), and in 1752 tlie first edition of 
 liis famous work " Observations on tlie Diseases of tlie 
 Army" appeared. On page 86, in speaking of the 
 causes of disease in armies, lie says : " The last source is 
 from hospitals, barracks, transport-ships, and, in a word, 
 from every crowded place where the air is- so pent up as 
 not only to lose part of its vital i^rinciple by frequent 
 resj^iration, but also to be corrupted by the perishable 
 matter of the body, which, as it is the most volatile 
 part of the humors, is also the most putrescent," etc. 
 
 And again he says : " As to the disposition of hos- 
 pitals with regard to preserving the j)urity of air, the 
 best rule is, to admit so few patients into each ward 
 that a person unacquainted with danger of bad air 
 mio-ht imaoine there was room to take in double or 
 triple the number." And, when speaking of hospitals 
 and typhus fever, he recommends barns and other open 
 buildings in preference to closed houses, and says that 
 pure air is of more imj)ortance than warmth, and adds, 
 " It may be received as a maxim that the more fresh 
 air we let into hospitals the less danger there will be of 
 breeding this dangerous distemper." He recommends 
 open fires as the best method of heating, and says sol- 
 diers may be treated under sheds. 
 
 About this time, science was making rapid progress 
 in all directions, and there seems to have been a general 
 awakening to the necessity of sanitary reform. 
 
 In a small volume of Van Swieten's, j^ublished in 
 1760, he gives the following aphorism: "The lodging 
 of a number of men in a place wanting in sj^ace should 
 ])e avoided with the greatest care; but, should it at any 
 time become necessary, the air must be renewed there 
 as often as 2:)ossible, whether the men who are lodged
 
 THEIR ORIGIN AND DEVELOPMENT. 25 
 
 togetlier are well or sick, for it is from a want of venti- 
 lation tliat tlie most dangerous diseases arise, including 
 even those wliicli are contagious." ' 
 
 In 1764 Donald Munro puLlislied a work " On the 
 Condition of Military Hospitals." In this he pro2:)osed 
 the application in hosj^itals of Sutton's method of venti- 
 lating by means of pi23es or ducts opening into the ceil- 
 ing of the wards and connecting with the flues of the 
 fires, and he also recommends the use of large sheds or 
 wooden huts, which he saj^s have been tried by Eichard 
 Brocklesby, and found to be the best buildings for 
 treating the sick of the army and navy. 
 
 Long before the time of Brocklesby no doubt wood- 
 en huts had been used for shelterins; the sick durino- 
 epidemics, from necessity — the object being, to sepa- 
 rate the diseased from the well, without any design of 
 placing the sick under the most favorable circumstances 
 to recover. 
 
 In the same year (1764) Eichard Brocklesby pub- 
 lished his " Economical and Medical Observations." In 
 an essay on the most effectual means of preserving the 
 health of seamen, by James Lind, M. D., published 
 1762, in London, we find the first definite proposal on 
 the classification of patients. He says : " In all hospi- 
 tals, there should be separate wards allotted for difter- 
 ent diseases, and the foul wards in a hospital ought 
 always to be the best aired, and, where the contagion 
 is eminently malignant, spacious tents with fireplaces 
 are greatly preferable to any close ward or apartment 
 for dissij^ating infection, and for the recovery of the dis- 
 eased." 
 
 Although the general interest in sanitary affairs, and 
 
 ' Crane " On the Establishment of Army Hospitals."
 
 26 HOSPITALS: 
 
 tlie views and practical suggestions of tlie above-men- 
 tioned works, undoubtedly brought about im^Dortant 
 reform in tlie management and internal arrangemepts 
 of tlie Englisli hospitals, yet no hospital was built on a 
 different plan or that could be considered an improve- 
 ment on the plan of the Eoyal Infirmary, except per- 
 haps one that was built at Stonehouse, near Plymouth, 
 England. 
 
 We have not been able to get a full description of 
 the plan of this hospital ; Ave know that it was com- 
 menced in 1756 and finished in 1764, and used for sick 
 seamen. The wards were in separate pavilions, with 
 only twenty beds to the ward, and the windows were 
 op230site. This was in all probability the first " pavil- 
 ion" hospital; the name of the architect was Rover- 
 head, of London. It was at the time considered a 
 model hospital, and was visited by members of the 
 committee appointed from the French Academy of Sci- 
 ences in 1786, to report upon a plan with which to 
 replace the Hotel-Dieu, and from its detached buildings 
 or pavilions they took ideas "which guided them in pre- 
 j)aring their famous report. 
 
 The improved plan of this pavilion-hospital at 
 Stonehouse was not adopted in England, nor do we 
 know of any hospital built in England on this plan 
 until 1860, when the Blackburn Infirmary was built 
 near Manchester, and this was but a reflection of the 
 Stonehouse plan from the Lariboisiere Hospital in 
 Paris, which was finished in 1854: after the plan sug- 
 gested by the French Academy committee in 1786, 
 fifty-eight years before. 
 
 In the writings of Pringle, Brocklesby, Munro, and 
 Lind, and in the building of the pavilion hosj^ital at
 
 THEIR PROOBESS IX AMERICA. 27 
 
 Stouelionse, the spirit of sanitary reform wliicli begau 
 with tlie Keformation seems to have readied its liio'liest 
 point of development in Great Britain, in so far as tlie 
 construction of hospitals was concerned, and except in 
 matters of internal arrangements no improvements were 
 made, and interest in the subject of hospital construc- 
 tion seems to have lain dormant for a century. 
 
 On the Continent up to 1776, a century ago, Vv^e 
 find nothing of interest to record as an improvement in 
 hospitals. The progress of science up to that time prac- 
 tically had not reached the subject of hospitals. The 
 civil hospitals were still in the hands of the ecclesias- 
 tics; and even in Paris, then the greatest scientific cen- 
 tre of the world, they were, according to the accounts 
 of numerous authorities, in a shocking condition. 
 
 AVe have traced the development of hospitals in 
 Europe up to the time of the Revolutionary War. We 
 will now turn to America. 
 
 Prescott, in his " Conquest of Mexico," vol. i., p. 48, 
 speaking of the Aztec civilization, says : " I must not 
 omit to notice here an institution the introduction of 
 which, in the Old World, is ranked among the benefi- 
 cent fruits of Christianity. Hospitals were established 
 in the princij)al cities, for the cure of the sick, and per- 
 manent refuge for the disabled soldiers ; and surgeons 
 were placed over them 'who were so far better than 
 those in Europe,' says an old chronicler, ' that they did 
 not i3rotract the cure, in order to increase the pay.' " 
 
 Mr. Prescott gives, as his authorities for the above 
 statements, "Torquemada, Monarch. lud., lib. xii., cap. 
 6; lib. xiv., cap. 3;" " Ixtlilxochitl, Hist. Chich., MS., 
 cap. 67." On page 309, of the same volume, he says, in 
 speaking of Montezuma, " He showed a similar munifi-
 
 28 HOSPITALS: 
 
 cent spirit in Lis public works, constructing and em- 
 bellisliing tlie temples, bringing water into the capital 
 by new channels, and establishing a hospital, or retreat 
 for invalid soldiers, in the city of Colhuacan." 
 
 In answer to certain questions, General J. W. 
 Phel];)S, an authority on the subject, writes, " There is 
 abundant evidence to show that the Aztecs came 
 from Eastern Asia, and that their civilization origi- 
 nated in Buddhist ideas." Like the Buddhists, their 
 knowledge of medicine was considerable; but their 
 religion, so unlike that of the Buddhists, could not have 
 prompted the building of hospitals, for they are sup- 
 posed to have sacrificed and eaten one in a thousand of 
 their population . every year, as a religious institution. 
 It is possible that the idea of the hospital may have 
 been directly derived from the Buddhists, and that it 
 was prompted by their religion before this sank into 
 cannibalism. 
 
 After America was settled by Europeans, it is said 
 that a small hospital was established at Quebec as early 
 as 1639.^ 
 
 The first account of a hospital in the territory now 
 known as the United States is given by E. B. O'Calla- 
 ghan, in his " New Netherland Begister." In speaking 
 of a hospital in use on Manhattan Island in 1658, he 
 says : " This hospital was established, at the request of 
 , Surgeon Hendricksen Varrevanger, for the reception of 
 sick soldiers — who had been previously billeted on 
 private families — and for the West India Company's 
 negroes. In 1679 this hospital consisted of 'five 
 houses.' " ' 
 
 ^ Dr. Toners "Contributions to the Annals of Progress in Medicine." 
 "' J. W. Beekman, " Centennial Address," New York Hospital, 1871.
 
 THEIR PROGRESS IX AMERICA. 29 
 
 Early in tlie eigliteentli century pest-lionses were 
 establisliecl at Salem, Massaclinsetts, at New York, and 
 Charleston, and in 1717 a liosj)ital for contagious cases 
 was bnilt at Boston. 
 
 In 1750 Dr. Thomas Bond originated a movement 
 to build a hospital in the city of Philadelphia. Dr. 
 Bond, in Lis efforts to bring the matter before the peo- 
 ple and to secure a charter fi'om the provincial govern- 
 ment, was assisted by Benjamin Franklin, at tliat time 
 a printer in Philadelphia. The charter was granted on 
 the 6tli of May, 1751 ; temporary buildings were used 
 till 1755, when the corner-stone of the present Penn- 
 sylvania Hospital building was laid, but the original 
 plan was not comj^leted until 1805. The hospital, 
 built on the original plan, is now in use. It consists 
 of a central administrative part, with two wings of 
 wards two stories high, with a basement. Considering 
 the early date at which the plan was adopted, it was 
 a very good one, and far surpasses the old monas- 
 tery and convent buildings that constitute a large part 
 of many of the most renowned hospitals now in use 
 abroad. 
 
 This was the iirst chartered hospital of this country. 
 In 1775 four hundred and thirty-five patients were ad- 
 mitted into it.* The scientific and philosophical works 
 of Benjamin Franklin had a marked influence in edu- 
 cating the people of this country in the practical appli- 
 cation of the teachings of sanitary science, and from his 
 connection with the Pennsylvania Hospital, and his 
 writings on ventilation, stoves, etc., it seems that to 
 him is due the credit of influencino; the selection of so 
 good a plan. 
 
 ' Dr. G. B. Wood, "Centennial Address," Pennsylvania Ilospita], 1851.
 
 30 HOSPITALS: 
 
 Mr. Beekman, in Ms " Ceutennial Address " before 
 the Society of tlie New York Hospital, says : 
 
 "In 1771 the city of New York was a small town 
 of about twenty-one thousand inhabitants, scarcely ex- 
 tending on the north as far as St. Paul's Church. 
 
 " The governors of King's College (now Columbia) 
 had established a medical school on the l7th of Sep- 
 tember, 1767, and to the exertions of two of the pro- 
 fessors, Dr. Samuel Bard and Dr. John Jones, the New 
 York Hospital owes its origin. 
 
 " The charter was obtained in 1771. The governors 
 empowered Dr. Jones in 1772, then intending to sail 
 for Europe, to make collections of money and to buy 
 medicines and apparatus abroad, and the next year 
 decided to build the hospital on a plan proj^osed by 
 Dr. Jones on his return. 
 
 " On the 6th of March, 1775, when hardly finished, 
 the hospital was completely destroyed by fire, and was 
 not rebuilt until 1791. In 1775 Dr. Jones published a 
 little book under the title ' Plain Concise Practical Re- 
 marks on the Treatment of Wounds and Fractures, to 
 which is added a Short Appendix on Camp and Mili- 
 tary Hospitals: Principally designed for the Use of 
 Young Military Surgeons in North America.' " This 
 little book was very useful during the Revolution. 
 
 The first pages of this Appendix relate to all hos- 
 pitals, and the whole subject of hospital reform is con- 
 cisely expressed. In a foot-note an outline of his j^lan 
 for the New York Hospital is given. As the advanced 
 views expressed in these remarks on civil hospitals, 
 illustrated by the few words on the plan, antedate by 
 more than ten years any other publication we have been 
 able to find, we will quote the following :
 
 TEEIR PROGRESS IN AMERICA. 31 
 
 " Among tlie variety of public errors and abuses to 
 be met witb in buman aiFairs, tbere is not one, perbaps, 
 wbicb more loudly calls for a speedy and effectual refor- 
 mation tban tbe misajoplied benevolence of bospitals for 
 tbe sick and wounded. 
 
 " AVe daily see persons of every rank and sex con- 
 tributing to tbese charities witb a spiiit of liberality 
 wbicb does bonor to bumanity, wbile many of tbem, 
 witb tbe most becoming zeal, are devoting tbeir time 
 and sacrificing tbeir private interest to tbe care of super- 
 intending tbe structure and management of tbe bouse ; 
 and yet an absurd, mistaken economy bas bitberto not 
 only rendered all tbis pious labor and expense, in a 
 great measure, useless, but even fatal and destructive 
 to tbe very end and aim of tbe intended purpose — tbat 
 of bealing tbe diseases of tbe sick and poor. 
 
 " To those who are unacquainted with tbe subject 
 in question, it will doubtless appear a very extraordi- 
 nary assertion tbat tbere is not at present, in the capi- 
 tal of the kingdom, a single hospital constructed upon 
 proper medical principles ; yet it is a fact very gener- 
 ally acknowledged by the most eminent men in tbe 
 profession of physic and surgery in England. 
 
 " If we inquire into the cause of such glaring ab- 
 surdities, we shall easily trace them to those sources 
 of darkness and isinorance from which most of our 
 civil and reli2:ious abuses have orio-inated: but bow 
 they should be continued, to disgrace the improve- 
 ments of more enlightened times, can only be resolved 
 by reflecting on the pride, obstinacy, and self-interest, 
 which are too generally annexed to ancient errors. 
 
 " If great and populous cities have been justly styled 
 the graves of the human species, the large and crowded
 
 32 HOSPITALS: 
 
 Los^^itals generally built in tliem may, with equal trutli 
 and propriety, be denominated tlie lazarettos or pest- 
 liouses of most of tlie unfortunate persons who, from 
 ill-directed motives of compassion, are carried into tliese 
 charities. In the two great hospitals of St. Thomas and 
 St. Bartholomew, in London, about six hundred j^atients 
 die annually, which is about one in thirteen of those 
 who are admitted as patients. 
 
 " In Paris it is supposed that one-third of all who 
 die there die in hospitals. The Hotel Dieu — a vast 
 building situated in the middle of that great city — 
 receives about twenty-two thousand persons annually, 
 one-fifth of which number die every year. It is imjDos- 
 sible for a man of any humanity to walk through the 
 long wards of this crowded hospital, without a mixture 
 of horror and commiseration at the sad spectacle of mis- 
 ery which presents itself. The beds are placed in triple 
 rows, with four and six patients in each bed ; and I 
 have more than once, in the morning rounds, found the 
 dead lying with the living; for, notwithstanding the 
 great assiduity and tenderness of the nurses, some of 
 whom are women of fomily and take the veil and pious- 
 ly devote themselves to that office, yet it is almost im- 
 2)ossible, from the vast number of patients, to bestow 
 timely assistance upon every individual. , 
 
 " If we compare the number of patients who die in 
 the county infirmaries of England with those of the 
 London and Paris hospitals, the pro23ortional difference 
 will be greatly in favor of the former — in the North- 
 ampton Infirmary one in nineteen dies annually, and in 
 that of Manchester, placed in a more airy situation, one 
 in twenty-two ; and, although the j)utrid air of great 
 cities is more unfavorable to health in general than that
 
 THEIR PROGRESS IX AMERICA. 33 
 
 of country towns, yet tlie great difference in mortality 
 will be found, upon a close and fair examination, to 
 arise from tlie structure and crowded wards of the hos- 
 pitals in overgrown capitals. 
 
 (" It is to be hoped that the hospital lately built in 
 this city will have fewer objections to its plan than any 
 hospital hitherto constructed ; the principal wards — 
 which are to contain no more than eight beds — are 
 thirty-six feet in length, twenty-four wide, and eighteen 
 high ; they are all well ventilated, not only from the 
 opposite disposition of the windows, but proper oj^enings 
 in the side-walls, and the doors open into a long passage 
 or gallery thoroughly ventilated from north to south.' ) 
 
 " For, if to the comparison between the mortality in 
 large city hospitals and those of country towns we fur- 
 ther add the proportional difference between the last 
 and that of private practice, it will be found to be in 
 favor of the latter. From all which facts it evidently 
 appears how essentially necessary pure air is to the cure 
 of diseases in general, and particularly those which arise 
 from putrescent causes, either internal or external. 
 
 " It is computed that a gallon of air is consumed 
 every minute by a man in health, and much more must 
 be necessary to one who is sick, as the morbid effluvia 
 which are continually exhaling from all parts of the 
 body and lungs must contaminate a larger portion of 
 the surrounding atmosphere, and render it less health- 
 ful to breathe in, for animals are observed to die much 
 sooner in foul air than in vacuo. 
 
 " But, the preceding facts not having been sufficient- 
 ly understood or attended to, a false economy has uni- 
 
 ^ Dr. Jones here refers to the New York Hospital, ■which was burned 
 down in 1775. 
 
 3
 
 34 HOSPITALS: 
 
 versally j)revailed in tlie structure of hospitals for tlie 
 sick; for those tliat liave liitlierto liad a principal direc- 
 tion, both in the architecture and management of them, 
 have confined their views entirely to objects of conven- 
 iency, cheapness, or ornament; and, in one of the last 
 hospitals built in London for lying-in women, there is 
 more expense bestowed on an elegant chapel in it than 
 ^vould have furnished four wards. 
 
 " In short, the physician and architect have, gener- 
 ally, two very opposite and incompatible views — the 
 latter laying out his plans so as to contain the greatest 
 number of persons in the least possible space, whereas 
 the former always aims at having the titmost room 
 which is consistent with use and conveniency. 
 
 " The same false maxims of economy which have 
 prevailed in the construction of hosj)itals in large cities 
 are too much adopted in the military hospitals of 
 camps and garrisons, as evidently appears from the 
 complaints made of them by Sir John Pringle, to '^vhose 
 excellent observations on the diseases of the army I am 
 principally indebted for the following remarks on the 
 means of preventing diseases in camp or garrison." 
 
 These j^^g^s? written one hundred and one years 
 ago, in their comprehensiveness reach down to this very 
 day; they show that Dr. Jones had studied the subject, 
 and was well prepared to take advantage of his trip 
 abroad, to see understandingly hospitals as they then 
 existed, ^nd to imbibe fully the spirit of hosj^ital-reform 
 at that time at work in England, and soon to express 
 itself in France through the famous report of the Acad- 
 emy of Sciences. 
 
 Dr. Jones's account gives us a very good idea of the 
 construction and sanitary condition of hosjoitals, just
 
 TEEIR PROGRESS IX AMERICA. 35 
 
 previous to the Kevoliitionary War. All writers of 
 tliat period substantiate tlie statements made by Dr. 
 Jones, that tlie condition of tbe hospitals in France was 
 very bad ; but, if tlie death-rate in the London hosjiitals 
 was only one in thirteen, their hygienic condition must 
 have been as good as it is to-day. It is interesting and 
 curious to compare this most excellent plan given by 
 Dr. Jones as that of the New York Hospital, destroyed 
 by fire more than one hundred years ago, with the seven- 
 story building just erected for the New York Hospital 
 on a space of ground only seventy feet by one hundred 
 and seventy-five in extent, which is to accommodate one 
 hundred and fifty patients. There are — 
 
 1. Basement containing dispensary, and nearly on 
 a level with the street. 
 
 2. Private wards and offices. 
 
 3. Common wards. 
 
 4. Common wards. 
 
 5. Common wards. 
 
 6. One ward and the operating-theatre. 
 
 7. Kitchen and drying-room. 
 
 8. Laundry. 
 
 Under all this is a sub-cellar. 
 
 In the very beginning of the Eevolutionary War 
 great solicitude was shown for the proper care of the 
 sick and wounded soldiers. After the battle of Breed's 
 (or Bunker) Hill, a hosj)ital was established at Cam- 
 bridge " in several private but commodious houses," 
 and Dr. John Warren, a brother and pupil of Dr. Jo- 
 seph Warren, who fell while commanding the troops 
 in that battle, was placed in charge, and soon after 
 this several hosj^itals were established around Boston.* 
 
 ' Bro^vn's "History of the ITedical Army Service of the United States."
 
 36 HOSPITALS: 
 
 General Wasliington, after his first inspection of tliej 
 army as commander-in-chief, on the 21st of July, ad- 
 dressed the following letter to the President of Con- 
 gress : " I have made inquiry into the establishment of 
 the hospital, and find it in a very unsettled condition. 
 There is no principal director, nor any subordination 
 among the surgeons; of consequence, disputes have 
 arisen, and must continue until it is reduced to some 
 system. I could wish it was immediately taken into 
 consideration, as the lives and health of both oflicers 
 and men so much depend on due regulation of this de- 
 j)artment." 
 
 Notwithstandins; this kind consideration evinced 
 for the sick and wounded by the commander-in-chief, 
 and by the whole American peojDle during the Eevolu- 
 tion, there was much suffering on account of the pover- 
 ty of the Government and the meagre resources of the 
 country, preventing the possibility of building and con- 
 ducting hospitals; consequently it was a necessity to 
 make use of all kinds of houses for the purpose of treat- 
 ing the sick and wounded, and we find but little to 
 record as adding to the development of hospitals. The 
 first director-generals of the hosj)itals during the Eevo- 
 lution, as Dr. John Morgan, Dr. William Shij^pen, and 
 most of the older and controlling surgeons, favored 
 general hosj^itals ; but there were several advocates of 
 small regimental hospitals after the teachings of Sir 
 John Pringle, among them Dr. Benjamin Eush and Dr. 
 James Tilton. 
 
 Dr. Eush, in his " Medical Inquiries and Observa- 
 tions," s^^eaking of the hospitals of the Eevolution, says : 
 
 " Hospitals are the sinks of human life in an army. 
 They robbed the United States of more citizens than
 
 THEIR PROGRESS IX AMERICA. 37 
 
 tlie sword. Humanity, economy, and pliilosopliy, all 
 concur in giving a preference to the convenience 
 and wholesome air of private houses ; and, should war 
 continue to be the absurd and un-Christian mode of 
 deciding national disputes, it is to be hoped that the 
 progress of science will be so great as to prevent, so far, 
 one of its greatest calamities, and to produce an aboli- 
 tion of hospitals for acute diseases. 
 
 " Perhaps there are no cases of sickness in which 
 reason and reliojion do not forbid the seclusion of our 
 fellow-creatures from the offices of humanity in j^rivate 
 families, except where they labor under the calamities 
 of madness and the venereal disease, or where they are 
 the subjects of some of the operations of surgery." 
 
 In the besrinnins: of the War of 1812, Dr. James 
 Tilton, of Delaware, published a small volume of " Eco- 
 nomical Observations on Military Hospitals and the 
 Prevention and Cure of Diseases incident to an Army." 
 In this hfe gives his exj)erience during the Revolutiou, 
 and describes the plan of hospital-huts and organization, 
 presented by him to Congress in 1781 ; on page 13 he 
 says : " It would be shocking to humanity to relate the 
 history of our general hospitals in the years 1777 and 
 1779, when it swallowed up at least one-half of our 
 army, owing to a fatal tendency in the system to throw 
 all the sick of the army into the general hospitals; 
 whence crowds, infection, and consequent mortality, too 
 affecting to mention." Again he says : " My brethren 
 of the faculty will probably think it an interesting fact 
 that more surgeons died in the American service, in pro- 
 portion to their number, than officers of the line ; a 
 strong evidence this, that infection is more dangerous, 
 in military life, than the weapons of war." On page
 
 38 HOSPITALS: 
 
 47 lie adds : " The cardinal point or principle to be ob- 
 served in the direction of all hospitals is to avoid infec- 
 tion ; when this can be done, the practice of hospitals 
 differs little or nothing from private j^ractice. But, 
 where infection or foul air is suffered to prevail, no 
 skill or address in practice can much avail. The cause 
 must be removed before the patient can be relieved by 
 medicine." 
 
 Dr. Tilton speaks favorably of tents for use as hos- 
 pitals in warm weather, but adds: "In cold climates 
 and winter seasons some better protection than tents 
 afford may be necessary. In such cases the best hosj^i- 
 tal I have ever contrived was upon the j^lan of an 
 Indian hut. The fire was built in the midst of the 
 ward, without any chimney, and the smoke, circulating 
 round about, passed off through an opening about four 
 inches wide in the Q'idge of the roof, etc. This w^as 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." He gives a ground- 
 plan and elevation for the log-hut hospital. 
 
 Dr. Tilton was appointed Surgeon-General of the 
 United States Army in 1813, when the office was 
 created, and he succeeded in conducting the hospitals 
 of that war very satisfactorily. Besides the works of 
 Drs. Eush and Tilton, describing the American hospi- 
 tals during the Revolution on the American side, and 
 of Dr. Jackson describing those of the British,, we find 
 little of much note. 
 
 About the time of the Revolutionary War in Amer- 
 ica, the most important movement, certainly the one 
 that eventually had the greatest influence in bringing 
 about a reform in the construction of civil hospitals.
 
 HISTORY OF THEIR DEYELOPMEFT. 30 
 
 was made in France just after tLe great fire of 1772, 
 when a part of tlie Hotel-Dieu was burned. Tlie con- 
 dition of the hospital at that time was such that many 
 fliYored its removaL The idea was, to divide its in- 
 mates among several hospitals, smaller, and situated 
 farther from the centre of the city. The agitation of 
 the sul;)ject resulted in a committee being aj^pointed 
 from the Academy of Sciences to report upon a plan. 
 The committee was composed of the most eminent men 
 of that jDeriod, Tenon, Bailly, Lavoisier, Laplace, and 
 others, who, in their report of the 2 2d of November, 
 1786, to the ministry of Louis XVL, urged the re- 
 moval of the hosjntal. At that time the inmates num- 
 bered five thousand, although the number of beds was 
 only about two thousand, all the beds being double, 
 and many holding four or six patients at one time. • 
 
 The committee proposed to replace it by four hospi- 
 tals of twelve hundred beds each. They claimed that 
 " a sick-ward should be entii^ely detached from other 
 buildings, so that its walls may be constantly exposed 
 to sun and wind, and that draughts of fresh air may 
 constantly renew an atmosphere which is perpetually 
 fouling itself." They preferred that these hospitals 
 should only have one floor of wards, but, as tins re- 
 quired too much ground, the j)lan was modified. A 
 Government edict, June, 1787, ordered the establish- 
 ment of four hospitals at the four cardinal points of 
 Paris, for twelve hundred beds each, and after the plans 
 suggested by the committee of the Academy. The 
 political events which followed prevented the execution 
 of the 23roject. 
 
 A supplementary report, dated the 12th of March, 
 1788, lays down more precisely the principles which
 
 40 HOSPITALS: 
 
 the plan of a model liosj^ital resolved on by the com- 
 mittee represents. 
 
 They proposed, as before, detached pavilions ar- 
 ranged in j)arallel lines ; that the buildings for the 
 offices, kitchens, pharmacy, and other administrative 
 purposes, should be in front ; that the pavilions on one 
 side should be for men, and those on the other side for 
 women, with the chapel and operating-room, etc., in the 
 rear of the plot. 
 
 They proposed that the pavilions should be three 
 stories in height, twenty-four feet wide by one hundred 
 and sixty-eight feet long, the ends of the buildings for 
 thirty feet being wider, and containing the service-rooms 
 for the wards; the wards to be one hundred and eight 
 feet long and fourteen or fifteen high. They proposed 
 that each ward should contain thirty-four to thirty-six 
 beds in two rows, each ward having its own English 
 water-closets, lavatory, kitchen for special diet, and sis- 
 ter's or nurse's room with every thing at hand for the 
 care and comfort of the patients. 
 
 They proposed that each pavilion should be sepa- 
 rated from the next by a garden about seventy-two feet 
 wide and as long as the building, with nothing in it to 
 intercept the air, and to serve as airing-ground for the 
 patients of each pavilion. They proposed that the pa- 
 vilions should be connected by a corridor running round 
 the whole of the central court, past the foot of the stairs 
 in each pavilion. This corridor was not to rise above 
 the ground-floor, so as not to intercept the circulation 
 of air. 
 
 A part of the committee visited England, and along 
 with the idea of the English watei^-closets, baths, etc., 
 they were impressed with the necessity of limiting the
 
 HISTORY OF THEIR DEVELOPMENT. 41 
 
 beds in a ward to from twelve to tliirty, a custom en- 
 tirely at variance with tliat wliicL. prevailed in tlie 
 Hotel-Dieu, where double-beds at that time were mul- 
 tiplied in a ward to the number of two or three hun- 
 dred. Said the Academy committee : " It is a mistake 
 to suppose that a partition-wall will divide a ward of 
 iifty beds into two wards of twenty-five beds each. 
 Contiguous, communicating w^ards are in reality but 
 one ward, and have a common atmosphere." 
 
 Husson, from whose works the above account is 
 abridged, says that " the wards built for La Pitie, in 
 Paris, 1792-1802, as dormitories for the orphans of, 
 soldiers, for whose use the building was taken, were 
 the first instance of the application of the principles 
 recommended by the Academy of Science." France 
 was convulsed with revolutions, and the practical re- 
 sults of the committee's work followed but slowly this 
 small be£::innin2:. 
 
 In 1788, by royal order, the memoirs of Tenon were 
 published, and added a valuable work to hosj^ital lit- 
 erature. 
 
 The work of John Howard, the philanthropist, from 
 1789 to 1793, in visiting all the prisons, lazarettos, and 
 hospitals, of England and the Continent, by drawing- 
 public attention to the subject, caused not only reform 
 in the sanitary condition and management of prisons, 
 but of hospitals also. He recommends that hospitals 
 should be placed out of town, and consist of buildings 
 not more than two stories high, with large and opposite 
 windows, and above all that in a hospital there should 
 be perfect cleanliness. 
 
 Soon after Howard, appeared the philosophical es- 
 says of Count Rumford, who devoted his life and a
 
 42 HOSPITALS: 
 
 large fortune to the pur2:)ose of improving tlie condition 
 of tlie poor. He endeavored to teacli the laboring- 
 classes tlie practical application of hygiene in their 
 houses, and to him is due the credit of making the first 
 efforts to systematize and direct charitable relief, so that 
 it might not do more harm than good. Such a work as 
 this must have influenced the internal arrangements and 
 management of hosj^itals. 
 
 In 1803, soon after the state assumed control of the 
 hosj^itals in France, the report of the Council General 
 did much toward improving the management of the 
 Jaosj)itals of Paris. Keform in classification, cleanliness, 
 nursing, and change in the administration in general, 
 were recommended. 
 
 During the first half of the j)resent century many 
 hospitals were built, and several well-known works, 
 that had some influence on hospitals, were published ; 
 among these are the writings of Morneau, in 1802 ; 
 Pastoret, in 1808 ; Cutbush, in 1808 ; Clavereau, in 
 1810; Larrey, in 1812; Barton, in 1814; Hennan, in 
 1820, etc., etc. ; and there was a gradual im23rovement 
 made in the internal arrangements ; but, except in mat- 
 ters of this kind, nothing was advanced that could be 
 considered an improvement upon the principles and 
 plans given in the report of the committee of the French 
 Academy of Sciences. 
 
 In fact, with one or two exceptions, in none of the 
 many hospitals established after 1786 — the date of the 
 report — were the advanced views of the committee car- 
 ried out. Almost all the hosj^itals built were large, 
 solid, many-storied structures, with the wards and ad- 
 ministrative offices, etc., all in one building. In 1829 
 a hospital was built at Bordeaux reproducing the plan
 
 HISTORY OF TUEIE DEVELOPMENT. 43 
 
 recommended by tlie committee ; and it was not until 
 1854, sixty-eiglit years after the rej^ort, wlieu tlie Lari- 
 boisiere Avas finislied, that Paris had a hospital to show 
 as the fruits of it. The plan of the Lariboisiere is al- 
 most exactly that proposed by the committee, and is 
 only an imj^rovement on it in detail, excepting, j)er- 
 haps, the ventilating apparatus. 
 
 Previous to 1859 neither Eno-land nor the United 
 States had a civil hospital that would compare favor- 
 ably with the plan 2:)roposed by Dr. John Jones in 
 ,1773. One of the first pavilion-hospitals built in Eng- 
 land, after the plan proposed by the French Academy's 
 committee, was Blackburn Infirmary, in 1859. The 
 first in the United States was the Episcoj^al Hospital 
 of Philadelphia, founded in 18G0. 
 
 In Germany there seems to have been but little 
 progress in the development until the early part of the 
 present century, when the plan of hospitals known as 
 the corridor-hospital was introduced and very gener- 
 ally adopted. The hospitals of Eussia were modeled 
 after those of Germany, and were in no respect better. 
 
 The next progressive step, after the report of the 
 French Academy's committee, in the development of 
 h.osj^itals was brought about by the fearful death-rate 
 of the English and French armies in the beginning of 
 the Crimean War. So great was the mortality, that 
 the whole English j^eople were aroused to the necessity 
 of better provision being made for the sick and wound- 
 ed. Miss JSTio-htino-ale, who had the trainins; as a nurse 
 at Kaiserwerth, selected a band of thirty-seven nurses, 
 and left for the seat of war on the 24th of October, 
 1854, and in 1855 the Government a2:)23ointed a sanitary 
 commission to proceed at once to the Crimea ; the mem-
 
 44 HOSPITALS: 
 
 berfe of tliis commission were John Sutlierland, M. D., 
 Hector G. Milroy, M. D., and Robert Rawlinson, Esq., 
 C. E. Tliey succeeded in introducing many valuable 
 sanitary reforms. 
 
 In 1854 Micbel Levy, Sanitary Inspector of tlie 
 Frencb army in tlie Crimea, suggested tlie use of wood- 
 en barracks or huts for hospitals, and at the same time 
 proposed a permanent tent-hospital. It was found by 
 experience that simple wooden huts, raised from the 
 ground, with double walls — to protect from the heat in 
 summer and cold in winter — with ridge-ventilation, and 
 heated by means of open fires or stoves, gave far better 
 results than any other kind of building.' 
 
 The following, afterward expressed by Dr. Suther- 
 land, will give the best idea of what was taught by the 
 experience of the Crimean War. He says : " But, while 
 admitting that large buildings may be improved if there 
 be time for doing so, it must be stated that no more 
 disastrous idea can take possession of men's minds than 
 that sick and maimed people ought, on grounds of hu- 
 manity, to be packed into churches, barracks, and other 
 unprepared buildings, with as little delay as possible. 
 This error has slain its tens of thousands in all wars." 
 
 The indefatigable and j)ractical work of Miss Night- 
 ingale in the hospitals during the Crimean War, and 
 her masterly-written answers to the questions of the 
 " Commissioners appointed to inquire into the Regula- 
 tions affecting the Sanitary Condition of the Army and 
 the Organization of Military Hospitals, and the Treat- 
 ment of the Sick and Wounded," published in 1858, 
 have justly made the name of Florence Nightingale 
 
 ' Eeport of the Proceedings of the Sanitary Commission dispatched to 
 the Seat of War in the East, 1855-'56.
 
 HISTORY OF THEIR DEVELOPMEXT. 45 
 
 most fiimoiis not only in connection witli nursing, Lnt 
 hospital-construction also. In 1859 tlie first edition of 
 her well-known book, " Notes on Hospitals," appeared. 
 
 This book of Miss Nightingale, on account of its 
 real worth and the earnest, practical, and telling way in 
 which it is written, has done more to bring about re- 
 form in hospital-construction than any other work ever 
 written. And her book, " Notes on Nursing," has made 
 her name a household word wherever the English lan- 
 guage is spoken. 
 
 These two books of Miss Nightingale were the first 
 to reach and educate the peojyJe. The general interest 
 in hospital-reform was very great in England for years 
 after the Crimean War, and the discussion of the sub- 
 ject between the advocates for new and imj^roved hos- 
 pitals to replace the venerable old hospitals, and the 
 non-progressive and conservative party, still shows it- 
 self. The " General Commission appointed for improv- 
 ing the Sanitary Condition of Barracks and Hospitals " 
 made a report, April, 1861, signed by John Sutherland, 
 W. H. Burrell, and Douglas Galton, whicli accej^ted 
 the ex]3erience of the Crimea, and the suggestions of 
 Miss Nightingale, and settled the question in regard to 
 military hospitals by the adoption of what is known as 
 the barrack-hospital plan. 
 
 In answer to the reforms proposed by Miss Nightin- 
 gale, and to counteract the general feeling that all old 
 hospitals should be replaced with new ones, the medi- 
 cal of&cers of the Privy Council, Dr. Bristowe and 
 Dr. Holmes, after visiting almost every hosj)ital in the 
 United Kingdom, made a most excellent but very con- 
 servative rej)ort.' 
 
 * Sixth Report of Medical Officers of the Privy Council, Eyre k Spottis- 
 woode, London, 1863.
 
 46 ' HOSPITALS: 
 
 Sir James Y. Simpson took uj) the subject and 
 brought forward statistics to show tlie relative mor- 
 tality of private practice and small hospitals in the 
 country, compared with the mortality of large city hos- 
 pitals, and, in his paj)er on " Hospitalism," advocates 
 small cottage-hospitals, outside the city limits. He was 
 answered by Matthews Duncan on the conservative 
 side. 
 
 Lately the subject of hosj^italism was warmly dis- 
 cussed in the British Medical Association, and in 1874 
 Mr. Erichsen published, in book-form, a course of lect- 
 ures oh " Hosj^italism." This little book, in which the 
 need of hos23ital-reform is plainly shown, not alone in 
 the matter of construction, but especially in all that 
 concerns internal arrangement, is of very great value. 
 
 The 2:>ractical results of the interest in hosj^itals 
 brought about by the Crimean War were, the building 
 of the famous Herbert Hospital at Woolwich, and the 
 establishing on a sure basis the detached pavilion-j)lan 
 of hospital-construction, the plan which had been pro- 
 posed, and on which a small hospital (Plymouth Naval 
 Hospital) had been erected, just one hundred years be- 
 fore. The Herbert Hospital is an imjorovement uj^on 
 the Lariboisiere ; but, like it, is modeled after the plan 
 proposed by the French Academy's committee of 1786 
 — the improvement being mainly in the details of in- 
 ternal arrangement. 
 
 Until the buildiDg of the Herbert HosjDital, the 
 Lariboisiere was the model hospital of the world. 
 Now, in the United Kingdom, the Herbert Hospital is 
 the model. 
 
 Since the building of the Herbert Hospital, several 
 hospitals have been erected ; among these the new St.
 
 EISTOEY OF THEIR DEVEL0P2IEXT. , 47 
 
 Tliomas's, wliicli only surpasses tlie Herbert in mag- 
 nificence of construction, but, instead of two floors of 
 ■wards to tlie pavilion, lias three witli an attic, and all 
 tlie pavilions on one side of tlie corridor. 
 
 The Eotherham Hospital, lately finished (1872), 
 has three small one-story wards. It is the only civil 
 hospital completed on the one-story plan, that we know 
 of, in England. One for one hundi^ed" and fifty beds is 
 buildino; at Manchester, 
 
 The influence of the Crimean experience did not do 
 so much for France. M. Husson's well-know^n work 
 was published in 1862, but nothing better than the 
 Lariboisiere w'as proposed. In Germany the corridor- 
 hosjDital had not been improved upon, nor until within 
 the last ten years had any important progress been 
 made. 
 
 Before the interest in sanitary and hospital reform 
 caused by the Crimean "War had quieted down, the 
 American people had an opportunity aftbrded them. to 
 make use of the valuable suggestions published in the 
 reports of the English commission, and, in doing so, 
 succeeded in developing the most perfect s}'stem of 
 army-hospitals ever known to the world. 
 
 Early in the late civil war a sanitary- commission 
 was organized, of which the Rev. H. "W. Bellows, 13. D., 
 was chairman. In July, 1861, the committee on hospi- 
 tals of this commission reported: "Your committee 
 venture to embody their conclusions in form of sugges- 
 tions, and would submit to the commission the pro- 
 priety of recommending to the Government that here- 
 after, instead of hii'ing old buildings for general hospi- 
 tals, they should order the erection of a sufficient num- 
 ber of wooden shanties or pavilions of appropriate
 
 48 HOSPITALS: 
 
 construction, and fully prorided witli ^yater for bath- 
 ing, washing, and water-closets, and ample arrange- 
 ments for ventilation and for securing warmtli in win- 
 ter, to accommodate from thirty to sixty each, and to 
 be sufficiently se2:)arated so as not to poison each other. 
 This smyo-estion embodies the latest and best views as 
 to the construction of hospitals, and its adoption would 
 save both time and money." And at the close of the 
 October session of the commission it was understood 
 that the Government would at once commence the erec- 
 tion of two cheap temporary model hospitals at Wash- 
 ington, " in conformity with j)lans carefully prepared by 
 a committee of the medical members of the commission, 
 and approved by it, as embodying the latest results of 
 sanitary science. The 23lans have been formally ap- 
 proved by the quartermaster-general, the commander-in- 
 chief, and the medical director of the Army of the 
 Potomac, and the ground for the example-building has 
 been staked out." ' 
 
 The medical members of the commission were Wil- 
 liam H. Van Bureii, M. D. ; Wolcott Gibbs, M. D. ; Eob- 
 ert C. Wood, M. D. ; Samuel G. Howe, M. D. ; Elisha 
 Harris, M.D.; C. K. Agnew, M.D.; J. S. Newberry, 
 M. D. Mr. F. L. Olmsted, civil engineer, was also a 
 member of the commission. 
 
 The works of Miss Nightingale and the Crimean 
 experience are frequently quoted by the committee, and 
 the plan of army-hospitals adopted was the practical 
 application of tlie temporary one-story Crimean hut 
 with ridge-ventilation, extended to the size of the wards 
 recommended by Miss Nightingale. The wards were 
 
 ^ United States Sanitary Commission Work and Purposes, Kew York, 
 1864.
 
 HISTORY OF THEIR DEVELOPMEXT. 49 
 
 connected by a corridor, and tlie first ones erected liad 
 tlie pavilions arranged on opposite sides of the corridor 
 after tlie plan of tlie Blackburn lufii-maiy. 
 
 The water-closets, nurses' rooms, etc., were usuall}' 
 placed at one end of the ward, or divided between the 
 two, the water-closets being at the free extremity, and 
 the nurse's room and dining-room next to the corridor. 
 The number of beds in each ward varied from twenty- 
 five to fifty. The wards were temporary in character, 
 with ridge-ventilation, and usually heated by stoves. 
 The administrative buildings were separate from the 
 pavilions and connected with them by the corridors ; 
 the wards were always one-story buildings. In fact, 
 the plan really differed from that recommended by Miss 
 Nightingale in these respects : the pavilions were only 
 one story high, were temporary in character, and always 
 had rido'e-ventilation. 
 
 The first hospitals were for only two hundred and 
 fifty beds, but later they were much larger; one, the 
 "West Philadelphia Hospital," contained 3,124 beds in 
 wards of forty-eight beds each. 
 
 The system was thoroughly tested during the war 
 on a scale never before equaled, there being at one time 
 in the Government hospitals as many as 134,000 beds. 
 The success was such that an army averaging 744,346 
 men passed through a four years' war with an annual 
 death-rate of only eighty-eight j^er thousand from all 
 causes, and it is estimated that thirty-three out of the 
 eighty-eight were violent deaths, leaving fifty-five from 
 disease in one thousand. 
 
 The same system and plan of hospitals were adopted 
 by the Confederate army during the Avar. 
 
 The exj^erience of the war may be said to have de- 
 4
 
 50 HOSPITALS: 
 
 velopei and establislied tlie following principles in tlie 
 construction of liosj)itals : 
 
 1. That the hospital should be placed on a large 
 area of ground, so that the 2:)avilions can be widely 
 separated from the administrative buildings and from 
 one another. 
 
 2. That the wards should be onhj one story in 
 height, and be ventilated by openings along the ridge 
 of the roof. 
 
 3. That the ward-pavilions should be put vq) not to 
 remain for generations to come, but only so long as they 
 are free from infection ; and that, when once they are 
 infected, they should be destroyed, and replaced with 
 entirely new structures. 
 
 Soon after the war, one-story wood pavilions of a 
 temporary character for the treatment of contagious 
 fevers were put up on Blackwell's Island, New York, 
 and in different places in the United States. Small 
 ones also were built in connection with large hospitals 
 for infectious cases ; but the first complete civil hosj)i- 
 tal, constructed after plans used during our American 
 war, is to be found in Germany. In 1867-68 a one- 
 story ward-pavilion hospital was planned and soon after 
 built in Leipsic. The old stone hospital is used as an 
 administrative building. There are fourteen one-story 
 ward-pavilions, or shed-hospitals as the Germans call 
 them. They are frame l^uildings filled in with brick, 
 one hundred feet long, thirty-two feet wide, fifteen feet 
 high at the eaves and twenty at the ridge. They are 
 placed sixty feet apart, raised four feet from the ground 
 on stone piers, and are connected by a corridor. They 
 have ridge-ventilation. ' 
 
 Each ward or shed has twenty-four beds, with
 
 HISTORY OF THEIR DEVELOPMENT. 51 
 
 nurse's room, batlis, kitchen, and closets, complete. 
 Durins* twelve montlis, Prof. Thiersch, who has charo-e 
 of tlie surgical clinic, performed two hundred and sixty- 
 six serious surgical operations, and did not lose a case 
 from pyaemia ; while, prior to the construction of the 
 new pavilions, in the old stone hospital, which is now 
 the central building, he lost from forty to fifty amputa- 
 tions from this canse annually. 
 
 In 1867, at Berlin, a one-story ward was built in 
 connection with Charity Hospital by Dr. Esse. Kiel 
 has two stone one-story ward-pavilions used as a garri- 
 son hospital, and at Dresden one-story ward-j)avilions 
 have been built. 
 
 Dr. Stephen Smith, of Kew York, wrote an essay 
 upon hospital-construction, and recommended a plan 
 for the Eoosevelt Hospital. The plan recommended 
 by Dr. Smith in this essay is very much the same as 
 that of Miss Nightingale. The Roosevelt Hospital, 
 opened in 1^871, has one one-story pavilion to show, as 
 the influence of the experiences of the war, but New 
 York City has had six other large new hospitals, all of 
 which are massive, many-storied buildings, costing im- 
 mense sums of money ; and one of these, the last, is 
 seven stories, and on a sj)ace of ground seventy by one 
 hundred and seventy-five feet. 
 
 In Boston, Massachusetts, the one-story pavilion 
 plan with ridge-ventilation has been adopted, and there 
 are two or three pavilions erected on the grounds of 
 the Massachusetts General, and one on the ground of 
 the Boston City Hospital, which surpass any in this 
 country, except perhaps one lately constructed in Phila- 
 delphia. 
 
 The organization of our Sanitary Commission and
 
 52 HOSPITALS: 
 
 tlie plans for military liospitals were carefully studied 
 and efficiently used by tlie Germans iii the late Franco- 
 German War. 
 
 So great was the success in treating the wounded in 
 the hospitals constructed on the American plan, that 
 since the war the Germans, in their thorough and ex- 
 haustive way, have taken up the subject with the view 
 of applying these principles to their civil hosj)itals. 
 Some of the first men in medicine and science have 
 Avritten monographs on the subject, such as Yirchow, 
 Steinberg, Esse, Esmarch, etc., and some of the profess- 
 ors of hygiene and surgery take uj) hospital-construction 
 as a part of their course in lecturing to students. 
 
 Within the past ten years several books and many 
 monographs and papers have been published on the 
 subject of hospitals, which we have not mentioned. 
 Among the books are : " On the Construction of Hospi- 
 tals," by Douglas Galton, 18G9 ; " Handy Book on Cot- 
 tage-Hosjoitals," by Horace SAvete, 1870;^ "Notes on 
 Lying-in Institutions," by Florence Nightingale, 1871 ; 
 and " Hospital Construction and Organization," Johns 
 Hopkins Hospital, 1875. Through the munificence of 
 the late Johns Hopkins, the trustees of the Johns Hop- 
 kins Hospital, of Baltimore, have at their command 
 three million dollars ($3,000,000), and fourteen (14) 
 acres of land to establish a General Hospital of three 
 hundred (300) beds. We trust they will build a 
 model hospital embodying all the late improvements, 
 which will Tje worthy of the Centennial Year of our 
 Kepublic.
 
 CONCLUSION AS TO THEIR ORIGIN. 53 
 
 CONCLUSIOX AS TO THE ORIGIN OF HOSPITALS. 
 
 The cliief object aimed at in a liospital is to pre- 
 serve life and relieve suffering. Every living tiling has 
 a certain amount of power to repair itself wlien injured, 
 and everytliing that lias life Las the power given it to 
 resist to some extent that which tends to destroy it. A 
 tree will grow more wood on that side sustaining the 
 greatest strain of a prevailing wind, and will grow to a 
 great height before spreading, if the shrubs and trees 
 around make this necessary, to enable it to get its share 
 of sunlight. The higher the organization, the greater 
 is this power of self-protection. When we reach living 
 things which have a nervous system, this power of self- 
 protection becomes more marked and is called the in- 
 stinct of self-preservation. As we ascend the scale of 
 animal life this instinct gradually widens its circle of 
 influence, and includes not only self but those of their 
 kind. Before we reach man, we see undoubted in- 
 stances of mutual sympathy and even love evinced by 
 the individual members of more than one race of ani- 
 mals for others not only of the same species, but of 
 entirely different families. 
 
 The idea of curing disease seems to be plainly fore- 
 shadowed in the instincts of animals. The sick doQ- 
 
 O 
 
 will seek and chew his medicine-grass, which, when 
 well, he never touches ; the cattle of the pine- wood dis- 
 tricts, where phosphorus is wanting in the grass, will 
 deliberately hunt up and chew bones which under oth- 
 er circumstances they would not eat. 
 
 In the crude develo2;)ment of religion and of the 
 curative art these will invariably be found associated 
 in the same individual. The medicine-man is the priest.
 
 54 HOSPITALS: 
 
 and the wise man wlio cures tlie evil spirit is the doctor 
 Society follows tlie general law of develoj^ment of organ 
 isms, viz., tlie growth of special organs for special func^ 
 tions, which become more distinct one from the other, 
 yet at the same time more dependent one upon the other 
 We therefore find, in higher civilizations, doctors of dis 
 ease distinct from priests ; and, in the highest and most 
 complete civilization of all, the priest making use of 
 the doctor of medicine to helj) him do his work of 
 charity. The hospital is the outcome. 
 
 It is true that hospitals nowadays are often organ- 
 ized and carried on independently of religious consider- 
 ations, purely on utilitarian grounds, to protect the well 
 from infectious and contagious disease ; but this 2')resup- 
 poses a knowledge of disease that did not exist at the 
 date of the origin of the first hospitals. Charity and 
 brotherly love influenced men and took shape in I'eli- 
 gious organizations long before sanitary science existed, 
 or made itself felt throuo'h the art of medicine. 
 
 History shows us that the credit of the origin of the 
 first hospitals is not due to medicine, but to religion. 
 
 So far as our knowledge of history goes, and as we 
 have shown in the foregoing resume, we find that hos- 
 pitals, as we understand them, have been the outcome 
 of only two or three civilizations, namely, that of Buddh- 
 ism, the fire-worshipers, and the Christian civilization. 
 In what way can this be accounted for ? It cannot be 
 due to the degree of civilization, for both Greece and 
 Kome, in many ways, reached a higher state of civiliza- 
 tion than did the early followers of Buddha or Christ ; 
 and yet, hosj^itals for the sick poor did not exist to any 
 extent, if at all, among them. It may be said that their 
 laws were so j^erfect and efficiently carried out, that
 
 CONCLUSION AS TO THEIR 0RIGI2i. 55 
 
 liosj^ital's sucli as we Lave were not needed ; but hos- 
 pitals must have been needed after battles, wLen tlie 
 soldiers were far removed from tlieir homes. A more 
 plausible excuse would be to say that the science of 
 medicine had not advanced to the same extent as amoni^: 
 the Buddhists and early Christians. 
 
 We cannot sj^eak so confidently about medicine 
 among the Buddhists ; but we know that, at the time of 
 the founding of the first hospitals by Christians, medi- 
 cine was not in advance of the time of Hippocrates. If 
 the Buddhists did excel in medicine, judging by the ex- 
 perience of to-day, it is more than probable that much 
 of this knowledge was acquired from the advantages 
 afforded by their hospitals for the study and practice 
 of medicine. There was nothing in the religion of 
 either the Greeks or Romans that made life sacred, or 
 that taught brotherly love. Physically and intellectu- 
 ally they reached a high state of development, but they 
 made morally but little progress. The Buddhist, taught 
 to believe that every living creature is sacred, does all 
 he can to prolong life; and to this eud he builds hospi- 
 tals, not only for men, but for animals and even insects. 
 The Christian, following in the footsteps of his Master, 
 extends his love and sympathy to all mankind, and, in 
 his efforts to show his sympathy by his acts, he builds 
 hospitals to prolong life and to relieve his suffering fel- 
 low-beings. 
 
 2-10- >'*■'''
 
 CHAPTER II. 
 
 EELATIONS OF HOSPITALS TO PAUPEEISM. 
 
 Hospitals may be classed as follows : 
 
 1. Public eleemosynary hospitals founded, support- 
 ed, and managed, by tlie state or municipal authority. 
 
 2. Public eleemosynary hospitals founded usually 
 by an individual, then incorporated under a charter, 
 given to a number of citizens as an association, support- 
 ed by endowment and by voluntary contributions, and 
 managed by an honorary board selected from the mem- 
 bers of the society. 
 
 3. Army and navy hospitals established, sui^ported, 
 and managed, by the state or government. 
 
 4. Church eleemosynary hosj)itals founded, support- 
 ed, and managed, by a number of persons representing 
 a sect or church. 
 
 5. Private hospitals carried on in the interests of 
 individuals. 
 
 Civil hospitals may be divided according to the 
 classes of diseases treated in them : 
 
 1. General hospitals for the treatment of medical 
 and surgical diseases that are not contagious or infec- 
 tious. As a rule, general hospitals have one or more 
 departments for the treatment of special cases connected 
 with them.
 
