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 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 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 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 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, 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 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 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 aui' 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