 NECESSITY FOR HOSPITALS. 57 
 
 2. Special liospitals — 
 For cLildren ; 
 For lying-in women ; 
 For fevers, as small-pox, tyj^lius, etc. ; 
 For diseases of women ; 
 For eye and ear ; 
 For throat ; 
 For epileptics ; 
 For incurables; 
 For crippled ; 
 For convalescents ; 
 For insane, etc., etc. 
 Civilization has not reached that state of perfection 
 in which hospitals can be dispensed with. 
 
 As long as armies exist, hospitals will be necessary. 
 Soldiers removed from their homes, when sick, must be 
 provided with special accommodations ; and after a 
 battle the vast number of wounded cannot be properly 
 cared for except in hospitals constructed esj^ecially for 
 the purpose. 
 
 During epidemics of contagious and infectious dis- 
 eases it becomes a necessity to separate those infected 
 from the well, and for their accommodation hospitals 
 must be erected. 
 
 In every community, especially in large cities, there 
 is always a certain number of paupers without any 
 liomes^ who must be cared for when sick, and the only 
 practical way of providing for them is to establish hos- 
 pitals. 
 
 In large cities 2;)rovision must be made for street- 
 casualties, and hospital-accommodations are neces- 
 sary. 
 
 Lastly, on account of difficulty in making suitable
 
 58 RELATIONS OF HOSPITALS TO PAUPERISM. 
 
 provision for the insane in jjrivate houses, hospitals or 
 asylums for the insane are necessary. 
 
 Throusrhout the Christian civilized nations of the 
 world the necessity for the establishment of hospitals, 
 on account of the above reasons, is recognized. Every 
 military post, where considerable numbers of soldiers 
 are stationed, has its hospital ; and no army outfit is 
 complete without S]3ecial arrangements for the erection 
 of suitable hospitals for the reception of the wounded. 
 Every city either has ready or speedily erects hospitals 
 to receive the infected duiing contagious epidemics, and 
 all cities and large towns have hospitals for the accom- 
 modation of the sick poor. In every country many in- 
 sane-asylums, both public and j^rivate, are found. 
 
 Army hospitals are necessary, and hospitals for the 
 insane and for contagious and infectious cases are neces- 
 sary ; and their size and number must be regulated as 
 the circumstances demand. But, in regulating the hos- 
 pital accommodations for the sick poor, necessity does 
 not so definitely fix a limit, and many perplexing ques- 
 tions arise. 
 
 In this country, in all large cities, any one repre- 
 senting himself as poor and sick can apj^ly either to the 
 public hosj)itals sui^ported by the State or to hosj^itals 
 supported by voluntary contributions ; and, if, on a sim- 
 ple onedical examination, his disease is of the class treat- 
 ed in the particular hospital — and there are hosj^itals 
 for every disease — he is admitted without reference as 
 to whether' he has a home, and in many cases without 
 any special iaquiry or investigation as to his circum- 
 stances. 
 
 In some places, as New York City, hospitals are so 
 numerous, and admission to them so freely granted,
 
 INCREASE AND COST QF CEARITIES. 50 
 
 tliat tliere is little or no restraint on im^^ostors. If re- 
 fused admission to one institution, tliey go to another, 
 and receive treatment and care witliout cost, wlien they 
 are fully able to provide for themselves. And so nu- 
 merous are the disj)ensaries where medicines and medical 
 advice can be obtained free of cost, merely for the ask- 
 ing, and so easily and readily can care and attention be 
 had in free hospitals, that the poor liave no necessity to 
 make provision for sickness, nor any inducement to 
 guard against disease, and so avoid the trouble and 
 expense incident to sickness. 
 
 It is estimated that about $10,000,000 are expended 
 in public and private charities annually in tke city of 
 New York, a city of one million inhabitants. A consid- 
 erable portion of this sum is expended on the hospitals, 
 which alone contain more than 6,000 beds, not includ- 
 ing insane or other asylums, but only institutions known 
 by the name of hospitals. About 4,000 of the 6,000 
 beds are in pnblic city or State hospitals, the remaining 
 2,000 being in hospitals suj)ported by voluntary chari- 
 ty. The official reports of tlie thirty-odd free dispensa- 
 ries give 307,060 as the number of patients applying 
 and receiving treatment in 1875 at the dispensaries, 
 against 20,031 treated at their homes by these insti- 
 tutions. 
 
 To say that $10,000,000 are exj^ended in charities, 
 that there are 6,000 free beds in the hospitals, ahd that 
 over 300,000 persons receive medicine and medical 
 advice free of cost at tke dispensaries, is certainly evi- 
 dence of the generosity and Christian spirit of charity 
 that prevail. But, when looked at in a direct, practical 
 way, these figures show something else. If these official 
 reports are to he relied %i])on^ then, in a population of
 
 60 RELATIONS OF HOSPITALS TO PAUPERISM. 
 
 one million, over 300,000 persons receive alms every 
 year ; or about one in every three of tlie peoj^le is w^ill- 
 ing to, and does, take alms ! We have added together 
 the numbers reported in the " Hand-book of the Benevo- 
 lent Institutions and Charities of New York in 1876," 
 as being the number of patients treated by the disj)ensa- 
 ries in 1875, and the sum total is, as stated above, over 
 300,000. We doubt if the number of individuals is so 
 large, for it is the custom of some dispensaries to count 
 each visit a patient makes as a patient treated ; but the 
 actual number is immense, and increasing out of all pro- 
 portion to the increase of population. 
 
 The truth is, the majority of our hospitals, as they 
 are at present managed^ are liable^to do more harm than 
 good. Apparently they do much good, and for the 
 time do relieve suffering and want, but in the end they 
 may do much harm. Giving help too readily, even 
 during sickness, is hurtful ; and when it is offered free- 
 ly, without the certain knowledge that it is really 
 needed, it very naturally removes the healthful stimu- 
 lus of necessity, the dread of which prompts every indi- 
 vidual to guard against and provide for the misfortune 
 of sickness. 
 
 The dispensaries, as they are now managed, without 
 any certain knowledge as to the need of the hel]) they 
 give, are nothing less than a promiscuous charity exact- 
 ly similar to the notorious " soup-kitchens," medicine 
 being substituted for soup. They offer to the ignorant 
 and poor an easy and ever-ready inducement to take 
 alms. They. are the first stepping-stones to the degra- 
 dation of pauperism. The self respect of an individual 
 is injured the moment he accepts alms, and a habit of 
 taking alms invariably tends to a complete loss of self-
 
 EDUCATION TO REPLACE AL2IS. 01 
 
 • 
 respect aud consequent degradation. It matters but 
 little whether alms be medicine or food, the principle 
 remains the same. 
 
 The hungry must be fed ; but we know that, instead 
 of continuing to feed the hungry, and gradually destroy- 
 ing their power to hel]o themselves, it is infinitely bet- 
 ter to teach them self-help, and to seek out and remove 
 the cause that induced the miserable condition of help- 
 lessness. For exactly the same reason, would it not be 
 better to teach the poor how to avoid getting sick, and 
 by every means in our power remove the causes that in- 
 duce disease among them, rather than to offer them the 
 best care and attention, without being sure that they 
 need help, thus teaching them to become careless about 
 avoiding sickness ? 
 
 It would be more creditable to the citizens of Xew 
 York, if they could say that no such institution as a 
 pauper hospital was needed within the limits of the 
 city, than it is to be able to say that two hundred es- 
 tablished charitable institutions and oro'anizations are 
 maintained; and instead of so many millions being 
 spent in cariug for the sick, would it not be better if 
 the same money, or perhaps only a small part of it, 
 were spent in carrying out sanitary works, and teach- 
 ing the people the laws of health ? 
 
 Suppose that, during the prevalence of an epidemic 
 of a contao;ious disease, the authorities should content 
 themselves with providing for those infected, and neg- 
 lect to take the necessary steps to remove the cause of 
 the disease by doing all that sanitary science indicated : 
 they would soon be called to account for neglect of 
 duty. It is a well-known fact in science that the great 
 majority of the cases of disease treated in our hospitals
 
 62 RELATIONS OF HOSPITALS TO PAUPERISM. 
 
 are induced by the bad sanitaiy condition of the homes 
 of the poor, and by the direct violation, through igno- 
 rance, of the plainest hygienic laws ; yet what direct 
 steps are taken to correct this constantly-acting cause 
 of sickness? The Health Department of New York 
 City is expected to do little else than prevent eiDidem- 
 ics of contagious and infectious diseases. The meagre 
 appropriation prevents them from doing much more. 
 
 This statement concerning the hospitals and chari- 
 ties of New York City cannot be called a fair example 
 of the condition in smaller places, but it shows very 
 plainly and truthfully the prevailing faults in the ad- 
 ministration of charities throus^hout the countrv. If 
 the results in smaller places are not so bad, it is due to 
 local circumstances, and not to a better understanding 
 of the subject, nor to the adoption of a more enlight- 
 ened system. 
 
 The circumstances are very much in favor of the 
 smaller cities and towns. Leaving out the many well- 
 known causes that tend to generate pauperism, and thus 
 increase the relative number of paupers in a large city, 
 which do not exist in towns or small cities, the main 
 reason that charity does not do so much harm in the 
 latter is, that the circumstances and the character of 
 every one are well known to the people, and this per- 
 sonal knowledge guides and directs the givers of chari- 
 ty ; whereas, in the large cities, it is seldom that the 
 giver of charity knows to whom he is giving, and per- 
 sonal hioioledge rarely exists at all ; when it does, it is 
 usually of such a character as to be of but little prac- 
 tical value. The difference between the life of the 
 rich and of the poor is so great that the rich cannot 
 comprehend the real needs of the poor. Charity with-
 
 PERSONAL RELATIONS IN CHARITY. G3 
 
 out tliis relation is like a man with a lieart, muscles, 
 and a spinal cord, to respond to external influences, but 
 Tvitliout a head and the brains to coordinate and direct 
 his acts. Unless these personal relations exist between 
 those who give and those who receive, no act of generos- 
 ity deserves the name of that charity which " blesseth 
 twice," for gratitude is not developed in those receiv- 
 ing help ; they give nothing in return for what they 
 receive. Experience teaches that to do for an indi- 
 vidual that which it is possible for him to do for him- 
 self will invariably tend to harm, unless he gives in 
 return an equivalent either by actual payment or in 
 gratitude. And experience also teaches that human 
 nature can only feel gratitude toward an individual. 
 In religion, God is represented as an individual, and for 
 all his great blessings we are told to "love him with 
 all our heart, with all our mind, and with all our soul." 
 We are not what we should be unless we give an equiv- 
 alent for all we receive. When the king was the state, 
 he could give to the j^oor, and receive love and loyalty 
 in return ; but now the people, the voters, the paupers 
 themselves, are a large part of the state, and paupers 
 take their alms from the state as a riglit. 
 
 Besides this tendency in hospitals, as charitable in- 
 stitutions, to increase pauperism, another serious objec- 
 tion to the use of public hospitals for the purpose of 
 treating the sick beyond the extent absolutely demand- 
 ed by necessity is, that every time an individual is re- 
 moved from his home — let that home be never so hum- 
 ble — and taken to a hospital, the family as an institu- 
 tion receives a blow. Then, too, except to those already 
 degraded, life in a paujDer hospital, especially with the 
 young, is hardening to the feelings, while in many
 
 04: EELATIOXS OF HOSPITALS TO PAUPERISM. 
 
 cases it subjects tlie moral to tlie influence of tlie im- 
 moral. 
 
 Another objection to hos2:)itals is the bad sanitary- 
 condition of many of them, and unless this is improved, 
 both as to the plan and the construction of the build- 
 ings, and the general and internal management, so as to 
 give a smaller "death-rate, and fewer deaths from hosjDi- 
 tal- diseases, than in the vast majority of hospitals nov^ 
 in use, it will be decidedly better, on sanitary grounds 
 alone, to treat in their homes all the sick poor who 
 have homes, even though they may be very bad and 
 unhealthy places to live in. As to the expense of treat- 
 ing the poor at their homes, it certainly would not be 
 greater than the expense of running the hospitals, if the 
 interest-money is added w^liich could be had from the 
 immense sums that are sunk in the massive, many- 
 storied hospital-buildings and the expensive city lots 
 on which they stand. 
 
 But, as poor-relief is now administered (and no 
 doubt under the best system that could be devised), a 
 certain number of hospitals for treating the sick poor 
 will be necessary. When j^roperly constructed and 
 managed, they are a great blessing to the poor ; while, 
 from the many advantages they aflbrd for the study and 
 teaching of clinical medicine and nursing, they are of 
 incalculable value to the whole community. Without 
 hospitals the diflaculties in teaching practical medicine 
 would be very great, and the whole method of giving 
 clinical instruction would be changed. A medical 
 school without the advantages afforded by hospital 
 instruction is a failure, and no one can exjDect to attain 
 eminence as a teacher or as an author in medicine or 
 surgery without hospital exj)erience as a basis, and hos-
 
 OBJECTIONS TO HOSPITALS. Q^ 
 
 pital practice and statistics as illustrating and verifyino- 
 Lis views. 
 
 Since tlie establishment of tlie training-school for 
 nurses in connection with St. Thomas's Ilosj^ital hj 
 MJss Nightingale, in England, sixteen years ago, and 
 in this country of the school for nurses in connection 
 with Bellevue Hospital, New York, four years ago, the 
 great advantages of hospital instruction are recognized 
 for those who are studying nursing. 
 
 There is a popular belief that doctors experiment on 
 hospital-patients, but only those ignorant of the facts as 
 they are at the present time can have such an idea. In 
 this country, at least, the acts of a physician in a hospi- 
 tal are more public and open to criticism than in pri- 
 vate practice. What he does is done in the presence 
 of several and often many persons capable of under- 
 standing whether he is making an experiment, and if 
 he makes a mistake it is known to all the hospital-staff; 
 whereas, in private practice, if he has the confidence of 
 the immediate family, on account of their inability to 
 understand, he can venture and make mistakes 'without 
 discovery. 
 
 In the founding of hospitals the question of their 
 usefulness to medical education has not been given due 
 consideration. As a rule, the idea of rendering imme- 
 diate personal relief to the suffering poor is the first, 
 and in many cases the only, acknowledged object aimed 
 at in establish ino- them. 
 
 o 
 
 The objections to civil hospitals, as now stated, may 
 be said to be — 
 
 1. As institutions, they tend to weaken the family 
 tie by separating the sick from their homes and their 
 relatives, who are often too ready to relieve themselves 
 
 5
 
 66 RELATIONS OF HOSPITALS TO PAUPERISM. 
 
 of tLe burden of tlie sick and lielpless of tlieir family. 
 Besides, wlien one or more of a family are removed, 
 those left at home are in an uncertain state of mind, and 
 in many instances in an unprotected condition. TLe 
 husband loses the good influence of his wife, and the 
 wife the protection of her husband; 
 
 2. The inmates of pauper-hospitals are liable to come 
 in contact with bad influences ; familiarity with suffer- 
 ing, unaccompanied by the occupation of relieving those 
 who are suffering, ends in hardening the sensibilities, 
 especially in the young. 
 
 3. Like all public and general charities without the 
 safeguard that personal knowledge affords, hospitals 
 tend to foster idleness, helplessness, and their natural 
 results, pauperism and crime. . 
 
 4. Hospitals, when badly constnicted or badly man- 
 aged, are liable to cause hospital-diseases among the 
 inmates and become centres of infection, thus defeating 
 the very object they are intended to promote. 
 
 On the other hand, the arguments in favor of civil 
 hospitals are — 
 
 1. They are a necessity under many circumstances 
 for giving shelter to the sick and helpless ; and are sup- 
 posed to be the most economical method of providing 
 for the sick poor. 
 
 2. They are of very great value as affording oppor- 
 tunity for a comparative study of diseases, and for giv- 
 ing practical instruction in the science of medicine and 
 the art of nursing, to the greatest advantage ; thus, by 
 helping directly a few individuals, indirectly rendering 
 a service of incalculable value to the world. 
 
 3. During contagious epidemics they are a ready 
 and practical means of providing for those who are in-
 
 PROPOSED PLAN FOR GOVERNING CHARITY. 07 
 
 fected, and by their isolation preventing the spread of 
 disease. 
 
 As means toward checking the undesirable multi- 
 plication of expensive institutions, to prevent hospitals 
 from breaking up or interfering with the family tie, and 
 at the same time to keep them from engendering pau- 
 perism, we suggest — 
 
 1. Do all that can be done to enlighten the poor to 
 help themselves, and to avoid the causes of disease. 
 
 2. Give indirect help by imjiroving the condition of 
 the homes of the poor, by strict laws in regard to the 
 existing condition, and the building of all dwelling- 
 houses, manufactories, schools, etc., etc., and in regard 
 to the sale of food, etc. 
 
 3. Limit hospital accommodations to those who 
 have no homes and to those who cannot be assisted 
 at their homes. 
 
 It is doubtful if the State can give out-door help, 
 even medical help, without doing more harm than 
 good ; it can only be done wisely by establishing a 
 Bureau of Intelligence for the supervision of charities 
 in connection with the Police Department, with officers 
 at each police-station, where the names and the num- 
 bers of the inmates in every house in the precinct or 
 district would be known ; and where a record, made 
 from personal knowledge of all individuals receiving 
 help, as to their cii'cumstances, the amount of aid 
 given, etc., would be kept. As far as possible, all help 
 rendered should be guided by this personal knowl- 
 edge ; and it should be obligatory on all charitable 
 institutions and associations to give infonnation of all 
 assistance afforded by them to individuals living in the
 
 68 RELATIONS OF HOSPITALS TO PAUPErdSM. 
 
 district. No lielj) should be allowed to go unrecorded, 
 except tliat giveu by a j^rivate individual as a personal 
 
 gift. 
 
 Tlirougli tliis Intelligence Bureau, reliable personal 
 knowledge of every applicant for hospital-relief could 
 be obtained. We fully appreciate tlie great difficulty 
 of organizing and uniting voluntary charities in this 
 country, where there are so many different religious 
 sects ; but, by establishing such a system as the above, 
 much could be done toward distributing helj) where it 
 is really needed, and toward preventing indiscriminate 
 charity and in detecting impostors. 
 
 To avoid the injurious moral effects of hosj^itals on 
 the characters of the inmates, and to prevent such bad 
 sanitary conditions in hospitals as are sure to result in 
 prolonged cures, and often in the generation of fatal 
 hospital-diseases, it is necessary to have hospitals con- 
 structed and managed in accordance with the teachings 
 of social and sanitary science. The rest of this essay 
 will be devoted to the pur230se of showing how this 
 can best be done in so far as sanitary science is con- 
 cerned.
 
 CHAPTER III. 
 
 OKGANIZATION AXD MANAGE^IEISTT. 
 
 More than four-fifths of all that we have been able 
 to find written on hospitals is mainly abont their con- 
 struction. Since the appearance of Miss Nightingale's 
 books, " Notes on Hospitals " and " Notes on Nui^sing," 
 many articles have been written on " Hospital-Construc- 
 tion " and there have been endless discussions as to the 
 best plans for building and for ventilating them ; but 
 rarely has the subject of organization or management 
 been treated of. Many times the results of carelessness 
 on the part of the doctors ; unwise and fraudulent man- 
 agement ; poor, untrained nurses ; bad food ; and gener- 
 al uncleanliness, have been unjustly attributed to faults 
 in the plan of construction. A well-managed, poorly- 
 constructed hospital will give a far better result than a 
 finely-constructed hosj^ital with bad management. 
 
 Tlie Board of Managers and the Medical Boards. — 
 In this country we find our civil hospitals organized as 
 follows : The governing power is vested in a board 
 termed the trustees, managers, or governors, and in the 
 case of a State or municipal institution called commis-
 
 70 ORGANIZATION AND MANAGEMENT. 
 
 sioners. The members of these boards are usually busi- 
 ness-men, wealthy merchants, bankers, etc. ISTow and 
 then the name of a prominent medical man will be 
 found among them, but, as a rule, the main elements 
 represented in these boards are the business or financial 
 and the j)hilanthropic elements; while in the State in- 
 stitutions politics is the ruling element. Science is 
 rarely represented in the boards of managers. 
 
 The medical board is generally comj)osed of promi- 
 nent medical men aj^pointed by the trustees. A physi- 
 cian of eminence can easily get a position, but not in- 
 frequently hospital appointments depend more upon the 
 influence an aj^plicant can bring to bear upon the trus- 
 tees than on his merits. 
 
 It would be supposed that the trustees naturally 
 are guided by the members of the medical board in 
 deciding upon the plan of construction, etc., when new 
 hospitals are undertaken; but often the j^lans of the 
 buildings have all been adopted before there is a medi- 
 cal board ; and not infrequently, even when there is a 
 medical board, the whole subject of construction is put 
 into the hands of a committee of the board of trustees 
 — a system which is apt to end in the adoption of a plan 
 prepared by some architect ; the result being a grand, 
 monumental, architectural building, with all the " mod- 
 ern improvements " in it so as to enable the largest pos- 
 sible number of people to live in the smallest possible 
 space. 
 
 The natural tendency of the architect's efforts is to 
 produce an imj)osing and pleasing effect as far as may 
 be compatible with the idea of making the most of a 
 very small space of ground, for he is constantly at work 
 devising the best plan to build houses in crowded cities
 
 BOARDS OF MANAGERS AXD MEDICAL BOARDS. 71 
 
 where every foot of ground must be made use of. The 
 fiiult cannot be said to rest altogether on the shoulders 
 of the trustees; they, no doubt, are guided by the 
 knowledge they have on the subject, and it must be a 
 very exceptional case where any other than conscien- 
 tious, philanthropic motives would influence them. But 
 business-men and politicians should not be expected to 
 decide questions of sanitary science. Nothing in their 
 training would lead one to suppose that they had the 
 requisite knowledge. The difficulty is, that scientific 
 men, especially physicians, do not take sufficient inter- 
 est in such matters. Badly-constructed hospitals and 
 dwelling-houses will be built, and the causes of disease 
 will continue to create preventable disease just so long 
 as doctors leave these matters to business-men and poli- 
 ticians and their architects. 
 
 For many years medical men have devoted their 
 enero-ies to discoverino; remedies with which to cure 
 disease. Lately they have been, and are still, studying 
 the results, i. e., the j)athology of disease. Very lately 
 the study of the causes, i. e., the etiology of disease, has 
 attracted much attention ; and we hope that soon there 
 will be a more general and direct interest shown in the 
 endeavor to prevent disease, the highest function of 
 science in medicine. At present, medical men are too 
 busy curing illness, to give much practical consideration 
 to methods of prevention. Suppose the trustees who 
 are about deciding upon a plan call in the members of 
 the medical board to advise them : nine-tenths of the 
 medical men, never having studied or even seriously 
 considered the subject of hospital-construction, would 
 be indifferent, or incapable of giving good advice, and 
 the few who understand the princij^les, not being pre-
 
 72 OEGAmZATION AND MANAGEMENT, 
 
 2:)ared as to tlie latest views in construction, and being 
 perhaps too busy Avitli their own private affairs to be- 
 stow that time and sj)ecial consideration on the subject 
 which wouhl enable them to give good advice, the 
 trustees and. architects are left to themselves to erect 
 a badly-planned hospital. 
 
 In New York City, since 18G5, the close of the war, 
 six new hosj^itals have been built — the smallest of these, 
 with the ground it stands on, costing about half a mill- 
 ion dollars ; and three of the six nearly, and one at least 
 quite, a million dollars. Only one of these new hospi- 
 tals can claim to be an improvement upon a hospital 
 erected in Europe just fifty years ago on a plan pro- 
 posed a hundred years ago, or can comj)are favorably 
 with the first New York hospital, that was destroyed 
 by fire a century ago ; and only this one of the six has 
 a building to show as an attempt toward fulfilling the 
 principles which should be adhered to, and which were 
 taught us by the experience of the late war. We mean 
 the detached surgical pavilion at Roosevelt Hospital. 
 
 The progress in the construction of hospitals can be 
 traced to scientific and medical men, aroused to a sense 
 of duty by the ravages of pestilence or war, and to 
 their iudifterence can with justice be attributed the 
 fact that ex2:>ensive buildings are erected for hosj^ital 
 purjioses to-day, which from a sanitary standpoint 
 would only be creditable to the middle ages. Some 
 of the most eminent in the medical profession go daily 
 to visit and treat the sick poor in hospital-wards, 
 where, if they themselves were suffering from a com- 
 pound fracture, or even an amputated finger, they could 
 not be paid to remain for a day, on account of the dan- 
 ger of contracting that fatal disease, 2">y9emia, from the
 
 BOARDS OF MANAGERS AND MEDICAL BOARDS. 73 
 
 atmos2:)liere of tlie wards. If tlie medical board is not 
 responsible for the sanitary condition of a hospital, who 
 is ? The trustees have never studied either sanitary 
 science or medicine; they accept the reports of the 
 medical board, without knowing that many of the 
 deaths in their institutions are due to disease gener- 
 ated by the bad sanitary condition of the hospital. 
 Examine closely the public reports of the medical 
 boards of hospitals, and see how rarely they give any 
 other impression than that everything is satisfactory, 
 and exactly as it should be. Yet the statistics in some 
 of these same reports will show a death-rate of one in 
 every seven of all patients admitted, and that one in 
 every fifteen of the deaths is recorded as due to hos- 
 pital-disease. 
 
 It is obvious that such a condition of things would 
 not be allowed to continue if the trustees or manao-ers 
 imderstood sanitary science. It has been proposed to 
 give the medical j)rofession a representation ; but we 
 believe that, if the members of the medical boards of 
 hospitals would properly inform themselves, and exert 
 their influence as they should do to bring about im- 
 provement, such a step would hardly be necessary. 
 Since they do not, it might be a good plan to have the 
 profession represented on the boards of managers, for 
 then they could be held more directly responsible. 
 But, under the present rules and by-laws of our hospi- 
 tals, there are certain objections to the practical work- 
 ing of this plan. It is a well-known fact that every 
 eminent physician has his set of favorites about him, 
 who would get the appointments of honor. If the medi- 
 cal profession is to be represented in the boards of mana- 
 gers, then we must have a diflerent method of making
 
 74 ORGANIZATION AND MANAGEMENT. 
 
 appointments for the positions of attending physicians 
 and surgeons ; and, in fact, a change in this respect is 
 at the present time very much needed, particularly in 
 laro-e cities where there are schools of medicine. 
 
 o 
 
 Tlie Value of Hospital Appointments. — The posi- 
 tion of manager or trustee to a hospital is seldom 
 sought after ; men of means and of social standing 
 are usually selected and urged to fill the position. It 
 is true, a man may accept the position to gratify vanity, 
 but he would hardly seek it for the sake of remunera- 
 tion, or as an important means of making a reputation 
 and acquiring valuable experience in his business. On 
 the other hand, an occasional request is made by hospi- 
 tal-trustees to be allowed to use the names of eminent 
 medical men as consulting physicians or surgeons ; but, 
 it is not at all necessary for them to seek doctors of 
 reputation and merit to fill the positions of attending 
 physicians and surgeons to a hospital. Such positions, 
 varying with the size and importance of the hospital, 
 give a physician, with average ability, a chance to build 
 up a reputation, secure a remunerative private practice, 
 and gain an experience valuable on account of the very 
 favorable opportunity for studying and comparing dis- 
 ease which nothing but a hospital could furnish, while 
 the vantage-ground on which he stands enables him to 
 secure a professorship) which a better teacher could not 
 get, because he could not give clinical lectures in hos- 
 pital to the students. 
 
 " In Dublin," says the Pliiladelpliia Medical Times^ 
 " large premiums are paid for hospital appointments. 
 In the Jervis Street Hospital five hundred pounds ster- 
 ling — three hundred to the foreman incumbent and two
 
 VALUE OF HOSPITAL APPOI^TMEN'TS. 75 
 
 liundred to the liospitals — is said to be tlie customary 
 sum." 
 
 As louo' as a doctor is interested in medicine, lie 
 will usually retain Ms hospital a2:)pointment ; if he is a 
 teacher or professor, the position is essential, to enable 
 him to give clinical lectures. Unless a physician holds 
 such a place, where he can make the acquaintance of and 
 teach the younger men of the profession his views, it 
 will be a difficult matter for him to become a consult- 
 ing physician, which is an enviable position for a physi- 
 cian, especially when his physical strength does not per- 
 mit him to endure the active life of a j)ractitioner. 
 
 Such is the value of a place on a medical board that 
 many physicians are not satisfied with holding one hos- 
 pital appointment, but take all they can get ; and phy- 
 sicians with large private practice will be found holding 
 two, three, four, and even more positions as visiting 
 physicians or surgeons to different hospitals. 
 
 For more reasons than one, it is wrong for one phy- 
 sician to hold two or three hospital apj)ointments at the 
 same time. If he has a private practice to attend to be- 
 sides pre^^aring and delivering two or more lectures 
 every week, it is utterly impossible for him to visit 
 once every day his hospital-patients and do his duty 
 toward them. Necessarily much of his work falls on 
 the house-staff, and the patients must be satisfied with 
 seeing the attending doctor pass hurriedly through the 
 wards, stopj^ing here and there to examine a case be- 
 longing to a class which at the time he is especially in- 
 terested in, or perhaps an interesting case which he is 
 going to bring before the students at his next lecture. 
 For one to monopolize so many positions is an injustice 
 to the rest of the profession. It may be from a sense
 
 Y6 ORGANIZATION AND MANAGEMENT. 
 
 of duty, a genuine spirit of charity, that eminent physi- 
 cians give their valuable time to the sick poor in hospi- 
 tals,' but it cannot be said to be charitable toward the 
 rest of the profession for them to hold at the same time 
 several very desirable positions which, if they are not 
 worth anything to tliem, would be of great value to 
 others. 
 
 If the trustees or managers of our hospitals would 
 make it a i)art of the constitution or by-laws of the 
 hospitals under their control that no physician or sur- 
 geon could hold the position of attending or visiting 
 j^hysician or surgeon to the hospital, and at the same 
 time hold a similar position in some other hospital, they 
 would do an act beneficial to the patients, as well as 
 one of justice toward the medical profession. 
 
 Besides the above restrictions, and for exactly the 
 same reasons, it would be well to limit the length of 
 time during which any one could hold the position of 
 attending physician or sui^geon. Let the term be ten 
 or fifteen years, so as to give each one a chance to re- 
 ceive the full benefits, and time sufficient to develop 
 what talent he has in him. Even though it be a work 
 of charity, it is hardly fair that one person should con- 
 tinue to do it, long after it has enabled him to reach 
 the highest position to which his ability entitles him, 
 and to the exclusion of others from a position without 
 the advantages of w^hich it is difficult for them to 
 make use of, or even make known, what ability they 
 may possess. 
 
 To every fifty patients, or every two wards, there 
 should be a visiting doctor and one assistant visiting 
 doctor on duty, and both of these should visit the 
 wards once every day. The number of visiting doctors
 
 INFLUENCE OF WOMEN IN HOSPITALS. 77 
 
 could be increased by having a given season during 
 wliicli tliey would be on duty, altei'nating every four or 
 six months with others of the medical board. To the 
 same number of patients there should be three resident 
 doctors. {See Relation of the Medical School to the 
 Hospital, in a subsequent chapter.) 
 
 The Injiuence of Women in Hospitals. — Besides the 
 need of scientific representation in the boards of mana- 
 gers, the want of another very essential influence is 
 noticeable in hospital management. 
 
 Into the housekeeping, the laundry, kitchen, and 
 nursing service of hospitals, abuses often creep and 
 become permanent fixtures, because the inspecting com- 
 mittees, all composed of men, do not detect them. The 
 wards, etc., may present a cleanly and orderly appear- 
 ance, while many abuses lie concealed, which only an 
 expert in housekeeping would discover. Prominent 
 business-men are not experts in housekeeping, nor is it 
 possible for men to equal women in this department, 
 not only because they have not had the experience, but 
 because Nature does not give them the gift. 
 
 Admitting that men can supervise the housekeeping 
 and nursing of a hospital and secure their being eco- 
 nomically done and to the eyes of an inspector well 
 done, still, as a rule, institutions so governed will be 
 wanting in one of the most desirable and essential par- 
 ticulars, namely, that gentle and refining moral influ- 
 ence which is seldom found outside of the house ^a^t 
 in order by a woman. Under men it might work as 
 smoothly and noiselessly as a Corliss engine, but the 
 good influence of human sympathy would be wanting, 
 and the subordinates would do their work for what
 
 78 ORGANIZATION AND MANAGEMENT. 
 
 they could " make " out of it, and in time would Ije- 
 come hardened and in some instances cruel; their high- 
 est aim and effort being to please the superintendent by 
 making a sufficiently good appearance to satisfy the vis- 
 iting committee. The case is im23roved where female 
 subordinates of good character are emj^loyed, but the in- 
 fluence to be effectual must come from the highest power. 
 It is the management, whatever that may be, which gives 
 the tone to the institution. Strict order and disci23line 
 will, or rather must, suffice in the housekeeping depart- 
 ment of a man-of-war and of barracks ; but in a hospi- 
 tal, to these, sympathy and kindness should be added. 
 The nearer a hospital resembles what we understand as 
 expressed by the word liome^ the better it is ; and, to 
 approach this, woman's influence must be felt, from the 
 board of manasrers down to the coal-heaver. 
 
 How is it practicable to introduce this influence 
 into the administration of hospitals ? A separate 
 board, composed entirely of ladies, to assist in man- 
 aging, has been tried. This plan seems to work very 
 well as long as the hospital is comparatively small ; 
 but, unless the different members of all the boards are 
 well known to each other, misunderstandings are sure 
 to arise, it being difficult to keep up harmony and 
 unity of action betw^een the board of governors, the 
 board of lady managers, and the medical board. To 
 obviate this complication, it has been suggested that 
 there should be a limited number of lady members 
 appointed on the board of governors instead of a sepa- 
 rate board of lady managers, it being understood that 
 the special duty of the ladies would be to supervise and 
 direct the organization and administration of the house- 
 keeping and nursing departments.
 
 INFLUENCE OF WOMEN IN UOSPITALS. 79 
 
 Five years ago tlie " State Charities Aid Associa- 
 tion " was organized. The Association is " composed 
 of ladies and gentlemen who propose to establish local 
 visiting committees for the almshouses, hospitals, and 
 other public institutions of charity throughout the city 
 and State of New York." The objects are — " 1. To 
 promote an active public interest in the New York 
 State Institutions of Public Charities, with a view to 
 the physical, mental, and moral unjn'ovement of their 
 pauper inmates. 2. To make the present pauper sys- 
 tem more efficient, and to bring about such reforms in 
 it as may be in accordance with the most enlightened 
 views of Christianity, science, and philanthropy." 
 
 For five years the Association has been thoroughly 
 organized and earnestly at work, and much good has 
 been accomplished. The membership now numbers 
 about twelve hundred. The ladies' committees regu- 
 larly visit and inspect the hospitals and other public 
 institutions. They have no direct authority, but indi- 
 rectly they have great influence on the management 
 and administration of these institutions. They have 
 succeeded in introducing trained nursing by establish- 
 ing: a " Trainings-School for Nurses " in connection with 
 Bellevue Hospital. This school, organized after the 
 system inaugurated by Miss Nightingale in England, 
 has proved to be a great success. The superintendent 
 of the school is a lady, both by birth and education, 
 and several of the fifty nurses and pupils, now at work 
 in the wards of the hospital, are refined and educated 
 women, who have taken up the work, not from neces- 
 sity, but choice. The introduction of these ladies into 
 the wards of this pau]3er-hospital has not only changed 
 completely the moral atmosphere of the place, and re-
 
 80 ORGANIZATION AND MANAGEMENT. 
 
 cluced tlie cleatli-rate, but promises to revolutionize "both 
 hosj^ital and private nursing tliroughout the country. ., 
 Already several scliools have been organized in other * 
 cities and are v^orking successfully. By means of these 
 training-schools for nurses, the influence of women can 
 be successfully introduced into hospitals. To every 
 fifty patients there should be not less than ten trained 
 nurses and student-nurses. (^See Relations of the 
 Training-School for Nurses to Hospitals, in a subse- 
 quent chapter.) 
 
 Both breathing and eating are essential to sustain 
 life ; but, since breathing must be kept up at all times, 
 we may say that breathing is of more importance than 
 eating. In the same sense ^ve may say that nursing, 
 which should be continuous, is of more imj^ortance to 
 the sick than medical attendance. 
 
 The Siqyerintendent. — The superintendent or execu- 
 tive officer of hospitals in this country is appointed by 
 the board of managers, and to them he is alone resjoon- 
 sible. In some cases the superintendent is a medical 
 man, but not infrequently he is simply the business 
 ao-ent of the trustees, and makes it his aim to maintain 
 as good an appearance of things as possible, and to 
 please the trustees by keeping down the exj)ense, with- 
 out much knowledge of, or much regard for, the welfare 
 of the patients. 
 
 In every hospital there are three legitimate inter- 
 ests ; 
 
 1. Charity, or the humanitarian interest, which seeks 
 to make the hospital serve the welfare of the j^atients ; 
 the motive being to have that done which will bring 
 immediate personal good.
 
 THE SUPERINTENDENT. 81 
 
 2. Learning, or tlie scientific interest, wliicli would 
 use tlie hospital for the pui'pose of studying and teach- 
 ing the science of medicine ; the motive being to have 
 that done which in the future will do good to all man- 
 kind. 
 
 3. The material or economic interest, which would 
 limit the expenses of the hospital ; the motive being to 
 make the wisest use of the funds. The guardians of 
 the first and the third are the trustees, assisted by the 
 nurses, medical men, and employes. The guardians of 
 the second are the attending medical staff, assisted by 
 the house-staff, nurses, and employes. These three in- 
 terests, in a properly-conducted hospital, should not be 
 conflicting ; but there is a fourth interest that often 
 sho^vs itself in hospitals — namely, selfishness, or the in- 
 terest of individuals, who strive to use the hospital 
 for the purpose of adding to their profits or their repu- 
 tation. It is this selfishness of individuals which inter- 
 feres with the true interests of the hosj^ital, and in most 
 cases is the real originating cause of serious quarrels 
 between the different parties representing them. Be- 
 sides, through the want of comprehensive ap23reciation, 
 and the natural tendency of individuals to become par- 
 tisans, and to see things from one standpoint, and 
 through personal misunderstanding and enmity, the 
 representatives of the true interests of the hospital 
 not infrequently become antagonistic. 
 
 The 2)osition of the suj^erintendent, especially in a 
 large hospital, to Avhich is attached a medical school, is 
 one of great importance. The superintendent should 
 be, if not a Christian man, at least one educated in and 
 guided by moral laws, otherwise he would not appre- 
 ciate the humanitarian interests ; he should be a person 
 G
 
 82 ORGANIZATION AND MANAGEMENT. 
 
 educated in medicine and guided by tlie laws of liealtli, 
 otherwise lie would not aj^preciate the scientific inter- 
 ests ; and he should be a person who understands and 
 is guided by the laws of economy, otherwise he would 
 not api^reciate the material interests of the hospital. 
 Besides, he must be a jjerson of executive ability and 
 sound j)ractical judgment, for it will be his duty to 
 ■ supervise and direct the employes, and to decide and 
 adjust the numerous minor differences of all these inter- 
 ests. 
 
 Suj^posing the superintendent to be a man possess- 
 ing a knowledge of and comprehensively appreciating 
 the laws of morals, health, and economy, and having 
 executive ability and practical judgment, what should 
 be his position, and his relations with the trustees and 
 the attending medical staff ? 
 
 The trustees are the manao:ers, the controllino; board 
 of the hospital. They should decide upon all the rules 
 and regulations. By them all the duties and powers 
 of the attending medical men and the superintendent 
 should be defined and decided. They should reserve 
 the right of revoking all rules and regulations defining 
 the duties and powers of every one connected with the 
 hospital. 
 
 The superintendent should rank in ]30sition with 
 the attending physicians and surgeons, and have a seat 
 at the meetings of the medical board, so as to be in- 
 formed on all questions coming before them, and he 
 should have a seat at the meetings of the executive 
 committee of both the board of trustees and the medical 
 board. All medical questions should be brought be- 
 fore the medical board for consideration, and for them 
 to report upon, and their rej^orts should be taken by
 
 THE SUPEEI2TTEXDEXT. 83 
 
 one of tlieir number, witli tlie superintendent, before 
 the board of trustees for final decision. 
 
 All questions arising, wliicli are not covered by tlie 
 rules and reo;ulations, sliould, if immediate action is re- 
 quired, be decided by the superintendent, whose deci- 
 sion should hold good till the matter is finally decided 
 by the board of trustees. 
 
 Once every month, just after the meeting of one of 
 the boards, there should be a joint meeting of the board 
 of trustees or their executive committee with the mem- 
 bers of the medical board, at which certain subjects 
 should be discussed. One object of this joint monthly 
 meetino; would be to brino; the members of the two 
 boards into personal acquaintance, and thus prevent 
 rumors and insinuations about individual members 
 from havino; undue influence. It is not an uncommon 
 thine:, in lars-e cities, to find trustees and the attendins: 
 medical men of the same hospital, personally strangers, 
 knowing nothing of each other, except by reputation 
 and report. 
 
 To be educated as a physician implies that a man 
 has studied the subject on which sanitary science is 
 based ; but it is rare to find a doctor who is a sani- 
 tarian ; in fact, many doctors seem never to have dii'ect- 
 ly considered the su1)ject. The superintendent, there- 
 fore, besides being a medical man, or one educated as 
 such, should be a good sanitarian, and one who has 
 given special study to hospital-construction, and who 
 has some knowledfre of mechanics and ci\"il eno-ineer- 
 ing. It is useless to depend upon a committee of in- 
 spection appointed from the members of the medical 
 board, whose duty it would be to sujoervise the sani- 
 tary condition of the hospital. They are men too bu>y
 
 84 OBGANIZATIOX AND MAFAGEMEXT. 
 
 to attend to tlie work, even in a routine way, and they 
 never tliink of studying up sanitary subjects. Tlie 
 duty of tlie superintendent would be the constant per- 
 sonal suj)ervision of tlie liosj^ital, esj^ecially in regard 
 to its hygienic and sanitary condition. In a large hos- 
 pital, under the superintendent there should be a stew- 
 ard, whose duty it would be to take charge of the ac- 
 counts and supj^lies of the hospital; a clerk, to have 
 charsce of th^ recordino; of admissions and dischars-e of 
 patients, and the books in the office ; a warden, to w^atch 
 the male attendants, and to have charge of the police 
 of the hospital ; and a lady suj^erintendent of the nurs- 
 ing, diet, and cleansing, of the hospital. 
 
 An important duty of the superintendent would be 
 to carefully supervise the construction and repairing of 
 all buildings. Let the plans be never so well prepared, 
 numerous questions will arise, which can only be de- 
 cided by a superintendent of the qualities described 
 above. Unless such a person is on the spot while the 
 work is going on, many opportunities will be lost for 
 makins: minor and sometimes radical and essential 
 changes in the carrying out of the j^lans. On this 
 account, it will be of the greatest importance to select 
 the superintendent before the work of building the hos- 
 pital is commenced. 
 
 The superintendent must be a man of position and 
 ability, and one who can be trusted with authority ; 
 otherwise he will be made a tool of, and will serve the 
 interests of some individual or clique, instead of those 
 of the hospital. Any attempt on the part of the tms- 
 tees or others to employ a superintendent of inferior 
 capacity, and to depend on supervising the hospital 
 from the outside, will result in failure.
 
 TUE SUPERINTENDENT. 85 
 
 For tlie details of internal management we refer our 
 readers to tlie " Hand-Book for Hospital Visitors," docu- 
 ment No. 13 of tlie State Charities Aid Association. It 
 is a book of one hundred and fifty pages, very complete 
 and practical, and supplies a want in hospital literature. 
 It will rank with Miss Nightingale's " Notes on Nurs- 
 ing," and' is more direct and better adapted for use in 
 hospitals.
 
 CHAPTER IV. 
 
 THE COISTSTRUCTIOjST OF A CIVIL nOSPITAL. 
 
 "VVe have said that a poorly-constructed hospital 
 well managed will give better results than one well 
 constructed but badly managed ; now we add, that a 
 properly-constructed hospital properly managed mil 
 give still better vital results and at the same time can 
 be managed with greater ease and economy. 
 
 The conservative and, in some cases, more or less in- 
 terested hospital authorities, who for years 23ast have 
 opposed a change in the construction of hospitals, now 
 claim that with intelligent and well-trained nurses, to- 
 gether with the adoption of Lister's antiseptic method 
 of dressing wounds, pyaemia and other hospital-dis- 
 eases will no longer occur, and therefore the necessity 
 for replacing the old, massive, many-storied hospitals 
 with those of modern construction no lono;er exists. It 
 would be well for those who so strongly resist any pro- 
 posed change of the old buildings, to study the history 
 of training-schools for nurses, before they undertake to 
 use the good influence of trained nurses as an argument 
 in opposing further improvement, for they will discover 
 that the advocates of improved plans of construction 
 are the very founders of these schools, and that it is
 
 EXCUSES FOB FAULTS OF CONSTRUCTION. 87 
 
 tliroiii>;li tlieir efforts tliat trained niirsiiiir lias Leen 
 introduced. We know full well tliat trained nursino- 
 and good management w^ill modify bad hospital in- 
 fluences ; and that, if the antiseptic method of dressing 
 ^rounds after Mr. Lister's teachings is eflSciently carried 
 out in all its details, pyaemia will occur less frequently 
 and the death-rate in hospitals will thereby be lessened : 
 still, foul air will continue to do harm by prolonging 
 convalescence and reducino; the 2:eneral health of 
 patients, thus extending their stay in hospital, and 
 rendering them more liable to a relapse, and always 
 depriving the patients of a certain amount of power 
 to resist successfully disease. Every one knows that 
 a man may not starve to death on poor food, but that 
 good food is much better, for it renders him less likely 
 to contract disease, and gives him strength to resist its 
 flital tendency. Exactly the same is true of air. 
 
 Good management, trained nursing, and im23roved 
 medical and surgical skill, may reduce the death-rate, 
 and to a great extent counteract the evil effects of bad 
 air; but these are no justification for the existence of 
 poorly-planned hospitals. Saying and even proving, 
 were that possible, that pyaemia and other diseases 
 caused by foul air occur in private practice equally as 
 often as in hospitals, should not prevent us from bring- 
 ing about a change in hospital-building vrhich should 
 rid us of these evils; from a sanitary standpoint it 
 would be absurd to assume, as this comj^arison re- 
 quires us to do, that our private houses are proj^erly 
 constructed. 
 
 If a ward is carefully sealed up and filled with 
 steam, and several bushels of chloride of sodium and 
 the black oxide of manganese are mixed and spread ^
 
 88 CONSTRUCTION OF A CIVIL HOSPITAL. 
 
 out in lead joaus placed on tlie floor, and if tlien several 
 carboys of sulj^liuric acid are poured on, tlius generat- 
 ing several tons of chlorine gas, and tlie ward is kept 
 closed for twenty-four Lours, undoubtedly that ward 
 may be said to be thoroughly disinfected, or at least 
 the disease-germs are rendered inert for a time. But 
 the very fact that the ward lias become infected to 
 such an extent as to render this process necessary is 
 the strongest possible argument against the fitness of 
 the ward for the inhabitation of the sick. 
 
 Admitting that disinfection not only renders inert 
 but actually destroys the disease-germs, as patients can- 
 not live in an atmosj^here of chlorine gas, nor in that of 
 any other disinfectant j)ossessing sufficient power to 
 even render the germs inert, therefore disinfection is 
 only a palliative, and not a preventive measure. " An 
 ounce of prevention is worth a pound of cure" is a 
 j)roverb equally as ap|)licable to an infected hospital as 
 it is to disease in man. Eemoval of the cause of disease 
 is the first law in sanitary science, and the more nearly 
 this law is followed in hosj^ital-construction the better 
 the results will be. 
 
 We will assume that it has been decided to estab- 
 lish a general hospital, say, of foui* hundred beds for 
 the purpose : 
 
 1. Of giving to the sick poor better care and atten- 
 tion than they can otherwise command while sick. 
 
 2. To afibrd the medical profession of the commu- 
 nity an oppoiliunity of studying and teaching the science 
 of medicine, to the fullest extent that this .can be done 
 without in any way interfering with the welfare of the 
 patients. 
 
 3. To afford those desirous of becoming nurses the
 
 LOCATIOX. 89 
 
 opportunity of being taught and trained as nurses to 
 the very best advantage. 
 
 All contaQ-ious and infectious cases are to be ex- 
 eluded as being dangerous to others. JS^o maternity 
 wards are to be connected with the hospital, on account 
 of the great danger to lying-in women of their contract- 
 ing puerperal fever when treated in wards connected 
 with a general hospital. 
 
 The hospital is for general medical and surgical dis- 
 eases, and such special diseases as are in no way dan- 
 gerous to others, and as can be conveniently treated in 
 connection with such an institution. There is to be a 
 limited number of beds for the use of strangers, and 
 others Avithout homes, willing to pay for hospital treat- 
 ment. 
 
 Location. — ^The first thino; to be decided is the loca- 
 tion. In a small city or to^Ti there is no question as 
 to whether the hospital should be placed in the midst 
 of the town, or outside in spacious grounds; but in 
 large cities many objections are made to the hospital 
 being removed from the centre of population. It is 
 claimed that the sick cannot be safely transported, and 
 on that account the hospital must be in town. The 
 real difficulty is that, if the hospital is out of town, the 
 managers and attending physicians and surgeons are in- 
 convenienced, and in the case of the doctors it would be 
 hardly possible for those in full practice to leave town 
 every day. Then, too, the medical schools are in town, 
 and, if the hospitals are out of town, clinical instruction 
 would be attended with difficulty. 
 
 In answer to this we would say that in large cities 
 where the streets average not more than fifty or sixty
 
 90 COKSTRUCTION OF A CIVIL HOSPITAL. 
 
 feet in width, unless a hospital can be in the centre of a 
 large park, it should be placed out of town for the fol- 
 io win sc reasons : 
 
 So as to give the patients the advantage of pure 
 air — doctors send their private patients out of town 
 to get the benefits of pui-e air ; to free the hospital and 
 its grounds from surrounding obstructions to the free 
 circulation of the outside air ; to remove the hospital 
 from sources that render the air impure, such as large 
 seivers, manufactories, the filth, dirt, and dust, of the 
 city streets and houses, etc. 
 
 On the ground of economy ; the land is cheaper, and 
 this permits the erection of cheap one-story buildings in 
 place of costly, many-storied structures. 
 
 As to the question of transportation, the improved 
 ambulances and other means of conveyance practically 
 do away with the difiiculty when combined with a sys- 
 tem of small reception-hospitals, one or more as the cir- 
 cumstances demand, of a few beds each, where emer- 
 gency-cases could be received and treated until able to 
 be carried to the general hospital. 
 
 As to the inconvenience to the managers, if they 
 are working for the welfare of the patients, then they 
 should do their duty, or give way to others who would. 
 The attending doctors who are expected to treat the 
 cases should not be men with very large private prac- 
 tice ; whether the hospital is in or out of town, they 
 cannot well spare the time to do the every-day work. 
 Such men, if they will hold the hospital positions, 
 should have assistants to do the work that they have 
 not the time to do. 
 
 As to the medical schools, the question is of more 
 importance; but, under a better system, where the
 
 PREPARATION OF TEE GROUNDS. 91 
 
 clinical instruction is confined to tlie more advanced 
 students, tlie difficulty would not be so great. 
 
 Whether in or out of town, tlie site of the hospital 
 should be selected as having the best natural advan- 
 tages; and these are: a porous and well-drained soil 
 and subsoil, with southern exposure, and with jorotec- 
 tion, in our climate, fi'om the north and east winds, but 
 in no way affected by receiving the di'ainage of higher 
 ground ; lastly, sufficiently removed from swamps, ponds^ 
 or any source of malarial emanations. 
 
 Prejparation of the Grounds. — Unless the soil is 
 remarkably well drained by nature, deep subsoil drains 
 should be laid with great care so as not to interfere 
 with the foundations of the different buildings, but at 
 the same time take every advantage of the natural lay 
 of the grounds. AVhether such drainage of the ground 
 is necessary or not, on account of the nature of the 
 soil, it will be an advantage, if j^roperly done, for 
 porous earth (and well-drained ground is porous) is 
 one of the very best disinfectants, and naturally ab- 
 sorbs noxious gases, and thus tends to purify the air 
 around the hospital. 
 
 In large cities sometimes it becomes a necessity to 
 erect one or more small reception-hosj)itals in crowded 
 districts ; but not infrequently large hospitals will be 
 built in locations where they should not be, and on 
 badly-drained soils. To modify the inevitable evil of 
 insufficient and impure air, when a hospital is built in a 
 crowded district suiTounded by blocks of houses, etc., 
 which obstruct the free circulation, an additional space 
 should be allowed, both within and without the wards, 
 to each patient ; and if the soil is damp, besides the
 
 92 CO^fSTEVCTIOK OF A CIVIL HOSPITAL. 
 
 effort to drain it, it would be well to raise tlie wliole 
 surface by adding several feet of suitable earth, and by 
 all means to j^ut tbe wards on raised foundations and 
 cover tlie surface beneatli tliem witb concrete and as- 
 phalt, and leave the space open to tlie sun and air. 
 
 Character of tlie Buildings. — The site being select- 
 ed, the next thing to do is to determine the character 
 of the buildings to be placed upon it. 
 
 More than a hundred years ago it was very clearly 
 shown that a large number of sick people should never 
 be assembled under the same roof, as it is impossible to 
 supply each patient with the requisite amount of fresh 
 air on account of the large quantities of poisonous gas 
 thrown off from the luno;s and emanatino: from the 
 bodies, the wounds and excretions of the patients, and 
 continually infecting the air ; that in a large building 
 the foul air of one part could not be prevented from 
 permeating the whole structure — in this way one 
 infectious case beiuo; liable to infect all the inmates ; 
 and that in a large building it was difficult to give each 
 patient sufficient sunlight. To obviate these difficulties 
 it was decided — 1. To divide a large hospital into a 
 number of small buildings ; 2. That the administrative 
 offices, the apartments of the officers and servants, the 
 stores, drugs, etc., should be in a separate building 
 from those containing the patients; 3. That the sepa- 
 rate buildings, or pavilions containing the sich, should 
 each contain only two or three wards, and the rooms or 
 wards in which the patients were to be treated should 
 have a limited number of beds in them ; 4. That the 
 wards should be so constructed as to give each j^atient 
 a lai'ge cubic space of air, and by means of opposite
 
 CLASSIFICATION- ACCORDING TO DISEASE. 93 
 
 windows, etc., to admit of easy ventilation and plenty 
 of suuliglit; 5. Tliat eacli ward should liave certain 
 necessary accessory or service rooms connected with 
 it ; 6. That the buildings or pavilions containing the 
 patients should be separated some distance from each 
 other and all other buildings, and connected with the 
 administrative building and the other pavilions by a 
 corridor or simple inclosed passage-way.* 
 
 These ])rinciples were plainly and definitely given 
 in the report of the committee appointed, from the mem- 
 bers of the French Academy of Sciences, to decide uj^on 
 a plan for rebuilding the IIotel-Dieu as early as 1V86. 
 
 Notwithstanding the fact that previous to 1860, 
 with only three or four exceptions, civil hospitals were 
 not constructed in accordance with the above princijoles, 
 still, since the completion of the Lariboisiere in 1854 on 
 the plan proposed by the French Academy's committee, 
 the above ideas have been in the main accepted, and in 
 most of the hosj)itals erected after 1860 they have been 
 carried out with various modifications, while, since the 
 apj^earance of Miss Nightingale's book, the " pavilion 
 plan " has become very popular. Accepting the above 
 principles, we proceed with our plan. 
 
 Classification of the Patients according to tlieir 
 Diseases. — We do not accept the usual custom of hav- 
 ing one j)lan of wards for all the patients of a general 
 hospital, and, since the character of the ward is to 
 depend upon the class of diseases to be treated in it, 
 we will first indicate a general system of classification : 
 
 ^ "We refer our readers to Miss Nightingale's book, " Notes on Hospi- 
 tals." In it will be found the best argument in favor of the pavilion plan 
 and against the old, massive, many-storied hospital-buildings now in use.
 
 94: CONSTRUCTION^ OF A CIVIL HOSPITAL. 
 
 Class L — ^Non-infected cases aucl those not liable 
 to become so or to infect others — as rheumatism, dis- 
 eases of the heart, liver, kidneys, etc. 
 
 Class II. — Non-infectious cases and not dangerous 
 to others, but liable to become infected — as slight 
 wounds, scalp-wounds, with slight fracture of skull, etc. 
 
 Class III. — ^Non-infectious, but liable to become so, 
 and dangerous at all times to others — as sloughing 
 wounds, burns, etc. 
 
 Class IV. — Infectious and contagious cases — as pyae- 
 mia, septicaemia, erysipelas, gangrene, etc. 
 
 The Ward. — Shall each ward be in a separate 
 pavilion, or shall there be two or more wards in each 
 pavilion ? 
 
 No one will attempt to deny that one-story pavil- 
 ions are more easily ventilated and have proportionate- 
 ly a greater surface exposed to sunlight than a build- 
 ing of two stories, and that the isolation of the patients 
 of a one-story ward is more complete than it is practi- 
 cable to attain in a pavilion containing two wards. 
 
 It is said that one-story pavilions are more expen- 
 sive: because, to build a hospital of one-story, more 
 ground-space is needed than for two ; that two pavil- 
 ions of one story are more costly than one pavilion with 
 two wards, as there are an extra roof and foundation ; 
 that the administration is more difficult ; and that it 
 requires more fuel to heat wards in separate, one-story 
 buildino;s. 
 
 In answer to the first objection as to the ground, 
 space, we would say at once, if there is not sufficient 
 ground for one-story buildings, then do not put up so 
 large a hospital, or select another site where land is
 
 COMPARATIVE COSTS OF COXSTRUCTIOIT. 05 
 
 cheaper ; liaving, if necessary, small receptioii-liospitals 
 and ambulance-wagons to transport the patients. It is 
 by no means certain that wards, one directly above the 
 other, are better placed than when separated, even 
 though the space between is not great. It is claimed 
 that germs float horizontally. But we know how soon 
 the outside air will dilute and dissipate foul air ; be- 
 sides, we know that almost all building-material is per- 
 meable to air which readily passes from one chamber 
 to another, although there are no communicating doors. 
 
 In answer to the second objection, as to the cost of 
 building — it is true there must be an e5:tra roof and 
 foundation, but the foundations need not be so deep nor 
 the walls so heavy in one-story as in two-story build- 
 ings, and there are no expensive stairways or elevators 
 as in the two-story buildings. We have examined the 
 contracts of various hospitals, and we are satisfied that 
 one-story pavilions are but little more expensive as 
 hospital-buildings than two-story pavilions, and not 
 so costly as buildings of many stories. 
 
 The new pavilion of the New York State Woman's 
 Hospital of three stories and an attic, to contain be- 
 tween sixty and sixty-five or seventy-five beds, has 
 already cost $108,000, and it is estimated that $30,000 
 more will be required to finish it ; and the New York 
 Hospital now being completed is a building of seven 
 stories, to contain a hundred and fifty beds. The con- 
 tract for the building alone is $432,000. This gives 
 for the Woman's Hospital pavilion a cost for the build- 
 ing alone of $2,143 to each patient, and of $2,836 for 
 the New York Hospital. The contract for the building 
 of the one-story pavilion of the Presbyterian Hospital 
 of Philadelphia for twenty-eight beds was only $12,000,
 
 96 CONSTRUCTION OF A CIVIL HOSPITAL. 
 
 or a cost of $428 for eacli bed. The lieating apparatus 
 and furnisliing made tlie total $15,000, or only $535 for 
 each bed. 
 
 Those who have had charge of hospitals of one-story 
 buildings claim that, as all the wards are on a level, 
 the administration is easier ; there are no stairs to keep 
 clean and ascend, nor elevators and lifts to work. We 
 admit that it requires more fuel to heat the one-story 
 wards, but we do not consider this an objection — on 
 the contrary, an advantage ; if fresh air enters the ward 
 so raj^idly, then we can be sure that the ventilation 
 is more perfect. In very cold climates double walls, 
 double roofs, and plate-glass windows, can be used. 
 
 Our conclusion is that, for the treatment of all the 
 classes of patients we have enumerated above, it is 
 desirable to have every ward in a separate, one-story 
 pavilion. For the treatment of cases coming under 
 Classes II. and III., it is essential that the wards should 
 be in one-story pavilions. For the treatment of Class 
 IV., isolated huts or tents are absolutely necessary. 
 
 Shall the Buildings he permanent or temporary in 
 Character f — The ancient Jews recos-nized the fact that 
 leprosy would infect the walls of a house, and that it 
 was necessary to scrape and purify the walls, and in 
 some instances entirely destroy the house, to prevent 
 the spread of the disease. And it is an undisputed 
 fact that certain infectious diseases will poison at least 
 for a time an apartment so as to render it dangerous as 
 a habitation ; that every case of these infectious diseases 
 evolves poisonous matter, or germs that are liable to 
 cause the same or a kindred disease in other persons ; 
 that if not all, at least many, of these disease-germs, are
 
 DISEASE-GERMS AND DISINFECTANTS. 97 
 
 conveyed from one person to another by means of actual 
 contact of clotliing or other material which has been on 
 or about the person infected ; that the poison is spread 
 by the air itself becoming poisoned, or in some way con- 
 veying the poisonous matter or disease-germ ; and that 
 air charged with these germs or particles is liable to 
 deposit them on all surfaces, and in all the openings, 
 crevices, or pores, into and through which it permeates. 
 Now, the latest and most reliable experiments on these 
 infections germs or particles show that time has but lit- 
 tle, and in some cases no, apparent effect on their vitality 
 or power to reproduce disease, and that the substances 
 known as disinfectants cannot be said always to destroy, 
 but only to prevent for a time, the process of fermenta- 
 tion or decomposition, or the develojDment of those con- 
 ditions which seem to be essential to the active state 
 of generation and propagation of the poison. To have 
 even this influence, the disinfecting substance must be 
 of a certain strength, and be made to reach each parti- 
 cle or germ. 
 
 The conclusion is, that practically the majority of so- 
 called disinfectants do nothino; more than substitute one 
 odor for another, and that many of them when thorough- 
 ly applied can only be relied upon to allay for a time 
 the active condition of disease-germs. Without ques- 
 tion intense heat of several hundred degrees, and certain 
 strong corrosive substances, can be made" to destroy 
 these poisonous germs ; but, both experience and ex- 
 perimental science show that in many cases, to com- 
 pletely destroy these germs, without at the same time 
 injuring or destroying the substance or material infect- 
 ed, is impossible, and that practically the task is so 
 difficult that it is better to remove, and not infre- 
 7
 
 98 COHSTRTJGTION OF A CIVIL EOSPITAL. 
 
 quently it is best to destroy, tlie infected substance or 
 material. 
 
 It is a well-kno\vn fact that nearly all building- 
 material is permeable to air. Lately Pettenkofer bas 
 sbown by experiment that a difference of temperature 
 in tbe air of a closed room from that of the outside air 
 causes a free flow through the walls of the room, and 
 that the quantity of air passing through varies accord- 
 ing to difference of temperature, or inequality of atmos- 
 pheric pressure, and the character of the wall ; but that 
 through all walls more or less air will pass, and that 
 the quantity of air that will pass through an ordinary 
 brick wall, with the usual plastered surface, is very 
 great. He says that in the case of an ordinary room, 
 with the windows and doors closed, mth an open fire 
 burning, more than half the air that enters the room 
 and passes up the chimney comes directly through the 
 walls. 
 
 If it is true that infectious geims are floating about 
 in the air, and that the walls are permeable to air, then 
 it is easy to understand that the walls of an apartment 
 would be liable to infection. There are facts that go 
 to show that walls do become infected with the poison 
 of disease. One striking instance is that which oc- 
 curred in 1864, when a ward in which fever-cases had 
 been treated in the old New York Hospital was being 
 renovated. "Out of five masons who were removing 
 the plaster, three died of fever in a few days." * 
 
 We do not doubt but that perfect cleanliness and 
 careful attention to ventilation, etc., will do much to 
 prevent the infection of the walls, and to obviate the 
 
 • Mr. J. "W, Beekman's " Centennial Address " before the Society of the 
 i^ew York Hospital.
 
 ^
 
 CHARACTER OF TUE WARD. 99 
 
 cLaiiger "svlien tliey are infected ; still many eases will 
 arise wliere the saturation of the walls of a buildino: in 
 wliicli a number of infectious cases liave been treated is 
 such as to demand complete destmction. Disinfection 
 and j^urification by exjDOSure to the weather may for a 
 time remove the danger, but cannot be relied upon as 
 certain and lasting preventives. Practically it is a very 
 expensive and difficult matter to secure impermeable 
 walls ; and even if walls could be made impermeable to 
 air, it is doubtful if they are desirable, on account of 
 preventing a free circulation of air through them, and 
 thus interferino- with ventilation. 
 
 In answer to the question " Should the wards (not 
 the entire pavilion, for we have the service-rooms in a 
 separate building) be permanent or temporary in char- 
 acter?" we would suggest that the pavilions for the 
 first and second classes of cases enumerated be perma- 
 nent in character, but that those for the third class 
 should be more or less temporary ; those for the fourth 
 class, of course, to be frecpiently destroyed and re- 
 newed. 
 
 JSi'umler of Beds to each Ward. — Givins: full con- 
 sideration to the number of sick that should live in £>ne 
 room, and to economy in having them properly attend- 
 ed to, from twelve to thirty-two has been found by 
 experience to be about the range. 
 
 Just as the character of a ward should depend upon 
 the class of disease to be treated in it, so should the 
 number of beds in each ward vary with the class of dis- 
 ease to be treated in them. 
 
 For medical and other cases not infectious or liable 
 to become so, we would place the number of beds at
 
 100 COXSTRUCTIOF OF A CIVIL HOSPITAL. 
 
 from twenty-five to twenty-nine ; for surgical and otlier 
 cases not infectious but likely to become so, from nine- 
 teen to twenty-five ; for severe cases extremely liable 
 to become infectious, and always dangerous to others, 
 the number of beds to the ward should not be more 
 than from twelve to sixteen.' 
 
 Infectious and contagious cases in connection with 
 a general hospital should be at once removed to tents 
 or huts containing not more than from two to four beds. 
 The number of beds should by no means be the same 
 as the number of patients in every ward, especially 
 when two or more severe cases are in it. There should 
 always be at least three or four beds empty, so as to 
 give time for changing and cleaning them, and so that 
 the beds adjacent to any special cases could be left 
 vacant. 
 
 The Cubic Air-Space to each Bed. — In regard to the 
 air, the important point is to insure a rapid, constant, 
 and comj)lete change of the atmosphere surrounding 
 the patient, and to efi'ect this without causing hurtful 
 draughts. For the convenience of administering to the 
 Avants of the patient, it is essential to allow a certain 
 amount of cubic air-space and surface area. About 
 1,800 cubic feet of air-space, with a surface area of 124 
 square feet, has been adopted as the space required. 
 We would have the space vary in accordance with the 
 class of disease to be treated in the bed. 
 
 The dimensions of the suro-ical ward containino- 
 twenty beds should be the same as the medical ward 
 
 ' The above figures are given supposing the dimensions of the wards for 
 all three classes to be the same, thus giving more than double the cubic air- 
 space to the third class that is allowed to the first class.
 
 SHAPE AND SIZE OF WARD. 101 
 
 for twenty-five beds, and tlie ward for twelve danger- 
 ous cases sliould be the same size. Thus, say that 
 1,800 cubic feet in the medical ward are allowed for 
 each bed, the allowance in the sursrical ward would be 
 2,100 cubic feet, and 3,600 cubic feet in the ward for 
 dangerous cases. 
 
 Slicqye of the Ward. — The shape of the ward usu- 
 ally recommended and very generally adopted is that 
 of a rectangle, with- a width of from twenty-four to 
 thirty feet, and a length varying with the number of 
 beds, usually about three times the extent of the width. 
 The height commonly adopted is from fourteen to six- 
 teen feet. 
 
 Within the last four years,^two wards have been 
 constructed in connection with the Massachusetts Gen- 
 eral Hospital at Boston, one of which is forty-four feet 
 square and the other forty-five by fifty-five. The square 
 ward has some advantao-es over the elonsrated, rectan- 
 gular form ; but, except in those cases where the num- 
 ber of beds in the ward is so small that the square 
 would not be more than thirty feet, and at the same 
 time allow sufficient air-sj^ace, we would give the pref- 
 erence to the elongated ward. 
 
 It is true that in the square ward the fireplaces or 
 stoves, and the ventilating-shafts, can be placed in the 
 centre of the ward, and thus be more nearly equidistant 
 from all the beds, whereas in the lono; ward two such 
 shafts are necessary, and that in the square ward the pa- 
 tients are all nearer, and more convenient to the service- 
 rooms. But in the long ward there is more wall-space, 
 and therefore the beds are not so near each other, as in 
 a square ward of the same capacity ; and if the square
 
 102 CONSTRUCTION OF A CIVIL HOSPITAL. 
 
 ward exceeds thirty feet, tliere is a greater volume of 
 air to be moved between o^^j^osite windows, tlie sun- 
 light does not so completely reach all parts of the ward, 
 and the surface of the ground beneath is further re- 
 moved from the purifying influences of light. In the 
 square ward the patients are nearer the service-rooms, 
 but at the same time they are more in danger of infec- 
 tion from that source. Then, too, if the service-rooms 
 are attached to one of the four sides of the ward, one- 
 fourth of the whole wall-surface is cut off from the out- 
 side air. 
 
 We would make the ward thirty feet wide, fifteen 
 feet to the roof at the eaves (the roof having a slant of 
 not less than thirty degrees), and long enough to give 
 for the medical ward, nine feet of wall-space to each 
 bed, for the surgical ward not less than ten feet, and 
 sixteen feet for the ward for dans^erous cases. 
 
 Position of the Ward in Relation to the Points of 
 the Compass. — If the long, rectangular ward is adopted, 
 then it is essential that the long axis of the ward should 
 be from north to south, so that the sun will shine half 
 the day on one side, and the other half on the opj)osite 
 side, thus exposing the largest possible surface to the 
 influence of the direct rays of the sun. 
 
 Position of the Service-Rooms. — ^The usual plan is 
 to attach the service-rooms of the ward directly to the 
 ends of wards ; the nurse's room, dining-room, ward- 
 kitchen, and extra room or small ward containing one 
 or more beds, being attached to the end of the ward 
 nearest the corridor, being in reality a part of the ward 
 partitioned off with a hall-Avay through its centre and
 
 COXNBCTIOy OF SERVICE-ROOMS WITH WARD. 103 
 
 connecting directly with the corridor which is usually 
 on the same level as the floor of the ward. At the 
 other end of the ward, in the corners, the water-closets 
 and bath-room are usually placed, being cut off from 
 the ward by lobbies. In some cases the ends of the 
 wards containing these service-rooms are -widened so as 
 to leave a broad passage-way between them, at the end 
 of which there is a larg-e mndow. 
 
 o 
 
 The service-rooms should be separated from the 
 ward and in a distinct building, placed at the north 
 end of the ward, and connected with it by means of a 
 shoi*t corridor. This corridor, or short passage-way, 
 should project from near the centre of the service-room 
 building until it reaches a point when, by a turn at 
 right angles, it could connect with the war J, opening 
 into the ward on the side in the corner. This short 
 23assage-way should be about six feet wide, so as to 
 allow a man to be carried throu2:h it on a stretcher. 
 It should be carefully guarded by swing-doors where it 
 turns at right angles and where it enters the ward, so 
 that it would be impossible for a current of air to cir- 
 culate through it from the service-room to the ward, 
 and it should be well lighted and carefully ventilated. 
 Thus we have the ward completely isolated. 
 
 The objects aimed at are — 1. To avoid the danger 
 which is to be apprehended from the proximity of the 
 numerous partitions, doors, etc., of the service-rooms as 
 affording places for harboring infection, and from the 
 emanations from water-closets, drains, sinks, and dining- 
 rooms ; 2. To diminish the risk of the foul air of one 
 ward reaching other wards by means of the corridors ; 
 3. To leave the ends of the ward free, so that a current 
 of air can pass through the ward as readily from end to
 
 104 COFSTEUCTIOF OF A CIVIL HOSPITAL. 
 
 end as from side to side ; 4. That if need be, on account 
 of tlie ward's becoming infected, it can be destroyed, 
 leavino; tlie basement and service rooms and tlie corri- 
 dors intact. 
 
 In a long ward it is very important that its ends 
 should be free, so as to allow a current of air to j)ass 
 freely and without the risk of bringing infection from 
 the service-rooms, for in all long, narrow chambers the 
 natural current of the inclosed air is in the direction 
 of the long axis, being that of the least resistance. Be- 
 sides, during the summer months, when the windows 
 are open, the prevailing winds in our vicinity are from 
 tbe south, and a current of air passing from end to end 
 moves a volume of air in the ward through an open end- 
 door or window, equal to at least three times as much 
 as one passing through a window from side to side. 
 
 The Foundation of the Ward. — The foundation of 
 the pavilions of a temporary hospital, such as is needed 
 during a war, may be of a very simple character; but 
 in a fixed, civil hospital the foundation should be care- 
 fully prepared, especially if the soil is not just what it 
 should be. The ward should rest on pillars of masonry 
 seven or eight feet above the level of the surface of the 
 ground, and arched, so that the floor of the ward would 
 rest on an asphalt and concrete surface to give it firm- 
 ness and protection from cold. If the pillars are of 
 brick, they should have layers of slate in each to inter- 
 cept the passage of ground-air up through them. The 
 surface of the ground beneath the ward, between the 
 arches and for several feet around the building, should 
 be covered with several inches of concrete and asphalt, 
 and left open to the air and Sun ; for we know that air
 
 OBJECTIOSS TO BASEMENTS AND CELLARS. 105 
 
 circulates freely in the ground, and tLat a lieated. room, 
 when the doors and tlie windows are closed, draws 
 air directly from the ground ; and that, as malarial 
 and noxious gases float near the ground, there is 
 constant danger of such gases being drawn into the 
 ward. 
 
 In very cold weather, if necessary, glass sashes could 
 be placed so as to close the space beneath the wards, 
 but it should not be kept closed, for we believe all 
 cellars and closed chambers of air, especially without 
 the influence of sunlight, to be injurious. The air 
 confined in such chambers becomes stagnant and pro- 
 lific of myriads of low grades of life, or living organ- 
 isms, which by decomposition soon infect it with poi- 
 sonous matter, and, when the chambers above are 
 heated, this foul air is sucked up into them through 
 the walls and floors. If the space beneath the ward is 
 left open and covered with concrete and asphalt, danger 
 from the ground-aii' is entirely prevented. 
 
 Material for huilding the Walls of the Ward. — :The 
 walls of the pennanent wards should be of well-made 
 brick, Avith an aii'-space between the inner and outer 
 surface so arranged as to connect with the space be- 
 tween the roof and ceiling, and be easily ventilated and, 
 if necessary, fumigated. We would give the preference 
 to bricks over wood, and to wood over stone, unless the 
 stone was porous and easily worked. As wooden walls 
 are cheaper than brick, we would use wood in construct- 
 ing the wards of a temporary character. Walls of wood 
 should be double, with an air-space between ; this is 
 necessary in severe climates to keep out the cold, and in 
 warm climates to prevent overheating. In warm cli-
 
 106 CONSTRUCTION OF A CIVIL HOSPITAL. 
 
 mates tlie space "between tlie walls sLould be arranged 
 so as to be easily ventilated and fumigated. 
 
 Should the walls of tlie wards be left permeable, or 
 an attempt be made to make them impermeable to air ? 
 
 The object in making the walls impermeable to air 
 would be to prevent them from becoming poisoned 
 with disease-germs, or infectious particles, or gases. 
 
 The object in leaving them permeable to air is to 
 allow a free circulation of air through them. It is 
 claimed that the constant passing of the air through 
 the walls is an imj)ortant part of ventilation ; that to 
 make the walls of our dwellings impermeable to air 
 would be as objectionable as to wear a rubber suit all 
 the time. Walls saturated with water are imjDermeable, 
 and it is said that this fact accounts for the unhealthi- 
 ness of houses with damp w^alls. 
 
 Besides interfering with ventilation, the expense of 
 making the walls impermeable to air is very great, and 
 practically very difficult to accomplish. Keen's cement 
 and Parian cement have been found about the best sub- 
 stances for wall-finish. Tiles and preparations of glass 
 have been proposed, and we have suggested sheet-zinc, 
 or sheet-iron plated with zinc, as a good material. 
 
 So far as impermeable walls, or walls supposed to 
 be impermeable, have been tried, in Lariboisiere and 
 St. Thomas's Hospitals, except that of being more easily 
 cleaned than the ordinary "hard-finish," certainly no 
 advantage can be claimed for them ; the practical re- 
 sults on the patients, so far as reducing the death-rate, 
 cannot be perceived. 
 
 It is very desirable that this question of imper- 
 meable walls should be tested by carefully-conducted 
 ex^^eriments and trials made under similar circum-
 
 PERMEABLE OR IMPERMEABLE WAULS? 107 
 
 stances. But since experience Las slio^yn tliat excel- 
 lent results — and, so far, better tlian in any otlier kind 
 of building yet tried — can be attained by treating dis- 
 ease in simple one-story buildings witli tlie ordinary 
 walls, we would adopt the ordinary " liard-finisli " for 
 the permanent buildings, and have the walls, when 
 well settled and dried, painted and varnished to the 
 height of six feet from the floor. For the walls of the 
 temporary pavilions the same or a cheaper material could 
 be used. Whenever the wall-plaster shows signs of age 
 by cracking or giving way, the plaster should be com- 
 pletely renewed, and it would be well, at intervals, to 
 scrape and renew the " hard-finish " in the permanent 
 wards, and to frequently give the walls of the tem23orary 
 wards a coating of kalsomine, and those for dangerous 
 cases a whitewashing after a thorough fumigation.' 
 
 llie Floors of the Ward. — The floors should be 
 laid on a firm foundation, so as not to spring or give, 
 and create cracks. The space between the beams be- 
 neath the floor should communicate with the space in 
 the walls so as to admit of ventilation and fumigation. 
 In Europe oak seems to be the best material, but in 
 this country the best hospital-floors we have seen are 
 made of closely-joined Georgia pine. The reason why 
 our oak floors are not usually good is, that the Quercus- 
 alba variety is the only oak-wood which will make good 
 floors, and it is very scarce here in America. 
 
 ' Mr. Dougall, of Glasgow, claims that the presence of alkaline sub- 
 stances induces decomposition of organic matter ; and he asserts that the 
 alkaline walls of hospitals, and the soap used in washing, tend greatly to 
 produce infectious germs and thus cause pyjemia and other hospital-dis- 
 eases. If this proves to ho true, then a complete change must be made in 
 the character of the walls of hospitals now in use.
 
 108 CONSTRUCTION OF A CIVIL HOSPITAL. 
 
 If pine is used, every plank sliould be carefully 
 selected as being well filled with resin, avoiding those 
 pieces in -wliicli after a little use the soft part will wear 
 away and the hard layers shale and splinter off, leaving 
 holes. Shaling does not depend npon the quality of 
 the pine, but upon the direction in which the saw cuts 
 the annual rings ; the saw should run as nearly as pos- 
 sible in the line of a radius from the centre of the log, 
 to turn out good flooring-planks. 
 
 The floors should be kept smoothly polished, waxed, 
 and rubbed, so as to make them impermeable to water 
 and easily cleaned without daily or frequent scrubbing. 
 
 The WlndoiDS. — There should be one window to 
 each bed. The height of them in all of the wards 
 should be from within two feet of the floor to within 
 one foot of the ceiling where it joins the wall. The 
 vddth need not exceed three feet in the medical and 
 permanent wards, but should be full three feet in the 
 temporary wards, and still wider in the wards for dan- 
 gerous cases. 
 
 All the wood-work, of which there should be as lit- 
 tle as possible about the windows and in the ward, 
 should be of hard wood, with all corners and edges 
 beveled off and every part of it kept well waxed and 
 polished. The window-sills should be of slate or stone. 
 
 For the sashes thick plate-glass, or single sash with 
 double glazing, is necessary in cold climates, and is 
 preferable to double sashes of small panes of thin glass. 
 Both sashes should be made to slide easily. The blinds 
 should be on the outside, and by a simple contrivance 
 could be worked from the inside without opening the 
 window-sash. In one-story pavilions with ridge-venti-
 
 WIND W- VENTILA TION. 109 
 
 lation, louvres over tlie windows are not necessar}^ "but 
 a narrow panel ten inches deep and as wide as tlie 
 door, just above tlie upper sash, should be hung witli 
 hinges at the bottom, so that it would pull out at the 
 top and direct the air upward on entering the ward. 
 
 We would place the windows directly opposite each 
 other. Alternate windows, or windows put opposite 
 to the wall-space on the other side, were tried in some 
 of the temporary army-hospitals in Paris during the 
 late Franco-German AYar. If a large ward had only a 
 few windows in it, such a disposition of them would be 
 an advantage, but, when they are as numerous as we 
 propose, we see no advantage to be derived from it. 
 
 The Doors and Roof. — In a ward there should be 
 three doors : one opening into the short corridor which 
 connects with the service-room building; the others, 
 one in each end of the ward, with a window on either 
 side. The doors should also be made of hard wood, 
 perfectly smooth, without mouldings or j^anels, and ke^^t 
 well polished. 
 
 The roof should be of slate, with an air-space be- 
 tween it and the ceiling of the ward. This space Should 
 communicate with the space in the walls, and be ar- 
 ranged so as to be easily ventilated and fumigated. 
 The ceiling should not be flat, but slope up and slant 
 parallel with the roof, and be rounded at the ridge and 
 where it joins the wall, so as not to have angles. The 
 wall in the four corners of the ward should be rounded 
 in the same way. 
 
 Tlie Piazza. — The door in the south end of the 
 ward should be wide enough to permit a bed to pass
 
 110 CONSTRUCTION OF A CIVIL HOSPITAL. 
 
 tliroiigli it, and should open on a piazza in summer and 
 a glass sun-room in winter. A platform or flooring, tlie 
 width of the ward, and projecting out twelve feet, with 
 a simple framework, over wljich an awning could be 
 stretched in summer and incased with sashes of class in 
 winter, would be all that would be required. A stair- 
 way or an inclined plane should connect the end of the 
 piazza with the ground. 
 
 THE SERVICE-ROOM BUILDING'. 
 
 The service-room building should be placed near 
 the north end of the ward, and sejDarated from the 
 ward by an open space of ten feet, and sufficiently at 
 one side so as not to overlap the end of the ward more 
 than one-fourth its width. In this position it would 
 not interfere with the end-to-end ventilation through 
 the ward, nor intercept the sunlight. 
 
 Dimensions of the Building. — ^To have a complete 
 set of service-rooms for a ward of twenty-five beds, the 
 dimensions of the building should be thirty-four feet 
 wide from east to west, by forty-six feet in length. 
 
 Tlie Basement. — The basement should be wholly 
 above-ground, so as to make the floor of the service- 
 rooms on a level with the floor of the ward. The base- 
 ment of this building should be divided into aj^art- 
 ments, for the heating apparatus, servants' bedroom, 
 and store-rooms, and should have a room where the old 
 clothes, boots, etc., and effects of the patients, could be 
 stored while in the hospital. In this room there should 
 be open-iuire cages built round against the walls, one 
 to each bed ia the ward, with doors and locks, instead
 
 SERVICE-ROOM BUILDING. Ill 
 
 of closed closets. In the end of tliis room, with a door 
 023enmg on the hall in the basement, there should be an 
 open-wire-work closet, in which Ijrooms and dust-pans 
 should be kept. The doors of this room should be 
 made to fit very closely ; for the window, instead of 
 having glass window-sashes, should be guarded by iron 
 bars, and arranged so that the rain would not beat in, 
 and left open, in order that the old clothes, etc., should 
 be continually exposed to the purifying influence of 
 fresh air. A closed apartment filled with these old 
 clothes, in a pauper-hospital, soon becomes a hot-bed 
 of infection. It should be a corner-room, so as to 
 have several windows, to prevent dampness. The stair- 
 way from the basement should be in the northeast cor- 
 ner, and be wide and easy of ascent, and ventilated by 
 three windows, and should be cut off from the hall of 
 the ser\dce-room building by a lobby with swing-doors. 
 
 The Service-Rooms. — The first floor should be di- 
 vided into two parts by a hall eight feet Avide passing 
 throusfh it from north to south. The south-end door of 
 this hall opens into the short corridor which connects 
 the service-room with the ward; and the door at the 
 north end of the hall should open out on the top of the 
 main corridor. 
 
 Wasli-Itoom and Wate?'- Closets. — On enterino- this 
 hall from the ward, on the south, there should be on 
 the left-hand side a door opening into a lobby, six by 
 twelve feet, containing a sink and four or more basins 
 for the use of the patients ; the lobby should have a 
 large window at the south end, and two doors besides 
 the one opening: on the hall, one of these doors leadinsr
 
 112 CONSTRUCTION OF A CIVIL HOSPITAL. 
 
 to the water-closets, wliicli slioiild be in a room eight by- 
 twelve feet, in the southwest corner of the building. 
 The closets should be three or four in number, and in 
 separate stalls, each stall having a window opening into 
 the outside air. 
 
 Batli-Room. — ^The other door of the lobby should 
 open into the bath-room, which is ten by fourteen feet, 
 with a door opening on the hall, and two windows into 
 the open air, having a movable bath on rollers which, 
 if necessary, could be run into the ward, and two stalls, 
 one for hot air, the other for steam-baths; the floor 
 should be impervious to water. 
 
 Day-Room and Dining -Room. — Next to the bath- 
 room on the same side of the hall, occupying the north- 
 east corner of the building, should be the ward day- 
 room, also used as a dining-room, and having a small 
 scullery with a little stove for heating and cooking cer- 
 tain delicacies (a good gas-stove would be sufficient for 
 this purpose), and a sink, etc. The day-room should be 
 fourteen by eighteen, and the scullery six by fourteen 
 feet. 
 
 An extra room or small ward for treating certain 
 cases, which would be better alone on account of being 
 troublesome to the other patients, should be provided. 
 This room should never be used for isolating infectious 
 or contagious cases. A door on the right, at the south 
 end of the hall, should open into this extra room or 
 ward, which should be twelve by eighteen feet, and 
 contain two beds — only one to be occupied by a patient, 
 the other to be used in case of the need of a special at- 
 tendant. There should be two windows, one oj^en to
 
 SERVICE-ROOM BUILDING. 113 
 
 tlie east and one to tlie south, and a ventilating open 
 fireplace in tlie northwest corner. 
 
 JVurse's Moom and Linen-Shelves. — ^The next door 
 on the right of the hall should open into a room twelve 
 by ten, in which should be open shelves — not closets to 
 cover that which should not be there — for the necessary 
 clean linen for the ward. This room should have a 
 window opening into the outside air, and a bed for the 
 ward-nurse, only to be used in case it is occasionally 
 thought advisable for any reason that the nurse should 
 not sleep in the nurse's home, or should remain near 
 the ward on account of some important case. 
 
 deception and Examining Hoom. — Beyond this 
 room, on the same side of the hdll, should be a room 
 ten by ten feet, with one window arranged so as to give 
 a good light. In this room should be an Oj^erating or 
 examining table and a closet for medicines, bandages, 
 etc., and a bed to be used by patients while recovering 
 from the effects of an ansesthetic. This is the reception 
 and examining room, also to be used for minor opera- 
 tions on patients, when it is not desirable to convey 
 them to the operating-theatre. 
 
 Every door in the service-room building should 
 have a large louvre over it, and be placed 023posite to a 
 door on the other side of the hall, so as to establish 
 direct cross-currents through the building. The door 
 leading into the short corridor should be low, not more 
 than seven feet, the height of the short corridor, so that 
 a large window could be placed above it, opening into 
 the outside air. The roof of the service-room building 
 should be a gabled roof; the walls of the building, like 
 8
 
 114 CONSTRUCTION OF A CIVIL HOSPITAL. 
 
 tliose of the ward, being fifteen feet from the eaves. 
 The ridge of the roof should be over the hall, with open- 
 ings in it for ridge- ventilation ; or, what would be bet- 
 ter, there should be a small cap-roof running the length 
 of and over the hall, with a space between it and the 
 main roof; the space to be protected by movable glass 
 sashes. 
 
 Such a service-room building as we have described 
 should be erected with the permanent wards for non- 
 infectious cases and those cases not dangerous to others, 
 but, in connection with the temporary wards of only 
 sixteen beds, the service-room building need not be so 
 elaborate. A building twenty-six feet square, divided 
 by a hall, and containing bath-room and water-closets, a 
 small day or dining room, an extra small ward, used 
 also as an examining-room, and a nurse's room, would 
 be sufficient. The service-room building in all cases 
 could be made permanent in character, for the ward 
 could be removed and renewed without affecting it. 
 
 Great care should be used to prevent any contagious 
 or infectious disease being treated in the small ward 
 in the service-room building, otherwise it will become 
 poisoned. 
 
 THE MAIN CORRIDOR. 
 
 Except where the severity of the weather makes it 
 necessary that there should be a closed passage-way 
 between the wards and the administrative building, a 
 simple covered way with a track for tramway-carriages 
 should be used, not only for the sake of economy, but 
 for sanitary reasons. A long, closed passage is apt to 
 have currents of air flowing through it in the direction 
 of its length, which are not diverted to any great ex-
 
 MAIN CORRIDOR OR PASSAGE-WAY. 115 
 
 tent by opening opposite windows, and tlius fonl air 
 is readily conveyed from one end of the corridor to 
 tlie other, and will find its way into any buildino- with 
 which the corridor is connected. 
 
 Besides, a corridor running over the ground is al- 
 ways an obstruction to the free circulation of the air, 
 and, when it is on the same level as the wards, which is 
 usually the case, it is a very serious obstacle to the cir- 
 culation of the outside air, and almost sure to convey 
 the foul atmosphere from one ward to another. 
 
 If it is sunken below the level of the ground, i. e., 
 is a basement corridor, then it is a chamber filled with 
 air continually fouling itself, on account of being de- 
 prived of good ventilation and sunlight ; and this foul 
 air is being constantly drawn into wards, esj)ecially in 
 the winter, when they are kept warm, and outside air 
 is barred out. 
 
 If a corridor must be the means of communication 
 between the buildings, then the wards must be on 
 basements hio;h enouorh to allow the corridor to be 
 wholly, above-ground, with its top not higher than on 
 a level with the floors of the wards. This would remove 
 the main objection to corridors as obstructing the free 
 circulation; but if they have direct connection with 
 the wards, or with a hall or lobby between the service- 
 rooms which has a direct connection with the ward, 
 there will yet be danger of their doing harm by carry- 
 in 2: foul air from one ward to another. 
 
 It is to obviate these dangers that we have pro- 
 posed that the wards should be on arched foundations, 
 raised so that the floor of the ward is eight feet from 
 the ground, and the service-rooms in a detached build- 
 ing connected by a short elbow-corridor guarded by
 
 116 CONSTRUCTION OF A CIVIL HOSPITAL. 
 
 self-closino" doors. The corridor witli its floor on a 
 level with tlie ground should be about eight feet high, 
 so that its top, as we have said above, would be on a 
 level with the floor of the wards, and be made to serve 
 as a walk to be used in pleasant weather in passing 
 from one buildinor to another. The inside of the corri- 
 dor should be about eight feet wide, and have a small 
 tramway-track for carriages in which the food and pa- 
 tients could be conveyed. There should be numerous 
 windows, and, except in very cold weather, those on 
 the south side should have the sashes removed. 
 
 The corridor should connect with the hasement of 
 the service-room building on the north end, so that, to 
 enter the ward from the inside of the corridor, it would 
 be necessaiy to go into the basement of the service-room 
 building, ascend the steps to the hall, and then go 
 throuo-h the short elbow-corridor. 
 
 From the top of the corridor to the end-door of the 
 ward there should be a bridge : during pleasant weath- 
 er the patients could thus walk directly out of the ward, 
 and take an airing without going either up or down 
 stairs. 
 
 In one of the five essays suggesting plans for the 
 Johns Hopkins Hosjoital, the author, accepting the idea 
 of separating the service-rooms from the ward, has given 
 a drawing in which the service-rooms are separate from 
 the ward, but are left on the line of the ward, and con- 
 nected by a short, straight passage. The objection to 
 such a plan is, that the end-to-end circulation is still 
 seriously interrupted, and the chance of a current find- 
 ing its way from the service-room building into the 
 ward is greater than when the service-room building 
 is at one side, and is connected only by an elbow-coiTi-
 
 MAIN CORRIDOR OR PASSAGE-WAY. 117 
 
 dor. From the fiict tliat tlie length of tlie ward and 
 the hall of the service-room are on a line, there will 
 always be a tendency to draw a current through the 
 neck ; besides, the air fi-om the windows of tlie service- 
 room can readily find its way into the end-windows of 
 the ward. 
 
 The same author gives a drawing in which the main 
 corridor passes between the ward and service-room 
 building, the connecting neck being on top of it, thus 
 obliging all passers-by to go through it. As the top 
 of the corridor will be used during the greater part of 
 the year for the general passage-way to tlie pavilions, 
 the communication between the ward and the service- 
 room would be very much exposed, and the patients 
 would be subjected to unpleasant encounters with any 
 one who might be passing ; besides, the corridor would 
 be so close to the ward that, during the winter months, 
 air from it would be drawn up into the wards.
 
 CHAPTER V. 
 
 WARMIlSrG ATfD VENTILATION. 
 
 Waeming an apartment would be an easy and very 
 simple process, if it were not a necessity to have the air 
 frequently changed or the apartment ventilated ; and if 
 it were not necessary to warm the air that enters the 
 room, ventilating an apartment would be comparatively 
 easy. During cold weather the two must work con- 
 jointly. 
 
 That system of warming and ventilating is the best 
 wliich can most rapidly and comj)leteIy remove all foul 
 air and replace it with air as pure and fresli as the 
 normal atmospliere that passes over tlie huilding^ and at 
 the same time keep the room at a comfortable tempera- 
 ture, and accomplish this without causing disagreeable 
 or hurtful draughts, injuring the building, or disturbing 
 the inmates, and at the smallest cost. 
 
 Since so many conditions must be fulfilled to secure 
 perfect ventilation, it is easy to account for the great 
 difficulty in attaining good ventilation, and to see why 
 so many plans have been tried and why so many fail. 
 
 There are two distinct and opposite ways of chang- 
 ing the air in a ward : one is to draw off the foul air by 
 suction exhaustion, and allow fresh air to be forced in
 
 DIFFERENT METHODS OF VENTILATING. 119 
 
 by atmosplieric pressure. The type of tlie metliods for 
 ventilating by suction is the open fireplace. 
 
 The other way of renewing tlie air is by driving 
 fresli air into the ward and displacing the foul air by 
 the application of mechanical force. The type of the 
 methods for ventilating by means of mechanical force is 
 the fan-ventilator. 
 
 The term " natural ventilation " has been applied by 
 writers on hospitals to the method by suction used in 
 conjunction with the windows, and " artificial ventila- 
 tion " to that by propulsion or the fan-ventilator. The 
 terms " ventilation by exhaustion " and " plenum venti- 
 lation" are also used. 
 
 In ventilation with open fire2:)lace the air enters 
 directly from the outside and is warmed in the ward ; 
 but, when the fan is used, it is necessary for the air to 
 pass through a channel and be warmed in cold weather 
 before it enters the war^. On this account, when the 
 method by propulsion is used, the following dangers 
 must be o;uarded aixainst : That the air before it enters 
 the ward has not taken up any foul gas or substance ; 
 that it has not lost any of its oxygen or other elements ; 
 that it has not been expanded by heat without a proper 
 amount of water being added ; that it has not been de- 
 tained in its passage long enough to become stagnant. 
 
 Air should not be allowed to stand still, especially 
 in the dark. With the light on it there will be motion, 
 for light produces heat, and heat causes expansion, and 
 expansion induces currents, unless the heat is equally 
 distributed, which is never the case. Air, like water, to 
 keep pure and fresh, must be in motion. Air, when con- 
 fined, in a very short time, from the germs that all air 
 seems to contain to a greater or less extent, will foul it-
 
 120 WARMING AND VENTILATION. 
 
 self by tlie biiili, life, deatli, and decomposition, of ani- 
 malcules, and soon loses its vitalizing power. 
 
 In ventilating by exhaustion all the foul air passes 
 out by one or a limited number of channels, while fresh 
 air enters wherever there is an opening and directly 
 through the walls if these are permeable to air. It is 
 estimated that in an ordinary house, with closed doors 
 and windows, one-half of all the air enters through the 
 walls. 
 
 In ventilating by propulsion all the fresh air enters 
 the ward by one channel, or necessarily a limited num- 
 ber of channels, while it escapes from the ward wher- 
 ever there is an opening, and through the walls if these 
 are permeable to air. "When the doors and windows 
 are closed we can assume that half the air passes 
 through the walls. Now, if the walls are permeable 
 to air, and if there are organic particles and disease- 
 germs floating in the air, it is very evident that, if half 
 of this foul air is forced through the walls, the walls 
 would be saturated in a very little while with poison- 
 ous matter, and that a strong wind impinging on the 
 outside wall would be liable to force this poisonous 
 matter back into the ward. Besides, such an accumu- 
 lation of poison would always be a source of danger. 
 Therefore, if the plenum or propulsion method is adopt- 
 ed, the walls of the ward sliould he impermeahle to air; 
 while, if the method by exhaustion or suction is used, 
 the incoming air would tend to purify j^ermeable walls 
 instead of poisoning them. 
 
 In the suction method half the fresh air permeates 
 and imperceptibly enters the ward, while all the fresh 
 air in the plenum method comes through the air-ducts. 
 Thus the fresh air in the plenum method would produce
 
 ASPIRATION VERSUS PROPULSION. 121 
 
 mucli greater clrauglits tliaii in the method by exhaus- 
 tion. These draughts would be very objectionable un- 
 less the air was warmed before entering the ward, and 
 even then Avould often be disagreeable. This fact also 
 explains why the anemometer shows motion more readi- 
 ly in a room ventilated by a fan than in one ventilated 
 by an open fire : it is commotion to a certain extent, and 
 not the steady flow created by an open fire. 
 
 The open fire is troublesome, and causes dust and 
 dirt ; and, unless some plan is adopted by which a part 
 of the heat that would ascend the flue is utilized, the 
 open fire could be called expensive. But, by regulating 
 the draughts and by using air-jackets, or hot-air cham- 
 bers so arranged as not to bate the air, an open fire can 
 be made comparatively inexpensive. 
 
 Practically the method of ventilating by the fan 
 cannot be applied to each detached ward separately 
 except at great expense; but one fan, by a long air- 
 duct, must be made to supply several wards with fresh 
 air, and to do this without in any way changing the 
 normal condition of air is a great difficulty, especially 
 in winter, when the air is heated before it enters the 
 ward. 
 
 To obviate somewhat this difficulty, we would sug- 
 gest that the air-duct from the f^m to the Avards, instead 
 of being underground, and made of brick and cement, 
 be raised several feet above the ground, and be made 
 principally of glass. This would give it sunlight, and 
 remove the dansfer of OTound-air. 
 
 To prevent the air when heated before it enters the 
 ward from becoming dry — as it will by expansion of its 
 vblume and consequent increase of its capacity to absorb 
 water — the heated air, instead of passing over water for
 
 122 WAEMIXa AXD VENTILATION. 
 
 only a sliort distance or having at one point steam-spray 
 thrown on it while passing as is the usual mode adopt- 
 ed, should be made to pass for some distance directly 
 over a broad surface of running hot water, so as to give 
 time (which is an important element) for the air to 
 absorb sufficient water before reaching the ward. 
 
 In public buildings, where for a short time a large 
 number of people are necessarily closely crowded to- 
 gether, such as churches, schools, theatres, legislative 
 halls, on board stcamshij)s, and in all hadly -constructed 
 liosjyitals or other inhabited buildings, ventilation by 
 the plenum method or the use of a fan is perhaps the 
 most available plan ; but we do not consider it the best 
 method of ventilating one-story pavilion-hospitals when 
 the wards are widely separated from each other and 
 from all other buildings. If the plenum method is the 
 best method, then why not build the pavilions with 
 many stories, and only wide enough apart to admit 
 sunlight, and keep the fan going winter and summer, 
 havino" the fresh air brouMit from a distance ? 
 
 We do not discard the use of fan-ventilation in one- 
 story wards upon theoretical grounds, for we are aware 
 that many scientific experimentalists have decided in 
 favor of the plenum method of ventilation as compared 
 with any other method ; but, so far, practical exj)erience 
 in hospitals has shown that the one-story pavilion-hospi- 
 tal with the exhaustion method, or so-called natural ven- 
 tilation, has given the best results in curing the sick, and 
 has produced fewer cases of hospital-disease than any 
 other. 
 
 We should be satisfied to alter our choice if by 
 actual trial the fan-ventilation proved to be beneficiaL 
 But the success attained in one-story ward-pavilions
 
 DIFFERENT METHODS OF WARMING. 123 
 
 witli open fires leaves little to be desired — not enougli 
 to warrant any effort toward a change by experiment- 
 ing on a large number of wards ; nor is a change desir- 
 able, except in so far as economy is concerned. 
 
 Warmiiig. — Heating may be classed under two gen- 
 eral heads : 
 
 1. By direct radiation ; that is, by rays of heat ema- 
 nating directly from the incandescent body in which 
 chemical changes are producing heat. The open fire is 
 the type and the only method now in use. Charcoal- 
 braziers are rarely used since chemistry has demon- 
 strated the danger from the gases given off by combus- 
 tion. 
 
 2. By indirect radiation ; that is, by the heat being 
 transmitted first to some intermediate body and thence 
 to the air and bodies in the ward. The closed stove, 
 coils heated by steam or hot water circulating in them, 
 and hot-air furnaces, are the usual methods adopted. 
 
 The du'ect radiation, or open fireplace, is a much 
 more cheerful and in every way more agreeable method 
 of heating to most persons, except for the accompanying 
 dust which it is difficult entirely to avoid. The open 
 fire does not seem to materially change or injure the 
 normal constituents of the air. 
 
 The hot-air furnace is the least desirable method. 
 It has all the bad qualities of the stove, without the 
 advantage of the slight ventilating draught of the stove, 
 while, being out of sight, a hot-air furnace not only con- 
 tinually bakes the dust, etc., in the air and deprives the 
 volume of air of its normal amount of air-moisture, but 
 it is also liable to become red hot, and poison the air 
 with carbonic oxide which passes through red-hot iron
 
 124 WAEMMG AND VENTILATION. 
 
 as readily as tlirougli a sieve. A poorly-constructed or 
 badly-managed stove is as objectionable as a furnace. 
 
 Steam-heat at low pressure is not so bad as tbe 
 above, but is not so agreeable or desirable as the heat 
 from hot-water coils. Coils of hot-water pipes can be 
 kept at a very low temperature, and, by using a large 
 number, the air can be heated to an agreeable warmth 
 and without materially injuring it, the air passing slow- 
 ly and in a large stream over the coils before it enters 
 the room. But, to produce this very desirable effect, on 
 account of the large amount of pipe required, it is a 
 more expensive method than open fires. Still, by hav- 
 ing the water below 200° Fahr., as coils are more easily 
 managed than open fires, they are very useful as an 
 auxiliary or supplement to open fires in heating and 
 ventilating a hospital- ward. The Chinese warm their 
 houses by means of furnaces which heat the floor and 
 walls of the ajiartment, the hot-air chambers being 
 beneath the floor and between the walls. In the best 
 houses the air is not allowed to pass directly from the 
 hot-air chambers into the room, but must transmit its 
 heat throu2:h the medium of the solid walls. If heat- 
 ing is the only object aimed at, such a method is very 
 economical, and the warmth is evenly distributed ; but 
 it would be next to impossible to secure walls so per- 
 fect that they would prevent entirely the passage of the 
 gases of combustion from entering the room. Besides, 
 the advantage of porous walls would be lost, and ven- 
 tilation would be difficult. 
 
 Open fires have this very great advantage over any 
 other method of heating a hosjiital-ward, that at the 
 same time they heat they prove to be powerful venti- 
 lators.
 
 PROPOSED METHOD OF WARMING. 125 
 
 We give below wliat we consider one of the best 
 methods of ventilating and heating a one-story ward 
 such as we have described as being thirty feet wide by 
 one hundred feet long. 
 
 Ward Heating and Ventilation, — In each ward 
 there should be t^vo main heatins: and ventilatinsf shafts 
 placed at a distance of twenty-five feet from either end 
 on the long axis of the ward. They should be circular 
 columns of masonry about three and a half feet in 
 diameter, passing up from the basement through the 
 ward and above the roof. In these shafts there should 
 be two open fireplaces or open soai:)stone stoves with 
 their backs to each other and facing the line of the short 
 axis of the ward. From the outside a duct for fresh 
 air, with a liigli lead so as to get pure air and avoid 
 surface or ground air, should lead to a hot-air chamber 
 behind each fireplace, which should have an exit for the 
 wanned air into the ward about three and a half feet 
 from the floor.' This exit should be covered and res^u- 
 lated by a register on the sides of the ventilating shaft 
 facing the side-walls of the ward. The four fire2:)laces 
 would usually be sufficient to heat the ward, but, as an 
 auxiliary in severe weather, there should be boxes of 
 hot-water coils between the walls in each of the four 
 corners of the ward, which would connect with a fresh- 
 air duct from the outside, and have warm-air registers 
 opening in the ward near the floor. These hot- water 
 coils could be placed just below the floor, in boxes well 
 protected from the cold, having valves in tlieir fresh-air 
 ducts, with handles in the ward, so as to easily regulate 
 
 ' These hot-air chambers should be so constructed as not to overheat or 
 bake the incoming fresh air.
 
 126 WARMING AND VENTILATION. 
 
 tlie amount of cold air admitted. The hot-water pipes 
 could run between the floor or in well-protected boxes 
 just beneath the floors. 
 
 Ward Ventilation. — During the winter the four 
 open fireplaces should be the principal ventilators. 
 The means of admitting fresh air should be the ducts 
 connected with the hot-air chambers behind the fire- 
 places, and the boxes of hot- water coils, the small sash 
 on hinges at the top of the windows; and, besides, 
 there should be three fresh-air ducts, one in the centre 
 of the ward, and the other two between either chimney 
 or ventilating; shaft and the ends of the wards. These 
 fresh-air ducts should be about twelve inches in diame- 
 ter, extending directly through the ridge of the roof to 
 a short distance above the roof, where they are protect- 
 ed by a cap, and where the fresh air enters them. At 
 this end there should be a cover or valve that could be 
 worked from the ward to cut off the draught at pleasure. 
 
 These ducts, made of thick wood, so that the aii' of 
 the ward would not readily heat them, should project 
 down into the ward until within seven and a half feet 
 of the floor, where there should be an adjustable scatter- 
 plate placed beneath the open end, to prevent the cold 
 from falling in a mass and to divert any chance out- 
 ward currents, and at the same time scatter the fresh 
 air and direct it upward. We have thoroughly tested, 
 this method of admitting the fresh air by two such 
 shafts in a hut with an open stove, and find that it 
 admits cold fresh air into a heated room to better 
 advantage than any method we have seen. 
 
 The objects aimed at in contriving these air-ducts 
 were — 1. To introduce cold fresh air and avoid
 
 PROPOSED MEinOD OB YEXTILATIOX. 127 
 
 draughts ; 2. To introduce the heavy cold air in such 
 a way that in falling to the floor it would assist venti- 
 lation by driving the foul air downward and outward. 
 This method of introducing the cold air forces the foul 
 gases and effete and poisonous organic matter down- 
 ward, which is the dii^ection they naturally take when 
 undisturbed by currents of some force in an upward 
 direction. With every expiration a certain amount of 
 carbonic-acid gas and effete organic matter is thrown 
 off by the lungs. The carbonic-acid gas, being of a 
 higher specific gravity than air, sinks to the floor. The 
 organic matter, when first thrown off, is held in solution 
 by the watery vapor of the breath. This watery vapor, 
 comfeis: in contact with cold air, condtenses and carries 
 with it, either in solution or in the form of solid 2:)arti- 
 cles, the organic matter to the floor. If the vapor does 
 not condense, the water is taken up by the air and the 
 organic matter set free in the form of solid particles, 
 which soon fall to the floor. This and similar effete 
 organic matter is what either produces or at least forms 
 the nidus for disease-germs. Now, it is found by ex- 
 periment that in the air of a closed chamber, where 
 the atmosphere has been still for some time and is left 
 undisturbed by currents, these germs will also settle, 
 so that fresh meat, milk, or vegetables, will remain for 
 days undisturbed by the process of decomposition or 
 fermentation, which always indicates the presence of 
 spores or bacteria, the product of these invisible germs. 
 From the above it is plain that a downward current 
 would remove these poisonous gases and particles by 
 the most direct route and in the direction they natu- 
 rally tend to take when left to themselves, and it is 
 equally obvious that agitation of the air and upward
 
 128 WARMING AND VENTILATION. 
 
 currents cause tliem to float about and settle and adhere 
 to tlie walls and remain longer in wards. 
 
 3. That while descending the air would be moder- 
 ately warmed and thus avoid a cold stratum of air 
 along the floor, which is likely to be the case in rooms 
 heated by open fires, and is sure to be the case if the 
 cold air is admitted at or near the floor or in the side- 
 walls. The descending shaft is necessary, for any open- 
 ing in a heated room that is in or near the ceiling will 
 act as an exit for the heated air which always tends to 
 ascend, unless the counter-suction is very powerful and 
 the air of the room but slightly heated. 
 
 In connection with these fresh-air ducts — to j)erfect 
 the process and prevent the fresh cold air as it leaves 
 the ducts from being drawn toward and uj:) the chim- 
 ney in 23lace of the foul air — there should be a number 
 of openings in the floor about three feet from the walls 
 and directly under the beds. These openings should 
 lead into foul-air ducts which run between the floors 
 and connect with a large foul-air shaft in the column 
 of masonry surrounding the flues of the two fireplaces. 
 The flues of the fires should be of thin iron so as to 
 heat this large foul-air shaft and cause a powerful suc- 
 tion on the smaller foul-air ducts. In the trials that 
 were made in the hut alluded to — a hut twenty feet 
 square with two descending fresh-air ducts — there were, 
 connected with the large shaft surrounding the stove- 
 pipe, three foul-air ducts with openings under the beds. 
 When a fire was lio-hted in the stove, shavino-s were 
 drawn into the openings under the beds and were car- 
 ried along up and out into the open air. 
 
 In the permanent wards with twenty or more beds 
 there should be a foul-air duct opening under each bed.
 
 FOUL-AIR ESCAPES. 129 
 
 These foul-air ducts should Le al)out six inches in diame- 
 ter, of cast-iron as perfect as the best gas-pi [)es, and so 
 arranged that with a graded slope and by means of 
 openings closed by screw-caps, near where they con- 
 verge and enter the large foul-air shaft, they could be 
 washed by pouring water in these openings and allow- 
 ing it to pass out by a small tube which runs from the 
 end under the bed through the outside wall. This 
 small drain-pipe should also be closed by a screw-cap. 
 Disinfecting water could be used when necessary. 
 As the openings would be under the beds, they need 
 not be covered by a register, but during the summer 
 when not in use should be closed and cleaned res^u- 
 larly. These openings should be fully as large as the 
 ducts. 
 
 Besides the means for the escape of the foul air up 
 the chimney and out at the foul-air shafts, there should 
 be several openings along the ridge of the roof, which 
 could be opened or closed at pleasure, for the purpose 
 of giving exit to the hot air in the upper part of the 
 ward, whenever it is desirable. 
 
 During the spring months, when it is not cold 
 enough for a fire nor warm enough to oj^en windows 
 wide, the hot-water coils could be used to give the 
 desirable warmth. For use at such a time, and even in 
 the summer when with the windows open the air is 
 heavy and still, there should be a special arrangement 
 for creatius; a drauo;ht without heatins: the air of the 
 ward. At this time a fan-ventilator would be useful, 
 and one of Desao-ulier's fan-ventilators invented in 
 1727, to be worked by hand, could be tried. A 
 draught could be secured by means of a small furnace ; 
 or, rather, places for lighting fires in should be ar- 
 9
 
 130 WARMING AND VENTILATION. 
 
 ranged beneatli tlie ward in tLe base of the ventilating 
 column. The draught from these fires should pass up 
 throu2:h the large foul-air shafts, and thus cause sue- 
 tion on the foul-air ducts without heating the air of the 
 ward. 
 
 To make a draught in summer, perhaps a better way- 
 would be to arrange a number of hot- water j^ipes in the 
 corner space in the ward, behind the coil used in win- 
 ter, so as to create a draught in a shaft directly in the 
 corner with an air-space and the masonry intervening 
 to prevent heating the air of the ward. Gas-jets in the 
 same position could be used. 
 
 Ligliting the Ward. — If gas is used, the pipe should 
 enter the ward throuo;h the elbow-corridor from the 
 service-room ; and in all parts except just where it 
 passes into the ward it should be exposed to view, and 
 kept in perfect order. Three or four jets at intervals 
 under the ridge of the roof would be sufficient. Each 
 jet should be covered with a glass globe, the opening 
 at the top of which should be continuous with a tube 
 leading directly into the open air, thus at once remov- 
 ing the gases of combustion. 
 
 No water-pipes should be laid in the ward, and 
 under no circumstances should any drainage-pipes be 
 either under, in, or about the ward-huilding. 
 
 Ward-Furnitu7'e. — There should be a centre-table 
 for use while wounds are being dressed, and for merely 
 temporarily setting things down on ; but usually there 
 should be nothing on it. The necessary medicines, in- 
 struments, etc., used by the doctors, could be brought in 
 on a rolling; table durins: their visits and then removed.
 
 WAED SERVICE-ROOM BUILDING. 131 
 
 Tliis table sliould be a slab of thick glass on a simple 
 polished iron frame and should have soft-rubber rollers. 
 
 By the side of each bed there should be a small 
 table, merely a glass slab fixed on an iron frame, and 
 a bent-wood chair with arms, and a wooden bottom 
 curved to make it comfortable, but every part smooth, 
 without holes, and kept polished. If softer material is 
 desirable for certain cases, rubber, air or water cushions 
 should be supplied, but no wool, hair, or other kinds 
 of cushions, should be allowed in the ward. 
 
 The bedsteads should be of wrought-iron, nickel- 
 plated, with the improved wire mattress, and when 
 necessary horse-hair mattress cleaned and fumigated 
 frequently ; the size .of the bed to be three feet wide 
 by six and a half long and two and a half feet high, 
 and without curtains. In movina; the beds two bars 
 with rubber rollers to slip on the feet should be used. 
 
 Every ward should have two screens in three folds, 
 and so large that with the two a bed could be sur- 
 rounded on three sides, yet giving room sufficient to 
 handle the patient. The frames of these screens should 
 also be of wrought-iron and nickel-plated, and covered 
 with white linen tied on, so that it could be removed 
 and a fresh ^over put on, at least once a week. Noth- 
 ing more is needed as furniture in the ward. 
 
 All urinals^ hed-pans, spit-cups, etc., should be of 
 glass, instead of porcelain ; for the least crack or shale 
 in porcelain or imperfection of the glazing will allow 
 organic matters to be absorbed and thus make them 
 poisonous. 
 
 It would be better to supply each patient with slip- 
 pers having rubber heel-tips to wear in the ward, if the 
 floors are slippery, than to use carpets.
 
 132 WARMING AND VENTILATION. 
 
 Attaclied to tlie wards tliere sliould be a liand- 
 carriage, on wlieels covered with rubber, for conveying 
 the patients about, and a bath-tub on rollers of rubber. 
 
 Heating and ventilating tlie Service- Hooni Build- 
 ing. — Instead of the usual methods of haviug the heat- 
 ing apparatus in one central building, or a general 
 boiler-house from which all the pavilions receive their 
 supply of steam or hot water, it is preferable, on account 
 of the wide separation of the pavilions, that there should 
 be a small boiler in the basement of each service-room 
 building which would supply the ward-coils with hot 
 water, and also heat the service-room building, the 
 elbow-corridor, and a certain j^roportion of the main 
 connecting corridor if necessary. As the main corridor 
 is cut off from all the buildings by doors, if well- 
 arranged tramway-cars are suj)plied for carrying the 
 patients, and others for conveying the food, it would 
 not be essential to heat the corridors ; they may be 
 merely closed passage-ways, or, what would be better, 
 a sim23le covered way protected by sashes on the north 
 side in winter. 
 
 The ventilation of the service-rooms should be as 
 carefully attended ■ to as that of the ward^ A foul-air 
 shaft should be arranged around the flue of the furnace, 
 and foul-air ducts similar to those in the ward should 
 open into the different rooms, es23ecially the water- 
 closets; and, if considered desirable, downward ventila- 
 tion for each closet could be arranged. 
 
 The small ward for special cases should have con- 
 nected with the open fire in it a foul-air shaft and have 
 a foul-air duct under each of the two beds ; also a fresh- 
 air duct coming in from under the eaves till it reaches
 
 WAEB SERVICE-ROOM BUILDING. 133 
 
 tlie centre of tlie room, tlien tiirniug at right angles and 
 descending to within seven feet of the floor, having a 
 scatter-plate, etc. 
 
 The stairway from the l)asement in the northeast 
 corner shoukl be thoroughly ventilated, and cut off 
 from the hall by a lobby.
 
 CHAPTER VI. 
 
 PAT-PATIENTS IX CIIAEITABLE IXSTITUTIOXS. 
 
 As we have said before, we believe liosj)itals as 
 cLaritable institutions slionld be limited to tlie sick 
 poor witliout homes ; that every effort should be made 
 to improve the condition of the homes of the poor, and 
 to teach the poor to avoid sickness, Now, it seems to 
 us that it would be a move in the wrong direction to 
 offer an inducement to the sick, either poor or rich, to- 
 leave their homes and enter a hosj)ital to be treated, 
 especially if the hosj^ital is called a charitable insti- 
 tution. 
 
 Independence and charity are incomj^atible. If the 
 pay-patients do not receive greater care and attention 
 and better food, there will be a strong temj^tation for 
 them to claim to be subjects for charity, so as to save 
 their money. We have seen this tested in one of our 
 large pauper-hospitals : as soon as the patients in the 
 pay- wards learned that they were no better off than 
 those in the free wards, they would almost without 
 exception, by failing to pay after the first installment, 
 claiming to be too poor to afford it, endeavor to get 
 into "the free wards. After a short time the pay-ward 
 was abandoned as a failure ; and, so far as we know, the
 
 PROVIDENT DISPENSARIES. 135 
 
 plan of having pay-patients in the general wards of any 
 of our charitable hospitals is practically a failure, and 
 is maintained more for the pui'pose of keeping out un- 
 desirable cases than for the income derived from those 
 willing to pay. The private-room plan succeeds better, 
 but a j^rivate room cannot be kept ujd in a public hos- 
 pital at less expense than in a private house or private 
 hospital, for the doctors are the only unpaid officials, 
 and, unless the pay-patient is made to pay for the doc- 
 tor's service, the private rooms will not materially add 
 to the income of the hospital. 
 
 If the attending physicians and sui'geons of all 
 our charitable institutions would refuse to attend pay- 
 patients in these institutions, private self-supporting 
 hospitals, entirely independent of charity, and free from 
 the stigma of pauperism, would soon arise in sufficient 
 number to supply all persons able and willing to pay 
 for hospital treatment. Such a step would be not only 
 best for the whole community, on account of its doing 
 away with a custom that tends to increase pauperism, 
 but would be at the same time an act of justice toward 
 their professional brethren who are not so fortunate as 
 to hold a position on the medical staff of a hospital. 
 The above remarks are equally as applicable to dispen- 
 saries for out-door patients as they are to hospitals for 
 in-door patients. The free and the pay dispensaries 
 should be separate and distinct institutions, the free 
 being based upon charit}" and strictly limited to the 
 needy, the pay being based upon utility and being self- 
 supporting institutions, as independent of charity and 
 as free from all connection with pauperism as a life- 
 insurance company or any other private corporation. 
 A " provident dispensary " claiming to be a charitable
 
 13G PAY-PATIENTS IN CHARITABLE INSTITUTIONS. 
 
 institution will supply a more enticing stepping-stone 
 to pauperism tlian is now so ud guardedly offered by our 
 badly-managed free out-door dispensaries. But, if a 
 well-regulated system of pay-dispensaries organized as 
 independent, self-supporting institutions could be made 
 to supj^lant tlie many free charity dispensaries at pres- 
 ent existing on the plan of " free soup-liouses," medi- 
 cine being given instead of soup, we believe much good 
 would be done. 
 
 At present the custom is, to offer hospital accommo- 
 dations to any who are willing to ]3ay for the care and 
 attention, and to ask the medical profession to attend 
 such persons without remuneration. This custom is in 
 2')rinciple an injustice, but practically, as yet, the num- 
 ber of pay-patients in public hosj^itals has not been 
 large. Such persons are charged a small sum if j)oor, 
 and put in the wards with the other patients, or 
 charged a high price if rich, and given a |)rivate room. 
 Patients in private rooms should be allowed to select 
 any ph^^sician on the medical board, and to j)ay him for 
 his services, in addition to what they pay the hosj^ital. 
 
 We will assume that thirty-two such rooms are 
 needed, twenty for men and twelve for women, 
 
 Pay- Wards. — These wards, divided into two sepa- 
 rate rows of rooms, should be constructed on the same 
 principles as the other wards. They should be only 
 one story high, and the service-rooms should be in a 
 separate building, and cQnnected by an elbow-corridor 
 with the ward. The ward should be on a raised base- 
 ment similar in every respect to the other wards, and 
 should have its piazza at the south end. The ward 
 should be thirty-two feet wide with a hall through the
 
 WAEDS FOE PAY-PATIENTS. I37 
 
 centre eight feet wide, witli rooms on eitlier side twelve 
 feet deep by fourteen wide, two of the rooms being six- 
 teen by eighteen feet for two beds, as it is sometimes 
 desirable to have an attendant or friend sleep in the 
 room with the patient. 
 
 These rooms should be fifteen feet to the ceiling, 
 with one window in the single and two in the double 
 rooms, opening to the outer air ; and, above the doors, 
 opening on the hall, there should be a transom-window. 
 The floors should be similar to those described in the 
 other wards, and without car^^ets ; rugs should be sup- 
 plied if needed, but carefully attended to as to cleaning. 
 The building should have a cap-roof the width of the 
 hall, with sashes of glass between it and the main roof. 
 Each room should have an open fireplace with foul-air 
 shaft and ducts, and afresh-air duct similar to that in the 
 small ward described in connection with the service-room 
 building of the other wards. Besides this, a curved tube 
 or box could be made to pass out through the hall-wall 
 and open into the outside air through a space between 
 the cap and the main roof The outside walls should 
 be similar to those described for the permanent pavil- 
 ions, but the partition-walls between the different rooms 
 and between the hall and the rooms should be made as 
 nearly as possible impermeable to air, for the air dra^\m 
 into a room through these walls would not be fresh, 
 and in some cases might be very bad. The accommo- 
 dation in such a ward should be limited to eighteen 
 beds. Therefore two detached pay-wards and two or 
 more special huts would be needed. 
 
 The service-room building for a pay-ward should be 
 separated in the same way and for the same reasons as 
 in the other buildings. The first floor, that on a level
 
 138 PAY-PATIENTS IN CHARITABLE INSTITUTIONS. 
 
 witli tlie ward, sliould be divided by a ball witb tbe 
 water-closets and two batb-rooms on one side, and a 
 comfortable dining-room witb an open fireplace and a 
 pantry communicating witb tbe kitcben by dumb-waiter, 
 and a room for tbe nurse in cbarge, on tbe otber side. 
 
 If bot-water coils are needed, mstead of baving a 
 boiler, bot water could be laid on from tbe administra- 
 tive buildings, as tbe pay-wards sbould be not far re- 
 moved from tbem. Hot water for tbe batbs and for 
 carrying to tlie rooms sbould be supj)lied by tbe kitcb- 
 en-range. No pipes except gas-pipes, and tbese exposed 
 to sigbt, sbould be laid on in tbe wards. 
 
 In tbe pay-ward, wbere tbe beds are in separate but 
 adjoining rooms, witb a common ball, no infectious or 
 contao;ious cases sbould be treated, and no case liable 
 to become infected or in any way dangerous to otbers 
 sbould be admitted ; for in sucb a building, altbougb 
 tbere are intervening walls, a case of tbe kind would be 
 more dangerous tban in a building witbout partitions. 
 Not tbat tbe patient in tbe next room is not for a time 
 in less danger of being poisoned tban be would be if no 
 wall intervened ; but an infectious cage, or one liable to 
 cause infection, would be more likely to poison bis own 
 room, and tbus do more permanent injury, tban a simi- 
 lar case in an open ward. 
 
 For all infectious cases, and for treating all severe 
 and dangerous cases among tbe pay-patients, tbere 
 sbould be buts sj^ecially constructed for tbat purpose. 
 
 i
 
 CHAPTER VII. 
 
 SPECIAL ISOLATED HUTS FOE CERTATN" LMPOETANT CASES, 
 SUCn AS OVAEIOTOMY ATO) OTHERS EXTEEilELY SEN- 
 SITIVE TO INFECTIOUS MATTEE. 
 
 It would be better if sucli cases were treated iu 
 every way separate from a liosj^ital in wliicli otlier dis- 
 eases are treated ; but a certain number of sucli cases 
 must be admitted to liospitals, and, unless special insti- 
 tutions exist for tlie sole purpose of caring for tbem, 
 they must be provided for in connection with general 
 hospitals. 
 
 We will give the plan of a hut with special refer- 
 ence to patients operated on for ovarian tumors. 
 
 Ovariotomy is one of the most formidable of all 
 operations in surgery, and while the operation is going 
 on the largest serous membrane in the body is exposed 
 to the air. This membrane, the surface of which is 
 many times as great as the largest stump of an ampu- 
 tated limb, is remarkable for its great susceptibility to 
 ahsorh septic poisons. When once inflammation sets iu, 
 the great majority of cases jDrove fatal. In fact, a pa- 
 tient after an operation for an ovarian tumor is the per-
 
 140 SPECIAL ISOLATED EUTS 
 
 feet type of a surgical case that is exquisitely sensitive 
 to septic influences. When once infected, on account 
 of the large surface and position of the membrane in- 
 volved, it seldom fails to generate and give off sufficient 
 poison to infect a building ; and, like a case of puerj)eral 
 fever, it renders the apartment, if not forever, at least 
 for weeks and months, unfit and dangerous for the treat- 
 ment of other cases. 
 
 On account of this extreme susceptibility to contract 
 septic diseases, and the harm such a case does to the 
 building, it is a direct violation of a sanitary lavr, and a 
 risk not only for the individual patient, but to all other 
 surgical cases treated in the building, for a case of ova- 
 riotomy to be treated either in the ward of a hospital, 
 or in a room near the ward, particularly if that room is 
 but a few steps from the water-closets and bath-room. 
 Ko nurse, doctor, or other attendant, who has the care of 
 other cases, especially other surgical cases, should be al- 
 lowed to have charge of, handle, or come near, a patient 
 operated on for an ovarian tumor. 
 
 Patients operated on for ovarian tumors should be 
 treated in small one-story huts, which should contain at 
 most not more than two beds, one for the patient, the 
 other to be used by the nurse or attendant during con- 
 valescence when the critical stage is past. 
 
 The building should be small, not only because such 
 a building is easily ventilated, but, if it were to become 
 infected, it could be destroyed, and a new one erected 
 at a small expense. 
 
 There should be two or more huts, so that they 
 could be used alternately and, when not in use, be left 
 open to the sun and air for purification.
 
 DETAILS OF CONSTRUCTIOK 
 
 141 
 
 THE PLAN OF THE nUT. 
 
 Ground. — The ground should be covered mth a 
 layer of concrete, and asphalted beneath and for several 
 
 %L 
 
 ISOLATthfc WooDEhl MUX", 
 
 A. ^TOv'e 
 
 B. ^?«ioi^E PlJe. 
 
 C?, ^.\\ Ri/cT^ lii<n)Eii^ Ti-OOFt Ff^oM sfrJneF^ "Ben x<» ^-[a-^s-.. 
 
 TOWlTl^ltJ '1 FEE]* Of TlOOT^ WIJI^ SCAJTEl^SBO/\l^r»,- 
 
 feet around the building, and surrounded by an open 
 shallow gutter as a drain.
 
 142 SPECIAL ISOLATED HUTS 
 
 Position. — As the building is square, its position 
 should be about north-nortlieast, that is, tlie side toward 
 the north should be about perpendicular to a line run- 
 ning north-northeast. In this position the rays of the 
 sun would reach all four sides of the hut during the 
 day. 
 
 Dimensions. — The drawing represents a hut twenty 
 feet square, eight feet high to the eaves, and fourteen 
 feet to the ridge of the roof, which gives 20 X 20 X H, 
 or 4,400 cubic feet of sj)ace. 
 
 Floor. — The floor should be of the heart of Georgia 
 yellow pine, which by nature is well filled with resin, 
 and should be well laid with tongue and groove. Car- 
 penters are accustomed to lay floors to be covered with 
 carpets, and, as a rule, are not skilled in putting down 
 closely-joined floors. The beams should be sealed be- 
 neath, so as to make the floor double and j^rotect from 
 the cold. 
 
 Height from Ground. — The floor should not be less 
 than two feet from the ground. During very severe 
 weather, if necessary, the space beneath could be closed 
 with glass sashes. Locust posts make the best under- 
 pinning for tem|)orary buildings. 
 
 Walls. — Brick walls would make a more substan- 
 tial and for some reasons a better building than wood. 
 If of wood, they should be double, with an air-space 
 of several inches between them, so arran2:ed as to be 
 opened at pleasure both at the top and bottom on the 
 outside of the building, but not from the inside. This
 
 DETAILS OF CONSTRUCTION. I43 
 
 would be of im^Dortance iu summer. The inside wall 
 should be closely joined, land planed and painted, or 
 polished. If the wall is of brick, an air-space should be 
 left in the centre, so arranged as to communicate with 
 the space between the roof and ceiling, and to allow of 
 easy ventilation and fumigation of all these spaces. 
 
 The Hoof. — The roof should be double, with an 
 air-space of several inches clear intervening — not so 
 much to keep out the cold as to prevent overheating 
 in summer. Tliis space should also be made so as to 
 be either closed or opened from the outside. The roof 
 should extend far enough beyond the walls to protect 
 them from the weather, especially at the gable-ends. 
 
 The Windoios. — The end-window facing the east, 
 and opposite the door, should extend from within two 
 feet of the floor and run up as high as the roof will 
 admit ; or there should be a small window above the 
 large one arranged on hinges so as to open at the top. 
 Besides this there should be an opening through the 
 end- walls just under the ridge, covered by a register, to 
 be closed or opened at pleasure. The two side-win- 
 dows, commencing about the same distance from the 
 floor, would necessarily be not more than six feet high. 
 Above the door there should be a small window on 
 hinges similar to the one above the end-window. All 
 the windoAvs should be not less than three feet mde ; 
 the large end-window might be four feet wide, so as to 
 give a good light for the operations. It would perhaps 
 be better to have a northern light, but the great major- 
 ity of operations are done in the afternoons, so that a 
 window facing east would answer every purpose. The
 
 14:4: SPECIAL ISOLATED HUTS. 
 
 sashes should be balanced with pulleys, and be of very 
 thick plate-glass or double glazed, not double sashed. 
 In a temporary building everything must be inexpen- 
 sive, but the glass of the windows could be used in- 
 definitely, and on that account it would not be bad 
 economy to have thick plate-glass. The w^ood-work 
 should be j)lain an cl^ smooth, and kept waxed and pol- 
 ished. . 
 
 The Door. — There should be but one door, three 
 and a half by seven feet, in the end facing west. It 
 should be wide enough to admit a patient carried on an 
 ordinary stretcher. The door should be perfectly plain 
 and without panels. During severe weather the en- 
 trance should be protected by a closed framework with 
 a door opening southward. 
 
 Huts for ovariotomy cases should not have a nurse's 
 room, but in huts for chronic suppurating wounds, etc., 
 the nurse's room should be in the northwest corner, 
 eight by twelve feet, the long axis lying east and west 
 so as to include one of the side- windows. It should be 
 separated from the w^ard by a partition, which should 
 not be more than seven feet high, with a space of about 
 one foot left open between it and the floor, so as to 
 allow a free circulation of air, and room for cleansing, 
 etc. This partition or screen should be perfectly plain 
 and smooth, without cracks and corners, and so put up 
 that it could be readily removed without disturbing the 
 building in any way. It should have a door three by 
 six and a half feet in the free corner. 
 
 . Heating. — In a temporary building of this kind the 
 expense would be too great to build a chimney and
 
 DETAILS OF CONSTRUCTIOX. I45 
 
 have an open fire ; therefore a Franklin soapstone 
 stove, or some kind of iron stove surrounded by a pro- 
 tector, must be used, being preferable to steam-heat, 
 even if it were possible to introduce it from other 
 buildings. The 2:)Osition of the stove should be in the 
 northeast corner, so that the force of the cold northeast 
 winds driving through the wall would carry the heated 
 air to the bed of the patient on the south side of the 
 room. By means of a special flue surrounding and 
 heated by the stove-pipe, the foul air of the ward 
 should be drawn off. A ten or twelve inch pipe 
 inclosing the ordinary six-inch stove-pipe would make 
 an excellent foul-air shaft. In so small a build in o- a 
 stove will heat it satisfactorily in cold weather, and, 
 unless the hut is double roofed, the heat of summer 
 will give more trouble. The stove should be an open 
 on«, of a rather large size, and in very cold climates the 
 stove-pipe should not pass directly into the foul-air 
 shaft, but ascend some distance before enterins; the 
 shaft, thus giving off more heat in the ward. 
 
 Ligliting. — The lighting must be either by a gas-jet, 
 or a lamp suspended near the centre ; the latter would 
 be less expensive. In either case the consumed air 
 from the light should be conveyed by means of a spe- 
 cial shaft or flue directly through the roof into the open 
 air; otherwise, while burning, an ordinary gas-jet will 
 consume more oxygen and give off more carbonic-acid 
 gas into the ward than seven patients ; whereas, if its 
 heated air is conveyed off by a tube to the open air, it 
 will assist materially in ventilating the room. Candles, 
 and not hand-lamps, should be used to su2:)plement this 
 central light. 
 10
 
 146 SPECIAL ISOLATED EUTS. 
 
 Ventilation. — During tlie weatlier not cold enough 
 to require a fire, tlie "building can be readily ventilated 
 by the 'windows ; but, when the weather necessitates 
 closino- the windows, other means should be and can be 
 easily arranged for drawing off the foul air. In each 
 corner of the floor of the room, three feet from the 
 walls, there should be an opening communicating with 
 a duct between the floors which leads to the foul-air 
 shaft of the stove ; or, if there is no special flue or shaft 
 in connection with the stove, and separate from its own 
 flue, it would be a simple matter to so arrange it that 
 the stove would draw all of its drauo;ht from these 
 ducts. The ducts for the huts for ovariotomy cases 
 should be cast-iron pipes similar to those described 
 for the wards. In the huts for infectious cases they 
 could be made of boards eight or twelve inches wide, 
 or of tin pipes covered with straw packing to protect 
 from the cold in case only one floor is laid. The ojdcu- 
 iug in the floor should be not less than ten or twelve 
 inches square, and protected by a grating, and so ar- 
 ranged as to catch dust, etc., in a dust-box, which could 
 be opened from beneath, and, if desirable, left open 
 during the summer ; yet, when malaria prevails, all 
 fresh air shoukl be admitted as high from the surface 
 of the ground as possible. 
 
 Now, much of the air would come in from the out- 
 side through unavoidable crevices and directly through 
 the boards ; but this would not be sufficient ; and, in- 
 stead of letting the air iu by the windows, it would be 
 better to convey the cold air as near the centre of the 
 room as possible before allowing it to scatter. To accom- 
 plish this, a very simple means would be, to have two
 
 VENTILATION OF THE HUT. 14 7 
 
 large sliafts or tubes ' pass through the ridge, projectino- 
 above, and opening into the air on the outside and pro- 
 tected by a cap ; on the inside they should come down 
 to the level of the top of the side-walls, tliat is, seven 
 or eight feet from the floor, where they should be ar- 
 ranged so as to be opened or shut at pleasure, but high 
 enough to be out of the reach of the patients; and just 
 beneath the openings there should be a scatter-plate so 
 fixed as to cause the cold air descendino^ to flare and 
 scatter through the room and thus prevent draughts of 
 cold air. A large, ordinary tin basin with flaring edges 
 swung beneath the end of the shaft would answer as a 
 scatter-plate. The shafts should be twelve by twelve 
 inches in diameter, or, if it is better to have them flat 
 so as to pass more readily through the roof, they should 
 be six by twenty-four inches and should pass through 
 the ridge on either side three feet from the centre of the 
 roof If thought desirable, two similar shafts can be 
 passed through the ridge with no projections down into 
 the ward, but opening near the roof for the purpose of 
 carrying off the overheated air ; by means, however, of 
 the two high openings in either gable all overheated 
 air could easily be got rid of 
 
 FUEIS^ITUEE. 
 
 Jjeds. — The beds should be of cast-iron, nickel- 
 plated, and a little wider than the usual hospital- 
 bed. The mattresses should be of hair, and tliey 
 should be often w^ashed and disinfected, and the next 
 patient should have a fresh mattress. If wire mat- 
 tresses equally good can be had, they would be better 
 
 ^ An account of wliicli lias aJready been given in describing the fresli-air 
 ducts of the wards.
 
 148 SPECIAL ISOLATED EUTS. 
 
 than hair. Hair pillows, treated in the same way, 
 should be used. The blankets should be changed as 
 often as the sheets ; they are just the things to catch 
 ors^anic particles, and retain the'm till decomj^osition 
 takes place, and thus poison the wound. 
 
 Tables. — A table with a glass top, five by two and 
 a half feet, should be in the ward, as it would be needed 
 for operations. There should also be a small stand of 
 iron for the basins and water-vessels. Water-pipes 
 should not be laid on in the building ; the drains 
 would cause more danger than the convenience would 
 compensate for. 
 
 Chairs. — The chairs should be plain, with wooden 
 bottoms. If a patient, while convalescing, should re- 
 quire an easy-chair, it should be brought in for the 
 occasion. No cushion or anything of the kind should 
 be allowed to remain in the room.
 
 CHAPTER VIII. 
 
 ADMINISTEATIVE BUILDINGS AND ARRANGEilENT OF THE 
 BUILDINGS ON THE GROUNDS. 
 
 Separation of the Ward-Pavilions. — Miss Niglitin- 
 gale laid down the rule tliat "the distance between 
 the Mocks (the pavilions) should not be less than 
 double the heis-ht of the block." This has been very 
 generally accepted. We do not think this allows suf- 
 ficient space. The distance between the pavilions 
 should not be less than three times the lieight of the 
 buildiugs. 
 
 In the ward-pavilions that we have described, meas- 
 urinof from the floor of the ward to the ridcre of the 
 roof, the height is about tweuty-four feet. Three times 
 this wonld be seventy-two feet, which we consider 
 should 1)6 the minimum of space left between each 
 ward and all other buildings, excepting -its service-room 
 building. If the ground-space is suihcient, we would 
 have the distance between the wards one hundred feet. 
 If tramway-carriages are used, the increased distance, 
 as it is on a level, would not make an appreciable dif 
 ference. 
 
 The isolating huts for special cases should also be
 
 150 ARRANGEMENT OF TEE BUILDINGS. 
 
 widely separated from eacli otlier and all other build- 
 ino-s. Tlie huts and tents for infectious cases should be 
 widely separated and j)laced on the grounds in a j)osi- 
 tion where they would be least likely to infect any 
 other buildings. 
 
 Position of tlie Ward-Pavilions. — The wards, with 
 their long axes lying north and south, should be ar- 
 ranged on the southern exposure of the grounds, not 
 only to get the sunlight, but, in our climate, during the 
 summer months, when the windows are open to receive 
 the full force of the prevailing w;nds. 
 
 On one side of the grounds should be placed the 
 wards for men, on the other the wards for women and 
 children. The j)ay- wards should be placed on either 
 side of the administrative building, but well separated 
 from it and all other build in^rs. 
 
 o 
 
 IJie Administrative Buildings. — These should be 
 separate from the vfards, and placed on that part of 
 the ground where they would not intercept the j)re- 
 vailing summer winds. The northern side of the 
 grounds would be the best position for them in our 
 American climate. The administrative or executive 
 building should occupy a central position on the 
 northern side, and have the kitchen, store-rooms, the 
 operating-theatre, drug-room,- etc., arranged around it 
 and connecting with the main corridor from the wards. 
 
 The executive building should have the reception- 
 offices, the managers' room, the medical-board room, 
 and the superintendent's office, on the first floor. On 
 the second floor there should be rooms for the members 
 of the house-staff; above these should be rooms for the
 
 THE ADMINISTRATIVE BUILDING. 151 
 
 male attendauts. Tlie basements could be used for cer- 
 tain stores. 
 
 The general kitchen should be placed in the rear of 
 the executive building, convenient to the main corridor. 
 The kitchen should be supplied with all the latest im- 
 provements in cooking-apparatus, and should have spe- 
 cial arrangements to prevent the flavors of all the differ- 
 ent articles cooked from mixino'. There should be a 
 sj^ecial diet-kitchen distinct from the general kitchen, 
 and under a diff^erent management. Connected with 
 the kitchen there should be well-arranged store-rooms 
 for vegetables, meats, etc. 
 
 Bath-House. — The general and medicated baths 
 should be convenient to the main corridor and near 
 enough to the kitchen to use tlie same boiler-house. 
 
 Tlie ApotliecarySliop. — The drugs for the wards 
 should be in a small buildino; convenient to the corri- 
 dor and to the operating-theatre. 
 
 Operating - Theatre. — The operating- tlieatre should 
 be. in a separate building as well ventilated, and kept 
 as scrupulously clean, as the wards. It should have an 
 operating-table surrounded by raised seats, with an 
 etherizing-room and a recovqry-room convenient. The 
 operating-room should have a good nortlierii light. In 
 no case should the operating-theatre be in the same 
 building or even near either the pathological rooms or 
 the dispensary for out-door patients. 
 
 If the wounds are poisoned by the foul air of an 
 operating-theatre during an operation, the best-con- 
 structed wards cannot save the i^atients. One who
 
 152 ARRANGEMENT OF BUILDINGS. 
 
 is familiar witli either pathological rooms or the steam- 
 ing stench of a crowded dispensary where all sorts of 
 people with all kinds of disease are assembled will 
 readily appreciate the danger of having an operating, 
 theatre in or near the same building. The number of 
 seats in an operating-theatre should be limited to the 
 number from which an operation could be closely ob- 
 served. It is useless to have a class of several hundred 
 students present at an operation ; it is not possible for 
 them to see it to' any advantage. 
 
 Accident - Ward. — Convenient to the ambulance- 
 drive and to the office, and near the operating-theatre, 
 there should be a small accident-ward, Avhere severe 
 cases could be detained to receive immediate treatment, 
 and where, if in a dying condition, they should remain 
 instead of being removed to a ward • to die in a few 
 hours and create a disturbance. 
 
 The Stable. — The stable for the ambulance-wagons 
 and horses should be on the outside near the northeast 
 or northwest corner of the grounds^ and should have 
 telegraphic communication with the offices in the execu- 
 tive building. The necessary workshops for the hospi- 
 tal should be in the same position. 
 
 The Autojpsy and Pathological Bidlding. — The 
 2yost-7nortem and pathological building should be in 
 either the northeast or northwest corner of the grounds, 
 and cut off from the rest of the grounds by a high wall 
 and intervening trees and shrubs. The attendants 
 should in every way be separate from those of the 
 wards.
 
 THE OUT-DOOR DISPE2TSART. 153 
 
 The doctors in tlie liospital, or tliose wlio visit the 
 wards, should never be allowed to make a ^ost-mortem 
 examination, or even be present when one is made on 
 an infectious case. There is always danger of infection 
 being conveyed to the wards from a ])OsUnortem build- 
 ing, and this cannot be too carefully guarded against. 
 
 The Out -Door Dispensary. — The dispensary-build- 
 ing should be adjoining the grounds of the pathological 
 building, and should have a separate entrance from that 
 of the hospital, with its own attendants distinct, both 
 medical and otherwise, from those of the hospital. If 
 it is in or near the executive building, the number of 
 persons passing in and out will create confusion, and 
 render discipline in the hospital more difficult, besides 
 being a constant source of filth and dirt, and of infec- 
 tious and contagious diseases. 
 
 The buildino-s for the trainino-.school and home of 
 the nurses should be in one of the corners of the grounds 
 nearest the executive building-. 
 
 The Laundry. — If convenient arrangements could 
 be made, it would be better to have the laundry entirely 
 removed from the hospital-grounds, on account of the 
 immense quantities of foul fumes necessarily generated 
 and given off from a large laundry. If it is on the 
 grounds, it should be on the outside, near the corner on 
 which the trainin2:-school buildino; is situated. 
 
 The laundry should be divided into not less than 
 two parts, one for washing ordinary soiled clothes, the 
 other for badly-soiled clothes. There should also be a 
 well-arranged hot-air chamber for disinfecting purposes, 
 and a mending-room, near the laundry.
 
 154 ARRANGEMENT OF BUILDINGS. 
 
 As far as j)ossible, tlie clothes sliould all be dried 
 out-of-doors in tlie open air and sunlight. Linen dried 
 in closed rooms not only is not purified by the open air 
 and sunlight, but in such a room one piece of linen not 
 well washed and containiug foul matter would taint all 
 the others, and after such a room has been used for some 
 time it necessarily becomes foul, and liable to infect any- 
 thing that is dried in it. In connection with the laun- 
 dry there should be a drying-yard, a part of whicli could 
 be covered with a roof of glass for use in bad weather. 
 
 The foul linen should be brought twice a day from 
 the wards, each ward liaving two large nickel-plated 
 metal vessels with close-fitting lids : one vessel for ordi- 
 nary linen, the other for badly-soiled linen. These ves- 
 sels should be regularly cleansed and disinfected every 
 day, and the one for the foul linen should always have 
 a disinfecting fluid in it. Such a thing as a " foul-linen 
 shoot" should never exist either about a hospital or 
 anywhere else. We have known, we are sorry to say, 
 of such " shoots " made of rougli bricks and plaster, with- 
 out any lining, being used in a hospital. 
 
 The Water -Sii'p'ply. — There should be an abundant 
 supply of water for the use of the hospital, and a reser- 
 voir for a reserve-supply in case of an accident to the 
 usual source. The water-pipes should be made to con- 
 nect with eacli service-room building of the pavilions, 
 and could be laid along the line of the corridors, but in 
 no place should they be laid near the sewer or drainage 
 pipes. 
 
 Sewers and Drainage-Pipes. — If practicable, the 
 hospital should have its own sewer-main leading direct-
 
 TEE SEWAGE AXD DRAIXAGE. I55 
 
 ly to tlie body of water in wliich tlie sewage of tlie 
 city empties ; it slioulcl be made as nearly as possil)le 
 of impermeable material and well ventilated, and so 
 arranged as to prevent a rising tide from forcing back 
 the foul gases into the drain-pij^es. On the hospital- 
 grounds the pipes should be impermeable to air, and 
 guarded with traps. Each drain-joipe should have its 
 own trap, and each pavilion should have a large trap 
 where its main drain enters the sewer. The sewers 
 should not run under any building, or near a ward, or 
 near any of the water-pipes. 
 
 The drain-pipes from the closets, sinks, etc., should 
 not only be. carefully guarded with traps, but should 
 be so constructed as to be easily and completely exam- 
 ined without tearing up any j^art of the building. 
 
 Special arrangements should be made to simulta- 
 neously flush every drain-pipe and sewer on the hospi- 
 tal-grounds once every twenty-four hours. 
 
 Cultivation of the Grounds. — There should be a 
 good supply of foliage on the grounds, not merely for 
 ornament or simply for shade, but for its purifying in- 
 fluence on the atmosphere. Between the wards there 
 should be grass-plots, with slirubs and flower-beds in 
 them. All space not covered with grass or flowers 
 should be asphalted. 
 
 In the space between the administrative Imildings 
 and the wards, and between the diflerent sets of wards, 
 there should be trees placed where they could not inter- 
 cept the sunlight from the wards, nor in any position 
 where they would to any great extent interrupt the free 
 circulation of air over the grounds. The trees should 
 be carefully selected with regard to their foliage, which
 
 156 ARRANGEMENT OF BUILDINGS. 
 
 sliould be of a nature not to make it clifBcult to keep 
 the grounds free from decaying vegetable matter. All 
 the grounds should be carefully ke^^t in order by a 
 skillful gardener. 
 
 The ^pathological and post-mortem building, the sta- 
 bles, and the laundry, should be cut off from the rest of 
 the grounds by dense hedges.
 
 CHAPTER IX. 
 
 EELATIOXS OF THE MEDICAL SCHOOL AIS^D THE TRAINmG- 
 SCHOOL FOR NURSES TO THE HOSPITAL. 
 
 THE MEDICAL SCHOOL. 
 
 Let us suppose tlie school to be conducted some- 
 vrhat after tlie following plan : 
 
 Requirements for entering the Medical Scliool. — A 
 good English education ; a good knowledge of mathe- 
 matics ; a good knowledge of Latin ; a good knowledge 
 of physics, especially chemical physics. 
 
 After Admission. — First Course: This course in- 
 clndes practical chemistry, biology, including botany, 
 anatomy, a part of physiology, and the use of the 
 microscope. To consist of work in laboratories and 
 didactic lectures to be given in the college buildings 
 entirely separated from the hospital-grounds. Time 
 allowed, two years; but every year there should be a 
 rigid examination. Those passing this examination 
 satisfactorily should be advanced to the second course. 
 
 Second Course:" The second course will include spe- 
 cial study of human anatomy, in the dissecting-room ; 
 physiology and pathology, in laboratories ; practical 
 pharmacy, hygiene, and sanitary subjects; and, during
 
 158 MEDICAL SCHOOL AND SCHOOL FOR NURSES. 
 
 tlie second year of tliis course, clinical lectures and in- 
 struction as far as can be given in connection witli out- 
 door patients of tlie dispensary. During tins course, 
 all lectures and instructions should be given in the 
 medical school and dispensary buildings, and not in 
 the hosj^ital j^roper. Time of course, two years. But, 
 as in the first course, more stress should be laid upon 
 the ability to pass the examination for the third and 
 final course than on the time of study. 
 
 Third Course: This course will include special study 
 of therapeutics and clinical medicine and surgery. Most 
 of the lecture instructions of this course should be driven 
 in the amphitheatre and wards of the hosj^ital. 
 
 If the jiathological, autopsy, and other school build- 
 ings, together with the dispensary for the out-door pa- 
 tients, are placed in one corner of the grounds, and 
 separated by a higli wall from the rest of the buildings, 
 and the students be divided into classes somewhat after 
 the plan just given, the relations of the medical school 
 with the liospital would, we think, be much simplified 
 and made more satisfactory than by the arrangements 
 usually adopted. 
 
 Only the advanced students of the third or gradu- 
 ating class would have access to the operating-amj^hi- 
 theatre and the wards of the hospital. Thus, instead 
 of a class of several hundred students of all grades, 
 creating a disturbance around the hospital, and cram- 
 ming to its utmost the amphitheatre to witness an 
 operation which they do not understand — and which, 
 if they were capable of appreciating, on account of the 
 crowd, they would be unable to see or gain any practi- 
 cal advantage from — there would be, if the require- 
 ments for attaining the third class were such as they
 
 PROFESSORS AND STUDENTS. I59 
 
 should be, not more than from thirty to fifty students 
 present at the operations and clinical lectures in the 
 amphitheatre of the hospital, and those present would 
 not only appreciate but see to advantage all that takes 
 place. 
 
 By means of a special competitive examination open 
 to the students who had reached the second year of the 
 iWvd Qouv Be, internes or house-staff could be selected: 
 say, that to every two wards, one medical, the other 
 surgical, a student would be aj^pointed to serve six 
 months as junior, six months as senior, and six months 
 as house physician or surgeon. This. would diminish 
 the third class by sixteen or twenty every year, and 
 those failing to obtain the position of interne could 
 during the last year of the third course be instructed 
 by the professors or attending physicians and surgeons 
 in the wards of the hospital. 
 
 The professors of the first course would have no con- 
 nection with the hospital. The professors and the class 
 of the second course would have no connection with the 
 wards of the hospital, thus avoiding a great source of 
 infection, namely, that caused by the medical and other 
 attendants of the post-mortem and pathological depart- 
 ments, who would carry infection into the wards on 
 their hands and in their hair and clothes. The profess- 
 ors of the third course should be the attending physi- 
 cians and surgeons to the hospital, and constitute the 
 medical board. In the hospital affairs they should be 
 as a board second in authority to the trustees alone. 
 
 The adoption of such a system as has been outlined 
 would not only serve the best interests of the students, 
 but those of the patients also. It would give the stu- 
 dents the special advantage of clinical instruction in
 
 160 MEDICAL SCHOOL A^^'D SCHOOL FOR NURSES. 
 
 a mucli more satisfactory manner than is at present 
 afforded in tliis country, and it would do away with 
 one of the worst features of medical schools abroad, 
 namely, where they take possession of a hospital, per- 
 mitting students of all grades to follow the attending 
 physicians and surgeons in» their visits to the wards, 
 and under the name of dressers to assist in caring for 
 the sick. 
 
 AVe do not consider the interests of the patients and 
 those of the student at all conflicting. On the contrary, 
 Ave think that a hospital, so far as the interests of the 
 patients are concerned, is very much improved by hav- 
 ing a medical school attached. 
 
 The very presence of the school insures a better and 
 higher class of attending physicians and surgeons than 
 could be otherwise obtained. The presence of the stu- 
 dents stimulates the professor to give his time and 
 close attention to each patient ; and the ability of 
 the house-staff causes him to be careful not to make 
 mistakes. His acts are public, and subjected to severe 
 criticism. 
 
 To make the hospital complete for the interests of 
 the medical school and of the training-school for nurses, 
 there should be a lying-in department, but the best 
 authorities are decidedly opposed to maternity-wards 
 being connected with a general hospital. A case of 
 puer2:)eral fever is perhaj^s the most infectious and dan- 
 gerous case possible, not alone to other ]ying-in women, 
 but to all patients with open surgical wounds ; and 
 there is no question but that the proximity of surgical 
 wards is sure to cause puerperal fever in lying-in wards. 
 
 It would be very desirable to have a maternity-hos- 
 pital established on some other building-spot as remote
 
 SMALL RECEPTION-HOSPITALS. 101 
 
 from tlie general hospital as convenience will allow. 
 We do not favor large lying-iu hospitals. Experience 
 teaches that any kind of a home is a safer place for a 
 woman to be delivered in than any hospital, but there 
 are a certain number of cases that have no homes and 
 must be provided for. All the lying-in wards should 
 be small, containing not more than from two to six 
 beds, and the wards should be in detached, one-story 
 cottages. 
 
 If there is no special building for the treatment of 
 the eye and ear, the oculist should have a room or 
 apartments well arranged with all the necessary appa- 
 ratus, and a certain number of beds assigned him, for 
 the treatment of eye and ear cases. 
 
 RECEPTION - HOSPITALS, AND SYSTEM OF AMBU- 
 LANCES TO SUPPLY THE HOSPITAL WITH PA- 
 TIENTS AND INCREASE ITS USEFULNESS. 
 
 It would be very desii'able to have two or more 
 small reception-hospitals established in the city for the 
 immediate reception of accident and other cases of emer- 
 gency before being removed to the general hosj^ital. 
 
 These reception-hospitals should contain not more 
 than from four to six beds. They should be distributed 
 in different parts of the city wliere they are most likely 
 to be needed. A surgeon (young men who have had 
 hospital experience would be the best suited for the 
 position) should be in charge with a nurse and an 
 orderly under him. 
 
 Each reception-hospital should be connected by tele- 
 graph with the police-stations in its district and with 
 the general hospital, and each should be supplied with 
 11
 
 162 MEDICAL SCHOOL AND SCHOOL FOR NURSES. 
 
 an ambulance, wliicli sliould be always in readiness to 
 start for tlie scene of an accident, witli all the apj^aratns 
 needed to care for accident-cases until tliey could be 
 transported to either the general hospital or the recej:*- 
 tion-hospital. 
 
 These reception-hospitals serving as feeders to the 
 general hospital, would add much to its usefulness and 
 keep it su];)plied with the most desirable cases for the 
 purpose of clinical instruction. 
 
 The interest of the municij^al officers might be en- 
 listed in the establishment of this system of small 
 reception-hospitals and ambulances, and perhaps they 
 might be induced to- carry them on in connection with 
 some public department of the city; as, for instance, in 
 connection with the police department, a part of the 
 police-stations being used for the hospital. The j)lan 
 would not be an expensive one. 
 
 THE TRAINING-SCHOOL FOR NURSES. 
 
 The building for the training-school should be in 
 the northwest corner of the grounds. It should be 
 arranged as the home for nurses, where they should 
 take their meals and sleep. 
 
 Allowing one nurse to every six patients for a hos- 
 pital of four hundred beds, there should be about sixty 
 nurses and student-nurse*s or pupils. To accommodate 
 each of these with a separate room ten by fifteen feet in 
 size, the building should be forty feet wide by one hun- 
 dred and fifty feet long and three stories high. On the 
 first floor there should be the apartments of the superin- 
 tendent of nurses, a reception-room, dining-room, and a 
 school or lecture room. On the upjier floors should 
 be the dormitories for the nurses, each nurse havinar
 
 ORGANIZATION OF TEE SCHOOL. 163 
 
 • 
 
 lier own room. The kitclieii, batlis, and water-closets 
 for this building should be separated from and con- 
 nected with the building by a short corridor, in the 
 same manner as has already been described in the plan 
 for the ward for pay-patients. The dormitories and 
 halls should be constructed and ventilated in the same 
 way as in the wards for pay-patients. 
 
 There should be a lady superintendent of nurses ; 
 under her, a general housekeeper, a Avoman to have 
 charge of the linen and laundry, and one to have charge 
 of the special diet-kitchen and special diet-list. 
 
 To each ward of twenty-four beds there should be 
 a head-nurse, and under her control as assistants there 
 should be a night-nurse and two or three probationers 
 or student-nurses, and, when needed, a special night- 
 nurse. The hea^l-nurses on the male side should have 
 besides the above, under their control, an orderly or 
 man assistant. 
 
 The lady superintendent should have full control 
 over all the nurses, should assign their duties, etc., but 
 she and all of the above-mentioned assistants should be 
 under the control of the resident superintendent of the 
 hospital. 
 
 Besides the above organization, in no way inter- 
 fering, but working in unison with it, there should be a 
 school board of instructors whose duty it would be to 
 give lectures and special didactic instructions to the 
 student-nurses during their pupilage, and to act as an 
 examining board of nurses. 
 
 There should be at least one instructor, a physician, 
 to teach the nurses what they should know about med- 
 ical cases and the administration of medicines ; one to 
 teach them what they should know about surgical
 
 164 MEDICAL SCHOOL AND SCHOOL FOR NURSES. 
 
 cases ; one to give instructions on liygiene and sanitary 
 subjects, and a skilled woman to teacli the cooking of 
 special diet. 
 
 These instructors, with the lady superintendent and 
 one other lady — from a committee of ladies whom the 
 trustees of the hospital should elect to inspect the 
 school and keep watch of the nurses after graduating 
 and to see to the general interests of the school outside 
 of the hospital — should constitute the Faculty of the 
 Training-School for Nurses. 
 
 It would be necessary for the instructors to prepare 
 suitable text-books for the nurses, as there are no good 
 ones in existence. 
 
 The students and assistant nurses can be spared 
 from the wards in the afternoons and evenings, long 
 enough to give sufficient time for study and recitations.
 
 CHAPTEK X. 
 
 IJIPROVEMENT OF HOSPITALS NOW IX USsf SMALL HOSPI- 
 TALS; LYING-IX hospitals; HOSPITALS FOE COXVA- 
 LESCEXTS ; AEMY HOSPITALS ; IXSAXE- ASYLUMS. 
 
 There is no immediate prosj^ect that any of the 
 large hospitals now in use will be replaced by entirely 
 new structures. 
 
 In the case of public hospitals under the control of 
 the State or municipal authorities, nothing less than a 
 political revolution brings about a change. The in- 
 stances are rare in which the ravages of a fatal epi- 
 demic give outsiders a chance to force a change for the 
 better. Hospitals founded by individuals or by be- 
 quests are, as a rule, spoiled in the beginning by the 
 strong tendency to put up a magnificent monumental 
 structure. So much money is usually sunk in these 
 fine buildings that there is nothing left to pay for new 
 buildings, and necessity comj^els a continuance of their 
 use. In all such cases about the only proposal that is 
 likely to meet with favor, so far as impro^dng the con- 
 struction of the hospital is concerned, is to have one or 
 more detached wards for certain classes of cases erected 
 on the grounds as far removed as jDossible from the old 
 buildings. Very often there is no ground-space for
 
 166 SMALL HOSPITALS. 
 
 sucli wards, but it is rarely tlie case that room cannot 
 be found to put up one or more isolating Luts and tlius 
 provide a place for dangerous cases. 
 
 In some cities there are laws regulating the con- 
 struction of, and the number of lodgers admitted into, 
 the lodging-houses, thus preventing the evils of over- 
 crowding. With the same end in view, it would be 
 wise and just for the same authorities to enact a law, if 
 not to regulate the construction of hospitals, at least to 
 regulate the iiumber of hospital inmates in accordance 
 with not only the cubic air-space, but the general hygi- 
 enic condition of the atmosj^here. Thus managers 
 would be compelled to imj^rove the construction of 
 their hosj)itals or make uj) for their defects by limiting 
 the number of inmates in each ward. The more faulty 
 the construction, the greater the cubic air-space which 
 must be allowed each patient. 
 
 SMALL HOSPITALS. 
 
 Hospitals containing as many as four hundred beds 
 must necessarily be comparatively few in number ; and 
 nearly all hospitals, like cities, must have small begin- 
 nings. 
 
 In this country the sick poor of small towns and 
 country districts are usually sent to the poor-house of 
 the county, and many of these almshouses have no spe- 
 cial accommodations for the sick. Where the number 
 of sick does not exceed ten or twel-ve, they could be 
 provided for by the erection of four or five cottages of 
 from two to six beds each, one or two being reserved 
 for infectious cases. The plan already given for the 
 isolating huts could be followed in building them. 
 
 In case the number of sick poor compelled to seek
 
 HOSPITALS FOR COUXTRY TOWNS. 167 
 
 treatment at the liands of the commnnity exceeds thir- 
 ty, it would be better to establish a hospital separate 
 from the almshouse. A small administrative buildinf»- 
 and two wards of not more than from sixteen to twenty 
 beds each — one for men, the other for women — supple- 
 mented by several isolating huts, would be all that 
 would be required. In these small hos]3itals none of 
 the principles laid down for the construction of the 
 larger liospitals should be violated. 
 
 Hospitals are often established by bequests from 
 private individuals and, except in our large cities, are 
 generally small. With the growth of towns and in- 
 crease of population of the country many new hospitals 
 will be built in a comparatively short time ; not less 
 than half a dozen j^roposed new hospitals for a small 
 number of beds have been brought to our notice within 
 the past two years. In cities it will be found that the 
 medical cases in a general public hosj)ital will be to 
 the surgical cases as two to one ; but in the country, if 
 the well-to-do class will do their duty toward the poor, 
 the majority of the sick poor can be best cared for in 
 their homes, and only those cases requiring special med- 
 ical or sursfical skill and the advantas^e of trained and 
 constant nursing would be sent to the hospital, and of 
 such cases the larger number will be surgical. If the 
 children are placed with the ,women, the accommoda- 
 tions for the sexes should be about equal. 
 
 We will su^^pose that a careful canvass of the town 
 and neio;hborino^ districts has been made to ascertain 
 the necessity for a hospital and the number of beds re- 
 quired to accommodate all the sick poor who actually 
 need hospital treatment, and that, as the result, it has 
 been decided to erect a hospital of seventy-two beds.
 
 168 SMALL HOSPITALS. 
 
 In establisliing tlie new lios2:)ital, many difficulties 
 may be expected in the^vay of seeming a good plau. 
 The trustees are j^retty sure to be men advanced in 
 years, and very natural!}' take the advice of men of 
 their own age who are connected with other hosj^itals, 
 and consequently attached to the old plans of construc- 
 tion. Besides, as the trustees have nev'er made a study 
 of sanitary matters, the strongest tendency, and the one 
 likely to influence their choice of a j)lan, will be to put 
 up an enduring monument. If the hosj^ital is founded 
 by the generous benevolence of some private individual, 
 the trustees will consider it their duty to see that the 
 buildings are monumental in character. And this feel- 
 ing will cause them to favor those j)laus that mass the 
 different parts of the hosj^ital under one roof, and pile 
 the wards one above the other. 
 
 The j^kin that masses all the different parts of a hos- 
 pital under one roof is the one that is likely to please 
 the trustees, for it is more in accordance with their 
 homes, their hotels, stores, and factories. They can 
 readily see and understand all the j)oints where a plan 
 favors economy and convenience of administration, for 
 all theii' lives they have studied such questions and 
 found that their success depended uj)on their apj^reci- 
 ation and understanding of these things. If they go 
 beyond this and allow other considerations to influence 
 the plan, it is likely to be in favor of aesthetic effect, 
 and they will in many cases consent to a large expendi- 
 ture of money and permit encroachments uj)on the eco- 
 nomic arrangements of the internal parts in order to get 
 a handsome and strikino- buildino;. On the other hand, 
 the plan that aims at making the healthiness of the hos- 
 pital the first and most important object to be attained,
 
 PLAX FOR A SMALL GENERAL HOSPITAL. 1G9 
 
 is objected to wlierever it seems to add to tlie expense, 
 interfere with the convenience of administration, or mar 
 the outside effect of the buihlings. The whole question 
 is one of education. Lookinsr at house-buihlins; in a 
 broad sense, we find there are four leading ideas that 
 determine the character of a house : First, to have it 
 j^rotect us from the inclemency of the weather ; second, 
 to have it convenient for carrying on the necessary work 
 of life ; third, to have it appear pleasing to the eye ; 
 fourth, to have it healthful. The first belongs to all 
 ages; the second has been more or less perfected; the 
 third, handed down to us by the Greeks, is looked upon 
 as being of the first importance by architects and build- 
 ers; the fourth belongs to the age of Inductive Science, 
 and is yet in its infancy. 
 
 The site should be chosen with the same care as in 
 the case of a large hospital, and with the view that, in 
 time, it may be necessary to increase the size of the hos- 
 pital, especially if the town is a new and growing one. 
 The hospital should be removed from the centre of the 
 town, and the grounds should be not less than four 
 hundred by six hundred feet. If there is a medical 
 school connected with the hospital, the school-buildings, 
 dissecting-room, laboratories, museum, and the out-door 
 dispensary, should all be on a separate lot from the 
 hospital-grounds. In preparing the grounds, laying 
 the drains, locating the buildings, and in all matters of 
 construction, the principles already given in the chapter 
 on " Construction" should be carried out. 
 
 The following plate and description will illustrate 
 what we consider a good plan for a small general hos- 
 pital :
 
 170 
 
 SMALL HOSPITALS. 
 
 A, S' 
 
 ,^ 
 
 ^ -sa 
 
 c? , 
 
 
 g ® <a 
 
 
 .^""e c% 
 
 
 © iS" a 
 
 
 ?)« ^ 
 
 ^ 
 
 f^. 
 
 
 i'a^-^^"C5! .3 >
 
 SUGGESTED PLAN FOE A SMALL HOSPITAL. 171 
 
 — 5 '^ 
 
 ^ 2 r- 
 
 I ^ i."^ S • ^ ^ ^ o ^ 8 
 
 « oi C fe H K 
 
 •5 o a p 
 
 •S "S "ir o 
 
 rt g ■= .2 
 
 <i d p4 S f=,' 
 
 O ^ 33 
 
 P > 5 
 
 
 
 
 tx 
 
 c-i 
 
 &4 
 
 
 
 
 o 
 
 
 
 
 
 
 
 
 
 '?' 
 
 'p 
 
 
 c 
 
 »■* 
 
 o 
 
 5 
 ^ 
 
 5 
 
 
 
 ^ 
 
 
 "rt 
 
 "5 
 
 o 
 
 .^ 
 
 '^ 
 
 3 
 
 c^ 
 
 ■pb 
 
 O 
 
 'Z 
 
 « 
 
 3 
 o 
 
 S 
 
 :^ 
 
 (5 
 
 c 
 
 c 
 
 03 
 
 > 
 
 ^ 
 
 fM 
 
 ^ 
 
 ^' 
 
 C) 
 
 2 ' 
 
 'S 
 
 1— 
 C3 
 
 ^ 
 
 a: 
 
 Ph 
 
 a 
 
 o 
 
 7*"
 
 172 LYIXa-m HOSPITALS. 
 
 LYING-IN HOSPITALS. 
 
 Home is tlie best place for tlie birtli of cliildren, not 
 only on moral but sanitary grounds. 
 
 Lying-in ^vards in a general lios^oital are no longer 
 admissible, and many authorities are opposed to Ijdng-in 
 hospitals of any kind. 
 
 For several days after delivery, on account of the 
 peculiar condition of the parts, a woman is exquisitely 
 sensitive to septic poison, and readily contracts a fatal 
 disease. For this reason it is next to impossible to pre- 
 vent the women of an obstetrical ward of a general hos- 
 pital from taking puerperal fever. The large amount 
 of discharge of decomposing matter that naturally fol- 
 lows the birth of a child, although it may not be dan- 
 gerous to the woman delivered, will in a few days, not- 
 withstanding the greatest care, render the same apart- 
 ment more or less dansferous to other cases of the same 
 kind, and the danger is greatly increased with every 
 case delivered until puerperal fever breaks out ; then it 
 is almost certain death for the healthiest woman to be 
 delivered in the same ward or in an adjoining aj)art- 
 ment. 
 
 It is true that by great care in keeping every- 
 thing perfectly clean in and about a lying-in hospi- 
 tal child-bed fever may be avoided, but in time the 
 dreaded disease will show itself, and one case will 
 give off enough poison to infect a whole building and 
 render it dangerous, at least for a season, to all cases 
 of delivery. 
 
 A woman in giving birth to a child is safer even in 
 the poorest home on a pile of straw, than she would be 
 in a hospital-ward where there are from ten to twenty
 
 NECESSITY FOR LYING-IN HOSPITALS. 173 
 
 women witli new-born infants, esj^ecially if tliis ward is 
 in or connected with a general hospital. When it is 
 possible to give a woman the necessary care during con- 
 finement in her home, it should always be done in pref- 
 erence to sending her to the best hospital. In a city 
 certain physicians and nurses should be assigned to the 
 different districts for this duty. 
 
 In a large city there will always be a certain num- 
 ber of women who must go to some institution as they 
 have no homes, and for this class accommodations must 
 be provided. But, instead of being treated in the wards 
 of a general hospital, these should be placed in a sepa- 
 rate institution, having a medical service of its own — 
 both visiting and resident doctors and all other attend- 
 ants being held in every way distinct from those of any 
 other hospital. 
 
 If the poor even in a very large city are attended in 
 their homes, as has been suggested, the lying-in hospi- 
 tal would not necessarily be very large ; under no cir- 
 cumstances should it exceed one hundred beds. 
 
 A large lying-in hosj^ital offers excellent oppor- 
 tunities for giving students and nurses the advan- 
 tages of clinical instruction, but assigning them to 
 attend cases in company with the district physician 
 is for many reasons a much better means of insti'uc- 
 tion. 
 
 FLAN FOR A LYING-IN HOSPITAL. . 
 
 The selection of the site and the preparation of the 
 grounds, the construction of the raised foundations, and 
 all the details of construction, should be carried out 
 with the same care we have suggested in the plan for 
 the general hospital.
 
 17i LTING-IY HOSPITALS. 
 
 By making a few changes, tlie plan suggested for a 
 hospital of seventy-two beds could be turned into one 
 for a lying-in hospital — the position and relation of 
 the buildings remaining as in the plate. The huts and 
 cottages, the stable and dead-house, should be very 
 much the same. In fact, the only important changes 
 to be made would be in the internal arrano-ement of the 
 administrative and ward-service buildino-s and in the 
 number of beds to each ward. 
 
 In or near the administrative buildinsr there should 
 be special accommodations for the waiting women 
 whose condition permits light work ; this Avould render 
 the wards less crowded and allow them to be alter- 
 nately vacated for cleansing and purification. 
 
 The ward-service building should have projecting 
 from it a special delivery-ward which should be cut 
 off from the rest of the building by a lobby. The 
 wards should contain not more than eight beds each ; 
 they should be thirty feet wide, and allow twelve feet 
 of wall-space to each bed ; in other respects they should 
 be the same as the wards of the general hospital. They 
 should be used alternately, one always being left open 
 and exposed to the air ; when needed, they could all 
 be used — some for those patients confined to their beds, 
 the others for those strong enough to sit up during the 
 day. The jiatients of the latter class could spend the 
 day in the dinincr-room of the service-buildins; or in the 
 waiting-ward, and thus allow their wards to be left 
 open, during the daytime at least. 
 
 The isolating huts shown in the plan would be use- 
 ful for infectious cases, and the special cottages would 
 serve for certain other cases which, for good reasons, it 
 would be best to keejD out of the wards. By extension
 
 OUT-OI-TOWX HOSPITALS. I75 
 
 of tlie main corridor, or covered way, tlie capacity of 
 the hospital could Ijg increased, but the limit of one 
 hundred beds should not be exceeded. Such a hos2;)i- 
 tal should be superintended by a woman — a lady both 
 by birth and education. 
 
 HOSPITALS FOR CONVALESCENTS. 
 
 The community which admits the need of a special 
 hospital to which the convalescents can be sent from its 
 other hospitals, virtually acknowledges that its hospi- 
 tals in use are defective. 
 
 AVere hospitals built and conducted as we have sug- 
 gested, cures would be more frequent, prompt, and com- 
 plete, periods of convalescence would be shortened, and 
 such a thing as a hospital for convalescents, as a sepa- 
 rate institution, would be superfluous; imless, indeed, 
 it were situated on a sea-shore or on an elevation suf- 
 ficiently high to give the inmates a change of climate 
 or at least a different atmosphere, and were used as a 
 place to which certain cases of special diseases, for the 
 successful treatment of which a change of the hind is 
 desii-able, could be sent. Still, if the city hosj^itals now 
 in use are to remain as they are, we too should advo- 
 cate the establishment of out-of-town hospitals where 
 all cases that could be removed from the immediate 
 care of the doctors and nurses should be sent ; for we 
 are satisfied the complete recovery of convalescents 
 would be very much hastened by a removal from the 
 necessarily bad atmosphere of most of the civil hospi- 
 tals that we have seen. A hospital to supplement 
 badly-built city hospitals should be located on a 
 healthy site accessible to the city, but far enough
 
 176 CONVALESCENT HOSPITALS. 
 
 away to give fresli air, and in a neighborhood where 
 land is comparatively cheap, so that the hos^^ital- 
 gronnds might include a farm on which certain of the 
 patients should labor. If a healthy sea-shore or healthy 
 highlands are accessible, they should be j^referred, for 
 the hospital could be made useful not only for conva- 
 lescents, but special accommodations could be made for 
 a large number of chronic cases that would be greatly 
 benefited l)y such a change. In this climate (New 
 York City) such a hospital would be of great service, 
 if in connection with it special arrangements v/ere 
 made for giving the sick children of the poorer classes 
 a few weeks of countrydife during the hot sumroer 
 months when the mortality among such children 
 is so very great, chiefly owing to the want of fresh 
 air. 
 
 The buildings needed for a convalescent hospital 
 w^ould be: an administrative building containing the 
 necessary offices and dwelling-rooms for the superin- 
 tendent. Connected with this in the rear should be a 
 general kitchen and two dining-rooms, one for each sex. 
 On either side of this administrative buildiniz" there 
 should be a long row of simple cottages connected with 
 the dining-rooms by a coA^ered way. These huts should 
 be about twenty-fl.ve feet square and ten feet to the 
 eaves, with windows on three sides, and should contain 
 four beds each. No drainage-pipes should be laid on 
 in these cottages. Special arrangements at some dis- 
 tance should be made for water-closets, and, when 
 necessary, earth-closets could be used in the huts. In 
 selecting the occupants for each hut, the strong should 
 be put with the weaker patients and compelled to take 
 care of them, to a certain extent, by keeping their quar-
 
 PLANS FOR CONVALESCENT HOSPITALS. 177 
 
 ters clean, etc. If fuel is expensive, a system of avcU- 
 arranged barracks might be substituted for the separate 
 cottages, but such a hospital would be chiefly useful 
 during the seven months of the year when flres aie not 
 much needed. 
 
 In a well-selected place on the grounds, at least 
 two well-constructed general hospital-wards, after the 
 plans we have given, should be erected for the treat- 
 ment of cases of relapse that are likely to occur, and 
 for certain chronic cases that most need the country 
 air. 
 
 A few special isolating huts should be kept for the 
 use of infectious cases that may develop. The success 
 and usefulness of such an institution would, more than 
 in one of any other kind, be dependent upon the charac- 
 ter and ability of the superintendent ; he should be able 
 to judge character well, for he must decide when and 
 to what extent it would be best for the patient to 
 work; able, also, to detect impostors and malingerers; 
 besides, his work, on account of its being removed some 
 distance from town, would be less inspected than if the 
 institution were more conveniently situated. A conva- 
 lescent hospital ought to cost comj)aratively little — 
 light duty being required from all patients who are 
 able to perform it, not only for the sake of economy 
 and discipline, but as a curative measure. 
 
 ARMY HOSPITALS. 
 
 In the case of hospitals connected with permanent 
 posts, the plans we have given for civil hospitals would 
 answer in every resjDect ; and even in the event of a war, 
 when hospitals must be hastily erected for the sick and 
 wounded, the same principles of construction should be 
 12
 
 178 AEMY HOSPITALS. 
 
 as closely followed as tlie circumstances of tlie case will 
 admit. ■ Every nation going to war should Lave on 
 hand or get ready a large supply of hospital-tents for 
 use during summer, or whenever the season or climate 
 is not too cold, and a number of one-story wooden pavil- 
 ions constructed in j^oi'table sections so arranged as to 
 be readily put together for use. These pavilions could 
 consist of two parts, the ward and the service-room 
 building. The number of beds should be limited to 
 twenty-eight to each pavilion. 
 
 The ward should be twenty-eight feet wide by one 
 hundred and twenty-six feet in length, and twelve feet 
 to the ridge of the roof. The service-room building 
 should be thirty-two feet square, and divided in the 
 centre by a hall with the water-closets or earth-closets, 
 bath-room, and servants' or nurses' room on one side, 
 and a scullery and dining or mess room on the other. 
 The connection with the wards should be by a short 
 corridor. 
 
 The pavilions should be raised on pillars several 
 feet from the ground, and, if there is malaria about, the 
 higher the better ; and they should be separated from 
 each other and all other buildings by a distance not 
 less than sixty feet. Two or more large stoves, as the 
 climate demands, will be found the most practical way 
 of warming temporary hospitals. The experience of 
 our civil war and the Franco-German War, compared 
 with all preceding wars, shows conclusively that tem- 
 porary one-story wooden buildings make the best army- 
 hospitals, and save thousands of lives that would be 
 sure to be lost if the sick and wounded were treated in 
 any public or private building that is nearest at hand, 
 as was the custom in former times.
 
 HOSPITALS FOB TEE INSANE. I79 
 
 INSANE-ASYLUMS. 
 
 To (To tliis subject justice would require mucli spe- 
 cial study, and fill a volume. 
 
 In this country most of our institutions are con- 
 structed on the massive monumental style, and man- 
 aged on the economical, prison system, and there is 
 still too much of the iron bars, dark cells, and strait- 
 jackets of the old Bedlam. Besides, the medical atten- 
 tion is scant and necessarily more or less inefiicient, 
 and the nursing is wretched ; in fact, the nurses do 
 not pretend to be anything more than keepers, and 
 the class from which they are selected is the same 
 as that from which keepers for criminals are derived. 
 Uncommon brute-force seems to be considered the 
 most desirable quality to make a good nurse for an 
 insane-asylum. 
 
 On Blackwell's Island, where the largest charitable 
 institutions of New York City are situated, there is 
 an insane-asylum containing thirteen hundred inmates. 
 The large majority of these are in an old building of 
 several stories, with wards for forty or fifty 2:>atients 
 each ; with the exception of the raving maniacs that are 
 in a badly-constructed lodge, the rest of the patients 
 are in cheap one-story wooden pavilions. At the pres- 
 ent time the whole institution is under the control of 
 one paid medical oificer, who sometimes has two or 
 three voluntary medical assistants, and sometimes is 
 entirely alone and is expected to render medical assist- 
 ance to all the patients, and at the same time act as 
 suj^erintendent or executive officer. 
 
 At the time of our visit the doctor informed us that 
 he had no hold on his assistants, and could never be
 
 180 INSANE-ASYLUMS. 
 
 sure how long tliey would remaiu with him. There 
 was in the whole hos^^ital one nurse to every twenty- 
 eight patients. In one of the wards intended for forty 
 we found ninety-three patients, and only two nurses in 
 charge. 
 
 On the same island, at Charity Hospital, where 
 there are usually one thousand patients, there are, be- 
 sides a medical executive officer, a house staff of twenty- 
 four and a visiting staff of twenty-seven medical men, 
 or about one doctor to every eighteen patients ; while 
 at the insane-asylum, allowing the physician two assist- 
 ants, there is only one doctor to four hundred and 
 twenty-five paii^ents! 
 
 The above account would not fairly represent the 
 condition of all our insane-asylums; but, even in our 
 best institutions for the insane, it will be found that 
 there are several hundred patients to each physician, 
 and the nurses too few in number and not above the 
 grade of common household servants. Some of the 
 buildings are magnificent structures put up at the cost 
 of millions of dollars, but, in our opinion, in many 
 respects unsuited for the purpose they are intended 
 to fulfill. 
 
 Of course, dangerous maniacs and raving, acute, 
 insane patients must have special arrangements for 
 their care ; but the large majority of the insane can 
 be treated very much as rational beings, and well- 
 trained, reliable nurses in sufficient number would 
 render unnecessary large wards and close confinement, 
 and enable most of the patients to be kept under 
 agreeable and natural conditions conducive to their 
 recovery. And if some of the money expended in 
 fine buildings was used to pay the best medical talent
 
 FAULTS OF OUR ASYLUMS. 181 
 
 to devote their time to the study and care of the 
 insane, the results would be much more satisfactory. 
 
 More than any other class of patients, the insane 
 are influenced l>y external conditions that surround 
 them, and that institution is the best which brings 
 its patients under conditions that make the nearest 
 approach to a cheerful and comfortable home.
 
 CHAPTEE XI. 
 
 HOSPITAL-BUILDINGS NOW IN USE. 
 
 Houses can be classified according to their different 
 plans, perhaps not so definitely and accurately as a 
 naturalist can arrange the different ty23es of animals or 
 2:)lants, but as readily and understandingly as can be 
 done with the other works of man. In studying over 
 and in grouping the buildings now in use as hospitals, 
 we find many old structures that can be very aj^pro- 
 priately called old fossils, and that, judged by their 
 past history, are truly comparable to the largest and 
 the most destructive of the ichthyosaurians of past 
 a£:es. 
 
 Our limited knowledge of the hospitals of Indiai* 
 compels us to confine our remarks to those of Europe 
 and America. We will use, for the pui'pose of illustra- 
 tion, chiefly those hospitals which we have had the 
 opportunity of visiting in person. 
 
 AYe recognize five distinct types in those now exist- 
 ing: 
 
 * 1. The Old Conglomerate, including all extempo- 
 rized and iiTegular hospitals. 
 
 2. The Old Block Plan. 
 
 3. The Corridor Plan.
 
 OLD HOSPITALS OF PARIS 183 
 
 4. The Pavilion System. 
 
 5, The One-Story Pavilion Plan. 
 
 THE OLD CONGLOMERATE. 
 
 Unless the early Chi'istians borrowed the ideas and 
 adopted the plans of the hospitals used hy the ancient 
 fire- worshipers — of which we have no evidence — it is 
 probable that the first hospitals of Europe were certain 
 rooms in or near the monasteries and convents, and 
 were inere appendages to those institutions. During 
 the middle ages the monks and members of the reli- 
 gious brotherhoods were about the only class who 
 understood medicine, and it is likely that the monks 
 and priests distributed medicine and gave advice 
 very much in the same way as is done to-day by our 
 out-door dispensaries. It is certain that they often 
 accommodated the sick in or near their monasteries 
 and churches. From such beginnings some of the most 
 famous hospitals in the world have grown. Of this 
 class the renowned old Hotel-Dieu of Paris is the most 
 illustrious examj^le. This immense old structure stood 
 on both banks of the Seine, with connecting portions 
 lying across and others running under the stream, and 
 only a few steps from the cathedral of Notre-Dame. 
 When we visited it five years ago the wards were filled 
 with patients, and in more ways than one it reminded 
 us of an old, gnarly, weather-beaten oak with a decay- 
 ing, rotten centre. Its different j)arts were shaped and 
 arranged with about as little uniformity and evident 
 order as the branches of an old oak, and its wards were 
 about as fit places for the sick to inhabit as the cavities 
 of a decaying tree would be for man to live in. It was 
 founded aboi^ the beginning of the seventh century by
 
 IS4: OLD HOSPITALS OF PARIS 
 
 St. Landry, Bisliop of Paris, and grew to an immense 
 size ; a century ago it contained several thousand beds 
 and from two to six patients to eacli bed. Early in tlie 
 sixteenth century the beds were still larger, having from 
 eight to twelve patients in each, and dui'ing the preva- 
 lence of the plague as many as sixty-eight thousand 
 died within the hospital in one year. Although it was 
 utterly condemned more than a hundred years ago, it 
 was in use as a hospital until within the past few 
 years. Fortunately, there is not such another example, 
 but there are many hospitals that can claim to be lesser 
 evils only on account of their smaller size. 
 
 La Cliarite was originally an old chapter-house. 
 In 1637 it was enlarged and turned into a hospital, and 
 now contains about four hundred beds. St.-Antoine 
 was an old convent opened as a hospital in 1795. In 
 1862 it was enlarged in a quadrilateral form, and now 
 holds four hundred and eighty beds. Beaujon^ once an 
 orphan- asylum, was also converted into a hospital in 
 1795. In 1844 new pavilions were added, making the 
 hospital surround a square yard. Several of the other 
 hospitals of Paris were old convent-buildings, and have 
 not been very much altered. 
 
 In this country and in England the early history of 
 our hospitals shows the source of some of our faulty 
 hospital-.buildings. After it has been decided that a 
 hospital is needed, before the managers or authorities 
 are prepared to build, either from the want of funds or 
 the necessity of the case, some old private dwelling or 
 public building is hastily fitted up and used as a hos- 
 pital ; and finally, instead of putting up a new building, 
 the extemporized hospital is enlarged by changes and 
 additions and indefinitely continued as a l^spital. Such
 
 EXTEMPORIZED HOSPITALS. 
 
 185 
 
 buildings make very bad liospitals, and it is false econ- 
 omy to use any old building, however much improved 
 by additions and changes, for the purpose of treatino- 
 the sick any longer than absolute necessity compels. 
 The 2^1ainest temporary Trooden shanties are preferable. 
 
 Fig. 1. 
 
 • HopiTAL Neckek. 
 
 A, wards ; B, chapel ; C, corridor ; D, pharmacy ; E, offices ; F, dwelUng ; 
 G, kitchen. 
 
 As examples of extemporized hospitals of the old 
 conglomerate class we take the following : Fig. 1 gives 
 tracings of the ground-plan of the Hopital Necke)\ of 
 Paris, originally a Benedictine monasteiy, which was 
 enlarged and turned into a hospital of one hundred and 
 twenty beds, in 1776. In 1862 it was further enlarged
 
 186 
 
 OLD CONGLOMERATE HOSPITALS. 
 
 by additions, and now contains tliree hundred and 
 eighty-six beds. There are three stories of wards, and 
 the buildings containing them surround three sides of 
 a square court, the fourth side being occupied by a gal- 
 lery. The larger wards contain twenty beds, and*the 
 
 Fig. 2. 
 
 tL.ly. 
 
 VJ 
 
 w 
 t»_ 
 
 tit---4Li 
 
 %' 
 
 \A/ I 
 
 Bellevce Hospital, of Xew Toue. 
 
 C, C, C. 
 
 D, E, F, G, n. 
 W, W, W, etc. 
 a, a, a, etc. 
 
 c and b. 
 
 d. 
 
 e and g. ♦ 
 
 h. 
 
 Courts. 
 
 OfSces, etc. 
 
 Wards. 
 
 Water-closets. 
 
 Xurses' Rooms. 
 
 Laundry. 
 
 Heating-apparatus. 
 
 Kitchen. 
 
 [3HJ 
 
 I 
 
 smaller six beds each. The nurses' rooms are between 
 wards, and the closets and baths at the ends of the 
 bull din o-s. 
 
 Fig. 2 represents the first floor of Bellevue Hospital, 
 of New York City. Two-thirds of the present building 
 now used as a hospital was originally an almshouse and 
 penitentiary, built 1811-16. At first only a small por- 
 tion was used for hos23ital purj^oses, but dui'ing epi-
 
 I 
 
 BELLEYUE HOSPITAL. 157 
 
 demies of ty]:)]ius fever and other diseases, and as tlie 
 city grew larger, it became more of a liospital. In 
 18-48 tlie almshouse and penitentiary inmates "were 
 removed and a regular medical board organized, and 
 the whole building was used as a hospital. In 1857 
 the hospital was so crowded that the garrets were used 
 as wards, and it became a necessity to enlarge the build- 
 ing. From 1857 to 1860 renovations were going on: 
 partitions which ran lengthwise in the buildings were 
 cut into arches, the windows enlarged, and on the old 
 portion a third story was added and a new wing built 
 on the northeast, which is a mere extension directly 
 connected with and on precisely the same plan as the 
 old almshouse portion. 
 
 From 1860 to 1873 the hos23ital usually contained 
 from seven to eight hundred patients, and during each 
 year from seven to eight thousand patients were ad- 
 mitted. Several wards were used for lying-in cases, 
 and from four to five hundred women were delivered 
 annually. Of the seven or eight thousand admitted on 
 an average, more than one thousand died in the hospi- 
 tal, making a mortality of one in every seven or eight, 
 or about 'twelve and a half per cent, of all the patients 
 admitted. During successive years in the printed re- 
 ports of the hospital, from sixty to seventy deaths are 
 reported as being caused by pyaemia and puerperal fever 
 alone, which is more than six per cent, of all the deaths. 
 From time to time efforts to imj)rove the hospital were 
 made by members of the medical board ; the fever and 
 contagious cases were removed and placed in temporary 
 one-story wooden pavilions on BlackweU's Island, and a 
 pavilion- ward was erected on the grounds for erysipelas 
 and other infectious cases. In 1874 a move was made
 
 188 OLD CONGLOMERATE HOSPITALS. 
 
 by tlie State Charities Aid Association to improve the 
 hospital, on account of the excessive mortality, esj^ecially 
 among the acute surgical and maternity cases, which 
 was obviously caused by the faulty sanitary condition 
 and construction of the buildincr. Althou2:h this move 
 did not effect satisfactorily the object aimed at, still, it 
 was the means of doing good, for, during a fearful epi- 
 demic of puerperal fever in the maternity- wards when 
 the death-rate was two out of every five of the women 
 delivered, the lying-in cases were all removed and the 
 maternity-service in the hospital was done away with 
 altogether. Since then the number of j)atients in the 
 surgical wards has been diminished, and a system of 
 artificial ventilation has been introduced. This venti- 
 lating apparatus has j)roved to be an utter failure. At 
 present the hospital consists of a central administrative 
 part, with wings on either side, three stories high, fifty 
 feet wide, rectangular in shape, and cut up into wards 
 by partition walls, through which doors open dii^ectly 
 from one ward to another, while between the wards are 
 the badly-drained bath-rooms and water-closets, with no 
 openings except directly into the wards. Joined direct- 
 ly to these wings, with only a narrow staircase inter- 
 vening in the j^assage, are the north and south portions 
 of the building, which are also three stories high, and 
 are divided into wards and arranged in exactly the 
 same manner as the central part, as will be seen by the 
 diagram ; some of the wards for twenty beds have only 
 six windows. 
 
 Charity Hospital^ of this city, built by the munici- 
 pal authorities as late as 1860, is a massive stone struct- 
 ure, several stories high, and contains usually more than 
 a thousand patients under one roof. The wards are
 
 IRREGULAB^ UOSPITALS. 
 
 189 
 
 not unlike tliose of Bellevue, Laving tlieir long axis 
 running across the building, thus causing tlie dis- 
 tance between opposite windows to be veiy great, 
 and making it necessary to place the beds along tbe 
 partition-walls, between whicli are tke water-closets, 
 baths, etc. 
 
 L'regular hospitals of the conglomerate class are 
 veiy numerous, and include many famous hospitals. 
 With the exception of the new St. Thomas's, all the 
 important hospitals of London can be classed under 
 this head. Also many hospitals on the Continent, and 
 all hospitals in this country built previous to 1860, 
 except those that we will mention hereafter, must be 
 
 Fig. 3. 
 
 King's College Hospital, London. 
 
 included. Fig. 3 represents one of the floors of King's 
 College Hospital^ of London. It is a good example of 
 the irregular class. The building is comparatively of a 
 recent date, put up since 1850, and crowded into a 
 small space near the Eoyal College of Surgeons, the
 
 190 OLD CONQLOMERJLTE HOSPITALS. 
 
 object being to have a liospital convenient to the col- 
 lege, wbile the evident aim of the architect was to 
 get in as many beds as jDossible. It is a four-story 
 building witli an attic, and contains one hundred and 
 fifty beds. The large ward shown in the diagram illus- 
 trates a double Avard with four rows of beds between 
 opposite windows, a very objectionable plan, but, as 
 will be seen by the following examples of the London 
 hospitals, a style that has been very generally adopted. 
 St. Bai'tJiolomeio's is the oldest of London hospitals ; it 
 dates back to 1102. It was rebuilt in 1730. Most of 
 the wards are in three separate buildings four stories in 
 height, with two wards on each floor. The wards are 
 divided by a partition, and have four rows of beds be- 
 tween the windows. 
 
 Guy's Hospital was founded in 1722. The old 
 building surrounds two small courts, with extensions 
 inclosing three sides of a larger square in the rear. A 
 new building contains two large w^ards on a floor, with 
 four rows of beds between the windows, and divided by 
 a partition similar to those of St. Bartholomew's. 
 
 London Hospital^ built in 1740, reminded us very 
 much of Bellevue ; it is of the same shape, and, being 
 in the east end of London, receives the poorest class of 
 patients; most of the wards are divided by a partition- 
 wall as at Bellevue, and have four rows of beds between 
 the windows. 
 
 Middlesex Hospital is on the block plan, and shaped 
 like the letter H. 
 
 GTiaring-Oross is a solid building several stories 
 high, and contains one hundred and eighteen beds. 
 The wards are almost square, and open directly into 
 each other.
 
 GERMAN HOSPITALS. 
 
 191 
 
 University College Hospital is something like the 
 regular old block plan, but must also be classed as an 
 
 Fig. 4. 
 
 AlLGEMEINE KkANKEXHAUS, of YlKNXA. 
 
 Tracings representing the ground-plan of the building. The partitions dividing the 
 buildings into wards are not given in the drawing. 
 
 irregular conglomerate hospital. All other English 
 hospitals built previous to 1860, with which we are 
 acquainted, are either irregular as the above, or slightly
 
 192 OLD CONGLOMERATE HOSPITALS. 
 
 modified, but by no means improved, by having por- 
 tions on tlie corridor plan. 
 
 Fig. 4 gives tracings representing tlie ground-pl^n 
 of tlie Vienna General Hospital. The partitions divid- 
 ing the buildings into wards, etc., are not given in the 
 diagram. As the wards have opposite windows and 
 only two rows of beds, it might have been classed 
 under the old block plan ; but it is also very irregular 
 and faulty. This hospital was established by the Em- 
 peror Joseph II., in 1784. It has accommodations for 
 three thousand patients, and usually contains as many 
 as two thousand inmates. The wards are constructed 
 on the old block plan and are in buildings two stories 
 high, which, as is shown by the diagram, surround nine 
 different squares or courts that serve as airing-grounds 
 for the patients. There are in all ninety-three wards, 
 of different sizes. The service-rooms are built, as in 
 Bellevue Hospital, between the ends of the wards ; the 
 windows are opposite, but placed so high that the 
 patients cannot look out of them. There are four am- 
 phitheatres, two dispensaries, two kitchens, and many 
 offices. 
 
 Munich General Hospital^ founded in 1808, is on 
 the same plan ; it contains live hundred beds, and is 
 built around three courts, two large and one small one. 
 But almost all the old hospitals of Germany are on the 
 corridor plan. 
 
 Most of the hospitals of Italy are old, irregular 
 buildings. 0ne of the oldest, opened 1456, is one of * 
 the monuments of the middle ages, to which we have 
 already alluded in Chapter I. It has fifty-six wards, 
 arranged for over three thousand beds. Fig. 5 gives 
 the outlines of the ground-plan. The two large crosses
 
 GEAND HOSPITAL OF MILAN: 
 
 193 
 
 ^L-±-Ji^ 
 
 
 1^ 1" 
 1 •■ 
 
 " L 
 1 
 
 •8- 
 f 
 
 — _— -n 
 J 
 
 3 n 
 
 13
 
 194 TEE OLD BLOCK FLAK 
 
 represent tlie main buildings. In tlie centre of tlie 
 cross is an altar for holding divine services. The ceil- 
 ings of the wards are from thirty to forty feet high. 
 Corridors run along both sides of the wards, and the 
 windows are placed above them. The outside wards, 
 completely inclosing the courts, are not so high, and 
 were evidently added later. 
 
 St. Louis Hospital^ at Turin, was originally a palace, 
 built 1794, and afterward turned into a hospital. It is 
 a two-story Greek cross, with a chapel in the centre, into 
 which the wards open. 
 
 The General Hospital of Madrid is an immense 
 quadrangular building, several stories high, begun in 
 1788, and now has sixteen hundred and twenty-one 
 beds. 
 
 The hospitals of the conglomerate class have all the 
 faults of the old block plan, and are still used as hospi- 
 tals either through ignorance or indifference as to what 
 is required for the proper care of the sick. 
 
 THE OLD BLOCK PLAN. 
 
 The hos]3itals of this plan usually consist of a solid 
 building several stories high, the central part being- 
 used for offices and administration-rooms, with wards 
 in wings on either side. When the hosj)ital is a large 
 one, the buildings extend more or less around a court- 
 yard, and in som^ cases around two or more court- 
 yards. 
 
 The evident design in adoj^ting such a plan seems 
 to be to save ground-space, make the administration 
 economical, and at the same time establish" an imposing 
 and endurino; monument. As a rule, manao-ers and
 
 ROYAL mFIRMARY OF EDINBURGH. 195 
 
 arcliitects have a strong, in fact an almost irresistible 
 predilection for such plans. 
 
 The old Royal Infirmarij., of Edinburgh, was one of 
 the first hospitals regularly designed and built on the 
 block plan. The history of the establishment of this 
 hospital, as related in a small volume published in 1778, 
 is strikingly like the history of many of our first hospi- 
 tals, and the plan of the buildings so similar that it is 
 evident the Eoyal Infirmary is the original model from 
 which the rules and regulations and the style of build- 
 ings have been derived. The following account, to- 
 gether with the diagram, was taken from the volume 
 referred to above : 
 
 "In the year 1725 the Royal College of Physicians, 
 who had long given gratuitous advice and medicines to 
 the sick poor at their hall, being thus well acquainted 
 with their miserable state, undertook to obtain sub- 
 scriptions for such a fund ; and, as a good example to 
 others, were the first subscribers, and engaged to attend 
 the infirmary regularly in their turns without fee or 
 reward. . . . The subscription of two thousand j^ounds 
 was no sooner completed, than the College of Physicians 
 called the contributors together, who named twelve of 
 their number as a committee for collecting the money 
 subscribed, for obtaining more subscriptions, and for 
 preparing a plan of management of the infirmary. . . . 
 This committee, having received as much money as, by 
 its annual rent, might maintain a few patients, and 
 having prepared a report concerning the management 
 of the hospital, called a meeting of contributors, where 
 twenty managers were elected, and such regulations as 
 were then deemed necessary were digested and ordered 
 to be printed; and on the 6th of August, 1729, a small
 
 196 ROYAL INFIRMARY OF EDIKBURGH. 
 
 hired house Avas opened for receiving sick poor. . . . 
 After several years of trial of the good effects of this 
 in&mary, the managers represented the advantages of 
 such a hosj^ital in an humble petition to his majesty, 
 who was graciously pleased to grant a charter, dated 
 the 25th of August, 1736." 
 
 The charter being granted, it was decided to build a 
 new hospital, and the foundation for half the building 
 was laid in 1738. Fig. 6 represents the second floor. 
 The book before us contains drawings of each floor, and 
 in the text is a full description. In describing the 
 building, which stands in four acres, the writer says : 
 
 " This house consists of a body and two wings, each 
 of three full stories, and an attic one, with garrets 
 above. . . . The body of the house is two hundred 
 and ten feet in length ; from each end of which, and at 
 right angles, a wing is extended seventy feet, having 
 vaulted cellars below. The middle of the body is 
 thirty-six feet wide, but the rest of the house is only 
 twenty-sixty feet wide. ... In the middle of the 
 house, contiguous to the great staircase, there is, on the 
 ground-floor a lobby or hall ; on the second floor, the 
 managers' room ; on the third floor, a consulting-room 
 for the physicians and surgeons, and a waiting-room for 
 the students ; and, on the attic, a large theatre, in which 
 upward of two hundred students, at once, see opera- 
 tions ; and the same serves as a chapel." The rest of the 
 building was mainly taken uj) by the wards, the larger 
 of which were eighty-one by twenty-six feet and con- 
 tained twenty-four beds ; the smaller were fifty by 
 twenty-six feet, with twelve beds each. There was one 
 window to two beds. The service-rooms were placed 
 at the ends of the wards. The writer goes on to say :
 
 FIRST BLOCK-PLAN HOSPITAL. 
 
 197 
 
 H 
 
 I i 
 
 s s
 
 198 THE OLD BLOCK FLAN. 
 
 " 111 the construction of tliis fabric nothing liatli been 
 more solicitously attended to than ventilation. In each 
 of the shorter wards, that is, those of the wings, are 
 opposite windows, a chimney at one end, and a door 
 opening to a stair at the other. In the longer wards, 
 or those in the body of the house, besides opposite win- 
 dows, is a door at each end leadins: to different stair- 
 cases, some of them having likewise a chimney at each 
 end. Other parts of the hospital, deemed somewhat 
 too confined for the ready admission of external air, are 
 furnished with artificial ventilators." Five years ago 
 this old building was still standing. Several other 
 buildings had been added, namely the old surgical 
 and the new surgical. For a time the old college- 
 building was used as a fever-hospital ; there was 
 also a lock-hospital ; some of these additions are on 
 the corridor plan. Lately, new pavilions have been 
 erected. 
 
 The above account of the old infirmary would an- 
 swer very well for a descrij)tion of the old Pennsylva- 
 nia Hospital now in use at Philadelphia. In the chap- 
 ter on the " History of Hospitals " we described its 
 origin and the steps of its development, which were 
 strikingly like those of the Edinburgh Infirmary. 
 
 The old building of the Massachusetts General Hos- 
 pital, at Boston, is on the same plan. The history of 
 the old New York Hospital is also very similar to that 
 of the Edinburgh Infirmary, and the new hosj^ital lately 
 completed in this city on Fifteenth Street by the govern- 
 ors of the New York Hosj^ital is on the old block plan, 
 and the ground-plans of the two hospitals might easily 
 be mistaken the one for the other ; but the elevation of 
 the New York building overtops that of the old Edin-
 
 NBW YORK HOSPITAL. 199 
 
 • 
 
 burgli Infirmary by several stories.' The two were con- 
 structed for tlie same number of inmates (about two 
 hundred). The New York Hosj^ital has all the faults 
 of the old infirmary plan slightly modified by some 
 modern improvements and a very uncertain and expen- 
 sive system of fan-ventilation; but, instead of being 
 surrounded by four acres of land, it is closely shut in 
 by adjoining dwelling-houses, and an old mansion, used 
 as a library and administrative building, fills up the 
 court formed by the extensions. 
 
 Taking either the New York Hospital lately opened 
 or the old Royal Infirmary, of Edinburgh, built a hun- 
 dred and forty years ago, as being about the best of the 
 hospitals on the old block plan, we sum up oui* objec- 
 tions under three heads : 
 
 1. The wards are placed one above the other. 
 
 2. The administrative ofiSces, the kitchen, operating- 
 theatre, the wards, in fact, the whole hospital, is under 
 one roof, and the different parts all communicate more 
 or less directly with each other. 
 
 3. The service-rooms are either in or closely con- 
 nected with the wards. 
 
 In the chapter on " Construction " we give in full 
 our reasons for making the above objections. • 
 
 THE CORRIDOR PLAN. 
 
 The Grand Hospital of Milan, which we have classed 
 under the irregular conglomerate, is the oldest hospital 
 with corridors, being opened in 1456 ; but the corridors 
 are' on both sides of the wards and attached to the out- 
 side of the buildings, instead of being only on one side 
 
 » We speak of this hospital and give the number of stories on page 35 
 of Chapter I.
 
 200 THE CORRIDOR PLAN. 
 
 and within the building, as in the regular corridor hos- 
 pital. We have not been able to trace satisfactorily 
 the origin and development of the corridor plan. 
 
 The small hospitals of this class usually consist of 
 a central portion and two wings, the administration 
 offices occupying the centre, and the wards and their 
 service-rooms the wings. The large hospitals, as in the 
 old block plan, are built more or less around a central 
 court. In fact, the corridor plan is the same as the old 
 block, with the addition of a corridor or narrow passage- 
 way that runs parallel with the long axis of the ward, 
 having doors and windows opening on the ward. In 
 some cases the corridor runs through the centre of the 
 building, with the wards on either side ; in these the 
 wards are usually quite small, being often merely small 
 rooms containing not more than three or four beds each. 
 Fig. 7 is a rough sketch of the principal floor of St. 
 Liike^s Hospital^ of New York. This was the first and 
 the only hospital built on the corridor j^lan in this 
 country, besides being one of our first church hospitals. 
 It was founded by the late Rev. Dr. W. A. Muhlen- 
 berg, of the Protestant Episcopal Church, May, 1854. 
 In the same year a newly-formed church sisterhood 
 opened a temporary hospital in an adjoining hired 
 house. Dr. Muhlenberg, in a short historical sketch, 
 says : " The chapel being finished, was oj)ened for divine 
 service on Ascension-day, 1857, and thenceforward on 
 Sunday afternoons, with the exception of four mouths 
 in the following winter. This was done in advance of 
 the opening of the hospital, for the purpose of declar- 
 ing the Christian faith to be the ground and predomi- 
 nating element of the institution. For a year, St. Luke's 
 appeared before the j^ublic as a church." A year later
 
 ST. LUKE'S HOSPITAL. 
 
 201 
 
 2 » 
 
 < £ 
 , o 
 
 <! £ 
 i> 
 
 a-:.S 
 £ = S 
 
 w X 
 
 o S-r. 
 
 o u 
 
 o 5 £ 
 
 
 ■^ o 
 
 a; —
 
 202 THE CORRIDOR FLAK 
 
 the wards were opened and the patients from the tem- 
 porary hospital were transferred to them. As will be 
 seen by the diagram, the wards and corridors open 
 directly on the chajjel. Only a few months before his 
 death the venerable Dr. Muhlenberg, who for many 
 years acted as superintendent, showed us over the hos- 
 pital ; he pointed with evident pride to the chapel and 
 called it an immense reservoir of pure air for the wards. 
 At the time of our visit not a window in it was open, 
 and we considered it a rece]3tacle for foul air. Tlie 
 results of treatment in this hospital have been compara- 
 tively very good, but we believe this is due to cleanli- 
 ness and good management, and to the favorable loca- 
 tion, rather than to the plan of construction. 
 
 During the first half of this century the corridor 
 plan seems to have been the favorite, and was the 
 fashion on the Continent about 1848. With few ex- 
 ceptions the principal hospitals of Germany, Austria, 
 Russia, and some of the smaller states of Europe, are 
 all constructed on this plan. In most of these the 
 corridor runs along one side, but in some it runs direct- 
 ly through the centre of the building. 
 
 Charite Hospital^ of Berlin, is on this plan. It has 
 three stories, and contains fourteen hundred beds. 
 The CatJiolic Hospital^ of the same city, has three 
 hundred and fifty beds in small wards opening on 
 corridors. 
 
 The following hospitals are all constructed on the 
 corridor plan : 
 
 Bethanien Hospital^ in Berlin, founded in 1847, has 
 three stories, and contains three hundred beds. 
 
 Hamhurg General Hospital^ enlarged in 1848, has 
 six or seven hundred beds.
 
 GEEMAIT CORRIDOR HOSPITALS. 203 
 
 Rotterdam Hospital., built in 1850, contains two Lun- 
 dred and sixty-five beds. 
 
 Bremen Hospital., erected in 1850, has two floors of 
 wards and two hundred and seventy-two beds. 
 
 Franhfort-on-tlie-Main Hospital., dated 1833, has two 
 hundred beds. 
 
 Both Kiel and Munich have lying-in hospitals con- 
 structed on the corridor plan. 
 
 The ground-plan of the Alexandrov Hospital^ of 
 Moscow, in shape resembles a horseshoe, with four pro- 
 jecting wings. It is a corridor hospital, built in 1861. 
 ' Hbpital Cochin, of Paris, built in 1780, for one hun- 
 dred and nineteen beds, is a corridor hospital. 
 
 Mancliester Royal Infirmary., England, erected in 
 1797, has a corridor running directly through the cen- 
 tre of the building, with wards on either side. 
 
 T}iQtHospital for Consumptives and Diseases of 
 the Chest, at BromjDton, built in 1 848, is a regular cor- 
 ridor hospital. Other hosj^itals of London are partly 
 corridor hospitals. 
 
 Fig. 8 gives the ground-plan of the hospital Rudolph- 
 stiftung, of Vienna. This is one of the latest and most 
 complete of the hospitals on the corridor plan. It was 
 opened in 1865. Except on the east side, the buildings 
 are three stories high. The corridor runs parallel with 
 the wards, and opens into them on the north side. 
 There are, in all, eight hundred beds. In this hospital, 
 and in several others on the corridor plan, an attemj^t 
 is made to divide the hospital into pavilions by large 
 stairways or by lower buildings intervening, but prac- 
 tically the hospital is still under one roof. 
 
 The only rational object that seems to be aimed at, 
 in placing a corridor on one side or in the middle of a
 
 204 
 
 THE CORRIDOR PLAN. 
 
 building containing liospital wards, is to afford a means 
 of passing to and fro without disturbing the patients as 
 much as would be done by passing tlirougli the wards. 
 Where the building is divided up into a number of 
 small wards or rooms, such a passage-way is necessary. 
 
 Fig. 8. 
 
 a 
 
 • p, 
 
 STORE 
 f 
 
 m 
 
 hi 
 
 [ ii 
 
 \\ IT' I 
 
 li ' 
 
 HALL J 
 
 l.t_J_! 
 
 i 
 
 '1^ / 
 
 Hospital Eudolph-stiftung. 
 
 A, administrative offices on the north ; 1, wards ; B, baths ; D, dispensary ; 
 
 S, stairs. 
 
 But one gathers from the old writers, and the talk of 
 old men, that tliey had an idea the corridor could be 
 used to supply the wards witb fresli air without letting 
 in the cold or draughts, and that the stairways were 
 the great ventilating wells. But w^e know now that 
 the corridors running parallel witk the wards not only
 
 OBJECTIONS TO TEE CORRIDOR PLAN. 205 
 
 interfere witli tliroiigli- ventilation from side to side and 
 intercept sunlight, but tliat they serve as foul-air chan- 
 nels to convey the tainted air from one ward to an- 
 other. 
 
 Previous to the completion of the Lariboisiere and 
 to the Crimean "War, and the books of Miss Nightingale, 
 little v^as generally known about sanitary laws, and the 
 corridor plan was coj)ied simply because it "was about 
 the only recognized design that was a departure from 
 the old conglomerate hospitals of the past, and did not 
 interfere with the desire of the founders to erect a monu- 
 ment, nor with the ambition of the architect to construct 
 an imposing edifice on a small space of ground. TVe 
 consider that corridor hospitals have all the ftiults of the 
 old block plan, namely : the whole hospital being under 
 one roof, the wards placed one above the other ; the 
 service-rooms in close proximity to the wards ; and, be- 
 sides, corridors that make ventilation more difficult in- 
 tercept sunlight, and add to the cost of construction. 
 
 THE PAVILION SYSTE.AL 
 
 In Chaj^ter I. we gave some account of the origin 
 and develo2">ment of the pavilion plan. Miss Nightin- 
 gale, in her "Notes on Hospitals," says: "The first 
 princij^le of hospital constiniction is to divide the sick 
 among separate j^avilions. By a hospital pavilion is 
 meant a detached block of buildings, capable of con- 
 taining 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 uncon- 
 nected Avith any other pavilion of which the hospital 
 may consist, or with the general administration offices,
 
 206 THE PAVILIOX PLAN. 
 
 excejDt by liglit, airy passages or corridors. A j^avilion 
 is indeed a sej^arate detached hospital, wliicli has, or 
 ouo-ht to have, as little connection in its ventilation with 
 any other ^ari of the hospital as if it were really a 
 separate establishment miles away. The essential feat- 
 ure of the pavilion construction is that of breaking up 
 hospitals of any size into a number of separate detached 
 parts, having a common administration, but nothing 
 else in common. , And the ol^ject sought is, that the 
 atmosphere of no one ^^avilion or ward should dif- 
 fuse 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 air from the out- 
 side." 
 
 The first hosj^ital with separate pavilions, so far as 
 we can learn, was erected in 1756-64 at Stonehouse, 
 near Plymouth, England. The famous report of the 
 committee of the French Academy of Sciences was 
 made in 1786. 
 
 St. Andre General Hospital^ of Bordeaux, founded 
 in 1390 and rebuilt 1829, was the first complete hospi- 
 tal constructed according to the principles laid down 
 by the rej)ort of the Academy's committee. It has six 
 hundred and fifty-four beds in twenty-four wards ; the 
 pavilions are arranged on either side of an open court, 
 around which runs an open gallery or corridor connect- 
 ing the pavilions on the ground-floor. 
 
 Hopital St. J'ean, at Brussels, was completed in 1843. 
 It consists of ten pavilions, only thirty-five feet apart, 
 and connected by a two-story corridor. 
 
 Hospital Za Princesse^ of Madrid, is a modern 
 building on the pavilion j^lan. There are eight ]3avil- 
 ions, four on each side of a large inclosed sj)ace, and
 
 LARIBOISIERE HOSPITAL. 
 
 207 
 
 connected by a corridor It contains three hundred 
 and fifty beds. 
 
 Fig. 9 is the ground-plan of Larihoisiere, commenced 
 
 Fig. 9. 
 
 G 
 
 sL. 
 
 c 
 
 1 
 
 IL 
 
 H i-&- Li 
 
 i 
 
 isij?-fijusn m 
 
 1= 
 
 m 
 
 IE 
 
 d 
 
 Id 
 
 n. 
 
 zz^iy 
 
 rrl^Tl -. 
 
 ■M 
 
 m 
 
 HiiL 
 
 h 
 
 i-p 
 
 IS 
 
 3 
 
 3 
 
 
 nzfi 
 
 
 ia 
 
 HopiTAL Lariboisiere. 
 
 in 1846, on plans furnished by Gauthier, and finished in 
 1854. 
 
 This hospital consists of a series of pavilions, ar- 
 ranged on two parallel lines, separated by an inclosed 
 space laid out as a garden. There are six of these
 
 208 THE PA VILION PLAK 
 
 cletaclied buildings for patients, containing in all six 
 hundred and six beds ; in front are buildings for tlie 
 offices, kitchen, and pharmacy, parallel with those for 
 the sisters and attendants, the laundry, chapel, operat- 
 ing-room, baths, etc., at the end farthest from the en- 
 trance. The pavilions contain three floors of wards ; 
 one large ward for thirty-two beds, and one small 
 adjoining ward for two beds on each floor. Each ward 
 has a sister's room and scullery ; at the ends are closets, 
 baths, etc. ; and a spacious staircase gives access to the 
 wards. All the 23avilions are connected by a glazed 
 corridor, one floor in height, over which is an open ter- 
 race, used by convalescents, and also as a means of 
 access between the first floors when the weather per- 
 mits. 
 
 Any one visiting this splendid hospital with its pol- 
 ished floors, its walls of Parian cement, its costly ma- 
 chinery for artificial ventilation, etc., etc., would be 
 inclined to think that it is perfect — that the patients 
 must do Avell. But time has shown a different result. 
 Its records give a mortality but little less than that of 
 the old hospitals. It may be well asked. Why is it not 
 a success ? 
 
 1. Forced or artificial ventilation cannot with safety 
 be made to take the place of natural or normal circula- 
 tion of unadulterated, fresh air, purified by the direct 
 rays of the sun. 
 
 2. The area on which the buildings stand is too 
 small for a hospital of six hundred and six beds. 
 
 3. The pavilions are three stories high and only 
 sixty feet apart, which is not sufficient space to allow a 
 free circulation of air. 
 
 4. The wards all communicate with a stairway at
 
 NEW ST. THOMAS'S HO SPIT A L. 209 
 
 one end, so that impure air readily passes from one to 
 the other; and, as the pavilions are connected by 
 large, spacious corridors, without doubt air is often 
 interchanged from one pavilion to another. 
 
 5. The closets, baths, and sinks, are placed at the 
 ends of the wards, so that a current of air passing from 
 end to end in the ward is liable to be made impure at 
 all times. 
 
 6. The pavilions are arranged around a court. 
 New St. Thomases Hospital^ in London, with the 
 
 exception that the pavilions have foui- floors of wards 
 instead of two, is built after the plans given in Miss 
 Nightingale's book, "Notes on Hosj^itals." On the 
 Thames embankment the eight jDavilions of St. Thom- 
 as's Hospital rear their stately fagades for a quarter of 
 a mile opposite the Houses of Parliament and West- 
 minster Abbey. These pavilions are built of red brick, 
 faced with sandstone, and covered w^ith slate. They 
 are situated about one hundred feet apart, the first and 
 second stories being connected in front by corridors. 
 The disiDensaries, drug-shop, etc., form a part of the cor- 
 ridors. The pavilions at either end are appropriated, 
 one to the executive offices, and the other to the medi- 
 cal college. The hosj)ital contains twenty wards, hav- 
 ing from twenty to twenty-eight beds each, with a small 
 ward of two beds attached to each, the sixth pavilion 
 being used for infectious cases, and containiug seven 
 wards of eight beds each. It is without doubt the 
 most magnificent hospital, and perhaps the finest struct- 
 ure used for charitable purposes, in the world. The 
 administrative and executive facilities could not be 
 more complete, even to the smallest detail; neither 
 space nor cost has been spared. 
 14
 
 210 
 
 TEE CORRIDOR PLAN. 
 
 Altliougli free from some, yet it has most of tlie 
 same serious faults which have been enumerated while 
 speaking of the Lariboisiere, namely : The pavilions have 
 too many stories ; the corridors are so constructed that 
 there must be more or less intercommunication of the 
 atmosphere of one pavilion with another. The nurses' 
 room, small ward, etc, block up one end, while the clos- 
 ets and baths fill up to a great extent the other end of 
 the wards. It is a great imj^rovement on the old plans ; 
 
 Herbert Hospital. 
 
 but so far the practical results have not been altogether 
 satisfactory. 
 
 Fig. 10 represents the ground-j^lan of Herbert Hos- 
 pital at Woolwich, built in 1863. At the time of its 
 erection it was considered by Miss Nightingale as fully 
 carrying out the true princij^les of hospital-construction. 
 It consists of four double and three single two-story 
 pavilions on a raised basement, connected by a corridor 
 through the centre. The corridor is of one story, with a
 
 E2TGLISH CORRIDOR HOSPITALS. 211 
 
 basement. There are six liundred and fifty beds. The 
 wards are twenty-six and a half feet wide, fourteen feet 
 long, and each bed has ninety-five superficial feet and 
 fourteen hundred cubic feet of sj^ace. To every two 
 beds there is one window. 
 
 The late writers on hospital-construction, as Galton, 
 also put forward the Herbert Hospital as a model. We 
 would make the same objections that we made to New 
 St. Thomas's, for, with the exception of being tAvo sto- 
 ries only to the pavilions, it is almost exactly the same. 
 
 Blachbiirn Infijinary^ England, commenced in 1859, 
 M'as one of the first pavilion hospitals built in England. 
 It occupies eight acres of land, not far from Manchester, 
 and is composed of six detached two-story pavilions 
 runnino; risjht and left from a connectinsr corridor. 
 
 Glasgow Surgical Hospital is a pavilion hospital 
 built in 1860. It has one hundred and ninety-eight 
 beds — eight wards of nineteen beds each — two wards 
 to a floor, with a staircase between them. The wards 
 are closed at both ends. 
 
 The New Infirmary built at Leeds, England, is a 
 large pavilion hospital. It consists of five buildings, 
 each two stories high, connected by a corridor. 
 
 The CJiorlton Union Worhliouse Hospital i^ also a 
 new i^avilion hospital. In fact, throughout the United 
 Kingdom of Great Britain the teachings of Miss Night- 
 ingale are generally acce]:)ted and carried out wherever 
 new hospitals are built. 
 
 Fig. 11 gives the plan of the Hospital of the Prot- 
 estant Episcopal Churchy of Philadelphia. This was the 
 first hospital constructed in America in which the sug- 
 gestions of the French Academy's committee were car- 
 ried out. Mr. Samuel Sloan ^vas the architect. The
 
 212 
 
 THE FA YILION FLAK 
 
 corner-stone was laid May, 1860. The hospital consists 
 of a central administrative building, containing a very 
 large chapel, operating-theatre, and offices. On either 
 side parallel with the administrative building are the 
 detached pavilions containing the wards. In each j)a- 
 vilion there are two floors of wards above the base- 
 
 FlG. 11. 
 
 
 
 Hospital of the Protestant Episcopal Church, of Philadelphia. 
 
 ment, besides an attic in w^hich are rooms for special 
 cases. These pavilions are connected with the admin- 
 istrative building by a two-story corridor running at 
 right angles with them. The wards are one hundred 
 and twenty feet long, thirty feet ten inches wide, by 
 sixteen feet in height, and contain thirty beds each.
 
 PAVILION HOSPITALS OF MEW YORK. 213 
 
 In 1863 tlie Boston Free City Hospital was partly 
 built. The original plan consisted of a grand central 
 administrative building, connected with six widely- 
 detached, three-story pavilions by curved, one-stoiy 
 corridors. Only two of the j)avilions on the old plan 
 were erected. Within the past three years several one- 
 story pavilions have been built on the grounds. 
 
 In 1867 one of the pavilions of the New Yorh State 
 Womaii's Hospital was opened, and the second pavil- 
 ion was finished a few months since. The buildings 
 are handsome structures, with four floors of wards, 
 and together can accommodate one hundred and 
 thirty-five patients. The two pavilions are almost 
 exactly alike. In the basement are the kitchen and 
 store-rooms. The first floor is divided by a hall and 
 partitioned into private rooms. The second and third 
 floors are alike, and have fourteen beds each. The 
 fourth floor has twenty-four beds. Each ward has its 
 water-closets and bath-room and nurses' room, or small 
 ward, at one end, where there are a service-staircase and 
 dumb-waiter from the basement to the top ward ; and 
 at the other end are a wide stairway and an elevator for 
 carrying up patients — one of the first ever introduced 
 into a hospital for that purpose. There are also in this 
 end the reception-roorn, office for the house-surgeon, and 
 an operating-room. The j^avilions are situated with 
 their long axes east and west; consequently the sun 
 shines only on one side. 
 
 The cases treated in this hospital are confined to 
 diseases j)eculiar to ^romen; no lying-in women are 
 received. The author resided in the older of these 
 pavilions as house-surgeon for eighteen months, and 
 knows from personal experience that the whole build-
 
 214 THE PAVILION PLAN. 
 
 ing liad a common atmosphere ; tliat tlie patients on tlie 
 fourtli floor could not help knowing what they were to 
 have for dinner long before it reached them ; and that 
 patients in all the wards suffered from malarial poison 
 arising from defective drainage in the cellar. After 
 the buildings had been in use a few years, it began to 
 be risky to operate upon certain cases, and within the 
 past few months it has been decided to erect huts or 
 cottages for the cases of ovariotomy, as lately nearly all 
 such cases operated on have died. 
 
 Since the erection of the first pavilion of the Wom- 
 an's Hospital several new hospitals on the pavilion plan 
 have been built in ISTew York City, or at least partly 
 built, one or more pavilions of each being completed, 
 and are now in use. The largest of these is the JRoose- 
 velt Hospital ; that is designed for three hundred beds, 
 and now has room for one hundred and eighty ; one of 
 the pavilions of this hospital is only one story high. 
 We will speak of it again. 
 
 Mount Sinai Hospital for IGO beds, is completed. 
 
 The German Hospital has one large pavilion com- 
 pleted; and \hQ Presbyterian Hospital has an elegant 
 administrative building, kitchen, laundry, steam-engine, 
 etc., but only one central pavilion finished for seventy 
 beds. 
 
 To criticise one of these is to criticise all, for they 
 are on very much the same plan, all three or four stories 
 high, with service-rooms, etc., at the ends, and all, ex- 
 cept the Roosevelt, have the j^avilions so placed as to 
 get sunlight only on one side. 
 
 There is a hospital in Providence, R. I., the MJiode 
 Island Hospital^ on the pavilion plan, very much the 
 same as the new hospitals of this city.
 
 OBJECTIONS TO THE PAVILION PLAN. 215 
 
 San Francisco, California, lias a large, two-story 
 pavilion hospital situated in spacious grounds. Chicac-o 
 is to liave a large pavilion hospital ; one of the pavil- 
 ions, of several stories, has been built. There are sev- 
 eral other smaller ones in the United States on the 
 same plan. 
 
 The regular pavilion plan is but a modification of 
 the old block plan, and we have exactly the same objec- 
 tions to it. We cannot say that all the hospital is un- 
 der one roof, but, where there are more than thirty 
 j^atients to the pavilion, we do say there are too many 
 patients under one roof. The wards are placed one 
 above the other, and the service-rooms are in close 
 proximity to the wards. 
 
 THE ONE-STORY PAVILION PLAN. 
 
 The principles of the one-story pavilion or barrack 
 plan are precisely those laid down by the committee 
 of the French Academy and taught by Miss Nightin- 
 gale, but the pavilions are all limited to one story in 
 height and to one ward to each pavilion. In Chapter 
 I. we have described their origin and development. 
 
 Fig. 12 gives the plan of the one-story pavilion of 
 the Presbyterian Hospital, of Philadelphia. This build- 
 ing was completed in 1875, and illustrates very well 
 about the best of the one-story pavilions that have been 
 erected. 
 
 As will be seen by comparing this diagram with 
 the plate giving our drawing for a surgical pavilion, 
 the plans are somewhat alike ; but in this the service- 
 rooms are in the same building as the patients, the win- 
 dows are too few, the beds too close together, and the
 
 216 
 
 THE ONE-STORY PAVILION PLAN. 
 
 Oai, 
 
 ^ffllL 
 
 r — I 
 
 1^ 
 
 iffigj^ 
 
 ^aEi^iEfe 
 
 gSj 
 
 r 
 
 Hffl^f 
 
 m-^\^\- 
 
 m^mA- 
 
 m-\^;\M- 
 
 'HPffl^ll I 
 
 S 
 
 ^c 
 
 H 
 
 LliiJ_.S
 
 AMERICAN ONE-STORY PAVILION HOSPITALS. 217 
 
 sitting-room at tlie end of tlie ward interferes witli tlie 
 ventilation. 
 
 In this country a number of one-story pavilions, in 
 connection with large civil hospitals, have been erected 
 since the civil war. On Blackwell's Island the New 
 York City authorities had a number of simple wooden, 
 one-story pavilions built on the jjlan of those used for 
 the temporary hospitals during the war. The first were 
 fever wards, but lately all the new buildings for the sick 
 are on the one-story plan, and at present two one-story 
 pavilions, to be used as a lying-in hospital, are being 
 constructed in which the wards will be separated from 
 the service-building by a space of ten feet and connected 
 by a short straight corridor. One of the surgical wards 
 of the Roosevelt Hospital is in a handsome one-story 
 pavilion ; but the building has a cellar beneath it, and 
 at the end adjoining the corridor are all the service- 
 rooms except the water-closets and baths, which are in 
 a small structure projecting from the side of the ward 
 near the centre — a very ol)jectionable place. 
 
 In Boston there are several one-story j^avilion wards ; 
 those on the grounds of the Boston Free City Hospital 
 are of the usual rectangular shape, with service-rooms 
 directly connected with Avards. One of the pavilions 
 of the 3£assacliusetts General Hospital has a square 
 ward similar to that given by one of the essayists in 
 the Johns Hopkins Hospital book, a review of Avhich 
 will be found in our Appendix, 
 
 The plans for the United States Marine Hospital at 
 San Francisco, California, are one-story pavilions, like 
 those used for army hospitals during our civil war. 
 
 In Great Britain the Glasgow Fever Hospital was 
 one of the first one-story pavilion hospitals erected.
 
 218 THE ONE-STORY PAVILION PLAN. 
 
 It consists of four parallel double pavilious oue story 
 high. Three are built of wood on brick pillars. The 
 fourth is of brick with hollow walls. There are ridge- 
 sashes and opposite windows. There are eleven beds 
 to the ward, and a small ward adjoining. 
 
 Fig. 13 gives the plan of the Rotlierham Hospital^ 
 built in 1872. This is one of the best and most com- 
 plete small hospitals in England. The buildings are 
 of stone. The pavilions are one stoiy high, and raised 
 some distance from the ground, and sixty feet apart. 
 The water-closets and baths are in the small projections 
 at the free ends of the wards. The small buildings at 
 the ends of* the corridors are wards for special cases, 
 and the two between the pavilions are wards for con- 
 valescents. The pavilions contain respectively twelve, 
 ten, and eight beds. 
 
 During the late Franco-German War both parties, 
 especially the Germau, adopted the American system 
 of erecting large temporary hospitals, composed of a 
 great number of one-story pavilions, built of wood, and 
 in some cases connected with the administrative build- 
 ing and with each other by a corridor. 
 
 Dr. Esse had a one-story wooden pavilion erected in 
 connection with Charity Hospital, of Berlin, in 1867, 
 and since then several civil hospitals on the American 
 one-story or barrack plan have been constructed, two 
 of which we speak of in Chapter I. — one at Leipsic, the 
 other at Kiel. The new City Hospital at Friedrichs- 
 hain, Berlin, built in 1870, is a pavilion-hospital. Some 
 of the wards are in one-story and others in two-story 
 pavilions. The pavilions are widely detached, and have 
 no connecting corridors — only gravel-walks between. 
 
 To the best of the one-story pavilions we can make
 
 ROTE ERE AM HOSPITAL. 
 
 219
 
 220 THE ONE-STORY PAVILION PLAN. 
 
 but one of tlie three objections wliicli we made to tlie 
 old block plan, for the hospital is not all under one 
 roof, nor are the wards placed one above the other ; 
 but the service-rooms, namely the water-closets, the 
 bath-room, the nurses' room, the scullery, and in some 
 cases a small ward, are all directl}^ connected with the 
 ward under the same roof, and alwaj^s blocking up one 
 and in many cases both ends 9f the ward. 
 
 How to correct the above faults, and to erect a hos- 
 pital on an improved one-story pavilion plan, we en- 
 deavored to show in the chapter on " Hospital-Con- 
 struction."
 
 appe:n" d IX. 
 
 A Review of " Five Essays relating to the Construction, Organization, and Manage- 
 ment of Hospitals, contributed hy their Authors, for the Use of the Johns Hop- 
 kins Hospital of Baltimore." Large 8vo, pp. xxi.-353. Numerous Plates. 
 New York : William Wood & Co., 18Y5. (Renew written for the Standing 
 Committee on Hospitals, State Charities Aid Association, at the request of Mr. 
 King.) 
 
 The object of this book is fully and clearly stated in the letter 
 of Mr. King, the President of the Board of Trustees, and may be 
 given in a few words. The late Johns Hopkins, a wealthy citizen 
 of Baltimore, bequeathed several million dollars (now estimated to 
 be 86,000,000) to trustees, with which to found a university, a col- 
 ored orphan asylum, and a hospital, and he added fourteen acres 
 of land in the city of Baltimore, on which the hospital is to be 
 built. 
 
 In a letter to the trustees Mr. Hopkins very definitely describes 
 his wishes concerning the trust. 
 
 The hospital is to be a general medical and surgical hospital, 
 and to contain four hundred beds ' when finished. The sick poor, 
 without regard to sex, age, or color, are to be received into it free 
 of cost, and a number of beds are to be provided for strangers and 
 others able and willing to pay. The hospital is to have a training- 
 school for nurses established in connection with it, and is to be 
 used to afford clinical teaching for the medical school of the uni- 
 versity. 
 
 In his letter Mr. Hopkins enjoined the trustees " to obtain the 
 
 * Working basis reduced now to three hundred beds.
 
 222 APPENDIX. 
 
 advice and assistance of those at home and abroad who have 
 achieved the greatest success in the construction and management 
 of hospitals." In accordance with this request the trustees selected 
 
 John S. Billings, Brevet Lieutenant-Colonel and Assistant Sur- 
 geon, U. S. A. ; 
 NoRTOisr FoLSOM, M. D., of Boston ; 
 Joseph Jones, M. D., of New Orleans ; 
 Caspak Morris, M. D., of Philadelphia ; 
 Stephen Smith, M. D., of New York — 
 
 each to prepare an essay upon the construction and organization 
 of the proposed Johns Hopkins Hospital. 
 
 Before taking up the discussion of the essays, we must speak 
 of the " Letters of Instruction " that preface them, one from Mr. 
 Hopkins to the trustees, the other from Mr. King, the President of 
 the Board of Trustees, to the authors of the essays. 
 
 Dr. Folsom in his paper, speaking of Mr. Hopkins's letter ad- 
 dressed to the trustees, very aptly says : " 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." Mr. 
 Hopkins has not alone shown his wisdom and practical judgment 
 in defining his wishes, but has displayed equal foresight in the 
 selection of the men who are to carry out his intentions. We 
 speak of this, because, in a great majority of instances, trustees of 
 hospitals are chosen mainly on account of high social position, or 
 for generous contributions to the finances, and seldom have much 
 actual practical knowledge about such institutions. Mr. King's 
 letter shows plainly that, if he has not had actual experience in 
 hospitals, he has at least made himself familiar with their organi- 
 zation, construction, and management, and that he has broad and 
 comprehensive views upon the subject. 
 
 The steps so far taken by the trustees of the Johns Hopkins 
 fund toward the building of the hospital are in striking contrast 
 with those pursued by most boards of managers of hospitals, and 
 we believe that the contrast will be still more marked in the future 
 when a comparison can be made between the practical workings of 
 the various institutions. 
 
 The only fault we have to find with Mr, King's letter of instruc- 
 tion is, the short time allowed for preparing the essays ; it should
 
 REVIEW OF DR. BILLINGS'S ESSAY. 223 
 
 have been six instead of two months. To this unavoidable haste 
 we are inclined to attribute the marked want of completeness that 
 is noticeable, with one exception, in all of the five essays. 
 
 DR. BILLINGS'S PLAN. 
 
 The first essay is by J. S. Billings, M. D,, who begins his paper 
 with some good suggestions about the medical school. 
 
 The remarks on organization and management are very general, 
 and some important points are treated of in a very few lines. For 
 instance, a mere reference is made to the training-school for 
 nurses, for which it is observed a separate building should be 
 prepared ; but no plan of organization is given, nor is the subject 
 again referred to. 
 
 " On the Causes of Hospitalism ; or, the Hurtful Influence of 
 Hospitals," an interesting chapter is given : not that there is 
 much that is new in it, but that it is a clear statement of the nature 
 and action of hospital poisons, so far as these are understood, and 
 is not to be found in other books on hospital-construction. 
 
 What Dr. Billings has to say about temporary versus perma- 
 nent hospitals is exceedingly interesting. He begins by giving his 
 reasons for having advocated the proposition a few years since, 
 that "no hospital should be constructed with a view to its being 
 used as such for more than fifteen years." After stating under 
 what circumstances he did so, he says : " 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 sweep- 
 ing." He then makes some remarks both for and against the bar- 
 rack-system, and concludes as follows : " 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." We, too, believe that such a 
 building can be adapted to the successful treatment of the great 
 majority, but not of all classes, of cases. 
 
 Dr. Billings next takes up the question of heating and ventila- 
 tion, his plan for which, he candidly admits, will be an experiment. 
 In his discussion of the subject and in his assertion that two-story
 
 224 APPENDIX. 
 
 pavilions may be made to furnish results equal to those of one 
 story, especially in a case like this where land is abundant, he 
 appears to us to give too much weight to theoretical views, and 
 shows a tendency to overlook the results of experience, and to fol- 
 low in the same steps that have led to the erection of all our mag- 
 nificent civil hospitals, which he nevertheless admits to have been 
 failures. 
 
 It is indeed difficult to understand why methods of ventilation, 
 theoretically so complete and perfect, have failed to give good 
 results when jout in practice. And yet it is a fact that, so far, 
 simple one-story buildings, with but little or no mechanical con- 
 trivances to perfect the ventilation, have given the best and the 
 only satisfactory results in the treatment of a large and important 
 class of patients ; while, on the contrary, those hospitals con- 
 structed at a great cost Avith (from a theoretical standpoint) all 
 the necessary contrivances for making the ventilation a near 
 approach to perfection, as, for instance, Lariboisiere, have failed 
 to give as good results as similar buildings without the mechanical 
 ventilating apparatus. 
 
 The general plan for the wards and service-rooms, in Dr. Bil- 
 lings's essay, does not diflfer essentially from that recommended by 
 Miss Nightingale. 
 
 We think the plan of having the wards raised on basements so 
 that the top of the corridor may serve as a walk on a level with 
 the floor of the ward a good one, and we approve of the wall and 
 the cubic space allowed each bed, and the number of beds to each 
 ward ; but we think the service-rooms and the small wards take up 
 too much space, and Avill make the plan expensive, besides block- 
 ing the end of the ward. 
 
 We would separate, in fact isolate, the service-rooms from the 
 ward, placing them near the end of the ward, a little to one side 
 of and connected with it by means of a short corridor. The object 
 thus aimed at is — 1. To avoid the danger which is to be appre- 
 hended from the proximity of the numerous partitions, doors, etc., 
 as affording places for harboring infection ; and from the emana- 
 tions from water-closets, drains, sinks, and dining-rooms ; 3. To 
 diminish the risk of the foul air of one ward reaching other wards 
 by means of the corridors ; 3. To leave the ends of the ward free, 
 so that a current of air can pass through the ward as readily from 
 end to end as from side to side ; 4. That if need be, on account
 
 REVIEW OF DR. BILLINGS'S ESSAY. 225 
 
 of the ward becoming infected, it can be destroyed, leaving intact 
 the basement and the service-rooms.' 
 
 Instead of the plan given for the private or pay patients' pavil- 
 ions, we would have them similar to the pavilions for the other 
 patients, with this difference : they should be forty feet wide in 
 place of thirty, so as to allow for a corridor in the centre with 
 rooms on both sides, say twelve by fifteen feet each, heated by an 
 open grate. The ward containing the rooms should be as com- 
 pletely separated from the service-rooms as was recommended for 
 the others. 
 
 After reading Dr. Billings's remarks on hospitalism, we are sur- 
 prised to find him recommending that the amphitheatre for opera- 
 tions should be crowded into the same building with the post-mor- 
 tem and pathological rooms. If what he says about these " disease- 
 germs," these little infectious floating particles, is true, then every 
 patient operated upon and every wound exposed in the operating- 
 amphitheatre would be liable to be poisoned — infected with a fatal 
 disease — before they enter the wards. 
 
 If the j^ost-mortem and jDathological rooms are placed on the 
 grounds at all, they should be in one corner of the lot, as complete- 
 ly isolated as possible. They should, under any circumstances, 
 have all attendants, both medical and others, entirely distinct from 
 those of the hospital, and the buildings might very well be sepa- 
 rated from the rest of the hospital by a high stone-wall. The 
 operating-theatre should be kept as well ventilated and as pure 
 and fresh as the wards themselves. 
 
 Under the head of "General Plan of Hospital" Dr. Billings 
 gives some good suggestions on the classification of patients ; and, 
 although we think to carry out this to the extent he recommends 
 wOl be a difficult matter, still, it should be done as far as is prac- 
 ticable. 
 
 Judging from what we know of pavilions of one, two, and three 
 stories, erected in this city, Boston, and Philadelphia, it strikes us 
 that Dr. Billings's estimate of the cost of his buildings is too Ioav 
 by at least one-third of the amount given. 
 
 ' A full description, with drawings and plan for carrying out this idea, was 
 given in a paper read before the State Charities Aid Association in New York, 
 December, 18Y3, and a brief reference to it published in the report of 'the special 
 committee appointed to take active measures for the erection of a new Bellevue 
 Hospital, February, 1874. 
 15"
 
 226 APPENDIX. 
 
 If Dr. Billings's one-story plan is adopted, we do not hesitate to 
 say that the hospital would be a very great improvement upon any 
 other in this country, but we cannot accept his essay completely, 
 and sum up our objections as follows : 
 
 1. He is too general in his remarks on the organization and 
 management of the hospital. 
 
 2. In his plan for the pavilions he does not recognize the advan- 
 tage of separating the ward from the service-rooms, and favors too 
 much the idea of two stories under circumstances where the ques- 
 tion of sufficient ground cannot arise. 
 
 3. His plan of heating and ventilation, as he himself admits, is 
 an experiment, and when the plans are closely examined we find 
 the fresh-air and foul-air ducts placed one directly above the other, 
 so that, unless at a great expense these ducts are made imper- 
 meable to air, there will be a constant interchange of their con- 
 tents ; and if we are to believe the teachings of Pettenkofer, that 
 almost everything is permeable to air, it will be next to impossible 
 to make the separation complete, arranged as Dr. Billings has 
 them. 
 
 4. In his plan for what he calls the third building, which " is 
 to contain the amphitheatre, out-door dispensary-rooms, dead- 
 house, and pathological laboratory," he violates the plainest sani- 
 tary law, and contradicts his own teaching given in previous 
 chapters. 
 
 5. We do not consider his plan of arranging the pavilions the 
 best, either for the good of the patient, or the convenience and 
 economy of administration. It has the merit of being uniform 
 and well-balanced, but in his plan for the one-story pavilions 
 (Plate IV.) these are too close to each other, and the private 
 wards too near the administrative building. 
 
 DR. is^ORTON rOLSOM'S PLAN. 
 
 Dr. Folsom's plan for the pavilions, the wards which he terms 
 " isolating wards," and the autopsy -building, together with his 
 method of heating and ventilation, is similar to that of the 
 Massachusetts General Hospital now in use. 
 
 The principles are exactly the same, but the details, especially 
 those relating to the administration, are more elaborate and are in 
 many respects improved. Dr. Folsom adopts one plan for all his
 
 REVIEW OF DR. FOLSOM'S ESSAY. 227 
 
 wards, except for the -wards he calls " isolating wards," and does 
 not speak of having his surgical wards differ from those of the 
 medical, and does not provide for a proper classification of dis- 
 eases. 
 
 In reference to the training-school for nurses, we think he has 
 misinterpreted the intentions of the founder when he proposes to 
 limit it to the use of the hospital. We believe that it was the 
 design of Mr. Hopkins, not merely to afford women wishing to 
 become nurses the opportunity of serving in that capacity in the 
 wards, but to establish a training-school in which the didactic part 
 of a nurse's education — of which Dr. Folsom thinks so little — 
 should be begun and developed until the profession is made an 
 honorable one, and nurses are raised above the level of servants. 
 
 Dr. Folsom decides in favor of having all the biAldings in which 
 the patients are treated only one story high, but also decides that 
 all parts of every building should be permanent in construction. 
 To this, as we have said before, we object. All wards for acute 
 surgical and fever cases should be so constructed as to be readily 
 destroyed and renewed ; for other cases not liable to become in- 
 fected, the wards may "be permanent in character. 
 
 The buildings in Dr. Folsora's plan are well arranged for the 
 convenience of administration, and so placed that the medical 
 superintendent can readily supervise all the workings of the hos- 
 pital ; but, in our judgment, the general plan is in several respects 
 objectionable : 
 
 1. The administrative building, dispensar}-, operating-theatre, 
 kitchen, laundry, autopsy-rooms, and the dead-house, are situated 
 on the west and southwest side of the grounds, exactly in the 
 position to intercept, during the summer, when the windows and 
 doors are open, the prevailing wind, and to permit the poisoned 
 atmosphere from these buildings to be carried directly into the 
 wards. 
 
 2. We cannot see the necessit}' of crowding together the laun- 
 dry, autopsy, dead-house, boilers, and kitchen, nor for having the 
 operating-theatre in such close proximity to the post-mortem 
 rooms. 
 
 3. The dispensary service and that of the hospital are in com- 
 mon, using the same pharmacy, etc. Such an arrangement may do 
 in a small hospital, but, for one of three or four hundred beds, 
 there will be, aside from the necessarily great risk of infection, and
 
 228 APPENDIX. 
 
 the unavoidable filth and dirt, much confusion if the out-patients 
 are to use the same entrance as the inmates of the hospital. It is 
 obvious that it would be difficult to keep order, if the out-patients, 
 of whom nothing is known, were allowed the freedom of the 
 grounds, and of at least a part of the main corridor in which the 
 attendants are constantly passing. Dr. Folsom recognizes this, 
 although his remedy is a doubtful one, when he proposes that 
 red and blue stripes be used to guide the patients in the cor- 
 ridors. 
 
 A dispensary for out-patients, if not under a separate manage- 
 ment, should at least be a distinct department, with attendants, 
 both medical and others, separate from those of the rest of the 
 hospital. 
 
 The plan fqf the wards adopted by Dr. Folsom is a great im- 
 provement on the two and three story buildings so generally erect- 
 ed, but we have several objections to it : 
 
 1. The square-shaped ward would do very well for certain medi- 
 cal cases, but not for fevers and acute surgical cases. Compared 
 with that usually adopted, in which the length is equal to the 
 width multiplied by three, the wall-space is diminished, obliging 
 the beds to be placed closer together, and if the service-rooms are 
 attached as Dr. Folsom has them, one-third of the wall-space is cut 
 off from the open air. Although the patients are nearer at hand 
 and more equidistant from the heating apparatus than in the long 
 ward, they are at the same time closer to a very common cause of 
 infection, namely, the water-closets, sinks, etc. 
 
 2. There is no real separation of the ward from the service- 
 rooms. The water-closets are very objectionably placed, and too 
 few in number. 
 
 3. The wards are not on high basements, the floors being on 
 the same level as that of the corridors. This is convenient for the 
 administration, but we have never yet seen a corridor in which the 
 circulation of air was not greatest in the direction of its length ; 
 in fact, we are satisfied that it is the natural direction of currents 
 in any closed, or even partially closed, narrow and long spaces, 
 and that it is impossible to prevent these currents from end to end 
 in corridors, and at the same time keep them warm in cold weather. 
 If the wards, therefore, have direct communication with the corri- 
 dor, the foul air of one ward mil be carried to the others. It is a 
 well-known fact that foul odors and kitchen-fumes are readily per-
 
 REVIEW OF DR. FOLSOM'S ESSAY. 229 
 
 ceptible in corridors at a distance of several hundred feet from the 
 point of entrance, although the windows on opposite sides of the 
 corridor are opened at several places between the two points. 
 Except in climates where the severity of the winters absolutely 
 necessitates closed corridors, the communication between wards 
 should be merely covered ways. 
 
 4. The corridors in Dr. Folsom's plan are objectionable, not 
 only because they are liable to carry foul air from one ward to an- 
 other, but also because, on account of their height compared with 
 that of the wards, they will in a great measure obstruct the free 
 circulation of outside air. Suppose a wind to be blowing from the 
 southwest, but little of its influence would be felt in pavilions 1, 2, 
 3, and 4, in his plan on the north side of the grounds. 
 
 5. The little dining-room across the corridor, with flat tin roof, 
 only seven feet high, would be very hot in summer. 
 
 6. As Dr. Folsom places his wards on low basements, and takes 
 the fresh air near the ground, it seems that he has not considered 
 the dangers of ground-air, or that he does not give much weight to 
 the late views of sanitarians on the subject. If hot water, heated 
 b}^ a small furnace attached to each pavilion, were used instead of 
 steam, and the fresh air received from high leads, we think that 
 the method of heating and ventilation proposed by Dr. Folsom 
 would be very much improved. 
 
 7. His " isolating wards " would not be so objectionable if the 
 service-rooms were removed from the centre and placed near one 
 end, and separated from the ward for patients. But we would 
 prefer to have a small ward of one or two beds in connection with 
 the service-rooms of each pavilion, for the purjDose of treating cases 
 not infectious nor liable to cause infection, but which for some 
 exceptional reason would be better removed from the ward. For 
 these wards of Dr. Folsom's another name than that of " isolating 
 wards " would be better, for they are certainly not suitable for the 
 treatment of such cases as require isolation on account of being 
 infected or liable to cause infection. 
 
 Dr. Folsom's pavilion for private patients is very complete, but 
 it would be better if the service-rooms were detached, and we be- 
 lieve that it is very desirable to have separate buildings for the 
 sexes, instead of one for both men and women. 
 
 The plan for the axitopsy-building is very elaborate, and one of 
 the best we have seen.
 
 230 APPENDIX. 
 
 DR. JOSEPH JONES'S PLAN. 
 
 We find little in Dr. Jones's essay that is original or valuable, 
 but he urges one excellent practice, namely, that of having the 
 wards at certain intervals thoroughly cleansed and left open to the 
 air and light for purification. He recommends that one-twelfth of 
 the beds in each ward and one in twelve of all the wards be always 
 left empty. 
 
 DR. CASPAR MORRIS'S PLAN. 
 
 The fourth essay, by Dr. Caspar Morris, is an able paper, con- 
 taining many good suggestions, especially in regard to the details 
 of construction and management, and is filled with facts left untold 
 by others. It is, however, extremely conservative in the argu- 
 ments against temporary buildings, and in favor of solid, two-story 
 pavilions. 
 
 On page 200, when urging the great necessity of the utmost 
 care in selecting building-material, and in carefully superintending 
 the work, to make sure that it is well done. Dr. Morris says : "One 
 open seam, or splintered edge of a joint, may become an irremedi- 
 able source of contamination, in a ward otherwise without objec- 
 tion, and thus render useless all the expenditure of thought in con- 
 triving and money and labor and material in construction, and 
 make unavailing the vigilance and neatness of service." And 
 again, under the head of " Drainage," page 234, he says : " The 
 v/hole system of drainage should be fully planned and laid out 
 before any further progress is made in the arrangement of the 
 buildings. The smallest negligence or oversight may render use- 
 less the utmost care and cost elsewhere." 
 
 Unless Dr. Morris expects to succeed in having hospital-con- 
 struction reach perfection and remain so for generations, we can- 
 not understand, after the above statements, why he should. recom- 
 mend so costly a plan as he does, and contend that every part 
 should be solid and permanent in character. We do not say that 
 all the wards of a hospital should be of a temporary character, but 
 we repeat that compound fractures, amputations, fevers, and other 
 cases liable to infect a building, should be treated in wards so con- 
 structed that, at any time deemed advisable, they may be removed 
 and renewed at a small cost, and that all infected cases should be 
 treated in temporary isolated huts or tents.
 
 REVIEW OF DR. MORRIS'S ESSAY. 231 
 
 In most hospitals the number of patients riequiring treatment 
 in temporary buildings would not be large, probably not more than 
 one in ten, while in other hospitals, on account of the proportion- 
 ally large number of acute surgical and fever cases, it may be 
 necessary to have one-fourth of the wards made temporary. From 
 what Dr. Morris says concerning the EjDiscopal Hospital of Phila- 
 delphia, we infer that not many such cases are received in that 
 hospital. 
 
 The great advantage as to the convenience of administration 
 and comparatively smaller cost of the two-story pavilions over the 
 one-story plan, so ably advocated by Dr. Morris, is by no means 
 conceded by all authorities ; on the contrary, many, especially 
 those who have had the superintendence of hospitals constructed 
 on the one-story plan, state that, as all the wards are on one level 
 the administration is very much simplified and more convenient 
 than in those hospitals where there are stairs, lifts, etc., and that 
 the difference of cost has been very much over-estimated ; that 
 increased thickness of wall and strength of material, together with 
 the necessary staircases, lifts, etc., required in the tv.'o-story j^lan, 
 make up for the extra roof and foundation of the one-story pavil- 
 ions. 
 
 To give our objections to Dr. Morris's plan would be to reit- 
 erate what we have already stated in our remarks on the preceding 
 papers. We agree with him, that the greatest care should be 
 given to the selection of the building-material, that the Avorkman- 
 ship should be the very best, and that bad management, want of 
 cleanliness, etc., etc., will render useless and unavailing the best- 
 constructed hospital ; but we do not think that all the advantages 
 afforded by the one-story buildings can be attained in pavilions of 
 two stories. We will formulate our opinion on this point by say- 
 ing that, where the ground-space is sufficient to permit it, every 
 ward of a hospital should be in a separate, one-story building, and 
 that acute surgical, fever, and other cases liable to infect each 
 other, or the building, should never be treated in two-story build- 
 
 DR. STEPHEN SMITH'S PLAK 
 
 The last and, in many respects, the best of the five essays is 
 by Dr. Stephen Smith. From a sanitary standpoint it is particu- 
 larly interesting. Under the head of the " Site of the Hospital "
 
 232 APPENDIX. 
 
 he gives us some interesting information on ground-air and ground- 
 water. Accepting the views of Pettenkofer as to the evil influ- 
 ences of ground-air and ground-water, Dr. Smith suggests an elab- 
 orate plan for draining the ground of its air and water bj " 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." 
 Such a system of drainage would undoubtedly improve the sani- 
 tary condition of the grounds, and make the soil a better absorbent 
 and a "better disinfecter " of foul gases. To drain the ground 
 of its air would be an experiment, and would cost something, 
 but to drain it of its water would be a simple matter ; and, 
 although the ground may have many natural advantages, we 
 believe that it would improve the sanitary condition of the hos- 
 pital. 
 
 Dr. Smith's suggestions on grading ajid cultivation are valu- 
 able, but care should be taken in planting trees not to interfere 
 with the free circulation of air. 
 
 One of the best parts of Dr. Smith's paper is on " The Classes 
 of the Sick to be received." We prefer this classification of the 
 patients to those given by the other essayists. 
 
 We accept his views on the questions of temporary versus per- 
 manent, and one versus two story pavilions, as well as his conclu- 
 sion, page 296 — " In the present instance, from every standpoint 
 of view, we can but regard the question as settled in favor of per- 
 manent pavilions of one-story wards " — with this proviso, that 
 some of these pavilions should be in part temporary, which he him- 
 self provides for in the classification of his paviHons (page 307 of 
 his essay). 
 
 In many respects Dr. Smith's plan for his pavilions and con- 
 necting corridor is similar to that of the paper already referred to 
 as having been read before the State Charities Aid Association ; 
 but (in his plans) he has failed to carry out with completeness 
 some of the most important points of that plan : 
 
 1. He has only partially separated the service-rooms from the 
 ward proper, and in his argument for this separation leaves out the 
 best reasons for its adoption. 
 
 2. He recommends that the wards be placed on raised base- 
 ments, and proposes that these basements should be closed and 
 serve as hot-air chambers, instead of having the ward on arches 
 with the surface beneath asphalted and open to the air and sun-
 
 REVIEW OF DR. SMITH'S ESSAY. 233 
 
 light, by which means the ward would be in no danger of receivin"- 
 the much-dreaded ground-air. 
 
 3. We do not approve of having the water-closets in the base- 
 ments, nor do we think that the corridor should be even partially 
 underground, but altogether above the level of the ground, with 
 the top not higher than the floors of the wards ; and it should con- 
 nect with the service-rooms on the outside, and not pass between 
 them and the ward. 
 
 4. If a second story to the service-rooms is needed to furnish 
 sleeping-rooms for the helpers, a second story might be added, 
 but we would not have any room up-stairs for the use of the 
 patients. 
 
 5. We cannot consider favorably the method of heating and 
 ventilation where Dr. Smith proposes that the wards should be 
 heated by means of hot-aii' chambers beneath the ward-floor direct- 
 ly in contact with the ground. If such a system is adopted, it will 
 indeed be necessary to drain the ground of its air ; and we are in- 
 clined to believe that, in spite of his carefully-constructed base- 
 ments, he would fail to prevent these hot-air chambers from sucking 
 up a large share of the ground-air, thus transmitting it to the wards, 
 and so bringing about the very danger he tells us should be so care- 
 fully avoided. We would much prefer the well-known and well- 
 tried plan of heating and ventilating by means of ojDen fires. We 
 would supplement these open fires by hot-water pipes in small 
 boxes under the floor, and we would have hot-water pipes so ar- 
 ranged in the ventilating-shaft that when needed the hot water 
 could be turned on and made to heat the shafts without warming 
 the ward. By means of these hot-water pipes in the shafts the 
 ward could be ventilated by suction, during the disagreeable, 
 murky days of the year, when a fire in the ward would be uncom- 
 fortable, and the necessity of forced ventilation is so much felt ; 
 thus we would avoid the expense of fan-ventilation. 
 
 Dr. Smith's observations on the defective medical education of 
 this country are admirable, and ought to have great weight as 
 coming from a college professor. 
 
 The idea of having a chapel used for school purposes might 
 well be carried out, but in connection with the hospital for con- 
 valescents.
 
 234 APPENDIX. 
 
 MR. JOHN R. NIERNSEE'S PLAN. 
 
 In the appendix to the five essays there is " A Description of 
 the Plan adopted for the Johns Hopkins Colored Asylum," and 
 also a plan by John R. Niernsee, the architect to the Board of Trus- 
 tees, for an octagon-shaped ward. The latter, as he says, is very 
 much the same as the square ward adopted by Dr. Folsom. 
 
 The octagon ward we like better than the square ward, because 
 only one-eighth instead of one-third of the wall-space is cut off 
 from the outside air by the contact of the service-rooms. 
 
 The closets in Mr. Niernsee's pavilion are well placed, and the 
 direct communication with the air of the corridor is not so short as 
 in Dr. Folsom's plan. 
 
 We heartily agree with Mr. Niernsee in some of his conclu- 
 sions, especially three of them, viz. : 
 
 1. "That hot-water heating is the most desirable and effective 
 mode as auxiliary in connection with open fires." 
 
 2. Where he proposes " to dispense with a large and expensive 
 apparatus concentrated in one place," and to have a small boiler 
 for each pavilion. 
 
 3. Where he recommends that the top of the corridor should be 
 on a level with the floor of the ward, and serve as a means of open 
 communication ; but we would also raise the ward high enough to 
 enable the corridor to be wholly above-ground. Air, like water, 
 must be in motion to keep fresh and pure ; but it must also be 
 acted upon by light, or its vital qualities will be greatly dete- 
 riorated. 
 
 In answer to Mr. Niernsee's argument that the octagon shape 
 gives more cubic air-space in proportion to the wall-space than 
 the oblong rectangular wards, we would say that the increase of 
 air-space in a ward is not of great importance compared with the 
 frequent, constant, and complete change of the air, and, instead of 
 wall-space being a disadvantage, up to a certain point it is very 
 desirable. 
 
 W. Gill Wylie. 
 
 New York, December, 1875. 
 
 At the same time that I sent a copy of the above review to the 
 trustees of the hospital, I forwarded a drawing, giving a plan for 
 arranging the buildings on the ground almost exactly the same as
 
 PLAN OF JOUNS HOPKINS HOSPITAL. 
 
 235 
 
 that in the plate, giving my suggested plan for a complete general 
 hospital. 
 
 The following diagram is taken from the N^ew York Jledical 
 Jiecord of March 10, 1877. In a lecture, given to the medical pro- 
 
 FiG. 14. 
 
 " Block Plan for Proposed Johns Hopkins Hospital." 
 
 "Explanation: 1. Administration Building; 2. Pay- Wards; 3. Kitchen; 4. 
 Nurses' Home ; 5. Dining-Rooms for Medical Officers and Nurses ; 6. Pharmacy ; 
 Y. Two-Story Wards ; 8. One-Story Wards ; 9. Isolating Wards ; 10. Residence of 
 Superintendent; 11. Dispensary; 12. Operating-Theatre; 13. Mortuary Building; 
 14. Greenhouse; 15. Laundry; 16. Space for Tents." 
 
 fession of Baltimore, February 5, 1877, by J. S. Billings, M. D,, 
 " On the Plans for the Johns Hopkins Hospital at Baltimore," this 
 plan was shown as that proposed for the hospital. Since the lect- 
 ure we understand that the four rectangular wards, adjacent to the 
 octagonal wards, in the figure, are to be changed into two pavilions 
 of two stories, thus leaving only four instead of eight one-story 
 pavilions. We do not know the details of construction decided 
 upon ; but there are three or four objectionable points about the
 
 236 APPENDIX. 
 
 above plan : 1. The two-storj pavilions ; 2. The position of the 
 corridors and incomplete separation of the service-buildings ; 3. 
 The so-called isolating wards, similar to those recommended by 
 Dr. Folsom, and proximity of the tents to the ends of the wards; 
 4. The scattered positions of the administrative building, which 
 will interfere with easy administration, and necessitates a huddling 
 together of the pavilions. 
 
 The plans are for three hundred beds, and not four hundred, as 
 was originally intended there should be. 
 
 W. G. W.
 
 II^DEX 
 
 Accident- ward, 152. 
 Administrative-building, 149. 
 Air, 119. 
 
 Alexandrow Hospital, 203. 
 Ambulance-system, 161. 
 American RcTolution, 35. 
 Apothecary-shop, 151. 
 Appointments, 74. 
 Architects, 10. 
 Army-hospitals, 40, 177. 
 Arrangement of the buildings, 149. 
 Asoka, 9. 
 
 Attending staff, 69. 
 Autopsy-building, 152. 
 Aztec hospitals, 27. 
 
 Bath-house, 151. 
 Bath-rooms, 112. 
 Beaujou, 184. 
 Beds, 99, 131. 
 Beckman, 15. 
 Beekman, J. W., 28. 
 Bellevue Hospital, 3, 186. 
 Bellows, Rev. H. W., 47. 
 Berlin City Hospital, 218. 
 Bethanian Hospital, 202. 
 Billings, Dr. John S., 223. 
 Blackburn Infirmary, 211. 
 Blackwell's Island, 179. 
 Block plan, 194. 
 Boerhaave, 22. 
 
 Bond, Dr. Thomas, 29. 
 Boston Free City Hospital, 213. 
 Bremen Hospital, 203. 
 Bristowe, Dr., 45. 
 Brocklesby, Richard, 23. 
 Buddhist hospitals, 9. 
 Building-material, 230. 
 Buildings, 92. 
 
 Caravansaries, 12. 
 
 Cardinal de Polignac, 19. 
 
 Catholic Hospital, Berlin, 202. 
 
 Charing-Cross Hospital, 190, 188. 
 
 Charity, 58, 68. 
 
 Charity Hospital, Berlin, 202.- 
 
 Charity Hospital of New York, ISO, 
 
 188. 
 Chicago Hospital, 215. 
 Chorlton Union Hospital, 211. 
 Church hospitals, 15. 
 Classification of hospitals, 56. 
 " " patients, 93. 
 
 Clinical lectures, 158. 
 Conglomerate hospitals, 183. 
 Convalescent hospitals, 174. 
 Convents, 12. 
 Corridor, 114. 
 Corridor plan, 199. 
 Cost of hospitals, 95. 
 Cottage hospitals, 139. 
 Count Rumford, 41.
 
 238 
 
 INDEX. 
 
 Crimean War, 43. 
 Cubic air-space, 100. 
 
 Day-room, 112. 
 Desaguliers, Jean T., 20. 
 Dimensions of wards, 100. 
 Dining-room, 112. 
 Direct radiation, 123. 
 Disease-germs, 96. 
 Disinfectants, 97. 
 Dispensaries, 60, 153. 
 Doors, 109. 
 Drainage, 154. 
 
 English hospitals, 189. 
 
 Episcopal Hospital of Philadelphia, 211. 
 
 Erichsen, Mr. Eric, 46. 
 
 Essays (published by Johns Hopkins 
 
 Hospital), 221. 
 Esse, Dr., 218. 
 Examining-room, 113. 
 Extemporized hospitals, 182. 
 
 Fire-worshipers, 11. 
 Floors, 107. 
 
 Folsom, Dr. JiTorton, 226. 
 Foul-air escapes, 129. 
 Foundation of the ward, 104. 
 Founding hospitals, 167. 
 Frankfort Hospital, 203. 
 Franklin, Benjamin, 29. 
 French Academy of Sciences, 39. 
 French hospitals, 206. 
 Furnaces, 123. 
 Furniture, 130. 
 
 Galton, Douglas, 45. 
 General plan, 149, 225. 
 German Hospital of New York, 214. 
 German hospitals, 47, 82, 202. 
 Glasgow Fever-Hospital, 217. 
 Glasgow Surgical Hospital, 211. 
 Grand Hospital of Milan, 193. 
 Guy's Hospital, 190. 
 
 Hales, Stephen, 21. 
 
 Hamburg General Hospital, 202. 
 
 Hamilton, 10. 
 
 Hand-book for Hospital Visitors, 85. 
 
 Heating, 123, 233. 
 
 Herbert Hospital, 210. 
 
 Holmes, Dr., 45. 
 
 Hopital Cochin, 203. 
 
 Hopital St. Jean, 206. 
 
 Hopkins, Johns, 221. 
 
 Hospitalers, 13. 
 
 Hospital construction, 86. 
 
 " diseases, 86, 96. 
 
 " Rudolph-stiftung, 203. 
 Hospitalia, 13. 
 Hospitals now in use, 165. 
 Hotel-Dieu, 32, 183. 
 House-building, 169. 
 Howard, John, 41. 
 Husson, 41. 
 Hut-hospitals, 44. 
 Huts, 139-148. 
 
 Impermeable walls, 106, 120. 
 Infection, 96. 
 Insane-asylums, 179. 
 Irregular hospitals, 189. 
 Isolatmg huts, 139. 
 Italian hospitals, 192. 
 
 Johns Hopkins Hospital, 52, 235. 
 Jones, Dr. John, 30. 
 Jones, Dr. Joseph, 230. 
 
 King, Mr., 223. 
 
 King's College Hospital, 189. 
 
 La Charite, 184. 
 Lamothe, 14. 
 
 La Princesse Hospital, 206. 
 Lariboisiere, 207. 
 Leeds Infirmary, 211. 
 Leon Owens, Mrs., 11. 
 Levy, Michel, 44. 
 Lighting the ward, 130. 
 Lind, James, 25. 
 Linen-room, 113. 
 Location of hospitals, 89. 
 London Hospital, 190.
 
 INDEX. 
 
 239 
 
 Lying-in hospitals, 172. 
 
 Management, 69-85. 
 Managers, boards of, 69. 
 Manchester Royal Infirmary, 203. 
 Massachusetts General Hospital, 198. 
 Material for building, 105. 
 Maternity-wards, 160, 172. 
 Medical boards, 69. 
 Medical school, 157. 
 Middlesex Hospital, 190. 
 Milan Grand Hospital, 15. 
 Monasteries, 12. 
 Monro, Donald, 23, 25. 
 Morris, Dr. Caspar, 230. 
 Mount Sinai Hospital, 214. 
 Muhlenberg, Dr. W. A., 200. 
 Munich General Hospital, 192. 
 
 Natural ventilation, 119. 
 Neirnsee, John R., 234. 
 New York City hospitals, 58, 213. 
 New York Hospital, Old, 30. 
 ■ " " " New, 35, 198. 
 
 New York Training-School for Nurses, 
 
 79. 
 Nightingale, Florence, 44. 
 Nurses, 162. 
 Nurses' room, 113. 
 
 One-story pavilion plan, 49, 215. 
 Open fires, 119, 124. 
 Operating-theatre, 151, 158. 
 Organization, 69-85. 
 Origin of hospitals, 1-55. 
 Out-door dispensary, 153. 
 Out of two hospitals, 174. 
 
 Paris hospitals, 32. 
 
 Pathological building, 152. 
 
 Pathological room, 159. 
 
 Pauper hospitals, 64. 
 
 Pauperism, relation to hospitals, 57. 
 
 Pay-patients, 134. 
 
 Pay-wards, 136. 
 
 Pavilion hospitals, 26. 
 
 Pavilion plan, 205. 
 
 Pennsylvania Hospital, 20, 198. 
 Permanent or temporary hospitals, 96, 
 
 120. 
 Pettenkofer, 98. 
 Phelps, J. W., 28. 
 Piazza, 109. 
 
 Plan for small hospital, 170. 
 Post-mortem room, 159, 225. 
 Preparation of the grounds, 91. 
 Presbyterian Hospital of New York, 214. 
 Presbyterian Hospital of Philadelphia, 
 
 215. • 
 
 Prescott, 27. 
 Pringle, Sir John, 23. 
 Provident dispensaries, 135. 
 
 Reception-hospitals, 161. 
 Repairing old hospitals, 165. 
 Report of committee of French Acade- 
 my, 39. 
 Rhode Island Hospital, 214. 
 Roof, 109. 
 
 Roosevelt Hospital, 214. 
 Rotherham Hospital, 218. 
 Rotterdam Hospital, 203. 
 Royal Infirmary of Edinburgh, 195. 
 Rush, Dr., 36. 
 
 St. Andre General Hospital, 206. 
 
 St.-Antoine, 184. 
 
 St. Bartholomew, 190. 
 
 St. Luke's Hospital, 200. 
 
 St. Thomas's Hospital, 209. 
 
 San Francisco Hospital, 215, 
 
 Sanitary Commission, U. S., 47. 
 
 Scavoneur, 10. 
 
 Service-rooms, 102, 110, 224. 
 
 Sewers, 154. 
 
 Sunpson, Sir J. Y., 40. 
 
 Site for hospital, 89. 
 
 Small hospitals, 166. 
 
 Smith, Dr. Stephen, 231. 
 
 Special huts, 130-148. 
 
 Stable, 152. 
 
 State Charities Aid Association, 79, 188. 
 
 Statistics, 4, 5. 
 
 Steam coils, 124.
 
 240 
 
 INDEX. 
 
 Stonehouse Hospital, 26, 206. 
 Stoves, 123. 
 Students, 1.58. 
 Superintendent, 80-85. 
 Sutherland, Dr. John, 45. 
 Swete, Horace, 52. 
 
 Tenon, 41. 
 
 Tilton, Dr. James, 37. 
 
 Toner, Dr., 13. 
 
 Town hospitals, 166. 
 
 Training-school for nurses, 162. 
 
 Trustees, 168. 
 
 University College Hospital, 191. 
 
 Urinals, 131. 
 
 United States Marine Hospital, 217. 
 
 Valetudinarians, 12. 
 
 Van Swieten, Gerard, 22, 24. 
 Ventilation, 19, 118, 126, 233. 
 Vienna General Hospital, 192. 
 
 "Wards, 94. 
 
 Warming, 123. 
 
 Washington, General George, 36. 
 
 Wash-room, 111. 
 
 Water-closets, 111. 
 
 Water-supply, 154. 
 
 Watson, Dr. John, 11. 
 
 Windows, 108. 
 
 Wise, Thomas A., 10. 
 
 Woman's Hospital of New York State, 
 
 213. 
 Women's influence, 77. 
 
 Zeudocliia, 13. 
 
 THE END. 
 
 \
 
 DESCRIPTIVE CATALOGUE 
 
 / OK 
 
 MEDICAL WORKS. 
 
 iisriDKx: OF sxjBjicaTS. 
 
 Anatomy 10 
 
 Anaesthesia 26 
 
 Acne 4 
 
 Body and Mind 18 
 
 Breatli, and Diseases which give it a Fetid 
 Odor 16 
 
 Cerebral Convolutions 7 
 
 Chemical Examination of the Urine in Dis- 
 ease 8 
 
 Chemical Analysis 14 
 
 " Technology 81 
 
 Chemistry of Common Life IT 
 
 Clinical Electro-Therapeutics 12 
 
 " Lectures and Essays 24 
 
 Comparative Anatomy G 
 
 Club-foot 27 
 
 Diseases of the Nervous Svstem 10, 12, 13 
 
 ' Bones ". 20 
 
 " " Women 2«, 2T 
 
 " " the Chest 20 
 
 " " Children 25, 29 
 
 " the Rectum.. 28 
 
 " " " Ovaries 31 
 
 Emergencies 15 
 
 Electricity and Practical Medicine 19 
 
 Foods 27 
 
 Galvano-Therapeutics 20 
 
 Hospitalism 26 
 
 Histology and Histo-Chemistry of M.in 8 
 
 Infiincy 6 
 
 Insanity in its Relation to Crime 12 
 
 Materia Medica and Thetapeuties 5. 2i 
 
 Medical Journal -"i 
 
 AldDtal Physiology C 
 
 PAGK 
 
 Midwifery 26, 27 
 
 Mineral Springs 80 
 
 Neurala:ia 2 
 
 Nervous System 12, 13 
 
 Nursing 22 
 
 Obstetrics 3, 7, 26, 27 
 
 Ovarian Tumors 23 
 
 " Diagnosis and Treatment 80 
 
 Paralvsis from Brain-Disease 8 
 
 Physiology 6, 9, 10, 1 1 
 
 Physiology of Common Life 17 
 
 Physiology and Pathology of the Mind 18 
 
 Physiological Effects of Severe Muscular 
 
 E.xercise 12 
 
 Pulmonary Consumption 4 
 
 Practical Medicine 21 
 
 Physical Cause of the Death of Christ 26 
 
 Popular Science 32 
 
 Puerperal Diseases 2 
 
 Reports 24 
 
 Recollections of Past Life 15 
 
 " of the Army of the Potomac. 17 
 
 Responsibility in Mental Diseases 18 
 
 Sea-Sickness 3 
 
 Surgical Pathology 4 
 
 " Diseases "of the Male Genito- Uri- 
 nary Organs 28 
 
 Surgery, Conser%-ative 2 
 
 '• Orthopedic 25 
 
 Syphilis 23 
 
 Science 32 
 
 Skin-Diseases 23 
 
 Therapeutics 6 
 
 Uterine Therapeutic'.^ 27 
 
 Winter and Spring 4 
 
 D. APPLETON & CO., 
 
 PUBLISHERS AND IMPORTERS, 
 
 549 &- 551 BJ^OADIVAY, NEW YORK. 
 1870.
 
 2 D. Appleton <& Co.^s Medical Publications. 
 
 ANSTIE. 
 
 IN CUr3.1^13-, and Diseases which resemble it. 
 
 By FRANCIS E. ANSTIE, M. D., F. R. C. P., 
 
 Senior Assistant Physician to Westminster Hospital ; Lecturer on Materia Medlca In ■West- 
 minster Hospital School ; and Physician to the Belgrave Hospital for Children ; Editor of 
 "The Practitioner" (London), etc. 
 
 1 vol., 12mo. Cloth, $2.50. 
 
 " It 13 a valuable contribution to scientific medicine."— The Lancet (^London). 
 
 BARKER. 
 The Puerperal Diseases. cHnicai zectures 
 
 delivered at £ellevue Hospital. 
 
 By FORDYCE BARKER, M. D., 
 
 Clinical Professor of Midwifery and the Diseases of Women in the Bellevue Hospital Medical 
 College; Obstetric Physician to Bellevue Hospital; Consulting Physician to the New York 
 State Women's Hospital ; Fellow of the New York Academy of Medicine ; formerly Presi- 
 dent of the Medic.ll Society of the State of New Yorlc; Honorary Fellow of the Obstetrical 
 Societies of London and Edinburgh; Honorary Fellow of the Eoyal Medical Society of 
 Athens, Greece, etc., etc., etc. 
 
 Third Edition. 1 vol., 8vo. Cloth. 526 pages. Price, $5 ; Sheep, $6. 
 
 "For nearly twenty years it h.is been my duty, as well as my privilege, to give clinical lect- 
 ures at Bellevue Hospital, on midwifery, the puerperal and the other diseases of women. This 
 volume is made up substantially from phonographic reports of the lectures which I have given 
 on the puerperal diseases. Having had rather exceptional opportunities for the study of these 
 diseases, I have felt it to be an imperative duty to utilize, so far as lay in my power, the advan- 
 tages which I have enjoyed for the promotion of science, and, I hope, for the interests of human- 
 ity. In many subjects, such as albuminuria, convulsions, thrombosis, and embohsm, septicfemia, 
 and pyaemia, the advance of science has been so rapid as to make it necessary to teach something 
 new every year. Those, therefore, who have formerly listened to my lectures on these subjects, 
 and who now do me the honor to read this volume, will not be surprised to find, in many par- 
 ticulars, changes in pathological views, and often in therapeutical teaching, from doctrines before 
 inculcated. At the present d.'iy, for the first time m the history of the world, the obstetric depart- 
 ment seems to be assuming its proper position, as the highest branch of medicine, if its rank be 
 graded by its importance to society, or by the intellectual culture and ability required, as com- 
 pared with that demanded of the physician or the surgeon. A man may become eminent as a 
 physician, and yet know very little of obstetrics; or he may be a successful and distinguished 
 surgeon, and be quite ignonant of even the rudiments of obstetrics. But no one can be a really 
 able obstetrician unless he be both physician and surgeon. And, as the greater includes the less, 
 obstetrics should rank as the highest department of our profession." — From Avthor'a Preface, 
 
 On Sea-Sickness, by fordyce barker, m. d. 
 
 1 vol., 16mo, 36 pp. Flexible Cloth, 76 cents. 
 
 Reprinted from the New York Medical JotrRNAL. By reason of the great demand for th« 
 number of that journal containing the paper, it is now presented in book- form, with such pre* 
 acriptions added as the author has found useful in relieving the suflferlng from sea-sickness. 
 
 BUCK. 
 Contributions to Reparative Surgery: 
 
 Showing its A2)plication to the Treatment of Deformi- 
 ties, produced by Destructive Disease or Injury • Con- 
 genital Defects from Arrest or Excess of Development / 
 and Cicatricial Contractions from Burns. 
 
 By GURDON buck, M. D. 
 Illustrated hy Numeroas- Engravings. 1 vol., 8vo.
 
 D. Appleton <jb 6^0. '*• Medical Publications. 3 
 
 BARNES. 
 
 Obstetric Operations, including the Treatment of 
 JTcpjiiorrhage, and forming a Guide to the 3fanagement 
 of Difficult Labor. 
 
 Br ROBERT BARNES, M. D., London, F. R. C. P., 
 
 Obstetric Physician and Lecturer on Obstetrics and the Diseases of Women and Children to St. 
 Georpe'8 Hospital ; Examiner in Obstetrics to the Royal College of Physicians and tlic Itoyal 
 College of Surgeons; President of the Metropolitan Branch of the British Medical Assoi'ia- 
 tion; late Examiner to the University of London ; formerly Obstetric Physician to tlic Lon- 
 don and to St. Thomas Hospitals ; and late Physician to the Eastern Division of the K'oyal 
 Maternity Charity. 
 
 Third Edition. Revised and extended. 1 vol., 8vo. 606 pages. Cloth, $4.50. 
 
 " Such a work as Dr. Barnes's was greatly needed. It is calculated to elevate the practice of 
 the obstetric art in this country, and to be of great service to the practitioner." — Lancet. 
 
 "The book of Dr. Barnes is not properly spe.aking, a dogmatic treatise on obstetric opera- 
 tions. It is a series of original lectures, comprising, at one and the same time, a piractical analvisis 
 of the serious accidents in parturition, the reasoned-out indications for, and the most judicious 
 researches iu the manner of operating, the method to choose, the instrument to prefer, and the 
 detaiKs of the manoeuvres required to insure success. The clearness of the style is perfect. The 
 order, without being altogether rigorous, is what it is able to be generally in a seriis of clinical 
 lectures. The description of the instruments, the application of the forceps, cephtilotripsy, em- 
 bryotomy, Cissarean section, the practical reflections on narrowing and malformation of the pel- 
 vis, ruptures of the uterus, jilaoenta prfevia, hiemorrhage, and, in fact, all the grand questions in 
 obstetrics are treated with accurate good sense. At each instant, by some remark or other, is 
 revealed a superior mind, ripened by having seen much and meditated much." — From Preface 
 to the French Edition by Prof. Pajot. 
 
 BASTIAN. 
 Paralysis from Brain Disease in its , 
 
 Common Forms. 
 
 By H. CHARLTON BASTIAN, M. A., M. D., F. R. S., 
 
 Fellow of the Royal College of Physicians ; Professor of Pathological Anatomy in University 
 College, London; Physician to LTniversity College Hospital; and Senior Assistant Physician 
 to the National Hospital for the Paralyzed and Epileptic. 
 
 "With Illustrations. 1 vol., 12mo. Cloth. Si. 75. 
 
 PREFACE. 
 
 These Lectures were delivered in University College Hospital last ye.ir, at a time when I was 
 doing duty for one of the senior physicians, and daring the same year — after they had been re- 
 produced from very full notes taken by my friend Mr. John Tweedy — they appeared in the pages 
 of T/ie Lancet. 
 
 They are now republished at the request of many friends, though only after having undergone 
 a very careful revision, during which a considerable quantity of new matter has been added. It 
 would have been easy to have very much increased the size of the book by the introduction of a 
 larger number of illustrative cases, and by treatment of many of the subjects at greater length, 
 but this the author has purposely abstained from doing, under the belief that in its present form 
 it is likely to prove more acceptable to students, and also perhaps more useful to busy practi- 
 tioners. 
 
 Kotwithstanding its defects and many shortcomings, the author is not without a hope that 
 this Uttle book may be considered in some measure to supply a deficiency which has long existed 
 In medical literature. No department of medicine stands more in need of being represented in 
 a text book of moderate compass; so that, imperfect as it is. this small work may perhaps be of 
 some service till it is superseded by something better. In it the author has endeavored to treat 
 the subject with more precision than has hitherto been customary, and, while the lectures contain 
 some novelties in method and mode of exposition, he hopes they may also be found not unfaitli- 
 fuUy to embody the principal facts at present known concerning this very Important class of 
 diseases.
 
 4 D. Appleton <& Co.^s 3Iedical Tuhlications. 
 
 BENNET. 
 On the Treatment of Pulmonary Con- 
 
 sionption, by Hygiene^ Climate^ and Medicine^ in its 
 Connection with Modern Doctrines. 
 
 Bt JAMES HENRY BENNET, M. D., 
 
 Member of ihe Royal College of Phyeicians, London ; Doctor of Medicine of the Univertlty of Paris, etc., etc. 
 
 1 vol., tMn 8vo. Cloth, $1.50. 
 
 An interesting and instmctive work, written in the strong, clear, and lucid manner which appean In all tbo con- 
 tributions of Dr. Bennet to medical or general literature. 
 
 '• We cordially commend this book to the attei.tion of all, for its practical common-iens« views of the nature and 
 treatment of the scourge of all temperate climates, pulmonary consumption," — JDetroii Review of Medicine, 
 
 Winter and Spring on the Shores of 
 
 the Mediterranean ; or, the Jiiviera, Mentone, Italy, 
 Corsica, Sicily, Algeria, JSpc'',., and Biarritz, as Win- 
 
 t^r Climates. 
 
 'ims work enibodies the experience often winters and sj'rin;f<i pasrrd By Dr. Bennet on the ihorei of the Mediter- 
 ranean, and coutaini much ralualle information for physici::u. .a relatiuo to Ihe health restoring climate of there- 
 erions described. 
 
 1 vol., 12mo 'i5i pp. Cloth, $3.nC. 
 
 " Exceedingly readable, apart from its special purposes, and well illustrated." — Erenivp C"y»niercxal, 
 ** It has a more aubatantial value for the physician, j>erha^s, than for any other class or profesaion. . . . We com- 
 mend this book to our readers as a Tolume pref^nting two capital qualificatiuns — it ii at ouce eott^rtaiuing and iaitrao* 
 tive."— i^, y. MedicalJournal 
 
 BILLHOTH. 
 General Surgical Pathology and The- 
 
 rapeutics, in I'^ifty Ziccturcs. A Text-hook for Students 
 and Physicians. 
 
 By Db. THEODOR BILLROTH. 
 
 Translated from the Fifth German Edition, with the special permission of the Author, by 
 CHARLES E. HACKLEY, A. M., M. D., 
 
 Surgeon, to the New York Eye and Ear Infirmary ; PLvfiician to the New York Hospital ; Fellow of the New York 
 
 Academy of Medicine, etc. 
 
 ^ vol., 8vo. 714 pp., and 152 Woodcuts. Cloth, $5.00; Sheep, $6.00. 
 
 Professor Theodor Billroth, one of the most noted authorities on Surpical I'atholoj^, gives in this volume a compleU 
 ritume of the existing state of knowledge lu this branch of medical science. Tlie fact of this publication going throogh 
 four editions in Germauy, and having been translated into French, Italian, Kuaaian, and irungarian, should be somt 
 guarantee for its standing. 
 
 *' The want of a bnriV In the English language, presenting in a concise form the views of the German patfaologlftAy 
 has long beeri fell ; and we venture to sav no dook could nmre perfectly supply that want than tlie present volum** 
 . . . We would itrungly recommend it to all who take any interest in the progress of thought and ob&«;rvatiun in soi^* 
 cal patiiology, and surgery-" — The Lancet. 
 
 ^' We can assure our readers that they will consider neither money wasted In it£ purchase, nor time In Its penuaL" 
 — 77(< Medical InvuligalOT, 
 
 BULKLEY. 
 
 Acne ; its Pathology, Etiology, Prog- 
 
 nosis, and Treatment. 
 
 By L. DUNCAN BULKLEY, A. M., M. D., 
 
 New York Hospital. 
 
 A monograph of about seventy pages, illustrated, founded on an analj- 
 sis of two hundred cases of various forms of Acne. {In x>rcss.)
 
 I). Appleton <& Co.''s Medical Publications. 6 
 
 BARTHOLOW. 
 
 A New Scientific and Practical Work 
 
 on Materia Medica and Therapeutics. 
 
 By ROBERTS BARTHOLOW, M. A., M. D., 
 
 Professor of the Theory and Practice of Medicine, and of Clinical Medicine, and formerly Profesa- 
 or of Materia Medica and Therapeutics in the Medical College of Ohio; Physician to the 
 Hospital of the Good Samaritan: Corresponding' Member of the New York Neurological 
 t^ociety ; Author of a Manual of llypodermie Medication, of the Russell Prize Essay on 
 Quinine, of the American Medical Association Prize Essay on Atropia, and of the Fiske Fund 
 ', Prize Essay on the Bromides, etc. 
 
 One vol., 8vo. Cloth. 548 pages. Price, $5.00. 
 
 In this work, a volume of moderate compass, is condensed the whole subject 
 of Materia Medica and Therapeutics, less Ih^ botanical and chemical details. The 
 author his included just that kind of infor.nation which is required by the student 
 and praclilioncr, and has omitted all tliose details now universally commitied to 
 the 'iiug'^ist and apothecary. Thj official names of iudividual remedies, and the 
 German and French synonyms, are first given ; then follows the list of pharma- 
 ceutical preparations, the composition of these and the doses; next the antago- 
 nists and incompatibles, and the synergists. The author gives a full account of 
 the physiological actions and the therapeutical applications of remedies, and he 
 is especially full and explicit on these important topics. As he states in his 
 preface : " In describing the physiological action of drugs, two methods may be 
 pursued : to present in chronological order a summary of the opinions of various 
 authorities on the subject in question ; or to condense in a connected description 
 that view of the subject which seems to the author most consonant with all the 
 facts. I have adopted the latter plan, from a conviction of its advantages for the 
 student, and of its utihty for the practitioner." 
 
 The utmost brevity consistent with clearness is kept in view throughout. A 
 very considerable portion of the book is devoted to the therapeutical applications 
 of remedies. The author states on this point : " As respects the therapeutical 
 applications of remedies, I have, as far as practicable, based them on the physio- 
 logical actions. Many empirical facts are, however, well founded in professional 
 experience. Although convinced that the most certain acquisitions to therapeu- 
 tical knowledge must come through the physiological method, I am equally clear 
 that well-established empirical facts should not be omitted, even if they are not 
 explicable by any of the known physiological properties of the remedies under 
 discussion." The practitioner will find in the therapeutical portion of the work 
 numerous valu.ible formulae, adapted to the exigencies of practice. 
 
 This treatise discusses subjects not heretofore introduced into therapeutical 
 works. The chapter on Aliment is quite full, and includes such topics as animal 
 and vegetable aliment, special plans of diet, denutrition, dry diet, vegetable diet, 
 animal diet, milk-diet, alimentation in acute diseases, in cachectic diseases, nutrient 
 cnemata, etc. The importance of knowledge on these subjects can hardly be 
 over-estimated. 
 
 Part I. treats of "the modes in which medicines are introduced into the orjfanism." 
 Part II. treats of "'the actions and uses of remedial .a^euts." under the severil subdivistona 
 of "ag-ents promotins: constructive metamorphosis," "agents promoting destructive metamor- 
 phosis," '• agents used to modify the functions of the nervous system," and " agents used to causd 
 some ev.icu.itiou from the body." 
 
 Part III. treats of " topical remedies," and includes such topics as " Antiseptics," " Counter- 
 irritants." '• Epispastics." '• .\cupuricture," "Uaunsclieldtismus," " Aquapuncture," "Bloodlet- 
 ting," " Escharotics," "Emollients, Demulcents, and Protectives." 
 
 Scarcely any topic in therapeutics fails to receive attention, and all are dis- 
 cussed with great conciseness, but clearly aud adequately.
 
 6 D. Appleton <& Co.^s 3fedical Puhlications. 
 
 CARPENTER 
 Principles of Mental Physiology, wuh 
 
 their Applications to the Training and Discipline of the 
 Mind and the Study of its Morbid Conditions. 
 
 By WILLIAM B. CARPENTER, M. D., LL. D., F. R. S., F. L. S., F. G. S., 
 
 Begistrar of the University of London j Corresponding Member of the Institute of France and of the American FMIo»- 
 
 aophical Society, etc. 
 
 1 vol., 8vo. Price, $3.00. 
 
 ** Among the numerous eminent writers this country has produced, none are more deserving of praise for having at- 
 tempted to apply the results of Physiological Research to the explination of the mutuil relations of the mind and 
 body than Dr. Carpenter. To him belongs the merit of having scientifically studied and of having in many inatancet 
 Bupplied a rational explanation of those phenomena which, under the names of mesmerism, spirit-rapping, electro- 
 biology, and hypnotism, have attracted so large ao amount of attention during the last twenty years. . , . We must 
 conclude by recommending Dr. Carpenter's work to the members of our own profession as applying many facts, tliat 
 have hitherto stood isolated, to the explanation of the functions of the brain and to psychological processes generally." 
 —The Lancet, 
 
 COMBE. 
 
 The Management of Infancy, physiologi- 
 cal and Moral. Intended chiefly for the Use of 
 Parents. 
 
 By ANDREW COMBE, M.D. 
 REVISED AND EDITED 
 
 Bt Sir JAMES CLARK, K, C. B., M. D., F. R. S., 
 
 Physician-iB-ordmary to the Queen. 
 
 First American from the Tenth London Edition. 1 vol., 12mo. 302 pp. 
 
 Cloth, S1.50. 
 
 "This excellent little book should be in the hand of every mother of ft family; and, If some 
 of our lady friends would master its contents, and either bring up their children by the light of 
 Its teachings, or communicate the truths it contains to the poor tjy whom they are surrounded, 
 we are conyinced that they would efl'ect infinitely more good than by the distribution of any 
 nmnber of tracts whatever. . . . We consider this work to be one of the few popular medical 
 treatises that any practitioner may recommend to his patients; and, though, if its precepta are 
 followed, he will" probably lose a few guineas, he will not begrudge them if he sees his friend's 
 children grow up healthy, active, strong, and both mentally and physically capable." — Tha 
 Lancet. 
 
 CHAUVEAU. 
 The Comparative Anatomy of the 
 
 Domesticated Animals. 
 
 By a. CHAUVEAU, 
 
 PEOFESSOE AT THE LTONS TETEEINAET SCHOOL. 
 
 Second edition, revised and enlarged, with the cooperation of S. ARLOING, 
 late Principal of Anatomy at the Lyons Veterinary School ; Professor at the 
 Toulouse Veterinary School. Translated and edited by GEORGE FLEMING, 
 F. R. G. S., M. A. I., Veterinary Surgeon, Royal Engineers. 
 
 1 vol., 8vo. Cloth. 957 pp., with 450 Illustrations. Price, $6.00.
 
 D. Applet on cfc Co. '5 Medical Ihcblications. ^ 
 
 DAVIS. 
 
 Conservative Surgery, as exhibited in remedying 
 some of the Mechanical Causes that operate injuriously 
 both in Health and Disease. With Ilhcstrations. 
 
 By HENRY G. DAVIS, M. D., 
 
 Member of the American Medical Association, etc, etc. 
 1 vol., 8vo. 315 pp. Cloth, $3.00. 
 
 The author has enjoyed rare facilities for the study and treatment of certain classes of disease, 
 «nd the records here presented to the profession are the gradual accuuiulation of over thirty 
 years' Investigation. 
 
 "Dr. Davis, bringing, as he does to his specialty, a great aptitude for the solntlon of mechani- 
 cal problems, takes a high rank as an orthopedic surgeon, and his very practical contribution to 
 the literature of the subject is both valuable and opportune. We deem it worthy of a place In 
 every physician's library. The style is unpretending, but trenchant, graphic, and, best of all, 
 <iulte intelligible."— Jfisdtca/ Record. 
 
 ECKER 
 The Cerebral Convolutions of Man, 
 
 represented according to Personal Investigations^ espe- 
 cially on their Development in the Foetus^ and with ref- 
 erence to the Use of Physicians. 
 
 By ALEXANDER ECKER, 
 
 Professor of Anatomy and Comparative Anatomy in the University of Freiburg. 
 
 Translated from the German by Robert T. Edes, M. D. 
 
 1 vol., 8vo. 87 pp. $1.25. 
 
 "The work of Prof. Ecker is noticeable principally for its succinctness and clearness, avoiding 
 long discussions on undecided points, and yet sufficiently furnished with references to make easy 
 its comparisons with the Ial)ors of others in the same direction. 
 
 "Entire originality in descriptive anatomy is out of the question, but the facts verified by out 
 author are here i>resented in a more intelligible manner than in any other easily-accessible work. 
 
 "The knowledge to be derived from this work is not furnished by any other text-book in tlM 
 English language."— JSoston Medical and Surgical Journal, January 20, 1878. 
 
 ELLIOT. 
 
 Obstetric Clinic, a Practical contribution to the Studi/ 
 of Obstetrics^ and the Diseases of Women and Children, 
 By the late GEORGE T. ELLIOT, M. D., 
 
 Late Professor of Obstetrics and Diseases of Women and Children in the Bellevne TTospItal 
 Medical College ; Physician to Bellevue Hospital and to the New York L>-ing-ln Asylum; 
 Consulting Physician to the Nurserj* and Child's Hospital ; Consulting Surgeon to the Stat« 
 ■Woman's Hospital ; Corrcsfionding Member of the Edinburgh Obstetrical Society and of th« 
 Royal Acaileiny of Havana; Fellow of the N. Y. Academy of Medicine; Member of th0 
 County Medical Society, of the Pathological Society, etc., etc. 
 
 1 vol., 8vo. 458 pp. Cloth, $4.50. 
 
 This work Is, in a measnre. a resume of separate papers previously prepared by the lat« Df. 
 Elliot; and contains, besides, a record of nearly two hundred Important and difficult cases in mid- 
 wifery, selected from his own practice. It baa met with a hearty reception, and haa received th« 
 highest encomiums both in this country and in Europe.
 
 8 D. Appleton & Co.^s Medical l^ublications, 
 
 PREY. 
 The Histology and Histo-Chemistry 
 
 of Man. A Practical Treatise on the Elements of Com' 
 position and Structure of the Hitman Body. 
 
 By HEINKICH FREY, 
 
 Professor of Medicine fti Zurich. 
 
 Translated from the Fourth German Edition, by Arthur E. J. Barker, 
 
 Surgeon to the City of Dublin Hospital; Demonstrator of Anatomy, Koyal Colleg'o of Surgeona, 
 Ireland ; Visiting Surgeon, Convalescent Uome, Stillorgan ; and re\ised by the Author. 
 "With C80 Engravings. 
 
 1 vol., 8vo. Cloth, $5.00 ; Sheep, $6.00. 
 
 CONTENTS. 
 The Elements of Composition and of Structure of the Body : Elements of Composition— Al- 
 buminous or Protein Compounds, IIa>moglobulin, Ilistogenic Derivatives of the Albuminous 
 Substances or Albuminoids, the Fatty Acids and Fats, the Carbohydrates, Non-Nitrogenous 
 Acids, Nitrogenous Acids, Amides, Amido-Acids, and Organic Bases, Animal Coloring Matters, 
 Cyanogen Compounds, Mineral Constituents; Elements of Structure— the Cell, the Origin of the 
 Remaining Elements of Tissue ; the Tissues of the Body — Tissues composed of Simple Cells, with 
 Fluid Intermediate Substance, Tissues composed of Simple Cells, Avith a small amount of Solid 
 Intermediate Substance, Tissues belonging to the Connective-Substance Group, Tissues com- 
 posed of Transformed, and, as a rule, Cohering Cells, with Homogeneous, Scanty, and more or less 
 SoUd Intermediate Substance, Composite Tissues: The Organs of the Body — Organs of the 
 Vegetative Type, Organs of the Animal Group. 
 
 FLINT. 
 Manual of Chemical Examination of 
 
 the Urine in Disease. With Brief Directions for the 
 Examination of the most Common Varieties of Urinary 
 
 Calculi, 
 
 By AUSTIN FLINT, Jr., M.D., 
 
 Professor of Physiology and Microscopy in the BcUevuo Hospital Medical College; Fellow of tlje 
 New York Academy of Medicine; Member of the Medical Society of the County of New 
 York ; llesident Member of the Lyceum of Natural History in the City of New York, etc. 
 
 Third Edition, revised and corrected. 1 vol., 12mo. 77 pp. Cloth, $1.00. 
 
 The chief aim of this little work is to enable the busy practitioner to make for 
 himself, rapidly and easily, all ordinary examinations of Urine ; to give him the 
 benefit of the author's experience in eliminating little difficulties in the manipula- 
 tions, and in reducing processes of analysis to the utmost simplicity that is con- 
 sistent with accuracy. 
 
 " We do not know of any work in English so complete and handy as the Manual now offered 
 to the Profession by Dr. Flint, and the high scientific reputation of the author is a sufBcient 
 guarantee of the accuracy of all the directions given." — Journal of Applied Chemistry. 
 
 "Wo can unhesitatingly recommend this Manual." — Psychological Journal. 
 ■ ■ ••• Eminently practical." — Detroit lieview Of Medicine.
 
 D. Appleton c& Co?s Medical Publications. ') 
 
 FLIlSrT. 
 
 The Physiology of Man. Designed to rep^ 
 resent the Existing State of Physiological Scietice as 
 applied to the Functions of the Human Body, 
 
 By AUSTIN" FLIXT, Jr., M. D., 
 
 Professor of Thyslolo^ and Microscopy in the P.cllcvue Hospital Jloflical Col'.eg^Ss nnd in th« 
 Long- Island Collef^o llospiUil; Fellow of tlio New York Academy of Medicine; Microscopiat 
 tx) Bellevuo lIospitaL 
 
 Kew and thorouglily revised Edition. In Five Volumes. 8vo. Tinted Paper. 
 Volume I. — The Blood ; Circulation^ Respiration. 
 
 8vo. 502 pp. Clotli, 84.50. 
 
 " If the remaining portions of this woi k arc compiled with the same care and 
 accuracy, the whole may vie with any of those that have of late years been pro- 
 duced in our own or in foreign languages." — British and Foixign Medico-Chirurgu 
 cal Revieiv. 
 
 " As a book of general information it will be found useful to the practitioner, 
 and, as a book of reference, invaluable in the hands of the anatomist and physi- 
 ologist." — Dublin Qicartcrbj Journai of Medical Science. 
 
 " The complete work will prove a valuable addition to our systematic treatises 
 on human physiology." — The Lancet. 
 
 " To those who desire to get in one volume a concise and clear, and at the 
 same time sufficiently full rcsunifi of ' the existing state of physiological science,' 
 wc can heartily recommend Dr. Flint's work. Moreover, as a work of typographi- 
 cal art it deserves a prominent pl;\ce upon our library-shelves. Messrs. Api)lcton 
 .^ Co. deserve the thanlvs of the juofcssion for the very handsome style in which 
 they issue medical works. They give us hope of a time when it will be very 
 generally believed by publishers that physicians' eyes are worth saving." — Jledi- 
 en' Gazette. 
 
 Volume II. — Alimentation / Digestion ; Absorption / 
 Z/ymph and Chyle. 
 
 8vo. 556 pp. Cloth, S4.50. 
 
 " The second instalment of this work fulfils all the expectations raised by the 
 perusal of the fii-st. . . . The author's explanations and deductions bear 
 evidence of much careful reflection and study. ... The entire work is one 
 of rare interest. The author's style is as clear and concise as his method iS 
 studious, careful, and elaborate." — Philadelj)hia Inquirer. 
 
 " We regard the two treatises already issued as the very best on human physi- 
 ology which the English or any other language affords, and we recommend them 
 with thorough confidence to students, practitioners, and laymen, as models of 
 literary and scientific ability." — ^V. Y. Medical Journal. 
 
 " We have found the style easy, lucid, and at the same time terse. The prac- 
 tical and positive results of physiological investigation are succinctly statecL 
 without, it would seem, extended discussion of disputed ^omis."— Boston Medical 
 and Surgical Journal. 
 
 " It is a volume which will be welcome to the advanced student, and as a 
 work of reference." — The Lancet. 
 
 " The leading subjects treated of are presented in distinct parts, each of which 
 IS designed to be an exhaustive essay on tht-t to which it refers."— Western Jour, 
 nal of Medicine.
 
 10 D. Appleton & Co.^s Medical Publications. 
 
 Flint's Physiology. Volume in.— Secretion ; Mo 
 cretion/ Ductless Glajids ; Nutrition j Animal Seat ^ 
 Movements / Voice and Speech. 
 
 8vo. 626 pp. Cloth, $4.50. 
 
 " Dr. Flint's reputation is sufficient to give a character to the book among the 
 profession, where it will chiefly circulate, and many of the facts given have been 
 verified by the author in his laboratory and in public demonstration." — Chicago 
 Courier. 
 
 " The author bestows judicious care and labor. Facts are selected with dis- 
 crimination, theories critically examined, and conclusions enunciated with com- 
 mendable clearness and precision." — American Journal of the Medical Sciences. 
 
 Yoluine IV. — The JVervous System. 
 
 8to. Cloth, $4.50. 
 
 This volume embodies the results of exhaustive study, and of a long and' 
 laborious series of experiments, presented in a manner remarkable for its strength 
 and clearness. No other department of physiology has so profound an interest 
 for the modern and progressive physician as that pertaining to the nervous- 
 system. The diseases of this system are now engaging the study and attention 
 of some of the greatest minds in the medical world, and in order to follow their 
 brilliant discoveries and developments, especially in connection with the science 
 of electrology, it is absolutely necessary to obtain a clear and settled knowledge- 
 of the anatomy and physiology of the nervous system. It is the design of this 
 work to impart that knowledge free from the perplexing speculations and uncer- 
 tainties that have no real value for the practical student of medicine. The 
 author boldly tests every theory for himself, and asks his readers to accept noth- 
 ing that is not capable of demonstration. The properties of the cerebro-spinal, 
 nervous, and sympathetic systems are treated of in a manner at once lucid,, 
 thorough, and interesting. 
 
 Although this volume is one, perhaps the most important one, of the author's* 
 admirable series in the Physiology of Man, it is nevertheless complete in itself 
 and may be safely pronounced indispensable to every physician who takes a pride 
 and interest in the progress of medical science. 
 
 Volume V. — Special Senses; Generation. 
 
 8vo. Cloth, $4.50. 
 
 " The present volume completes the task, begun eleven years ago, of preparing 
 a work, intended to represent the existing state of physiological science, as ap- 
 plied to the functions of the human body. The kindly reception which the first 
 four volumes have received has done much to sustain the author in an under- 
 taking, the magnitude of which he has appreciated more and more as the work 
 has progressed. 
 
 " In the fifth and last volume, an attempt has been made to give a clear account 
 of the physiology of the special senses and generation, a most difficult and delicate 
 undertaking. . . , 
 
 "Finally, as regards the last, as well as the former volumes, the author can 
 only say that he has spared neither time nor labor in their preparation; and the 
 imperfections in their execution have been due to deficiency in ability and oppor- 
 tunity. He indulges the hope, however, that he has written a book which may 
 assist his fellow-workers, and interest, not only the student and practitioner of 
 medicine, but some others who desire to keep pace with the progress of Natural 
 Science. ' ' — Eilracts from Preface.
 
 D. Appleton <& Co.^s Medical Publications. 11 
 
 Flint's Text-Book of Human Physi- 
 
 ology, for the Use of Students and Practitioners of Medi- 
 cine. 
 
 In one large octavo volume of 978 pages, elegantly printed on fine paper, and 
 profusely illustrated with three Lithographic Plates and 313 Engrav- 
 ings on Wood. Price, in cloth, $6.00 ; sheep, $7.00. 
 
 While Prof. Flint's "Physiology of Man," in five octavo volumes, also published by D. Apple- 
 ton & Co., is invaluable as a book of reference, giving an epitome of the literature of physiology, 
 with copious references to other authors, the pubUshers have appreciated the necessity for a new 
 text-book, for the use of students and practitioners of medicine. 
 
 This new work is intended to meet this pressing want, and It contains most of the facts pre- 
 sented In the larger treatise, without historical references or discussions of minor and contro- 
 verted questions. The high reputation of the author as a public teacher, and the success of the 
 larger treatise, render it certain that the " Text-book " will be admirably adapted to the wants of 
 medical students. 
 
 In the " Text-book," all Important points connected with Human Physiology are treated of 
 ftilly and clearly, and many subjects, such as the Nervous System, the Special Senses, etc., the 
 treatment of which is barren and unsatisfactory in many works written or republished In this 
 country, are brought fully up to the requirements of the day. 
 
 The publishers have given great attention to the execution of the illustrations, few of which 
 are familiar to American readers. It being almost impossible to reproduce some of the cuts 
 taken from foreign works, they have succeeded in obtaining abroad about one hundred electro- 
 types from the original engravings contained in Sappey'a great work upon Anatomy, which are 
 unequaled In their mechanical execution. The subject of Generation is also illustrated by litho- 
 graphic plates taken from Haeckel. 
 
 The great care necessary in the printing of the elaborata illustrations has caused an unavoid- 
 able delay in the appearance of the work ; but the publishers feel confident that it will ftilly meet 
 their expectations, and justify the reputation of its author. 
 
 " la preparing this text-book for the use of students and practitioners of medicine, I have en- 
 deavored to adapt it to the wants of the profession, as they have appeared to me after a consider- 
 able experience as a public teacher of human physiology. My large treatise in five volumes is 
 here condensed, and I have omitted bibliographical citations and matters of purely historical In- 
 terest. Many subjects, which were considered rather elaborately in my larger work, are here 
 presented in a much more concise form. I have added, also, numerous illustrations, which I 
 hope may lighten the labors of the student. A few of these are original, but by far the greatest 
 part has been selected from reliable authorities. I have thought it not without historical Interest 
 to reproduce exactly some of the classical engravings from the works of great discoverers, such 
 as illustrations contained in the original editions of Fabricius, Harvey, and Asellius. In addition, 
 I have reproduced a few of the beautiful microscopical photographs taken at the United States 
 Army Medical Museum, under the direction of Dr. J. J. Woodward, to whom I here express my 
 grateful acknowledgments. I have also to thank M. Sappey for his kindness In furnishing 
 electrotypes of many of the superb engravings with which his great work upon Anatomy is Illus- 
 trated. 
 
 " My work in five volumes was intended as a book of reference, which I hope will continue to 
 be useful to those who desire an account of the literature of physiology, as well as a statement of 
 the facts of the science. I have always endeavored, in public teaching, to avoid giving undue 
 prominence to points in which I might myself be particularly interested, ftom having made them 
 subjects of special study or of original research. In my text-book I have carried out the same 
 idea, striving to teach, systematically and with uniform emphasis, what students of medicine ore 
 expected to learn in physiology, and avoiding elaborate discussions of subjects not directly con- 
 oected with practical medicine, surgery, and obstetrics. While I have referred to my original 
 observations upon the location of the sense of want of air in the general system, the new ex- 
 cretory function of the liver, the function of glycogenosis, the influence of muscular e.xerclse upon 
 the elimination of urea, etc., I have not considered these subjects with great minuteness, and 
 have generally referred the reader to monographs for the details of my e.xperiments. 
 
 " Finally, in presenting this work to the medical profession, I cannot refrain from an expres- 
 sion of my acknowledgments to the publishers, who have spared nothing in carrying out mr 
 views, and have devot^ special pains to the mechanical execution of the Illustrations." — AtUhort 
 Prefact.
 
 J2- D. Appleton & Co^s 3Iedical Publications. 
 
 FLINT. 
 On the Physiological Effects of Severe 
 
 and Protracted Muscular Exercise. With special refer- 
 ence to its Influence xipon the Excretion of Nitrogen. 
 By AUSTIN FLINT, Jr., M. D., 
 
 Trofessor of Physiology in the Bellevue Hospital Medical College, New York, etc., etc. 
 1 vol., 8vo. 91 pp. Cloth, $1.00. 
 
 This monograph on the relations of Urea to Exercise is the result of a thorough and careful 
 Investigation made in the case of Mr. Edward Payson Weston, the celebrated pedestrian. Tlie 
 chemical analyses were made under the direction of R. O. Doreinus, M. D.. Professor of Chemistry 
 and To.xicology in the Bellevue Hospital Medical College, by Mr. Oscar Locw, his assistant. The 
 observations were made with the cooperation of J. C. Dalton. M. D , Professor of Physiology in 
 the College of Physicians and Surgeons; Ale.vander B. Mott, M. D., Prol'essor of Surgical .Vuat- 
 omy; W. H. Van Buren, M. D., Profes.sor of Principles of Surgery; Austin Flint, M. D., Pro- 
 fessor of the Principles and Practice of Medicine; W. A. Hammond, J[. I)., Professor of Diseases 
 of the Mind and Nervous System— all of the Bellevue Hospital Medical College. 
 
 "This work will be found interesting to every physician. A number of important results 
 were obtained valuable to the physiologist." — Cincinnati Medical Repertory. 
 
 HAMILTON. 
 
 Clinical Electro-Therapeutics. {Medicaiand 
 
 ISurgical.) A Manual for Physicians for the Treatment 
 more especially of Nervous Piseases. 
 
 By ALLAN McLANE HAMILTON, M. D., 
 
 Physician in charge of the New York State Hospital for Diseases of the Nervous System ; Mem- 
 ber of the New York Neurological and County Medical Societies, etc., etc. 
 
 With Numerous Illustrations. 1 vol., 8vo. Cloth. Price, $2.00. 
 
 This work is the compilation of well-tried measures and reported cases, and is intended as a 
 simple guide for the general practitioner. It is as free from confusing theories, technical terms, 
 and unproved statements, as possible. Electricity is indorsed as a very valuable remedy iu cer- 
 tain diseases, and as an invaluable therapeutical me.ans in nearly all forms of Neevous Dxsrasb; 
 but not as a specific for every human ill, mental and physical. 
 
 HAMMOND. 
 
 Insanity in its Relations to Crime, a 
 
 Text and a Commentary. 
 
 By WILLIAM A. HAMMOND, M. D. 
 1 vol., 8vo. 77 pp. Cloth, $1.00. 
 
 " A part of this essay, under the title ' Society versus Insanity,' was contributed to Putnam's 
 Magazine, for September, 1S70. The gi-eater portion is now tirst published. The importance of 
 the subject considered can scarcely be over-estimated, whether we regard It from the stand-point 
 of science or social economy; and, if I have aided in its elucidation, my object will have been at- 
 tained." — From Author's Preface. 
 
 Clinical Lectures on Diseases of the 
 
 Nervous System. Delivered at the Bellevue Hospital 
 Medical College. 
 
 By WILLIAM A. HAMMOND, M. D., 
 
 Professor of Diseases of the Mind and Nervous System, etc. Edited, with Notes, by T. M. B. 
 CROSS, M. D., Assistant to the Chairs of Diseases of the Mind and Nervous System, etc. 
 
 In one handsome volume of 300 pages. Price, $3.50.
 
 D. Appleton & Co.''s Medical Publications. 13 
 
 HAMMOND. 
 A Treatise on Diseases of the Nervous 
 
 System. 
 
 By WILLIAM A. HAMMOND, M. D., 
 
 Professor of Diseases of tlic Mind and Nervous System in the Medical Department of the Univer- 
 sity of the City of New Tork ; President of the New York Neurological Society, etc., etc. 
 
 Sixth Edition, 1 vol., 8vo. Strong Cloth Binding, $6.00; Sheep, S7.00. 
 
 The remarkable success attendant on the issue of the five previous editions of this work in 
 less than four years has eneonrap-ed the author and publishers to attempt to make the work still 
 more worthy the confidence of the medical profession. A great part of the treatise has boon en- 
 tirely rewritten, and several new chapters hare been added. By a change in type, and enliir^nng 
 the page, the new matter, amounting to one-half of the original work, has been added without 
 increasing materially the bulk of the volume. Many new illustrations have been incorporated in 
 the text, and the whole treatise has been brought fully up to the present time. In addition to 
 the fund of personal observation and experience adduced by Prof. Hammond, the labors of Eng- 
 lish, French, and German writers have received due attention. 
 
 Among the diseases considered in the present edition, wliich were not treated of in the former 
 editions, arc : Chronic Verticalar Meningitis ; Chronic Basilar Meningitis; Cervical Pachy-Mcn- 
 Ingitls; Spinal Paralysis of Adults; Amyotrophic Lateral Spinal Sclerosis; Facial Atrophy; 
 Organic Diseases of Nerves ; Chronic AlcohoUc Intoxication; Delirium Tremens ; E.xophthalmic 
 Goitre; and Anapeiratic Paralysis — paralysis induced by a frequent repetition of certain mnsfular 
 actions. Besides which, extensive alterations and additions have been made to the remarks on 
 other aCbctions — the departments of Morbid Anatomy, Pathology, and Treatment, being espe- 
 cially amplified. 
 
 NOTICES OF FORMER EDITIONS. 
 
 " Free from useless verbiage and obscurity, it is evidently the work of a man who knows « hat 
 he is writing about, and knows how to write about it." — Chicago Medical Jovrnal. 
 
 "Unquestionably the most complete treatise on the diseases to which it is devoted which has 
 yet appeared in the English language." — London Medical Times and Gazette. 
 
 "This is a valuable and comprehensive book; it embraces many topics, and extends overs 
 wide sphere. One of the most valuable parts of it relates to the Diseases of the Brain ; while the 
 remaining portion of the volume treats of the Diseases of tlie Spinal Cord, the Cerebro-spinal 
 System, the Nerve-Cells, and the Peripheral Nerves."— iJri^M Medical Journal. 
 
 "The work before us is unquestionably the most exhaustive tre.itise, on the diseases to which 
 It is devoted, that has yet appeared in English. And its distinctive value arises from the fact 
 that the work is no mere rafflciamento of old observations, but rests on his own experience and 
 practice, which, as we have before observed, have been very extensive." — American Journal of 
 Sifphilography. 
 
 "The author of this work has attained a high rank among our brethren across the Atlantic 
 from previous labors in connection with the disorders of the nervous system, as well as from 
 various other contributions to medical literature, and he now holds the official appointments of 
 Physician to the New Tork State Hospital for the Diseases of the Nervous System, and Professor 
 «f the same department in the Bellevue Hospital Medical College. The present treatise is the 
 friilt of the experience thus acquired, and we have no hesitation in pronouncing it a most valu- 
 kble addition to our systematic Uterature."— C/a^f^ow Medical Journal.
 
 14 
 
 D. Appleton & Co.'^s Medical Publications. 
 
 HOFFMANlSr. 
 Manual of Chemical Analysis, as appUed 
 
 to the Examination of Medicinal Chemicals and their 
 Preparations. A Guide for the Determination of their 
 Identity and Quality, and for the Detection of Impuri- 
 ties and Adulterations. For the use of Pharmaceutists, 
 Physicians, Druggists, and Manufacturing Chemists, and 
 Pharmaceutical and Medical Students. 
 
 Bt FRED. HOFFMANN, Phil. D. 
 
 Oue vol., 8vo. Richly Illustrated. Cloth. Price, $3. 
 
 SPECIMEN OF ILLUSTRATIONS. 
 
 This volume is a carefully -prepared work, and well up to the existing state of both the science 
 fnd art of modern pharmacy. It is a book which will find its place in every medical and phar- 
 maceutical laboratory and "library, and is a safe and instructive gnide to medical students and 
 practitioners of medicine."— J»n^"rica« Journal of Science and Arts. 
 
 In America this work has already met with general and unqualified approval ; and in Europe 
 IS now beiner welcomed as one of the best and most important additions to modem pharmsoea* 
 tical literature. 
 
 Send for descriptire circular. Address 
 
 D. APPLETON & CO., 549 & 551 Broadway, N. Y. City.
 
 D. Appleton & Co.^s Medical Publications. 15 
 
 HOLLAND. 
 
 Recollections of Past Life, 
 
 By 81E HENRY HOLLAND, Bart, M. D., F. R. S., K C. B., etc., 
 President of the Royal Inetitation of Great Britain, Physiclan-ln-Ordinary to the Queen, 
 
 etc., etc. 
 
 1 vol., 12mo, 351 pp. Price, Cloth, $2.00. 
 
 A very entertaining and instructive narrative, partakizig eomewhat of the nature of 
 autobiography and yet distinct from it, in this, that its chief object, as alleged by the 
 writer, is not so much to recount the events of his own life, as to perform the oflBce of 
 chronicler for others with whom he came in contact and was long associated. 
 
 The "Life of Sir Henry Holland " is one to be recollected, and he has not erred In gir- 
 Ing an outline ot it to tbe public." — Tht Lancet. 
 
 " His memory was— is, we may say, for he is still alive and in possession of all his 
 facalties— stored with recollections of the most eminent men and women of this cen- 
 tury. ... A life extendin? over a period cT eij^hty-four years, and passed in the most 
 active manner, in the midst of the b»9t society, which tlie world has to offer, must neces- 
 sarily be full of singular interest: and Sir Henry Holland has fortunately not waited until 
 his memory lost its freshnees before recalling some of the incidents in it." — The New 
 York Times. 
 
 HOWE. 
 Emergencies, and How to Treat Them. 
 
 The Etiology, Pathology, and Treatment of Accidents, 
 Diseases, and Cases of Poisoning, which demand 
 Prompt Attention. Designed for Students and Prac- 
 titioners of Medicine, 
 
 By JOSEPH W. HOWE, M. D., 
 
 CUnloal Professor of Surgery in the Medical Department of the University of New York 
 
 Visiting Surgeon to Charity Hospital ; Fellow of the New York Academy 
 
 of Medicine, etc., etc. 
 
 1 vol., 8vo. Ciotii, $3.00. 
 
 "This work has a taking title, and was written by a gentlemen of acknowledged ability, to 
 fill a void in the profession. ... To the general practitioner in towns, villages, and In the 
 country, where the aid and moral support of a consultation cannot be availed of, this volume 
 will be recognized as a valuable help. We commend it to the profession. — Cincinnati Lancti 
 and Observer. 
 
 " This work is certainly novel in character, and its usefuhiess and acceptabllitv are as marked 
 as its novelty. . . . The book is confidently recommended." — liichmond and Louisville Med- 
 ical Journal. , , , ,..,,,., » ^ 
 
 " This volume Is a practical illustration of the positive side of the physician s hfe, a constant 
 remhider of what he is to do in the sudden emergencies which frequently occur in practice. 
 . . . The author wastes no words, but devotes bimsilf to the description of each disease as if 
 the patient were under his hands. Because it is a good book we recommend it most heartily t« 
 the profession."— 5o«ton Jfedical and Surgical Journal. 
 
 " This work bears evidence of a thorough practical acouaintance with the different branches 
 of the profession. ITie author seems to possess a peculiar aptitude for imparting Instruction 
 as well as for simpUfying tedious details. ... A careful peru.sal will amply repay the student 
 tiadprACtit\oneT.''—S'ew York ^fedical Journal."' ^ , r t ^r d .i^i^^y.^1 
 
 "This is the best work of the kind we have ever seen."— Ae^c York Journal of Peydtoloffical 
 Medicine.
 
 16 D. Appleton <& Co.''s Jledical Publications. 
 
 HOWE. 
 The Breath, and the Diseases which give 
 
 it a Fetid Odor. With Directions for Treatment. 
 By JOSEPH W. HOWE, M. D., 
 
 uthor of "Emerfjeccies," "Winter Homes," etc; Clinical Professor of Surpery in the Medical 
 Department of the University of New York; Visiting"- Sur^reon to Charity and St. Francis 
 Hospitals; Fellow of the New York Academy of Mcdieiue, etc. 
 
 "It is somewhat remarkable that the subject of fetid breath, which occasions so much annoy- 
 ance. . . . should )iave attracted so little attention from authors and investigators. Hence a 
 thorougrhly scicnlitic exposition of the whole subject, such as Dr. Howe h.as piven us, has long 
 been a desideratum. . . . Tins Uttle volume well deserves the attention of physicians, to whom 
 we commend it most hitrhly." — Chicago Medical Journal. 
 
 " . . . To any one sulTeiinp from the affection, either in his own person or in th.it of his inti- 
 mate acquaintances, we can commend this volume as containing all thai is known concerning the 
 suliject, set forth in a pleasant style." — Philaddphia Medical Times. 
 
 '■ This little work is on a subject that has heretofore been almost entirely ignored by medical 
 authors, yet its importance is well known by every practitioner. . . . Tlie author gives a succinct 
 account of the diseased conditions in which a fetid bre.ith is an impi)rtnnt symjitom, witli his 
 method of treatment. We consider the work a real addition to medical literatui-e." — Cincinnati 
 Medical Journal. 
 
 HUXLEY AND YOUMANS. 
 The Elements of Physiology and Wy- 
 
 giene. With Numerous Illustrations. 
 
 ByTUOMAS II. HUXLEY, LL. D., F.R.S., and 
 
 WILLIAM JAY YOUMANS, M. D. 
 
 New and Revised Edition. 1 vol., 12mo. 420 pp. SI. 75. 
 
 A text-book for educational institutions, and a valuable elementary work for students of medi- 
 cine. The greater jiortion is from the pen of Professor HiLxley, adajjtod by Dr. Youmans to the 
 circumstances and requirements of American education. The eminent claim of Professor IIux- 
 ley"s "Elementary Physiology" is, that, while up to the times, it is trustworthy in its presenta- 
 ti"U of the subject; while rejecting discredited doctrines and doubtful speculations, it embodies 
 the latest results that are established, and represents the itresent actual state of physiological 
 knowledge. 
 
 •'A valuable contribution to anatomical and physiolor;ical science." — Religious Telescope. 
 
 " A clear and well arranged work, embracing the latest discoveries and accei)ted theories." — 
 Buffalo Commercial. 
 
 "Teeming with information concerning the human physical economy." — Evening Journal. 
 
 HUXLEY. 
 The Anatomy of Vertebrated Animals. 
 
 By THOMAS HENRY HUXLEY, LL.D., F. R. S., 
 
 Author of " Man's Place in Nature," '■ On the Origin of Species," " Lay Sermons and Addresses,** 
 
 etc. 
 
 1 vol., 12mo. Cloth, $2.50. 
 
 The former works of Prof Hu.tley leave no room for doubt as to the importance and value of 
 his new volume. It is one which will be very acceptable to all who are interested in the subject 
 of which it treats. 
 
 "This long-expected work will be cordially welcomed by all students and teachers of Com- 
 parative Anatomy as a compendious, reliable, and, notwithstanding its small dimensions, most 
 comiirehensive guide on the subject of which it treats. To praise or to criticise the work of so 
 accomplished a master of his favorite science would bo equally out of place. It is enough to say 
 that it realizes, in a rem.arkable degree, the anticipations which have been formed of it; and that 
 It presents an extraordinary combination of wide, general news, with the clear, accurate, and 
 Bucninct statement of a prodigious number of individual facts." — Xainre.
 
 D. Appleton <S> Co.^s Medical Publicatiojis. 17 
 
 JOHNSON. 
 The Chemistry of Common Life. 
 
 Illustrated with numerous Wood Engravings. 
 By JAMES F. JOHNSON, M. A., F. R. S., F. G. S., etc., etc., 
 
 Author of "Lectvires on Agricultural Chemistry and Geology," "A Catechism of Agricultural 
 Chemistry and Geology," etc. 
 
 2 vols., 12)110. Cloth, $3.00. 
 
 It has been the object of tlie author in this work to exliibit the 
 
 present condition of chemical knowledge, and of matured scientific 
 
 opinion, upon the subjects to which it is devoted. The reader will not 
 
 ho surprised, therefore, should he find in it some things which differ 
 
 from what is to be found in other popular works already in his hands or 
 
 on the shelves of his library. 
 
 LETTERMAN. 
 Medical Recollections of the Army of 
 
 the Potomac. 
 
 By JONATHAN LETTERMAN, M. D., 
 
 Late Surgeon U. 8. A., and Umiical Director of the Ai-my of the Potomac. 
 1 vol., 8vo. 134 pp. Cloth, Sl.OO. 
 " This accouut of the medical department of the Army of the Poto- 
 mac has been prepared, amid pressing engagements, in the hope that 
 the labors of the medical officers of that army may be known to an in- 
 telligent people, with whom to know is to appreciate; and as an affeo 
 tionate tribute to many, long my zealous and efficient colleagues, who, 
 in days of trial and danger, which have passed, let us hope never to re- 
 turn, evinced their devotion to their country and to the cause of hu- 
 manity, without hope of promotion or expectation of reward." — Preface. 
 
 " We venture to assert that but few who open this volume of medical annala, 
 pregnant as they are with instruction, will care to do otherwise than finish them 
 at a sitting." — Medical Record. 
 
 " A graceful and afiFectionate tribute." — N. Y. Medical Journal. 
 
 LEWES. 
 
 The Physiology of Common Life. 
 
 By GEORGE HENRY LEWES, 
 
 Author of "Seaside Studies," "Life of Goethe," etc. 
 
 2 volt., 12mo. Cloth, $3.00. 
 The object of this work differs from that of all others on popular 
 flcience in its attempt to meet the wants of the student, while meeting 
 those of the general reader, who is supposed to be wholly unacquainted 
 with anatomy and physiology.
 
 18 D. Appleion <t CoJ's Medical Publications. 
 
 MAUDSLEY. 
 The Physiology and Pathology of the 
 
 Mind. 
 
 By henry MAUDSLEY, M. D., London, 
 Fellow of the Eoyal College of Physicians ; Professor of Medical Jurisprudence In University Col- 
 lege, London; President-elect of the Medico-Psychological Association; Honorary Member of 
 the Medico-Psychological Society of Paris, of the Imperial Society of Physicians of Vienna, 
 and of the Society for the Promotion of Psychiatry and i'orensic Psychology of Vienna; 
 formerly Eesident Physician of the Manchester Royal Lunatic Asylum, etc., etc. 
 
 1 VOL, 8vo. 422 pp. Cloth, $3.00. 
 
 This work aims, in the first place, to treat of mental phenomena from a 
 physiological rather than from a metaphysical point of view ; and, secondly, to 
 bring the manifold instructive instances presented by the unsound mind to bear 
 upon the interpretation of the obscure problems of mental science. 
 
 " Dr. Maudsley has had the courage to undertake, and the skill to execute, what is, at least in 
 English, an original enterprise."— Xo/irfon Saturday Review. 
 
 " It is BO full of sensible reflections and sound truths that their wide dissemination could not 
 but be of benefit to all thinking peTSonsy— Psychological Journal. 
 
 " Unquestionably one of the ablest and most important works on the subject of which it 
 treats tliat has ever appeared, and does credit to his pliilosophical acumen and accurate observa- 
 tion."— J/edica/ liecord. 
 
 " We lay down the book with admiration, and we commend it most earnestly to our readers 
 as a work of extraordinary merit and originality — one of those productions that are evolved only 
 occasionally in the lapse of years, and that serve to mark actual and very decided advantages in 
 knowledge and science." — N. T. Medical Journal. 
 
 Body and Mind : An inquiry into their Conr 
 nection and Mutual Influence, especially in reference to 
 Mental Disorders ; an enlarged and revised edition to 
 which are added Psychological Essays. 
 
 By henry MAUDSLEY, M. D., London, 
 Author of " The Physiology and Pathology of the Mind." 
 
 1 vol., 12mo. 155 pp. Cloth, $1.00. 
 
 The general plan of this work may be described as being to bring man, both 
 in his physical and mental relations, as much as possible within the scope of sci- 
 entific inquiry. 
 
 " A representative work, which every one must study who desires to know what Is doing In th* 
 way of real progress, and not mere chatter, about mental physiology and pathology." — Lancet. 
 " It distinctly marks a step in the progress of scientific psychology." — The Practitioner. 
 
 Responsibility in Mental Diseases. 
 
 By henry MAUDSLEY, M. D., London, 
 Author of " Body and Mind," " Physiology and Pathology of the Mind." 
 
 1 vol., 12mo. 313 pp. Cloth, $1.50. 
 
 " This book Is a compact presentation of those facts and principles which require to be taken 
 Into account in estimating human responsibility — not legal responsibility merely, but responsi- 
 bility for conduct in the family, the school, and all phases of social relation in which obligation 
 enters as an element. The work is new in plan, and was written to supply a wide-felt want 
 wlUch has not hitherto been met." — The Pojmlar Science Monthly.
 
 D. Appleton <b Co.'' a Medical Fublicatiom. 
 
 19 
 
 MEYER. 
 Electricity in its Relations to Practical 
 
 Medicine. 
 
 B7 Db. MORITZ MEYER, 
 
 Boyal Counsellor of Health, eto. 
 
 Translated from the Third German Edition, with Notes and Additions, 
 A New and Kevised Edition, 
 
 By WILLIAM A. HAMMOND, M. D., 
 
 Professor of Diseases of the Mind and Nervous System, and of Clinical Medicine, In the BeUevnt 
 Hospital Medical College; Vice-President of the Academy of Mental Sciences Natioiial 
 Institute of Letters, Arts, and Sciences; late Surgeon-Genera U. 8. A,, etc. 
 
 1 vol., 8vo. 497 pp. Cloth, $4.50. 
 " It is the duty of every physician to study the action of electricity, 
 to become acquainted with its value in therapeutics, and to follow the 
 improvements that are being made in the apparatus for its application in 
 medicine, that he may be able to choose the one best adapted to the 
 treatment of individual cases, and to test a remedy fairly and withont 
 prejudice, which already, especially in nervous diseases, has been used 
 with the best results, and which promises to yield an abundant harrort 
 in a still broader domain." — From Author's Preface. 
 
 BPaCDCKN OF nXnSTBATIONS. 
 
 Baxton-EttfaighaaBen Apparatoi. 
 
 " Those who do not read German are under great obligations to WnHtm A. 
 Hammond, who has given them not only an excellent translation of a most^ ex* 
 cellent work, but has given us much valuable information and many suggestion* 
 from his own personal experience." — Medical Record. 
 
 " Dr. Moritz Meyer, of Berlin, has been for more than twenty years a laborious 
 and conscientious student of the application of electricity to practical medicine, 
 and the results of his labors are given in this volume. Dr. Hammond, in making 
 a translation of the third German edition, has done a real service to the profession 
 of this country and of Great Britain. Plainly and concisely written, and simply 
 and clearly arranged, it contains just what the physician wants to know on the 
 •nbject." — N. Y. Medical Journal. 
 
 " It is destined to fill a want long felt by phyiicians in this country." — Jo^tmcA 
 of Obstetrics
 
 20 D. Appleton cb Go.'^s Medical Publications. 
 
 MAKKOE. 
 A Treatise on Diseases of the Bones. 
 
 By THOMAS M. MARKOE, M. D., 
 
 Professor of Surgery in the College of Physicians and Surgeons, New York, etc 
 
 ■n'lxn NUMEPvOUS illusteations. 
 
 1 vol., 8vo. Cloth, S4.50. 
 
 This valuable work is a treatise on Diseases of the Bones, embracing their 
 structural changes as affected by disease, their clinical history and treatment, in- 
 cluding also an account of the various tumors which grow in or upon them. None 
 of the injuries of bone are included in its scope, and no joi7tt diseases, excepting 
 where the condition of the bone is a prime factor in the problem of disease. As 
 the work of an eminent surgeon of large and varied experience, it may be re- 
 garded as the best on the subject, and a valuable contribution to medical litera- 
 ture. 
 
 "The book which I now offer to my professional brethren contains the substance of the lec- 
 tures which I have delivered during the past t'velve years at the college. ... I have followed 
 the leadings of my own studies and observations, dwelling more on those branches where I had 
 seen and studied most, and perhaps too much neglecting others where my own experience was 
 more barren, and therefore to me less interesting. I have endeavored, however, to make np the 
 deficiencies of my own knowledge by the free use of the materials scattered so richly through 
 our periodical literature, which scattered leaves it is the right and the duty of the systematic 
 writer to collect and to embody in any account he m;iy offer of the state of a science at any given 
 penod."— Extract from Author''s Preface. 
 
 NEFTEL. 
 
 GalvanO- Therapeutics. The Physiological and 
 
 Thera2yei(tical Action of the Galvanic Current vpon 
 
 the Acoustic, Optic, Sympathetic, and Pneumogastric 
 
 Nerves. 
 
 By WILLIAM B. NEFTEL. 
 
 1 vol., 12mo. 161 pp. Cloth, $1.50. 
 
 This book has been republished at the request of several aural surgeons anil 
 other professional gentlemen, and is a valuable treatise on the subjects of which 
 it treats. Its author, formerly visiting physician to the largest hospital of St. 
 Petersburg, has had the very best facilities for investigation. 
 
 " This little work shows, as far as it goes, full knowledge of what has been 
 done on the subjects treated of, and the author's practical acquaintance with 
 them." — New York Medical Journal. 
 
 " Those who use electricity should get this work, and those who do not 
 should peruse it to learn that there is one more therapeutical agent that they 
 could and should possess." — The Medical Investigator.
 
 U. Appleton <& Co.^s JJedical Publicatiom. H 
 
 NIEMEYER 
 A Text-Book of Practical Medicine, 
 
 With Particular Reference to Phijsiology and Patho' 
 logical Anatomy. 
 
 By the late Dr. FELIX VON NIEMEYER, 
 
 Professor of Pathology and Therapeutics; Director of the Medical Clinic of the University of 
 
 Tubingen. 
 
 Translated from the Eighth German Edition, by special permission of 
 
 the Authoi-, 
 
 By GEORGE H. nUMPIIREYS, M. D., 
 
 lAtA )ne of the Physicians to the Bureau of Medical and Suri,'ical Relief at Bcllevue Hospital ft* 
 the Oat-door Poor ; Fellow of the New York Academy of Medicine, etc., 
 
 and 
 
 CHARLES E. HACKLEY, M. D., 
 
 One of the Physicians to the New York Hospital; one of the Surgeons to the New York Ey# 
 and Ear Inliruiary ; Fellow of the Now York Academy of Medicine, etc. 
 
 Revised Edition. 2 vols., 8vo. 1,528 pp. Cloth, $9.00 ; Sheep, $11.00. 
 
 The author undertakes, first, to give a picture of disease which shall 
 be as lifelike and faitlifiil to nature as possible, instead of being a mere 
 theoretical scheme; secondly, so to utilize the more recent advances 
 of pathological anatomy, physiology, and physiological chemistry, as to 
 furnish a clearer insight into the various processes of disease. 
 
 The work has met with the most flattering reception and deserved 
 success; has been adopted as a text-book in many of the medical colleges 
 both in this country and in Europe; and has received the very highest 
 encomiums from the medical and secular press. 
 
 " It is comprehensive and concise, and is characterized by clearness and 
 originality." — Dnhlin Quarterly Journal of Jfeilicine. 
 
 " Its author is learned in medical literature ; he has arranged his material* 
 with care and judgment, and has thought over them." — 77ie Lancet. 
 
 " As a full, systematic, and thoroughly practical guide for the student and 
 physician, it is not excelled by any similar treatise in any language." — Appletcms^ 
 Journal. 
 
 " The author is an accomplished pathologist and practical physician ; he is not 
 only capable of appreciating the new discoveries, which during the last ten years 
 have been unusually numerous and important in scientidc and practical medicine^ 
 but, by his clinical experience, he can put these new views to a practical test, and 
 give judgment regarding them." — Edinhurcih Medical Journal. 
 
 " From its general excellence, we are disposed to think that it will soon take 
 its place among the recognized text-books." — American Quarterly Journal of 
 Medical Sciences. 
 
 " The first inquiry in this country regarding a German book generally is, ' l» 
 it a work of practical value? " Without stopping to consider the justness of the 
 American idea of the ' practical,' we can unhesitatingly answer, ' It is I' " — A^eit 
 York Medical Journal. 
 
 " The author has the power of sifting the tares from the wheat — a matter of 
 the greatest importance in a text-book for students." — British Medical Journal. 
 
 " Whatever exalted opinion our countrymen may have of the author's talent* 
 of observation and his practical good sense, his text-book will not disappoint 
 them, while those who are so unfortunate as to know him only by name, have 10 
 ftore a rich treat." — New York MeJictd Record
 
 22 D. Appleton cfe Co.^s Jfedical JPuhUcations. 
 
 NIGHTINQALE. 
 
 Notes on Nursing: what U is, and what U is not. 
 
 By FLORENCE NIGHTINGALE. 
 
 1 vol., 12mo. 140 pp. Cloth, 75 cents. 
 
 Every-day sanitary knowledge, or the knowledge of nursing, or, in other 
 words, of how to put the constitution in such a state as that it will have no dis- 
 ease or that it can recover from disease, takes a higher place. It is recogni2ed 
 as the knowledge which every one ought to have — distinct from medical knowl- 
 edge, which only a profession can have. 
 
 NEUMANN. 
 Hand-Book of Skin Diseases. 
 
 By Dr. ISIDOR NEUMANN, 
 Lecturer on Skin Diseases in the Royal University of Vienna. 
 
 rranslated from advanced sheets of the second edition, furnished by the 
 Anther; with Ifotes, 
 
 By LUCIUS D. BULKLEY, A. M., M. D., 
 
 fkorgeonto the New York Dispensary, Department of Venereal and Skin Diseases; AsBiat- 
 ant to the Skin Clinic of the College of Physicians and Surgeons, New York; Mem- 
 ber of the New York Dermatological Society, etc., etc. 
 
 1 Tol., 8to. Abaut 450 pages and 66 Woodcnts. Cloth, $4.00. 
 
 Prof. Neumann ranks second only to Hebra, whose assistant he was for many year* 
 *nd his work may be considered as a fair exponent of the German practice of Dermatolo 
 gy. The book is abundantly illustrated with plates of the histology and pathology of the 
 akin. The translator has endeavored, by means of notes from French, English, and Ameri- 
 can sources, to make the work valuable to the student as well as to the practitioner. 
 
 " It is a work which I shall heartily recommend to my class of students at the Univer- 
 sity of Pennsvlvania, and one which I feel sure will do much toward enlightening the pr<^ 
 fession on this subject." — LouU A. Duhring. 
 
 "I know it to be a good book, and I am sure that it is well translated; and it is Inter- 
 esting to find it illustrated by references to the views of co-laborers in the same field."— 
 Erasmus Wilson. 
 
 " So complete as to render it a most useful book of reference." — T. McCaU Anderson. 
 
 "There certainly is no work extant which deals so thoroughly with the Pathological 
 Anatomy of the Skin as does this hand-book."— iV. Y. Medical Record. 
 
 "The original notes by Dr. Bulkley are very practical, and are an important adjunct to 
 the text. . . . I anticipate for it a wide circulation. "—iSi/cM Z>urA:««, io»tort. 
 
 " I have already twice expressed my favorable opinion of the book In print, and am 
 glad that it is given to the public at last." — James C. White, Boston. 
 
 "More than two years ago we noticed Dr. Neumann's admirable work in Its originAl 
 fbape ; and we are therefore absolved from the necessity of saying more than to repeat 
 oar strong recommendation of it to English readers." — Practitioner.
 
 o 
 
 D. Appleton <& Co.^s Medical Publicatiofis. 28 
 
 PAG-ET. 
 Clinical Lectures and Essays. 
 
 By Sir JAMES PAGET, Bart., 
 F. R. 8., D. 0. L., Oxon., LL. T)., Cantab. ; Sergeant-Surgeon Extraordinary to her Majesty th# 
 Queen; Surgeon to H. K. H. the Prince of Wales; Consulting Surgeon to St. Bartholomew'* 
 HospitiU. 
 
 Edited by HOWARD MARSH, 
 Assietant Surgeon to St Bartholomew's Hospital, and to the Hospital for Sick Childreo, 
 
 1 vol., 8to. Cloth. Price, $5.00. 
 
 CONTENTS. 
 Thk Various Risks op Operations — Thk Calamities of Surgery — Staji- 
 
 MERINO TVITH OTHER ORGANS THAN THOSE OF SPEECH — CaSES THAT B0NE-SkTTER3 
 
 CURE — Strangulated Hernia — Chronic Pyaemia — Nervous Mimicry — Treat- 
 ment OF Carbuncle — Sexual Hypochondriasis — Gouty Phlebitis — Residual 
 Abscess — Dissection-Poisons — Quiet Necrosis — Senile Scrofula — Scarlet Pe- 
 ter after Operations — ^Notes for the Study of some Constitutional Disease* 
 —Notes — Index. 
 
 PEASLEE. 
 
 Varian 1 UmorS J Their Fathology, Diagnosis, and 
 
 Treatment, with Reference especially to Ovariotomy, 
 
 By E. R. PEASLEE, M.D., 
 Professor of Diseases of Women in Dartmouth College ; one of the Consulting Physicans to the 
 New York State Woman's Hospital; formerly Professor of Obstetrics and Diseases of 
 Women in the New York Medical College; Corresponding Member of the Obstetrical 
 Society of Berlin, etc. 
 
 1 vol., 8vo. Illustrated with many Woodcuts, and a Steel Engraving of Dr. E. 
 McDowell, the " Father of Ovariotomy." Price, Cloth, $5.00. 
 
 This valuable work, embracing the results of many years of successful experience in the de- 
 partment of which it treats, will prove most acceptable to the entire profession ; wliile the high 
 Standing of the author and his knowledge of the subject combine to make the book the best in 
 the language. It is divided into two parts : the first treating of Ovarian Tumors, their anatomy, 
 pathology, diagnosis, and treatment, except by extirpation ; the second of Ovariotomy, its history 
 and statistics, and of the operation. Fully illustrated, and abounding with information, the result 
 of a prolonged study of the subject, tlie work should be in the hands of every physician in th» 
 country. 
 
 The following are some of the opinions of the press, at home and abroad, of this great work, 
 which has been justly styled, by an eminent critic, " the most complete medical monograph on a 
 practical subject ever produced in this country." 
 
 "His opinions upon what others have advised are clearly set forth, and are as Interesting and 
 Important as are the propositions he has himself to advance; while.there are a freshness, a vigor, 
 an authority about his writing, which great practical knowledge alone can confer."' — The Lancet. 
 
 "Both Wells's and Peaslee's works will be received with the respect due to the great repu- 
 tation and skill of their authors. Botli exist not only as masters o(^ their art, but as clear and 
 graceful writers. In either work the student and practitioner will find the fruits of rich expe- 
 rience, of earnest thought, and of steady, well-balanced judgment. Aa England is proud of 
 Wells, 80 may America well be proud of Peaslee, and the great world of science may be proud 
 QtXioth"— British Medical Journal. 
 
 " This is an excellent work, and does great credit to the industry, ability, science, and learning 
 of Dr. Peaslee. Few works issue from the medical press so complete, so exhaustively learned, 
 Bo imbued with a practical tone, without losing other substantial good qualities."— jSyinAur^A 
 Medical Journal. 
 
 " In closing our review of this work, we cannot avoid again expressing our appreciation of 
 the thorough study, the careful and honest statements, and candid spirit, which cliaracterize it. 
 For the use of the student we should give the preference to Dr. Feaslee's work, not only from 
 its completeness, but from its more methodical arrangement."— American Journal of Medical 
 Sciences.
 
 24 D. Appleton & Go.^s Medical Publications. 
 
 PEREIRA. 
 
 Dr. Pereira's Elements of Materia 
 
 Medica and Therapeutics. Abridged and adapted for 
 the Use of 3fedical and Pharmaceutical Practitioners 
 and Students, and comprising all the Medicines of the 
 British Pharmacopoeia, with such others as are frequently 
 ordered in Prescriptions, or required by the Physician. 
 
 Edited bt ROBERT BENTLEY and THEOPHILUS REDWOOD. 
 
 ITew Edition. Brought down to 1872. 1 vol., Royal 8vo. Cloth, $7.00 ; Sheep, 
 
 $8.00. 
 
 XvCpOrtS. Bellevue and Charity Hospital Reports for 
 1870, containing Valuable Contributions from 
 
 {6AA.a E. Tatloe. M. D., Austin Flint, M. D., Le-sos A. Saybe, M. D., "William A. IlAJki- 
 MONO, M. D., T. Gaillard Thomas, M. D., Frank H. Hamilton, M. D., and others, 
 
 1 vol., Svo. Cloth, 84.00. 
 
 "These institutions are the most important, as reg'ards accommodations for pationts and 
 ■variety of cases treated, of any on this continent, and are surpassed by but few in the world. 
 ■The gentlemen conaeftod with them are acknowled;?ed to be among the tirst in their profession, 
 and the volume is an important addition to the professional hterature ot this count y.^—Pei/cTu)- 
 iogioal Journal. 
 
 KICHAKDSOK 
 Diseases of Modern Life. 
 
 By Dr. B. W. RICHARDSON, F. R. S. 
 1 vol., 12nio. S2.00. 
 , Paet the FntsT.— phenomena OF DISEASE, INCIDENTAL AND GENERAL. 
 Chap. I. — Natural Life to Natural Death. Euthanasia. 
 
 '■ II. — Phenomena of Disease, Classification and Distribution. 
 
 '■ III. — Disease Antecedent to 15irth. 
 
 " IV. — External Origins and Causes of Disease. 
 
 '■ V. — Phenomena of Disease, fiom Causes External and Uncontrollable. 
 
 " VI. — Phenomena of Disease, from Causes External .and Communicable. 
 
 '■ VII. — PhenT)mena of Disease, incidental to Old Age and Natural Decay. 
 
 Part the Second.— PHENOMENA OF DISEASE, INDUCED AND SPECIAL. 
 
 Chap. I. — Definition and Classification of Induced Diseases. 
 
 " II. — Disease from Worry and Mental t- train (Broken Heart). 
 
 " III. — Disease from "Worry and Mental Strain, continued (Paralysis). 
 
 " IV. — Disease from Physical Strain. 
 
 " V. — Disease from Combined Physical and Mental Strain. 
 
 " VI. — Disease from the Influence of the Passions. 
 
 ^' VII.— Disease from Alcohol. Physiological Proem. 
 
 •" VIII. — Phenomena of Disease froiii Alcohol. The Functional Type. 
 
 " IX. — Organic Disease from Alcohol 
 
 ■" X. — Disease from Tobacco. Physiological Phenomena. 
 
 ■" XI. — Disease from Tobacco, continued (of the Heart and Lungs). 
 
 ■" XII. — Disease from Tobacco, continued (of the Brain and Nervous System). 
 
 •" XIII. — Disease from the Use of Narcotics (from Opium, Chloral, and Absiflthe). 
 
 ■" XIV. — Disease fi-om Misuse of Foods. 
 
 " XV. — Disease incident to some Occupations. 
 
 " XVI.— Disease from Late Hours and Deficient Sleep. 
 
 " XVII. — Disease from Imperfect Supply of Air. 
 
 * XVIII. — Disease from Imitation and Moral Contagion. 
 
 Part the Thtbd.— SUMMARY OF PRACTICAL APPLICATIONS.
 
 D. Appleton & Co.''s Medical Publications. 26 
 
 SAYRE. 
 Lectures on Orthopedic Surgery, and 
 
 Diseases of the Joints. Delivered at Dellevue IIos}}ital 
 Medical College during the Winter Session of 1874-1875, 
 
 By lewis a. SAYRE, M. D., 
 
 Professor of Orthopedic Surgery, Fractures and Dislocations, and Clinical Surgery, In Bellevnc 
 Hospital Medical College; Surgeon to Bcllevuo Hospital; Consulting Surgeon to Charity 
 Hospital; Consulting Surgeon to St. Elizabeth's Hospital; Consulting Surgeon to North- 
 western Dispensaiy; Member of the American Medical Association; Permanent Member 
 of the New York State Medical Society; Fellow of the New York Academy of Medicine ; 
 Member of the New York County Medical Society, of the New York Pathological Society, 
 of the Society of Neurology, of the Medico-Legal Society; Honorary Member of the New 
 Brunswick Medical Society; Honorary Member of the Medical Society of Norway; Knight 
 of the Order of Wasa, by His Majesty the King of Sweden, etc., etc. 
 
 Illustrated by Numerous Wood-Engravings. 1 vol., 8vo. Cloth, tS.OO; Sheep, 
 
 S6.0U. 
 
 These lectures are published at the request of medical gentlemen of the highest standing, m 
 dlifcreiit sections of our country, as well as many abroad, who are anxious to have Dr. Sayre'» 
 peculiar views and extended experience in this specialty given to the profession in a plain au<J 
 practical manner. The book contains the substance of his course of lectures delivered at BellO' 
 Tue Hospital Medical College, as well as many import.ant cases from his note-book, and from iha 
 hospital records. He has also added a number of cases before presented by him to the profes- 
 sion in medical journals, or at the different medical societies, which are considered worthy of 
 permanent record. 
 
 The work is enriched by beautiful and excellent illustrations, engraved from original draw- 
 tngs and photographs prepared expressly therefor. The author having enjoyed exceptional op- 
 portunities for the study and treatment of these diseases, the results of his labors cannot fail to 
 be of inestimable value to every student and practitioner, and of service to suffering humanity. 
 
 STEINER. 
 
 Compendium of Children's Diseases. 
 
 A Hand-booh for Practitioners and Students. 
 By Dr. JOHANN STEINER, 
 
 Professor of the Diseases of C3iildren in the University of Prague, and Physician to the FranclS' 
 Josej)h Hospital for Sick Children. 
 
 Translated from the Second German Edition by Lawson Tait, P. R. C. S., 
 
 Surgeon to the Birmingham Hospital for TVomcn ; Consulting Surgeon to the West Bromwlclt 
 Hospital; Lecturer on Physiology at the Midland Institute. 
 
 1 vol., 8vo. Cloth, $3.50. 
 
 TRANSLATOR'S PREFACE. 
 
 Dr. Stoiner's book has met -nith such m.nrked success in Germany that a second edition hn» 
 already .ippeared. a circumstance which has delayed the appearance of its English form. In ordef 
 that I might be able to give his .additions and corrections. 
 
 In Germany the use of the metric system has not yet entirely superseded the local measures; 
 but it is rapidly doing so, as In England. I have, therefore, rendered all thermometric observa- 
 tions in the Centigrade scale, and all measurements in centi- and millimetres. 
 
 I have added as an Appendix the '• Kules for Management of Infants" which have been issnetl 
 by the staff of the Birmingham Sick Children's Hosi'Sital, because I think that they have sot ao 
 example by freely distributing these rules among the poor for which they ciunot bo sulDciently 
 commended, and which it would be wise for other sick children's hospitals to follow. 
 
 I have also added a few notes, chiedy, of course, relating to the surgical ailmtuts of children. 
 
 BEKMiNQnAM, October, 1874. LAWSON TAIT.
 
 26 D. Appleton tb Co.^s Medical Publications. 
 
 STKOUD. 
 The Physical Cause of the Death of 
 
 Christ, and its Melations to the Principles and Practice 
 of Christianity. 
 
 By WILLIAM STROUD, M. D. 
 With a Letter on the Subject, by Sir James "Y. Simpson, Bart., M. D. 
 1 vol., 12mo. 422 pp. Cloth, $2.00. 
 This Important and remarkable book is, Is its ovm phce, a masterpiece, and will be considered 
 M a standard work for many years to come. 
 
 "The principal point insisted on is, that the death of Christ was caused by rupture or lacera- 
 tion of the heart. Sir James Y. Simpson, who had read the author's treatise and various com- 
 ments on it, expressed himself very positively in favor of the views maintained by Dr. Stroud." 
 — Psychological Journal. 
 
 SIMPSON. 
 The Posthumous Works of Sir James 
 
 Young Simpson, Bart., M. D. In Three Volumes. 
 
 Volume I. — Selected Obstetrical and Gjjncecological Works of Sir James Y. Simpson, 
 Bart., M. D., D. C. L.. late Professor of Midwifery in the University of Edinburgh. Contain- 
 ing the substance of his Lectures on Midwifery. Edited by .r. Watt Black, A. M» M. D., 
 Member of the Royal College of Physicians, London ; Physician- Accoucheur to Cliaring 
 Cross Hospital, London : and Lecturer on Midwifery and Diseases of Women and Children 
 in the Hospital School of Medicine. 
 
 1 vol., 8vo. 862 pp. Cloth, $3.00. 
 
 This volume contains all the more important contributions of Sir .Tames T. Simpson to the 
 Btudy of obstetrics and diseases of Women, with the exception of his clinical lectures on the latter 
 subject, which will shortly appear in a separate volume. This first volume contains many of the 
 papers reprinted from his Obstetric Memoirs and Contributions, and also liis Lecture Notes, now 
 published for the first time, containing the substance of the practical part of his course of mid- 
 wifery. It is a volume of great interest to the profession, and a fitting memorial of its renowned 
 and talented author. 
 
 "To many of our readers, doubtless, the chief of the papers It contains are familiar. To 
 others, although pmbably they may be aware that Sir James Simpson has \vritten on the sub- 
 jects, the papers themselves will bo new and fresh. To the first class we would recommend thl« 
 edition of Sir James Simpson's works, as a valuable volume of reference ; to the latter, as a colleo- 
 tion of the works of a great master and improver of his art, the study of which cannot fail to malu 
 them better prepared to meet and overcome its difficulties." — MediccU Times and Gazette. 
 
 Volume II. — Anaesthesia, Htspilallsm, etc. Edited by Sir Waltkr Simpson, Bart. 
 1 vol., 8vo. 560 pp. Cloth, $3.00. 
 " We say of this, as of the first volume, that it should find a place on the table of every prao- 
 iitioner ; for, though it is patchwork, each piece may be picked out and studied with pleasure and 
 pro at" — The Lancet (London). 
 
 Volume III. — The Diseases of Women. Edited by Alex. Simpson, M. D., Professor 
 of Midwifery in the University of Edinburgh. 
 
 1 vol., 8vo. Cloth, $3.00. 
 One of the best works on the subject extant. Of inestimable value to every physician. 
 
 SWETT. 
 A Treatise on the Diseases of the Chest. 
 
 Being a Course of Lectures delivered at the New York 
 Hospital. 
 
 By JOHN A. SWETT, M. D., 
 
 Professor of the Institutes and Practice of Medicine in the New York University ; Physician to 
 the New York Hospital ; Member of the New York Pathological Society. 
 
 1 vol., 8vo. 687 pp. $3.50. 
 
 Embodied in thia Tolome of lectures is the experience of ten years in hospital and i»lTata 
 Oractlce.
 
 D. Appleton db Cc's Medical Publications. 27 
 
 SAYKE. 
 A Practical Manual on the Treatment 
 
 of Cluh-Foot. 
 
 By lewis a. SAYRE, M. D., 
 
 Professor of Orthopedic Surgery in Bellevue Hospital Medical College; Surgeon to Bellevne and 
 
 Charity Hospitals, etc. 
 
 1 vol , 12ino. New and Enlarged Edition. Cloth, $1.00. 
 
 " The object of this work is to convey, in as concise a manner as possible, all the practical In- 
 formation and instruction necessary to enable the general practitioner to apply that plan of treat- 
 ment which has been so successful in my own hands." — Preface. 
 
 "The book will very well satisfy the wants of the majority of general practitioners, for whoM 
 use, as stated, it is intended." — Isiew York Medical JouinaL 
 
 SMITH. 
 
 On Foods. 
 
 Br EDWARD SMITH, M. D., LL. B., F. R. S., 
 
 Fellow of the Eoyal College of Physicians of London, etc., etc. 
 1 vol., 12mo. Cloth. Price, $1.75. 
 
 " Since the issue of the author's work on " Practical Dietary," he has felt the want of another, 
 •which would embrace all the generally-known and less-known"foods, and contain the latest scien- 
 tific knowledge respecting them. The present volume is intended to meet tbis want, and will be 
 found useful for reference, to bi'th scientific and general readers. The author extends the ordl- 
 narjf view of foods, and includes water and air, since they are important both in Uielr food and 
 sanitary aspects. 
 
 SCHKOEDER 
 
 A Manual of Midwifery. including the Pa- 
 thology of Pregnancy and the Puerperal State. 
 
 By Dr. KARL SCHROEDER, 
 Professor of Midwifery and Director of the Lying-in Institution in the University of Erlangen. 
 
 TEANSLATED FKOM TUE THIRD GEBMAN EDITION 
 
 By CHARLES H. CARTER, B. A., M. D., B. S. London, 
 
 Member of the Eoyal College of Physicians, London, and Physician Accoucheur to St George'i, 
 
 Hanover Square, Dispensary. 
 
 With Twenty-six Engravings on Wood. 1 vol., 8vo. Cloth. 
 "The translator feels that no apology is needed in ofi'ering to the profession a translation of 
 Schroeder's Manual of Midwifei-y. The work is well known in Germany and extensively used aa 
 a text-book; it has already reached a third edition within the short space of two years, and it ia 
 hoped that the present translation will meet the want, long felt in this countrj', of a manual of 
 midwifeiy embracing the latest scientific researches on the subject. 
 
 TILT. 
 
 A Hand-Book of Uterine Therapeu- 
 tics and of Diseases of Women. 
 
 By EDWARD JOHN TILT, M. D., 
 Member of the Eoyal College of Physicians ; Consulting Physician to the Farringdon General 
 Dispensary; Fellow of the EoyalMedical and Chirurgical Society, and of several British and 
 foreign societies. 
 
 1 vol., 8vo. 345 pp. Cloth, $3.50. 
 
 Second American edition, thoroughly revised and amended: 
 
 " In giving the result of his labors to the profession the author has done a great work. Our 
 readers will find its pages very interesting, and. at the end ol their task, will feel gniteful to the 
 author for many very valuable suggestions as to the treatment of uterine diseases." — The Lancet. 
 
 "Dr. Tilt's ' Hand-Book of Uterine Therapeutics ' supplies a want which has often been felt. 
 . . It may, therefore, be read not only with pleasure and Instruction, but will also be fonnd 
 TeiT useful as a book of reference." — The Medical Mirror. 
 
 " Second to none on the therapeutics of uterine disease." — Journal of Obstetric*.
 
 S8 D. Appleton d? Co.'s Medical Publications. 
 
 VAN BUREN AND KEYES. 
 A Practical Treatise on the Surgical 
 
 Diseases of the Genito- Urinary Organs^ including Syphi- 
 lis. Designed as a Manual for Students and Practition- 
 ers. With JEngravings and Cases. 
 
 By W. H. van BUKEN, A. M., M. D., 
 
 Professor of Priuciples of Surgery, with Diseases of the (icnito-Uritiary System and Clinical 
 Surgery, in Bellevue Hospital Medical College; Consulting Sui-geou "to Ibc ^ew York Hos- 
 pital, the Charity Hospital, etc. ; and 
 
 E. L. KEYES, A. M., Vi. D., 
 
 Professor of Dermatol' iry In Bellevue Hospital Medical Collr;:i^; PuvfTCon to thi^ Charity Hos- 
 pital, Venereal ]>i' ses; Consulting De'-matologisl to the liuieuu of (Jut-Door liclict," Belle- 
 vue Hospital, etc 
 
 1 vol., 8vo. ClotH, $6.00; Sheep, $6.00. 
 
 This work is really a coi.-jieii ilium of, and a book ol" ruierence to, all modem 
 works treating in any way of the Kuigical diseases of the genito-uriuaiy organs. At 
 the same time, no other single book contains so laige an array of original facts con- 
 cerning the class of diseases with which it deals. These facts are largely drawn 
 from the extensive and varied experience of the authors. 
 
 Many important branches of genito-urinary diseases, as the cutaneous maladiea 
 of the penis and scrotiun, receive a thorough and exhaustive treatment that the pro- 
 fessional reader will search for elsewhere in vain. 
 
 The work is elegantly and profusely illustrated, and enriched by fiftj'-five 
 original cases, settiug forth obscure and difficult points in diagnosis and treatment. 
 
 "The first part is devoted to the Surgical Diseases of the Genito-TJrinary Organs; and part 
 fiecond treats of Chancroid and Sj'philis. The authors 'appear to have succeeded admirably in 
 giving to the world an exhaustive .and reliable tieatise on this important class of diseases.' " — 
 Morlhwestern Medical and Surgical Jonrnal. 
 
 '■It is a most complete digest of what has long been known, and of what has been more re- 
 cently discovered, in the field of syi>hilitic and genito-urinary disorders. It is jierhaps not an 
 £.\aggeration to say that no single worli ujion the same subject has jet appeared, in this or any 
 foreifin language, wliich is superior to it."— (Jbicago Medical Examiner. 
 
 " The commanding rej)Utatiou of Dr. Van Buren in this specialty aud of the great school .ind 
 lios])ital froui whicli lie has drawn his clinical materials, together with the general interest which 
 attaches to the subject-matter itself, will, we trust, lead very many of those for whom it is our 
 flllice to cater, to possess themselves at once of the volume and form their own opinions of its 
 ixiL-rii.''^— Atlanta Medical and Surgical Journal. 
 
 Lectures upon Diseases of the Rectum. 
 
 Delivered at the Pellevue Hospital Medical College. 
 Session o/1869-'70. 
 
 By W. H. van buren, M. D., 
 
 1 vol., 12mo. 164 pages. Cloth, $1.50. 
 
 " It seems hardly necessary to more than mention the name of the author of this admirable 
 little volume in order to insuio the character of his bool^. No one in this country has enjuved 
 greater advantages, and had a more extensive field of observation in this specialty, than Dr. 
 Van Buren. aud no one has i>aid the same amount of attention to the subject. . . . Here is the 
 «xpei-ience of years summed up aud given to the prolessional world in a plain and practical uiaa- 
 ner." — Psychuk/gicul Journal.
 
 D. Appleton & Co.^s Medical Publications. -^c) 
 
 VOQEL. 
 A Practical Treatise on the Diseases 
 
 of Children. Second American from the Fourth 
 German Edition. Illustrated ly Six Lithographic 
 Plates. 
 
 By ALFRED VOGEL, M. D., 
 
 Professor of Clinical Medicine in the University of Dorj)at, SomIk. 
 TRANSLATED AND EDITED BY 
 
 n . R A r n A E L , m . d . , 
 
 Lit0 Boom Svirgeon to Bellevuo Ilosi.ital ; Physician to the Eastern Dispensary for ihe Dieeuoe 
 
 of Children, etc., etc. 
 
 1 vol., 8vo. 611 pp. Cloth, $4.50. 
 
 The work is well up to the present state of pathological knowledge ; 
 complete without unnecessary prolixity; its symptomatology accurate, 
 evidently the result of careful observation of a competent and experi- 
 enced clinical practitioner. The diagnosis and differential relations of 
 diseases to each otlier are accurately described, and the therapeutics 
 judicious and discriminating. All polypharmacy is discarded, and only 
 the remedies which appeared useful to the author commended. 
 
 It contains much that must gain for it the merited praise of all im- 
 partial judges, and prove it to bo an invaluable text-book for the stu- 
 dent and practitioner, and a safe and useful guide in the difficult but all- 
 important department of Padiatrica. 
 
 " Rapidly passing to a fourth edition in Germany, and translated into three 
 other languages, Anaerica now has the credit of presenting the first English ver- 
 eion of a book whicli must take a prominent, if not the leading, position among 
 works devoted to this class of disease." — N. Y. Medical Journal. 
 
 " The profession of this country are under many obligations to Dr. Raphael 
 for bringing, as he has dona, this truly valuable work to their notice." — Medical 
 iUcord. 
 
 "The translator has been more than ordinarily successful, and bis labors 
 have resulted in what, in every sense, is a valuable contribution to medicii 
 ecience." — Psychological Journal. 
 
 "We do not know of a compact text-book on the diseases of children more 
 complete, more comprehensive, more replete with practical remarks and scientific 
 facts, more in keeping with the development of modem medicine, and more 
 worthy of the attention of the profession, than that which has been the subjed 
 of our remarks." — Join-nal of Olstetrict.
 
 30 D. Appleton <& Co.^s Medical Publications. 
 
 WALTON. 
 
 The Mineral Springs of the United 
 
 States and Canada, with Analyses and Notes on the 
 Prominent Spas of Europe, and a List of Sea-side 
 Resorts. An enlarged and revised edition. 
 
 By GEORGE E. WALTON, M.D., 
 
 Lecturer on Materia Medica in the Miami Medical College, Cincinnati, 
 
 Second Edition, revised and enlarged. 1 vol., 12mo. 390 pp., witli Maps. $2.00. 
 
 The author has given the analyses of all the springs in this country and 
 those of the principal European spas, reduced to a uniform standard of 
 one wine-pint, so that they may readily be compared. He has arranged 
 the springs of America and Europe in seven distinct classes, and de- 
 scribed the diseases to which mineral waters are adapted, with refer- 
 ences to the class of waters applicable to the treatment, and the pecul- 
 iar characteristics of each spring as near as known are given — also, the 
 location, mode of access, and post-office address of every spring are men- 
 tioned. In addition, he has described the various kinds of baths and 
 the appropriate use of them in the treatment of disease. 
 
 EXTKACTS FROM OPINIONS OF THE PRESS. 
 
 "... Precise and comprehensive, presenting not only reliable analyses of 
 the waters, but tVieir therapeutic value, so that physicians can hereafter advise 
 their use as intelligently and beneficially as they can other valuable alterative 
 iigents." — Sanitarian. 
 
 "... Will tend to enlighten both the profession and the people on this 
 question." — N. Y. Medical Journal. 
 
 "... Contains in brief space a vast amount of important and interesting 
 matter, well arranged and well presented. Nearly every physician needs just 
 Buch a volume " — Richmond and Louisville Medical Journal. 
 
 "... Fills this necessity in a scientific and pleasing manner, and can be read 
 with advantage by the physician as well as layman." — American Jour, of Obstetrics. 
 
 TJsrviBBiTT or VnonnA, June 9, 1878. 
 
 Gentlkmsk : I have received by mail a copy of Dr. Walton's work on the 
 Mineral Springs of the United States and Canada. Be pleased to accept my 
 thanks for a work which I have been eagerly looking for ever since I had the 
 pleasure of meeting the author in the summer of 1871. He satisfied me that 
 he was well qualified to write a reliable work on this subject, and I doubt not 
 he has met my expectations. Such a work was greatly needed, and, if ofiered 
 for sale at the principal mineral springs of the country, will, I believe, com- 
 mand a ready sale. Very respectfully yours, 
 
 J. L. Cabell, M. D.
 
 D. Appleton <& Co.^s Medical Publications. 31 
 
 WELLS. 
 Diseases of the Ovaries ; Their DiagnoeU 
 
 and Treatment. 
 
 By T. SPENCER WELLS, 
 
 fellow and Member of Council of the Eoyal College of Surgeons of England ; nonomry Fello-w 
 of the King and Queen's College of Physicians in Ireland; Surgeon in Ordinary to the 
 Queen'B Household; Surgeon to the Samaritan Hospital for Women; Member or the Im- 
 perial Society of Surgery of Parts, of the Medical Society of Paris, and of the Medical Soci- 
 ety of Sweden; Honorary Member of the Royal Society of Medical and Natural Science 
 of Brussels, and of the Medical Societies of Pesth and Helslngfors ; Honorary Fellow of 
 the Obstetrical Societies of Berlin and Leipzig. 
 
 1 vol, 8vo. 478 pp. Illustrated. Cloth, Price, $4.50. 
 
 In 1865 the author issued a volume containing reports of one hundred and 
 fourteen cases of Ovariotomy, which was little more than a simple record of 
 facts. The book was soon out of print, and, though repeatedly asked for a 
 new edition, the author was unable to do more than prepare papers for the 
 Royal Medical and Chirurgical Society, as series after series of a hundred casea 
 accumulated. On the completion of five hundred cases he embodied the resulta 
 in the present volume, an entirely new work, for the student and practitioner, 
 and trusts it may prove acceptable to them and useful to suffering women. 
 
 " Arrangements have been made for the publication of this volume in Lon- 
 don on the day of its publication in New York." French and German transla- 
 tions are already in press. 
 
 WAaiSTER. 
 A Hand - book of Chemical Tech- 
 
 nology. 
 
 By RUDOLPH WAGNER, Ph. D., 
 
 Professor of Chemical Technology at the University of Wurtzburg. 
 
 Translated and edited, from the eighth German edition, with exteajislve 
 
 additions, 
 
 By WILLIAM CROOKES, F. R. S. 
 
 With 336 Illustrations. 1 vol., 8vo. 781 pages. Cloth, $5.00. 
 
 Under the head of Metallurgic Chemistry, the latest methods of preparing Iron, Cobalt, 
 Nickel Copner. Copper Salts, Lead and Tin. and th«ir Salts, BismntK Zinc, Zinc SalU, Cad- 
 mium, Antimony, Arsenic, Mercury. Platinum, Silver. Gold, Manpanates, Ainminnm. and 
 Magneslnm, are "described. The various applications of the Voltaic Current to Electro- M«ital- 
 lurgT follnw under this division. The preparation of Potash and Soda SalU*. the mannfactur* 
 of Sulphuric Acid, and the recovery of Sulphur from Soda Waste, of course occupy prominnnt 
 places in the consideration of chemical man\if:wture3. It Is dillicult to over-estiinnte the mer- 
 cantile value of Mond's process, as well a.s the many new and impiirtant applications of Bisul- 
 phide of Carbon. The manufacture of Soap will be'founil to include much detail. The Tech- 
 noloerv of Olaes, Stone-ware, Limes, and Mortars, will present mnch of Interest to the Builder 
 and Engineer. The Technology of Vegetable Fibres has been considered to include the pren- 
 aration of Flax, Hemp, Cotton, as well as Paper-making; while the applicati.ins of V egetabl* 
 Products will be found to include Sugar-boiling. Wine and Beer Brewing, the Distillation of 
 Bpirita. the Baking of Bread, the Preparation of Vinegar, the Preservation of Wo<>d, etc. 
 
 Dr. Wagner gives much tnforiuatifin in reference to the production of Potash from Sugar 
 realdnes. The use of Baryta Salts is also flilly described, as well an the preparation of Sugar 
 from Reet-ronta, Tanning, the Preservation of Meat, Milk. etc„ the Preparation of Pho8ph»- 
 ms and Animal Charco.iL are con.sldered as belonging to the Tecl^nology of Animal Product*. 
 The Preparation of Materials for Dyeing has necessarily required much space ; while the flnW 
 Mctlon* of the book hare been devoted to the Technology of Heating and lUamlnatloa.
 
 THE NEW YORK MEDICAL JOURNAL 
 
 JAMES B. EVXTEB, M. D., Editor. 
 Published Monthly, Volumes begin in January and July. 
 
 "Among the numerous records of Medicine and tin- collateral sciences published In America, 
 the above Journal occupies a high position, and deservedly so." — The Lancet (London). 
 
 "One tf the best medicil journals, by-the-by, published on the American Continent."— Zon- 
 don Medical 'J imes and Gazette. 
 
 "A very high-class journal." — London Medical Mirror. 
 
 "The editor and the contribiitors r.mk among our most distinguished medical men, and each 
 nnrabcr contains matter that does honor to American medical literature." — Boston Journal of 
 Chemistry. 
 
 "Full of valuable originnl papers, abounding in scientific .ability." — Chicago Medical Timet 
 
 " We know no other jicriodical that we would rather present as a specimen of American sklL 
 tnd intelligence than the New York Medical Jouu.nal." — Franklin lieposilory. 
 
 " The New Tork Medical Jouiinai,, edited by Dr. James B. Hunter, is one of the sterling 
 periodicals of this country. The present editor has gre.itly improved the work, and evinces a 
 marked aptitude for the responsible duties so well discharjred. The contents of this journal are 
 always interesting and instructive ; its original matter is often classic in value, and the selected 
 articles are excellent exponents of the progress and truth of medical science." — liichmond and 
 Louisville Medical Journal, 
 
 Terms, $4.00 per Annum 5 or 40 Cents per Number. 
 
 ^ — ^ — .^ 
 
 THE POPULAR SCIENCE MONTHLY. 
 
 Conducted hy Prof. E. L. YOUMAjYS. 
 
 Each Number contains 128 pages, with numerous Descriptive and 
 Attractive Illustrations. 
 
 Published Monthly. Volumes begin in May and November. 
 
 Terms, $5 per Auuuiu, or Fifty Cents per Number 
 
 Tire PoPTr-AS Science Mokthlt was started to promote the diffusion of valuable scientlfli 
 knowledge, ia a readable and attractive form, among nil classes of the community, and has thus 
 far met a W.int supjilied by no other periodical in the United States. 
 
 The great feature of the magazine isi, that its contents are not what science ^cas ten or more 
 years since, but what it is to-day, fresh from the study, the laborntniy, and the experiment: 
 clothed in the language of the authors, inventors, and scientists themselve.">, which coujjirise the 
 leading minds of Kngland. Franco, ticrmany. and the United States. Among popular articles, 
 covering the whole range of Natitkal Science, we have the latest thouj;hts and words of Her- 
 bert Spencer, and Professors Huxley, Tyndall. and li. A. I'n'Ctor. Since the start, it has jiroved 
 ft gratifying success to every friend of scientillc progress and universal education; and those wlio 
 believed th.at science could not be made any thing but dry study, are disappointed. 
 
 The press all over the land is warmly commending it. We subjoin a few encomiiims fl-om 
 those recently given: 
 
 " A journal which promises to be of eminent value to the cause of popular education in thla 
 country." — Sent York 'J'ribune. 
 
 "lt"is, beyimd coiii[iarison, the best attempt at journalism of the kind ever made in this coun- 
 try." — Home Journal. 
 
 "Tlie initial iiumhcris admirably con.stitutod."— ^r^rtinf? Mall. 
 
 *' In our opinion, the right idea has been happily hit in the plan of this new monthly." — Buffalo 
 Courier. 
 
 " J ust the publication needed at the present day." — Montreal Gazette. 
 
 Payment, in all cases, must be made in advance, 
 
 Eemittances should be made by postal money-order or check to the rubhsbers, 
 
 JD. jLJPJPLJ^TOir ^ CO., 
 
 S40 & 551 Broadtvaij, Xetv Tork,
 
 UNIVERSITY OF CALIFORNIA LIBRARY 
 
 Los Angeles 
 This book is DUE on the last date s£aiii|>ctl below. 
 
 JUN 1 T I960- 
 
 JU1V4 fiECH 
 MAY 4 1970 
 
 ^£8 2 1 Rlc-0 
 
 SIOME 
 
 r«?i 
 
 w(\n4Rtc 
 
 OCT 1 4 RECU 
 
 ? 
 
 m^^ ^^"SEP29 1992 
 
 FEB 
 
 2 7 RtC'O 
 BIOMED LIB. 
 
 JUN 2 9 RECD 
 
 Form L9-40m-5,'67(H2161s8)'iTOS'- 
 
 b,nniedical UbrarV 
 Biomedical Library 
 
 A,
 
 3 1158 00447 3269